Possible Functional Moving Toes Syndrome

Background: Moving toes syndrome has been classically described as an organic movement disorder, on occasion related to peripheral nerve injuries. The association between nerve trauma and movement disorders has become a controversial topic, and the functional etiology of moving toes syndrome has recently been proposed. Case Report: We describe two cases of moving toes syndrome with clinical features typically suggestive of a functional movement disorder. Discussion: The presence of entrainability and distractibility in the described patients is an indication of attentional influences on their involuntary movements. However, it is possible that if there is a subcortical origin, the toe movements could be influenced by voluntary commands

A Woman With a Novel Mutation of THAP1 With a Prominent Response to Deep Brain Stimulation of the Globus Pallidus Internus

A 27-year-old woman presented with generalized dystonia that began at age 15 years as dystonic posturing of the right hand when writing. She was diagnosed with cervical dystonia and botulinum toxin injections were tried, providing minimal pain relief and no improvement of the dystonia. The cervical dystonia was partially responsive to sensory tricks. She was most bothered by her cervical dystonia, and disability was 6 on Part II of the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS). On examination, she had increased rate of eye blinking and occasional spasms involving the lower face, mouth, and jaw, and mild dysarthria. Severe right torticollis and an intermittent head tremor were present. Dystonic posturing of the right upper extremity and increased handgrip were observed while writing. Mild left foot inversion was present while walking. The Fahn-Marsden Scale score was 16, and TWSTRS Part I score was 20. A trial of carbidopa/levodopa did not provide benefit. Deep brain stimulation (DBS) surgery targeting the globus pallidus internus (GPi) was performed, resulting in moderate improvement 1 month after the procedure, prior to initial programming (TWSTRS Part I = 18, Fahn-Marsden = 8.5). She experienced further benefit 2 months after initial programming (TWSTRS Part I = 13, Fahn-Marsden = 3). Whole-exome sequencing revealed a frameshift mutation, confirmed as a novel 2–base pair deletion mutation in exon 3 of the THAP1 gene (heterozygous exon 3 c.377_378delCT, p.Pro126Args*2) via full sequencing analysis of DYT6

Serological markers and risk factors for hepatitis B and C viruses in patients infected with human immunodeficiency virus

Both hepatitis B and hepatitis C viruses (HBV and HCV) infection are common in HIV-infected individuals as a result of shared risk factors for acquisition. A serological study for HBV and HCV was performed in 251 HIV-positive individuals from Medellín, Colombia. A qualitative RT-PCR for HCV was done in 90 patients with CD4+ T-cell count < 150 per mm³. Serological markers for HBV infection were present in 97 (38.6%) patients. Thirty six of them (37.1%) had isolated anti-HBc. A multivariate analysis indicated that the following risk factors were significantly associated with the presence of these markers: age (OR = 1.05, 95% CI: 1.01-1.08), pediculosis pubis (OR = 1.83, 95% CI: 1.01-3.33), men who have sex with men and women (OR = 3.23, 95% CI: 1.46-7.13) and men who have sex only with men (OR = 3.73, 95% CI: 1.58-8.78). The same analysis restricted to women showed syphilis as the only significant risk factor. Thus, HBV infection was considerably associated with high risk sexual behavior. HCV was present in only two (0.8%) of HIV patients. Both of them were positive by RT-PCR and anti-HCV. This low frequency of HIV/HCV coinfection was probably due to the uncommon intravenous drug abuse in this population. The frequent finding of isolated anti-HBc warrants molecular approaches to rule out the presence of cryptic HBV infection.La infección por los virus de la hepatitis B y hepatitis C (VHB y VHC) es frecuente en individuos infectados por el VIH como resultado de compartir factores de riesgo para su contagio. Se realizó un estudio serológico para el VHB y VHC en 251 individuos VIH positivos de la ciudad de Medellín, Colombia. En 90 pacientes con un recuento de linfocitos T < 150 células por mm³ se hizo una PCR-RT cualitativa para el VHC. Se encontraron marcadores serológicos para la infección por el VHB en 97 (38.6%) pacientes. Treinta y seis de 97 (37.1%) tuvieron un anti-HBc aislado. El análisis multivariado indicó que los factores de riesgo significativos asociados a la presencia de estos marcadores fueron: edad (OR = 1.05, 95% IC: 1.01-1.08), pediculosis púbica (OR = 1.83, 95% IC: 1.01-3.33), hombres que tienen sexo con hombres y mujeres (OR = 3.23, 95% IC: 1.46-7.13) y hombres que tienen sexo solo con hombres (OR = 3.73, 95% IC: 1.58-8.78). El mismo análisis restringido a mujeres mostró que la sífilis fue el único factor de riesgo significativo. Por lo tanto, la infección por el VHB fue considerablemente asociada a conductas sexuales de alto riesgo. El VHC se presentó en solo 2 (0.8%) de los pacientes VIH. Ambos pacientes fueron positivos por la PCR-RT y los anti-VHC. La baja frecuencia de la coinfección VIH/VHC fue probablemente debido al bajo uso de drogas intravenosas en esta población. El hallazgo frecuente de anti-HBc como marcador aislado asegura estudios moleculares para descartar la presencia de infección críptica por el VHB

