Diagnosis and initiation of treatment in Parkinson's disease

Psychological Factors Affecting Assertiveness in Subjects with Parkinson's Disease

Background/Objectives: Assertiveness, defined as the positive affirmation of oneself, encompasses the ability to refuse requests, express anger, disagree or oppose others, show affection, and uphold personal beliefs without causing conflict. Deficits in assertive behavior are often linked to pathological changes in the basal ganglia and prefrontal dopaminergic systems, commonly observed in Parkinson's disease (PD), and are predictive of poor clinical outcomes. Psychological factors such as mood alterations and cognitive dysfunction may also impact assertiveness. This study investigated the psychological factors influencing assertiveness in individuals with PD. Methods: A cross-sectional study was conducted, involving 160 patients with PD attending a movement disorders outpatient clinic. The participants underwent assessment using a battery of standardized neuropsychological tests to evaluate cognitive function, assertiveness, mood, dysarthria, and quality of life (QoL). Results: All dimensions of assertiveness correlated with depression and anxiety. Individuals experiencing mood disturbances may struggle to express themselves assertively. Similarly, some dimensions of assertiveness correlated also with the QoL, indicating that, overall, well-being affects assertive behavior. Gender emerged as a significant influencer of assertiveness across all dimensions. Specifically, in subjects with PD, the male gender was associated with lower scores in assertiveness compared to women. No significant correlations were found between assertiveness and dysarthria. Conclusions: The findings highlight the importance of adopting a holistic approach to PD management, addressing not only motor symptoms but also psychological challenges which patients may encounter in their daily lives.

Measurement of the facial nerve thickness and its correlation with freezing phenomenon and hypomimia in Parkinson's disease

OBJECTIVE

Hypomimia is one of the diagnostic features in Parkinson's disease, and freezing blocks may also occur with the degenerative process. We investigated that the thickness of the cranial facial nerve that innervates facial expressions, and the relationship between bradymimia and freezing phenomena in these patients.

METHODS

We included 70 patients and healthy participants in this cross-sectional study. Clinical characteristics, modified Hoehn and Yahr (mHY) stages, Unified Parkinson's Disease Rating Scale (UPDRS) scores and Freezing of Gait Questionnaire (FOG-Q) scores of Parkinson's patients were recorded. FOG-Q was scored between 1 and 4 points. The thickness of the facial nerve and its neighborhoods of numerically equal groups were measured radiologically in the internal acoustic channel (IAC) with magnetic resonance imaging of temporal lobe. Right and left facial nerve thicknesses were compared.

RESULTS

The right facial nerve thicknesses of the patient and control groups were measured as 0.97 ± 0.12 mm and 1.20 ± 0.10 mm at the proximal level and 0.71 (0.69-0.81) mm and 1.21 (1.13-1.24) mm at the distal level, respectively (P < 0.001). Notably, the facial nerve was more atrophied on the right than on the left (P < 0.001). Facial nerve to IAC ratio (%) was significantly lower and cerebrospinal fluid thickness distance (%) measurement was significantly higher (P < 0.001). Also, the FOG-Q and facial nerve to IAC ratio were negatively correlated (P = 0.049, rho = -0.335).

CONCLUSIONS

Our study provides new information about the facial nerve and its neighborhoods and clinical relationships in individuals with PD. In studies investigating hypomimia and FOG in Parkinson's, neuroimaging of the facial nerve can also be used. These results need to be proven with more comprehensive studies.

Anxiety, depression, and quality of life in Parkinson's disease: the implications of multidisciplinary treatment

