A randomized, double-blind, placebo-controlled trial of antidepressants in Parkinson disease

OBJECTIVE

To evaluate the efficacy and safety of a selective serotonin reuptake inhibitor (SSRI) and a serotonin and norepinephrine reuptake inhibitor (SNRI) in the treatment of depression in Parkinson disease (PD).

METHODS

A total of 115 subjects with PD were enrolled at 20 sites. Subjects were randomized to receive an SSRI (paroxetine; n = 42), an SNRI (venlafaxine extended release [XR]; n = 34), or placebo (n = 39). Subjects met DSM-IV criteria for a depressive disorder, or operationally defined subsyndromal depression, and scored >12 on the first 17 items of the Hamilton Rating Scale for Depression (HAM-D). Subjects were followed for 12 weeks (6-week dosage adjustment, 6-week maintenance). Maximum daily dosages were 40 mg for paroxetine and 225 mg for venlafaxine XR. The primary outcome measure was change in the HAM-D score from baseline to week 12.

RESULTS

Treatment effects (relative to placebo), expressed as mean 12-week reductions in HAM-D score, were 6.2 points (97.5% confidence interval [CI] 2.2 to 10.3, p = 0.0007) in the paroxetine group and 4.2 points (97.5% CI 0.1 to 8.4, p = 0.02) in the venlafaxine XR group. No treatment effects were seen on motor function.

CONCLUSIONS

Both paroxetine and venlafaxine XR significantly improved depression in subjects with PD. Both medications were generally safe and well tolerated and did not worsen motor function.

CLASSIFICATION OF EVIDENCE

This study provides Class I evidence that paroxetine and venlafaxine XR are effective in treating depression in patients with PD.

Cognitive performance of GBA mutation carriers with early-onset PD: the CORE-PD study

OBJECTIVE

To assess the cognitive phenotype of glucocerebrosidase (GBA) mutation carriers with early-onset Parkinson disease (PD).

METHODS

We administered a neuropsychological battery and the University of Pennsylvania Smell Identification Test (UPSIT) to participants in the CORE-PD study who were tested for mutations in PARKIN, LRRK2, and GBA. Participants included 33 GBA mutation carriers and 60 noncarriers of any genetic mutation. Primary analyses were performed on 26 GBA heterozygous mutation carriers without additional mutations and 39 age- and PD duration-matched noncarriers. Five cognitive domains, psychomotor speed, attention, memory, visuospatial function, and executive function, were created from transformed z scores of individual neuropsychological tests. Clinical diagnoses (normal, mild cognitive impairment [MCI], dementia) were assigned blind to genotype based on neuropsychological performance and functional impairment as assessed by the Clinical Dementia Rating (CDR) score. The association between GBA mutation status and neuropsychological performance, CDR, and clinical diagnoses was assessed.

RESULTS

Demographics, UPSIT, and Unified Parkinson's Disease Rating Scale-III performance did not differ between GBA carriers and noncarriers. GBA mutation carriers performed more poorly than noncarriers on the Mini-Mental State Examination (p = 0.035), and on the memory (p = 0.017) and visuospatial (p = 0.028) domains. The most prominent differences were observed in nonverbal memory performance (p < 0.001). Carriers were more likely to receive scores of 0.5 or higher on the CDR (p < 0.001), and a clinical diagnosis of either MCI or dementia (p = 0.004).

CONCLUSION

GBA mutation status may be an independent risk factor for cognitive impairment in patients with PD.

A comparison of nine scales to detect depression in Parkinson disease: which scale to use?

OBJECTIVE

The Methods of Optimal Depression Detection in Parkinson's Disease (MOOD-PD) study compared the psychometric properties of 9 depression scales to provide guidance on scale selection in Parkinson disease (PD).

METHODS

Patients with PD (n = 229) from community-based neurology practices completed 6 self-report scales (Beck Depression Inventory [BDI]-II, Center for Epidemiologic Studies Depression Rating Scale-Revised [CESD-R], 30-item Geriatric Depression Scale [GDS-30], Inventory of Depressive Symptoms-Patient [IDS-SR], Patient Health Questionnaire-9 [PHQ-9], and Unified Parkinson's Disease Rating Scale [UPDRS]-Part I) and were administered 3 clinician-rated scales (17-item Hamilton Depression Rating Scale [HAM-D-17], Inventory of Depressive Symptoms-Clinician [IDS-C], and Montgomery-Åsberg Depression Rating Scale [MADRS] and a psychiatric interview. DSM-IV-TR diagnoses were established by an expert panel blinded to the self-reported rating scale data. Receiver operating characteristic curves were used to estimate the area under the curve (AUC) of each scale.

