Objective: To highlight the importance of GME training on screening for cervical dystonia in patients presenting for headaches or cervicalgia. Background: Cervical dystonia (CD) is a condition of involuntary overactivation of the cervical musculature resulting in abnormal head posture. Notably, comorbid headache in CD is present in up to 75% of patients. Although the prevalence of CD is reported to be quite low, underdiagnosis or misdiagnosis is common. This is likely due to the challenging physical diagnosis often requiring a movement disorder specialist, and the lack of focused training in neurology residency programs. Although CD can improve with Botulinum toxin (BT), greater than 50% of patients remain untreated. Design/Methods: From 2017–2020, an IRB-reviewed Quality Improvement Project was initiated by a Movement Disorder Neurologist in a GME-Residency program. Chart review was performed on all patients presenting for headache, migraine, or cervicalgia, and the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) was performed to assess for comorbid cervical dystonia. Results: During this timeframe, 6455 patients presented for headache, migraine, cervical dystonia, or cervicalgia. 306 patients were diagnosed with both cervicalgia and headache. Of those patients, 5% were ultimately diagnosed with cervical dystonia. All diagnoses of cervical dystonia were made by a Movement Disorder Neurologist or resident trained in this screening approach. All patients diagnosed with cervical dystonia had chronic headaches, and most had daily headaches. Of patients diagnosed with cervical dystonia, 86% were started on treatment with BT, with a 91% success rate. Conclusions: Patients with cervical dystonia commonly present to Neurology for headache or migraine, as comorbid pain is frequent. Underdiagnosis of dystonia may lead to suboptimal treatment choices. Formalized training of residents to use TWSTRS on patients with headache and cervicalgia may enhance diagnosis and improve treatment outcomes. Disclosure: Dr. Inoue has nothing to disclose. Dr. Dalton has nothing to disclose. Dr. Hack has nothing to disclose. Dr. Baker has nothing to disclose.

Patients with Parkinson’s disease admitted to the hospital have unique presentations. This unique subset of patients requires a multidisciplinary approach with a knowledge-based care team that can demonstrate awareness of complications specific to Parkinson’s disease to reduce critical care admissions, morbidity, and mortality. Early recognition of toxic exposures, medication withdrawals, or medication-induced symptoms can reduce morbidity and mortality. This review can assist in the critical assessment of new or exacerbating Parkinson’s disease symptoms.

Background Botulinum toxin type A (BoNTA) injection into the masticatory muscles has been widely used to treat a number of painful and nonpainful conditions; however, no systematic reviews have been performed on the long-term effect to the mandibular bone. Objective Our systematic review aimed to evaluate the impact of botulinum toxin injection into the masticatory muscles on mandibular bone based. Methods PubMed, Embase, Ovid, CINAHL and Web of Science were searched for human studies assessing mandibular bone after injection of BoNTA using computed tomography (CT) and cone beam CT (CBCT). Results Seven studies were eligible for review; five reported significant bony changes to one or more areas of the mandible. Most frequently affected were the condylar head, coronoid process and ramus. The most frequent changes were decreased bone volume, cortical thickness and cortical and trabecular density. Conclusions This is the first systematic review to examine an association between BoNTA injection into the masticatory muscles and mandibular bone quality. Data were analysed from a limited number of studies with a small sample size, and the quality of the included studies was very low. While the majority of available evidence suggests BoNTA injection results in bony change, further study is required to confirm a dose-dependence effect and the impact of gender and age. High-quality trials should utilise a combination of software analysis and radiologist review, with longer-term follow-up to monitor for persistence of bony effect and clinical significance.

Friday, May 1April 14, 2020Free AccessMindfulness as an Adjunctive Treatment Strategy for Reduction of Migraine Pain During a Single Office Visit (773)Virginia Baker, Andrew Garrett, and Nawaz HackAuthors Info & AffiliationsApril 14, 2020 issue94 (15_supplement)https://doi.org/10.1212/WNL.94.15_supplement.773 Letters to the Editor

Wednesday, April 29April 14, 2020Free AccessA Multidisciplinary Approach to Psychiatric Comorbidities in a Military Migraine Population (747)Virginia Baker and Nawaz HackAuthors Info & AffiliationsApril 14, 2020 issue94 (15_supplement)https://doi.org/10.1212/WNL.94.15_supplement.747 Letters to the Editor