Anxiety and depression in Parkinson’s disease (PD) reduce well-being of the patients. Emotional alterations influence motor skills and cognitive performance; moreover, they contribute significantly and independently to worsen rehabilitative treatment response. We investigated anxiety, depression, and quality of life in PD patients subjected to multidisciplinary rehabilitative training. The self-controlled study included 100 PD patients (49 males and 51 females with the mean age of 64.66 years) admitted to 60 days hospitalization rehabilitative program, between January 2017 and December 2018. Motor, cognitive, linguistic abilities, and functional independence were evaluated at admission (T0 baseline visit) and 60 days after (T1) the multidisciplinary rehabilitation including motor exercises, speech therapies, and cognitive intervention. The multidisciplinary rehabilitation improved functional status in PD patients and exerted its positive effects on mood, motor abilities, autonomy in the activities of daily life, perception of quality of life, cognitive performance and speech skills. Non-motor symptoms may worsen severe disability and reduce quality of life. They are often poorly recognized and inadequately treated. Nonetheless, multidisciplinary rehabilitative training represents an optimal strategy to improve disease management. The study was approved by Istituito di Ricovero e Cura a Carattere Scientifico (IRCCS) Centro Neurolesi “Bonino-Pulejo” Ethical Committee (approval No. 6/2016) in June 2016.

Analysis of the Effects of Whole-Body Vibration in Parkinson Disease - Systematic Review and Meta-Analysis

BACKGROUND

Because of discrepant published results, there is a need to systematically analyze the literature that has evaluated the effectiveness of harmonic whole-body vibration (WBV) and randomized WBV in patients with Parkinson disease (PD).

OBJECTIVE

To evaluate the effectiveness of harmonic versus randomized WBV on motor symptoms, balance, gait, and mobility in people with PD. TYPE: Meta-analysis.

LITERATURE SURVEY

Established databases PubMed, EMBASE, CINAHL, Cochrane, Trip, and PEDro; library of the Saarland University; and electronic library of journals, including publications from 1960 to November 2017, were scanned by using "Parkinson" and "vibration" as combined search terms.

METHODOLOGY

First, data were extracted from the full-text version, including number of participants, severity of disease, medication status, study design, use of vibration treatment, duration of study, number of treatment sessions and trials per session, vibration frequency and amplitude, duration of trials and rest periods, and pre- and posttest data. Qualitative analysis was performed by using the PEDro score. Standardized mean differences (SMD) with 95% confidence intervals (CI) were used to verify the efficacy of harmonic versus randomized WBV on mobility, balance, gait, and motor symptoms.

SYNTHESIS

From 244 publications found in online databases, 17 eligible studies fulfilled eligibility criteria and were further analyzed qualitatively. Out of those, 7 studies attained moderate to high quality (mean PEDro score 4.6 points, SD 2.9) and were then further analyzed quantitatively. A large variation, between no effects (SMD = 0.06, 95% CI = -0.78 to 0.90) and weak effects (SMD = 0.46, 95% CI = -0.51 to 1.43), was found for motor symptoms, balance, gait, and mobility.

CONCLUSIONS

There is no clear evidence of a PD symptom-reducing effect (motor symptoms, balance, gait, and mobility) of WBV compared with respective control conditions. Only a few studies found significant group differences for mobility and motor symptoms. Therefore, the overall effects of vibration therapy on PD remain somewhat inconsistent. Further high-quality studies should determine the efficacy of harmonic versus randomized WBV.

LEVEL OF EVIDENCE

II.

How Well Do Caregivers Detect Depression and Anxiety in Patients With Parkinson Disease?

Depression and anxiety are prevalent in Parkinson disease (PD) yet underrecognized in clinical practice. Caregiver reports are frequently utilized to aid in the assessment of neuropsychiatric symptoms but little is known about caregivers' ability to recognize them in patients with PD. This study sought to examine the accuracy of caregiver reports. Eighty patient-caregiver dyads were involved. Accuracy of caregiver recognition was assessed by examining the level of agreement between caregiver ratings on the Neuropsychiatric Inventory and patients' diagnosis of depression and anxiety on the Mini-International Neuropsychiatric Interview (MINI)-Plus. The agreement between caregiver report and MINI-Plus diagnosis was low for both depression (6.3%) and anxiety (17.5%). The presence of depression was overreported, while anxiety was largely underestimated by caregivers. Caregiver distress significantly predicted inaccurate caregiver identification of depression ( R² = .51, P < .001) and anxiety ( R² = .08, P < .05). Results indicate that caregivers may be poor at recognizing depression and anxiety in patients with PD. Utilization of caregiver report should take into account potential biases that affect caregiver judgment.

