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1.  Comparable Botulinum Toxin Outcomes between Primary and Secondary Blepharospasm: A Retrospective Analysis 
Background
Blepharospasm is a focal cranial dystonia, which could be idiopathic in origin or secondary to an underlying disorder that commonly impairs quality of life. Botulinum toxin (BoNT) injections have become the treatment of choice; however, a less favorable response to BoNT is expected in secondary blepharospasm. No studies have been conducted comparing outcomes between blepharospasm cohorts. We therefore aim to compare BoNT outcomes in primary and secondary blepharospasm subjects.
Methods
A retrospective review of 64 blepharospasm subjects receiving BoNT therapy was conducted. Demographics, BoNT treatment schedules, duration of BoNT therapy, and side effects were recorded. Outcome measures were duration of benefit, peak-dose benefit recorded with the Clinical Global Impressions Scale (CGIS), and related side effects.
Results
No difference was found between the two cohorts regarding duration of benefit from treatment (primary 9.47 weeks vs. secondary 9.63 weeks, p = 0.88). Perceived peak-dose benefit was more commonly reported as “very much improved” in secondary patients, but this was not significant (p = 0.13). Higher BoNT dosages were required in both groups over time, with a mean increase of 20.5% in primary and 26.5% in secondary blepharospasm. Ptosis (8%) and diplopia (6%) were the most common reported side effects. Mean follow-up in years was similar between groups, 3.6 years for primary vs. 2.4 years for secondary blepharospasm (p = 0.17).
Discussion
BoNT injections were effective with comparable benefits seen in both primary and secondary blepharospasm populations. Clinicians should be aware of the similar benefit from BoNT reported in secondary blepharospasm patients. The average duration of benefit in this cohort was comparable with previous reports.
doi:10.7916/D8H41Q4X
PMCID: PMC4266684  PMID: 25562037
Cranial dystonia; botulinum toxin; Parkinson's; tardive syndromes; Clinical Global Impressions Scale
2.  Using the Timed Up & Go Test in a Clinical Setting to Predict Falling in Parkinson's Disease 
Objective
To investigate the ability of the Timed Up & Go test to identify patients with Parkinson's disease at risk for a fall.
Design
Cross-sectional cohort study.
Setting
Sixteen participating National Parkinson's Foundation Centers of Excellence.
Participants
A query yielded a total of 2985 records (1828 men and 1157 women). From these, 884 were excluded because of a lack of crucial information (age, diagnosis, presence of deep brain stimulation, disease duration, inability of performing the Timed Up & Go test without assistance) at the time of testing, leaving 2097 patients included in the analysis.
Interventions
Not applicable.
Main Outcome Measures
The primary outcome measure for this study was falls. The chief independent variable was the Timed Up & Go test.
Results
The initial model examined the prediction of falls from the Timed Up & Go test, adjusting for all study covariates. The estimated models in the imputed data sets represented a significant improvement above chance (χ2 range [df=17], 531.29–542.39, P<.001), suggesting that 74% of participants were accurately classified as a faller or nonfaller. The secondary model in which the question of whether the effect of Timed Up & Go test was invariant across disease severity demonstrated 75% of participants were accurately classified as a faller or nonfaller. Additional analysis revealed a proposed cut score of 11.5 seconds for discrimination of those who did or did not fall.
Conclusions
The findings suggest that the Timed Up & Go test may be an accurate assessment tool to identify those at risk for falls.
doi:10.1016/j.apmr.2013.02.020
PMCID: PMC4144326  PMID: 23473700
Accidental falls; Gait; Nervous system diseases; Rehabilitation
3.  Deep Brain Stimulation for Tremor Associated with Underlying Ataxia Syndromes: A Case Series and Discussion of Issues 
Background
Deep brain stimulation (DBS) has been utilized to treat various symptoms in patients suffering from movement disorders such as Parkinson's disease, dystonia, and essential tremor. Though ataxia syndromes have not been formally or frequently addressed with DBS, there are patients with ataxia and associated medication refractory tremor or dystonia who may potentially benefit from therapy.
