The Experiences of Patients with Deep Brain Stimulation in Parkinson's Disease: Challenges, Expectations, and Accomplishments

OBJECTIVES

Deep brain stimulation (DBS) is a safe and effective alternative treatment of some movement disorders such as Parkinson's disease. Although DBS is an effective treatment for Parkinson's disease, because of the necessity of surgical intervention, follow-up and the effects on symptoms, this study was carried out to determine the challenges, expectations and accomplishments of patients with DBS in Parkinson's disease.

MATERIALS AND METHODS

This qualitative study was carried out at the Neurosurgery Department of a research hospital in Turkey with seven patients who underwent DBS between 2008 and 2018. In the study, the challenges, expectations, and accomplishments of patients were investigated by using three focus group interviews in October 2018.

RESULTS

Among the participants, six patients were male, and one patient was female. The mean age of the patients was 56.85±16.48. Three main themes were revealed in the study. These were (1) Reborn; decrease in dependence, sense of accomplishment, enjoyment of life, (2) Prejudice; perceived as severely ill by others and (3) Fear; not being accustomed to the device, loss of device function.

CONCLUSION

The results obtained from this study can be used in the process of adaptation to this process by discussing and evaluating the challenges, expectations and accomplishments of the Parkinson's patient in DBS with healthcare professionals and other patients.

GSK-3β inhibition by curcumin mitigates amyloidogenesis via TFEB activation and anti-oxidative activity in human neuroblastoma cells

The translocation of transcription factor EB (TFEB) to the nucleus plays a pivotal role in the regulation of basic cellular processes, such as lysosome biogenesis and autophagy. Autophagy is an intracellular degradation system that delivers cytoplasmic constituents to the lysosome, which is important in maintaining cellular homeostasis during environmental stress. Furthermore, oxidative stress is a critical cause for the progression of neurodegenerative diseases. Curcumin has anti-oxidative and anti-inflammatory activities, and is expected to have potential therapeutic effects in various diseases. In this study, we demonstrated that curcumin regulated TFEB export signalling via inhibition of glycogen synthase kinase-3β (GSK-3β); GSK-3β was inactivated by curcumin, leading to reduced phosphorylation of TFEB. We further showed that H₂O₂-induced oxidative stress was reduced by curcumin via the Nrf2/HO-1 pathway in human neuroblastoma cells. In addition, we showed that curcumin induced the degradation of amyloidogenic proteins, including amyloid-β precursor protein and α-synuclein, through the TFEB-autophagy/lysosomal pathway. In conclusion, curcumin regulates autophagy by controlling TFEB through the inhibition of GSK-3β, and increases antioxidant gene expression in human neuroblastoma cells. These results contribute to the development of novel cellular therapies for neurodegenerative diseases.

Clinical Perspectives of Parkinson's Disease for Ophthalmologists, Otorhinolaryngologists, Cardiologists, Dentists, Gastroenterologists, Urologists, Physiatrists, and Psychiatrists

Parkinson's disease (PD) is a multisystemic disorder characterized by various non-motor symptoms (NMS) in addition to motor dysfunction. NMS include sleep, ocular, olfactory, throat, cardiovascular, gastrointestinal, genitourinary, or musculoskeletal disorders. A range of NMS, particularly hyposmia, sleep disturbances, constipation, and depression, can even appear prior to the motor symptoms of PD. Because NMS can affect multiple organs and result in major disabilities, the recognition and multidisciplinary and collaborative management of NMS by physicians is essential for patients with PD. Therefore, the aim of this review article is to provide an overview of the organs that are affected by NMS in PD together with a brief review of pathophysiology and treatment options.

