Use of non-invasive stimulation in movement disorders: a critical review

BACKGROUND

Noninvasive stimulation has been widely used in the past 30 years to study and treat a large number of neurological diseases, including movement disorders.

OBJECTIVE

In this critical review, we illustrate the rationale for use of these techniques in movement disorders and summarize the best medical evidence based on the main clinical trials performed to date.

METHODS

A nationally representative group of experts performed a comprehensive review of the literature in order to analyze the key clinical decision-making factors driving transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS) in movement disorders. Classes of evidence and recommendations were described for each disease.

RESULTS

Despite unavoidable heterogeneities and low effect size, TMS is likely to be effective for treating motor symptoms and depression in Parkinson's disease (PD). The efficacy in other movement disorders is unclear. TMS is possibly effective for focal hand dystonia, essential tremor and cerebellar ataxia. Additionally, it is likely to be ineffective in reducing tics in Tourette syndrome. Lastly, tDCS is likely to be effective in improving gait in PD.

CONCLUSIONS

There is encouraging evidence for the use of noninvasive stimulation on a subset of symptoms in selected movement disorders, although the means to optimize protocols for improving positive outcomes in routine clinical practice remain undetermined. Similarly, the best stimulation paradigms and responder profile need to be investigated in large clinical trials with established therapeutic and assessment paradigms that could also allow genuine long-term benefits to be determined.

Free carnitine and branched chain amino acids are not good biomarkers in Huntington's disease

BACKGROUND

Huntington's disease (HD), caused by an expanded CAG repeat at HTT, has no treatment, and biomarkers are needed for future clinical trials.

OBJECTIVE

The objective of this study was to verify if free carnitine and branched chain amino acids levels behave as potential biomarkers in HD.

METHODS

Symptomatic and asymptomatic HD carriers and controls were recruited. Age, sex, body mass index (BMI), age of onset, disease duration, UHDRS scores, and expanded CAG tract were obtained; valine, leucine, isoleucine, and free carnitine were measured. Baseline and longitudinal analysis were performed.

RESULTS

Seventy-four symptomatic carriers, 20 asymptomatic carriers, and 22 non-carriers were included. At baseline, valine levels were reduced in symptomatic and asymptomatic HD carriers when compared to non-carriers. No difference in free carnitine or isoleucine+leucine levels were observed between groups. BMI of symptomatic individuals was lower than those of non-carriers. Valine levels correlated with BMI. Follow-up evaluation was performed in 43 symptomatic individuals. UHDRS total motor score increased 4.8 points/year on average. No significant reductions in BMI or valine were observed, whereas free carnitine and isoleucine+leucine levels increased.

CONCLUSIONS

Although valine levels were lower in HD carriers and were related to BMI losses observed in pre-symptomatic individuals, none of these metabolites seem to be biomarkers for HD.

Minimal prevalence of Huntington's disease in the South of Brazil and instability of the expanded CAG tract during intergenerational transmissions

Huntington’s disease (HD) is due to dominant expansions of the CAG repeat of the HTT gene. Meiotic instability of the (CAG)_n might impact the disorder frequency. We report on HD minimal prevalence in Rio Grande do Sul (RS) state, Brazil, and on intergenerational instability of the (CAG)_n in HD families. Symptomatic and at-risk subjects from 179 HD families were ascertained between 2013 and 2016. Clinical, molecular and family history data were obtained. Expanded (CAG)_n length differences between parent and child (delta-expanded-(CAG)_n) were calculated. Effect of parental age on the (CAG)_n instability upon transmission was inferred by correlating delta-expanded-(CAG)_n between siblings to their age differences. HD minimal prevalence in RS state was estimated as 1.85:100,000 inhabitants. Alleles with (CAG)_27-35 were found on 21/384 non-disease associated chromosomes (5.5%); among 253 expanded alleles, four (1.6%) were within reduced penetrance range with (CAG)_36-39. In 32 direct transmissions, mean instability was larger among paternal than maternal transmissions. In direct transmissions and in 51 sibling pairs, parental age at the time of child birth were not correlated with delta-expanded-(CAG)_n. Briefly, HD prevalence in RS state was lower than those reported for European populations. Expanded (CAG)_n transmissions were unstable and not associated to parental age.

Interpersonal sensitivity and persistent attenuated psychotic symptoms in adolescence

Interpersonal sensitivity defines feelings of inner-fragility in the presence of others due to the expectation of criticism or rejection. Interpersonal sensitivity was found to be related to attenuated positive psychotic symptom during the prodromal phase of psychosis. The aims of this study were to examine if high level of interpersonal sensitivity at baseline are associated with the persistence of attenuated positive psychotic symptoms and general psychopathology at 18-month follow-up. A sample of 85 help-seeking individuals (mean age = 16.6, SD = 5.05) referred an Italian early detection project, completed the interpersonal sensitivity measure and the structured interview for prodromal symptoms (SIPS) at baseline and were assessed at 18-month follow-up using the SIPS. Results showed that individuals with high level of interpersonal sensitivity at baseline reported high level of attenuated positive psychotic symptoms (i.e., unusual thought content) and general symptoms (i.e., depression, irritability and low tolerance to daily stress) at follow-up. This study suggests that being "hypersensitive" to interpersonal interactions is a psychological feature associated with attenuated positive psychotic symptoms and general symptoms, such as depression and irritability, at 18-month follow-up. Assessing and treating inner-self fragilities may be an important step of early detection program to avoid the persistence of subtle but very distressing long-terms symptoms.