Methods
A retrospective database review was performed, searching for cases of ataxia where tremor and/or dystonia were addressed by utilizing DBS at the University of Florida Center for Movement Disorders and Neurorestoration between 2008 and 2011. Five patients were found who had DBS implantation to address either medication refractory tremor or dystonia. The patient's underlying diagnoses included spinocerebellar ataxia type 2 (SCA2), fragile X associated tremor ataxia syndrome (FXTAS), a case of idiopathic ataxia (ataxia not otherwise specified [NOS]), spinocerebellar ataxia type 17 (SCA17), and a senataxin mutation (SETX).
Results
DBS improved medication refractory tremor in the SCA2 and the ataxia NOS patients. The outcome for the FXTAS patient was poor. DBS improved dystonia in the SCA17 and SETX patients, although dystonia did not improve in the lower extremities of the SCA17 patient. All patients reported a transient gait dysfunction postoperatively, and there were no reports of improvement in ataxia-related symptoms.
Discussion
DBS may be an option to treat tremor, inclusive of dystonic tremor in patients with underlying ataxia; however, gait and other symptoms may possibly be worsened.
doi:10.7916/D8542KQ5
PMCID: PMC4101398  PMID: 25120941
Tremor; SCA2; SCA17; fragile X syndrome; myoclonic dystonia; deep brain stimulation; unilateral
4.  The “Brittle Response” to Parkinson’s Disease Medications: Characterization and Response to Deep Brain Stimulation 
PLoS ONE  2014;9(4):e94856.
Objective
Formulate a definition and describe the clinical characteristics of PD patients with a “brittle response” (BR) to medications versus a “non-brittle response” (NBR), and characterize the use of DBS for this population.
Methods
An UF IRB approved protocol used a retrospective chart review of 400 consecutive PD patients presenting to the UF Center for Movement Disorders and Neurorestoration. Patient records were anonymized and de-identified prior to analysis. SPSS statistics were used to analyze data.
Results
Of 345 included patients, 19 (5.5%) met criteria for BR PD. The BR group was comprised of 58% females, compared to 29% in the NBR group (P = .008). The former had a mean age of 63.4 compared to 68.1 in the latter. BR patients had lower mean weight (63.5 vs. 79.6, P = <.001), longer mean disease duration (12.6 vs. 8.9 years, P = .003), and had been on LD for more years compared to NBR patients (9.8 vs. 5.9, P = .001). UPDRS motor scores were higher (40.4 vs. 30.0, P = .001) in BR patients. No differences were observed regarding the Schwab and England scale, PDQ-39, and BDI-II. Sixty-three percent of the BR group had undergone DBS surgery compared to 18% (P = .001). Dyskinesias were more common, severe, and more often painful (P = <.001) in the BR group. There was an overall positive benefit from DBS.
Conclusion
BR PD occurred more commonly in female patients with a low body weight. Patients with longer disease duration and longer duration of LD therapy were also at risk. The BR group responded well to DBS.
doi:10.1371/journal.pone.0094856
PMCID: PMC3986256  PMID: 24733172
5.  An Eight-Year Clinic Experience with Clozapine Use in a Parkinson’s Disease Clinic Setting 
PLoS ONE  2014;9(3):e91545.
Background
To examine our eight year clinic-based experience in a Parkinson’s disease expert clinical care center using clozapine as a treatment for refractory psychosis in Parkinson's disease (PD).
Methods
The study was a retrospective chart review which covered eight years of clozapine registry use. Statistical T-tests, chi-square, correlations and regression analysis were used to analyze treatment response for potential associations of age, disease duration, and Hoehn & Yahr (H&Y) score, and degree of response to clozapine therapy.
Results
There were 36 participants included in the analysis (32 PD, 4 parkinsonism-plus). The characteristics included 30.6% female, age 45–87 years (mean 68.3±10.15), disease duration of 17–240 months (mean 108.14±51.13) and H&Y score of 2 to 4 (mean 2.51±0.51). The overall retention rate on clozapine was 41% and the most common reasons for discontinuation were frequent blood testing (28%), nursing home (NH) placement (11%) and leucopenia (8%). Responses to clozapine across the cohort were: complete (33%), partial (33%), absent (16%), and unknown (16%). Age (r = −0.36, p<0.01) and H&Y score (r = −0.41, p<0.01) were shown to be related to response to clozapine therapy, but disease duration was not an associated factor (r = 0.21, p>0.05).
