Faculty Bibliography

Background/UNASSIGNED:Although the COVID-19 pandemic is affecting a relatively small proportion of the global population, its effects have already reached everyone. The pandemic has the potential to differentially disadvantage chronically ill patients, including those with Parkinson's disease (PD). The first health care reaction has been to limit access to clinics and neurology wards to preserve fragile patients with PD from being infected. In some regions, the shortage of medical staff has also forced movement disorders neurologists to provide care for patients with COVID-19. Objective/UNASSIGNED:To share the experience of various movement disorder neurologists operating in different world regions and provide a common approach to patients with PD, with a focus on those already on advanced therapies, which may serve as guidance in the current pandemic and for emergency situations that we may face in the future. Conclusion/UNASSIGNED:Most of us were unprepared to deal with this condition given that in many health care systems, telemedicine has been only marginally available or only limited to email or telephone contacts. In addition, to ensure sufficient access to intensive care unit beds, most elective procedures (including deep brain stimulation or the initiation of infusion therapies) have been postponed. We all hope there will soon be a time when we will return to more regular hospital schedules. However, we should consider this crisis as an opportunity to change our approach and encourage our hospitals and health care systems to facilitate the remote management of chronic neurological patients, including those with advanced PD.

Neck pain and headache are two of the most common complications of whiplash injury. Therefore, we performed a systematic literature search on PubMed and Embase for publications reporting on the prevalence of neck pain and headache following whiplash injury. The literature search identified 2,709 citations of which 44 contained relevant original data. Of these, 27 studies provided data for the quantitative analysis. For non-population-based studies, the present meta-analysis showed that a pooled relative frequency of neck pain was 84% CI (68-95%) and a pooled relative frequency of headache was 60% (46-73%), within 7 days following whiplash injury. At 12 months post-injury, 38% (32-45%) of patients with whiplash still experienced neck pain, while 38% (18-60%) of whiplash patients reported headache at the same time interval post-injury. However, we also found considerable heterogeneity among studies with I-values ranging from 89-98% for the aforementioned meta-analyses. We believe that the considerable heterogeneity among studies underscores the need for clear-cut definitions of whiplash injury and standardized reporting guidelines for post-whiplash sequelae such as neck pain and headache. Future studies should seek to optimize these aspects paving the way for a better understanding of the clinical characteristics and natural course of whiplash-associated sequelae.

Non-steroidal anti-inflammatory drugs (NSAIDs), commonly known as COX-1/COX-2 inhibitors, can be effective in treating mild to moderate migraine headache. However, the mechanism by which these drugs act in migraine is not known, nor is the specific contribution of COX-1 versus COX-2 known. We sought to investigate these unknowns using celecoxib, which selectively inhibits the enzymatic activity of COX-2, by determining its effects on several migraine-associated vascular and inflammatory events. Using in vivo two-photon microscopy, we determined intraperitoneal celecoxib effects on CSD-induced blood vessel responses, plasma protein extravasation, and immune cell activation in the dura and pia of mice and rats. Compared to vehicle (control group), celecoxib reduced significantly CSD-induced dilatation of dural arteries and activation of dural and pial macrophages but not dilatation or constriction of pial arteries and veins, or the occurrence of plasma protein extravasation. Collectively, these findings suggest that a mechanism by which celecoxib-mediated COX-2 inhibition might ease the intensity of migraine headache and potentially terminate an attack is by attenuating dural macrophages activation and arterial dilatation outside the blood brain barrier (BBB), and pial macrophages activation inside the BBB.

OBJECTIVE: Rotator cuff tendon tears are the most common soft tissue injuries in the shoulder joint. Various animal models have been described for this condition, but all current translational animal models have inherent weaknesses in their ability to generate chronically degenerated rotator cuff tendons. The objective of this study was to evaluate a partial infraspinatus tendon transection model as a means of creating a chronically degenerated rotator cuff tendon in an ovine model and compare the injury characteristics of this model to those observed in human patients with severe chronic rotator cuff tendon injuries. STUDY DESIGN/METHODS: The infraspinatus tendons of six sheep were partially detached followed by capping of the detached medial section of the tendon with Gore-Tex. Human tissue samples of the supraspinatus tendon were harvested from patients undergoing primary reverse shoulder arthroplasty and served as positive controls of chronic rotator cuff tendinopathy. RESULTS: Transected sheep tendons were characterized predominantly by an acute reactive and reparative pathological process as compared with the chronic degenerative changes observed in the human tendons. In contrast, the non-transected portion of the ovine tendon showed histological changes, which were more chronic and degenerative in nature when compared with the transected tendon. CONCLUSION/CONCLUSIONS: Overall, histological features of the non-transected portion of ovine tendon were more similar to those observed in the chronic degenerated human tendon.

