David Charles | Vanderbilt University (original) (raw)

Papers by David Charles

Toxins

Blepharospasm and oromandibular dystonia are focal dystonias characterized by involuntary and oft... more Blepharospasm and oromandibular dystonia are focal dystonias characterized by involuntary and often patterned, repetitive muscle contractions. There is a long history of medical and surgical therapies, with the current first-line therapy, botulinum neurotoxin (BoNT), becoming standard of care in 1989. This comprehensive review utilized MEDLINE and PubMed and provides an overview of the history of these focal dystonias, BoNT, and the use of toxin to treat them. We present the levels of clinical evidence for each toxin for both, focal dystonias and offer guidance for muscle and site selection as well as dosing.

Frontiers in neurology, 2018

Tremor is one of the most visible features of Parkinson's disease (PD), and the majority of P... more Tremor is one of the most visible features of Parkinson's disease (PD), and the majority of PD patients experience tremor during the course of the disease. However, the distress caused by this cardinal motor feature for patients early in the course of their PD is commonly underappreciated. People living with early stage PD often experience intense embarrassment and difficulties due to their tremor that limit social interactions, and tremor frequently interferes with the ability to perform activities of daily living and simple tasks at home and work. Although tremor is primarily managed with medications, both tremor response and satisfaction with medical therapy are highly variable. This review offers an overview of reports of the patient experience of tremor in early stage PD and current management options for this cardinal motor feature.

Journal of Parkinson's disease, Jan 27, 2018

Clinical trials are often hindered by inadequate patient recruitment. Overly optimistic investiga... more Clinical trials are often hindered by inadequate patient recruitment. Overly optimistic investigator predictions of participation can lead to unmet recruitment goals and costly trial extensions. A patient-focused approach estimating recruitment in clinical trials may provide higher accuracy. To predict the feasibility of recruitment in a future deep brain stimulation (DBS) in early-stage Parkinson's disease (PD) multicenter trial by understanding motivations and concerns to participation of past and potential future DBS in early-stage PD clinical trial subjects. To identify motivating factors and barriers influencing trial participation, an end-of-trial survey was administered to subjects enrolled in a DBS in early-stage PD pilot trial with subjects randomized to receive DBS plus optimal drug therapy (DBS+ODT) or ODT alone (NCT#00282152, IDE#G050016). Pilot trial survey results were analyzed in conjunction with results of a previously-reported survey querying patients with early...

Journal of neurology, 2018

Longitudinal cohort studies provide important information about the clinical effectiveness of an ... more Longitudinal cohort studies provide important information about the clinical effectiveness of an intervention in the routine clinical setting, and are an opportunity to understand how a population presents for treatment and is managed. INTEREST IN CD2 (NCT01753349) is a prospective, international, 3-year, longitudinal, observational study following the course of adult idiopathic cervical dystonia (CD) treated with botulinum neurotoxin type A (BoNT-A). The primary objective is to document long-term patient satisfaction with BoNT-A treatment. Here we report baseline data. This analysis includes 1036 subjects (67.4% of subjects were female; mean age was 54.7 years old; mean TWSTRS Total score was 31.7). BoNT-A injections were usually given in line with BoNT-A prescribing information. The most commonly injected muscles were splenius capitis (87.3%), sternocleidomastoid (82.6%), trapezius (64.3%), levator scapulae (40.9%) and semispinalis capitis (26.9%); 35.5% of subjects were injected ...

Current pharmaceutical design, Jan 29, 2017

Biosimilars have the potential to create competition, lower costs, and increase patient access to... more Biosimilars have the potential to create competition, lower costs, and increase patient access to biological medications. However, biological medications are sensitive to their manufacturing processes and difficult to precisely characterize, leading to questions about substitution and interchangeability among products. This article reviews the role of biosimilars in patient access to therapeutic antibodies. Although pathways for the approval of biosimilars have been developed, important issues remain unresolved. Interchangeability, or the designation of one medicine as clinically similar to and/or substitutable for another, is specified in some countries but restricted or awaiting policy resolution in others. Non-medical switching, or the switching among biological medications to select a less expensive product, for reasons unrelated to patient health and safety, is controversial because of the potential for complications related to repeated switching (eg, immunogenicity and loss of...

