Treatment of advanced Parkinson's disease

Therapeutic singing-induced swallowing exercise for dysphagia in advanced-stage Parkinson's disease

Background

With longer life spans and medical advancements, the rising number of patients with advanced-stage Parkinson's disease (PD) warrants attention. Current literature predominantly addresses dementia and fall management in these patients. However, exploring the impact of swallowing function on patients with advanced PD is crucial. Previous research has demonstrated notable enhancements in the quality of life related to voice for participants following a group singing-intervention program. To further elucidate the effect of individual singing-induced swallowing exercises, our study aimed to investigate the quantitative and qualitative effects of therapeutic singing on swallowing function in patients with advanced PD in comparison to a matched usual care control group. The hypothesis of this study is that therapeutic singing-induced swallowing exercises can assist to maintain swallowing function in patients with advanced PD.

Methods

This prospective matched control study compared the effects of a 6-week therapeutic singing-based swallowing intervention on swallowing function and quality of life in patients with advanced PD. The intervention group received individual sessions with a music therapist and conventional individual physical therapy. The control group received the same standard physical therapy for 6 weeks without music intervention. The primary outcome measure was Video Fluoroscopic Dysphagia Scale (VDS).

Results

The study revealed that the intervention group maintained swallowing function, whereas the control group experienced deterioration, indicating significant time-dependent changes in Penetration-Aspiration Scale (PAS), National Institutes of Health-Swallowing Safety Scale (NIH-SSS), and VDS. Analysis of PAS and NIH-SSS liquid food scores in both groups showed significant time effects. However, the intervention group exhibited no significant differences between the pre- and post-tests, indicating preservation of the swallowing function. VDS of liquid food indicated an interaction effect between time and group in the pharyngeal phase and total scores. The Swallowing-Quality of Life showed significant time-effect improvement in the intervention group.

Conclusion

Therapeutic singing exercises may help maintain swallowing function in advanced PD patients, potentially enhancing quality of life related to swallowing in those with advanced-stage diseases.

Clinical trial registration

https://cris.nih.go.kr/cris/search/listDetail.do, identifier KCT0008644.

Quality of life outcomes after deep brain stimulation in acquired dystonia: a systematic review and meta-analysis

BACKGROUND

Dystonia is a condition that affects the ability to control the movement and function of the body's muscles. It can cause not only physical problems, but also mental problems, resulting in impaired health-related quality of life (HRQoL). However, the effect of deep brain stimulation on quality of life in acquired dystonia remains unclear.

METHODS

We conducted a systematic literature review from January 2000 to October 2022，determined the eligible studies, and performed a meta-analysis of HRQoL outcomes based on the Short-Form Health Survey-36 (SF-36) after DBS to evaluate the effects of DBS on physical and mental QoL.

RESULTS

A total of 14 studies met the inclusion criteria and were systematically reviewed. A comprehensive meta-analysis was performed for 9 studies that reported physical and psychological data or physical component summary (PCS), or mental component summary (MCS) for SF-36. The mean (SD) age at DBS implantation was 34.29 (10.3) years, and the follow-up period after implantation was 2.21 (2.80) years. The random effects model meta-analysis revealed that both physical and mental domains of the SF-36 improved following DBS. There was no statistically significant difference between the physical domains (effect size=1.34; p<0.0001) and the mental domains (effect size=1.38; p<0.0001).

CONCLUSION

This is the first meta-analysis that demonstrates significant benefits in HRQoL following DBS in patients with acquired dystonia. There were significant improvements in both physical QoL and mental QoL.

Efficacy and safety of magnetic resonance-guided focused ultrasound for Parkinson's disease: a systematic review and meta-analysis

Objective

Magnetic resonance imaging-guided focused ultrasound (MRgFUS) is a novel noninvasive treatment for drug-resistant Parkinson's disease (PD) related tremor. This study aims to evaluate MRgFUS's efficacy and safety in PD through a systematic review and meta-analysis, examining pre-and post-treatment MDS-UPDRSIII and/or CRST scores and associated adverse events.

Materials and methods

We conducted an extensive literature search across PubMed, Embase, Web of Science, and Cochrane Library databases, screening studies based on set criteria and analyzing MDS-UPDRSIII, CRST, and adverse events pre- and post-MRgFUS treatment.

Results

Out of 468 retrieved articles, 20 studies involving 258 patients, spanning 2014-2023, were included.17 studies indicated significant MDS-UPDRSIII score reductions post-MRgFUS treatment, while 3 showed significant CRST score declines. In the "on" medication state, pooled MDS-UPDRSIII scores at 1, 3, 6, and 12 months were 12.18 (95% CI: 5.83-18.52), 12.10 (95% CI: 8.22-15.97), 14.85 (95% CI: 9.28-20.41), and 20.65 (95% CI: 12.15-29.14) respectively. In the "off" state, scores were 11.45 (95% CI: -3.50-26.40), 14.71 (95% CI: 4.95-24.46), 21.52 (95% CI: 19.28-23.75), and 22.28 (95% CI: 15.26-29.30). Adverse events were typically mild and transient, with speech disturbances, ataxia, and sensory abnormalities being common post-operative neurological complications.

Conclusion

MRgFUS offers an effective and relatively safe treatment option for patients with drug-resistant PD-related tremor.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, No. CRD42023428332.

Healthcare resource utilization and device-aided therapy discussions with eligible patients across the Parkinson's disease continuum: Revelations from the MANAGE-PD validation cohort

INTRODUCTION

Device-aided therapy may improve the quality of life (QoL) for people with advanced Parkinson's disease (PD) and poorly controlled symptoms with oral therapy. MANAGE-PD is a validated tool classifying patients based on symptom control and advanced treatment eligibility. This study focused on patient/caregiver reported outcomes and healthcare resource utilization among patients grouped by MANAGE-PD categories.

METHODS

Device-aided therapy-naïve patients receiving oral treatments were identified from the Adelphi Parkinson's Disease Programme. Patients were categorized (category 1 to 3) using MANAGE-PD. PD-specific QoL (PDQ-39), care partner burden (ZBI), satisfaction with current treatment, healthcare resource utilization, associated healthcare costs, and future treatment discussion with providers were measured. Categories were compared using ANOVA, t-test, chi square and adjusted regression analyses.

RESULTS

Of the analytical sample (n = 2709), 18.9% were inadequately controlled on current therapy and potentially eligible for device-aided therapies (category 3). As expected, they had worse patient/caregiver reported outcomes versus patients in categories 1 or 2. However, the degree of difference in healthcare resource utilization, including: greater number of hospitalizations, emergency room (ER) visits and consultations, higher likelihood of being recipients of respite care, and greater PD treatment burden, was unexpected. Importantly, of patients in category 3 and their care partners, >40% did not report discussions with providers about device-aided therapies.

CONCLUSION

MANAGE-PD category 3 patients had significantly higher burden on healthcare resources versus patients well-controlled with oral treatment or requiring only oral medication adjustments; yet almost half had no discussion on device-aided therapies with providers. Device-aided therapies may be considered in these patients.

Retinal Changes in Parkinson's Disease: A Non-invasive Biomarker for Early Diagnosis

Parkinson's disease (PD) is caused due to degeneration of dopaminergic neurons in the substantia nigra pars compacta (SNpc) which leads to the depletion of dopamine in the body. The lack of dopamine is mainly due to aggregation of misfolded α-synuclein which causes motor impairment in PD. Dopamine is also required for normal retinal function and the light-dark vision cycle. Misfolded α-synuclein present in inner retinal layers causes vision-associated problems in PD patients. Hence, individuals with PD also experience structural and functional changes in the retina. Mutation in LRRK2, PARK2, PARK7, PINK1, or SNCA genes and mitochondria dysfunction also play a role in the pathophysiology of PD. In this review, we discussed the different etiologies which lead to PD and future prospects of employing non-invasive techniques and retinal changes to diagnose the onset of PD earlier.