PECLIDES Neuro: A Personalisable Clinical Decision Support System for Neurological Diseases

Neurodegenerative diseases such as Alzheimer's and Parkinson's impact millions of people worldwide. Early diagnosis has proven to greatly increase the chances of slowing down the diseases' progression. Correct diagnosis often relies on the analysis of large amounts of patient data, and thus lends itself well to support from machine learning algorithms, which are able to learn from past diagnosis and see clearly through the complex interactions of a patient's symptoms and data. Unfortunately, many contemporary machine learning techniques fail to reveal details about how they reach their conclusions, a property considered fundamental when providing a diagnosis. Here we introduce our Personalisable Clinical Decision Support System (PECLIDES), an algorithmic process formulated to address this specific fault in diagnosis detection. PECLIDES provides a clear insight into the decision-making process leading to a diagnosis, making it a gray box model. Our algorithm enriches the fundamental work of Masheyekhi and Gras in data integration, personal medicine, usability, visualization, and interactivity. Our decision support system is an operation of translational medicine. It is based on random forests, is personalisable and allows a clear insight into the decision-making process. A well-structured rule set is created and every rule of the decision-making process can be observed by the user (physician). Furthermore, the user has an impact on the creation of the final rule set and the algorithm allows the comparison of different diseases as well as regional differences in the same disease. The algorithm is applicable to various decision problems. In this paper we will evaluate it on diagnosing neurological diseases and therefore refer to the algorithm as PECLIDES Neuro.

Frequency-Specific Optogenetic Deep Brain Stimulation of Subthalamic Nucleus Improves Parkinsonian Motor Behaviors

Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is an effective therapy for the motor symptoms of Parkinson's disease (PD). However, the neural elements mediating symptom relief are unclear. A previous study concluded that direct optogenetic activation of STN neurons was neither necessary nor sufficient for relief of parkinsonian symptoms. However, the kinetics of the channelrhodopsin-2 (ChR2) used for cell-specific activation are too slow to follow the high rates required for effective DBS, and thus the contribution of activation of STN neurons to the therapeutic effects of DBS remains unclear. We quantified the behavioral and neuronal effects of optogenetic STN DBS in female rats following unilateral 6-hydroxydopamine (6-OHDA) lesion using an ultrafast opsin (Chronos). Optogenetic STN DBS at 130 pulses per second (pps) reduced pathologic circling and ameliorated deficits in forelimb stepping similarly to electrical DBS, while optogenetic STN DBS with ChR2 did not produce behavioral effects. As with electrical DBS, optogenetic STN DBS exhibited a strong dependence on stimulation rate; high rates produced symptom relief while low rates were ineffective. High-rate optogenetic DBS generated both increases and decreases in firing rates of single neurons in STN, globus pallidus externa (GPe), and substantia nigra pars reticular (SNr), and disrupted β band oscillatory activity in STN and SNr. High-rate optogenetic STN DBS can indeed ameliorate parkinsonian motor symptoms through reduction of abnormal oscillatory activity in the STN-associated neural circuit, and these results highlight that the kinetic properties of opsins have a strong influence on the effects of optogenetic stimulation.SIGNIFICANCE STATEMENT Whether STN local cells contribute to the therapeutic effects of subthalamic nucleus (STN) deep brain stimulation (DBS) in Parkinson's disease (PD) remains unclear. We re-examined the role of STN local cells in mediating the symptom-relieving effects of STN DBS using cell type-specific optogenetic stimulation with a much faster opsin, Chronos. Direct optogenetic stimulation of STN neurons was effective in treating the symptoms of parkinsonism in the 6-hydroxydopamine (6-OHDA) lesion rat. These results highlight that the kinetic properties of opsins can have a strong influence on the effects of optogenetic activation/inhibition and must be considered when employing optogenetic to study high-rate neural stimulation.

Feasibility of changing for a rechargeable constant current neurostimulator in Parkinson's disease

BACKGROUND

Little is known about outcome and settings adaptations after replacement of constant-voltage non-rechargeable implantable pulse generator (CV-nrIPG) by constant-current rechargeable IPG (CC-rIPG).

OBJECTIVE

To determine the feasibility and safety of replacing a CV-nrIPG by a CC-rIPG in Parkinson's disease (PD) and the subsequent outcome.