PM & R : the journal of injury, function, and rehabilitation, Jan 7, 2017

OnabotulinumtoxinA is approved for the treatment of upper and lower limb spasticity in adults. Gu... more OnabotulinumtoxinA is approved for the treatment of upper and lower limb spasticity in adults. Guidance on common postures and onabotulinumtoxinA injection paradigms for upper limb spasticity has been developed using a Delphi Panel. However, similar guidance for lower limb spasticity has not been established. To define a clinically recommended treatment paradigm using onabotulinumtoxinA for each common posture among patients with post-stroke lower-limb spasticity (PSLLS); to identify the most common PSLLS aggregate postures. Clinical experts provided insight regarding onabotulinumtoxinA treatment for PSLLS using an adaptation of the Delphi consensus process. Delphi panel. Ten expert clinicians in neurology and physical medicine and rehabilitation who treat PSLLS. A minimum of 2 rounds of anonymous voting occurred for each recommendation until consensus was reached (≥66% agreement). The first round was conducted using a survey; the second round was an in-person meeting. Reached conse...

Journal of Parkinson's disease, Jan 30, 2016

The FDA approved a multicenter, double-blind, Phase III, pivotal trial testing deep brain stimula... more The FDA approved a multicenter, double-blind, Phase III, pivotal trial testing deep brain stimulation in 280 people with very early stage Parkinson's disease (PD; IDE#G050016). In partnership with The Michael J. Fox Foundation for Parkinson's Research, we conducted a survey to investigate motivating factors, barriers, and gender differences for participation in a trial testing DBS in early PD. The majority of survey respondents (72%) indicated they would consider learning more about participating. Men and women with early PD are likely to consider enrolling in trials of invasive therapies that may slow symptom progression and help future patients.

Neurocase, Aug 23, 2016

Deep brain stimulation (DBS) of the subthalamic nucleus (STN) improves the motor symptoms of Park... more Deep brain stimulation (DBS) of the subthalamic nucleus (STN) improves the motor symptoms of Parkinson's disease (PD). The STN may represent an important relay station not only in the motor but also the associative cortico-striato-thalamocortical pathway. Therefore, STN stimulation may alter cognitive functions, such as working memory (WM). We examined cortical effects of STN-DBS on WM in early PD patients using functional near-infrared spectroscopy. The effects of dopaminergic medication on WM were also examined. Lateral frontal activity during WM maintenance was greater when patients were taking dopaminergic medication. STN-DBS led to a trend-level worsening of WM performance, accompanied by increased lateral frontal activity during WM maintenance. These findings suggest that STN-DBS in PD might lead to functional modifications of the basal ganglia-thalamocortical pathway during WM maintenance.

PM & R : the journal of injury, function, and rehabilitation, Feb 23, 2016

OnabotulinumtoxinA reduces muscle hypertonia associated with post-stroke spasticity (PSS). PSS ma... more OnabotulinumtoxinA reduces muscle hypertonia associated with post-stroke spasticity (PSS). PSS manifests as several common postures. To define treatment paradigms for PSS upper-limb common postures. Modified Delphi method. Expert panel. Ten injectors experienced in the treatment and clinical research of PSS (physiatrists and neurologists) were invited to participate in the Delphi panel. The Delphi panel reviewed an electronic worksheet with PSS upper limb postures to define onabotulinumtoxinA treatment paradigms (Round 1). During Round 2, panel members discussed in person Round 1 results and voted until consensus (≥66% agreement). Recommendations were geared toward those with new or early injection experience. Expert consensus on onabotulinumtoxinA treatment parameters for PSS including muscles to inject, dose per muscle and posture, and treatment adjustments for suboptimal response. For each posture, consensus was reached on targeted subsets of muscles. Doses ranged for individual ...

Neurotherapeutics, 2009

Exciting treatments postulated to slow the progression of Parkinson's disease (PD) include g... more Exciting treatments postulated to slow the progression of Parkinson's disease (PD) include gene therapy and deep brain stimulation (DBS). These therapies also have risks of death or permanent disability. If DBS, for example, were proven to be disease modifying, standard treatment ...