Lacosamide exhibits neuroprotective effects in a rat model of Parkinson's disease

BACKGROUND

Parkinson's disease (PD) is a chronic and progressive neurodegenerative disorder that primarily affects the motor system. Although there are several treatments available to alleviate PD symptoms, there is currently no cure for the disease. Lacosamide, an anti-epileptic drug, has shown promising results in preclinical studies as a potential neuroprotective agent for PD. In this study, we aimed to investigate the neuroprotective effect of lacosamide in a murine model of PD.

METHODS

Twenty-one adult male rats were randomly divided into the following three groups (n = 7): 1 group received stereotaxical infusion of dimethyl sulfoxide (vehicle, group 1), and the others received stereotaxical infusion of rotenone (groups 2 and 3). The apomorphine-induced rotation test was applied to the rats after 10 days. Thereafter, group 2 was administered isotonic saline, whereas group 3 was administered lacosamide (20 mg/kg,i.p.) for 28 days. Apomorphine-induced rotation tests were performed to assess the effect of lacosamide on motor function. In addition, immunohistochemistry and biochemistry were used to assess the dopaminergic neuron loss in the substantia nigra and MDA, TNF-α and HVA levels, respectively.

RESULTS

In rats with Parkinson's disease induced by rotenone, levels of malondialdehyde and TNF-α significantly increased and HVA levels decreased, whereas in mice treated with lacosamide, levels of malondialdehyde and TNF-α significantly decreased and HVA levels increased. The apomorphine-induced rotation test scores of lacosamide-treated mice were lower compared with the untreated group. Furthermore, treatment with lacosamide significantly mitigated the degeneration of dopaminergic projections within the striatum originating from the substantia nigra and increased tyrosine hydroxylase (TH) immunofluorescence, indicative of preserved dopaminergic neuronal function.

CONCLUSION

In conclusion, our study provides evidence that lacosamide has a neuroprotective effect on the rat model of PD. Further studies are required to investigate the underlying mechanisms and evaluate the potential clinical use of lacosamide as a neuroprotective agent for PD.

Levodopa-Carbidopa Intestinal Gel for Parkinson's Disease over 11 years: One Center's "Real-World" Experience

BACKGROUND

Levodopa-carbidopa intestinal gel (LCIG) therapy has been shown to be a safe and effective treatment for advanced Parkinson's disease (PD). Limited data are available regarding long-term benefits and complications in Canada. Objective of the study was to review long-term experience and clinical outcomes in PD patients with LCIG therapy over 11 years in a multidisciplinary University clinic setting.

METHODS

Chart review was done on PD patients with LCIG from 2011 to 2022. Data collected: dosing, UPDRS-III motor scores, OFF times, hours with dyskinesias, MoCA, complications, discontinuation reasons, and nursing time requirements.

RESULTS

Thirty-three patients received LCIG therapy with a mean follow-up of 3.25±2.09 years. UPDRS-III scores showed reduction of 15% from baseline (mean 35.9) up to 4 years (mean 30.4). Daily OFF time improved from baseline (mean 7.1 ± 3.13 hours) up to 5 years (mean 3.3 ± 2.31 hours; -53.5%; p < 0.048), and dyskinesias remained stable. Nursing time averaged 22 hours per patient per year after PEG-J insertion and titration. Most common complications were PEG-J tube dislodgement and stoma site infection (0-3zero to three events/patient/year). Serious side effects were seen in four (12%) patients resulting in hospitalization and/or death. Nine patients (27.2%) discontinued the treatment due to lack of improved efficacy over oral therapy or development of dementia and 10 (30%) died of causes unrelated to LCIG infusion.

CONCLUSION

Patients on LCIG showed improved motor function over 5-year follow-up. Serious complications were uncommon. Dedicated nursing time is required by LCIG-trained nurses in a multidisciplinary setting for optimum management.

The Management of Parkinson's Disease: An Overview of the Current Advancements in Drug Delivery Systems

Parkinson's disease (PD) has significantly affected a large proportion of the elderly population worldwide. According to the World Health Organization, approximately 8.5 million people worldwide are living with PD. In the United States, an estimated one million people are living with PD, with approximately 60,000 new cases diagnosed every year. Conventional therapies available for Parkinson's disease are associated with limitations such as the wearing-off effect, on-off period, episodes of motor freezing, and dyskinesia. In this review, a comprehensive overview of the latest advances in DDSs used to reduce the limitations of current therapies will be presented, and both their promising features and drawbacks will be discussed. We are also particularly interested in the technical properties, mechanism, and release patterns of incorporated drugs, as well as nanoscale delivery strategies to overcome the blood-brain barrier.

Endocytosis of AMPA receptors: Role in neurological conditions

AMPA receptors are glutamate-gated ion channels, present in a wide range of neuron types and in glial cells. Their main role is to mediate fast excitatory synaptic transmission, and therefore, they are critical for normal brain function. In neurons, AMPA receptors undergo constitutive and activity-dependent trafficking between the synaptic, extrasynaptic and intracellular pools. The kinetics of AMPA receptor trafficking is crucial for the precise functioning of both individual neurons and neural networks involved in information processing and learning. Many of the neurological diseases evoked by neurodevelopmental and neurodegenerative malfunctions or traumatic injuries are caused by impaired synaptic function in the central nervous system. For example, attention-deficit/hyperactivity disorder (ADHD), Alzheimer's disease (AD), tumors, seizures, ischemic strokes, and traumatic brain injury are all characterized by impaired glutamate homeostasis and associated neuronal death, typically caused by excitotoxicity. Given the important role of AMPA receptors in neuronal function, it is not surprising that perturbations in AMPA receptor trafficking are associated with these neurological disorders. In this book chapter, we will first introduce the structure, physiology and synthesis of AMPA receptors, followed by an in-depth description of the molecular mechanisms that control AMPA receptor endocytosis and surface levels under basal conditions or synaptic plasticity. Finally, we will discuss how impairments in AMPA receptor trafficking, particularly endocytosis, contribute to the pathophysiology of various neurological disorders and what efforts are being made to therapeutically target this process.

Safety of Deep Repetitive Transcranial Magnetic Stimulation (drTMS) against Medical Refractory Symptoms in Parkinson Syndromes: First German Real-World Data with a Specific H5 Coil

So far, deep repetitive transcranial magnetic stimulation (drTMS) has shown promising results as an add-on treatment for Parkinson's disease (PD) but not for non-idiopathic Parkinson Syndromes (PS). We aimed to investigate the safety and feasibility of drTMS application in patients with different Parkinson Syndromes and medical refractory symptoms. Multifaceted real-world data (n = 21) were retrospectively analyzed regarding adverse effects as well as short-term effects of the drTMS treatment on patients' self-rated symptom severity and motor, cognitive, and emotional functions. The drTMS treatment with H5 coil included a sequential 1 Hz primary motor cortex stimulation contralateral to the more-affected body side and a bilateral 10 Hz stimulation of the prefrontal cortex. Overall, drTMS could be safely administered to patients with different PSs and medical refractory symptoms, but large variation was apparent in the rate and severity ratings of the reported adverse event/adverse device effect. The treatment significantly decreased the subjective main symptom severity. This effect was more pronounced in older patients with PD. Furthermore, analysis showed an improvement in depression, but no effect could be established in terms of cognitive performance. drTMS can be safely administered to patients with PS and medical refractory symptoms and can decrease the subjective motor symptom severity and depression.

Management of advanced Parkinson’s disease in Israel: Clinicians viewpoint and action items

Parkinson’s disease (PD) is taking a staggering toll on healthcare systems worldwide, with the bulk of the expenditures invested in the late stages of the disease. Considering the rising life expectancy and the increasing prevalence of PD across the globe, a clear understanding of the early signs and treatment options available for advanced PD (APD), will facilitate tailoring management programs and support services. This task is complicated by the lack of both global consensus in defining APD and standardized care guidelines. This perspective prepared by a panel of movement disorder specialists, proposes to extend and optimize currently accepted PD coding to better reflect the diverse disease manifestations, with emphasis on non-motor features. The panel seeks to promote timely diagnosis by adjustment of evaluation tools for use by community neurologists and suggests modification of eligibility criteria for advanced therapy. Moreover, it advocates multidisciplinary assessments of APD patients to drive personalized, patient-centered and holistic management. Overall, earlier and more targeted intervention is expected to markedly improve patient quality of life.