Conclusions
This single-center experience highlights the challenges associated with clozapine therapy in PD psychosis. Frequent blood testing remains a significant barrier for clozapine, even in patients with therapeutic benefit. Surprisingly, all patients admitted to a NH discontinued clozapine due to logistical issues of administration and monitoring within that setting. Consideration of the barriers to clozapine therapy will be important to its use and to its continued success in an outpatient setting.
doi:10.1371/journal.pone.0091545
PMCID: PMC3960134  PMID: 24646688
6.  Rescue GPi-DBS for a Stroke-associated Hemiballism in a Patient with STN-DBS 
Tremor and Other Hyperkinetic Movements  2014;4:tre-04-214-4855-1.
Background
Hemiballism/hemichorea commonly occurs as a result of a lesion in the subthalamic region.
Case Report
A 38-year-old male with Parkinson’s disease developed intractable hemiballism in his left extremities due to a small lesion that was located adjacent to the right deep brain stimulation (DBS) lead, 10 months after bilateral subthalamic nucleus (STN)-DBS placement. He underwent a right globus pallidus internus (GPi)-DBS lead implantation. GPi-DBS satisfactorily addressed his hemiballism.
Discussion
This case offered a unique look at basal ganglia physiology in human hemiballism. GPi-DBS is a reasonable therapeutic option for the treatment of medication refractory hemiballism in the setting of Parkinson’s disease.
doi:10.7916/D8XP72WF
PMCID: PMC3918512  PMID: 24587970
Globus pallidus internus; subthalamic nucleus; deep brain stimulation; hemiballism; stroke
7.  Hospitalization in Parkinson disease: A survey of National Parkinson Foundation Centers☆ 
Parkinsonism & related disorders  2011;17(6):440-445.
Objectives
To explore current practices and opinions regarding hospital management of Parkinson disease (PD) patients in specialized PD Centers.
Methods
Fifty-one out of 54 National Parkinson Foundation (NPF) Centers worldwide completed an online survey regarding hospitalization of PD patients.
Results
Many Centers were concerned about the quality of PD-specific care provided to their patients when hospitalized. Primary concerns were adherence to the outpatient medication schedule and poor understanding by hospital staff of medications that worsen PD. Few Centers had a policy with their primary hospital that notified them when their patients were admitted. Rather, notification of hospitalization came often from the patient or a family member. Several Centers (29%) reported not finding out about a hospitalization until a routine clinic visit after discharge. Quick access to outpatient PD care following discharge was a problem in many Centers. Elective surgery, fall/fracture, infection, and mental status changes, were identified as common reasons for hospitalization.
Conclusions
There is a perceived need for PD specialists to be involved during hospitalization of their patients. Improvement in communication between hospitals and PD Centers is necessary so that hospital clinicians can take advantage of PD specialists’ expertise. Education of hospital staff and clinicians regarding management of PD, complications of PD, and medications to avoid in PD is critical. Most importantly, outpatient access to PD specialists needs to be improved, which may prevent unnecessary hospitalizations in these patients.
doi:10.1016/j.parkreldis.2011.03.002
PMCID: PMC3895941  PMID: 21458353
Parkinson’s disease; Hospitalization; Complications; Deep brain stimulation; International care
8.  Driving Errors in Parkinson’s Disease: Moving Closer to Predicting On-Road Outcomes 
Between-group differences and on-road driving errors that predicted pass or fail on-road outcomes are described in a comparison of 101 drivers with PD and 138 healthy control drivers.
Age-related medical conditions such as Parkinson’s disease (PD) compromise driver fitness. Results from studies are unclear on the specific driving errors that underlie passing or failing an on-road assessment. In this study, we determined the between-group differences and quantified the on-road driving errors that predicted pass or fail on-road outcomes in 101 drivers with PD (mean age = 69.38 ± 7.43) and 138 healthy control (HC) drivers (mean age = 71.76 ± 5.08). Participants with PD had minor differences in demographics and driving habits and history but made more and different driving errors than HC participants. Drivers with PD failed the on-road test to a greater extent than HC drivers (41% vs. 9%), χ2(1) = 35.54, HC N = 138, PD N = 99, p < .001. The driving errors predicting on-road pass or fail outcomes (95% confidence interval, Nagelkerke R2 =.771) were made in visual scanning, signaling, vehicle positioning, speeding (mainly underspeeding, t(61) = 7.004, p < .001, and total errors. Although it is difficult to predict on-road outcomes, this study provides a foundation for doing so.
doi:10.5014/ajot.2014.008698
PMCID: PMC3871971  PMID: 24367958
automobile driving; forecasting; Parkinson disease; task performance and analysis; safety
9.  A Novel DYT-5 Mutation with Phenotypic Variability within a Colombian Family 
Tremor and Other Hyperkinetic Movements  2013;3:tre-03-138-4462-2.