First Confirmed Case of Vancomycin-ResistantEnterococcus faeciumMeningitis in Turkey:

Vancomycin-resistant enterococci are unusual etiologic agents of bacterial meningitis and pose significant therapeutic difficulties. We report the first confirmed case of nosocomial vancomycin-resistant Enterococcus faecium meningitis in Turkey. The patient was treated with chloramphenicol and cerebrospinal fluid cultures became negative, but clinical success was not achieved. We also review the previously reported cases of vancomycin-resistant Enterococcus faecium meningitis.

[Depressive and anxiety symptoms in a community sample of young adults and correlation with help-seeking behavior]

AIMS

To evaluate: (i) self-perceived stress, depressive and anxiety symptoms in a community sample of young adults; (ii) which elements have most impact on the development of mental disease; (iii) if high levels of mental disease are related to help-seeking behavior.

MATERIALS AND METHODS

The study was carried out on a sample of 1660 university students. The evaluation of the perceived stress was conducted using the Stress-Related Vulnerability Scale (SVS), the evaluation of depressive and anxiety symptoms with Beck Depression Inventory-II (BDI-II) and Beck Anxiety Inventory (BAI). A descriptive analysis of all the data collected was carried out and the principal links between variables and level of mental disease were detected. Finally the reasons for the failure to seek help were investigated.

RESULTS

Mean scores of BDI-II and BAI were respectively 10.9 (sigma = 8.3) and 11.4 (sigma = 9.4) and about 4% of the sample showed a pathological level of stress with the SVS. Female sex, non resident status and conflictual family climate were found to be more related with more severe anxious and depressive symptoms. Moreover, the latter ones were found to be strongly related with help-seeking behavior.

CONCLUSION

In this sample mental disease associated with distress show a significant percentage. Higher level of anxiety and depressive symptoms are more related to perceived need for help and help-seeking behavior. Nevertheless the level of unexpressed help-seeking turn out to be high for multiple reason.

Hepatic toxocariasis: US, CT and MRI findings

Visceral larva migrans (VLM) most commonly occurs as a febrile disease of childhood particularly affecting children between 1 and 7 years of age. Pulmonary, dermatological, hepatic, lymphatic, cardiac, rheumatological and neurological manifestations may occur. VLM seems to be a rare disease in adults. We report the imaging findings of a woman with hepatic toxocariasis. Ultrasonography showed a solitary hepatic lesion measuring 4 x 3 cm, displaying a hypoechoic-heterogeneous pattern with ill-defined borders and distal acoustic enhancement, located in the right sub-diaphragmatic area. Two enlarged periportal lymph nodes and moderately dilated intrahepatic biliary ducts were also noted. The probability of toxocariasis was discussed, based on sonographic and biopsy findings, and the final diagnosis was confirmed by a specific ELISA test. In summary, a clinical picture of cholestasis initially resembling hepatitis or malignancy should be further evaluated by imaging techniques, and the ultrasound examiner should be familiar with the possible findings of hepatic toxocariasis, which consist of focal ill-defined hepatic lesions, hepato-splenomegaly, biliary dilatation, sludge and periportal lymph node enlargement.

Effect of chronic Pseudomonas aeruginosa infection on the development of atherosclerosis in a rat model

In order to investigate the possible relationship between atherosclerosis and chronic Pseudomonas aeruginosa infection, 66 Wistar rats were given five separate intratracheal inoculations of either P. aeruginosa or sterile saline at 4-week intervals. The rats were divided into four groups: group 1 was infected with P. aeruginosa and fed a diet containing cholesterol 1% w/v; group 2 was infected with P. aeruginosa and fed a normal diet; group 3 was not infected and was fed a diet containing cholesterol 1% w/v; and group 4 (the control group) was not infected and was fed a normal diet. One month after the final inoculation, the rats were killed humanely; computerised image analysis was used to evaluate sections of the aorta and heart, and the maximal wall thickness of the aorta and coronary artery. The aortic wall thickness was significantly greater for group 1 (329.53 +/- 58.06 microm) compared to groups 2 (190.59 +/- 27.81 microm; p < 0.0001), 3 (262.90 +/- 61.12 microm; p < 0.0004) and 4 (158.00 +/- 30.30 microm; p < 0.0001). Similarly, the coronary artery wall thickness was significantly greater for group 1 (72.96 +/- 10.67 microm) compared to groups 2 (35.07 +/- 8.53 microm; p < 0.0001), 3 (41.45 +/- 10.22 microm; p < 0.0001) and 4 (32.30 +/- 5.27 microm; p < 0.0001). These findings strengthen the hypothesis that chronic infection plays a role in the pathogenesis of atherosclerosis.

