A Threat to Military Combat Power: Dietary Supplements.

BACKGROUND: The use of dietary supplements by young warfighters is pervasive and comes with a readiness cost, especially in the deployed setting. Predatory targeting and marketing by various unscrupulous companies put this population at risk for a higher than baseline risk for adverse events. METHODS: We report on 6 serious adverse events experienced by warfighters while deployed in Kuwait and Afghanistan. Presented is a discussion of current practice gaps and solutions, as well as details regarding how polypharmacy contributes to the seriousness of the threat posed by problematic supplements. RESULTS: The morbidity associated with the 6 cases of dietary supplement adverse events compromised mission readiness and was costly in terms of health and health care expenditures. CONCLUSION: The military dietary supplement issue needs exposure, review, and action at the highest levels of government.

Nitrous Oxide-induced Subacute Combined Degeneration Presenting with Dystonia and Pseudoathetosis: A Case Report.

PURPOSE: Nitrous oxide (N2O) is neurotoxic by interfering with vitamin B12 bioavailability. The clinical picture is indistinguishable to that of subacute combined degeneration (SCD). A movement disorder might occur though it is not a characteristic feature. We report a patient with N2O-induced SCD, exhibiting a combination of different involuntary movements. CASE REPORT: A 20-year-old woman presented with one month of progressive unsteady gait, involuntary movements and tingling sensation in a stocking-glove distribution. She had used N2O and ketamine intermittently for recreational purposes for about two years. Neurological examination demonstrated normal cranial nerve functions except for dystonia in the facial muscle and tongue. Her muscle strength was full, but there were bilateral hyperreflexia and extensor plantar response. She exhibited dystonia in four limbs with athetoid movement in fingers and toes, worsened by eye closure. Vibration and proprioception were impaired. Laboratory tests revealed anemia (Hb: 9.9 g/dl) with normal mean corpuscular volume (85.7 fL) and decreased iron level (22 µg/dl) while other results were normal including serum vitamin B12 level (626 pg/ml). Magnetic resonance imaging showed a hyperintense lesion from C1 to C6 level in the posterior column. She was diagnosed as having SCD caused by N2O abuse, presenting with generalized dystonia and pseudoathetosis. The involuntary movements disappeared with vitamin B12 supplementation. CONCLUSION: Movement disorders may be the rare manifestations of SCD associated with N2O abuse. Early recognition of the etiology is vital because it is treatable with vitamin B12 and methionine.

Mice expressing the ADNFLE valine 287 leucine mutation of the Β2 nicotinic acetylcholine receptor subunit display increased sensitivity to acute nicotine administration and altered presynaptic nicotinic receptor function.

Several mutations in α4 or ß2 nicotinic receptor subunits are linked to autosomal dominant nocturnal frontal lobe epilepsy (ADNFLE). One such missense mutation in the gene encoding the ß2 neuronal nicotinic acetylcholine receptor (nAChR) subunit (CHRNB2) is a valine-to-leucine substitution in the second transmembrane domain at position 287 (ß2VL). Previous studies indicated that the ß2VL mutation in mice alters circadian rhythm consistent with sleep alterations observed in ADNFLE patients (Xu et al., 2011). The current study investigates changes in nicotinic receptor function and expression that may explain the behavioral phenotype of ß2VL mice. No differences in ß2 mRNA expression were found between wild-type (WT) and heterozygous (HT) or homozygous mutant (MT) mice. However, antibody and ligand binding indicated that the mutation resulted in a reduction in receptor protein. Functional consequences of the ß2VL mutation were assessed biochemically using crude synaptosomes. A gene-dose dependent increase in sensitivity to activation by acetylcholine and decrease in maximal nAChR-mediated [(3)H]-dopamine release and (86)Rb efflux were observed. Maximal nAChR-mediated [(3)H]-GABA release in the cortex was also decreased in the MT, but maximal [(3)H]-GABA release was retained in the hippocampus. Behaviorally both HT and MT mice demonstrated increased sensitivity to nicotine-induced hypolocomotion and hypothermia. Furthermore, WT mice display only a tonic-clonic seizure (EEG recordable) 3 min after injection of a high dose of nicotine, while MT mice also display a dystonic arousal complex (non-EEG recordable) event 30s after nicotine injection. Data indicate decreases in maximal response for certain measures are larger than expected given the decrease in receptor expression.

[Effect of acupuncture treatment for a patient with severe axial dystonia appearing during treatment for schizophrenia].

