Economic Evaluation of Interventions in Parkinson's Disease: A Systematic Literature Review

Holographic Ultrasound Modulates Neural Activity in a 1-Methyl-4-Phenyl-1,2,3,6-Tetrahydropyridine-Induced Mouse Model of Parkinson's Disease

Ultrasound (US) has emerged as a noninvasive neurostimulation method for motor control in Parkinson's disease (PD). Previous in vivo US neuromodulation studies for PD were single-target stimulation. However, the motor symptoms of PD are linked with neural circuit dysfunction, and multi-target stimulation is conducted in clinical treatment for PD. Thus, in the present study, we achieved multi-target US stimulation using holographic lens transducer based on the Rayleigh-Sommerfeld diffraction integral and time-reversal methods. We demonstrated that holographic US stimulation of the bilateral dorsal striatum (DS) could improve the motor function in 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP)-induced mouse model of PD. The holographic US wave (fundamental frequency: 3 MHz, pulse repetition frequency: 500 Hz, duty cycle: 20%, tone-burst duration: 0.4 ms, sonication duration: 1 s, interstimulus interval: 4 s, spatial-peak temporal-average intensity: 180 mw/cm2) was delivered to the bilateral DS 20 min per day for consecutive 10 d after the last injection of MPTP. Immunohistochemical c-Fos staining demonstrated that holographic US significantly increased the c-Fos-positive neurons in the bilateral DS compared with the sham group (P = 0.003). Moreover, our results suggested that holographic US stimulation of the bilateral DS ameliorated motor dysfunction (P < 0.05) and protected the dopaminergic (DA) neurons (P < 0.001). The neuroprotective effect of holographic US was associated with the prevention of axon degeneration and the reinforcement of postsynaptic densities [growth associated protein-43 (P < 0.001), phosphorylated Akt (P = 0.001), β3-tubulin (P < 0.001), phosphorylated CRMP2 (P = 0.037), postsynaptic density (P = 0.023)]. These data suggested that holographic US-induced acoustic radiation force has the potential to achieve multi-target neuromodulation and could serve as a reliable tool for the treatment of PD.

Exercise as medicine in Parkinson's disease

Parkinson's disease (PD) is an incurable and progressive neurological disorder leading to deleterious motor and non-motor consequences. Presently, no pharmacological agents can prevent PD evolution or progression, while pharmacological symptomatic treatments have limited effects in certain domains and cause side effects. Identification of interventions that prevent, slow, halt or mitigate the disease is therefore pivotal. Exercise is safe and represents a cornerstone in PD rehabilitation, but exercise may have even more fundamental benefits that could change clinical practice. In PD, the existing knowledge base supports exercise as (1) a protective lifestyle factor preventing the disease (ie, primary prevention), (2) a potential disease-modifying therapy (ie, secondary prevention) and (3) an effective symptomatic treatment (ie, tertiary prevention). Based on current evidence, a paradigm shift is proposed, stating that exercise should be individually prescribed as medicine to persons with PD at an early disease stage, alongside conventional medical treatment.

Acupuncture Effect on Reaction-Time Changes in Parkinson's Disease Patients-Case Study Series

Background: Parkinson's Disease (PD) is a progressive neurodegenerative condition associated with deficit in reaction time which can lead to falls, resulting in limited independence, diminished quality of life, heightened rates of institutionalization and increased healthcare costs. We aimed to examine the effects of an acupuncture protocol in motor time response after an auditory stimulus. Methods: This study employed a case series design. Reaction time to exposed rhythmic and random auditory stimuli outcomes were evaluated at six different moments over a month-long acupuncture treatment protocol using the MP 36 system from Biopac Systems. Results: We observed a tendency to have more pronounced improvements in the time response in the more affected side of the body compared with the contralateral one. Patients tended to show better values of response to random auditory stimuli compared to rhythmic auditory ones. We also observed a tendency to obtain better results when considering the accumulative effects of the acupuncture protocol. Conclusions: Our findings indicated a possible role of reaction time as a sensitive and useful tool for motor function assessment in PD patients. Also, from our results, we concluded that the acupuncture protocol used may lead to an improvement in efficacy of motor response after aleatory and rhythmic stimulus; we also found a tendency for a higher efficacy of acupuncture in random stimuli responses in the first stages of the disease. However, further in-depth research, including a statistical evaluation with a larger participant pool, is necessary to validate and confirm these promising results.

Health-related quality of life in Parkinson's disease: systematic review and meta-analysis of EuroQol (EQ-5D) utility scores

INTRODUCTION

Evaluating the Health-related quality of life (HRQoL) of individuals with Parkinson's disease (PD) holds significant importance in clinical and research settings. The EQ-5D is a widely recognized tool for comprehensive measurement of HRQoL using utility values. This study aims to systematically review and synthesize EQ-5D utility values from existing literature on patients with PD and their caregivers.

METHODS

We conducted a systematic search for studies that provided EQ-5D utility scores for patients with PD, using PubMed-Medline, Scopus, and Embase and selected the studies. The selected studies underwent systematic review, including an assessment of their quality. We performed a meta-analysis using a random-effect model and conducted a meta-regression analysis to investigate sources of heterogeneity among the studies.

