Intradialytic breakthrough seizures refractory to multiple classes of antiepileptic medications are not common and can be due to many different reasons. Pyridoxine deficiency is an under-recognized cause of such seizures and frequently missed in clinical practice. Many factors specifically related to dialysis can lead to pyridoxine deficiency and in turn can contribute to refractory seizures. Herein, we report one of the very few cases of intradialytic breakthrough refractory seizures secondary to pyridoxine deficiency recognized in the literature.

Parkinson\'s disease (PD) is the second most common neurodegenerative disease and is growing in prevalence and disability. The standard treatment for PD is oral levo-dopa (LD) with carbidopa (CD). As PD progresses, despite higher doses of LD/CD, plasma levels of LD fluctuate, and may be associated with motor fluctuations and dyskinesia.
The development of two new subcutaneous preparations of LD/CD (ND0612 and ABBV-951) for the treatment of motor fluctuations in PD is described in detail. Both reduce motor fluctuations and dyskinesia with minor infusion site adverse events. A third subcutaneous preparation, DIZ102, is in early-stage development.
The premise for using continuous release LD in advanced PD is that steady state levels of LD will prevent motor fluctuations/dyskinesia, but this is not the whole story, and will limit the benefits of subcutaneous continuous release LD. With its present pump system ND0612 cannot be used as monotherapy, whereas ABBV-951 can be. Having to combine with oral LD/CD will complicate the use of ND0612. Both ND0612 and ABBV-951 only cause modest reductions in OFF time. It is not clear whether these subcutaneous preparations will have more benefits than the intestinal gel, which also reduces OFF time and dyskinesia.

Malignant syndrome (MS) in Parkinson\'s disease (PD) is a rare complication that occurs in patients who have a history of PD and are taking dopaminergic drugs. The syndrome is quite similar to neuroleptic malignant syndrome (NMS) in presentation and is a potentially fatal syndrome. Awareness of symptoms, early diagnosis, and the ability to differentiate it from NMS is important to prevent mortality. Clinical manifestations of MS are similar to NMS and include altered mentation, rigidity, fever, leukocytosis, and elevated serum creatine kinase (CK). However, MS is differentiated from NMS by the precipitating factors; of which, the commonest precipitating factor for MS is dopaminergic drug withdrawal or dose reduction while other less common causes include infection, dehydration, and hot weather. We present a rare case of MS in a patient with a history of PD precipitated by severe dehydration and hot weather in the absence of dopaminergic drug withdrawal. He presented with fever, severe rigidity, altered mentation, dehydration, leukocytosis, and elevated CK. He was correctly diagnosed with MS and promptly treated, preventing mortality. The triad of fever, severe rigidity, and altered sensorium in a patient with a history of PD should prompt evaluation for MS in addition to NMS to initiate appropriate treatment and prevent mortality.

Syndrome of inappropriate antidiuretic hormone secretion (SIADH) is the most common electrolyte disorder associated with neurological conditions. Parkinson\'s disease (PD) has not been known to be causative of SIADH. We present the case of a 71-year-old male patient with diabetes type II (T2DM) and hypothyroidism admitted with progressive confusion, slow speech, and severe fatigue for one week, accompanied by sluggish body movements for a few months. A neurological exam revealed mild arm rigidity, bradykinesia, resting tremors, and stiff gait. The exam was otherwise normal. Initial blood work showed hypo-osmolar hyponatremia (Na 122 mEq/L, serum osmolarity (Osm) 275 mOsm/kg, and urine Osm 672 mOsm/Kg). CT chest showed localized infiltrate. The initial diagnosis was SIADH secondary to pulmonary process, most probably pneumonia. After starting him on a fluid restriction of 1.5 L/day and urea 15 mg BID, sodium improved gradually to 133 mEq/L on discharge. Urine osmolality continued to be elevated ranging between 700 and 800 mOsm/Kg. An active pulmonary process was ruled out by a pulmonologist. Parkinsonism was diagnosed four weeks after discharge by Neurology who started carbidopa/levodopa. As extrapyramidal symptoms improved, urine osmolality improved as well to 400 mOsm/Kg. Sodium level was maintained between 135 and 137 while urea treatment was stopped and fluid restrictions removed. New-onset SIADH was thought to be secondary to Parkinson\'s disease. Parkinson\'s disease treatment (carbidopa/levodopa) is known to cause SIADH. In this case, the treatment itself and a dose increase led to improvement in sodium levels and urine osmolality concomitantly with the improvement of the patient\'s extrapyramidal symptoms.

Parkinsonism is a rare manifestation of brain tumors that has most commonly been reported in association with gliomas and meningiomas. In this paper, we describe a unique case of secondary Parkinsonism that was precipitated by a craniopharyngioma. A 42-year-old female presented with resting tremors, rigidity, and bradykinesia. Her past medical history was significant for a craniopharyngioma resection four months prior. The postoperative course was complicated by severe delirium, panhypopituitarism, and diabetes insipidus. Notably, she was taking haloperidol and aripiprazole daily for four months to manage her delirium and psychotic episodes. Her preoperative brain MRI showed a compressive effect of the craniopharyngioma on the midbrain and nigrostriatum. Drug-induced Parkinsonism was initially suspected given extended treatment with antipsychotics. Haloperidol and aripiprazole were stopped, and benztropine was started with no improvement. Consequently, the patient was treated with carbidopa/levodopa with symptomatic improvement. A dopamine transporter (DaT) scan was done after starting carbidopa/levodopa and showed asymmetric decreased uptake in dopamine transporter in the striatum. Only one other case of Parkinsonism following craniopharyngioma resection was found in the literature review. Unlike our example, the symptoms resolved following surgical intervention and did not require a long-term treatment with carbidopa/levodopa. The purpose of our case report is to highlight brain tumors as a potential cause of secondary Parkinsonism in younger patients for an early surgical intervention can be curative.