Tractography patterns of subthalamic nucleus deep brain stimulation

Deep brain stimulation therapy is an effective symptomatic treatment for Parkinson’s disease, yet the precise mechanisms responsible for its therapeutic effects remain unclear. Although the targets of deep brain stimulation are grey matter structures, axonal modulation is known to play an important role in deep brain stimulation’s therapeutic mechanism. Several white matter structures in proximity to the subthalamic nucleus have been implicated in the clinical benefits of deep brain stimulation for Parkinson’s disease. We assessed the connectivity patterns that characterize clinically beneficial electrodes in Parkinson’s disease patients, after deep brain stimulation of the subthalamic nucleus. We evaluated 22 patients with Parkinson’s disease (11 females, age 57 ± 9.1 years, disease duration 13.3 ± 6.3 years) who received bilateral deep brain stimulation of the subthalamic nucleus at the National Institutes of Health. During an initial electrode screening session, one month after deep brain stimulation implantation, the clinical benefits of each contact were determined. The electrode was localized by coregistering preoperative magnetic resonance imaging and postoperative computer tomography images and the volume of tissue activated was estimated from stimulation voltage and impedance. Brain connectivity for the volume of tissue activated of deep brain stimulation contacts was assessed using probabilistic tractography with diffusion-tensor data. Areas most frequently connected to clinically effective contacts included the thalamus, substantia nigra, brainstem and superior frontal gyrus. A series of discriminant analyses demonstrated that the strength of connectivity to the superior frontal gyrus and the thalamus were positively associated with clinical effectiveness. The connectivity patterns observed in our study suggest that the modulation of white matter tracts directed to the superior frontal gyrus and the thalamus is associated with favourable clinical outcomes and may contribute to the therapeutic effects of deep brain stimulation. Our method can be further developed to reliably identify effective deep brain stimulation contacts and aid in the programming process

Normative vs. patient-specific brain connectivity in deep brain stimulation

Brain connectivity profiles seeding from deep brain stimulation (DBS) electrodes have emerged as informative tools to estimate outcome variability across DBS patients. Given the limitations of acquiring and processing patient-specific diffusion-weighted imaging data, a number of studies have employed normative atlases of the human connectome. To date, it remains unclear whether patient-specific connectivity information would strengthen the accuracy of such analyses. Here, we compared similarities and differences between patient-specific, disease-matched and normative structural connectivity data and estimation of clinical improvement that they may generate. Data from 33 patients suffering from Parkinson's Disease who underwent surgery at three different centers were retrospectively collected. Stimulation-dependent connectivity profiles seeding from active contacts were estimated using three modalities, namely either patient-specific diffusion-MRI data, disease-matched or normative group connectome data (acquired in healthy young subjects). Based on these profiles, models of optimal connectivity were constructed and used to estimate the clinical improvement in out of sample data. All three modalities resulted in highly similar optimal connectivity profiles that could largely reproduce findings from prior research based on a novel multi-center cohort. In a data-driven approach that estimated optimal whole-brain connectivity profiles, out-of-sample predictions of clinical improvements were calculated. Using either patient-specific connectivity (R = 0.43 at p = 0.001), an age- and disease-matched group connectome (R = 0.25, p = 0.048) and a normative connectome based on healthy/young subjects (R = 0.31 at p = 0.028), significant predictions could be made and underlying optimal connectivity profiles were highly similar. Our results of patient-specific connectivity and normative connectomes lead to similar main conclusions about which brain areas are associated with clinical improvement. Still, although results were not significantly different, they hint at the fact that patient-specific connectivity may bear the potential of estimating slightly more variance when compared to group connectomes. Furthermore, use of normative connectomes involves datasets with high signal-to-noise acquired on specialized MRI hardware, while clinical datasets as the ones used here may not exactly match their quality. Our findings support the role of DBS electrode connectivity profiles as a promising method to investigate DBS effects and to potentially guide DBS programming