Tennessee Medicine Journal of the Tennessee Medical Association, Nov 1, 2007

One woman with profound mental retardation and spasticity living in a public residential developm... more One woman with profound mental retardation and spasticity living in a public residential developmental center was treated with intrathecal baclofen therapy and botulinum toxin type A injections. After one year of regular injections, extension across the right elbow increased 49 degrees. After one year of ITB, range of motion for left hip abduction increased 28 degrees; right hip abduction 9 degrees; left hip flexion 3 degrees; right hip flexion 1 degree; right knee flexion 31 degrees. Our case demonstrates the importance of a multidisciplinary approach in order to ease care and prevent complications. Expanded investigations should be carried out to evaluate the efficacy of combined therapy in patients with mental retardation.

Journal of the National Medical Association, Sep 1, 2005

Decreased revenue from clinical services has required academic hospitals and physicians to improv... more Decreased revenue from clinical services has required academic hospitals and physicians to improve productivity. Medical student education may be a significant hindrance to increased productivity and income. This study quantifies the amount of time spent by faculty members teaching medical students in an ambulatory neurology clinic as well as the amount of time students occupied rooms when seeing patients on their own. Over a three-week period in an ambulatory neurology clinic, an observer noted these quantities of time, and the opportunity costs of both amounts of time were determined. Attending physicians spent an average of 19.6 minutes per medical student per half-day teaching, which translates to an average cost of 20.78perhalf−dayclinic.Studentsspentanaverageof49.9minutesperhalf−dayseeingpatientsintheabsenceofanattendingphysician,anopportunitycosttotheclinicof20.78 per half-day clinic. Students spent an average of 49.9 minutes per half-day seeing patients in the absence of an attending physician, an opportunity cost to the clinic of 20.78perhalf−dayclinic.Studentsspentanaverageof49.9minutesperhalf−dayseeingpatientsintheabsenceofanattendingphysician,anopportunitycosttotheclinicof142.50 per student per half-day.

Tennessee Medicine Journal of the Tennessee Medical Association, Oct 1, 2003

Individuals with hydranencephaly, a congenital deformity resulting in a virtual absence of cerebr... more Individuals with hydranencephaly, a congenital deformity resulting in a virtual absence of cerebral hemispheres, generally do not survive past infancy. Two published cases report survival past the age of 10. We report the oldest known survivor at 20 years, 6 months and compare the behavioral and anatomical characteristics of these three cases. Finally, this condition is discussed in regards to the concept and implications of minimally conscious state (MCS).

Tennessee Medicine Journal of the Tennessee Medical Association, Feb 1, 2007

Generalized dystonia is a disabling disorder that can severely affect quality of life. Pharmacolo... more Generalized dystonia is a disabling disorder that can severely affect quality of life. Pharmacological treatment is unsatisfactory, and surgical therapy has been the focus for symptom improvement. We present the first case report of a patient with disabling generalized dystonia treated with a thalamotomy and deep brain stimulation of the thalamus and globus pallidus (DBS-Vim, DBS-GPi). His tremor and dystonic symptoms have dramatically improved through combining these surgical interventions.

Journal of Parkinson's disease, Jan 26, 2016

Subthalamic nucleus deep brain stimulation (STN-DBS) is well-known to reduce medication burden in... more Subthalamic nucleus deep brain stimulation (STN-DBS) is well-known to reduce medication burden in advanced stage Parkinson's disease (PD). Preliminary data from a prospective, single blind, controlled pilot trial demonstrated that early stage PD subjects treated with STN-DBS also required less medication than those treated with optimal drug therapy (ODT). The purpose of this study was to analyze medication cost and utilization from the pilot trial of DBS in early stage PD and to project 10 year medication costs. Medication data collected at each visit were used to calculate medication costs. Medications were converted to levodopa equivalent daily dose, categorized by medication class, and compared. Medication costs were projected to advanced stage PD, the time when a typical patient may be offered DBS. Medication costs increased 72% in the ODT group and decreased 16% in the DBS+ODT group from baseline to 24 months. This cost difference translates into a cumulative savings for th...