Feasibility and positive effects of scalp acupuncture for modulating motor and cerebral activity in Parkinson's disease: A pilot study

BACKGROUND

A variety of acupuncture therapies have shown efficacy in Parkinson's disease (PD).

OBJECTIVE

To evaluate scalp acupuncture (SA) effects on motor and cerebral activity by using gait equipment and resting-state functional magnetic resonance imaging (rs-fMRI).

METHODS

Twelve patients with PD received SA. They underwent the first functional-imaging scan after tactile stimulation and the second scan following needle removal. Gait test and local sensation assessment were performed immediately after each functional scan. Gait parameter differences between pre- and post-SA were analyzed using a paired t-test and altered brain areas in degree centrality (DC) and fractional amplitude of low-frequency fluctuation (fALFF) were identified between the two scans.

RESULTS

Eight patients completed the experiment. Stride length, maximum ankle height, maximum ankle horizontal displacement, gait speed, and range of shank motion significantly increased post-treatment (P <  0.05). fALFF in left middle frontal gyrus and DC in left cerebellum (corrected) increased, while fALFF in left inferior parietal lobule (corrected) during SA decreased, compared with those in tactile stimulation. A positive correlation was observed between right limb swings and both fALFF areas.

CONCLUSIONS

Differences in gait and brain analyses presented modulation to motor and brain activity in PD, thus, providing preliminary evidence for SA efficacy.

The Cost Effectiveness of Levodopa-Carbidopa Intestinal Gel in the Treatment of Advanced Parkinson's Disease in England

BACKGROUND

Parkinson's disease is a progressive neurodegenerative disease, which significantly impacts patients' quality of life and is associated with high treatment and direct healthcare costs. In England, levodopa/carbidopa intestinal gel (LCIG) is indicated for the treatment of levodopa-responsive advanced Parkinson's disease with troublesome motor fluctuations when available combinations of medicinal products are unsatisfactory.

OBJECTIVE

We aimed to determine the cost effectiveness of LCIG compared to the standard of care for patients with advanced Parkinson's disease in England, using real-world data.

METHODS

A Markov model was adapted from previous published studies, using the perspective of the English National Health System and Personal and Social Services to evaluate the cost effectiveness of LCIG compared to standard of care in patients with advanced Parkinson's disease over a 20-year time horizon. The model comprised 25 health states, defined by a combination of the Hoehn and Yahr scale, and waking time spent in OFF-time. The base case considered an initial cohort of patients with an Hoehn and Yahr score of ≥ 3, and > 4 h OFF-time. Standard of care comprised standard oral therapies, and a proportion of patients were assumed to be treated with subcutaneous apomorphine infusion or injection in addition to oral therapies. Efficacy inputs were based on LCIG clinical trials where possible. Resource use and utility values were based on results of a large-scale observational study, and costs were derived from the latest published UK data, valued at 2017 prices. The EuroQol five-dimensions-3-level (EQ-5D-3L) instrument was used to measure utilities. Costs and quality-adjusted life-years were discounted at 3.5%. Both deterministic and probabilistic sensitivity analyses were conducted.

RESULTS

Total costs and quality-adjusted life-years gained for LCIG vs standard of care were £586,832 vs £554,022, and 2.82 vs 1.43, respectively. The incremental cost-effectiveness ratio for LCIG compared to standard of care was £23,649/quality-adjusted life-year. Results were sensitive to the healthcare resource utilisation based on real-world data, and long-term efficacy of LCIG.

CONCLUSIONS

The base-case incremental cost-effectiveness ratio was estimated to be within the acceptable thresholds for cost effectiveness considered for England.

Psychometric Properties of Clinical Indicators for Identification and Management of Advanced Parkinson's Disease: Real-World Evidence From G7 Countries

Introduction

Standardized and validated criteria to define advanced Parkinson’s disease (PD) or identify patient eligibility for device-aided therapy are needed. This study assessed the psychometric properties of clinical indicators of advanced PD and eligibility for device-aided therapy in a large population.

Methods

This retrospective analysis of the Adelphi Parkinson’s Disease Specific Programme collected data from device-aided therapy-naïve people with PD in G7 countries. We assessed the presence of 15 clinical indicators of advancing PD and seven indicators of eligibility for device-aided therapy in patients classified with advanced PD or as eligible for device-aided therapy by the treating physician. Accuracy was assessed using area under the curve (AUC) and multivariable logistic regression models. Construct validity was examined via known-group comparisons of disease severity and burden among patients with and without each clinical indicator.

Results

Of 4714 PD patients, 14.9% were classified with advanced PD and 17.5% as eligible for device-aided therapy by physician judgment. The presence of each clinical indicator was 1.9- to 7.3-fold more likely in patients classified with advanced PD. Similarly, the presence of device-aided therapy eligibility indicators was 1.8- to 5.5-fold more likely in patients considered eligible for device-aided therapy. All indicators demonstrated high clinical screening accuracy for identifying advanced PD (AUC range 0.84–0.89) and patients eligible for device-aided therapy (AUC range 0.73–0.80). The Unified Parkinson’s Disease Rating Scale (UPDRS) score, cognitive function, quality of life, and caregiver burden were significantly worse in indicator-positive patients.

Conclusion

Specific clinical indicators of advanced PD and eligibility for device-aided therapy demonstrated excellent psychometric properties in a large sample, and thus may provide an objective and reliable approach for patient identification and treatment optimization.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40120-021-00313-9.

Advanced Parkinson’s disease (PD) refers to the stage of disease when motor complications are difficult to manage with standard therapy. Patients reaching this stage of the disease may benefit from a treatment change from pills to the so-called device-aided therapies. However, there is currently no unanimous definition of advanced PD, which makes it challenging to identify suitable candidates for device-aided therapies. There is urgent need to define specific features (or ‘clinical indicators’) to support healthcare professionals and patients in the identification of advanced PD as well as to define suitability for device-aided therapy. This study aimed to assess the accuracy of 15 clinical indicators and seven device-aided therapy eligibility criteria using information from a large database of 4714 patients in G7 countries. Physicians classified 14.9% of patients as having advanced PD and 17.5% were judged to be eligible for device-aided therapy. Each clinical indicator or device-aided therapy eligibility indicator was detected more frequently in patients classified as having advanced PD and in patients considered eligible for device-aided therapy, respectively. All indicators had high accuracy for identifying advanced PD and device-aided therapy-eligibility. These previously identified clinical indicators of advanced PD and device-aided therapy eligibility may provide an objective and reliable approach for patient screening and treatment optimization.

Polypharmacy in chronic neurological diseases: Multiple sclerosis, dementia and Parkinson's disease

Polypharmacy is an important aspect of medication management and particularly affects elderly and chronically ill people. Patients with dementia, Parkinson's disease (PD) or multiple sclerosis (MS) are at high risk for multimedication due to their complex symptomatology. Our aim was to provide an overview of different definitions of polypharmacy and to present the current state of research on polypharmacy in patients with dementia, PD or MS. The most common definition of polypharmacy in the literature is the concomitant use of ≥5 medications (quantitative definition approach). Polypharmacy rates of up to >50% have been reported for patients with dementia, PD or MS, although MS patients are on average significantly younger than those with dementia or PD. The main predictor of polypharmacy is the complex symptom profile of these neurological disorders. Potentially inappropriate medication (PIM), drug-drug interactions, poor treatment adherence, severe disease course, cognitive impairment, hospitalisation, poor quality of life, frailty and mortality have been associated with polypharmacy in patients with dementia, PD or MS. For patients with polypharmacy, either the avoidance of PIM (selective deprescribing) or the substitution of PIM with more suitable drugs (appropriate polypharmacy) is recommended to achieve a more effective therapeutic management.