METHODS

A prospective cohort of thirty PD patients, whose CV-nrIPG was replaced by a CC-rIPG in University Hospital of Lyon between January 2017 and December 2018 (rIPG group) and 39 PD patients, who underwent the replacement of a CV-nrIPG by the same device in 2016 (nrIPG group), were enrolled in this study. Three surgeons performed the operations. Duration of hospitalization for the replacement as well as the number of in or outpatient visits during the first 3 months after the surgery were recorded. In the rIPG group, we compared preoperative DBS settings and the theoretical amplitude estimated using Ohm's law to the amplitude used at the end of follow-up. We assessed patients' and clinicians' opinion on the patient global functioning after the replacement using Clinical Global Impression score.

RESULTS

Duration of hospitalization (P=0.47) and need for additional hospitalizations (P=0.73) or consultations (P=0.71) to adapt DBS parameters did not differ between the two groups. Neurological condition (CGI score) was considered as unchanged by both patients and neurologists. Final amplitude of stimulation using CC-rIPG was not predicted by Ohm's law in most cases.

CONCLUSIONS

Replacing CV-nrIPG by CC-rIPG is safe and well tolerated but require neurological expertise to set the new parameters of stimulation.

Exosomes from Human Periapical Cyst-MSCs: Theranostic Application in Parkinson's Disease

The scientific community continuously strives to get new disease models, to discover early markers or novel therapeutic approaches, improving the diagnosis and prognosis of several human pathologies. Parkinson's Disease (PD) is characterized by a long asymptomatic phase, characterized by a selective loss of dopaminergic neurons. Recently, the human Periapical Cyst-Mesenchymal Stem Cells (hPCy-MSCs) have been differentiated in functional dopaminergic neurons: such oral-derived MSCs and the hPCy-MSCs-derived exosomes may represent a strategic and useful in vitro study-model, as well as intriguing therapeutic carriers. Circadian rhythm (CR) alteration variously impacts on PD pathways: an interesting research target is represented by the analysis of the exosomes released by dopaminergic neurons, derived from neural-differentiated hPCy-MSCs, after having reproduced in-vitro PD-like conditions. This review aims to describe the crosstalk among some aspects of circadian rhythm related to the onset of PD and the exosomes released by cells of PD patients. More in detail: the first part of this article will describe the main characteristics of circadian rhythm and the involvement of the exosomes found to be effective in the pathogenesis of PD. Finally, the authors will suggest how those exosomes derived from dopaminergic neurons, obtained by oral-derived stem cells (hPCy-MSCs) may represent a smart model for the in vitro research on PD, to find new biomarkers, to test new drugs or, fatally, to find new pathways applicable in future therapeutic approaches.

ERK/MAP Kinase Activation is Evident in Activated Microglia of the Striatum and Substantia Nigra in an Acute and Chronically-Induced Mouse Model of Parkinson's Disease

INTRODUCTION

Parkinson's Disease (PD) is a debilitating, age-related disorder characterized by selective degeneration of dopaminergic neurons in the midbrain substantia nigra (SNc). Dopaminergic neurons originating in the midbrain project to the striatum (Caudate-putamen-CPU). Although studies have suggested that the extracellular signal-regulated kinase ½ (ERK ½) in the brain is activated after 1-Methyl-4-phenyl-1, 2,3,6-tetrahydropyridine (MPTP) exposure, to our knowledge no study has yet been done to demonstrate whether such activation occurs in neurons or in glia.

MATERIAL AND METHODS

In the current study, we utilized both an acute and a repeat dose mouse model of PD using the neurotoxicant MPTP as the causative agent. Immunohistochemical studies using phospho ERK ½ antibody suggested that ERK ½ activation takes place in the striatum (CPU) and SNc of both animal models. Moreover, double immunolabeling studies using phospho ERK ½ and the microglial marker, CD11b or the astrocyte marker, Glial Fibrillary Acidic Protein (GFAP) suggested that the phospho ERK ½ was present exclusively in the microglia and not in the astrocytes.

RESULTS

Western Blot results suggested that there were no alterations in ERK in either MPTPtreated animals or in control animals; however, phospho ERK ½ was found to be significantly increased in the striatum and SNc in both acute chronic mouse PD models. Tyrosine Hydroxylase (TH) immunolabeling revealed significant decreases in dopaminergic neurons in the SNc in both animal models' concomitant with activation of microglia and ERK activation.