We performed acupuncture treatment on first consultation for a female 28-year-old patient with severe axial dystonia, causing involuntary movement and abnormal posture of the neck and body, which had developed during treatment for schizophrenia. Involuntary movement involving elevation of the right shoulder began to occur in October X-1. Drugs were prescribed by her doctor, but her involuntary movement worsened and spread to the whole body. Thereafter, she began receiving acupuncture treatment at the out patient clinic for dystonia at the Kansai Medical College Hospital in July X. Involuntary movements of her neck involved repeated left lateral bending or a rigidly straight posture while sitting and standing. Her neck also showed a left lateral bend and right rotation. Her body showed a left lateral bend and right shoulder elevation. The neck problems in this case were induced by a hypertonicity of the left sternocleidomastoid (SCM), which caused the left lateral bending and right rotation of the neck. Problems in her body involved left lateral bending due to hypotonicity of the left abdominal muscle and hypotonicity of the left back muscles, which were unable to control the left lateral bending of the body. The right shoulder elevation was caused by a hypertonicity of the right trapezius and this was another of her problems. Acupuncture treatments were given using a penetrating needle method. The treatment points were left LI4 to decrease the hypertonicity of the left SCM, left ST41 to increase the hypotonicity of the left abdominal muscles, right BL60 to increase the hypotonicity of the right back muscles and right TE5 to decrease the hypertonicity of the right trapezius. At the initial stage of acupuncture treatment, the patient was not able to attend the hospital regularly enough to obtain sufficient improvement by acupuncture. In December X+1, she started to receive acupuncture treatment weekly, and the posture of the neck and body improved. In May X+3, her neck and body postures remained erect while sitting and she did not show involuntary movement. For problems of dystonia, we perform acupuncture treatment, using meridian and acupressure points selected based on the oriental medicine system, and we achieved improvement of symptoms in this case. The patient also achieved improved stability with regard to the symptoms of schizophrenia. It is suggested that acupuncture treatment has had a positive effect on tardive dystonia including axial dystonia.

Movement disorders possibly induced by traditional chinese herbs.

The authors describe the neurological presentation and CT/MRI findings in 4 patients exposed to overdoses of decoctions of two different Chinese herbs. Case 1, a 15-year-old boy, ingested herba serissae along with the safe-dosage Salvia miltiorrhiza for treating a left renal stone. Sophora subprostrata root (SSR) was primarily used for treating three other diseases: viral B hepatitis in case 2, a 9-year-old boy; infection of the throat and a low fever in case 3, a 11-year-old girl, and a minor facial infection in case 4, a 12-year-old boy. All patients showed complex neurological manifestations primarily including convulsions, mental changes and dystonia syndromes. Their CT and/or MRI revealed abnormal density lesions in the striatum and globus pallidus bilaterally. They excluded the possibility of Wilson's disease in each of the 4 patients and suggested that overdosage of SSR and herba serissae could cause intoxications of the central nervous system, particularly damage to the basal ganglia. Chemically, coumarin (case 1) and matrine and oxymatrine (cases 2-4) in the two medicinal herbs are suggested to be possibly responsible for the morbidity.

[Neurological syndromes associated with the ingestion of plants and fungi with a toxic component (II). Hallucinogenic fungi and plants, mycotoxins and medicinal herbs]. / Sindromes neurológicos asociados con el consumo de plantas y hongos con componente tóxico (II). Hongos y plantas alucinógenos, micotoxinas y hierbas medicinales.

INTRODUCTION: A wide range of fungi and medicinal herbs, rich in hallucinogenic substances and widely used for mystic and medicinal purposes, can give rise to neurotoxic symptoms. DEVELOPMENT: We review the toxic syndromes that can arise from the ingestion of hallucinogenic fungi, cacti and plants, together with descriptions of cases of acute poisoning resulting from the use of medicinal herbs and from foodstuffs that are contaminated by mycotoxins. A series of different psychedelic fungi belonging to the Psilocybe, Panaeolus and Stropharia genera contain hallucinogenic alkaloids such as psilocybin. Some of the most notable plants displaying hallucinogenic and sedative properties are Papaver somniferum, Erytroxylum sp. and Cannabis sativa. Infusions of ayahuasca are obtained from the lianas and roots of different plants with psychoactive properties, such as Banisteriopsis caapi and Psychotria viridis, which contain alkaloids derived from tryptamine and from the beta carboline harmala. Peyote, a cactus rich in mescaline, and Claviceps purpurea (a fungus rich in LSD) are strong hallucinogens. We also examine ergotism and mycotoxicosis from Arthrinium sp. Poisoning from mycotoxin containing moulds on sugar cane can give rise to encephalopathy and late dystonia. Some of the more noteworthy medicinal plants for which neurological toxicity has been reported are Hypericum perforatum, kava kava (Piper methysticum), Aconitum sp. and Callilepis laureola. CONCLUSIONS: Because of the increasingly more widespread consumption of herbs and fungi and their potentially neurotoxic effects, in clinical practice there is a need to be aware of the neurological syndromes deriving from their use.