The Long-Term Impact of Levodopa/Carbidopa Intestinal Gel on 'Off'-time in Patients with Advanced Parkinson's Disease: A Systematic Review

INTRODUCTION

Levodopa/carbidopa intestinal gel (LCIG; carbidopa/levodopa enteral suspension) has been widely used and studied for the treatment of motor fluctuations in levodopa-responsive patients with advanced Parkinson's disease (PD) when other treatments have not given satisfactory results. Reduction in 'off'-time is a common primary endpoint in studies of LCIG, and it is important to assess the durability of this response. This systematic literature review was conducted to qualitatively summarise the data on the long-term effects of LCIG therapy on 'off'-time.

METHODS

Studies were identified by searching PubMed, EMBASE and Ovid on 30 September 2019. Studies were included if they reported on patients with PD, had a sample size of ≥ 10, LCIG was an active intervention and 'off'-time was reported for ≥ 12 months after initiation of LCIG treatment. Randomised clinical trials, retrospective and prospective observational studies, and other interventional studies were included for selection. Data were collected on: 'off'-time (at pre-specified time periods and the end of follow-up), study characteristics, Unified Parkinson's Disease Rating Scale (UPDRS) II, III and IV total scores, dyskinesia duration, quality of life scores, non-motor symptoms and safety outcomes.

RESULTS

Twenty-seven studies were included in this review. The improvement in 'off'-time observed shortly after initiating LCIG was maintained and was statistically significant at the end of follow-up in 24 of 27 studies. 'Off'-time was reduced from baseline to end of follow-up by 38-84% and was accompanied by a clinically meaningful improvement in quality of life. Stratified analysis of 'off'-time demonstrated mean relative reductions of 47-82% at 3-6 months and up to 83% reduction at 3-5 years of follow-up. Most studies reported significant improvements in activities of daily living and motor complications. Most frequent adverse events were related to the procedure or the device.

CONCLUSION

In one of the largest qualitative syntheses of published LCIG studies, LCIG treatment was observed to provide a durable effect in reducing 'off'-time.

INFOGRAPHIC

Video Abstract.

Mechanisms of Antiparkinsonian Anticholinergic Therapy Revisited

Before the advent of L-DOPA, the gold standard symptomatic therapy for Parkinson's disease (PD), anticholinergic drugs (muscarinic receptor antagonists) were the preferred antiparkinsonian therapy, but their unwanted side effects associated with impaired extrastriatal cholinergic function limited their clinical utility. Since most patients treated with L-DOPA also develop unwanted side effects such as L-DOPA-induced dyskinesia (LID), better therapies are needed. Recent studies in animal models demonstrate that optogenetic and chemogenetic manipulation of striatal cholinergic interneurons (SCIN), the main source of striatal acetylcholine, modulate parkinsonism and LID, suggesting that restoring SCIN function might serve as a therapeutic option that avoids extrastriatal anticholinergics' side effects. However, it is still unclear how the altered SCIN activity in PD and LID affects the striatal circuit, whereas the mechanisms of action of anticholinergic drugs are still not fully understood. Recent animal model studies showing that SCINs undergo profound changes in their tonic discharge pattern after chronic L-DOPA administration call for a reexamination of classical views of how SCINs contribute to PD symptoms and LID. Here, we review the recent advances on the circuit implications of aberrant striatal cholinergic signaling in PD and LID in an effort to provide a comprehensive framework to understand the effects of anticholinergic drugs and with the aim of shedding light into future perspectives of cholinergic circuit-based therapies.

Factors Associated with Health-Related Quality of Life in Late-Stage Parkinson's Disease

Background

There is limited knowledge on health-related quality of life (HRQoL) in late-stage Parkinson's disease (PD).

Objective

To assess factors associated with HRQoL in patients with late-stage PD, with a focus on health care provision.

Methods

The Care of Late Stage Parkinsonism (CLaSP) project is the largest study on late-stage PD to date. The current study analyzed data of 401 patients from 6 European countries in whom HRQoL was assessed with the 8-item PD Questionnaire in patients without dementia. Factors potentially associated with HRQoL were assessed and examined in linear regression analyses.

Results

Better HRQoL was associated with living at home, greater independence in activities of daily living (Schwab and England Scale), less severe disease (Hoehn and Yahr stage), better motor function (Unified PD Rating Scale Part III), and lower non-motor symptoms burden (Non-Motor Symptoms Scale [NMSS]) across all NMSS domains. Having a PDspecialist as physician for PD, contact with a PDnurse, and no hospital admission during the past 3 months were associated with better HRQoL, but having seen a physiotherapist or occupational therapist was associated with worse HRQoL.

Conclusions

The results emphasize the importance of optimizing treatment for motor and multiple non-motor symptoms to improve HRQoL in patients with late-stage PD. PD-specific health care resources, particularly PDnurses, are likely important in addressing issues to improve HRQoL in this population. Worse HRQoL in those who had recently seen a physiotherapist or occupational therapist may reflect referral based on factors not measured in this study.

Characterizing Advanced Parkinson's Disease: Romanian Subanalysis from the OBSERVE-PD Study

OBSERVE-PD was a cross-sectional, multicountry, observational study conducted in 128 Movement Disorders Centers (MDCs) in 18 countries. Overall, the study enrolled 2615 patients. The aim was to determine the proportion of patients with advanced Parkinson's disease (APD) versus non-APD from MDCs and to uncover the clinical burden of APD, as well as a correlation between overall assessment of APD and several indicators of APD. The advanced stage of the disease and severity were assessed by investigators using their clinical judgement. Data were collected during a single visit between February 2015 and January 2016. Agreement on physician judgement of APD diagnosis and fulfillment of at least one previously established APD indicator was calculated. Motor and nonmotor symptoms (NMSs), activities of daily living, treatment complications, quality of life (QoL), conventional treatments, and device-aided therapy (DAT) eligibility were assessed. Here, country-specific results of 161 Romanian patients with PD are presented. In total, 59.0% of patients were diagnosed with APD and 78.8% met at least one APD indicator. There was only moderate agreement between clinical judgement of APD and overall fulfillment of APD indicators. All scores related to motor symptoms, NMSs, and treatment complications, as well as to QoL, showed a higher disease burden for patients with APD versus non-APD. Physicians considered 73.7% of patients with APD eligible for DAT. The majority of patients eligible for DAT (54.3%) did not receive such treatment. Our results highlight the importance of earlier recognition of APD, by combining clinical judgement with more standardized clinical tools, such as generally recognized APD criteria. However, timely diagnosis of APD alone is not enough to improve patient outcomes. Other critical factors include patient acceptance and access to appropriate treatment.

STN versus GPi deep brain stimulation for dyskinesia improvement in advanced Parkinson's disease: A meta-analysis of randomized controlled trials

BACKGROUND

Deep brain stimulation (DBS) of the subthalamic nucleus (STN) and the globus pallidus internus (GPi) are currently the most common and effective surgical targets for advanced Parkinson's disease (APD). Herein, we conducted a meta-analysis to evaluate the comprehensive efficacy of STN-DBS and GPi-DBS in patients with APD.

METHODS

We conducted a systematic search for relevant articles written in English in the Cochrane Library, PubMed, and EMBASE databases through January 2020. Studies comparing the efficacy and clinical outcomes of GPi-DBS and STN-DBS for APD were included and analyzed.

RESULTS

Ten eligible trials with a total of 857 patients were included in this meta-analysis. The results showed no significant difference between the STN-DBS and GPi-DBS groups in Unified Parkinson's Disease Rating Scale (UPDRS) III scores during the on and off-medication phases(SMD, 0.1; 95 % CI, -0.04 to 0.25; p = 0.17, on-med), (SMD,-0.12;95 % CI -0.37 to 0.13, p = 0.33,off-med). Dyskinesia scores and the activities of daily living (ADLs) scores during the on-medication phase showed significant differences in favor of GPi stimulation (SMD, 0.16; 95 % CI, 0.01-0.32; P < 0.05)/(SMD, 0.18; 95 % CI, 0.01-0.34; P < 0.05). The ADLs score during the off-medication phase showed no significant difference between the STN-DBS and GPi-DBS groups (SMD, -0.11; 95 % CI, -0.32-0.11; P = 0.33). The LED showed significant differences in favor of STN stimulation (SMD, -0.57; 95 % CI, -0.74-0.40; P < 0.00001).

