Liquid levodopa/carbidopa produces significant improvement in motor function without dyskinesia exacerbation

We performed the first double-blind, crossover comparison between levodopa/carbidopa (LD/CD) in optimized liquid versus tablet doses to measure plasma LD levels and relative effects on disabilities (motor function, fluctuations, and dyskinesias) in patients with Parkinson's disease. Twenty-three subjects with motor fluctuations were optimized with open-label LD/CD tablets and liquid. In a double-dummy design, patients randomly received 2 weeks of liquid and 2 weeks of tablet LD/CD. Twice during each arm, we evaluated patients hourly 9 AM to 4 PM with the use of plasma LD levels, the Unified Parkinson's Disease Rating Scale, a dyskinesia rating scale, and "on-off" ratings. Patients receiving liquid LD/CD ingested significantly higher doses and had significantly improved motor function and total "on" time, without an increase in dyskinesia severity. The number of motor fluctuations in the two phases was not significantly different. LD levels and variability were also equivalent with the two formulations. At optimized dosing, liquid LD/CD offers a means to significantly improve motor disability in patients with Parkinson's disease without exacerbating dyskinesia.

Alpha-tocopherol in the ventricular cerebrospinal fluid of Parkinson's disease patients: dose-response study and correlations with plasma levels

OBJECTIVE

To determine if ventricular cerebrospinal fluid (vCSF) alpha-tocopherol levels in Parkinson's disease (PD) patients can be increased by oral alpha-tocopherol supplementation and whether vCSF levels are linearly related to plasma alpha-tocopherol levels.

BACKGROUND

In spite of its putative neuroprotective properties, alpha-tocopherol has failed to alter PD clinical progression. However, the ability of supplemental alpha-tocopherol to affect brain or vCSF levels has never been assessed in humans nor has a dose response curve for alpha-tocopherol in vCSF been established.

METHODS

Five PD patients with Ommaya catheters received oral dl-alpha-tocopherol over 5 months. Each patient ingested alpha-tocopherol daily with monthly dosage increases (400, 800, 1,600, 3,200, 4,000 IU/day). Plasma and vCSF samples were obtained at baseline and at the end of each month. Alpha-tocopherol levels were determined in triplicate by high-pressure liquid chromatography with fluorometric and electrochemical detection.

RESULTS

At baseline, endogenous alpha-tocopherol was detected in plasma and vCSF, with a greater than one-hundred-fold difference between the fluid compartments (mean plasma level 18.76 microM/l (SD +/- 4.69) versus mean CSF level 0.114 microM/l (SD +/- 0.084). A clear dose-response curve occurred in plasma, with statistically significant increases over baseline developing even with 400 IU/d. With higher doses, a significant increase continued without evidence of saturation. However, there was no significant increase in vCSF alpha-tocopherol levels at any dose, including the supraclinical (4,000 IU/d). There was no correlation between plasma and vCSF alpha-tocopherol levels.

CONCLUSION

Oral alpha-tocopherol supplementation, even at supraclinical doses, fails to increase vCSF alpha-tocopherol levels. This lack of change may be due to limited passage across the blood-brain barrier or very rapid alpha-tocopherol metabolism. All prior negative studies on efficacy of alpha-tocopherol in PD may need reevaluation in light of these pharmacologic data.

Genetic variability of the CYP 2D6 gene is not a risk factor for sporadic Parkinson's disease

Genetic studies of the frequencies of mutant alleles for coding cytochrome P-450 monooxygenase (CYP 2D6) in Parkinson's disease (PD) patients have been inconsistent. We studied the mutants A and B in 80 strictly defined sporadic PD patients divided into young age onset of the disease (< 40 years, N = 20), mid age onset (40-50 years, N = 12), and older age onset (> 50 years, N = 48). They were compared with 108 controls from the same geographic area. There were no significant differences in allele or genotype frequencies between PD patients and controls. Future genetic studies in PD should focus on other alleles or other areas of the genome.

