Richard Trosch

Subcutaneous apomorphine in patients with advanced Parkinson's disease: A dose-escalation study with randomized, double-blind, placebo-controlled crossover evaluation of a single dose ☆

OBJECTIVE To further explore the efficacy and safety of subcutaneous apomorphine (APO) in treating off episodes in APO-naïve patients with advanced Parkinsons disease (PD). METHODS 56 patients receiving optimized oral anti-PD medication were evaluated on separate days for response to single increasing doses of APO. Acute response to oral anti-PD medication and APO dose escalation (2-10 mg) was evaluated under unblinded conditions. At the 4 mg APO dose, placebo was randomly introduced under double-blind crossover conditions. RESULTS Mean changes from pre-dose in Unified Parkinsons Disease Rating Scale motor scores indicated significant improvement following APO 4 mg versus placebo at 20 min (p=0.0002), 40 min (p<0.0001; maximum improvement) and 90 min (p=0.0229). Improvements showed significant dose-response at 20 min, 40 min (both p<0.0001) and 90 min (p=0.0049). Adverse events were more common with APO than placebo, and also showed significant dose-response (p<0.0001). Common adverse events associated with APO included yawning, dizziness, nausea, somnolence and dyskinesias, and were generally mild to moderate. There were no significant differences between APO and placebo in the incidence of hypotension associated with a postural change from a sitting to standing position. CONCLUSIONS Subcutaneous APO provided rapid, effective relief of off episodes associated with advanced PD.

Levodopa‐responsive parkinsonism following central herniation due to bilateral subdural hematomas

A 66-year-old man suffered bilateral subdural hematomas progressing to central herniation, despite repeated surgical evacuations. This eventually resolved, leaving him with a severe parkinsonian syndrome that was responsive to levodopa. MRI and CT showed midbrain compression from central herniation, and a follow-up MRI revealed thinning of the pars compacta. The clinical and radiologie evidence suggested that midbrain compression from central herniation was the probable cause of parkinsonism in this patient.

Emotional facial paresis with striatocapsular infarction

Emotional facial paresis (EFP) refers to hemifacial paresis of emotionally evoked or spontaneous smiling or weeping with preserved volitional movements of the face. The anatomical location for this phenomenon has been controversial. We report a 15-year-old boy with EFP. Follow-up MRI demonstrated infarction limited to the head of the caudate, putamen and anterior limb of the internal capsule on the contralateral side. This case lends support for selective damage at a striatal or capsular site in the production of EFP.

Physicians' experience with RYTARY (carbidopa and levodopa) extended-release capsules in patients who have Parkinson disease

A discussion between Dr. Dee Silver and Dr. Richard Trosch provides insight and advice for physicians considering a switch from immediate-release carbidopa-levodopa (IR CD-LD) to RYTARY as a treatment for patients with Parkinson disease (PD). The dialogue describes how they identify patients with PD who may and may not be successful switching to RYTARY, how they approach the conversion process and patient compliance, and how they address some side effects that may occur after patients begin taking RYTARY. The clinicians also discuss their experiences with how long it takes to establish a stable regimen as well as provide general advice regarding conversion from treatment with IR CD-LD to RYTARY.

Spectrum of practice in the routine management of cervical dystonia with abobotulinumtoxinA: findings from three prospective open-label observational studies

BackgroundCervical dystonia is a heterogeneous disorder with several possible presentations, for which first-line therapy is often botulinum toxin (BoNT). In routine clinical practice the success of each BoNT injection is dependent on several variables, including individual presentation and injection technique. Large multicenter, observational studies provide important information on individualized administration strategies that cannot be otherwise ascertained from controlled clinical trials. In this meta-analysis of patient level data, we aimed to evaluate the clinical characteristics of patients with cervical dystonia undergoing routine treatment with botulinum toxin, specifically abobotulinumtoxinA. We also aimed to characterize current abobotulinumtoxinA injection techniques and parameters and to explore international differences in patient presentation and treatment.MethodsThis was a meta-analysis of baseline data from three prospective, international, multicenter, observational studies (NCT01314365, NCT00833196 and NCT01753349) of botulinum toxin treatment for the routine management of adult cervical dystonia.ResultsData presented illustrate the significant heterogeneity of CD presentation in routine practice. Most subjects presented with a complex pattern of dystonic movements and the majority had additional components of shoulder elevation, tremor and/or jerk. Dosing was generally in accordance with that recommended in the abobotulinumtoxinA prescribing information, although the range of dosing also indicates that injections are tailored to individual presentation. Sub-group analyses at the country level revealed distinct differences in injection practice.ConclusionsThis meta-analysis is based on the largest dataset of subjects with cervical dystonia studied to date. The heterogeneity revealed in our baseline findings support the need to develop consistent, practical and comprehensive best practice guidelines.