CONCLUSIONS

Both STN and GPi-DBS were equally effective in improving motor dysfunction. STN-DBS was superior for medication reduction, whereas GPi-DBS perhaps led to less dyskinesia and improved the postoperative ADLs (on-medication) in APD patients. Hence, the goals of DBS can be important in the target selection. More studies comparing the adverse events and quality of life between the two targets are needed.

Ambulatory surface electromyography with accelerometry for evaluating daily motor fluctuations in Parkinson's disease

OBJECTIVE

To evaluate motor fluctuations in patients with advanced Parkinson's disease (PD) using a small-sized wearable device for surface electromyography (EMG) with accelerometry (ACC) for 24 hours.

METHODS

Seven PD patients with medication were measured once, and nine patients with directional deep brain stimulation (dDBS) twice: before and after the dDBS reprogramming. EMG and ACC parameters were compared with clinical rating scores and patients' home diaries.

RESULTS

The combination of EMG and ACC parameters (first principal component PC₁) correlated significantly with patient's condition as quantified by the motor score of Unified Parkinson's Disease Rating Scale and it changed significantly with dDBS reprogramming in line with decreased PD symptoms. Monitoring data detected in comparison with the home diaries: 91 % concordance with tremor, 76 % with rigidity, and 74 % with dyskinesia. In the DBS group, the wake-up time with abnormal neuromuscular function was reduced with reprogramming in all except one patient based on measurements.

CONCLUSIONS

A wearable device measuring simultaneously both muscle activity and motion can provide continuous and dynamic information about patient's condition and motor fluctuations at home.

SIGNIFICANCE

The present method may help to modify pharmacologic management and DBS treatment in advanced PD.

Quality of life outcomes after globus pallidus internus deep brain stimulation in idiopathic or inherited isolated dystonia: a meta-analysis

BACKGROUND

Several studies reported the beneficial effects of globus pallidus internus deep brain stimulation (GPi DBS) on health-related quality of life (HRQoL) in patients with inherited or idiopathic isolated dystonia. However, the impact of this intervention on physical and mental/psychological domains and the effects over time remain unclear.

METHODS

We conducted a systematic literature review from January 2000 to May 2019 and performed a meta-analysis of HRQoL outcomes based on the Short Form Health Survey-36 (SF-36) after GPi DBS in patients with inherited or idiopathic isolated dystonia to evaluate the effects of DBS on physical and mental QoL.

RESULTS

Seven studies comprising 144 patients with dystonia (78, generalised; 34, segmental; and 32, focal cervical) were included in this comprehensive analysis. The mean (SD) age at DBS implantation was 41.0 (11.4) years, and the follow-up period after implantation was 3.2 (3.8) years. The random effects model meta-analysis revealed that both physical and mental domains of SF-36 improved following DBS with a significantly larger effect size for the physical domains (effect size=0.781; p<0.0001) compared with the mental domains (effect size=0.533; p<0.0001). A moderator variable analysis demonstrated that effect sizes for HRQoL improvement were maintained over time.

CONCLUSIONS

This is the first meta-analysis that demonstrates significant benefits in HRQoL following DBS in patients with inherited or idiopathic isolated dystonia. The benefits are greater for physical QoL domains compared with mental/psychological QoL. These findings highlight the importance of a comprehensive multidisciplinary approach to improve mental/psychological QoL.

Survival and Health Care Use After Deep Brain Stimulation for Parkinson's Disease

OBJECTIVES

To compare long-term survival of Parkinson's disease (PD) patients with deep brain stimulation (DBS) to matched controls, and examine whether DBS was associated with differences in injurious falls, long-term care, and home care.

METHODS

Using administrative health data (Ontario, Canada), we examined DBS outcomes within a cohort of individuals diagnosed with PD between 1997 and 2012. Patients receiving DBS were matched with non-DBS controls by age, sex, PD diagnosis date, time with PD, and a propensity score. Survival between groups was compared using the log-rank test and marginal Cox proportional hazards regression. Cumulative incidence function curves and marginal subdistribution hazard models were used to assess effects of DBS on falls, long-term care admission, and home care use, with death as a competing risk.

RESULTS

There were 260 DBS recipients matched with 551 controls. Patients undergoing DBS did not experience a significant survival advantage compared to controls (log-rank test p = 0.50; HR: 0.89, 95% CI: 0.65-1.22). Among patients <65 years of age, DBS recipients had a significantly reduced risk of death (HR: 0.49, 95% CI: 0.28-0.84). Patients receiving DBS were more likely than controls to receive care for falls (HR: 1.56, 95% CI: 1.19-2.05) and home care (HR: 1.59, 95% CI: 1.32-1.90), while long-term care admission was similar between groups.

CONCLUSIONS

Receiving DBS may increase survival for younger PD patients who undergo DBS. Future studies should examine whether survival benefits may be attributed to effects on PD or the absence of comorbidities that influence mortality.

Disparities in Deep Brain Stimulation Use for Parkinson's Disease in Ontario, Canada

OBJECTIVE

To examine whether sociodemographic characteristics and health care utilization are associated with receiving deep brain stimulation (DBS) surgery for Parkinson's disease (PD) in Ontario, Canada.

METHODS

Using health administrative data, we identified a cohort of individuals aged 40 years or older diagnosed with incident PD between 1995 and 2009. A case-control study was used to examine whether select factors were associated with DBS for PD. Patients were classified as cases if they underwent DBS surgery at any point 1-year after cohort entry until December 31, 2016. Conditional logistic regression modeling was used to estimate the adjusted odds of DBS surgery for sociodemographic and health care utilization indicators.

RESULTS

A total of 46,237 individuals with PD were identified, with 543 (1.2%) receiving DBS surgery. Individuals residing in northern Ontario were more likely than southern patients to receive DBS surgery [adjusted odds ratio (AOR) = 2.23, 95% confidence interval (CI) = 1.15-4.34]; however, regional variations were not observed after accounting for medication use among older adults (AOR = 1.04, 95% CI = 0.26-4.21). Patients living in neighborhoods with the highest concentration of visible minorities were less likely to receive DBS surgery compared to patients living in predominantly white neighborhoods (AOR = 0.27, 95% CI = 0.16-0.46). Regular neurologist care and use of multiple PD medications were positively associated with DBS surgery.

CONCLUSIONS

Variations in use of DBS may reflect differences in access to care, specialist referral pathways, health-seeking behavior, or need for DBS. Future studies are needed to understand drivers of potential disparities in DBS use.

Synergistic Neuroprotective Effect of Endogenously-Produced Hydroxytyrosol and Synaptic Vesicle Proteins on Pheochromocytoma Cell Line Against Salsolinol

Oxidative stress triggers a lethal cascade, leading to Parkinson's disease by causing degeneration of dopaminergic neurons. In this study, eight antioxidants were screened for their neuroprotective effect on PC12 cells (pheochromocytoma cell line) under oxidative stress induced by salsolinol (OSibS). Hydroxytyrosol was found to be the strongest neuroprotective agent; it improved viability of PC12 cells by up to 81.69% under OSibS. Afterward, two synaptic vesicle proteins, synapsin-1 and septin-5, were screened for their neuroprotective role; the overexpression of synapsin-1 and the downregulation of septin-5 separately improved the viability of PC12 cells by up to 71.17% and 67.00%, respectively, compared to PC12 cells only treated with salsolinol (PoTwS) under OSibS. Subsequently, the PC12+syn⁺+sep^- cell line was constructed and pretreated with 100 µM hydroxytyrosol, which improved its cell viability by up to 99.03% and led to 14.71- and 6.37-fold reductions in the levels of MDA and H₂O₂, respectively, and 6.8-, 12.97-, 10.57-, and 7.57-fold increases in the activity of catalase, glutathione reductase, superoxide dismutase, and glutathione peroxidase, respectively, compared to PoTwS under OSibS. Finally, alcohol dehydrogenase-6 from Saccharomyces cerevisiae was expressed in PC12+syn⁺+sep^- cells to convert 3,4-dihydroxyphenylacetaldehyde (an endogenous neurotoxin) into hydroxytyrosol. The PC12+syn⁺+sep^-+ADH6⁺ cell line also led to 22.38- and 12.33-fold decreases in the production of MDA and H₂O₂, respectively, and 7.15-, 13.93-, 12.08-, and 8.11-fold improvements in the activity of catalase, glutathione reductase, superoxide dismutase, and glutathione peroxidase, respectively, compared to PoTwS under OSibS. Herein, we report the endogenous production of a powerful antioxidant, hydroxytyrosol, from 3,4-dihydroxyphenylacetaldehyde, and evaluate its synergistic neuroprotective effect, along with synapsin-1 and septin-5, on PC12 cells under OSibS.