RESULTS

The search result of 13,417 articles that were reviewed, 130 studies with 33,914 participants were selected for systematic review, and 79 studies were included for meta-analysis. The pooled EQ-5D utility values and visual analog score (VAS) among PD were 62.72% (60.53-64.93, I2 = 99.56%) and 0.60 (0.55-0.65, I2 = 99.81%), respectively. The pooled scores for caregivers' EQ-VAS and EQ-5D utility were 70.10% (63.99-76.20, I2 = 98.25%) and 0.71 (0.61-0.81, I2 = 94.88%), respectively. Disease duration (P < 0.05) showed a negative correlation with EQ-5D utility values on meta-regression.

CONCLUSION

The pooled utility values of PD and their caregivers help to understand their HRQoL and aid in conducting health economics research. The negative association between disease duration and utility values highlights the evolving nature of HRQoL challenges, suggesting the need for appropriate long-term disease management.

Racial Disparities in Low-Value Care in the Last Year of Life for Medicare Beneficiaries With Neurodegenerative Disease

Background and Objectives

There are racial disparities in health care services received by patients with neurodegenerative diseases, but little is known about disparities in the last year of life, specifically in high-value and low-value care utilization. This study evaluated racial disparities in the utilization of high-value and low-value care in the last year of life among Medicare beneficiaries with dementia or Parkinson disease.

Methods

This was a retrospective, population-based cohort analysis using data from North and South Carolina fee-for-service Medicare claims between 2013 and 2017. We created a decedent cohort of beneficiaries aged 50 years or older at diagnosis with dementia or Parkinson disease. Specific low-value utilization outcomes were selected from the Choosing Wisely initiative, including cancer screening, peripheral artery stenting, and feeding tube placement in the last year of life. Low-value outcomes included hospitalization, emergency department visits, neuroimaging services, and number of days receiving skilled nursing. High-value outcomes included receipt of occupational and physical therapy, hospice care, and medications indicated for dementia and/or Parkinson disease.

Results

Among 70,650 decedents, 13,753 were Black, 55,765 were White, 93.1% had dementia, and 7.7% had Parkinson disease. Adjusting for age, sex, Medicaid dual enrollment status, rural vs urban location, state (NC and SC), and comorbidities, Black decedents were more likely to receive low-value care including colorectal cancer screening (adjusted hazard ratio [aHR] 1.46 [1.32-1.61]), peripheral artery stenting (aHR 1.72 [1.43-2.08]), and feeding tube placement (aHR 2.96 [2.70-3.24]) and less likely to receive physical therapy (aHR 0.73 [0.64-0.85)], dementia medications (aHR 0.90 [0.86-0.95]), or Parkinson disease medications (aHR 0.88 [0.75-1.02]) within the last year of life. Black decedents were more likely to be hospitalized (aHR 1.28 [1.25-1.32]), more likely to be admitted to skilled nursing (aHR 1.09 [1.05-1.13]), and less likely to be admitted to hospice (aHR 0.82 [0.79-0.85]) than White decedents.

Discussion

We found racial disparities in care utilization among patients with neurodegenerative disease in the last year of life, such that Black decedents were more likely to receive specific low-value care services and less likely to receive high-value supportive care than White decedents, even after adjusting for health status and socioeconomic factors.

Effectiveness of Live-Streaming Tele-Exercise Intervention in Patients With Parkinson's Disease: A Pilot Study

OBJECTIVE

Exercise can improve both motor and nonmotor symptoms in people with Parkinson's disease (PwP), but there is an unmet need for accessible and sustainable exercise options. This study aimed to evaluate the effect, feasibility, and safety of a regularly performed live-streaming tele-exercise intervention for PwP.

METHODS

A live-streaming exercise intervention for PwP was implemented twice a week for 12 weeks. We measured the motor and nonmotor symptom scores of the included patients before and after the intervention. Changes in clinical scores from baseline to postintervention were analyzed using paired t-tests. Factors associated with improvements in clinical scores and compliance were analyzed using Pearson's correlation analysis.

RESULTS

Fifty-six participants were enrolled in the study. There were significant improvements in Hospital Anxiety and Depression Scale (HADS)-anxiety (p = 0.007), HADS-depression (p < 0.001), Unified Parkinson's Disease Rating Scale (UPDRS) part III (p < 0.001), UPDRS total (p = 0.015), Hoehn and Yahr stage (p = 0.027), and Parkinson's Disease Fatigue Scale-16 (p = 0.026) scores after the intervention. Improvements in motor symptoms were associated with improvements in mood symptoms and fatigue. Higher motor impairment at baseline was associated with a greater compliance rate and better postintervention composite motor and nonmotor outcomes (ΔUPDRS total score). Overall, the 12-week tele-exercise program was feasible and safe for PwP. No adverse events were reported. The overall adherence rate was 60.0% in our cohort, and 83.4% of the participants were able to participate in more than half of the exercise routines.