Dystonia as acute adverse reaction to cough suppressant in a 3-year-old girl.

Cough suppressant preparations containing mixtures of dextromethorphan or codeine with antihistamines, decongestants (sympathomimetic), expectorants and antipyretics with either sedative or anticholinergic activity have been associated with dystonic reactions in children. We report on a 3-year-old girl who presented with episodic stiffness and abnormal posturing with rigidity after arbitrary maternal administration of a mixture of methylcodeine and extract from Hedera plant.

Complicaciones motoras precoces en parkisonianos de novo tratados con L-Dopa más inhibidor periférico de la decarboxilasa / Early motor complications in parkisonians of novo treated with L-Dopa plus descarboxylase inhibitor

En una serie de 27 pacientes con enfermedad de Parkinson esencial de novo, en grado 2,7 de Hoehn y Yahr como promedio, con un rango de 1 a 4, tratados con levodopa más benserazida durante 16 semanas, se observaron efectos motores adversos leves a moderados en 12 casos (44,4 por ciento): 8 pacientes presentaron diskinesias, 7 distonías y un deterioro de final de dosis. La dosis máxima de levodopa ID utilizada fue de 750 mg los que alcanzaron a la tercera semana, previo ascenso paulatino desde 125 mg inicial. Posteriormente, se buscó la mínima dosis efectiva la cual correspondió a una cifra de 475 mg como media con un rango de 250 a 750 mg correspondiente a 49,7 por ciento de reducción, lográndose un efecto antiparkinsoniano similar al obtenido con la dosis máxima. Se discuten los posibles factores que hayan influido en el porcentaje alto de efectos motores adversos encontrados en esta serie

Thalamotomy for the alleviation of levodopa-induced dyskinesia: experimental studies in the 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine-treated parkinsonian monkey.

This work set out to test the hypothesis that thalamotomy in the area of the thalamus which receives the input from the medial segment of the globus pallidus would decrease or prevent levodopa-induced dyskinesia. Peak dose dyskinesia is a major problem in the treatment of parkinsonian patients with levodopa therapy but this remains the best pharmacological agent for treating the condition. The hypothesis was derived from previous work which has suggested that reduced pallidal inhibition of the thalamus results in dyskinesia [Crossman (1990) Movement Dis. 5, 100-108]. A neuroanatomical tracing study was carried out prior to the thalamotomy work, using the anterograde tracer wheatgerm-agglutinin conjugated to horseradish peroxidase. This delineated the anterior part of the ventrolateral thalamus in the primate in terms of its afferent inputs. Wheatgerm agglutinin-horseradish peroxidase was injected into the medial segment of the globus pallidus bilaterally in three Macaca fascicularis and traced to terminals in the ventral thalamus and other brain areas. The appropriate thalamic area involved was plotted on atlas sections in preparation for stereotactic thalamotomy. Previous studies of neuronal input to the ventral thalamus are confusing due to the different nomenclatures used by different workers. Early workers used cytoarchitectonic boundaries which do not correspond with function. There are also differences in nomenclature between man, monkey and other animals. The current study maps the pallidal terminal territory within the thalamus in terms of stereotactic co-ordinates related to a published macaque atlas [Shantha et al. (1968) A Stereotaxic Atlas of the Java Monkey Brain. S. Karger, Basel] and can thus be used by other workers in the field. A well-established primate model of Parkinsonism was used for the thalamotomy study. Eight monkeys (Macaca fascicularis) were rendered parkinsonian with 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine. Regular dosing with levodopa or apomorphine reliably resulted in peak-dose dyskinesia which was scored in terms of its choreic and dystonic components. A radiofrequency electrode was used to create the ablative lesions. Chorea was always reduced and frequently abolished by a thalamotomy located in the pallidal terminal territory. This result was obtained after 10 thalamotomies in a total of six animals. Four animals received bilateral lesions, with an interval between operations and two animals underwent unilateral surgery.(ABSTRACT TRUNCATED AT 400 WORDS)

Open label evaluation of cannabidiol in dystonic movement disorders.

Cannabidiol (CBD), a nonpsychoactive cannabinoid of Cannabis, was given to 5 patients with dystonic movement disorders in a preliminary open pilot study. Oral doses of CBD rising from 100 to 600 mg/day over a 6 week period were administered along with standard medication. Dose-related improvement in dystonia was observed in all patients and ranged from 20 to 50%. Side-effects of CBD were mild and included hypotension, dry mouth, psychomotor slowing, lightheadedness, and sedation. In 2 patients with coexisting Parkinsonian features, CBD at doses over 300 mg/day exacerbated the hypokinesia and resting tremor. CBD appears to have antidystonic and Parkinsonism-aggravating effects in humans.