Parkinsonism Related Disorders, 2005

Movement Disorders Clinical Practice, 2015

Background: Cervical dystonia is thought to result in high disease burden, but limited informatio... more Background: Cervical dystonia is thought to result in high disease burden, but limited information exists on its impact on employment and work productivity. We utilized data from the Cervical Dystonia Patient Registry for the Observation of OnabotulinumtoxinA Efficacy (ClinicalTrials.gov identifier: NCT00836017) to assess the impact of cervical dystonia on employment and work productivity and examine the effect of onabotulinumtoxinA treatments on work productivity. Methods: Subjects completed a questionnaire on employment status and work productivity at baseline and final visit. Baseline data were examined by severity of cervical dystonia, predominant subtype, presence of pain, prior exposure to botulinum toxin, and/or utility of a sensory trick. Work productivity results at baseline and final visit were compared in subjects who were toxin-na€ ıve at baseline and received three onabotulinumtoxinA treatments. Results: Of 1,038 subjects, 42.8% were employed full-or part-time, 6.1% unemployed, 32.7% retired, and 11.8% disabled. Of those currently employed, cervical dystonia affected work status of 26.0%, caused 29.8% to miss work in the past month (mean, 5.1 AE 6.4 days), and 57.8% reported decreased productivity. Half of those unemployed were employed when symptoms began, and 38.5% attributed lost employment to cervical dystonia. Pain, increasing severity, and anterocollis/retrocollis had the largest effects on work status/ productivity. Preliminary analyses showed that absenteeism and presenteeism were significantly decreased following onabotulinumtoxinA treatments in the subpopulation that was toxin-na€ ıve at baseline. Conclusions: This analysis confirms the substantial negative impact of cervical dystonia on employment, with cervical dystonia-associated pain being a particularly important driver. OnabotulinumtoxinA treatment appears to improve work productivity.

Tennessee Medicine Journal of the Tennessee Medical Association, Sep 1, 2009

The discovery of human immunodeficiency virus type 1 (HIV) infection in an individual who recentl... more The discovery of human immunodeficiency virus type 1 (HIV) infection in an individual who recently moved from a developmental center prompted the center to offer HIV testing to current and former residents. The guardians of 199 (93 percent) of the Center's current residents consented to testing. The remaining 14 current residents (seven percent) were not tested because informed consent for testing was not received. Consent for testing of 41 former residents was also obtained. All people who underwent testing were seronegative. Whether former residents who were not included in the present analysis received testing from other sources is not known.

Toxins

Blepharospasm and oromandibular dystonia are focal dystonias characterized by involuntary and oft... more Blepharospasm and oromandibular dystonia are focal dystonias characterized by involuntary and often patterned, repetitive muscle contractions. There is a long history of medical and surgical therapies, with the current first-line therapy, botulinum neurotoxin (BoNT), becoming standard of care in 1989. This comprehensive review utilized MEDLINE and PubMed and provides an overview of the history of these focal dystonias, BoNT, and the use of toxin to treat them. We present the levels of clinical evidence for each toxin for both, focal dystonias and offer guidance for muscle and site selection as well as dosing.

Frontiers in neurology, 2018

Tremor is one of the most visible features of Parkinson's disease (PD), and the majority of P... more Tremor is one of the most visible features of Parkinson's disease (PD), and the majority of PD patients experience tremor during the course of the disease. However, the distress caused by this cardinal motor feature for patients early in the course of their PD is commonly underappreciated. People living with early stage PD often experience intense embarrassment and difficulties due to their tremor that limit social interactions, and tremor frequently interferes with the ability to perform activities of daily living and simple tasks at home and work. Although tremor is primarily managed with medications, both tremor response and satisfaction with medical therapy are highly variable. This review offers an overview of reports of the patient experience of tremor in early stage PD and current management options for this cardinal motor feature.

Journal of Parkinson's disease, Jan 27, 2018

Clinical trials are often hindered by inadequate patient recruitment. Overly optimistic investiga... more Clinical trials are often hindered by inadequate patient recruitment. Overly optimistic investigator predictions of participation can lead to unmet recruitment goals and costly trial extensions. A patient-focused approach estimating recruitment in clinical trials may provide higher accuracy. To predict the feasibility of recruitment in a future deep brain stimulation (DBS) in early-stage Parkinson's disease (PD) multicenter trial by understanding motivations and concerns to participation of past and potential future DBS in early-stage PD clinical trial subjects. To identify motivating factors and barriers influencing trial participation, an end-of-trial survey was administered to subjects enrolled in a DBS in early-stage PD pilot trial with subjects randomized to receive DBS plus optimal drug therapy (DBS+ODT) or ODT alone (NCT#00282152, IDE#G050016). Pilot trial survey results were analyzed in conjunction with results of a previously-reported survey querying patients with early...

