Untangling the relationship between fat distribution, nutritional status and Parkinson's disease severity.

BACKGROUND: Parkinson's disease (PD) is responsible for significant changes in body composition. AIMS: We aimed to test the association between PD severity and fat distribution patterns, and to investigate the potential modifier effect of nutritional status in this association. METHODS: We enrolled 195 PD subjects consecutively admitted to a university geriatric day hospital. All participants underwent comprehensive clinical evaluation, including assessment of total and regional body composition (dual-energy X-ray absorptiometry, DXA), body mass index, nutritional status (Mini-Nutritional Assessment, MNA), motor disease severity (UPDRS III), comorbidities, and pharmacotherapy. RESULTS: The fully adjusted linear regression model showed a negative association between UPDRS III and total body fat in kg and percentage (respectively, B - 0.79; 95% CI - 1.54 to - 0.05 and B - 0.55; 95% CI - 1.04 to - 0.05), percentage android fat (B - 1.07; 95% CI - 1.75 to - 0.39), trunk-leg fat ratio (B - 0.02; 95% CI - 0.04 to - 0.01), trunk-limb fat ratio (B - 0.01; 95% CI - 0.06 to - 0.01) and android-gynoid fat ratio (B - 0.01; 95% CI - 0.03 to - 0.01). After stratification by MNA score, all the parameters of android-like fat distribution resulted negatively associated (p < 0.001 for all) with UPDRS III, but only among subjects with a MNA < 23.5 (risk of malnutrition or malnutrition). CONCLUSION: We found a negative association between severity of motor impairment and total fat mass in PD, more specific with respect to an android pattern of fat distribution. This association seems to be driven by nutritional status, and is significant only among patients at risk of malnutrition or with overt malnutrition.

Expert recommendations for diagnosing cervical, oromandibular, and limb dystonia.

BACKGROUND: Diagnosis of focal dystonia is based on clinical grounds and is therefore open to bias. To date, diagnostic guidelines have been only proposed for blepharospasm and laryngeal dystonia. To provide practical guidance for clinicians with less expertise in dystonia, a group of Italian Movement Disorder experts formulated clinical diagnostic recommendations for cervical, oromandibular, and limb dystonia. METHODS: A panel of four neurologists generated a list of clinical items related to the motor phenomenology of the examined focal dystonias and a list of clinical features characterizing neurological/non-neurological conditions mimicking dystonia. Thereafter, ten additional expert neurologists assessed the diagnostic relevance of the selected features and the content validity ratio was calculated. The clinical features reaching a content validity ratio > 0.5 contributed to the final recommendations. RESULTS: The recommendations retained patterned and repetitive movements/postures as the core feature of dystonia in different body parts. If present, a sensory trick confirmed diagnosis of dystonia. In the patients who did not manifest sensory trick, active exclusion of clinical features related to conditions mimicking dystonia (features that would be expected to be absent in dystonia) would be necessary for dystonia to be diagnosed. DISCUSSION: Although reliability, sensitivity, and specificity of the recommendations are yet to be demonstrated, information from the present study would hopefully facilitate diagnostic approach to focal dystonias in the clinical practice and would be the basis for future validated diagnostic guidelines.

Long-term results of a multicenter study on subthalamic and pallidal stimulation in Parkinson's disease.

We report the 5 to 6 year follow-up of a multicenter study of bilateral subthalamic nucleus (STN) and globus pallidus internus (GPi) deep brain stimulation (DBS) in advanced Parkinson's disease (PD) patients. Thirty-five STN patients and 16 GPi patients were assessed at 5 to 6 years after DBS surgery. Primary outcome measure was the stimulation effect on the motor Unified Parkinson's Disease Rating Scale (UPDRS) assessed with a prospective cross-over double-blind assessment without medications (stimulation was randomly switched on or off). Secondary outcomes were motor UPDRS changes with unblinded assessments in off- and on-medication states with and without stimulation, activities of daily living (ADL), anti-PD medications, and dyskinesias. In double-blind assessment, both STN and GPi DBS were significantly effective in improving the motor UPDRS scores (STN, P < 0.0001, 45.4%; GPi, P = 0.008, 20.0%) compared with off-stimulation, regardless of the sequence of stimulation. In open assessment, both STN- and GPi-DBS significantly improved the off-medication motor UPDRS when compared with before surgery (STN, P < 0.001, 50.5%; GPi, P = 0.002, 35.6%). Dyskinesias and ADL were significantly improved in both groups. Anti-PD medications were significantly reduced only in the STN group. Adverse events were more frequent in the STN group. These results confirm the long-term efficacy of STN and GPi DBS in advanced PD. Although the surgical targets were not randomized, there was a trend to a better outcome of motor signs in the STN-DBS patients and fewer adverse events in the GPi-DBS group.

Impact of disease duration and cardiovascular dysautonomia on hypertension in Parkinson's disease.