Early American professorships in neurology

American universities recognized and institutionalized the emerging importance of neuroscience in medicine by establishing neurological professorships as early as the 1860s. Nearly 20 years before Charcot assumed his celebrated chaired professorship for Diseases of the Nervous System in France, Harvard University created a professorship of Physiology and Pathology of the Nervous System (1864), naming Brown-Sequard as its recipient. In 1867, the new Bellevue Hospital Medical School established a combined neurology/psychiatry chair with William A. Hammond as professor, and the University of Pennsylvania created a clinical professorship devoted specifically to neurology in 1875, naming Horatio C. Wood. Although modest in their university power base and their clinical research/laboratory programs, these American posts were internationally unique for their time and solidly entrenched neurology as a specific division in early US medical education.

Charcot and aphasia

Whereas the beginning part of Charcot's career was occupied with a rigorous and unerring devotion to the anatomo-clinical method, his later career shared attention with physiologic and psychological analyses of hysteria. The seeming paradox between these differing approaches to neurologic study can be better understood by an analysis of Charcot's work on aphasia. This area of study grew out of Charcot's larger research effort on cerebral localization, but was not well known, because most of his lectures on aphasia were never widely published or distributed in either French or English. In analyzing aphasia, Charcot began with anatomic lesions, but gradually incorporated cases of hysterical aphasia, as evidence of dynamic lesions of the same brain areas. Although aphasia never represented a prominent area of study for Charcot, it held a particularly important place in his career first because it provided this transition between anatomic and physiologic approaches to neurologic research, and second because it permitted a natural two-way passage between the topics of cerebral localization and hysteria.

Clinical research criteria for the diagnosis of progressive supranuclear palsy (Steele-Richardson-Olszewski syndrome): report of the NINDS-SPSP international workshop

To improve the specificity and sensitivity of the clinical diagnosis of progressive supranuclear palsy (PSP, Steele-Richardson-Olszewski syndrome), the National Institute of Neurological Disorders and Stroke (NINDS) and the Society for PSP, Inc. (SPSP) sponsored an international workshop to develop an accurate and universally accepted set of criteria for this disorder. The NINDS-SPSP criteria, which were formulated from an extensive review of the literature, comparison with other previously published sets of criteria, and the consensus of experts, were validated on a clinical data set from autopsy-confirmed cases of PSP. The criteria specify three degrees of diagnostic certainty: possible PSP, probable PSP, and definite PSP. Possible PSP requires the presence of a gradually progressive disorder with onset at age 40 or later, either vertical supranuclear gaze palsy or both slowing of vertical saccades and prominent postural instability with falls in the first year of onset, as well as no evidence of other diseases that could explain these features. Probable PSP requires vertical supranuclear gaze palsy, prominent postural instability, and falls in the first year of onset, as well as the other features of possible PSP. Definite PSP requires a history of probable or possible PSP and histopathologic evidence of typical PSP. Criteria that support the diagnosis of PSP, and that exclude diseases often confused with PSP, are presented. The criteria for probable PSP are highly specific, making them suitable for therapeutic, analytic epidemiologic, and biologic studies, but not very sensitive. The criteria for possible PSP are substantially sensitive, making them suitable for descriptive epidemiologic studies, but less specific. An appendix provides guidelines for diagnosing and monitoring clinical disability in PSP.

Prevalence of parkinsonian signs and associated mortality in a community population of older people

BACKGROUND

Older people frequently have signs of parkinsonism, but information about the prevalence of parkinsonism and mortality among those with the condition in the community is limited.

METHODS

A stratified random sample of 467 residents of East Boston, Massachusetts, 65 years of age or older, were given structured neurologic examinations. Using uniform, specified combinations of parkinsonian signs, we estimated the prevalence of four categories of signs--bradykinesia, gait disturbance, rigidity, and tremor--and of parkinsonism, defined as the presence of two or more categories. We did not study Parkinson's disease because it could not be distinguished from other conditions that can cause parkinsonism. Proportional-hazards models were used to compare the risk of death among people with and those without parkinsonism.

