Haloperidol discontinuation in a herpes simplex encephalitis patient with atypical abnormal movements using the herbal medicine Ukgansan-gami: A case report.

Recently, the herbal medicine Ukgansan (Yigansan in China, Yokukansan in Japan) was reported to be effective in the management of movement disorders. We report the case of a 62-year-old woman with herpes simplex encephalitis exhibiting atypical abnormal movements in the chronic stage. While controlling the abnormal movements with haloperidol, an antipsychotic agent, we prescribed Ukgansan-gami, an extract of a variant of Ukgansan, at a dose of 12 g/day to prevent the recurrence of abnormal movements and allow for the discontinuation of haloperidol. The patient was successfully treated with Ukgansan-gami, with no further recurrence of symptoms, making the use of haloperidol no longer necessary. The potential mechanism of action of Ukgansan involves the inhibition of nervous system hyperexcitability through the suppression of glutamate sodium channels, as well as attenuation of hypermotility through serotonin regulation. The present case suggests that herbal medicine therapy was likely to be an alternative to antipsychotics.

The Medicinal Chemistry of Natural and Semisynthetic Compounds against Parkinson's and Huntington's Diseases.

Among the diseases affecting the central nervous system (CNS), neurodegenerations attract the interest of both the clinician and the medicinal chemist. The increasing average age of population, the growing number of patients, and the lack of long-term effective remedies push ahead the quest for novel tools against this class of pathologies. We present a review on the state of the art of the molecules (or combination of molecules) of natural origin that are currently under study against two well-defined pathologies: Parkinson's disease (PD) and Huntington's disease (HD). Nowadays, very few tools are available for preventing or counteracting the progression of such diseases. Two major parameters were considered for the preparation of this review: particular attention was reserved to these research works presenting well-defined molecular mechanisms for the studied compounds, and where available, papers reporting in vivo data were preferred. A literature search for peer-reviewed articles using PubMed, Scopus, and Reaxys databases was performed, exploiting different keywords and logical operators: 91 papers were considered (preferentially published after 2015). The review presents a brief overview on the etiology of the studied neurodegenerations and the current treatments, followed by a detailed discussion of the natural and semisynthetic compounds dividing them in different paragraphs considering their several mechanisms of action.

Status Dystonicus in a Child with Familial Idiopathic Hypoparathyroidism.

Hypoparathyroidism leading to status dystonicus is rarely reported in literature. The authors present an 8-y-old girl with idiopathic familial hypoparathyroidism who presented with status dystonicus. She was managed successfully with midazolam infusion, calcium and vitamin D supplementation, and oral anti-dystonia drugs.

Botulinum toxin for upper oesophageal sphincter dysfunction in neurological swallowing disorders.