CONCLUSION

These observations suggest that ERK activation takes place following MPTP treatment and that activation of ERK occurs primarily in the microglia. The data provided also suggest that ERK activation may be involved in transcriptional activation of microglia following neurotoxicant insults.

Analysis of Relationships between Spinal Deformity and Walking Ability in Parkinson's Disease Patients

Introduction

This study aimed to determine impacts on walking ability of spinal deformity and imbalance as distinct from movement disorders in Parkinson's disease (PD).

Methods

Thirty-two patients (15 males, 17 females; mean age 72.5 years) were analyzed. Three, thirteen, eleven, and five were at Hoehn-Yahr stages I, II, III, and IV, respectively. In addition to various spinal imbalance and deformity classifications the following were assessed: Cobb angle (CA) for scoliosis, thoracic kyphosis (TK) at T2-12, thoracolumbar kyphosis(TLK) at T12-L2, lumbar lordosis(LL) at L1-S1, pelvic tilt(PT), pelvic incidence(PI), and sagittal vertical axis(SVA). The Timed Up and Go (TUG) test was used to measure walking ability. Patients were evaluated using the Unified Parkinson's Disease Rating Scale (UPDRS) part III, and bone mineral density (BMD) scans.

Results

Nineteen patients (59%) had spinal deformity and imbalance within the following classifications: thoracic scoliosis, 1; thoracic kyphosis, 2; lumbar scoliosis, 15; Pisa syndrome, 3; camptocormia, 2. Mean values were 20.0° CA for scoliosis, 42.3° TK, 14.8° TLK, 26.7° LL, 20.8° PT, 48.8° PI, and 66.4 mm SVA. The mean TUG score was 13.9s. The UPDRS III mean was 36.6±24.5 points. Mean BMD was 0.856 g/cm² at lumbar L2-4 and 0.585 g/cm² at the femoral neck. UPDRS part III (P<0.001), LL (P<0.05), and femoral neck BMD (P<0.05) significantly correlated to TUG test results.

Conclusions

Distinct from the movement disorders of PD (UPDRS III), loss of normal LL and loss of BMD at the femoral neck were shown to be correlated with diminished walking ability (TUG test) in PD patients. When UPDRS improved in response to L-dopa, walking ability improved. In addition to any PD-specific interventions that contribute to the maintenance of ambulation, interventions specific to the restoration of LL, as well as early treatment for osteoporosis may positively affect HRQOL in PD.

Learning from the past and expecting the future in Parkinsonism: Dopaminergic influence on predictions about the timing of future events

The prolonged reaction times seen in Parkinson's disease (PD) have been linked to a dopaminergic-dependent deficit in using prior information to prepare responses, but also have been explained by an altered temporal processing. However, an underlying cognitive mechanism linking dopamine, temporal processing and response preparation remains elusive.

To address this, we studied PD patients, with or without medication, and age-matched healthy individuals using a variable foreperiod task requiring speeded responses to a visual stimulus occurring at variable onset-times, with block-wise changes in the temporal predictability of visual stimuli.

Compared with controls, unmedicated patients showed impaired use of prior information to prepare their responses, as reflected by slower reaction times, regardless of the level of temporal predictability. Crucially, after dopamine administration normal performance was restored, with faster responses for high temporal predictability.

Using Bayesian hierarchical drift-diffusion modelling, we estimated the parameters that determine temporal preparation. In this theoretical framework, impaired temporal preparation under dopaminergic depletion was driven by inflexibly high decision boundaries (i.e. participants were always extremely cautious). This indexes high levels of uncertainty about temporal predictions irrespectively of stimulus onset predictability.

Our results suggest that dopaminergic depletion in PD affects the uncertainty of predictions about the timing of future events (temporal predictions), which are crucial for the anticipatory preparation of responses. Dopamine, which is affected in PD, controls the ability to predict the timing of future events.

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Parkinson’s patients cannot use prior temporal information to prepare motor responses.

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Temporal preparation is restored to normality by dopamine administration.

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Temporal preparation declines with increasing uncertainty about temporal predictions.

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Dopaminergic depletion linked to inflexibly high uncertainty in temporal predictions.