Background and aims: Dementia is considered a nonsupportive diagnostic feature for multiple system atrophy (MSA). Nevertheless, post-mortem verified dementia with Lewy bodies and Parkinson's disease masquerade as MSA. Cognitive impairment (CI), especially executive dysfunction, may occur in MSA patients. It is, however, unclear whether CI manifests in early disease stages.
Objective(s): To compare the prevalence of CI in MSA versus other Lewy Body disorders (LBD), including dementia with Lewy bodies and Parkinson's disease, in early (<3 years from symptom onset) versus more advanced disease stages (>=3 years from symptom onset).
Method(s): A total of 364 patients (LBD: n=83; MSA: n=281) of the natural history study of synucleinopathies register have been analysed. Consensus diagnostic criteria for dementia with Lewy bodies, Parkinson's disease and MSA were applied. To assess CI, the Montreal Cognitive Assessment (MoCA) has been used.
Result(s): In early disease stages, median MoCA scores did not differ significantly between MSA and LBD. In advanced disease stages, MSA patients had a significantly higher median MoCA score compared to LBD patients (27 versus 25, p=0.006). Comparison of the median MoCA Scores of LBD versus MSA patients at early and advanced disease stages
Conclusion(s): In patients with longer disease duration severity of CI helps to differentiate LBD from MSA

Background and aims: Inadequate norepinephrine (NE) release in neurogenic orthostatic hypotension (nOH) causes fall in standing blood pressure. Ampreloxetine, a novel, long-acting NE reuptake inhibitor may improve symptoms of nOH. The objective of this study was to explore durability of effect and safety of once-daily oral ampreloxetine for symptomatic treatment of nOH.
Method(s): In an open-label, phase 2, exploratory study, subjects received ampreloxetine (3-20mg) once-daily for up to 20 weeks, with 4-week follow-up after ampreloxetine withdrawal and restarting alternative pressor agents. Assessments included Orthostatic Hypotension Symptom Assessment Item 1 (OHSA#1; dizziness, lightheadedness, feeling faint), OHSA/Orthostatic Hypotension Daily Activities Scale (OHDAS) composite scores, and change in Patient Global Impression of Severity (PGI-S).
Result(s): Seventeen symptomatic subjects (baseline OHSA#1 score >4) were enrolled (mean age, 65 years). At Weeks 4 and 20, mean (SD) improvement on OHSA#1 was -3.8 (3.1) and -3.1 (3.0) point, and ~77% and ~86% of subjects reported >=1-point improvement, respectively. Improvement, seen as early as Week 1, was sustained throughout the study. Deterioration to baseline severity was observed after ampreloxetine withdrawal. Similar trends were seen in OHSA/OHDAS composite scores, and change in PGI-S. Most common adverse events (AEs) were urinary tract infection (24%), hypertension (19%) and headache (14%), with no study-drug-related serious AEs. Ampreloxetine showed durable symptom improvement over 20 weeks, with return to baseline severity after ampreloxetine withdrawal. Ampreloxetine was well tolerated.
Conclusion(s): These encouraging findings of durable symptom improvement with open-label ampreloxetine treatment are being evaluated in ongoing Phase 3, doubleblind, confirmatory studies in subjects with nOH

Blindness and vision impairment are unpredictable complications of tuberculous meningitis (TBM) that are often unrecognized in the acute stages of illness due to inability to assess vision in patients with depressed levels of consciousness or confusion. We present a patient with definite TBM confirmed by positive Xpert MTB/RIF assay of cerebrospinal fluid (CSF) who developed binocular blindness two weeks after diagnosis and initiation of standard anti-tuberculosis treatment (ATT). Ophthalmological exam demonstrated complete bilateral abducens nerve palsies, impaired pupillary responses to light, normal optic discs, and visual acuity of hand motion only in each eye. Brain CT showed progressive enlargement of the third and lateral ventricles. We managed the patient medically with dexamethasone, acetazolamide, and substitution of moxifloxacin for ethambutol. Serial brain CTs confirmed gradual resolution of hydrocephalus. The patient had complete neurological recovery at six months except for residual blindness in the right eye. Visual acuity in the left eye recovered to normal (20/20). The assessment and management of vision impairment in TBM is discussed.