BACKGROUND: Adequate upper oesophageal sphincter (UOS) opening is critical to safe and efficient swallowing due to the close proximity of the UOS to the airway entrance. Many people with neurological conditions, progressive and non-progressive, present with UOS dysfunction. The consequences for the person include difficulty swallowing food with subsequent choking and aspiration (passage of material into the trachea beyond the level of the true vocal cords). Clinical complications include aspiration pneumonia, weight loss, dehydration and malnutrition. Tube feeding is often indicated but is associated with increased mortality. Quality of life is also frequently impacted. A range of interventions exist that aim to improve UOS function and swallowing. These include compensatory strategies, rehabilitation techniques, pharmacological interventions and surgery. Over the last two decades, botulinum toxin has been gaining popularity as an intervention for UOS dysfunction, with some evidence to suggest that it is successful in improving swallow function. Despite a number of studies investigating its efficacy, there is a lack of consensus regarding whether this intervention is effective in improving swallowing for individuals with UOS dysfunction associated with neurological disease. OBJECTIVES: To establish the efficacy and safety of botulinum toxin use aimed at improving UOS dysfunction in people with swallowing difficulties (dysphagia) associated with non-progressive and progressive neurological disease. SEARCH METHODS: We searched the following electronic databases for published trials: the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (1950 to 2013); EMBASE (1980 to 2013); AMED (Allied and Complementary Medicine) (1941 to 2013); CINAHL (Cumulative Index to Nursing and Allied Health Literature) (1937 to 2013). We also searched major clinical trials registers: CCT (http://www.controlled-trials.com); Clinical Trials (http://www.clinicaltrials.gov); Chinese Clinical Trial Register (www.chictr.org); ACTR (http://www.actr.org.au/. We examined the reference lists of all potentially relevant studies to identify further relevant trials. We handsearched published abstracts of conference proceedings from both the Dysphagia Research Society and the European Society of Swallowing Disorders. Digestive Disease Week (published in Gastroenterology) was also handsearched. Additionally, we searched ProQuest Dissertations & Theses for dissertation abstracts. SELECTION CRITERIA: Only randomised controlled trials were sought. DATA COLLECTION AND ANALYSIS: Independent searches were completed by JR, AM, MC and MW. Two review authors (JR and MW) independently inspected titles, abstracts and key words identified from the literature search. MAIN RESULTS: No randomised controlled studies were retrieved. Twenty-nine studies were excluded, mainly on the basis of trial design. AUTHORS' CONCLUSIONS: It was not possible to reach a conclusion on the efficacy and safety of botulinum toxin as an intervention for people with UOS dysfunction and neurological disease. There is insufficient evidence to inform clinical practice. Directions for future research are provided.

A new multiple sclerosis spasticity treatment option: effect in everyday clinical practice and cost-effectiveness in Germany.

Sativex® (GW Pharmaceuticals PLC, Porton Down, UK; Laboratorios Almirall, SA, Barcelona, Spain), a cannabinoid oromucosal spray containing a 1:1 ratio of 9-δ-tetrahydrocannabinol and cannabidiol, has been licensed in Germany since July 2011 as add-on therapy for moderate-to-severe multiple sclerosis (MS) treatment-resistant spasticity symptoms. The 'MOVE 2' study evaluated clinical outcomes, treatment satisfaction, quality of life (QoL) and provision of care in MS patients with spasticity receiving Sativex in everyday clinical practice. Data from 300 patients were collected from 42 specialized MS centers across Germany and were available for this analysis. Assessments, including the MS spasticity 0-10 numerical rating scale, modified Ashworth scale, patients' and physicians' clinical impressions, and QoL scales were rated at baseline and at 1 and 3 months after starting treatment with Sativex. Sativex provided relief of MS-related spasticity in the majority of patients who were previously resistant to treatment. In addition, clear improvements were noted in MS spasticity-associated symptoms (e.g., sleep quality, bladder function and mobility), activities of daily living and QoL. Sativex was generally well tolerated. The majority of patients (84%) reported no adverse events, and there was only a limited risk of serious adverse reactions. Furthermore, based on data from Sativex clinical trials, a Markov model-based analysis has shown that Sativex is a cost-effective treatment option for patients with MS spasticity in Germany.

Endocannabinoid system modulator use in everyday clinical practice in the UK and Spain.

Spasticity is a disabling complication of multiple sclerosis. Some commonly used oral medications include baclofen, tizanidine, anticonvulsants and benzodiazepines, but their benefits are modest. Sativex® (GW Pharmaceuticals PLC, Porton Down, UK; Laboratorios Almirall, SA, Barcelona, Spain) is a unique cannabinoid-based medicine with two main active ingredients; 9-δ-tetrahydrocannabinol, which acts mainly on cannabinoid 1 receptors in the CNS and plays a key role in the modulation of spasticity and spasms, and cannabidiol, which has different properties, including minimization of the psychoactivity associated with 9-δ-tetrahydrocannabinol. Sativex is indicated for symptomatic improvement in adult patients with moderate-to-severe multiple sclerosis-related spasticity who have not responded adequately to other first- or second-line antispasticity medications, and who demonstrate clinically significant improvement in spasticity-related symptoms during an initial trial of therapy. Over the past couple of years, Sativex has been approved for use in a number of European countries and ongoing postmarketing studies are evaluating the possible risks associated with Sativex treatment by systematically collecting all suspected adverse reactions that occur in patients from the start of treatment. Interim data from the UK as well as Spanish Sativex safety registries confirm that clinical benefit is maintained over the longer term despite the expected trend for deterioration owing to disease progression. Even after more than 2 years of use, no new safety/tolerability signals have emerged with Sativex, including no evidence of driving impairment and no relevant incidence of falls or other adverse events of concern, such as psychiatric or nervous system events. Sativex appears to be a well-tolerated and useful add-on therapy in patients who have not achieved an adequate response with traditional antispastic agents.

