Antiphospholipid-related chorea.

Chorea can be associated with autoimmune diseases such as antiphospholipid syndrome and has been associated with the isolated presence of antiphospholipid antibodies (aPL). Chorea is a rare neurological manifestation of antiphospholipid syndrome. The pathophysiological mechanisms underlying aPL-related chorea are still debated. One postulated mechanism is aPL or other autoantibody binding to brain-blood vessel endothelium, resulting in endothelial dysfunction secondary to a proinflammatory cascade, with sequalae of inflammation and local microthrombosis. Another postulated mechanism considers immune-mediated attack (aPL or antibasal ganglia antibodies) against specific basal ganglia epitopes. Here, we report a patient with isolated aPL-related chorea that followed a relapsing-remitting course. We highlight the role of brain metabolic imaging with fluorodeoxy glucose positron-emission tomography in the diagnostic workup of chorea and the challenges in the practical management of aPL-related chorea with symptomatic treatments.

A study investigating the experience of working for people with Parkinson's and the factors that influence workplace success.

PURPOSE: The experience of working for people with Parkinson's disease (PD) is known to vary substantially and affects the length of time in employment after diagnosis. This study aims at exploring the experience of working for people with PD and to create a model detailing the factors that influence their workplace success. METHOD: A qualitative grounded theoretical approach was used. Seventeen working people with PD were selected for individual interviews which were conducted sequentially. Data were analyzed in an iterative, inductive process of coding to identify common themes and to generate a model that explains the data. RESULTS: Two core themes that influence workplace success for people with PD were identified. 'Feeling in control of Parkinson's' describes the actions that they make to remain in control. 'Being able to control Parkinson's in the workplace' describes external factors that they believe influence their ability to work successfully. CONCLUSIONS: The theoretical model demonstrates how a variety of factors interplay to influence workplace success for people with PD. PD is often poorly understood but the ability to explore and devise strategies for oneself and the flexibility to work around a fluctuating daily pattern were regularly identified as strategies that facilitated success. Implications for Rehabilitation The experience of working for people with Parkinson's is variable and is influenced by how in control the person with Parkinson's feels and the strategies they use to manage challenges. There is a need for greater workplace education to enhance employers' understanding of Parkinson's to ensure better support for strategies or reasonable adjustments by employers. People with Parkinson's are able to devise strategies to overcome some of their own specific workplace challenges including through technology but often, they prefer not to use disability aids. Daily fluctuations in Parkinson's symptoms are an important factor influencing workplace success.

Demyelination during tumour necrosis factor antagonist therapy for psoriasis: a case report and review of the literature.

Central nervous system (CNS) demyelination in a patient receiving tumour necrosis factor alpha (TNF-α) antagonist therapy in our practice prompted a search of the literature to assess the evidence for a causal relationship between TNF antagonist therapy and demyelination. We summarise clinical data extracted on 65 reported cases of CNS demyelination in patients receiving TNF antagonist therapy and show that the data are consistent with a drug-related aetiology given the temporal relationship between TNF antagonist initiation and symptoms, de-challenge-re-challenge phenomenon and the later age of disease onset compared with sporadic multiple sclerosis. Research on TNF signalling pathways also suggests a plausible causative role of TNF antagonist therapy in demyelination. However to date, controlled trial and pharmacovigilance data do not show an increased risk of demyelination in patients receiving TNF antagonist therapy. These data may be underpowered to exclude such a risk and pooled, collaborative data from multiple registries are warranted. Given the uncertainty in this area, clinicians should adhere to existing clinical guidance advising avoidance of TNF antagonist therapy in patients with a personal or family history of demyelination, and ensure all suitable patients are enrolled in long term safety registries in countries where these are established.

Progressive striatal and cortical dopamine receptor dysfunction in Huntington's disease: a PET study.

We have studied the progression of striatal and extrastriatal post-synaptic dopaminergic changes in a group of 12 patients with Huntington's disease using serial (11)C-raclopride PET, a specific marker of D2 dopamine receptor binding. All patients had two (11)C-raclopride PET scans 29.2 +/- 12.8 months apart, and six of them had a third scan 13.2 +/- 3.9 months later. We found a mean annual 4.8% loss of striatal (11)C-raclopride binding potential (BP) between the first and second scans, and a 5.2% loss between the second and third scans. Statistical Parametric Mapping (SPM) localized significant baseline reductions in (11)C-raclopride BP in both striatal and extrastriatal areas, including amygdala, temporal and frontal cortex in Huntington's disease compared with normal subjects matched for age and sex. When the (11)C-raclopride scans performed 29 months after the baseline scans were considered, SPM revealed further significant striatal, frontal and temporal reductions in (11)C-raclopride BP in Huntington's disease. Cross-sectional Unified Huntington's Disease Rating Scale (UHDRS) scores correlated with (11)C-raclopride binding, but there was no correlation between individual changes in UHDRS motor scores and changes in striatal binding. Performance on all neuropsychological measures deteriorated with time but only the accuracy score of the one-touch Tower of London test correlated significantly with striatal and putamen D2 binding. In summary, serial (11)C-raclopride PET demonstrates a linear progression of striatal loss of D2 receptors in early clinically affected Huntington's disease patients over 3 years. SPM also revealed a progressive loss of temporal and frontal D2 binding. Changes over time in clinical scores and in neuropsychological assessments, except for measures of planning, did not correlate with striatal D2 binding. This probably reflects both contributions from other affected brain structures and high variance in these measures.