Background
DYT-5 dystonia usually presents as a dopa-responsive dystonia (DRD) with early or late parkinsonian manifestations and/or dystonic features. Genetically, these patients have been described as having a wide array of independent mutations in the guanosine triphosphate cyclohydrolase 1 gene (GCH1), and these patients may also have a wide array of clinical manifestations.
Methods
A Colombian family with six affected female members was characterized.
Results
Three members, including the index case, revealed mild parkinsonism, whereas three granddaughters of the index case showed severe generalized dystonia. No men were affected. There was anticipation, and a female predominance was uncovered. Treatment with levodopa was generally effective except in a case with severe skeletal deformities and contractions. Detailed genetic analysis in the index case revealed a new mutation in exon 1 of GCH1 (c.159delG).
Discussion
This study revealed a new mutation of GCH1 that resulted in heterogeneous clinical presentations of DRD within a large family.
PMCID: PMC3822405  PMID: 24255805
DRD, dopamine; Parkinson's disease; dystonia, genetics
10.  DBS Candidates That Fall Short on a Levodopa Challenge Test 
The neurologist  2011;17(5):263-268.
Introduction
Candidacy for deep brain stimulation (DBS) in Parkinson disease (PD) is typically assessed by the preoperative motor response to levodopa along with an interdisciplinary evaluation. However, recent cases treated at our institution have achieved good outcomes with DBS despite a sub-30% improvement in motor scores. The aim of this study was to examine the outcomes of DBS in a subset of patients who failed to reach the 30% motor improvement threshold.
Methods
A review of all DBS patients treated at the University of Florida Movement Disorders Center between 2002 and 2009 was performed utilizing a DBS database. All patients with sub-30% improvement in Unified Parkinson Disease Rating Scale Part III after dopaminergic medication administration were included.
Results
Nine patients were identified; DBS was performed for severe dyskinesia (n = 5), “on/off motor” fluctuations (n = 1) and medication-refractory tremor (n = 3). The target symptoms were improved in all patients. Postoperatively, scores on the Unified Parkinson Disease Rating Scale Part II and III and subscores on Parkinson disease questionnaire-39 improved (P < 0.05).
Conclusions
Although motor response to levodopa remains the primary selection criteria for DBS candidacy in Parkinson disease, patients who do not meet the 30% threshold and have disabling symptoms may still benefit from DBS. Select patients with severe dyskinesia, “on/off” motor fluctuations, and/or medication-refractory tremor may experience significant benefits from DBS and should be considered on a case by case basis through an interdisciplinary team evaluation.
doi:10.1097/NRL.0b013e31822d1069
PMCID: PMC3789884  PMID: 21881468
deep brain stimulation; Parkinson disease; levodopa challenge test; dyskinesia; on-off motor fluctuations; tremor; quality of life
11.  Are Selective Serotonin Reuptake Inhibitors Associated With Greater Apathy in Parkinson’s Disease? 
Apathy is a common neuropsychiatric feature of Parkinson’s disease (PD), but little is known of relationships between apathy and specific medications in PD. Following a retrospective database and chart review of 181 Parkinson’s patients, relationships between Apathy Scale scores and use of psychotropic and antiparkinsonian medications were examined with multiple regression. Controlling for age, sex, education, and depression, the use of selective serotonin reuptake inhibitors (SSRIs), but not other antidepressants, was associated with greater apathy. Use of monoamine oxidase B inhibitors was associated with less apathy. Longitudinal studies are needed to evaluate a potential SSRI-induced apathy syndrome in PD.
doi:10.1176/appi.neuropsych.11090210
PMCID: PMC3759813  PMID: 23037646
12.  Do Stable Patients With a Premorbid Depression History Have a Worse Outcome After Deep Brain Stimulation for Parkinson Disease? 