Journal of neurology, 2018

Longitudinal cohort studies provide important information about the clinical effectiveness of an ... more Longitudinal cohort studies provide important information about the clinical effectiveness of an intervention in the routine clinical setting, and are an opportunity to understand how a population presents for treatment and is managed. INTEREST IN CD2 (NCT01753349) is a prospective, international, 3-year, longitudinal, observational study following the course of adult idiopathic cervical dystonia (CD) treated with botulinum neurotoxin type A (BoNT-A). The primary objective is to document long-term patient satisfaction with BoNT-A treatment. Here we report baseline data. This analysis includes 1036 subjects (67.4% of subjects were female; mean age was 54.7 years old; mean TWSTRS Total score was 31.7). BoNT-A injections were usually given in line with BoNT-A prescribing information. The most commonly injected muscles were splenius capitis (87.3%), sternocleidomastoid (82.6%), trapezius (64.3%), levator scapulae (40.9%) and semispinalis capitis (26.9%); 35.5% of subjects were injected ...

Current pharmaceutical design, Jan 29, 2017

Biosimilars have the potential to create competition, lower costs, and increase patient access to... more Biosimilars have the potential to create competition, lower costs, and increase patient access to biological medications. However, biological medications are sensitive to their manufacturing processes and difficult to precisely characterize, leading to questions about substitution and interchangeability among products. This article reviews the role of biosimilars in patient access to therapeutic antibodies. Although pathways for the approval of biosimilars have been developed, important issues remain unresolved. Interchangeability, or the designation of one medicine as clinically similar to and/or substitutable for another, is specified in some countries but restricted or awaiting policy resolution in others. Non-medical switching, or the switching among biological medications to select a less expensive product, for reasons unrelated to patient health and safety, is controversial because of the potential for complications related to repeated switching (eg, immunogenicity and loss of...

PM & R : the journal of injury, function, and rehabilitation, Jan 7, 2017

OnabotulinumtoxinA is approved for the treatment of upper and lower limb spasticity in adults. Gu... more OnabotulinumtoxinA is approved for the treatment of upper and lower limb spasticity in adults. Guidance on common postures and onabotulinumtoxinA injection paradigms for upper limb spasticity has been developed using a Delphi Panel. However, similar guidance for lower limb spasticity has not been established. To define a clinically recommended treatment paradigm using onabotulinumtoxinA for each common posture among patients with post-stroke lower-limb spasticity (PSLLS); to identify the most common PSLLS aggregate postures. Clinical experts provided insight regarding onabotulinumtoxinA treatment for PSLLS using an adaptation of the Delphi consensus process. Delphi panel. Ten expert clinicians in neurology and physical medicine and rehabilitation who treat PSLLS. A minimum of 2 rounds of anonymous voting occurred for each recommendation until consensus was reached (≥66% agreement). The first round was conducted using a survey; the second round was an in-person meeting. Reached conse...

Journal of Parkinson's disease, Jan 30, 2016

The FDA approved a multicenter, double-blind, Phase III, pivotal trial testing deep brain stimula... more The FDA approved a multicenter, double-blind, Phase III, pivotal trial testing deep brain stimulation in 280 people with very early stage Parkinson's disease (PD; IDE#G050016). In partnership with The Michael J. Fox Foundation for Parkinson's Research, we conducted a survey to investigate motivating factors, barriers, and gender differences for participation in a trial testing DBS in early PD. The majority of survey respondents (72%) indicated they would consider learning more about participating. Men and women with early PD are likely to consider enrolling in trials of invasive therapies that may slow symptom progression and help future patients.