Contemporary management of overactive bladder.

Overactive bladder is a prevalent condition with bothersome symptoms that greatly impact health-related quality of life. Despite a multitude of treatment options, many patients go untreated or undertreated. This article addresses the contemporary management of overactive bladder, including behavioral and lifestyle modifications, pelvic floor muscle therapy, biofeedback, drug therapy, neuromodulation, and botulinum toxin. We highlight the new drugs and therapies that have been brought into clinical use over the past few years, and discuss important clinical implications of therapy as well as promising new agents that are currently in advanced stages of development.

[Spasticity in children cerebral palsy: diagnosis and treatment strategies].

Spasticity in children cerebral palsy has its own peculiarities due to the presence of pathological tonic reflexes, pathological sinkinetic activity during arbitrary movements, disturbance of coordinative interactions of muscle synergists and antagonists, increase of total reflex excitability. Physiotherapeutic methods, massage, therapeutic exercises, kinesitherapy, biological feedback training (BFT), methods of orthopedic correction, neurosurgery are widely used in the treatment of spasticity. The use of botulinum toxin type A is a new effective approach to the treatment of spasticity that improves motor functions and quality of life of children with children cerebral palsy. It is being used in the treatment of children and adolescence in a polyclinic unit of the Moscow psychoneurological hospital since 2001. The experience of treatment with botulinum and wide implementation of this method indicated that botulinum toxin injections in the complex treatment of spasticity allow to optimize approaches to treatment of children and adolescence with children cerebral palsy and to increase significantly the quality of medical-social rehabilitation of patients.

Working memory and mental imagery in cerebral palsy: a single case investigation.

In this study we describe visuospatial working memory and visual mental imagery of a child with Cerebral Palsy. Beyond a moderate impairment of visuomotor integration skills, cognitive level and memory span, poor performance emerged in figures reconstruction, in memorizing matrix patterns and movements along a path. No such deficits were observed in recalling figures and their positions on a grid and learning groups of words using a visual imagery strategy. This case highlights that impaired action execution impairs performance in imagery tasks as well, but not when alternative strategies (e.g., verbal encoding) can be adopted. Results are discussed considering recent evidence on working memory and visual imagery links, and their role in motor rehabilitation training.

Botulinum toxin injection in dysphagia syndromes with preserved esophageal peristalsis and incomplete lower esophageal sphincter relaxation.

BACKGROUND: Botulinum toxin injection into the lower esophageal sphincter (LES) treats dysphagia syndromes with preserved peristalsis and incomplete LES relaxation (LESR). We evaluated clinical and esophageal motor characteristics predicting response, and compared duration of efficacy to similarly treated achalasia patients. METHODS: Thirty-six subjects (59 ± 2.2 years, 19F/17M) with incomplete LESR on high resolution manometry (HRM) treated with botulinum toxin injection were identified. Individual and composite symptom indices were calculated, and HRM characteristics extracted. Symptom resolution for 6 months was a primary outcome measure, and repeat botulinum toxin injection, dysphagia recurrence or employment of alternate therapeutic approaches were secondary outcome measures. Duration of response was compared using Kaplan-Meier survival curves to a historical cohort of similarly treated achalasia subjects. KEY RESULTS: Response lasted a mean of 12.8 ± 2.3 months. Symptom relief for >6 months was seen in 58.3%; short (<6 months) response was associated with younger age, higher chest pain index, and esophageal body spastic features (P ≤ 0.04). On multivariate logistic regression, chest pain, younger age and contraction amplitudes >180 mmHg independently predicted <6 months relief (P < 0.05 for each). On survival analysis, relief with a single injection extended to 1 year in 54.8% and 1.5 years in 49.8%, statistically equivalent to that reported by 42 similarly treated achalasia subjects (59 ± 3.2 years, 24F/18M). Symptom relief was more prolonged compared to achalasia when repeat injections were performed on demand (P = 0.003). CONCLUSIONS & INFERENCES: Botulinum toxin injections can provide lasting symptom relief in dysphagia syndromes with incomplete LESR. Prominent perceptive symptoms and non-specific spastic features may predict shorter relief.

