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ACKNOWLEDGMENTS This work was supported by the National Institute of Environmental Health Sciences (ES 06418) award to JMG 17mg duetact sale, as well as by the William T buy 16 mg duetact mastercard. Gossett Parkinson’s Disease Center and Louis Hayman Parkinson’s Disease Copyright 2003 by Marcel Dekker order 17mg duetact free shipping, Inc duetact 16 mg. Research Fund, both of the Department of Neurology, Henry Ford Health System. Polymeropoulos MH, Lavedan C, Leroy E, Ide SE, Dehejia A, Dutra A, Pike B, Root H, Rubenstein J, Boyer R, Stenroos ES, Chandrasekharappa S, Athanassiadou A Papapetropoulos T, Johnson WG, Lazzarini AM, Duvoisin RC, Di Iorio G, Golbe LI, Nussbaum RL, et al. Mutation in the a-synuclein gene identified in families with Parkinson’s disease. Kruger R, Kuhn W, Muller T, Woitalla D, Graeber M, Kosel S, Przuntek H, Epplen JT, Schols L, Riess O. Ala30Pro mutation in the gene encoding a- synuclein in Parkinson’s disease. Gasser T, Muller-Myhsok B, Wszolek ZK, Oehlmann R, Calne DB, Bonifati V, Bereznai B, Fabrizio E, Vieregge P, Horstmann RD. A susceptibility locus for Parkinson’s disease maps to chromosome 2p13. Recent advances in the genetics and pathogenesis of Parkinson disease. De Michele G, Filla A, Volpe G, De Marco V, Gogliettino A, Ambrosio G, Marconi R, Castellano AE, Campanella G. Environmental and genetic risk factors in Parkinson’s disease: a case-control study in southern Italy. Increased risk of Parkinson’s disease in parents and siblings of patients. Plante-Bordeneuve V, Taussig D, Thomas F, Ziegler M, Said G. A clinical and genetic study of familial cases of Parkinson’s disease. Marder K, Tang MX, Mejia H, Alfaro B, Cote L, Louis E, Groves J, Mayeux R. Risk of Parkinson’s disease among first-degree relatives: a community- based study. Rybicki BA, Johnson CC, Peterson EL, Kortsha GX, Gorell JM. A family history of Parkinson’s disease (PD) and its effect on other PD risk factors. Tanner CM, Ottman R, Goldman SM, Ellenberg J, Chan P, Mayeux R, Langston JW. De Rijk MC, Breteler MMB, Graveland GA, Ott A, Grobbee DE, van der Meche FGA, Hofman A. Prevalence of Parkinson’s disease in the elderly: The Rotterdam Study. Mayeux R, Marder K, Cote LJ, Denaro J, Hemenegildo N, Mejia H, Tang M- X, Lantingua R, Wilder D, Gurland B, Hauser A. The frequency of idiopathic Copyright 2003 by Marcel Dekker, Inc. Parkinson’s disease by age, ethnic group, and sex in northern Manhattan, 1988–1993. Fall P-A, Axelson O, Fredriksson M, Hanson G, Lindvall B, Olsson J-E, Granerus A-K. Age standardized incidence and prevalence of Parkinson’s disease in a Swedish community. Morens DM, Davis JW, Grandinetti A, Ross GW, Popper JS, White LR. Epidemiologic observations on Parkinson’s disease: incidence and mortality in a prospective study of middle-aged men. Ecogenetics of Parkinson’s disease: prevalence and environmental aspects in rural areas. Obtaining occupational exposure histories in epidemiologic case-control studies.