A novel RAB39B gene mutation in X-linked juvenile parkinsonism with basal ganglia calcification

OBJECTIVES

Mutations in RAB39B have been reported as a potential cause of X-linked Parkinson's disease (PD), a rare form of familial PD. We conducted a genetic analysis on RAB39B to evaluate whether RAB39B mutations are related to PD in the Chinese population.

METHODS

In this study, 2 patients from an X-linked juvenile parkinsonism pedigree were clinically characterized and underwent whole-exome sequencing. A comprehensive screening for RAB39B mutations in 505 sporadic patients with PD and 510 healthy controls in a Chinese population was also performed.

RESULTS

A novel mutation, c. 536dupA (p.E179fsX48), in RAB39B was identified in the juvenile parkinsonism pedigree. Brain MRI and CT scans in the 2 patients revealed calcification within the bilateral globus pallidus. No other potentially disease-causing RAB39B mutations were found in sporadic PD patients and controls.

CONCLUSIONS

X-linked juvenile parkinsonism could be caused by a RAB39B mutation, and basal ganglia calcification may be a novel clinical feature of RAB39B-related parkinsonism. © 2016 International Parkinson and Movement Disorder Society.

Single-photon emission tomography

Single-photon emission computed tomography (SPECT) is a functional nuclear imaging technique that allows visualization and quantification of different in vivo physiologic and pathologic features of brain neurobiology. It has been used for many years in diagnosis of several neurologic and psychiatric disorders. In this chapter, we discuss the current state-of-the-art of SPECT imaging of brain perfusion and dopamine transporter (DAT) imaging. Brain perfusion SPECT imaging plays an important role in the localization of the seizure onset zone in patients with refractory epilepsy. In cerebrovascular disease, it can be useful in determining the cerebrovascular reserve. After traumatic brain injury, SPECT has shown perfusion abnormalities despite normal morphology. In the context of organ donation, the diagnosis of brain death can be made with high accuracy. In neurodegeneration, while amyloid or (18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) are the nuclear diagnostic tools of preference for early and differential diagnosis of dementia, perfusion SPECT imaging can be useful, albeit with slightly lower accuracy. SPECT imaging of the dopamine transporter system is widely available in Europe and Asia, but since recently also in the USA, and has been accepted as an important diagnostic tool in the early and differential diagnosis of parkinsonism in patients with unclear clinical features. The combination of perfusion SPECT (or FDG-PET) and DAT imaging provides differential diagnosis between idiopathic Parkinson's disease, Parkinson-plus syndromes, dementia with Lewy bodies, and essential tremor.

The tumor suppressor PTEN regulates motor responses to striatal dopamine in normal and Parkinsonian animals

Phosphatase and Tensin homolog deleted on chromosome 10 (PTEN) is a dual lipid-protein phosphatase known primarily as a growth preventing tumor suppressor. PTEN is also expressed in neurons, and pathways modulated by PTEN can influence neuronal function. Here we report a novel function of PTEN as a regulator of striatal dopamine signaling in a model of Parkinson's disease (PD). Blocking PTEN expression with an adeno-associated virus (AAV) vector expressing a small hairpin RNA (shRNA) resulted in reduced responses of cultured striatal neurons to dopamine, which appeared to be largely due to reduction in D2 receptor activation. Co-expression of shRNA-resistant wild-type and mutant forms of PTEN indicated that the lipid-phosphatase activity was essential for this effect. In both normal and Parkinsonian rats, inhibition of striatal PTEN in vivo resulted in motor dysfunction and impaired responses to dopamine, particularly D2 receptor agonists. Expression of PTEN mutants confirmed the lipid-phosphatase activity as critical, while co-expression of a dominant-negative form of Akt overcame the PTEN shRNA effect. These results identify PTEN as a key mediator of striatal responses to dopamine, and suggest that drugs designed to potentiate PTEN expression or activity, such as cancer chemotherapeutics, may also be useful for improving striatal responses to dopamine in conditions of dopamine depletion such as PD. This also suggests that strategies which increase Akt or decrease PTEN expression or function, such as growth factors to prevent neuronal death, may have a paradoxical effect on neurological functioning by inhibiting striatal responses to dopamine.