RESULTS

All scales performed better than chance (AUC 0.75-0.85). Sensitivity ranged from 0.66 to 0.85 and specificity ranged from 0.60 to 0.88. The UPDRS Depression item had a smaller AUC than the BDI-II, HAM-D-17, IDS-C, and MADRS. The CESD-R also had a smaller AUC than the MADRS. The remaining AUCs were statistically similar.

CONCLUSIONS

The GDS-30 may be the most efficient depression screening scale to use in PD because of its brevity, favorable psychometric properties, and lack of copyright protection. However, all scales studied, except for the UPDRS Depression, are valid screening tools when PD-specific cutoff scores are used.

The relation between depression and parkin genotype: the CORE-PD study

BACKGROUND

Mutations in parkin are a known genetic risk factor for early onset Parkinson's disease (EOPD) but their role in non-motor manifestations is not well established. Genetic factors for depression are similarly not well characterized. We investigate the role of parkin mutations in depression among those with EOPD and their relatives.

METHODS

We collected psychiatric information using the Patient Health Questionnaire and Beck Depression Inventory II on 328 genotyped individuals including 88 probands with early onset PD (41 with parkin mutations, 47 without) and 240 first and second-degree relatives without PD.

RESULTS

Genotype was not associated with depression risk among probands. Among unaffected relatives of EOPD cases, only compound heterozygotes (n = 4), and not heterozygotes, had significantly increased risk of depressed mood (OR = 14.1; 95% CI 1.2-163.4), moderate to severe depression (OR = 17.8; 95% CI 1.0-332.0), depression (score ≥ 15) on the Beck Depression Inventory II (BDI-II) (OR = 51.9; 95% CI 4.1-657.4), and BDI-II total depression score (β = 8.4; 95% CI 2.4-11.3) compared to those without parkin mutations.

CONCLUSIONS

Relatives of EOPD cases with compound heterozygous mutations and without diagnosed PD may have a higher risk of depression compared to relatives without parkin mutations. These findings support evidence of a genetic contribution to depression and may extend the phenotypic spectrum of parkin mutations to include non-motor manifestations that precede the development of PD.

Clinical vignettes in Parkinson's disease: a collection of unusual medication-induced hallucinations, delusions, and compulsive behaviours

Hallucinations, delusions, and compulsive behaviors are frequent iatrogenic complications of the treatment of motor dysfunction in Parkinson's disease (PD). Although these have been studied, and the phenomenology described, there are few detailed descriptions of the various psychiatric problems our treated PD patients live with that allow physicians who do not have a great deal of experience with PD patients to appreciate the extent of their altered lives. This report is a compilation of vignettes describing these behavioral problems that the treating neurologist or psychiatrist attributed to the medications used for treating PD.

Olfaction in Parkin heterozygotes and compound heterozygotes: the CORE-PD study

BACKGROUND

While Parkinson disease (PD) is consistently associated with impaired olfaction, one study reported better olfaction among Parkin mutation carriers than noncarriers. Whether olfaction differs between Parkin mutation heterozygotes and carriers of 2 Parkin mutations (compound heterozygotes) is unknown.

OBJECTIVE

To assess the relationship between Parkin genotype and olfaction in PD probands and their unaffected relatives.

METHODS

We administered the University of Pennsylvania Smell Identification Test (UPSIT) to 44 probands in the Consortium on Risk for Early-Onset Parkinson Disease study with PD onset ≤50 years (10 Parkin mutation heterozygotes, 9 compound heterozygotes, 25 noncarriers) and 80 of their family members (18 heterozygotes, 2 compound heterozygotes, 60 noncarriers). In the probands, linear regression was used to assess the association between UPSIT score (outcome) and Parkin genotype (predictor), adjusting for covariates. Among family members without PD, we compared UPSIT performance in heterozygotes vs noncarriers using generalized estimating equations, adjusting for family membership, age, gender, and smoking.