CONCLUSION

The live-streaming tele-exercise intervention is a safe, feasible, and effective nonpharmacological treatment option that can alleviate fatigue and improve mood and motor symptoms in PwP.

Cost Effectiveness of Deep Brain Stimulation for Parkinson's Disease: A Systematic Review

BACKGROUND AND OBJECTIVE

Deep brain stimulation (DBS) is an established treatment for Parkinson's disease (PD) in patients with advanced motor symptoms with an inadequate response to pharmacotherapies. Despite its effectiveness, the cost effectiveness of DBS remains a subject of debate. This systematic review aims to update and synthesize evidence on the cost effectiveness of DBS for PD.

METHODS

To identify full economic evaluations that compared the cost effectiveness of DBS with other best medical treatments, a comprehensive search was conducted of the PubMed, Embase, Scopus, and Tufts Cost-Effective Analysis registry databases. The selected papers were systematically reviewed, and the results were summarized. For the quality appraisal, we used the modified economic evaluations bias checklist. The review protocol was a priori registered with PROSPERO, CRD42022345508.

RESULTS

Sixteen identified cost-utility analyses that reported 19 comparisons on the use of DBS for PD were systematically reviewed. The studies were primarily conducted in high-income countries and employed Markov models. The costs considered were direct costs: surgical expenses, calibration, pulse generator replacement, and annual drug expenses. The majority of studies used country-specific thresholds. Fourteen comparisons from 12 studies reported on the cost effectiveness of DBS compared to best medical treatments. Eleven comparisons reported DBS as cost effective based on incremental cost-utility ratio results.

CONCLUSIONS

The cost effectiveness of DBS for PD varies by time horizon, costs considered, threshold utilized, and stage of PD progression. Standardizing approaches and comparing DBS with other treatments are needed for future research on effective PD management.

Cost-effectiveness analysis of insecticide ban aimed at preventing Parkinson's disease in Central California

BACKGROUND

Our study assessed whether banning specific insecticides to reduce the PD burden in three Central California (CA) counties is cost-effective.

METHOD

We applied a cost-effectiveness analysis using a cohort-based Markov model to estimate the impact and costs of banning seven insecticides that were previously associated with PD in these counties as well as mixture exposures to some of these pesticides. We relied for our estimations on the cohort of 65- and 66-year-olds living in these counties who were unaffected by PD at baseline in 2020 and projected their incidence, costs, and reduction in quality-adjusted-life-years (QALY) loss due to developing PD over a 20-year period. We included a shiny app for modeling different scenarios (https://sherlockli.shinyapps.io/pesticide_pd_economics_part_2/).

RESULTS

According to our scenarios, banning insecticides to reduce the occurrence of PD in three Central CA counties was cost-effective relative to not banning insecticides. In the worst-case scenario of exposure to a single pesticide, methomyl, versus none would result in an estimated 205 (95 % CI: 75, 348) additional PD cases or 12 % (95 % CI: 4 %, 20 %) increase in PD cases over a 20-year period based on residential proximity to pesticide applications. The increase in PD cases due to methomyl would increase health-related costs by $72.0 million (95 % CI: $5.5 million, $187.4 million). Each additional PD patient due to methomyl exposure would incur $109,327 (95 % CI, $5554, $347,757) in costs per QALY loss due to PD. Exposure to methomyl based on workplace proximity to pesticide applications generated similar estimates. The highest PD burden and associated costs would be incurred from exposure to multiple pesticides simultaneously.

CONCLUSION

Our study provides an assessment of the cost-effectiveness of banning specific insecticides to reduce PD burden in terms of health-related QALYs and related costs. This information may help policymakers and stakeholders to make decisions concerning the regulation of pesticides.

Economic Evaluations Comparing Deep Brain Stimulation to Best Medical Therapy for Movement Disorders: A Meta-Analysis

BACKGROUND

Movement disorders (Parkinson's disease, essential tremor, primary dystonia) are a debilitating group of conditions that are progressive in nature. The mainstay of treatment is best medical therapy; however, a number of surgical therapies are available, including deep brain stimulation. Economic evaluations are an important aspect of evidence to inform decision makers regarding funding allocated to these therapies.

OBJECTIVE

This systematic review and meta-analysis evaluated the cost effectiveness of including deep brain stimulation compared with best medical therapy for movement disorder indications in the adult population.

METHODS

Ovid Medical Literature Analysis and Retrieval System Online, Embase, and Cochrane Central Register of Controlled Trials were queried. Only economic evaluations reporting incremental cost-effectiveness ratios for including deep brain stimulation versus best medical therapy for movement disorders were included. Studies were reviewed in duplicate for inclusion and data abstraction. Data were harmonized using the Consumer Price Index and Purchasing Power Parity to standardize values to 2022 US dollars. For inclusion in meta-analyses, studies were required to have sufficient data available to calculate an estimate of the incremental net benefit. Meta-analyses of pooled incremental net benefit based on the time horizon were performed. The study was registered at PROSPERO (CRD42022335436).