Update on the Management of Parkinson's Disease for General Neurologists

Management of Parkinson's disease (PD) is complicated due to its progressive nature, the individual patient heterogeneity, and the wide range of signs, symptoms, and daily activities that are increasingly affected over its course. The last 10–15 years have seen great progress in the identification, evaluation, and management of PD, particularly in the advanced stages. Highly specialized information can be found in the scientific literature, but updates do not always reach general neurologists in a practical and useful way, potentially creating gaps in knowledge of PD between them and neurologists subspecialized in movement disorders, resulting in several unmet patient needs. However, general neurologists remain instrumental in diagnosis and routine management of PD. This review provides updated practical information to identify problems and resolve common issues, particularly when the advanced stage is suspected. Some tips are provided for efficient communication with the members of a healthcare team specialized in movement disorders, in order to find support at any stage of the disease in a given patient, and especially for a well-timed decision on referral.

A Network Pharmacology-Based Study of the Molecular Mechanisms of Shaoyao-Gancao Decoction in Treating Parkinson's Disease

Parkinson's disease (PD) is another major neurodegenerative disorder following Alzheimer's disease, which not only seriously reduces the survival in patients, affecting patient's quality of life, but also imposes a tremendous burden on families and even the whole society. It is urgent to find out effective drugs without side effects. The present study applied a creative approach called network pharmacology to explore the active compounds and therapeutic targets of Shaoyao-Gancao Decoction (SYGCD) for treating PD. We identified a total of 48 active compounds mediating 30 PD-related targets to exert synergism, and the same target can be enriched in multiple signal pathways and biological processes, expounding that the decoction can exert synergistic effect on PD by multi-targets and multi-pathways. Furthermore, the molecular docking analysis showed that active compounds and targets can be well combined. These results highlighted the molecular mechanisms underlying the efficiency of SYGCD for PD treatment at a systematic level, investigating thoroughly the innovative therapeutic tactics for PD in traditional Chinese medicine.

Improvement of Subthalamic Nucleus Deep Brain Stimulation in Sleeping Symptoms in Parkinson's Disease: A Meta-Analysis

Introduction

The aim of this meta-analysis was to evaluate the effects of STN DBS on sleep quality and restless leg symptoms in individuals with PD.

Methods

We searched the PubMed, Web of Science, EMBASE, CNKI, and WANFANG databases published between 1990 and 2019. The articles included were those that contained both pre- and postsurgery data acquired using International RLS Study Group criteria and the Pittsburgh sleep quality index (PSQI) questionnaire with patients' follow-up of at least three months. All studies that met the quality requirements were included in a meta-analysis performed using STATA 12.0 software.

Results

Of 73 articles identified, 7 studies comprising 82 patients were qualified for the current meta-analysis. After adjusting for heterogeneity in study effect sizes, the random effects meta-analysis indicated that STN DBS improved sleep quality and restless leg symptoms significantly (SMD = −1.111, 95% CI: −1.918∼−0.304, P=0.007). Subgroup analysis showed that different sleep scoring criteria had different effects on the condition of sleeping after surgery.

Conclusions

STN DBS is a powerful method in the management of sleep quality and restless leg symptoms in PD patients, but its long-term effects with larger populations must be thoroughly assessed.

Upstream regulators of phosphoinositide 3-kinase and their role in diseases

Phosphoinositide 3-kinase (PI3K), a crucial signaling molecule, is regulated by various upstream regulators. Traditionally, receptor tyrosine kinases and G protein-coupled receptor are regarded as its principle upstream regulators; however, recent reports have indicated that spleen tyrosine kinase, β-arrestin2, Janus kinase, and RAS can also perform this role. Dysregulation of PI3K is common in the progression of various diseases, including, but not limited to, tumors, Alzheimer's disease, Parkinson's disease, rheumatoid arthritis, and acute myelogenous leukemia. The aim of this review is to provide a perspective on PI3K-related diseases examining both the classical and nonclassical upstream regulators of PI3K in detail.

Parkinson's Disease in the Era of Personalised Medicine: One Size Does Not Fit All

The concept of personalised medicine in Parkinson's disease has arrived where the implications of findings made in research are certain to have an increasing impact upon clinical practice. Disease heterogeneity in Parkinson's disease has been well described and lends itself to the construct of personalised medicine where it is hypothesised that a greater understanding of genetic and pathophysiological contributions may underpin the sub-groups described. This in turn has driven the development of potentially individualised disease-modifying therapies where, for example, we are beginning to see treatments that target patients with Parkinson's disease with specific genetic mutations. Furthermore, clinicians are increasingly recognising the need to tailor their management approach to patients depending on their age of presentation, acknowledging differential side-effect profiles and responses especially when considering the use of device-assisted technologies such as infusion or surgery. Clearly, individualising the treatment of both motor and non-motor symptoms will remain imperative but, in the future, personalised medicine may provide clearer insights into various aspects of a patient's symptomatology, disease course and thus the best therapeutic approaches.

Parkinson's disease: Mechanisms, translational models and management strategies

Parkinson's disease is a progressive neurodegenerative disorder. The classical motor symptoms include resting tremors, bradykinesia, rigidity and postural instability and are accompanied by the loss of dopaminergic neurons and Lewy pathology. Diminished neurotransmitter level, oxidative stress, mitochondrial dysfunction and perturbed protein homeostasis over time worsen the disease manifestations in elderly people. Current management strategies aim to provide symptomatic relief and to slow down the disease progression. However, no pharmacological breakthrough has been made to protect dopaminergic neurons and associated motor circuitry components. Deep brain stimulation, stem cells-derived dopaminergic neurons transplantation, gene editing and gene transfer remain promising approaches for the potential management of neurodegenerative disease. Toxin or genetically induced rodent models replicating Parkinson's disease pathology are of high predictive value for translational research. This review addresses the current understanding, management strategies and the Parkinson's disease models for translational research. Preclinical research may provide powerful tools to quest the potential therapeutic and neuroprotective compounds for dopaminergic neurons and hence possible cure for the Parkinson's disease.

Chlorogenic Acid Exerts Beneficial Effects in 6-Hydroxydopamine-Induced Neurotoxicity by Inhibition of Endoplasmic Reticulum Stress

BACKGROUND Chlorogenic acid (CGA), a dietary polyphenol derived from many plants, has been previously reported to exert neuroprotective properties. However, its pharmacological role in Parkinson's disease (PD) and the underlying mechanisms are unclear. MATERIAL AND METHODS In the present study, we investigated the beneficial effects of CGA against the toxicity of 6-hydroxydopamine (6-OHDA) in animal and cellular models. One week after 6-OHDA administration, the behavioral activities of rats were determined by rotarod test and apomorphine-induced rotational test. The viability and apoptosis of SH-SY5Y cells following 6-OHDA exposure were determined by MTT assay and annexin V-FITC/PI double staining, respectively. The activities of antioxidant enzymes in the rat striatal tissues and SH-SY5Y cells were detected by ELISA. RESULTS The results demonstrated that 6-OHDA-induced PD-like behavioral impairments of rats were significantly forestalled by CGA administration. The increased apoptosis and reduced activities of antioxidant enzymes in the striatum of 6-OHDA-lesioned rats were also attenuated by CGA. Moreover, in an in vitro experiment, the impaired viability and enhanced apoptosis of 6-OHDA-injured SH-SY5Y cells were significantly restored by CGA pretreatment. In addition, CGA also obstructed 6-OHDA-induced ROS production and endoplasmic reticulum (ER) stress in SH-SY5Y cells. CONCLUSIONS Taken together, these data show that CGA might be an effective neuroprotective compound that mitigates oxidative stress and ER stress in PD.