RESULTS

Among probands with PD, compound heterozygotes had higher UPSIT scores (31.9) than heterozygotes (20.1) or noncarriers (19.9) (p < 0.001). These differences persisted after adjustment for age, gender, disease duration, and smoking. Among relatives without PD, UPSIT performance was similar in heterozygotes (32.5) vs noncarriers (32.4), and better than in heterozygotes with PD (p = 0.001).

CONCLUSION

Olfaction is significantly reduced among Parkin mutation heterozygotes with PD but not among their heterozygous relatives without PD. Compound heterozygotes with PD have olfaction within the normal range. Further research is required to assess whether these findings reflect different neuropathology in Parkin mutation heterozygotes and compound heterozygotes.

New professional development system for UK engineers

In July 2007, the Engineering and Technology Board launched a pilot professional development system to guide and support UK engineers through the process of registration and beyond. The system, which manages the process by which engineers record their progress against professional objectives, has since been reviewed and updated in accordance with extensive user trials. It now provides a comprehensive, step-by-step framework for achieving recognition as either a chartered engineer (CEng), an incorporated engineer (IEng) or an engineering technician (Eng Tech). By mapping its users' progress against the requirements laid down in the UK Standard for Professional Engineering Competence (UK-Spec), and identifying individual gaps and challenges, the professional development system supports and guides its users along a structured career path.

The impact of depressive symptoms in early Parkinson disease

BACKGROUND

Depressive disorders may affect up to 50% of patients with Parkinson disease (PD) and are associated with increased disability and reduced quality of life. No previous study has systematically examined the impact of depressive symptoms in early, untreated PD.

METHODS

We administered the 15-item Geriatric Depression Scale (GDS-15) as part of two NIH-sponsored phase II clinical trials in PD, enrolling 413 early, untreated PD subjects. We used linear mixed models to examine the relationship of depressive symptoms, measured by the GDS-15, with motor function and activities of daily living (ADLs), as measured by the Unified PD Rating Scale (UPDRS). A time-dependent Cox model was used to examine the effect of demographic and clinical outcome measures as predictors of investigator-determined time to need for symptomatic therapy for PD.

RESULTS

A total of 114 (27.6%) subjects screened positive for depression during the average 14.6 months of follow-up. Forty percent of these subjects were neither treated with antidepressants nor referred for further psychiatric evaluation. Depression, as assessed by the GDS-15, was a significant predictor of more impairment in ADLs (p < 0.0001) and increased need for symptomatic therapy of PD (hazard ratio = 1.86; 95% CI 1.29, 2.68).

CONCLUSIONS

Clinically important depressive symptoms are common in early Parkinson disease (PD), but are often not treated. Depressive symptoms are an important contributor to disability and the decision to start symptomatic therapy for motor-related impairment in early PD, highlighting the broad importance of identifying and treating depression in this population.

Hypoxia-inducible-factor 2 alpha mediates cisplatin resistance in the lung adenocarcinoma cell line A549

10573

Background: Hypoxia in solid tumors is associated with cancer progression, metastasis and resistance to chemotherapy. The hypoxia inducible factors (HIF-1a and HIF-2a) are key players in the response to hypoxia affecting angiogenesis, proliferation and apoptosis. Here we investigated the role of HIF-1a and HIF-2a in cellular resistance to cisplatin in non small lung cancer cells (A549). Results: Hypoxia reduced the efficiency of cisplatin treatment on A549 cells via enhancement of drug efflux activity. In addition, hypoxia induced the hypoxia-responsive-element (HRE) reporter gene assay, demonstrating the transcriptional activity of HIF-1a and HIF-2a. Administration of cisplatin further increased the reporter activity under both normoxic and hypoxic conditions. This correlated with the induction of HIF-2a protein expression upon cisplatin treatment in normoxia and hypoxia, whereas HIF-1a was suppressed. Additionally, cisplatin induced nuclear accumulation of HIF-2a. Suppression of HIF-2a by RNA interference potentiated the sensitivity to cisplatin treatment in hypoxic A549 cells. In vivo growth delay assay gave analogues results for subcutaneous A549 tumors treated with cisplatin and suppression of HIF-2a. In comparison, other cytostatic drugs such as doxorubicin and gemcitabine differed with respect to HIF signalling. Doxorubicin induced both HIF-1a and HIF- 2a. Cellular sensitivity to doxorubicin was increased via suppression of HIF-1a and HIF-2a. Gemcitabine appeared to act independent of HIF. The underlying mechanism of hypoxia-induced resistance was due to increased mRNA expression of drug resistance proteins such as MDR1, MRP1 and LRP. These were found to be HIF-2a but not HIF-1a dependent. Conclusion: This data identified HIF-2a as a key player in the hypoxia induced cisplatin resistance and show on the molecular level that HIF-2a is a credible target for therapeutic strategies.