RESULTS

There were 2190 studies reviewed, with 14 economic evaluations included following a title/abstract and full-text review. Only studies considering Parkinson's disease were available for the meta-analysis. Quality of the identified studies was low, with moderate transferability to the American Healthcare System, and certainty of evidence was low. However, studies with a longer time horizon (15 years to lifetime) were found to have significant positive incremental net benefit (indicating cost effectiveness) for including deep brain stimulation with a mean difference of US$40,504.81 (95% confidence interval 2422.42-78,587.19).

CONCLUSIONS

Deep brain stimulation was cost effective for Parkinson's disease when considered over the course of the patient's remaining life after implantation.

TRIAL REGISTRATION

Clinical Trial Registration: PROSPERO (CRD42022335436).

[Problems in organizing neurosurgical care for patients with Parkinson's disease in the Russian Federation]

BACKGROUND

Currently, there are some problems in the Russian Federation complicating development of neurosurgical care for patients with Parkinson's disease (PD).

MATERIAL AND METHODS

In 2022, neurologists - movement disorders specialists were surveyed to analyze situation with PD pharmacological treatment and referral of patients for surgical treatment in Russian constituent entities. Data on neurosurgical treatment of PD were obtained by collecting information on the surgical activity of medical institutions in the Russian Federation. Most hospitals involved in PD treatment took part in this study.

RESULTS

The state of neurosurgical care for patients with PD is analyzed and possible ways to improve the quality of treatment are discussed.

CONCLUSION

Over the past 20 years, a system of neurosurgical care for patients with PD has been formed in 14 centers in the Russian Federation (2022). Obstacles to its further development can be divided into 3 categories: problems of patient selection and routing, complexity of organization and financing surgeries, and imperfect postoperative patient management. Ways to overcome these obstacles imply expanding the network of centers for extrapyramidal diseases, development of domestic neurostimulation systems, improving the distribution of quotas taking into account the capabilities of hospitals, specialized training of neurologists for extrapyramidal centers and neurosurgeons for deep brain stimulation centers, adequate financing and systematization of postoperative management of patients with PD.

Cost-Effectiveness Analyses of Non-Pharmacological and Non-Surgical Interventions in Idiopathic Parkinson's Disease: A Systematic Review

Background

Interest in non-pharmacological/non-surgical interventions to treat Parkinson's disease (PD) has substantially increased. Although a few health-economic studies have been conducted, summary information on the cost-effectiveness is still scarce.

Objective

To give an overview of cost-effectiveness analyses (CEA) focusing on non-pharmacological/non-surgical interventions in PD patients.

Methods

A systematic literature search was conducted in five databases. Studies were included that provided cost-effectiveness analysis (CEA) or cost-utility analysis (CUA) of non-pharmacological/non-surgical interventions in PD patients. Study quality was assessed with the Drummond and CHEERS 2022 checklists, respectively for economic evaluation.

Results

N = 9 studies published between 2012-2023 were identified. Most studies undertook a CUA (n = 5); n = 3 reported a combination of CEA and CUA, and n = 1 a pure CEA. Most studies (n = 6) examined physical exercise. The CEA studies identified additional costs of 170€ -660€  for the improvement of one single unit of a clinical outcome and savings of 18.40€ -22.80€  per score gained as measured with established instruments. The four studies that found significant quality of life benefits show large variations in the incremental cost effectiveness ratio (ICER) of 3,220€ -214,226€  per quality-adjusted life year (QALY); notably interventions were heterogenous regarding content and intensity.

Conclusions

Despite increasing numbers of non-pharmacological/non-surgical intervention trials in PD patients, health-economic evaluations are rare. The examined intervention types and health-economic results vary greatly. Together with the heterogeneity of the health-economic studies these factors limit the conclusions that can be drawn. Further research and a standardization of methods is needed to allow decision makers to make meaningful interpretations, and to allocate scarce resources.

6-hydroxydopamine affects multiple pathways to induce cytotoxicity in differentiated LUHMES dopaminergic neurons

The debilitating effects of Parkinson's disease (PD) progress over time and are pathophysiologically characterized by the formation of Lewy bodies due to the accumulation of α-synuclein aggregates resulting in the death of dopaminergic neurons. In the present study, we determined cell death pathways activated by acute exposure to 6-hydroxydopamine (6-OHDA) in differentiated LUHMES cells empirically followed by a 24 h toxin free interval, henceforth termed as washout/recovery period. Acute 6-OHDA exposure led to morphological changes in LUHMES cells and resulted in significant loss of neurite length and neurite thickness. Generation of reactive oxygen species and loss of mitochondrial membrane potential in the neuronal processes were persistent even after the recovery period. Our results show that 6-OHDA exposure leads to significant reduction in expression of mitochondrial OXPHOS complexes I, II, and IV and activation of caspase mediated apoptotic cell death cascade as observed by enhanced protein expression of cleaved-PARP-1 and cleaved-Caspase-3. Immunofluorescence microscopy approach confirmed that cell death occurs independent of the AIF translocation to the nucleus. Our experimental model, led to a ∼5-fold lower α-synuclein monomer expression and, interestingly, resulted in loss of protein ubiquitination in whole cell lysates. Altogether, this work provides evidence of multiple pathways targeted by 6-OHDA in differentiated LUHMES cells and expands research avenues for addressing the knowledge gap regarding the effect of 6-OHDA in the ubiquitin proteasome system for PD therapies.