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Dopamine regulates the uncertainty of predictions about the timing of future events.

A Smart Device System to Identify New Phenotypical Characteristics in Movement Disorders

Parkinson's disease and Essential Tremor are two of the most common movement disorders and are still associated with high rates of misdiagnosis. Collected data by technology-based objective measures (TOMs) has the potential to provide new promising and highly accurate movement data for a better understanding of phenotypical characteristics and diagnostic support. A technology-based system called Smart Device System (SDS) is going to be implemented for multi-modal high-resolution acceleration measurement of patients with PD or ET within a clinical setting. The 2-year prospective observational study is conducted to identify new phenotypical biomarkers and train an Artificial Intelligence System. The SDS is going to be integrated and tested within a 20-min assessment including smartphone-based questionnaires, two smartwatches at both wrists and tablet-based Archimedean spirals drawing for deeper tremor-analyses. The electronic questionnaires will cover data on medication, family history and non-motor symptoms. In this paper, we describe the steps for this novel technology-utilizing examination, the principal steps for data analyses and the targeted performances of the system. Future work considers integration with Deep Brain Stimulation, dissemination into further sites and patient's home setting as well as integration with further data sources as neuroimaging and biobanks. Study Registration ID on ClinicalTrials.gov: NCT03638479.

Gambling behavior in Parkinson's Disease: Impulsivity, reward mechanism and cortical brain oscillations

Psychopathological components, such as reward sensitivity and impulsivity, and dopaminergic treatment are crucial characteristics related to the development of Pathological Gambling (PG) in Parkinson's Disease (PD). The aim of the present study is to investigate the differences in decision-making in PD patients with or without PG considering both neurophysiological and behavioral aspects. The IOWA Gambling Task (IGT) and electroencephalographic (EEG) activity were considered to elucidate the decision and post-feedback processes in PG. The sample included fifty-two PD patients, divided in three groups: 17 PD patients with active gambling behavior (PD Gamblers, PDG); 15 PD patients who remitted from PG (PD Non-Gamblers, PDNG); and a Control Group (CG) composed by 20 patients with PD only. EEG and IGT performance were recorded during decision and post-feedback phase. Results showed worse performance and an increase of the low frequency bands in the frontal area for the PDG group compared to the other two groups. In addition, higher BAS (Behavioral Activation System) and BIS-11 (Barratt Impulsiveness Scale) personality components were correlated to groups' behavioral response. These results show an anomalous behavioral (IGT) and cortical response of PDG patients related to their inability to use adequate control mechanisms during a decision-making task where reward mechanisms (BAS) and impulsivity (BIS-11) are relevant.

Psychiatric Manifestation in Patients with Parkinson's Disease

Parkinson's disease (PD) is the second most common neurodegenerative disorder. Although its major manifestation is motor symptoms, resulting from the loss of dopaminergic neurons in the substantia nigra, psychiatric symptoms, such as depression, anxiety, hallucination, delusion, apathy and anhedonia, impulsive and compulsive behaviors, and cognitive dysfunction, may also manifest in most patients with PD. Given that the quality of life - and the need for institutionalization - is so highly dependent on the psychiatric well-being of patients with PD, psychiatric symptoms are of high clinical significance. We reviewed the prevalence, risk factors, pathophysiology, and treatment of psychiatric symptoms to get a better understanding of PD for improved management.

The Prevalence of Cerebral Microbleeds in Non-Demented Parkinson's Disease Patients

BACKGROUND

Cerebral microbleeds (CMBs) are associated with cerebrovascular risk factors and cognitive dysfunction among patients with Parkinson's disease (PD). However, whether CMBs themselves are associated with PD is to be elucidated.

METHODS

We analyzed the presence of CMBs using 3-Tesla brain magnetic resonance imaging in non-demented patients with PD and in age-, sex-, and hypertension-matched control subjects. PD patients were classified according to their motor subtypes: tremor-dominant, intermediate, and postural instability-gait disturbance (PIGD). Other cerebrovascular risk factors and small vessel disease (SVD) burdens were also evaluated.