Objective This quality improvement project was implemented in order to highlight the association between headache, mTBI and depression on lost productivity and resource utilization. Background Mood disorders, environment and traumatic brain injury are common in patients with headache, and have been shown to influence clinical course, treatment response and outcome. Although widely recognized, the association of these factors on clinical outcomes, resource utilization and productivity is not well understood. Methods All patients presenting to a military referral center for migraines are assessed for presence of traumatic brain injury, Headache Impact Score (HIT-6) and Patient Depression Questionnaire (PHQ-9). Based on screening, patients are offered referral to mental health and a multidisciplinary headache education course. Results 237 patients were seen for headache or migraine. 180 patients had severely disabling headaches. These patients accounted for 146 emergency room visits over the course of one year. Of headache patients, 65% met criteria for depression and 15% of patients had severe depression. Only 37% of these patients carried a formal diagnosis of depression and 38% had been seen by mental health. Lost productivity and duty limitations were significantly associated with severity of depression. In service members screening positively for mild, moderate or severe depression, duty restrictions had been placed on 8.3%, 32.5% and 53.8%, respectively. Only 3.8% of patients who did not screen for depression had similar duty limitations. A history of mTBI strongly correlated with comorbid depression. Lost productivity and duty limitations were not impacted by other headache characteristics or HIT-6 scores. Conclusions This quality improvement project identified a practice gap for treatment of comorbid depression in patients presenting to Neurology for headache. Depression strongly correlated with productivity loss, highlighting a possible target for the economic burden of headache.

Toxins identified as causing parkinsonism and being related to overall idiopathic Parkinson disease risk range from heavy metals to pesticides to contaminants in synthetic heroin. Several described in this article exhibit significant oxidative stress on neurons of the central nervous system and have a particular predilection toward damage of dopaminergic neurons. Although many of these toxins have well-established connections with Parkinson disease risk, a few continue to be studied with data still being produced. The parkinsonisms caused by these agents have variable responses to dopaminergic therapies. This article discusses manganese, mercury, MPTP, organochlorines, organophosphates, paraquat, rotenone, and Agent Orange.

Monday, April 27April 14, 2020Free AccessThe Use of Leadership Training to Improve Access to Care in a Deployed Setting (783)Virginia Baker and Nawaz HackAuthors Info & AffiliationsApril 14, 2020 issue94 (15_supplement)https://doi.org/10.1212/WNL.94.15_supplement.783 Letters to the Editor

Tuesday, April 28April 14, 2020Free AccessThe First Graduate Medical Education-led Quality and Safety Team in the Military at the Largest Health Care System in the United States (765)Erick Roff, Steven McKnight, Virginia Baker, and Nawaz HackAuthors Info & AffiliationsApril 14, 2020 issue94 (15_supplement)https://doi.org/10.1212/WNL.94.15_supplement.765 Letters to the Editor

Objective To evaluate the efficacy of increasing access to care for patients with migraines in a rural setting. Outcomes include decreased resource utilization, decreased hospitalizations, polypharmacy reduction, and decreased disability in a remote Pacific population. Methods Data were collected on all patients presenting to a single neurologist in a deployed military setting for migraines. Access to care was supplemented through health fairs, radio shows, telemedicine, and education of primary care providers. Results Over the course of 1 year, 300 providers were educated through public health fairs and telemedicine counseling. This strategy helped reduce consults by 50% and decrease clinic wait times from 2 months to 7 days. Two hundred twenty-one patients with chronic migraine or episodic migraine were seen in the neurology clinic over the course of 1 year. Of these patients, polypharmacy reduction was achieved in 71% of patients with chronic migraines and in 44% of patients with episodic migraines. Over the course of 1 year, only 13% of patients with chronic migraines and 11% of patients with episodic migraines were treated in an acute care setting. Less than 2% of patients had limitations in their work duties because of migraines. Conclusion Increased access to care provided benefits in reduction of specialist overutilization, reduction in hospitalizations, and reduction in disability. Patients with chronic migraine did not have increased use of medical resources or decreased productivity in this cohort.

May 9, 2019April 9, 2019Free AccessAn Interdisciplinary Approach Between Neurology and Neurosurgery for the Treatment of Headaches in the Setting of Aqueductal Stenosis (P5.10-005)Virginia Baker, Nawaz Hack, and Laurence DavidsonAuthors Info & AffiliationsApril 9, 2019 issue92 (15_supplement) Letters to the Editor

•Dopa-responsive Dystonia (DRD) is a levodopa responsive, progressive, lower extremity dystonia with diurnal variation. •This condition can manifest with other symptoms including intellectual disability, seizures, autonomic dysfunction, and cerebral palsy. •DRD can cause pure hypotonia without dystonia or other extrapyramidal signs. •Consider this diagnosis and a trial of Levodopa in pediatric patients with unexplained hypotonia.