Neurosurgery  2011;69(2):357-361.
BACKGROUND
Deep brain stimulation (DBS) has been associated with mood sequelae in a subset of patients operated on in either the subthalamic nucleus or the globus pallidus internus for the treatment of Parkinson disease.
OBJECTIVE
To compare mood and motor outcomes in those with and without a presurgical history of depression.
METHODS
Unilateral subthalamic nucleus or unilateral globus pallidus internus DBS patients followed up for a minimum of 6 months were included. All patients underwent a comprehensive outpatient psychiatric evaluation by a board-certified psychiatrist. Psychiatric diagnoses were based on Diagnostic and Statistical Manual, fourth edition, text revision, nomenclature (American Psychiatric Association, 2000). Motor and mood outcomes were compared.
RESULTS
A total of 110 patients were included. There were no significant differences in baseline variables between the 2 groups. Those with a preoperative history of depression had significantly higher Beck Depression Inventory scores than the nondepression group after DBS (8.97 ± 7.55 vs 5.92 ± 5.71; P = .04). Patients with a depression history had less improvement (11.6%) in pre/post-DBS change when Unified Parkinson Disease Rating Scale motor scores were compared (P = .03) after adjustment for stimulation site and baseline demographic and clinical variables. Patients with a higher levodopa equivalent dose had a worse clinical motor outcome.
CONCLUSION
Patients with a preoperative depression history had higher Beck Depression Inventory scores after DBS and significantly less (albeit small) improvement in pre/post-DBS change in Unified Parkinson Disease Rating Scale motor scores than patients without a history of depression.
doi:10.1227/NEU.0b013e3182160456
PMCID: PMC3593636  PMID: 21415789
DBS; Deep brain stimulation; Depression; DSM; Outcomes; Psychiatry; Psychology
13.  Mood and Motor Trajectories in Parkinson's Disease: Multivariate Latent Growth Curve Modeling 
Neuropsychology  2011;26(1):71-80.
Objective
Apathy is a common feature of Parkinson's disease (PD) that can manifest independently of depression, but little is known about its natural progression in medically-managed patients. The present study sought to characterize and compare trajectories of apathy, depression, and motor symptoms in PD over 18 months.
Method
Data from a sample of 186 PD patients (mean disease duration of 8.2 years) followed by the University of Florida Movement Disorders Center were obtained from a clinical research database. Scores on the Unified Parkinson's Disease Rating Scale (motor portion), Apathy Scale, and Beck Depression Inventory at three time-points (baseline, 6 months, 18 months) were analyzed in a structural equation modeling framework.
Results
A multivariate growth model controlling for age, sex, education, and disease duration identified linear worsening of both apathy (slope estimate = 0.73; p <.001) and motor symptoms (slope estimate = 1.51; p <.001), and quadratic changes in depression (slope estimate = 1.18; p = .07). All symptoms were positively correlated. Higher education was associated with lower apathy, depression, and motor severity. Advanced age was associated with greater motor and apathy severity. Female sex and longer disease duration were associated with attenuated motor worsening. Antidepressant use was associated only with depression scores.
Conclusions
These longitudinal results support the differentiation of apathy and depression in PD. Like motor progression, apathy progression may be linked at least partially to dopaminergic neurodegeneration. Empirically-supported treatments for apathy in PD are needed.
doi:10.1037/a0025119
PMCID: PMC3296901  PMID: 22142359
Apathy; depression; antidepressants; structural equation modeling; neurodegeneration
14.  Correction: Quantitative Normative Gait Data in a Large Cohort of Ambulatory Persons with Parkinson’s Disease 
PLoS ONE  2012;7(10):10.1371/annotation/d4b5158e-0dd1-4e14-b03a-1af4d5f06c0e.
doi:10.1371/annotation/d4b5158e-0dd1-4e14-b03a-1af4d5f06c0e
PMCID: PMC3525691
15.  Quantitative Normative Gait Data in a Large Cohort of Ambulatory Persons with Parkinson’s Disease 
PLoS ONE  2012;7(8):e42337.