RESULTS

Two-hundred and five patients with PD and 205 control subjects were included. The prevalence of CMBs was higher in PD patients than in controls (16.1% vs. 8.8%; odds ratio [OR], 2.126; P = 0.019); CMBs in the lobar area showed a significant difference between PD patients and controls (11.7% vs. 5.9%; OR, 2.234; P = 0.032). According to the motor subtype, CMBs in those with PIGD type showed significant difference from controls with respect to the overall brain area (21.1% vs. 8.9%; OR, 2.759; P = 0.010) and lobar area (14.6% vs. 4.9%; OR, 3.336; P = 0.016). Among PD patients, those with CMBs had higher age and more evidence of SVDs than those without CMBs.

CONCLUSION

We found that CMBs are more frequent in PD patients than in controls, especially in those with the PIGD subtype and CMBs on the lobar area. Further study investigating the pathogenetic significance of CMBs is required.

A pathway for Parkinson's Disease LRRK2 kinase to block primary cilia and Sonic hedgehog signaling in the brain

Parkinson’s disease-associated LRRK2 kinase phosphorylates multiple Rab GTPases, including Rab8A and Rab10. We show here that LRRK2 kinase interferes with primary cilia formation in cultured cells, human LRRK2 G2019S iPS cells and in the cortex of LRRK2 R1441C mice. Rab10 phosphorylation strengthens its intrinsic ability to block ciliogenesis by enhancing binding to RILPL1. Importantly, the ability of LRRK2 to interfere with ciliogenesis requires both Rab10 and RILPL1 proteins. Pathogenic LRRK2 influences the ability of cells to respond to cilia-dependent, Hedgehog signaling as monitored by Gli1 transcriptional activation. Moreover, cholinergic neurons in the striatum of LRRK2 R1441C mice show decreased ciliation, which will decrease their ability to sense Sonic hedgehog in a neuro-protective circuit that supports dopaminergic neurons. These data reveal a molecular pathway for regulating cilia function that likely contributes to Parkinson’s disease-specific pathology.

Editorial note: This article has been through an editorial process in which the authors decide how to respond to the issues raised during peer review. The Reviewing Editor's assessment is that all the issues have been addressed (see decision letter).

Decreased subregional specificity of the putamen in Parkinson's Disease revealed by dynamic connectivity-derived parcellation

Parkinson's Disease (PD) is associated with decreased ability to perform habitual tasks, relying instead on goal-directed behaviour subserved by different cortical/subcortical circuits, including parts of the putamen. We explored the functional subunits in the putamen in PD using novel dynamic connectivity features derived from resting state fMRI recorded from thirty PD subjects and twenty-eight age-matched healthy controls (HC). Dynamic functional segmentation of the putamina was obtained by determining the correlation between each voxel in each putamen along a moving window and applying a joint temporal clustering algorithm to establish cluster membership of each voxel at each window. Contiguous voxels that had consistent cluster membership across all windows were then considered to be part of a homogeneous functional subunit. As PD subjects robustly had two homogenous clusters in the putamina, we also segmented the putamina in HC into two dynamic clusters for a fair comparison. We then estimated the dynamic connectivity using sliding windowed correlation between the mean signal from the identified homogenous subunits and 56 other predefined cortical and subcortical ROIs. Specifically, the mean dynamic connectivity strength and connectivity deviation were then compared to evaluate subregional differences. HC subjects had significant differences in mean dynamic connectivity and connectivity deviation between the two putaminal subunits. The posterior subunit connected strongly to sensorimotor areas, the cerebellum, as well as the middle frontal gyrus. The anterior subunit had strong mean dynamic connectivity to the nucleus accumbens, hippocampus, amygdala, caudate and cingulate. In contrast, PD subjects had fewer differences in mean dynamic connectivity between subunits, indicating a degradation of subregional specificity. Overall UPDRS III and MoCA scores could be predicted using mean dynamic connectivity strength and connectivity deviation. Side of onset of the disease was also jointly related with functional connectivity features. Our results suggest a robust loss of specificity of mean dynamic connectivity and connectivity deviation in putaminal subunits in PD that is sensitive to disease severity. In addition, altered mean dynamic connectivity and connectivity deviation features in PD suggest that looking at connectivity dynamics offers an additional dimension for assessment of neurodegenerative disorders.