April 27, 2018April 10, 2018Free AccessUsing Botox, biofeedback and lifestyle modifications as therapy for medication refractory post-traumatic headache (PTHA) in the military population of Okinawa. (P6.295)Nawaz Hack and Kathryn EliasenAuthors Info & AffiliationsApril 10, 2018 issue90 (15_supplement)https://doi.org/10.1212/WNL.90.15_supplement.P6.295 Letters to the Editor

April 26, 2018April 10, 2018Free AccessTelemedicine as a pivotal part of rural neurology and migraine management. (P5.162)Nawaz Hack, Claudio Osorio, and Regine ReimersAuthors Info & AffiliationsApril 10, 2018 issue90 (15_supplement) Letters to the Editor

ObjectiveOur aim was 1) to reduce disability, as characterized by headache frequency, duration and severity in patients with post-traumatic headache (PTHA), 2) to reduce the number of medical boards and work limitations in patients with post traumatic headache, and 3) to reduce use of medical resources and clinic visits related to headache or migraine.BackgroundModifiable risk factors for PTHA include stressful life event, sleep disturbances, and medication overuse. Cognitive-behavioral strategies, biofeedback, and relaxation therapy may have an important role in treatment and preventing progression to chronic post-traumatic headache (CPTHA). There is limited literature and a known practice gap for implementation of these techniques.Design/methodsAn IRB approved project focused on patients who were seen for PTHA and CPTHA. 1) Intervention consisted of lifestyle teaching, cognitive-behavioral therapy and biofeedback, supplemented by decreasing polypharmacy. 2) Patients were followed for 2years and a retrospective review was conducted for 2years prior to presentation. 3) Outcome measures included reduction in migraine intensity or frequency, improved quality of life, duty status, and decreased utilization of clinic visits.ResultsOver the course of one year, 221 patients were treated for migraines in the Naval Okinawa Neurology Clinic. Of these, 22 active duty service members and 3 Dependents suffered a mild TBI prior to onset. After intervention, there was a 36% decrease in PTHA frequency, 56% decrease in headache severity and 60% of patients had improved quality of life as compared to the 2years prior to intervention. Twenty-four percent had reduction in polypharmacy. Appointment frequency for migraine decreased from an average of 6.8 to 2.6 per year.ConclusionsAn implemented program geared towards reducing polypharmacy was shown to improve safety, quality of life and reduce hospitalizations from the burden of migraines. Our systematic approach resulted in quality of life improvements and decreased use of medical resources.Trial registrationAuthors received the approval of NAVMED West, Okinawa Naval Hospital Institutional Review Board on January 13th, 2016. QI.2016.0021.

Importance:Although seroepidemiological studies indicate that greater than 50% of the population has been infected with John Cunningham virus (JCV), the sites of JCV persistence remain incompletely characterized.Objective:To determine sites of JCV persistence in immunologically healthy individuals.Design, Setting, and Participants:Tissue specimens from multiple sites including brain, renal, and nonrenal tissues were obtained at autopsy performed in the Department of Pathology at the University of Kentucky from 12 immunologically healthy patients between February 9, 2011, and November 27, 2012. Quantitative polymerase chain reaction was performed on the tissue specimens and urine. Serum JCV antibody status was determined by enzyme-linked immunosorbent assay.Main Outcomes and Measures:The detection and quantification of JCV from the tissues by quantitative polymerase chain reaction illuminated sites of viral persistence. These results were correlated with JCV antibody levels.Results:Autopsies were performed on 12 individuals, 10 men and 2 women, ranging in age from 25 to 75 years (mean, 55.3 years). Seven of 12 individuals were JCV antibody seropositive based on absorbance units. Serostatus was associated with amounts of JCV DNA in urine and its tissue distribution. John Cunningham virus DNA was found in 75% of genitourinary tissue samples from donors (18 of 24) with high JCV antibody levels, 13.3% of donors with low levels i(4 of 30), and 0% of seronegative persons (0 of 32). In nongenitourinary tissues, JCV DNA was detected in 45.1% of tissue samples of donors (32 of 71) with high JCV, 2.2% of donors with low JCV serostatus (2 of 93), and 0% of seronegative persons (0 of 43). Genitourinary tissues had higher copy numbers than other sites. John Cunningham virus DNA was detected in urine of seronegative individuals in a research-grade assay.Conclusions and Relevance:Persistent (latent or actively replicating) JCV infection mostly predominates in genitourinary tissues but distributes in other tissues at low copy number. The distribution and copy numbers of the virus appear to correlate with urinary JCV shedding and serostatus.