Modelling the Cost Effectiveness of Treatments for Parkinson's Disease: An Updated Methodological Review

OBJECTIVE

This article systematically reviewed the methodological quality of modelling approaches for economic evaluations of the treatment of motor symptoms in Parkinson's disease in studies published after 2010.

METHODS

A systematic literature search was undertaken using PubMed, EconLit, the Cochrane Database of Systematic Reviews, National Health Service Economic Evaluation Database and Health Technology Assessment databases of the UK National Health Service Centre for Review and Dissemination (March 2010 to July 2022). Quality was assessed using a checklist from the German Scientific Working Group.

RESULTS

A total of 20 studies were evaluated, with the majority based on Markov models (n = 18). Studies assessed the cost effectiveness of medical (n = 12) or surgical (n = 8) treatment, and included costs from a payer or healthcare provider's perspective (n = 17). Furthermore, all studies included quality-adjusted life-years as an effect measure. In the quality assessment of the literature, a mean score of 42.1 points (out of 56 points) on the checklist of the German Scientific Working Group was achieved. Seventeen studies concluded the intervention under study was (likely) cost effective. No intervention was classified as cost ineffective.

CONCLUSIONS

The quality of economic evaluation models in Parkinson's disease has improved in terms of calculating cost and transition parameters, as well as carrying out probabilistic sensitivity analyses, compared with the published literature of previous systematic reviews up to 2010. However, there is still potential for further development in terms of the integration of non-motor complications and treatment changes, the transparent presentation of parameter estimates, as well as conducting sensitivity analyses and validations to support the interpretation of results.

Current Treatments and New, Tentative Therapies for Parkinson’s Disease

Parkinson’s disease (PD) is a neurodegenerative pathology, the origin of which is associated with the death of neuronal cells involved in the production of dopamine. The prevalence of PD has increased exponentially. The aim of this review was to describe the novel treatments for PD that are currently under investigation and study and the possible therapeutic targets. The pathophysiology of this disease is based on the formation of alpha-synuclein folds that generate Lewy bodies, which are cytotoxic and reduce dopamine levels. Most pharmacological treatments for PD target alpha-synuclein to reduce the symptoms. These include treatments aimed at reducing the accumulation of alpha-synuclein (epigallocatechin), reducing its clearance via immunotherapy, inhibiting LRRK2, and upregulating cerebrosidase (ambroxol). Parkinson’s disease continues to be a pathology of unknown origin that generates a significant social cost for the patients who suffer from it. Although there is still no definitive cure for this disease at present, there are numerous treatments available aimed at reducing the symptomatology of PD in addition to other therapeutic alternatives that are still under investigation. However, the therapeutic approach to this pathology should include a combination of pharmacological and non-pharmacological strategies to maximise outcomes and improve symptomatological control in these patients. It is therefore necessary to delve deeper into the pathophysiology of the disease in order to improve these treatments and therefore the quality of life of the patients.

Infusion Therapies in the Treatment of Parkinson's Disease

Oral levodopa is the gold-standard therapy for treating Parkinson's disease (PD) but after a few years of treatment the therapeutic window narrows, and patients often experience various treatment-related complications. Patients in this advanced PD stage may benefit from alternative therapy, such as continuous intrajejunal delivery of levodopa-carbidopa intestinal gel (LCIG; or carbidopa-levodopa enteral suspension), continuous intrajejunal delivery of levodopa-carbidopa-entacapone intestinal gel, or continuous subcutaneous apomorphine infusion. Consideration and initiation of infusion therapies in advanced PD are suggested before the onset of major disability. The present review summarizes clinical evidence for infusion therapy in advanced PD management, discusses available screening tools for advanced PD, and provides considerations around optimal use of infusion therapy.

Effectiveness of Acupuncture in Parkinson’s Disease Symptoms—A Systematic Review

Background: Parkinson’s disease (PD) is the second most common neurodegenerative disease. Several pharmacological and surgical therapies have been developed; however, they are accompanied by some adverse effects. As a result, many patients have been resorting to complementary medicine, namely acupuncture, in the hope of obtaining symptomatic improvements without having disruptive side effects. Therefore, advances in research in this area are very important. This work presents a systematic review of the effectiveness of acupuncture treatments in relieving PD symptoms. Methods: EMBASE, Medline, Pubmed, Science Direct, The Cochrane Library, Cochrane Central Register of Controlled Trials (Central) and Scielo databases, were systematically searched from January 2011 through July 2021. Randomised controlled trials (RCTs) published in English with all types of acupuncture treatment were included. The selection and analysis of the articles was conducted by two blinding authors through Rayyan application. Results: A total of 720 potentially relevant articles were identified; 52 RCTs met our inclusion criteria. After the exclusion of 35 articles, we found 17 eligible. The included RCTs reported positive effects for acupuncture plus conventional treatment compared with conventional treatment alone in the UPDRS score. Conclusions: Although all the studies reviewed pointed out a positive effect of acupuncture on improving motor and non-motor symptoms in Parkinson’s disease, we found great discrepancies regarding the studies’ design and methodology, making difficult any comparison between them.