Neurocase, Aug 23, 2016

Deep brain stimulation (DBS) of the subthalamic nucleus (STN) improves the motor symptoms of Park... more Deep brain stimulation (DBS) of the subthalamic nucleus (STN) improves the motor symptoms of Parkinson's disease (PD). The STN may represent an important relay station not only in the motor but also the associative cortico-striato-thalamocortical pathway. Therefore, STN stimulation may alter cognitive functions, such as working memory (WM). We examined cortical effects of STN-DBS on WM in early PD patients using functional near-infrared spectroscopy. The effects of dopaminergic medication on WM were also examined. Lateral frontal activity during WM maintenance was greater when patients were taking dopaminergic medication. STN-DBS led to a trend-level worsening of WM performance, accompanied by increased lateral frontal activity during WM maintenance. These findings suggest that STN-DBS in PD might lead to functional modifications of the basal ganglia-thalamocortical pathway during WM maintenance.

PM & R : the journal of injury, function, and rehabilitation, Feb 23, 2016

OnabotulinumtoxinA reduces muscle hypertonia associated with post-stroke spasticity (PSS). PSS ma... more OnabotulinumtoxinA reduces muscle hypertonia associated with post-stroke spasticity (PSS). PSS manifests as several common postures. To define treatment paradigms for PSS upper-limb common postures. Modified Delphi method. Expert panel. Ten injectors experienced in the treatment and clinical research of PSS (physiatrists and neurologists) were invited to participate in the Delphi panel. The Delphi panel reviewed an electronic worksheet with PSS upper limb postures to define onabotulinumtoxinA treatment paradigms (Round 1). During Round 2, panel members discussed in person Round 1 results and voted until consensus (≥66% agreement). Recommendations were geared toward those with new or early injection experience. Expert consensus on onabotulinumtoxinA treatment parameters for PSS including muscles to inject, dose per muscle and posture, and treatment adjustments for suboptimal response. For each posture, consensus was reached on targeted subsets of muscles. Doses ranged for individual ...

Neurotherapeutics, 2009

Exciting treatments postulated to slow the progression of Parkinson's disease (PD) include g... more Exciting treatments postulated to slow the progression of Parkinson's disease (PD) include gene therapy and deep brain stimulation (DBS). These therapies also have risks of death or permanent disability. If DBS, for example, were proven to be disease modifying, standard treatment ...

Tennessee Medicine Journal of the Tennessee Medical Association, Nov 1, 2007

One woman with profound mental retardation and spasticity living in a public residential developm... more One woman with profound mental retardation and spasticity living in a public residential developmental center was treated with intrathecal baclofen therapy and botulinum toxin type A injections. After one year of regular injections, extension across the right elbow increased 49 degrees. After one year of ITB, range of motion for left hip abduction increased 28 degrees; right hip abduction 9 degrees; left hip flexion 3 degrees; right hip flexion 1 degree; right knee flexion 31 degrees. Our case demonstrates the importance of a multidisciplinary approach in order to ease care and prevent complications. Expanded investigations should be carried out to evaluate the efficacy of combined therapy in patients with mental retardation.

Journal of the National Medical Association, Sep 1, 2005

Decreased revenue from clinical services has required academic hospitals and physicians to improv... more Decreased revenue from clinical services has required academic hospitals and physicians to improve productivity. Medical student education may be a significant hindrance to increased productivity and income. This study quantifies the amount of time spent by faculty members teaching medical students in an ambulatory neurology clinic as well as the amount of time students occupied rooms when seeing patients on their own. Over a three-week period in an ambulatory neurology clinic, an observer noted these quantities of time, and the opportunity costs of both amounts of time were determined. Attending physicians spent an average of 19.6 minutes per medical student per half-day teaching, which translates to an average cost of 20.78perhalf−dayclinic.Studentsspentanaverageof49.9minutesperhalf−dayseeingpatientsintheabsenceofanattendingphysician,anopportunitycosttotheclinicof20.78 per half-day clinic. Students spent an average of 49.9 minutes per half-day seeing patients in the absence of an attending physician, an opportunity cost to the clinic of 20.78perhalf−dayclinic.Studentsspentanaverageof49.9minutesperhalf−dayseeingpatientsintheabsenceofanattendingphysician,anopportunitycosttotheclinicof142.50 per student per half-day.

Tennessee Medicine Journal of the Tennessee Medical Association, Oct 1, 2003

Individuals with hydranencephaly, a congenital deformity resulting in a virtual absence of cerebr... more Individuals with hydranencephaly, a congenital deformity resulting in a virtual absence of cerebral hemispheres, generally do not survive past infancy. Two published cases report survival past the age of 10. We report the oldest known survivor at 20 years, 6 months and compare the behavioral and anatomical characteristics of these three cases. Finally, this condition is discussed in regards to the concept and implications of minimally conscious state (MCS).