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Dopamine transporter brain imaging to assess the effects of pramipexole vs cheap 17 mg duetact overnight delivery. The REAL-PET study: slower progression in early Parkinson’s disease treated with ropinirole compared with 1-dopa generic duetact 17 mg fast delivery. Results of a 3-year randomized order 17mg duetact free shipping, double-blind duetact 17 mg low cost, PET-controlled study of pergolide vs. Are dopamine receptor agonists neuroprotective in Parkinson’s disease? Pierantozzi M, Palmieri MG, Mazzone P, Marciani MG, Rossini PM, Stefani A, Giacomini P, Peppe A, Stanzione P. Deep brain stimulation of both subthalamic nucleus and internal globus pallidus restores intracortical inhibition in Parkinson’s disease paralleling apomorphine effects: a paired magnetic stimulation study. Apomorphine: an underutilized therapy for Parkinson’s disease. A randomized, double- blind, placebo-controlled trial of subcutaneously injected apomorphine for parkinsonian off-state events. Stocchi F, Vacca L, De Pandis MF, Barbato L, Valente M, Ruggieri S. Subcutaneous continuous apomorphine infusion in fluctuating patients with Parkinson’s disease: long-term results. Manson AJ, Hanagasi H, Turner K, Patsalos PN, Carey P, Ratnaraj N, Lees AJ. Intravenous apomorphine therapy in Parkinson’s disease: clinical and pharmacokinetic observations. Chronic agonist therapy for Parkinson’s disease: a 5-year study of bromocriptine and pergolide. Viewpoint: Early combination therapy with bromocriptine and levodopa in Parkinson’s disease. Pergolide versus bromocriptine for levodopa-induced motor complications in Parkinson’s disease. Bromocriptine versus levodopa in early Parkinson’s disease. Guttman M, International Pramipexole-Bromocriptine Study Group. Double- blind comparison of pramipexole and bromocriptine treatment with placebo in advanced Parkinson’s disease. Long-term study or pergolide in Parkinson’s disease. Pergolide in the treatment of patients with early and advanced Parkinson’s disease. A Multicenter double-blind placebo controlled trial of pergolide as adjunct to Sinemet in the treatment of Parkinson’s disease. Bromocriptine for levodopa-induced motor complications in Parkinson’s disease. Falling asleep at the wheel; motor vehicle mishaps in persons taking pramipexole and ropinirole. Pathologic gambling in patients with Parkinson’s disease. Pramipexole in patients with early Parkinson’s disease. Pramipexole versus levodopa as initial treatment for Parkinson’s disease: a four-year randomized controlled trial. Clinical evaluation of pramipexole in advanced Parkinson’s disease: results of a randomized, placebo-controlled, parallel group study. Ropinirole for the treatment of early Parkinson’s disease. Rascol O, Brooks DJ, Korczyn AD, De Deyn PP, Clarke CE, Lang AE. A five-year study of the incidence of dyskinesia in patients with early Parkinson’s disease who were treated with ropinirole or levodopa.

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These methods have been now used in the GPi and STN to deliver high-frequency stimulation instead of creating lesions in those nuclei 16mg duetact with visa. DEEP BRAIN STIMULATION HARDWARE 1 1 The Activa Tremor Control therapy and the Activa Parkinson Control therapy are approved therapies in the United States and Europe duetact 16 mg with amex. These devices and other hardware have undergone multiple changes since they were first introduced buy duetact 16 mg amex. Presently the implanted hardware is manufactured by Medtronic order 16 mg duetact otc, Inc. The Activa Tremor Control and Parkinson Control therapies consist of a DBS lead, an extension wire that connects the DBS lead to an implantable pulse generator (IPG), and the neurostimulator. The intracranial end of both leads has four platinum-iridium contacts. The DBS leads are connected to the neurostimulator by the extension wire that is tunneled under the skin. There have been multiple models of stimulators 1 that have been used for Activa therapy. The Itrel II Neurostimulator, 1 1 Model 7424 was initially used. The Soletra Model 7426 and Kinetra are the two neurostimulators presently available. The Kinetra has the advantage of using one stimulator to control both sides, instead of two separate Soletra neurostimulators, one for each side. The neurostimulators are typically implanted subcutaneously in the infraclavicular area. The neurostimulators can be programmed for monopolar stimulation or bipolar stimulation. Adjustable parameters include pulse width, amplitude, stimulation fre- Copyright 2003 by Marcel Dekker, Inc. The patient can turn the 1 stimulator on or off using a hand-held magnet or using Access Review , which also has a feature to tell the patient if the neurostimulator is on or off. The typical stimulation parameters are stimulation frequency of 135– 185 Hz, pulse width of 60–120 ms, and amplitude of 1–3 v. ADVANTAGES AND DISADVANTAGES OF DBS The advantages of the DBS system include no destructive lesion in the brain, adjustment of stimulation