The authors evaluated the association of Parkinson's disease (PD) duration with hypertension, assessed by office measurements and 24-hour (ambulatory) monitoring, in 167 patients. Hypertension was evaluated through both office and ambulatory blood pressure (BP) measurements. Among participants (mean age 73.4±7.6 years; 35% women), the prevalence of hypertension was 60% and 69% according to office and ambulatory BP measurements, respectively (Cohen's k=0.61; P<.001). PD duration was inversely associated with hypertension as diagnosed by office measurements (odds ratio [OR], 0.92; 95% confidence interval [CI], 0.86-0.98) but not by ambulatory monitoring (OR, 0.94; 95% CI, 0.81-1.01). Ambulatory BP patterns showed higher nocturnal BP among patients with long-lasting disease. In conclusion, ambulatory BP monitoring improves the detection of hypertension by 15% in PD, compared with office evaluation. The likelihood of having hypertension does not decrease during the PD course; rather, BP pattern shifts towards nocturnal hypertension.

Association of depressive symptoms with circadian blood pressure alterations in Parkinson's disease.

To assess whether among patients with Parkinson's disease (PD) depression, a common non-motor symptom associated with reduced survival, is associated with cardiovascular dysautonomia. We enrolled 125 subjects with PD consecutively admitted to a geriatric day hospital. All participants underwent comprehensive evaluation, fasting blood sampling, and 24-h ambulatory blood pressure monitoring. The percent reduction in nocturnal blood pressure (dipping) was calculated. Depressive symptoms were assessed through the 15-item Geriatric Depression Scale (GDS); a score ≥5 identified moderate to severe symptoms. Among participants (mean age 72.7 ± 7.8 years, 32 % women) 61 subjects (49 %) presented with a GDS score ≥ 5. When compared with other participants, subjects with a GDS score ≥ 5 had reduced adjusted levels of percent systolic (-2.6 ± 2.7 vs. 4.7 ± 2.5; p = 0.003), diastolic (0.6 ± 2.8 vs. 7.4 ± 2.6; p = 0.007), and mean blood pressure dipping (-0.7 ± 2.6 vs. 6.8 ± 2.5; p = 0.002). In separate logistic regression models, depressive symptoms were associated with reduced systolic (OR 0.94; 95 % CI 0.89; 0.98), diastolic (OR 0.94; 95 % CI 0.90; 0.99), and mean blood pressure dipping (OR 0.93; 95 % CI 0.89; 0.98), after adjusting for potential confounders. Depressive symptoms are prevalent, and independently associated with cardiovascular dysautonomia among patients with Parkinson's disease. This might explain the remarkable incidence of sudden death, as well as the association of depressive symptoms with reduced survival reported in these patients. The finding of depressive symptoms in subjects with Parkinson's disease should therefore prompt assessment of cardiovascular autonomic function.

Chronic motor cortex stimulation in patients with advanced Parkinson's disease and effects on striatal dopaminergic transmission as assessed by 123I-FP-CIT SPECT: a preliminary report.

OBJECTIVE: The objective of this study was to assess striatal dopamine transporter availability in patients with advanced Parkinson's disease (PD) before and after 13 months of unilateral extradural motor cortex stimulation (EMCS) with [123I]N-ω-fluoropropyl-2-ß-carbo-methoxy-3-ß-(4-iodophenyl)nortropane single photon emission computed tomography (123I-FP-CIT SPECT). METHODS: Six PD patients (five women and one man, aged 63.2 ± 5.6 years) underwent 123I-FP-CIT SPECT and clinical evaluation [Unified Parkinson's Disease Rating Scale (UPDRS) and Parkinson's Disease Quality of Life Scale (PDQL)] preoperatively, 8 and 13 months after EMCS. Striatum-to-occipital cortex, caudate-to-occipital cortex and putamen-to-occipital cortex 123I-FP-CIT uptake ratios were calculated using the region of interest method. RESULTS: Total and part III UPDRS scores significantly decreased at 8 and 13 months after stimulation (P=0.02 and 0.04, respectively); UPDRS part II and PDQL scores improved after 13 months (P=0.02 and 0.04, respectively). No significant differences in 123I-FP-CIT uptake ratios between baseline and follow-up were found in the examined regions. However, a progressive reduction in 123I-FP-CIT uptake ratios in the striatum contralateral to the implant was found. In contrast, no further decrease in 123I-FP-CIT uptake ratios was detected in the striatum ipsilateral to the implant. There were no correlations between changes in 123I-FP-CIT uptake ratios with disease duration, changes in medication dosage and motor UPDRS scores. CONCLUSION: Despite a small but highly selected sample of advanced PD patients, our results showed that no further dopamine transporter reduction occurred in the striatum ipsilateral to the implant side. This finding could lead to the hypothesis that EMCS might elicit a 'neuroprotective' effect, as suggested by significant clinical benefits.