Short- and Long-Term Efficacy and Safety of Deep-Brain Stimulation in Parkinson's Disease Patients aged 75 Years and Older

Objective: The aim of this study was to investigate the efficacy and safety of deep-brain stimulation (DBS) in the treatment of patients with Parkinson’s disease aged 75 years and older. Methods: From March 2013 to June 2021, 27 patients with Parkinson’s disease (≥75 years old) who underwent DBS surgery at the First Medical Center of the PLA General Hospital were selected. The Unified Parkinson’s Disease Rating Scale Part 3 (UPDRS-III), 39-item Parkinson’s Disease Questionnaire (PDQ-39), and Barthel Index for Activities of Daily Living (BI) scores were used to evaluate motor function and quality of life before surgery and during on and off periods of DBS at 1 year post operation and at the final follow-up. A series of non-motor scales were used to evaluate sleep, cognition, and mood, and the levodopa equivalent daily dose (LEDD) was also assessed. Adverse events related to surgery were noted. Results: The average follow-up time was 55.08 (21−108) months. Symptoms were significantly improved at 1 year post operation. The median UPDRS-III score decreased from 35 points (baseline) to 19 points (improvement of 45.7%) in the stimulation-on period at 1 year post operation (t = 19.230, p < 0.001) and to 32 points (improvement of 8.6%) at the final follow-up (t = 3.456, p = 0.002). In the stimulation-off period, the median score of UPDRS-III increased from 35 points to 39 points (deterioration of −11.4%) at 1 year post operation (Z = −4.030, p < 0.001) and 45 points (deterioration of −28.6%) at the final follow-up (Z = −4.207, p < 0.001). The PDQ-39 overall scores decreased from 88 points (baseline) to 55 points (improvement of 37.5%) in the stimulation-on period at 1 year post operation (t = 11.390, p < 0.001) and 81 points (improvement of 8.0%) at the final follow-up (t = 2.142, p = 0.044). In the stimulation-off period, the median PDQ-39 score increased from 88 points to 99 points (deterioration of −12.5%) at the final follow-up (Z = −2.801, p = 0.005). The ADL-Barthel Index score increased from 25 points (baseline) to 75 points (improvement of 66.7%) at 1 year post operation (Z = −4.205, p < 0.001) and to 35 points (improvement of 28.6%) at the final follow-up (Z = −4.034, p < 0.001). In the stimulation-off period, BI scores decreased from 25 points to 15 points (deterioration of −40%) at 1 year post operation (Z = −3.225, p = 0.01) and to 15 points (deterioration of −40%) at the final follow-up (Z = −3.959, p = 0.001). Sleep, cognition, and mood were slightly improved at 1 year post operation (p < 0.05), and LEDD was reduced from 650 mg (baseline) to 280 mg and 325 mg at 1 year post operation and the final follow-up, respectively (p < 0.05). One patient had a cortical hemorrhage in the puncture tract on day 2 after surgery, five patients had hallucinations in the acute stage after surgery, and one patient had an exposed left-brain electrode lead at 4 months post operation; there were no infections or death. Conclusion: DBS showed efficacy and safety in treating older patients (≥75 years old) with Parkinson’s disease. Motor function, quality of life, activities of daily living, LEDD, and sleep all showed long-term improvements with DBS; short-term improvements in emotional and cognitive function were also noted.

Economic evaluations of fall prevention exercise programs: a systematic review

Objective

To investigate cost-effectiveness and costs of fall prevention exercise programmes for older adults.

Design

Systematic review.

Data sources

Medline, Embase, Web of Science, Scopus, National Institute for Health Research Economic Evaluation Database, Health Technology Assessment database, Tufts Cost-Effectiveness Analysis Registry, Research Papers in Economics and EconLit (inception to May 2022).

Eligibility criteria for study selection

Economic evaluations (trial-based or model-based) and costing studies investigating fall prevention exercise programmes versus no intervention or usual care for older adults living in the community or care facilities, and reporting incremental cost-effectiveness ratio (ICER) for fall-related outcomes or quality-adjusted life years (QALY, expressed as cost/QALY) and/or intervention costs.

Results

31 studies were included. For community-dwelling older adults (21 economic evaluations, 6 costing studies), results ranged from more effective and less costly (dominant) interventions up to an ICER of US$279 802/QALY gained and US$11 986/fall prevented (US$ in 2020). Assuming an arbitrary willingness-to-pay threshold (US$100 000/QALY), most results (17/24) were considered cost-effective (moderate certainty). The greatest value for money (lower ICER/QALY gained and fall prevented) appeared to accrue for older adults and those with high fall risk, but unsupervised exercise appeared to offer poor value for money (higher ICER/QALY). For care facilities (two economic evaluations, two costing studies), ICERs ranged from dominant (low certainty) to US$35/fall prevented (moderate certainty). Overall, intervention costs varied and were poorly reported.