Comprehensive facial rehabilitation improves function in people with facial paralysis: a 5-year experience at the Massachusetts Eye and Ear Infirmary.

BACKGROUND: The Facial Grading Scale (FGS) is a quantitative instrument used to evaluate facial function after facial nerve injury. However, quantitative improvements in function after facial rehabilitation in people with chronic facial paralysis have not been shown. OBJECTIVE: The objectives of this study were to use the FGS in a large series of consecutive subjects with facial paralysis to quantitatively evaluate improvements in facial function after facial nerve rehabilitation and to describe the management of chronic facial paralysis. DESIGN: The study was a retrospective review. METHODS: A total of 303 individuals with facial paralysis were evaluated by 1 physical therapist at a tertiary care facial nerve center during a 5-year period. Facial rehabilitation included education, neuromuscular training, massage, meditation-relaxation, and an individualized home program. After 2 months of home exercises, the participants were re-evaluated, and the home program was tailored as necessary. All participants were evaluated with the FGS before the initiation of facial rehabilitation, and 160 participants were re-evaluated after receiving treatment. All participants underwent the initial evaluation at least 4 months after the onset of facial paralysis; for 49 participants, the evaluation took place more than 3 years after onset. RESULTS: Statistically significant increases in FGS scores were seen after treatment (P<.001, t test). The average initial score was 56 (SD=21, range=13-98), and the average score after treatment was 70 (SD=18, range=25-100). LIMITATIONS: A limitation of this study was that evaluations were performed by only 1 therapist. CONCLUSIONS: For 160 patients with facial paralysis, statistically significant improvements after facial rehabilitation were shown; the improvements appeared to be long lasting with continued treatment. The improvements in the FGS scores indicated that patients can successfully manage symptoms with rehabilitation and underscored the importance of specialized therapy in the management of facial paralysis.

[Alternative treatments for interstitial cystitis]. / Les traitements de recours dans la cystite interstitielle.

Interstitial cystitis is the first cause of bladder pain. In case of failure of the usual treatments, several other modalities have been proposed. These therapeutic modalities are posterior sacral root neuromodulation, posterior tibial nerve stimulation, vanilloid agent intravesical instillation, intradetrusor botulinum toxin injections and surgery. A certain efficiency of each of these treatments in the interstitial cystitis has been reported. However, the evaluation of these treatments is limited and the level of evidence is too low to propose these treatments in routine.

Elbow tendinopathy and tendon ruptures: epicondylitis, biceps and triceps ruptures.