parameters to increase efficacy or reduce adverse effects, bilateral operations with relative safety and reduced adverse effects, and the potential use of future neuroprotective therapies when available. The disadvantages include cost of the system, time and effort involved in programming the system, repeat surgeries related to device problems, use of general anesthesia to implant the stimulator, and battery replacement every 3–7 years. DEEP BRAIN STIMULATION OF THE THALAMUS Efficacy Studies DBS of the thalamus is increasingly replacing thalamotomy as the preferred surgery for the treatment of medication resistant PD tremor. There are multiple reports regarding the efficacy of these procedures for parkinsonian tremor (Table 1) (4–17). The majority of the studies have reported that even though tremor is markedly improved, this often does not result in improvement in activities of daily living. As DBS of the thalamus does not improve bradykinesia, rigidity, or drug-induced dyskinesias, this procedure should be restricted to PD patients whose major disability is tremor. TABLE 1 Selected Studies of Deep Brain Stimulation of the Thalamus Number Tremor Follow-up Author of implants improvement (%) (months) Benabid et al. There are very few randomized, controlled trials of thalamic DBS in PD. Open-label evaluations have indicated that 65–95% of patients have improvement in tremor (5,6,8,9). Studies with randomized, blinded evaluations have confirmed the results of unblinded studies. The majority of the studies evaluated the efficacy of unilateral thalamic stimulation.

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A splint that is entirely volar based can provide finger support or have the fingers free generic duetact 17 mg on-line. A dorsal-based resting hand splint will provide wrist dorsiflexion discount 17mg duetact amex, finger exten- sion cheap 16 mg duetact, thumb abduction purchase 17mg duetact otc, and correction wrist ulnar deviation (A, B). The splint tends to be easy for caretakers to apply and is comfort- able if no excessive stretch is applied at the time of construction. For postoperative sup- port, the dorsal-based wrist extension splint is used during the day so that the child can start using active finger flexion. B tion and extension as well as finger abduction (Figure 6. Often, children tolerate these splints poorly immediately after initial splint construction. However, if the wear time is gradually increased, a goal of 4 to 8 hours per 24-hour period can often be achieved. This goal is ideal if children can tol- erate the orthotic for this length of time; however, it is still worthwhile even if they can only tolerate the orthotic for 2 to 4 hours per day. Thumb Splint Thumb abduction and flexion is another common deformity. In most cases, this thumb deformity is combined with finger flexion and wrist flexion con- tractures, especially in children with quadriplegic pattern CP; therefore, the thumb deformity can be splinted using the global resting hand splint. For younger children with hemiplegia, thumb abduction can make finger grasp difficult. Using small, soft thumb abduction splints or low-temperature- molded abduction splints (Figure 6. These splints should be limited to the absolute minimal amount of skin coverage possible because all skin coverage will reduce sensory feedback and the children will tend not to use their extremity. Swan Neck Splints Extensor tendon imbalance in the fingers may cause the fingers to become locked, with hyperextension of the proximal interphalangeal joint (PIP). This imbalance is most common in the long and ring fingers but occasionally oc- curs in the index finger. A metal or plastic figure-of-eight splint to prevent this hyperextension can be made (Figure 6. Usually, a plastic splint is used 186 Cerebral Palsy Management A Figure 6. Thumb abduction splints can be constructed from a number of materials. Using low-temperature plastic, a well-molded first and, if individuals find the splinting function beneficial, a metal splint splint can be formed (A). There are also many is made, which is very cosmetically appealing because it looks like a cosmetic commercial splints available that are often finger ring. In some individuals, these rings become uncomfortable because more comfortable for the child (B, C). These of the amount of force that the ring exerts over the very narrow area of skin. It is this narrow skin pressure that may limit the use of ring orthoses. Spinal Orthoses Soft Thoracolumbar Sacral Orthosis (TLSO) Most children with CP who develop scoliosis are nonambulatory children with quadriplegic pattern involvement. The scoliosis is in no way impacted by the use of orthotics. The preferred orthotic is a soft thoracolumbar sacral orthosis (TLSO) with metal or plastic stays that are embedded in a soft plastic material (Figure 6. This soft ma- terial is well tolerated by sensitive skin and does not apply high areas of pres- sure. This soft TLSO works like a corset to support sitting.

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