Conclusions

Most economic evaluations investigated fall prevention exercise programmes for older adults living in the community. There is moderate certainty evidence that fall prevention exercise programmes are likely to be cost-effective. The evidence for older adults living in care facilities is more limited but promising.

PROSPERO registration number

PROSPERO 2020 CRD42020178023.

Exploring the link between Parkinson's disease and type 2 diabetes mellitus in Drosophila

Parkinson's disease (PD) is the second most common neurodegenerative disease. Diabetes mellitus (DM) is a metabolic disease characterized by high levels of glucose in blood. Recent epidemiological studies have highlighted the link between both diseases; it is even considered that DM might be a risk factor for PD. To further investigate the likely relation of these diseases, we have used a Drosophila PD model based on inactivation of the DJ-1β gene (ortholog of human DJ-1), and diet-induced Drosophila and mouse type 2 DM (T2DM) models, together with human neuron-like cells. T2DM models were obtained by feeding flies with a high sugar-containing medium, and mice with a high fat diet. Our results showed that both fly models exhibit common phenotypes such as alterations in carbohydrate homeostasis, mitochondrial dysfunction or motor defects, among others. In addition, we demonstrated that T2DM might be a risk factor of developing PD since our diet-induced fly and mouse T2DM models present DA neuron dysfunction, a hallmark of PD. We also confirmed that neurodegeneration is caused by increased glucose levels, which has detrimental effects in human neuron-like cells by triggering apoptosis and leading to cell death. Besides, the observed phenotypes were exacerbated in DJ-1β mutants cultured in the high sugar medium, indicating that DJ-1 might have a role in carbohydrate homeostasis. Finally, we have confirmed that metformin, an antidiabetic drug, is a potential candidate for PD treatment and that it could prevent PD onset in T2DM model flies. This result supports antidiabetic compounds as promising PD therapeutics.

Wuzi Yanzong pill attenuates MPTP-induced Parkinson's Disease via PI3K/Akt signaling pathway

Wuzi Yanzong Pill (WYP) was found to play a protective role on nerve cells and neurological diseases, however the molecular mechanism is unclear. To understand the molecular mechanisms that underly the neuroprotective effect of WYP on dopaminergic neurons in Parkinson's disease (PD). PD mouse model was induced by the 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP). Gait and hanging tests were used to assess motor behavioral function. Immunofluorescence assay was used to determine TH-positive neurons in substantia nigra (SN). Apoptosis, dopamine and neurotrophic factors as well as expression of PI3K/Akt pathway were detected by TUNEL staining, ELISA and western blotting, respectively. First, it was observed that WYP intervention improved abnormal motor function in MPTP-induced PD model, alleviated the loss of TH⁺ neurons in SN, and increased dopamine content in brain, revealing a potential protective effect. Second, network pharmacology was used to analyze the possible targets and pathways of WYP action in the treatment of PD. A total of 126 active components related to PD were screened in WYP, and the related core targets included ALB, GAPDH, Akt1, TP53, IL6 and TNF. Particularly, the effect of WYP on PD may be medicate through PI3K/Akt signaling pathway and apoptotic regulation. The WYP treated PD mice had higher expression of p-PI3K, p-Akt and Bcl-2 but lower expression of Bax and cleaved caspase-3 than the non-WYP treated PD mice. Secretion of brain-derived neurotrophic factor (BDNF) and cerebral dopamine neurotrophic factor (CDNF) were also increased in the treated mice. WYP may inhibit apoptosis and increase the secretion of neurotrophic factor via activating PI3K/ Akt signaling pathway, thus protecting the loss of dopamine neurons in MPTP-induced PD mice.

Patient Utilities in Health States Based on Hoehn and Yahr and Off-Time in Parkinson's Disease: A Swedish Register-Based Study in 1823 Observations

BACKGROUND

Cost-effectiveness models in Parkinson's disease often include health states based on Hoehn and Yahr (H&Y) and time in 'off'. Few studies have investigated utilities in these health states.

OBJECTIVE

The aim of this study was firstly to explore utilities in health states based on H&Y and off-time, and secondly to investigate to what extent H&Y and off-time correlated with EQ-5D dimensions.

METHODS

Patients with idiopathic Parkinson's disease in the National Parkinson's Disease Patient Registry (PARKreg) in Sweden with observations of EQ-5D-3L, H&Y and off-time were included. Correlations with EQ-5D dimensions were analyzed. The relationship between the EQ-5D-3L and H&Y and off-time were estimated by a linear mixed-model with random intercept.

RESULTS

Among patients in PARKreg, 1823 observations fulfilled inclusion criteria. The dimensions 'self-care', 'mobility' and 'usual activities' correlated moderately with H&Y (r_s = 0.45, r_s = 0.46, r_s = 0.45). Weak correlations were found for 'anxiety/depression' and 'pain/discomfort' (r_s = 0.24, r_s = 0.22) (p values < 0.001). All dimensions correlated weakly with off-time. The fitted model included H&Y, time in 'off', and sex. All H&Y stages were found to be significant and had large and monotonous impact on EQ-5D. Off-time was not significant, but improved the model goodness of fit. Predicted values ranged from 0.733 to - 0.106.