No significant financial relationships to disclose.

Phase II study of lenalidomide in patients (pts) with metastatic renal cell cancer (MRCC)

4533

Background: Immunomodulatory drugs are compounds that originated via the deliberate structural modification of thalidomide. Lenalidomide (Revlimid) is a derivative with enhanced immunological and anti-angiogenic properties lacking toxicities associated with thalidomide. Objectives were to determine response rate, time to progression (TTP), one-year survival, and toxicity in patients with progressive MRCC. Methods: Eligibility included: progressive measurable MRCC, adequate organ/marrow function, zubrod performance status (ZPS) ≤ 2, ≤ 1 prior therapy, and no active CNS involvement. Lenalidomide is administered orally at a dose of 25mg daily for 21 days with 7 days rest (28-day cycle), with dose modifications for toxicity. Re-evaluation is done every 3 cycles (12 weeks). RECIST criteria is utilized to determine response rate. TTP is determined from entry into study. Results: 40 pts enrolled. 30 male/10 female, range 38–73 (median 63) years. 38 pts had clear cell carcinoma; 2 pts with papillary. 24 pts received prior immunotherapy and/or chemotherapy. 3 pts met criteria for good prognosis, 33 intermediate and 4 poor. Sites of disease included: lung, nodal, bone, adrenal, kidney, and liver. 17 pts had 1 metastatic site, 13 pts 2 metastatic sites, and 10 pts 3 or more metastatic sites. 36 pts completed at least 12 weeks of therapy. 4 pts had early progressive disease. 1 pt had a CR, 2 pts achieved a PR. 52% of pts had a prolonged TTP ≥ 6 months and 25% ≥ 12 months. Median overall survival of 14.8 months (4.1− 22.2+). Treatment related adverse events included: reversible grade 1/2 non-hematologic toxicity consisting of: nausea, diarrhea, constipation, myalgia and fatigue. 19 pts with grade 3/4 neutropenia and 9 pts with grade 3/4 thrombocytopenia. Median duration of therapy is 6 months (2 - 22). Conclusion: Lenalidomide was well tolerated. Anti-tumor activity has been demonstrated by the following: tumor regression and delayed TTP. The tumor effect was also demonstrated as a second line therapy following cytokine failure.

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Interferon-alpha (INF) and gefitinib or imatinib in patients (pts) with metastatic renal cell carcinoma (RCC)

14616

Background: Overexpression of EGFR is associated with aggressive clinical behavior in several solid tumors and is frequent in RCC. We recently found that the majority of RCCs express c-kit and PDGFR-beta. EGFR tyrosine kinase (TK) is inhibited by GEF, while IM is an inhibitor of Bcr-Abl, c-kit and PDGFR TKs. IFN has activity in MRCC and is used in front-line therapy. This trial evaluates time to progression (TTP) determined from time of study entry and response rate of INF in combination with GEF or IM, as well as tumor expression of c-kit and EGFR-beta. Methods: Pts with MRCC were assigned to a treatment arm: IFN/GEF or IFN/IM. Eligibility included: MRCC, any previous therapy, PS ≤2, adequate organ/marrow function and no active CNS involvement. Pts received IFN 3MU subcutaneously TIW on week 1, then 6MU TIW thereafter. GEF dose is 500 mg and IM 600 mg daily. Tumor response is assessed using RECIST every 12 weeks. Results: 16 MRCC pts (12 M/4 F) with a median age of 58 (24–77) have been enrolled. Histology: 6 papillary, 7 clear cell, 1 chromophobe, 1 collecting duct and 1 unclassified. 14 pts received IFN/GEF and 4 pts IFN/IM. Two pts crossed over from IFN/IM to IFN/GEF. Of 14 pts on IFN/GEF, 3 demonstrated a partial response (PR) and 7 had stable disease at 12 weeks. Of 6 papillary, 3 had PR. 8 pts progressed on IFN/GEF at a median of 20 weeks (1–36). 4 pts are still on treatment. On IFN/IM, 3 pts had stable disease at 12 weeks, 2 at 24. 2 pts progressed at 4 and 14 weeks, two crossed over to GEF at 24 weeks. Adverse events of IFN/GEF included skin rash and diarrhea and of IFN/IM skin rash, thrombocytopenia and leukopenia. Both arms had flu-like symptoms and fatigue. Conclusions: IFN/GEF and IFN/IM combinations are well tolerated. Preliminary results show the potential of delaying TTP in pts with MRCC. The observed high tumor response rate of the papillary type to IFN/GEF requires validation in a larger number of pts. Enrollment is ongoing. Updated response data and tissue correlates will be presented.