Natural or Plant Products for the Treatment of Neurological Disorders: Current Knowledge

BACKGROUND

In recent decades, complementary and alternative medicine (CAM) has become very popular in the treatment of several chronic diseases. Natural products as one of the CAM modalities offer potential opportunities to discover lead compounds for novel drug development. The use of CAM or natural products in the prevention of neurodegenerative diseases is comparatively a newer area.

METHOD

A structured online literature search for peer-reviewed research articles was conducted on the PubMed, Europe PMC, Medline and Google Scholar portals, using phrases: natural products for neurologic disorders, phytomedicine for neurodegenerative diseases, natural therapeutics for neurological symptopms etc. Results: The retrieved data showed the natural therapeutics with anti-oxidative and anti-inflammatory salutations evidently plays a crucial role in protecting neurons. Of these, the most promising are caffeine, trigonelline, shogaol, curcumin, resveratrol, baicalein, wogonin, ginsenosides, tanshinones, withanolides, picrosides, parthenolide, cannabinoids, Devil's claw and white willow bark, including Chinese formulations Renshen Shouwu and Shengmai San. Though several herbs and their active ingredients have been studied in laboratory and clinical settings, only a few have been investigated for their molecular mechanisms of action. Notably, despite the promising and safe therapeutic benefits of CAM/herbal medicines, there exists a possible risk when combining them with prescription drugs. As a result, many drugs have shown changes in blood pressure, hepatotoxicity, seizures etc. when combined with certain herbs.

CONCLUSION

Certainly, extensive work is needed to make sure that patients should take a regimen of protective and restorative therapy under an experienced healthcare professional. This article updates on the current knowledge of promising natural products used in neurological disorders.

Excessive Daytime Sleepiness in Parkinson's Disease: Clinical Implications and Management

Objective

Excessive daytime sleepiness (EDS) is one of the most common sleep abnormalities in patients with Parkinson's disease (PD), yet its multifactorial etiology complicates its treatment. This review summarized recent studies on the epidemiology, etiology, clinical implications, associated features, and evaluation of EDS in PD. The efficacy of pharmacologic and non-pharmacologic treatments for EDS in PD was also reviewed.

Data Sources

English language articles indexed in PubMed and Cochrane databases and Chinese-language papers indexed in Wanfang and National Knowledge Infrastructure databases that were published between January 1987 and November 2017 were located using the following search terms: "sleepiness", "sleep and Parkinson's disease", and "Parkinson's disease and treatment".

Study Selection

Original research articles and critical reviews related to EDS in PD were selected.

Results

EDS is a major health hazard and is associated with many motor and nonmotor symptoms of PD. Its causes are multifactorial. There are few specific guidelines for the treatment of EDS in PD. It is first necessary to identify and treat any possible factors causing EDS. Recent studies showed that some nonpharmacologic (i.e., cognitive behavioral therapy, light therapy, and repetitive transcranial magnetic stimulation) and pharmacologic (i.e., modafinil, methylphenidate, caffeine, istradefylline, sodium oxybate, and atomoxetine) treatments may be effective in treating EDS in PD.

Conclusions

EDS is common in the PD population and can have an immensely negative impact on quality of life. Its causes are multifactorial, which complicates its treatment. Further investigations are required to determine the safety and efficacy of potential therapies and to develop novel treatment approaches for EDS in PD.

Gait Patterns in Parkinson's Disease with or without Cognitive Impairment

Background and Purpose

Cognitive and gait disturbance are common symptoms in Parkinson's disease (PD). Although the relationship between cognitive impairment and gait dysfunction in PD has been suggested, specific gait patterns according to cognition are not fully demonstrated yet. Therefore, the aim of this study was to investigate gait patterns in PD patients with or without cognitive impairment.