Parkinson's disease: Diagnosis and appreciation of comorbidities

Parkinson's disease (PD) is a complex neuropsychiatric disorder that manifests with a variety of motor and nonmotor symptoms. Its incidence increases with age. It is important for clinicians to be able to distinguish symptoms of aging and other comorbidities from those of PD. The diagnosis of PD has traditionally been rendered using strict criteria that mainly rely on the cardinal motor symptoms of rest tremor, rigidity, and bradykinesia. However, newer diagnostic criteria proposed by the Movement Disorders Society for diagnosis of PD collectively reflect a greater appreciation for the nonmotor symptoms. The treatment of PD remains symptomatic and the most noticeable improvements have been documented in the motor symptoms. Levodopa remains the gold standard for therapy, however there are now many other potential medical and surgical treatment strategies. Nonmotor symptoms have been shown to affect quality of life more than the motor symptoms. There is ongoing research into symptomatic and disease modifying treatments. Given the multisystem involvement in PD, an interdisciplinary patient-centered approach is recommended by most experts. This chapter addresses first the diagnostic approach and the many geriatric considerations. This is followed by a review of the nonmotor symptoms. Finally, a summary of current treatment strategies in PD is presented along with potential treatment complications.

Turning on the Left Side Electrode Changed Depressive State to Manic State in a Parkinson's Disease Patient Who Received Bilateral Subthalamic Nucleus Deep Brain Stimulation: A Case Report

No previous reports have described a case in which deep brain stimulation elicited an acute mood swing from a depressive to manic state simply by switching one side of the bilateral deep brain stimulation electrode on and off. The patient was a 68-year-old woman with a 10-year history of Parkinson’s disease. She underwent bilateral subthalamic deep brain stimulation surgery. After undergoing surgery, the patient exhibited hyperthymia. She was scheduled for admission. On the first day of admission, it was clear that resting tremors in the right limbs had relapsed and her hyperthymia had reverted to depression. It was discovered that the left-side electrode of the deep brain stimulation device was found to be accidentally turned off. As soon as the electrode was turned on, motor impairment improved and her mood switched from depression to mania. The authors speculate that the lateral balance of stimulation plays an important role in mood regulation. The current report provides an intriguing insight into possible mechanisms of mood swing in mood disorders.

Parkinson's Disease: Basic Pathomechanisms and a Clinical Overview

PD is a common and a debilitating degenerative movement disorder. The number of patients is increasing worldwide and as yet there is no cure for the disease. The majority of existing treatments target motor symptom control. Over the last two decades the impact of the genetic contribution to PD has been appreciated. Significant discoveries have been made, which have advanced our understanding of the pathophysiological and molecular basis of PD. In this chapter we outline current knowledge of the clinical aspects of PD and the basic mechanistic understanding.

Triggering of inflammasome by impaired autophagy in response to acute experimental Parkinson's disease: involvement of the PI3K/Akt/mTOR pathway

Several lines of evidence suggest that the inflammasome activation is involved in the progression of neurodegenerative diseases. However, the relation between Parkinson's disease (PD) and the inflammasome is still unclear. This study was designed to assess the involvement of inflammasome in acute experimental PD. Specifically, acute PD was induced in C57BL/6 mice by an injection of 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP). At seven days from MPTP induction, mice were euthanized and the midbrains were sampled to carry out immunohistochemical evaluations and western blot analysis. Our results show the activation of Nod-like receptor-3 inflammasome in acute MPTP mice, as suggested by the increase of nuclear factor-κB expression, which represents the first signal for inflammasome induction. The Nod-like receptor-3 assembly induces the activation of caspase-1, which in turn activates interleukin-1β and interleukin-18 production, as confirmed by our evaluations. A dysregulation of autophagy system was also found in acute MPTP mice by looking at the expression of Beclin-1, LC-3, and Bcl-2, chosen as markers of autophagy. Thus, in an effort to identify the molecular mechanism underlying the well-known crosstalk between autophagy and the inflammasome, we evaluated the involvement of the phosphoinositide-3 kinase/protein kinase-B/mammalian target of rapamycin (PI3K/Akt/mTOR) pathway, which plays a key role in autophagy. Our results showed a clear upregulation of this signaling after MPTP induction. Taken together, our findings suggest that the triggering of inflammasome could be linked to impaired autophagy because of aberrant upstream activation of the PI3K/Akt/mTOR pathway. Finally, our results propose the inflammasome as a new potential therapeutic target in the management of PD.

Treating the Motor Symptoms of Parkinson Disease

PURPOSE OF REVIEW

After a patient is diagnosed with Parkinson disease (PD), there are many therapeutic options available. This article provides examples of prototypical patients encountered in clinical practice and illustrates the various pharmacologic and nonpharmacologic treatment options for the motor symptoms of PD.

RECENT FINDINGS

Levodopa became available in the late 1960s and remains the gold standard for the treatment of PD even today. Since that time, amantadine, monoamine oxidase type B inhibitors, dopamine agonists, and catechol-O-methyltransferase inhibitors have emerged as monotherapy, add-on therapies, or both, in the armamentarium against PD. The most appropriate time to start such drugs remains a clinical decision according to patient symptoms. However, earlier use of levodopa is the more common practice due to its superior benefit and the side effects of dopamine agonists. Deep brain stimulation continues to be the most effective treatment for motor symptoms in appropriate patients, and advances in technology may improve efficacy. New ways to deliver levodopa have emerged (effective extended-release oral preparations and levodopa/carbidopa intestinal gel), and these medications provide additional options for certain patients. Exercise and neurorehabilitation are increasingly recognized as important tools to combat the motor symptoms of PD. Nondopaminergic drugs may help non-levodopa-responsive motor symptoms.

SUMMARY

Treatment of PD is multifaceted and requires a tailored pharmacotherapeutic and nonpharmacologic approach for a given patient. Patients should be at the center of care, and clinicians should try to provide optimum benefit through the many treatment options available.

Feasibility of large-scale deployment of multiple wearable sensors in Parkinson's disease

Wearable devices can capture objective day-to-day data about Parkinson's Disease (PD). This study aims to assess the feasibility of implementing wearable technology to collect data from multiple sensors during the daily lives of PD patients. The Parkinson@home study is an observational, two-cohort (North America, NAM; The Netherlands, NL) study. To recruit participants, different strategies were used between sites. Main enrolment criteria were self-reported diagnosis of PD, possession of a smartphone and age≥18 years. Participants used the Fox Wearable Companion app on a smartwatch and smartphone for a minimum of 6 weeks (NAM) or 13 weeks (NL). Sensor-derived measures estimated information about movement. Additionally, medication intake and symptoms were collected via self-reports in the app. A total of 953 participants were included (NL: 304, NAM: 649). Enrolment rate was 88% in the NL (n = 304) and 51% (n = 649) in NAM. Overall, 84% (n = 805) of participants contributed sensor data. Participants were compliant for 68% (16.3 hours/participant/day) of the study period in NL and for 62% (14.8 hours/participant/day) in NAM. Daily accelerometer data collection decreased 23% in the NL after 13 weeks, and 27% in NAM after 6 weeks. Data contribution was not affected by demographics, clinical characteristics or attitude towards technology, but was by the platform usability score in the NL (χ2 (2) = 32.014, p<0.001), and self-reported depression in NAM (χ2(2) = 6.397, p = .04). The Parkinson@home study shows that it is feasible to collect objective data using multiple wearable sensors in PD during daily life in a large cohort.