[Table: see text]

A phase II trial to assess the activity of MVA5T4 plus interleukin-2 in patients (Pts) with metastatic renal cell carcinoma (MRCC)

14642

Background: MVA 5T4 consists of a highly attenuated vaccinia virus (modified Vaccinia Ankara, MVA) containing the human tumor associated antigen (TAA) 5T4. Greater than 90% of renal cell cancers are overexpressed by the 5T4 antigen. The primary purpose of this trial is to validate the hypothesis that, in this group of pts, it is possible to induce immune responses either humoral and/or cellular to 5T4 and to break tolerance to the antigen. The immune response will be correlated to clinical outcome. Methods: Eligibility included: pathologic diagnosis of confirmed clear cell or papillary cancer, progressive measurable MRCC, adequate organ/marrow function, Karnofsky Performance Status (KPS) ≥ 80%, any prior therapy, and no active CNS involvement. The dosage schedule of subcutaneous low dose IL-2 will be an initial dose 250,000 U/kg/dose for 5 days in week 1 followed by 125,000 U/kg/dose for 5 days each of weeks 2–6 inclusive. There will then be a 2 week recovery period before the next cycle commences. The dosage regimen of MVA 5T4 will be intramuscular injections given 14 days prior to the first cycle, day 0 and 1 injection given at the beginning of week 4 of the first cycle. In subsequent cycles, booster injections of MVA 5T4 will be given at week 1 only, prior to the commencement of subcutaneous IL-2 therapy. Results: 10 pts have been treated with MVA 5T4 and the LD IL2 regimen. The combination has been extremely well tolerated with no MVA 5T4 related events thus far. Although the study is still continuing to accrue, there are early signs of clinical responses in a number of patients receiving the combination. The immunological analysis is in progress. Conclusion: MVA 5T4 is well tolerated in this group of patients. The immune response will be presented along with clinical outcome.

[Table: see text]

Invariant sets for the varactor equation

The differential equation with f ( t ) positive, periodic and continuous is studied. After describing some physical applications of this equation, we construct a variety of invariant sets for it, thereby partitioning the phase plane into regions in which solutions grow without bound and also those in which bounded periodic solutions exist.

Differential impairment of spatial location memory in Huntington's disease

OBJECTIVE

To determine whether a differential impairment of spatial memory exists in Huntington's disease (HD).

METHODS

Patients with HD and age matched neurologically normal subjects, as well as patients with Alzheimer's disease (AD) and Parkinson's disease (PD), learned the locations of nine items on a 3 x 3 grid over as many as 10 trials. Delayed recall of the items and their spatial locations was tested.

RESULTS

Patient with HD performed worse than normal subjects on all measures, and intermediate between AD and PD patients. However, they were the only subject group in whom delayed recall of spatial locations was poorer than delayed recall of object identity. This effect was independent of the severity of dementia.

CONCLUSIONS

HD patients have a differential impairment in memory for object-location information. This finding may relate to the involvement of the caudate nucleus, the primary site of pathology in HD, in corticostriatal circuits linking it with parietal association cortex. It is also consistent with views of the dorsal striatum as responsible for the acquisition over trials of specific place responses.