Background
Gait performance is widely evaluated to assess health status in older adult populations. While several investigators have presented normative values for spatiotemporal gait parameters drawn from older adult populations, the literature has been void of large-scale cohort studies, which are needed in order to provide quantitative, normative gait data in persons with Parkinson’s disease. The aim of this investigation was to provide reference values for clinically important gait characteristics in a large sample of ambulatory persons with Parkinson’s disease to aid both clinicians and researchers in their evaluations and treatments of gait impairment.
Methodology/Principal Findings
Gait performance was collected in 310 individuals with idiopathic Parkinson’s disease as they walked across a pressure sensitive walkway. Fourteen quantitative gait parameters were measured and evaluated with respect to Hoehn and Yahr disease staging and gender. Disease duration and age were controlled for in all analyses. Individuals with the greatest Parkinson’s disability walked significantly slower with shorter steps and stride lengths than the mild and moderately affected groups. Further, the most affected patients spent more time with both feet on the ground, and walked with a wider base of support than the moderately disabled patients. No differences were detected between the mild and moderate disability groups on any of the gait parameters evaluated.
Conclusions/Significance
Reference values for 14 gait parameters in a large cohort of ambulatory patients with Parkinson’s disease are provided and these may be highly useful for assessing and interpreting an individual’s gait dysfunction. It is important for clinicians and researchers to appreciate the lack of change in quantitative parameters as PD patients move from mild to moderate gait impairment.
doi:10.1371/journal.pone.0042337
PMCID: PMC3411737  PMID: 22879945
16.  MEASUREMENT OF PATIENT CENTERED OUTCOMES IN PARKINSON’S DISEASE: WHAT DO PATIENTS REALLY WANT FROM THEIR TREATMENT? 
Background
Parkinson’s disease (PD) impacts several domains of functioning, some of which may be neglected when designing treatment or evaluating outcome using current clinical standards. We therefore argue that taking the patients’ perspectives of their condition may allow for a more in-depth assessment of patient goals and subsequent tailoring of care.
Methods
One hundred and forty-eight patients with idiopathic PD completed a modified version of the Patient Centered Outcomes Questionnaire (PCOQ-PD), to evaluate treatment success and expectations from the patient’s perspective across 10 motor and non-motor functional domains. We also examined patient subgroups based on importance of improvement in various domains.
Results
Patients’ ratings suggested there was substantial variation in functional interference that was generally unrelated to demographic variables. On average, across all domains, patients indicated a 50.32% reduction in symptoms would be successful (range= 40.63% to 58.23%), regardless of treatment experience. Change scores between patients’ usual levels of symptom interference and their treatment success levels suggested a greater degree of change was desired in motor versus non-motor domains (p<.05). Finally, cluster analyses revealed two patient subgroups based on overall importance of improvement (High vs. Low Importance Endorsement). Notably, the two groups differed in self-reported usual symptom levels despite having similar clinical severity.
Conclusions
We empirically examined treatment success from the PD patient’s view as opposed to clinician judgment alone, thereby broadening the set of criteria by which to evaluate outcome. Findings from this exploratory study may guide future treatment emphases and guide patient-provider communication via clarification of patient-defined success.
doi:10.1016/j.parkreldis.2010.09.005
PMCID: PMC3034811  PMID: 20952243
Parkinson’s disease; patient-centered; treatment outcome; success criteria; improvement importance
17.  Effect of Deep Brain Stimulation on Parkinson's Nonmotor Symptoms following Unilateral DBS: A Pilot Study 
Parkinson's Disease  2011;2011:507416.
Parkinson's disease (PD) management has traditionally focused largely on motor symptoms. Deep brain stimulation (DBS) of the subthalamic nucleus (STN) and globus pallidus internus (GPi) are effective treatments for motor symptoms. Nonmotor symptoms (NMSs) may also profoundly affect the quality of life. The purpose of this pilot study was to evaluate NMS changes pre- and post-DBS utilizing two recently developed questionnaires. Methods. NMS-Q (questionnaire) and NMS-S (scale) were administered to PD patients before/after unilateral DBS (STN/GPi targets). Results. Ten PD patients (9 STN implants, 1 GPi implant) were included. The three most frequent NMS symptoms identified utilizing NMS-Q in pre-surgical patients were gastrointestinal (100%), sleep (100%), and urinary (90%). NMS sleep subscore significantly decreased (−1.6 points ± 1.8, P = 0.03). The three most frequent NMS symptoms identified in pre-surgical patients using NMS-S were gastrointestinal (90%), mood (80%), and cardiovascular (80%). The largest mean decrease of NMS scores was seen in miscellaneous symptoms (pain, anosmia, weight change, and sweating) (−7 points ± 8.7), and cardiovascular/falls (−1.9, P = 0.02). Conclusion. Non-motor symptoms improved on two separate questionnaires following unilateral DBS for PD. Future studies are needed to confirm these findings and determine their clinical significance as well as to examine the strengths/weaknesses of each questionnaire/scale.