RESULTS

One hundred fifty-nine persons had parkinsonism, 301 did not, and 7 could not be classified. The overall prevalence estimates were 14.9 percent for people 65 to 74 years of age, 29.5 percent for those 75 to 84, and 52.4 percent for those 85 and older. With a mean follow-up period of 9.2 years, 124 persons with parkinsonism (78 percent) and 146 persons without (49 percent) died. Adjusted for age and sex, the overall risk of death among people with parkinsonism was 2.0 (95 percent confidence interval, 1.6 to 2.6) times that among people without. Among people with parkinsonism, the presence of gait disturbance was associated with an increased risk of death.

CONCLUSIONS

Parkinsonism is very common among people over the age of 65, and its prevalence increases markedly with age. Parkinsonism is associated with a twofold increase in the risk of death, which is strongly related to the presence of a gait disturbance.

Levodopa stability in solution: time course, environmental effects, and practical recommendations for clinical use

We defined the temporal stability characteristics of levodopa/carbidopa (LD/CD) solution, and determined the effects of temperature, ascorbate, and light on LD stability over 7 days. At room temperature and without ascorbate, LD levels significantly declined by 48 h. Ascorbate prolonged stability to 72 h. Refrigeration and freezing prevented a significant decline in LD levels for the full 7 days. Light or darkness had no effect on stability. LD/CD solution, if made daily, requires no special handling and longer stability is maintained with ascorbate, refrigeration, or freezing.

Charcot as therapeutic interventionist and treating neurologist

Although Jean-Martin Charcot's best-known medical and scientific contributions relate to anatomical-clinical correlation, he was also a highly regarded physician. His published lectures and articles, as well as documents at the Bibliothèque Charcot, demonstrate his active interest in therapeutic interventions and in bringing new experimental treatments to France for study. He investigated the efficacy of bromides for epilepsy, colchicine for gout, and ergots and anticholinergic drugs for Parkinson's disease. Nonpharmacologic treatments in which he took interest included physical rehabilitation/speech therapy, hydrotherapy, electrical stimulation of weakened muscles, isolation, and exotic interventions such as suspension and vibratory treatments with special chairs and helmets. Letters from his patients reveal an active interchange, with patients complimenting Charcot on successful treatments but also demanding more effective ones when his prescriptions did not abate their conditions. These documents demonstrate that Charcot was not a therapeutic nihilist but was particularly active in therapeutic investigations in the context of 19th-century medical science.

Factors predictive of the need for levodopa therapy in early, untreated Parkinson's disease. The Parkinson Study Group

OBJECTIVE

To identify characteristics of patients with early, untreated Parkinson's disease that are the most important predictors of rapid functional decline.

DESIGN

Prospective observational study of a cohort of 800 patients with early, untreated Parkinson's disease who were involved in a multicenter, randomized, double-blind, controlled clinical trial of selegiline hydrochloride (L-deprenyl) and vitamin E (alpha-tocopherol).

PRIMARY OUTCOME VARIABLE

Time from randomization to the onset of disability that necessitated levodopa therapy (end point), as judged by the enrolling investigator.

METHODS

Stepwise Cox regression was used in combination with clinical judgment to identify the most important independent baseline predictors of the primary end point among a host of variables, including treatment with selegiline and vitamin E, global and specific clinical measures of disease severity, demographic variables, and neuropsychological test results.

RESULTS

In addition to selegiline treatment and global disease severity measures, such as the stage according to the criteria of Hoehn and Yahr, impaired domestic capacity, and the activities of daily living score, the complex of postural instability/gait difficulty and bradykinesia were found to be the factors that were most highly associated with the risk of reaching the end point.

CONCLUSIONS

The findings suggest that patients with Parkinson's disease whose early clinical presentation includes either postural instability/gait difficulty or bradykinesia are at high risk for rapid functional decline.