Methods

We studied 86 patients at an average of 4.8 years after diagnosis of PD. Cognitive impairment was defined as scoring 1.5 standard deviation below age- and education-specific means on the Korean version of the Mini-Mental State Examination (K-MMSE). Three-dimensional gait analysis was conducted for all patients and quantified gait parameters of temporal-spatial data were used. Relationships among cognition, demographic characteristics, clinical features, and gait pattern were evaluated.

Results

Cognitive impairment was observed in 41 (47.7%) patients. Compared to patients without cognitive impairment, patients with cognitive impairment displayed reduced gait speed, step length, and stride length. Among K-MMSE subcategories, “registration,” “attention/calculation,” and “visuospatial function” were significantly associated with speed, step length, and stride length. However, age, disease duration, Hoehn-Yahr (HY) stage, or Unified Parkinson's Disease Rating Scale (UPDRS) motor score was not significantly related to any gait analysis parameter.

Conclusions

Our present study shows that cognitive impairment is associated with slow and short-stepped gait regardless of HY stage or UPDRS motor score, suggesting that cognitive impairment may serve as a surrogate marker of gait disturbance or fall in PD patients.

Transcranial sonography in carriers of Gaucher disease

Background: Glucocerebrosidase (GBA) mutation is the most common genetic risk factor in Parkinson's disease (PD). Transcranial sonography (TCS) shows increased substantia nigra (SN) echogenicity in both idiopathic and genetic forms of PD. The goal of this study was to compare maximal area of SN hyperechogenicity (aSNmax) and diameter of third ventricle (DTV) between GBA mutation carriers and healthy controls. Methods: Twenty-six carriers of GBA mutation and twenty-six healthy controls underwent TCS. The aSNmax and the DTV were measured. Mini-mental status examination (MMSE) and demographic data of the subjects were recorded, too. Results: Mean aSNmax in GBA mutation carriers was significantly higher (0.31 ± 0.06 cm²) than controls (0.16 ± 0.04 cm²). Moreover, DTV was significantly higher in GBA mutation carriers group (3.98 ± 0.90 vs 3.29 ± 0.56 cm). Conclusion: Increased SN echogenicity and increased third ventricle diameter in GBA mutation carriers may be caused by alterations in iron metabolism with reference to their genetic status.

Protective role of microRNA-221 in Parkinson's disease

OBJECTIVE

The present study aimed to explore the role and the underlying mechanism of miR-221 in Parkinson's Disease.

MATERIALS AND METHODS

To perform our investigation, a PD cell model was created by using 6-OHDA. Cell viability and proliferation assays, and flow cytometry analysis were performed to detect cell viability and apoptosis. The qRT-PCR and western blotting were used for gene and protein level detection.

RESULTS

We found that the expression of miRNA-221 is significantly lower in 6-OHDA treated PC12 pheochromocytoma cells compared to the normal cells. The results of further analysis indicated that miR-221 mimic significantly promoted the cell viability and proliferation of PC12 cells treated with 6-OHDA. MiR-221 mimic significantly inhibited 6-OHDA-treated PC12 cells from apoptosis. These effects were eliminated by PTEN over-expression. We also revealed that PTEN was a direct target gene of miR-221. Moreover, we found miR-221 mimic significantly promoted the phosphorylation of AKT in PC12 cells treated with 6-OHDA, and over-expression of PTEN could eliminate this effect.

CONCLUSIONS

MiR-221 plays a protective role in Parkinson's Disease via regulating PC12 cell viability and apoptosis by targeting PTEN. Therefore, miR-221 may serve as a potential therapeutic target for Parkinson's disease treatment (Fig. 3, Ref. 27).

The motor and cognitive features of Parkinson's disease in patients with concurrent Gaucher disease over 2 years: a case series

We report the cognitive features and progression of Parkinson’s disease (PD) in five patients with concurrent Gaucher disease. The patients presented at an earlier age than patients with sporadic PD, as previously noted by others; but in contrast to many previous reports, our patients followed a variable clinical course. While two patients developed early cognitive deficits and dementia, three others remained cognitively intact over the follow-up period. Thus, in this small case series, PD in the context of GD more closely resembles idiopathic PD in terms of its clinical heterogeneity in contrast to PD associated with GBA heterozygote mutations.