doi:10.4061/2011/507416
PMCID: PMC3246796  PMID: 22220288
18.  Differential Response of Dystonia and Parkinsonism following Globus Pallidus Internus Deep Brain Stimulation in X-Linked Dystonia-Parkinsonism (Lubag) 
Background
X-linked dystonia-parkinsonism (XDP; DYT3; Lubag) is an adult-onset hereditary progressive dystonia/parkinsonism which is typically minimally responsive to pharmacological treatment.
Case Report
We report a 63- year-old man with a diagnosis of XDP who underwent bilateral globus pallidus internus deep brain stimulator (GPi-DBS) placement. His course initially began with right hand tremor and dystonia at age 57 and progressed to also include bradykinesia and rigidity. The patient tolerated the procedure without significant complications. GPi-DBS improved his right hand dystonia, but did not significantly improve his parkinsonism.
Conclusion
DBS may be a therapeutic option for select cases of XDP, but its specificindications must be carefully discussed, as the available cases have had mixed responses. Whether other targets may be more effective is not known.
doi:10.1159/000319961
PMCID: PMC2969112  PMID: 20714213
X-linked dystonia-parkinsonism; Globus pallidus internus; Cognitive impairment; Medication-resistant parkinsonism
19.  Binge Eating in Parkinson Disease: Prevalence, Correlates, and the Contribution of Deep Brain Stimulation 
Of 96 Parkinson’s disease (PD) patients at the University of Florida Movement Disorders Center, one (1%) met diagnostic criteria for binge eating disorder (BED). Eight (8.3%) exhibited subthreshold BED. Psychometric criteria classified problem gambling in 17.8%, hoarding in 8.3%, buying in 11.5%, hypersexuality in 1.0%, and mania in 1.0% of patients. More overeaters met psychometric criteria for at least one additional impulse control disorder (67% vs. 29%). No more overeaters than non-overeaters were taking a dopamine agonist (44% vs. 41%). More overeaters had a history of subthalamic DBS (44% vs. 14%). History of DBS was the only independent predictor of overeating.
doi:10.1176/appi.neuropsych.23.1.56
PMCID: PMC3075093  PMID: 21304139
Parkinson’s disease; binge eating; impulse control disorders
20.  The Frequency of Nonmotor Symptoms among Advanced Parkinson Patients May Depend on Instrument Used for Assessment 
Parkinson's Disease  2011;2011:290195.
Background. Nonmotor symptoms (NMS) of Parkinson's disease (PD) may be more debilitating than motor symptoms. The purpose of this study was to determine the frequency and corecognition of NMS among our advanced PD cohort (patients considered for deep brain stimulation (DBS)) and caregivers. Methods. NMS-Questionnaire (NMS-Q), a self-administered screening questionnaire, and NMS Assessment-Scale (NMS-S), a clinician-administered scale, were administered to PD patients and caregivers. Results. We enrolled 33 PD patients (23 males, 10 females) and caregivers. The most frequent NMS among patients using NMS-Q were gastrointestinal (87.9%), sleep (84.9%), and urinary (72.7%), while the most frequent symptoms using NMS-S were sleep (90.9%), gastrointestinal (75.8%), and mood (75.8%). Patient/caregiver scoring correlations for NMS-Q and NMS-S were 0.670 (P < 0.0001) and 0.527 (P = 0.0016), respectively. Conclusion The frequency of NMS among advanced PD patients and correlation between patients and caregivers varied with the instrument used. The overall correlation between patient and caregiver was greater with NMS-Q than NMS-S.
doi:10.4061/2011/290195
PMCID: PMC3144664  PMID: 21808724
21.  Management of the hospitalized patient with Parkinson’s disease: Current state of the field and need for guidelines✩ 
Parkinsonism & related disorders  2010;17(3):139-145.