Early American neurologic textbooks

Although European treatises were translated and available to American doctors interested in neurology during the 19th century, the early American neurologic textbooks were distinctive in their comprehensive integration of basic and clinical science. William A. Hammond, in 1871, published the first comprehensive American textbook of neurology, preceding the manuals by Gowers (1886) and Oppenheim (1894) by more than a decade. Four other American adult neurologic textbooks expanded on Hammond's model and incorporated other important topics, including neurologic anatomy, the formal examination, neurochemistry, and complete bibliographies. Bernard Sachs' 1895 textbook was the first pediatric neurologic textbook published in America and made significant contributions to the organization of childhood neurologic disorders. These works functioned as centralized resources for neurologic information, were influential educational tools, and helped foster a growing appreciation of the American neurologic school both nationally and internationally.

Teaching tape for the motor section of the unified Parkinson's disease rating scale

We developed a teaching tape of the motor section of the Unified Parkinson's Disease Rating Scale (UPDRS) to provide investigators with a visual document of three raters' interpretations of the scoring system for each item except rigidity. The rate of agreement for the selected samples was always significant, with Kendall's coefficient of concordance W ranging between 0.97 and 0.62. We also provided full UPDRS ratings on sample patients that may be used for training and for multicenter studies to assure uniformity of rating. The study identified several items of the UPDRS motor examination for which written instructions were vague, including speech, action tremor, finger taps, rapid alternating movements, and postural stability. Future versions of the scale should address these problems and correct ambiguities. This project offers the first attempt to provide a visual analog for the UPDRS.

Mortality and hallucinations in nursing home patients with advanced Parkinson's disease

We monitored 11 patients with advanced Parkinson's disease (PD) who entered nursing homes over a 5-year period and assessed chronicity of nursing home care, mortality, and hallucinatory status. Two years after the original study's close, none of these patients had ever been discharged from the nursing homes and all were dead. The mortality rate among the nursing home patients was significantly greater than that in 22 community-dwelling subjects with PD who were matched for age, gender, and disease duration. Hallucinatory status was generally stable; 82% of patients had the same hallucinatory status (presence or absence) at the two assessments. Four subjects from the original community-dwelling control group entered nursing homes during the follow-up period. Whereas motor and intellectual impairment scores were similar between these patients and the remaining 18 in the community, the presence of hallucinations was significantly greater among patients transferred to nursing homes. The study demonstrates the permanency of nursing home placement in advanced PD and the high mortality associated with such placement. It also documents the chronicity of hallucinatory behavior in these patients with advanced PD and reinforces our previously reported observations on the relationship between hallucinations and placement in chronic-care facilities.

Akathisia in Parkinson's disease

This study evaluated the prevalence and clinical characteristics of akathisia in a tertiary care Parkinson's disease (PD) practice, and assessed the agreement between investigators for the diagnosis of akathisia in PD, and the sensitivity and specificity of a brief patient questionnaire. Fifty-six consecutive PD patients completed an akathisia questionnaire and then were clinically evaluated for akathisia by two examiners blinded to the patient questionnaire. Overall, 45% of PD patients had akathisia as determined by clinical evaluation. Interrater reliability for the diagnosis of akathisia was high (K = 0.89). Patient self-report of restlessness agreed with examiner diagnosis in 89% of the patients. The presence of akathisia was associated with the severity and age of onset of PD. Symptoms most frequently affected the legs, and associated movements were suppressible for brief periods.