CONCLUSION

This study provides utilities for health states reflecting the current modeling practice of interventions targeting motor symptoms in Parkinson's disease. Future research should investigate patient utilities in health states that also capture non-motor symptoms of the disease, as the management of and options for treatments targeting these symptoms increases.

Acute effects of acupuncture in balance and gait of Parkinson disease patients - A preliminary study

INTRODUCTION

Balance and gait disorders are relevant symptoms in the quality of life of Parkinson's patients. Currently, there is no therapy to reverse or treat this condition. Acupuncture treatment is believed to improve motor ability through the cortico-basal-thalamus-cortical-ganglia.

AIM

To investigate qualitatively the acute effect of acupuncture on balance and gait in Parkinson's disease in 7 patients.

METHODS

This is a randomized and controlled crossover study. The same individual patient was part of both, experimental (real acupuncture) and control group (false acupuncture/sham), and the sequence was randomized. Balance and gait parameters were measured at two different moments, before and after treatment, using four force platforms as well as the collection of 3D markers positions taken by 11 cameras. Images were analyzed using Qualisys Track Manager software that let us extract data related to the quality of gait and balance.

RESULTS

Statistically significant differences were found in gait speed (p = 0.016), gait cadence (p = 0.006), support base width (p = 0.0001), medio-lateral oscillation (p = 0.017), left-right step length (p = 0.0002), and stride length: right-right (p = 0.0000) and left-left (p = 0.0018), time of left support phase (p = 0.029), right support phase (p = 0.025) and double support phase (p = 0.015), between the initial and final moments for the experimental group. Differences in right-left stride length were found for both groups.

CONCLUSION

Our results suggest that the acupuncture protocol used objectively could improve gait in Parkinson disease patients. A deep research involving a statistical evaluation supported on a larger number of voluntaries should be accomplished to confirming these promising preliminary results.

A novel method for automatic classification of Parkinson gait severity using front-view video analysis

BACKGROUND

Gait impairment is an essential symptom of Parkinson's disease (PD).

OBJECTIVE

This paper introduces a novel computer-vision framework for automatic classification of the severity of gait impairment using front-view motion analysis.

METHODS

Four hundred and fifty-six videos were recorded from 19 PD patients using an RGB camera during clinical gait assessment. Gait performance in each video was rated by a neurologist using the unified Parkinson's disease rating scale for gait examination (UPDRS-gait). The proposed algorithm detects and tracks the silhouette of the test subject in the video to generate a height signal. Gait features were extracted from the height signal. Feature analysis was performed using the Kruskal-Wallis rank test. A support vector machine was trained using the features to classify the severity levels according to UPDRS-gait in 10-fold cross-validation.

RESULTS

Features significantly (p< 0.05) differentiated between median-ranks of UPDRS-gait levels. The SVM classified the levels with a promising area under the ROC of 80.88%.

CONCLUSION

Findings support the feasibility of this model for Parkinson's gait assessment in the home environment.

Parkinson's disease advanced therapies - A systematic review: More unanswered questions than guidance

In advanced Parkinson's disease (PD), therapeutic interventions include device-aided therapies such as continuous subcutaneous apomorphine infusion (CSAI), levodopa-carbidopa intestinal gel (LCIG) infusion, and deep brain stimulation (DBS). We reappraised the evidence guiding the decision of appropriate device-aided therapies in advanced PD, and systematically reviewed the literature (including ongoing clinical trials) comparing CSAI, LCIG, DBS in terms of efficacy and cost-effectiveness, with particular consideration to possible conflicts of interests. Of 14,980 documents screened, sixteen were included (4 and 13 studies examining efficacy and cost-effectiveness, respectively). LCIG and DBS showed higher efficacy compared to best medical therapy (BMT). DBS was more expensive than BMT and LCIG. Lifetime costs of CSAI were lower of those of DBS, and DBS lifetime costs were lower than those of LCIG. The majority of studies (11 out of 16) showed direct or indirect sponsorship from pharmaceutical or device companies. Only one ongoing clinical trial comparing LCIG with DBS was found. Device-aided therapies address unmet needs in advanced PD. LCIG and DBS are superior to BMT in head-to-head studies; however, initial and lifetime costs should be considered when choosing those therapies. Guidelines to assist clinicians and patients to choose device-aided therapies, free from conflict of interests, are required.

The Choice Between Advanced Therapies for Parkinson's Disease Patients: Why, What, and When?

When oral dopaminergic medication falls short in the treatment of Parkinson's disease, patients are left with motor response fluctuations and dyskinesias that may have a large impact on functioning in daily life. They may benefit from one of the currently available advanced treatments, namely deep brain stimulation, continuous levodopa-carbidopa intestinal gel, and continuous subcutaneous apomorphine infusion. The indication, choice between the separate advanced treatments and the timing can be challenging and will be discussed against the background of the progressive nature of the disease, the heterogeneity of disease manifestation and variable patient characteristics.