Parkinson\'s disease (PD) is an increasing threat to first-world nations as their population ages, with around one in 100 suffering from it by age 60. Incurable, with treatments that do little to delay disease progression, PD induces severe disability and even death in those afflicted. The search for preventative measures has revealed the widely used psychoactive stimulant caffeine, which competitively inhibits adenosine receptors to induce a wide variety of effects. The inhibition of inflammation and microglial cell activation to reduce reactive oxygen species (ROS)-induced cellular damage and the resultant mitochondrial dysfunction of the dopaminergic neurons appears to be the main pathway, inducing neuronal loss via the activation of the intrinsic pathway to apoptosis. Mouse models and human data reinforce that caffeine delays the onset of PD in a dose-dependent manner. Evidence suggests it is more beneficial in men than women and is not beneficial at all in women undergoing hormone replacement therapy (HRT). Additionally, some studies suggest that although caffeinated drinks such as cola and tea are beneficial, there may be other products in coffee that prevent the effect, though this requires further research. Although there is strong evidence that caffeine is neuroprotective, there is less evidence that it delays the onset of PD. Given the association with cardiovascular disease, it may be disadvantageous overall to the majority of the population to supplement caffeine, though still a beneficial preventative technique for individuals with a genetic predisposition to PD that may otherwise suffer early onset.

Parkinsonism-hyperpyrexia syndrome (PHS) is a rare, potentially fatal neurological emergency, that is seen in Parkinson\'s Disease (PD) patients and mimics neuroleptic malignant syndrome. The most common trigger for PHS is sudden withdrawal of anti-parkinsonian medications, specifically levodopa. However, it can also be due to Deep Brain Stimulation (DBS) device malfunction. In this work, we describe three cases of PHS; the first of which is related to DBS battery depletion, and the remaining two to dopaminergic withdrawal. Additionally, we will include the results of a literature review on PHS, its etiologies, presentation, and management.

Parkinson\'s disease (PD) is the second most frequent neurodegenerative disorder following Alzheimer\'s disease. Advanced stages of PD, 4 or 5 of the Hoehn and Yahr Scale, are characterized by severe motor complications, limited mobility without assistance, risk of falling, and non-motor complications. The aim of this review was to provide a practical overview on specific artificial intelligence (AI) systems for the management of advanced stages of PD, as well as relevant technological limitations. The authors conducted a systematic search on PubMed and EMBASE with predefined keywords searching for studies published until December 2020. Full articles that satisfied the inclusion criteria were included in the systematic review. To minimize results bias, the reference list was manually searched for pertinent articles to identify any additional relevant missed publications. Exclusion criteria included the following: Other stages of PD than 4 and 5 of the Hoehn and Yahr Scale, case reports, reviews, practice guidelines, commentaries, opinions, letters, editorials, short surveys, articles in press, conference abstracts, conference papers, and abstracts published without a full article. The search identified 21 studies analyzing AI-based applications and robotic systems used for the management of advanced stages of PD, out of which 6 articles analyzed AI-based applications for autonomous management of pharmacologic therapy, 5 articles analyzed home-based telemedicine systems and 10 articles analysed robot-assisted gait training systems. The authors identified significant evidence demonstrating that current AI-based technologies are feasible for automatic management of patients with advanced stages of PD. Improving the quality of care and reducing the cost for patients and healthcare systems are the most important advantages.

OBJECTIVE: To assess the role, efficacy and tolerability of levodopa-carbidopa in the management of small and older children with different types of amblyopia.
METHODS: Prospective randomised placebo controlled clinical study, in which 50 amblyopic patients between 5 and 20 years of age with visual acuity (V/A) < 20/40 were included, was carried on. After having attained the best possible refractive correction, patients were randomly divided into 2 groups. They were prescribed levodopa-carbidopa (10:1) (4-6mg/kg/day in 2-3 divided doses) or placebo, plus full-time occlusion of the sound eye, for a period of three months. Assessment of improvement in V/A, compliance and tolerance was done at follow up visits. Data was analyzed using computer software Ms-Excel and Epi-Info Version 6.0. The statistical significance was assessed by Chi-Square/Fisher\'s Exact Test.
RESULTS: Visual acuity for the amblyopic eye improved significantly in both groups but there was significant improvement in group 1 than group 2 (P = 0.0001). In a subgroup of patients older than 12 years, levodopa group showed statistically significant improvement in baseline V/A (P = 0.0001). In patients with severe amblyopia, each group showed significant improvement in baseline V/A (p < 0.05), but was significantly more in group 1 (P = 0.0001). Compliance rates were similar among the groups and levodopa-carbidopa at a dose range of 4-6 mg/kg/day was well tolerated.
CONCLUSIONS: Levodopa-carbidopa can be used as an adjunct to conventional occlusion therapy in amblyopia particularly in older children and severe cases of amblyopia, and it is well tolerated.