Effects of L-DOPA monotherapy on psychomotor speed and [11C] raclopride binding in high-risk older adults with depression

Background: A high-risk subgroup of older patients with depression has slowed processing and gait speeds. This study examined whether carbidopa/levodopa (L-DOPA) monotherapy increased dopamine availability, increased processing/gait speed, and relieved depressive symptoms. Methods: Adult outpatients with depression >59 years old underwent baseline [11C]raclopride positron emission tomography followed by open L-DOPA for 3 weeks (1 week each of 150 mg, 300 mg, and 450 mg). Generalized estimating equations tested the pre- and post-L-DOPA differences in processing and gait speed measures, depressive symptoms, and reported side effects. The decrease in binding potential between the pre- and posttreatment scans indexed enhanced synaptic dopamine availability induced by L-DOPA treatment. Results: Thirty-six subjects participated (age, 75.3 ± 7.5 years; 44.4% male). Significant, dose-dependent increases in processing and gait speed were observed with L-DOPA (450-mg dose: processing speed factor score effect size = 0.41, p = .001; dual-task gait speed effect size = 0.43, p = .002). [11C]raclopride decrease in binding potential was significantly different from 0 in sensorimotor (t24 = −4.85, p < .001) and associative striatum (t24 = −2.52, p = .019) but not in limbic striatum (t24 = 0.265, p = .793). Depressive symptoms decreased significantly on the Hamilton Rating Scale for Depression (effect size = −0.37, p = .002). Dropout rate was 8.3%, and nausea was the most frequently reported side effect. Conclusions: By enhancing availability of dopamine, L-DOPA improved processing and gait speed in older adults with depression and significantly decreased [11C]raclopride binding in selected striatal subregions

Neuroanatomical predictors of L-DOPA response in older adults with psychomotor slowing and depression: A pilot study

Background: Declining function in dopamine circuits is implicated in normal aging and late-life depression (LLD). Dopamine augmentation recently has shown therapeutic promise, but predictors of response are unknown. Methods: Depressed elders with slowed gait underwent baseline magnetic resonance imaging (MRI) and [11C]raclopride positron emission tomography (PET). Subjects then received open treatment with carbidopa/levodopa (L-DOPA) for three weeks. Linear regressions examined relationships between baseline MRI measures, [11C]raclopride binding, and behavioral outcomes. Results: Among N = 16 participants aged 72.5 ± 6.8 years, higher left superior temporal gyrus volume was associated with higher processing speed at baseline, while cortical thinning in a processing speed network was associated with greater improvement following L-DOPA. Greater volume and cortical thickness in brain regions associated with mobility were associated with higher baseline gait speed. Higher baseline white matter hyperintensity volume predicted less post-L-DOPA improvement on dual task gait speed and IDS-SR scores. Higher [11C]raclopride binding in the associative striatum was associated with cortical thickness in some, but not all, processing speed brain regions, while higher binding in sensorimotor striatum was significantly associated with left caudate volume. Limitations: Limiting the conclusions drawn from this pilot study are the small sample size and open administration of L-DOPA. Conclusions: Greater baseline brain volumes and cortical thickness in regions supporting cognition and gait were associated with higher behavioral performance, while lower structural integrity was associated with increased responsivity to L-DOPA. If substantiated in larger studies, these findings could facilitate the targeting of dopaminergic treatments to those LLD patients most likely to respond