Objective
To review the literature and to identify practice gaps in the management of the hospitalized Parkinson’s disease (PD) patient.
Background
Patients with PD are admitted to hospitals at higher rates, and frequently have longer hospital stays than the general population. Little is known about outpatient interventions that might reduce the need for hospitalization and also reduce hospital-related complications.
Methods
A literature review was performed on PubMed about hospitalization and PD between 1970 and 2010. In addition, in press peer-reviewed papers or published abstracts known to the authors were included. Information was reviewed by a National Parkinson Foundation workgroup and a narrative review article was generated.
Results
Motor disturbances in PD are believed to be a causal factor in the higher rates of admissions and complications. However, other conditions are commonly recorded as the primary reason for hospitalization including motor complications, reduced mobility, lack of compliance, inappropriate use of neuroleptics, falls, fractures, pneumonia, and other important medical problems. There are many relevant issues related to hospitalization in PD. Medications, dosages and specific dosage schedules are critical. Staff training regarding medications and medication management may help to avoid complications, particularly those related to reduced mobility, and aspiration pneumonia. Treatment of infections and a return to early mobility is also critical to management.
Conclusions
Educational programs, recommendations, and guidelines are needed to better train interdisciplinary teams in the management of the PD patient. These initiatives have the potential for both cost savings and improved outcomes from a preventative and a hospital management standpoint.
doi:10.1016/j.parkreldis.2010.11.009
PMCID: PMC3070297  PMID: 21159538
Complications; Surgery; Perioperative; Fall; Fracture; Confusion; Medication
22.  Role of rasagiline in treating Parkinson’s disease: Effect on disease progression 
Rasagiline is a second generation, selective, irreversible monoamine oxidase type B (MAO-B) inhibitor. It has demonstrated efficacy in monotherapy for early Parkinson’s disease (PD) patients in one large randomized, placebo-controlled trial (TVP-1012 in Early Monotherapy for Parkinson’s Disease Outpatients), and has shown ability to reduce off time in more advanced PD patients with motor fluctuations in two large placebo-controlled trials (Parkinson’s Rasagiline: Efficacy and Safety in the Treatment of “Off”, and Lasting Effect in Adjunct Therapy With Rasagiline Given Once Daily). Preclinical data abound to suggest potential for neuroprotection by this compound against a variety of neurotoxic insults in cell cultures and in animals. The lack of amphetamine metabolites provides an advantage over the first generation MAO-B inhibitor selegiline. One large trial has investigated the potential for disease modification in PD patients (Attenuation of Disease progression with Azilect Given Once-daily) and preliminary results maintain some possible advantage to earlier initiation of the 1 mg/day dose. The clinical significance of the difference detected remains a consideration.
PMCID: PMC2695242  PMID: 19753135
rasagiline; Parkinson’s disease; neuroprotection; selegiline
23.  Paroxysmal Kinesigenic Dyskinesia-like Symptoms in a Patient with Tourette Syndrome 
Tremor and Other Hyperkinetic Movements  2011;1:tre-01-31-157-1.
Background
Paroxysmal kinesigenic dyskinesia (PKD) is characterized by episodic dystonia or choreiform movements provoked by sudden voluntary movement. PKD is not commonly reported in Tourette syndrome (TS). We describe a unique case of TS with PKD-like episodic dyskinesia that responded to carbamazepine.
Case Report
A 36-year-old male with long-standing TS developed paroxysmal “cramping”. Attacks were provoked by quick, sudden arm movements, which induced dystonic cramping, or by reaching overhead, which caused painful contraction of truncal muscles. The spells typically lasted 5–20 seconds and occurred multiple times daily. The patient’s mother suffered from intermittent dystonic toe curling. In view of the similarity of symptoms to PKD, carbamazepine was prescribed at 400 mg daily. The symptoms resolved completely. Inadvertent discontinuation led to relapse, and resumption led to recapture of benefit.
Discussion
This case demonstrates the possibility that PKD-like symptoms may co-occur with TS and may be responsive to carbamazepine.
PMCID: PMC3570039  PMID: 23440654
Tourette syndrome; paroxysmal kinesigenic dyskinesia

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