Utility of an objective dyskinesia rating scale for Parkinson's disease: inter- and intrarater reliability assessment

Although dyskinesia is a frequent and important problem in Parkinson's disease (PD), a reliable assessment measure has not been thoroughly developed and tested. We modified the Obeso dyskinesia scale to create an objective rating scale for dyskinesia assessment during activities of daily living. Thirteen physicians and 15 study coordinators involved in a clinical trial independently reviewed videotape segments of PD patients performing three tasks: walking, putting on a coat, and lifting a cup to the lips for drinking. Raters evaluated the severity of worst dyskinesia seen, the types of all dyskinesias seen, and the type of dyskinesia most associated with motoric disability. For all assessments, the total group showed statistically significant inter- and intrarater reliability. Physicians had a higher consistency than did coordinators, but for most measures the difference was not statistically significant. Physicians and coordinators found the scale easy to use and especially practical for rating dyskinesia severity and for identifying the most disabling dyskinesia. Dyskinesias can be assessed in clinical trials and warrant regular documentation.

Talipexole and adult Gilles de la Tourette's syndrome: double-blind, placebo-controlled clinical trial

Talipexole is a new dopamine autoagonist with putative preferential activity on presynaptic dopamine receptors. In a double-blind, placebo-controlled study, we tested the drug's safety and efficacy in 13 adult men with Gilles de la Tourette's syndrome. The drug was poorly tolerated because of clinically significant sedation and dizziness. Tics did not improve at tolerable doses. These findings suggest that talipexole has no role in the regular management of tic disorders.

Neurologic health outcomes and Agent Orange: Institute of Medicine report

The National Academy of Sciences' Institute of Medicine conducted an independent scientific investigation to evaluate the strength of evidence for human health effects among veterans exposed to herbicides used in Vietnam and to suggest future research recommendations. Neurologic domains where multiple studies had been performed in military, occupational, or environmental situations were (1) cognitive and neuropsychiatric effects, (2) motor/coordination dysfunction and other central nervous system disorders, and (3) peripheral neuropathy. In all categories, no strong evidence established an association between herbicides used in Vietnam and clinical neurologic disorders. Methodologic weaknesses, long durations between exposure and assessments, and poor exposure measures limited many studies. The committee concluded that the available evidence was insufficient to determine an association between neurologic disorders and exposure to herbicides used in Vietnam. Neurotoxicologic studies available did not suggest strong biological plausibility for neurologic alterations related to herbicide exposure. Furthermore, given the large uncertainties in the epidemiologic studies reviewed and inadequate control for important confounders, the committee could not quantify a degree of risk for neurologic disorders from herbicide exposure likely to be experienced by Vietnam veterans. Although not part of the neurologic report, the risk of brain tumors was considered in the cancer analysis, and the committee concluded that there is limited/suggestive evidence of no association between exposure to herbicides and brain tumors.

Physical therapy and Parkinson's disease: a controlled clinical trial

In a randomized, single-blind, crossover study, we evaluated physical disability in moderately advanced Parkinson's disease (PD) patients after 4 weeks of normal physical activity and 4 weeks of an intensive physical rehabilitation program. We used a timed motor task and a standard assessment of PD severity (the Unified Parkinson's Disease Rating Scale [UPDRS] with subscales for mentation, activities of daily living [ADL], and motor function) completed by an investigator blinded to the physical rehabilitation status of the patient. Following physical rehabilitation, there was significant improvement in the UPDRS ADL and motor scores, but no change in mentation score. During the 6 months following physical rehabilitation, patients did not regularly exercise, and the UPDRS scores returned to baseline. We conclude that physical disability in moderately advanced PD objectively improves with a regular physical rehabilitation program, but this improvement is not sustained when normal activity is resumed.

Risk factors for nursing home placement in advanced Parkinson's disease

We evaluated the risk factors for nursing home placement of patients with Parkinson's disease (PD) by matching 11 PD patients permanently admitted to nursing homes with two control PD patients remaining at home. Risk factors assessed were motor severity, presence of hallucinations/delusions, and presence of memory of problems. The only statistically significant risk factor was the presence of hallucinations/delusions. Motor severity and the presence of memory problems did not have an impact on nursing home placement. There was no risk factor synergy for hallucinations, motor disability, and mental impairment. Since all patients in this series who entered nursing homes remained there permanently, these data suggest that vigorous efforts to control hallucinations may be warranted to prevent nursing home placement.