Lateral and medial epicondylitis are common causes of elbow pain in the general population, with the lateral variety being more common than the medial by a ratio reportedly ranging from 4:1 to 7:1. Initially thought to be an inflammatory condition, epicondylitis has ultimately been shown to result from tendinous microtearing followed by an incomplete reparative response. Numerous nonoperative and operative treatment options have been employed in the treatment of epicondylitis, without the emergence of a single, consistent, universally accepted treatment protocol. Tendon ruptures about the elbow are much less frequent, but result in more significant disability and loss of function. Distal biceps tendon ruptures typically occur in middle-aged males as a result of an event that causes a sudden, eccentric contraction of the biceps. Triceps tendon ruptures are exceedingly rare but usually have a similar etiology with a forceful eccentric contraction of the triceps that causes avulsion of the tendon from the olecranon. The diagnosis of these injuries is not always readily made. Complete ruptures of the biceps or triceps tendons have traditionally been treated surgically with good results. With regard to biceps ruptures, there continues to be debate about the best surgical approach, as well as the best method of fixation of tendon to bone. This article is not meant to be an exhaustive review of the broad topics of elbow tendinopathy and tendon ruptures, but rather is a review of recently published information on the topics that will assist the clinician in diagnosis and management of these conditions.

Treatment of refractory gastroparesis: gastric and jejunal tubes, botox, gastric electrical stimulation, and surgery.

Refractory gastroparesis is a challenging disorder for gastroenterologists, internists, surgeons, and all health care professionals involved in the care of these patients. It should be managed by a stepwise algorithm beginning with dietary modifications, then prokinetic and antiemetic medications, measures to control pain and address psychological issues, and endoscopic or surgical options in selected patients, including placement of feeding jejunostomy tubes.

Atypical dystonic shoulder movements following neuralgic amyotrophy.

Peripherally induced movement disorders are relatively rare. Here, we present 3 patients who suffered a lesion of the brachial plexus because of neuralgic amyotrophy and developed involuntary movements of their shoulder muscles. The nature of the involuntary movements, which did not easily comply with classic descriptions of hyperkinetic movement disorders, is probably best referred to as dystonia.

Urinary incontinence-procedural and surgical treatments for women.

BACKGROUND: A range of surgical treatment options is available for women suffering from stress and urge urinary incontinence refractory to conservative and medical management. OBJECTIVE: This article discusses the indications for surgical treatments for stress and urge urinary incontinence in women; and the advantages, disadvantages and side effects of these treatments. DISCUSSION: Women who fail to respond to pelvic floor physiotherapy for stress urinary incontinence have available to them a range of variably invasive surgical treatment options including bio-injectable agents, sling surgery, colposuspension, and prostheses. Women with urge urinary incontinence refractory to the newer anticholinergic agents can be treated with minimally invasive options such as bladder injections of botulinum toxin and sacral neuromodulation, as well as more invasive major urinary tract surgery.

Botulinum toxin: new option for refractory lower urinary tract symptoms in women.

Lower urinary tract symptoms refractory to standard therapies create significant distress and quality of life impact for women with these disorders. Likewise, they are challenging for clinicians caring for these women. Once conservative measures are exhausted, the few remaining treatment options are often invasive and associated with significant morbidity. Botulinum toxin is an emerging medical therapy with increasing applications in the lower urinary tract and pelvic floor, which has proven to be an effective and safe alternative for the treatment of some refractory pelvic floor disorders.

Risk of extrapyramidal syndrome in schizophrenic patients treated with antipsychotics: a population-based study.

To compare the prevalence of extrapyramidal syndrome (EPS) between the first-generation antipsychotics (FGAs) and second-generation antipsychotics (SGAs), the co-prescribing rate of anti-Parkinson drugs (APDs) of each antipsychotic drug was analyzed using population database. Fourteen antipsychotics had been prescribed during the 5-year study period. Among the SGAs, quetiapine had the lowest crude co-prescribing rate of APDs (27.09%), whereas risperidone had the highest rate (66.50%). Among the FGAs, thioridazine and loxapine had the lowest (60.99%) and highest rates (96.35%), respectively. The rankings of the co-prescribing rate of APDs among antipsychotics, in increasing order, were quetiapine, clozapine, olanzapine, thioridazine, zotepine, chlorpromazine, risperidone, sulpiride, clotiapine, flupentixol, haloperidol, zuclopentixol, trifluoperazine, and loxapine. The results indicate that the risk of EPS appears to be lower in SGAs than in FGAs; however, the considerably high rate of EPS in some of the newer generation of antipsychotics warrants clinical attention.