Tennessee Medicine Journal of the Tennessee Medical Association, Feb 1, 2007

Generalized dystonia is a disabling disorder that can severely affect quality of life. Pharmacolo... more Generalized dystonia is a disabling disorder that can severely affect quality of life. Pharmacological treatment is unsatisfactory, and surgical therapy has been the focus for symptom improvement. We present the first case report of a patient with disabling generalized dystonia treated with a thalamotomy and deep brain stimulation of the thalamus and globus pallidus (DBS-Vim, DBS-GPi). His tremor and dystonic symptoms have dramatically improved through combining these surgical interventions.

Journal of Parkinson's disease, Jan 26, 2016

Subthalamic nucleus deep brain stimulation (STN-DBS) is well-known to reduce medication burden in... more Subthalamic nucleus deep brain stimulation (STN-DBS) is well-known to reduce medication burden in advanced stage Parkinson's disease (PD). Preliminary data from a prospective, single blind, controlled pilot trial demonstrated that early stage PD subjects treated with STN-DBS also required less medication than those treated with optimal drug therapy (ODT). The purpose of this study was to analyze medication cost and utilization from the pilot trial of DBS in early stage PD and to project 10 year medication costs. Medication data collected at each visit were used to calculate medication costs. Medications were converted to levodopa equivalent daily dose, categorized by medication class, and compared. Medication costs were projected to advanced stage PD, the time when a typical patient may be offered DBS. Medication costs increased 72% in the ODT group and decreased 16% in the DBS+ODT group from baseline to 24 months. This cost difference translates into a cumulative savings for th...

Parkinsonism Related Disorders, 2005

Movement Disorders Clinical Practice, 2015

Background: Cervical dystonia is thought to result in high disease burden, but limited informatio... more Background: Cervical dystonia is thought to result in high disease burden, but limited information exists on its impact on employment and work productivity. We utilized data from the Cervical Dystonia Patient Registry for the Observation of OnabotulinumtoxinA Efficacy (ClinicalTrials.gov identifier: NCT00836017) to assess the impact of cervical dystonia on employment and work productivity and examine the effect of onabotulinumtoxinA treatments on work productivity. Methods: Subjects completed a questionnaire on employment status and work productivity at baseline and final visit. Baseline data were examined by severity of cervical dystonia, predominant subtype, presence of pain, prior exposure to botulinum toxin, and/or utility of a sensory trick. Work productivity results at baseline and final visit were compared in subjects who were toxin-na€ ıve at baseline and received three onabotulinumtoxinA treatments. Results: Of 1,038 subjects, 42.8% were employed full-or part-time, 6.1% unemployed, 32.7% retired, and 11.8% disabled. Of those currently employed, cervical dystonia affected work status of 26.0%, caused 29.8% to miss work in the past month (mean, 5.1 AE 6.4 days), and 57.8% reported decreased productivity. Half of those unemployed were employed when symptoms began, and 38.5% attributed lost employment to cervical dystonia. Pain, increasing severity, and anterocollis/retrocollis had the largest effects on work status/ productivity. Preliminary analyses showed that absenteeism and presenteeism were significantly decreased following onabotulinumtoxinA treatments in the subpopulation that was toxin-na€ ıve at baseline. Conclusions: This analysis confirms the substantial negative impact of cervical dystonia on employment, with cervical dystonia-associated pain being a particularly important driver. OnabotulinumtoxinA treatment appears to improve work productivity.

Tennessee Medicine Journal of the Tennessee Medical Association, Sep 1, 2009

The discovery of human immunodeficiency virus type 1 (HIV) infection in an individual who recentl... more The discovery of human immunodeficiency virus type 1 (HIV) infection in an individual who recently moved from a developmental center prompted the center to offer HIV testing to current and former residents. The guardians of 199 (93 percent) of the Center's current residents consented to testing. The remaining 14 current residents (seven percent) were not tested because informed consent for testing was not received. Consent for testing of 41 former residents was also obtained. All people who underwent testing were seronegative. Whether former residents who were not included in the present analysis received testing from other sources is not known.