Poster 182 Baseline Characteristics of Cervical Dystonia Subjects in Observational Routine-Practice Studies are Different to Those from Randomized Controlled Trials

peritendinous FCR steroid injection, but pain recurred within 6 months. Next, partial thickness Triangular Fibrocartilage tear with wrist effusion was diagnosed with MRI. Wrist arthroscopy with debridement did not result in lasting relief either. The patient was then offered FCR tenotomy versus surgical excision, which she declined. Setting: At 2 years, this patient was evaluated by Rehabilitation medicine in an outpatient setting. Results: The patient was diagnosed with focal dystonia of FCR with Writer’s cramp. 50U of intramuscular Botulinum toxin A was injected into the FCR, Flexor-Pollicis-Longus, and Flexor-Digitorum-Superficialis, followed by rehabilitation with specialized hand therapy. The patient reported gradual improvement, with resolution of symptoms in 4 weeks. Discussion: Focal dystonia should be sought out early in the course of persistent wrist pain, especially in the setting of failed conservative management for common conditions such as flexor tendinitis, and definitely before surgical intervention. Botulinum toxin can be used as an early non-invasive diagnostic tool for focal dystonia, and should improve pain intensity and frequency in case this is the diagnosis, thus avoiding expensive investigations such as MRI, as well as surgical management such as joint arthroscopy or tenotomy. Conclusions: A high index of suspicion for FCR focal dystonia should exist for persistent wrist pain that has failed conservative and surgical management for other diagnoses. Botox has merit for use as both a diagnostic and therapeutic tool for FCR dystonia. Further study can help in establishing evidence for this treatment method. Level of Evidence: Level V

Poster 498 Geographic Differences in the Characteristics of Cervical Dystonia Patients

Design: Cross-sectional survey. Setting: A major academic-medical and trauma center in West Africa. Participants: Residents and medical students completing training in 7 medical and surgical specialties (N1⁄4253). Interventions: Not applicable. Main Outcome Measures: Responses to a 25-item survey organized into four domains: 1. General attitudes towards persons with disability (PWDs); 2. Perceived adequacy of disability education; 3. Importance of disability training and education to current and future practice; and 4. General perceived value of caring for PWDs. Results: Of all respondents, 51% were female, 94 were residents, 159 were medical students and the mean age was 24.0 3.85 years old. Majority of respondents were in a surgical (41%) or medical specialty (21%). Residents had limited experience with PWDs (12% had some experience and 13% had little experience) whereas medical students had very limited experience (a total of 50% had little to no experience with PWDs) and more negative responses towards PWDs. Overall, residents demonstrated significantly higher mean composite scores than medical students for general perceived value of care for PWD (P 1⁄4 .0001), importance of disability education (P 1⁄4 .0001), and perceived adequacy of disability education score (P 1⁄4 .006). There was no statistically significant difference between the 2 groups for general attitudes composite score (P 1⁄4 .08). The mean composite scores of West-African trainees in each of the survey domains were comparable to the scores of physiatry residents in the United states, with the highest positive attitudes demonstrated for importance of disability education and perceived adequacy of disability education. Conclusions: The study highlights attitudinal health challenges towards disabled persons in a milieu devoid of rehabilitation-trained physicians and identifies areas of opportunity for strategic interventions. Level of Evidence: Level III

Poster 306 Clinical Characteristics of Cervical Dystonia: Differences between Patients Previously Treated with Botulinum Neurotoxin Type A and Naïve Patients

Twenty-one muscles were selected for injection at Visit 1; of these the 5 most commonly injected were splenius capitis (93% of patients), sternocleidomastoid (SCM) (91%), trapezius (63%), levator scapulae (42%), and the semispinalis capitis (27%). Other muscles were injected with a frequency between 0.4e6%. The mean total injected volumes were 1.05 1.16 mL for splenius capitis, 0.68 0.78 mL for SCM, 0.67 0.58 mL for trapezius, 0.42 0.26 mL for levator scapulae and 0.56 0.33 mL for semispinalis capitis. Mean number of injection points were: splenius capitis (2.7 1.5), SCM (2.2 1.2), trapezius (2.7 1.6), levator scapulae (1.5 0.7), and semispinalis capitis (2.0 1.3). At Visit 2 the frequency of muscles injected, the injected volume, and injection points were similar to Visit 1. Injection guidance techniques were used in 37% (SCM) to 57% (levator scapulae) of Visit 1 injections, and this did not change at Visit 2. Analyses by study center revealed that when an injector uses guidance for one muscle, they generally use it for all muscles. Conclusion: In these interim analyses, 5 muscles were identified as being most frequently injected for CD, with other muscles being injected at much lower rates. The muscles and injection method (volume and number of injection points) are in line with recommendations in the literature and did not change between visits.

Poster 305 Patterns of Cervical Dystonia of Patients Receiving BoNT-A Treatment

Twenty-one muscles were selected for injection at Visit 1; of these the 5 most commonly injected were splenius capitis (93% of patients), sternocleidomastoid (SCM) (91%), trapezius (63%), levator scapulae (42%), and the semispinalis capitis (27%). Other muscles were injected with a frequency between 0.4e6%. The mean total injected volumes were 1.05 1.16 mL for splenius capitis, 0.68 0.78 mL for SCM, 0.67 0.58 mL for trapezius, 0.42 0.26 mL for levator scapulae and 0.56 0.33 mL for semispinalis capitis. Mean number of injection points were: splenius capitis (2.7 1.5), SCM (2.2 1.2), trapezius (2.7 1.6), levator scapulae (1.5 0.7), and semispinalis capitis (2.0 1.3). At Visit 2 the frequency of muscles injected, the injected volume, and injection points were similar to Visit 1. Injection guidance techniques were used in 37% (SCM) to 57% (levator scapulae) of Visit 1 injections, and this did not change at Visit 2. Analyses by study center revealed that when an injector uses guidance for one muscle, they generally use it for all muscles. Conclusion: In these interim analyses, 5 muscles were identified as being most frequently injected for CD, with other muscles being injected at much lower rates. The muscles and injection method (volume and number of injection points) are in line with recommendations in the literature and did not change between visits.