Reassessment of subacute MPTP-treated mice as animal model of Parkinson's disease

1-Methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) mouse model remains the most commonly used animal model of Parkinson's disease (PD). There are three MPTP-treatment schemes: acute, subacute and chronic. Considering the advantages of the period and similarity to PD, the subacute model was often chosen to assess the validity of new candidates, but the changes caused by the subacute MPTP treatment and the appropriate positive control for this model remain to be further confirmed. The aim of this study was: to estimate the value of the subacute MPTP mouse model in aspects of behavioral performance, biochemical changes and pathological abnormalities, and to find effective positive drugs. Male C57BL/6 mice were injected with MPTP (30 mg·kg^-1·d^-1, ip) for 5 consecutive days. Three days before MPTP injection, the mice were orally administered selegiline (3 mg·kg^-1·d^-1), pramipexole (3 mg·kg^-1·d^-1), or medopar (100 mg·kg^-1·d^-1) for 18 days. Behavioral performance was assessed in the open field test, pole test and rotarod test. Neurotransmitters in the striatum were detected using HPLC. Protein levels were measured by Western blot. Pathological characteristics were examined by immunohistochemistry. Ultrastructure changes were observed by electron microscopy. The subacute MPTP treatment did not induce evident motor defects despite severe injuries in the dopaminergic system. Additionally, MPTP significantly increased the α-synuclein levels and the number of astrocytes in the striatum, and destroyed the blood-brain barrier (BBB) in the substantia nigra pars compacta. Both selegiline and pramipexole were able to protect the mice against MPTP injuries. We conclude that the subacute MPTP mouse model does not show visible motor defects; it is not enough to evaluate the validity of a candidate just based on behavioral examination, much attention should also be paid to the alterations in neurotransmitters, astrocytes, α-synuclein and the BBB. In addition, selegiline or pramipexole is a better choice than medopar as an effective positive control for the subacute MPTP model.

Glucose-6-phosphatase-α participates in dopaminergic differentiation

OBJECTIVE

 Induction of dopaminergic (DA) differentiation is a cell-based therapy for Parkinson's disease (PD). Here, we explore the key factors of DA differentiation with a focus on glucose-6-phosphatase (G6Pase), a marker enzyme for the endoplasmic reticulum (ER) associated with cell differentiation.

METHODS

 We cultured SH-SY5Y human neuroblastoma cells, a model system for PD research, and added glial cell-derived neurotrophic factor (GDNF; 25, 50, or 100 ng/ml) to stimulate differentiation. Subsequently, several methods, such as microRNA/mRNA microarrays, quantitative real-time polymerase chain reaction (qRT-PCR) and western blot were used to detect target genes and proteins respectively.

RESULTS

 Light microscopy revealed that 50 ng/ml GDNF most effectively induced DA differentiation. MicroRNA/mRNA microarrays identified that G6PC mRNA was significantly upregulated, which might be influenced by three downregulated microRNAs. Follow-up qRT-PCR results were consistent with the microarray findings, and western blots also supported the results.

DISCUSSION

Taken together, our results demonstrate that G6PC, a subunit of G6Pase, participates in DA differentiation. Our findings may contribute to provide a foundation for the research on the mechanism of DA differentiation as well as cell-based therapy for PD.

A randomized, fixed-dose, dose-response study of ropinirole prolonged release in advanced Parkinson's disease

AIM

This Phase IV, double-blind, randomized, parallel-group study characterized the dose-response and tolerability of fixed doses of ropinirole prolonged release (PR) in subjects with advanced Parkinson's disease.

PATIENTS & METHODS

Subjects receiving concomitant l-dopa received once-daily ropinirole PR 4, 8, 12, 16 or 24 mg, or placebo, up-titrated for 13 weeks, maintained for 4 weeks.

RESULTS

At maintenance period week 4, ropinirole PR significantly reduced total awake 'Off-time' (16 mg; p = 0.027); increased absolute awake time spent 'On' without troublesome dyskinesia from baseline versus placebo (8 mg; p = 0.036); improved Unified Parkinson's Disease Rating Scale motor scores versus placebo (all doses; p = 0.005-0.016). Incidence of adverse events was similar between treatment groups; no dose-related trends were observed.

CONCLUSION

Ropinirole PR (16 mg) reduced 'Off-time' with 8 mg the likely lowest maximally effective dose, and the safety profile was consistent with previous studies.

Technology-aided leisure and communication: Opportunities for persons with advanced Parkinson's disease

OBJECTIVE

This study investigated whether simple technology-aided programs could be used to promote leisure and communication engagement in three persons with advanced Parkinson's disease.

METHOD

The programs included music and video options, which were combined with (a) text messaging and telephone calls for the first participant, (b) verbal statements/requests, text messaging, and reading for the second participant, and (c) verbal statements/requests and prayers for the third participant. The participants could activate those options via hand movement or vocal emission and specific microswitches.

RESULTS

All three participants were successful in activating the options available. The mean cumulative frequencies of option activations were about five per 15-min session for the first two participants and about four per 10-min session for the third participant.

CONCLUSION

The results were considered encouraging and relevant given the limited amount of evidence available on helping persons with advanced Parkinson's disease with leisure and communication.

First-in-human assessment of PRX002, an anti-α-synuclein monoclonal antibody, in healthy volunteers

BACKGROUND

α-Synuclein is a major component of pathologic inclusions that characterize Parkinson's disease. PRX002 is an antibody that targets α-synuclein, and its murine parent antibody 9E4 has been shown in preclinical studies to reduce α-synuclein pathology and to protect against cognitive and motor deteriorations and progressive neurodegeneration in human α-synuclein transgenic mice.

METHODS

This first-in-human, randomized, double-blind, placebo-controlled, phase 1 study assessed the impact of PRX002 administered to 40 healthy participants in 5 ascending-dose cohorts (n = 8/cohort) in which participants were randomly assigned to receive a single intravenous infusion of study drug (0.3, 1, 3, 10, or 30 mg/kg; n = 6/cohort) or placebo (n = 2/cohort).

RESULTS

PRX002 demonstrated favorable safety, tolerability, and pharmacokinetic profiles at all doses tested, with no immunogenicity. No serious adverse events, discontinuations as a result of adverse events, or dose-limiting toxicities were reported. Serum PRX002 exposure was dose proportional; the average terminal half-life across all doses was 18.2 days. A significant dose-dependent reduction in free serum α-synuclein (unbound to PRX002) was apparent within 1 hour after PRX002 administration, whereas total α-synuclein (free plus bound) increased dose-dependently, presumably because of the expected change in kinetics following antibody binding.

CONCLUSIONS

This study demonstrates that serum α-synuclein can be safely modulated in a dose-dependent manner after single intravenous infusions of an anti-α-synuclein antibody. These findings support continued development of PRX002, including further characterization of its safety, tolerability, pharmacokinetics, and pharmacodynamic effects in the central nervous system in patients with Parkinson's disease. © 2016 The Authors. Movement Disorders published by Wiley Periodicals, Inc. on behalf of International Parkinson and Movement Disorder Society.

Modified biomolecule as potential vehicle for buccal delivery of doxepin

Aim: Doxepin is a traditional tricyclic antidepressant with analgesic and anesthetic properties when applied topically to the mucosa. Doxepin is one approach in treating insomnia and depression in Parkinson's disease. Patients with Parkinson's disease suffer difficulties in swallowing. Therefore, it was the aim of this study to develop a buccal-adhesive delivery system. Methods: Pectin was modified with cysteine. Stability assays in form of disintegration assay according to the Ph.Eur were performed. Furthermore, bioadhesiveness on buccal mucosa was investigated incorporating the drug doxepin. Results: The adhesiveness was improved 1.4-fold and revealed a sustained release over 3 h. Conclusion: Taking these findings into account, the modifications render this designed excipient fruitful for buccal delivery.