Human fascioliasis

Fasciola hepatica, a zoonotic liver fluke, can also cause disease in humans. Common symptoms are epigastric pain, upper abdominal pain and malaise. Fever and arthralgia are common in acute fascioliasis. Eosinophilia is the predominant laboratory finding, especially in patients with the acute form of the disease. Diagnosis and treatment is not easy, as physicians rarely encounter this disease, and effective drugs are not available in many countries. Human fascioliasis may be underestimated. Patients with eosinophilia and abdominal pain should be evaluated for F. hepatica infestation by parasitological, radiological and serological tests.

The structure of the avian fast skeletal muscle troponin T gene: seven novel tandem-arranged exons in the exon x region

To elucidate the mechanism that produces enormous molecular diversity in troponin T (TnT) of fast skeletal muscle, we determined the 5'-half genomic sequence of the chicken fast muscle TnT gene. The sequence of ca. 16 kb included seven exons (exons 1, 2, 3, 4, w, 5, and 6), which have been reported previously and presumed by sequencing TnT cDNAs. Additionally we found six 15 nt and one 18 nt sequences in the region between exons 5 and 6 (i.e. the exon x region). They were encompassed by consensus splice donor and acceptor sites and preceded by putative branch sites, and designated herein as exons xa to xg. Our result shows that the sequence derived from exons x1, x2, and x3, the exons presumed previously by cDNA sequencing, is actually encoded by the seven exons xa to xg, establishing the precise gene structure in the exon x region. Based on our data, together with that on the 3'-half genomic sequence of the quail fast muscle TnT gene, we conclude that the avian fast skeletal muscle TnT gene includes 27 exons, 16 of which are alternatively spliced.

Natural occurrence of fast- and fast/slow-muscle chimeric fibers in the expression of troponin T isoforms

Rhomboideus, one of the back muscle tissues, and its single fibers were studied in chickens by immunostaining with antisera against fast- and slow-muscle-type troponin T isoforms. Nonuniform distribution of slow-muscle-type isoforms was for the first time detected in single fibers isolated from the muscle, although fast-muscle-type troponin T isoforms were distributed over the whole length of the fiber. Based on these observations, we conclude that fast- and fast/slow-muscle chimeric fibers exist in normal skeletal muscle tissue and that the existence of chimeric fibers is direct evidence showing that myonuclei subjected to different determination in troponin T isoform expression can together form a single muscle fiber.

Fructosamine in HbS and G6PD-deficient Saudi Arabs in the Eastern Province of Saudi Arabia

Plasma fructosamine, total proteins and albumin were estimated in a group of 77 sickle cell anaemia and 32 glucose-6-phosphate dehydrogenase (G6PD)-deficient Saudi Arabs and the results compared with those obtained in a group of 30 normal controls. The mean values of fructosamine in the sickle cell anaemia and G6PD-deficient patients were not statistically different from those of the controls. The mean values of the total proteins and albumin were also not significantly different from those of the normal group. It is concluded that fructosamine level is not affected by sickle cell anaemia and G6PD deficiency, and provides a useful tool for monitoring diabetic patients in regions with high prevalence of haemoglobinopathies and G6PD deficiency.

A comparative study of glycosylated haemoglobin level in the Arabian camel (Camelus dromedarius) during different seasons

1. The extent of haemoglobin glycosylation from 60 camels has been determined (4.39%) in blood samples drawn during winter. 2. Phosphate (9.45 mg/dl), DPG (2.9 mumol/ml) and glucose (138 mg/dl) levels were also recorded. 3. In addition the P50 at pH 7.4 was measured (22.8 Torrs). 4. The data obtained compared with human blood levels and with levels reported for camels during summer sampling. 5. Despite the fact that camels have higher blood glucose levels than humans, the extent of glycosylation is much less in camel blood than in human blood.

A study of the biochemical characteristics of NADP+ isocitrate dehydrogenase from the liver and kidney of the Arabian camel (Camelus dromedarius)

1. NADP+ isocitrate dehydrogenase was partially purified from camel liver and kidney by an FPLC. 2. The specific activity of the purified preparation from liver was 63.5 mumol/min/mg protein and from the kidney was similar, 58.7 mumol/min/mg protein. 3. The enzyme from the two sources were similar in their pH optimum (7.6), electrophoretic mobility and stability to thermal inactivation at 60 degrees C. 4. Heat inactivation was accelerated by oxidized glutathione and cystine and decreased by dithiothreitol, reduced glutathione and cysteine. 5. The molecular weight of the enzyme from both organs was estimated as 60,000 +/- 5000. 6. Divalent metal ions increased the activities of both enzymes, with maximum catalytic activity in the presence of Mn2+ ions.