Initial medication in patients of newly diagnosed Parkinson's disease in Taiwan

Introduction

Several treatment guidelines for Parkinson’s disease (PD) had been proposed in recent decades. The aim of current study was to investigate the initial medication utilized in newly diagnosed PD subjects in Taiwan during an eleven-year period.

Methods

A total of 7,550 patients with newly diagnosed Parkinsonism were retrospectively enrolled from the National Health Insurance Research Database of Taiwan from 2000 to 2010. After excluding patients at risk of secondary or atypical Parkinsonism, those never receiving medication or having incomplete data, 1,645 subjects were included. The participants were then divided into four treating regimen groups, namely levodopa (LD) only group, dopamine agonist (DA) only group, LD+DA group, and No-LD, No-DA group. The demographic data and medication retention rate were compared across the four treatment groups.

Results

LD only and No-LD, No-DA regimens were the main initial choice of PD treatment in Taiwan. LD containing drugs were more often prescribed to the elderly population than the other two treatment regimens, while No-LD, No-DA medication was the major initial choice for younger patients. DA only regimen occupied only 3–4% of the initial PD prescriptions and was given predominantly by neurologists. Over the eleven-year period, there is a trend for the middle-aged population to receive medication containing LD as initial treatment. The one year retention rate of anti-Parkinsonism medication was around 30–50% in our population. Age, polypharmacy, change of one-year daily levodopa equivalent dosage and newly onset of dementia, stroke and psychiatric diseases all affect drug compliance in PD patients.

Conclusions

This is the first long-term study to explore initial pharmacotherapies in an Asian PD population. We hope to provide evidence for adjusting government policies and public education of physicians and PD patients in the future.

Transgenic expression of human glial cell line-derived neurotrophic factor from integration-deficient lentiviral vectors is neuroprotective in a rodent model of Parkinson's disease

Standard integration-proficient lentiviral vectors (IPLVs) are effective at much lower doses than other vector systems and have shown promise for gene therapy of Parkinson's disease (PD). Their main drawback is the risk of insertional mutagenesis. The novel biosafety-enhanced integration-deficient lentiviral vectors (IDLVs) may offer a significant enhancement in biosafety, but have not been previously tested in a model of a major disease. We have assessed biosafety and transduction efficiency of IDLVs in a rat model of PD, using IPLVs as a reference. Genomic insertion of lentivectors injected into the lesioned striatum was studied by linear amplification-mediated polymerase chain reaction (PCR), followed by deep sequencing and insertion site analysis, demonstrating lack of significant IDLV integration. Reporter gene expression studies showed efficient, long-lived, and transcriptionally targeted expression from IDLVs injected ahead of lesioning in the rat striatum, although at somewhat lower expression levels than from IPLVs. Transgenic human glial cell line-derived neurotrophic factor (hGDNF) expression from IDLVs was used for a long-term investigation of lentivector-mediated, transcriptionally targeted neuroprotection in this PD rat model. Vectors were injected before striatal lesioning, and the results showed improvements in nigral dopaminergic neuron survival and behavioral tests regardless of lentiviral integration proficiency, although they confirmed lower expression levels of hGDNF from IDLVs. These data demonstrate the effectiveness of IDLVs in a model of a major disease and indicate that these vectors could provide long-term PD treatment at low dose, combining efficacy and biosafety for targeted central nervous system applications.

SPECT molecular imaging in Parkinson's disease

Parkinson's disease (PD) is a common disorder, and the diagnosis of Parkinson's disease is clinical and relies on the presence of characteristic motor symptoms. The accuracy of the clinical diagnosis of PD is still limited. Functional neuroimaging using SPECT technique is helpful in patients with first signs of parkinsonism. The changes detected may reflect the disease process itself and/or compensatory responses to the disease, or they may arise in association with disease- and/or treatment-related complications. This paper addresses the value of SPECT in early differential diagnosis of PD and its potential as a sensitive tool to assess the pathophysiology and progression, as well as the therapeutic efficacy of PD.