Potential negative effect of total parenteral nutrition on the human circadian clock.

When patients cannot eat on their own, total parenteral nutrition (TPN) is a clinically beneficial method of maintaining nutrition. However, many animal studies have demonstrated that circadian rhythms are strongly affected by feeding time, raising the concern that continuous TPN around the clock may have an unexpected negative impact on the circadian clock of patients. To investigate this concern, we compared clock gene expression of aged subjects with or without TPN using hair follicle cells and found that while none of the non-TPN subjects showed any obvious defects in circadian rhythms of peripheral clock gene expression, a portion of aged subjects receiving continuous TPN showed abnormal circadian rhythms in peripheral clocks. Continuous TPN around the clock may therefore potentially perturb peripheral circadian rhythms, giving rise to the proposal that TPN needs to be administered with consideration to time factors.

Postural instability via a loss of intermittent control in elderly and patients with Parkinson's disease: A model-based and data-driven approach.

Postural instability is one of the major symptoms of Parkinson's disease. Here, we assimilated a model of intermittent delay feedback control during quiet standing into postural sway data from healthy young and elderly individuals as well as patients with Parkinson's disease to elucidate the possible mechanisms of instability. Specifically, we estimated the joint probability distribution of a set of parameters in the model using the Bayesian parameter inference such that the model with the inferred parameters can best-fit sway data for each individual. It was expected that the parameter values for three populations would distribute differently in the parameter space depending on their balance capability. Because the intermittent control model is parameterized by a parameter associated with the degree of intermittency in the control, it can represent not only the intermittent model but also the traditional continuous control model with no intermittency. We showed that the inferred parameter values for the three groups of individuals are classified into two major groups in the parameter space: one represents the intermittent control mostly for healthy people and patients with mild postural symptoms and the other the continuous control mostly for some elderly and patients with severe postural symptoms. The results of this study may be interpreted by postulating that increased postural instability in most Parkinson's patients and some elderly persons might be characterized as a dynamical disease.

Bright light improves sleep in patients with Parkinson's disease: possible role of circadian restoration.

Parkinson's disease (PD) is one of the most common neurodegenerative disorders. Among the most common manifestations of PD are sleep problems, which are coupled with the adverse effects of dopaminergic therapies (DT). A non-pharmacological solution for these sleep problems has been sought to avoid additional pharmacological intervention. Here, we show that bright light therapy (BLT) is effective for improving sleep in Japanese PD patients receiving DT. Furthermore, experimental evaluation of peripheral clock gene expression rhythms revealed that most PD patients receiving DT who experienced improved sleep following BLT showed a circadian phase shift, indicating the existence of a correlation between circadian modulation and sleep improvement. Conversely, this result indicates that sleep problems in PD patients receiving DT may arise at least in part as a result of circadian dysfunction. Indeed, we found that chronic dopaminergic stimulation induced a rapid attenuation of autonomous oscillations of clock gene expression in ex vivo cultured mouse suprachiasmatic nucleus (SCN) at the single neuron level. In conclusion, BLT is a promising medical treatment for improving sleep in PD patients receiving DT. This BLT-induced improvement may be due to the restoration of circadian function.

Bile acid abnormality induced by intestinal dysbiosis might explain lipid metabolism in Parkinson's disease.

Intestinal dysbiosis refers to an imbalance in the intestinal flora. The concept of small intestinal bacterial overgrowth (SIBO), a condition of abnormal proliferation of the small intestine microbiota, has been proposed as a form of small intestine dysbiosis. In Parkinson's disease patients, weight loss and metabolic disorders such as lipid abnormalities are frequently encountered. This was a prospective investigation of the presence of SIBO using the lactulose breath test, Parkinson's disease symptoms, medications, abdominal symptoms, and blood data involving 39 Parkinson's disease patients. Of the 39 patients, 19 were positive for SIBO, 16 were negative, and 4 were equivocal. SIBO-positive patients had a significantly smaller dopaminergic drug load (dopamine replacement of Parkinson's disease drug potency) (P = 0.009) and significantly lower serum triglyceride (TG) (P = 0.024) and total bilirubin (P = 0.019) levels. No relationship was seen between the presence or absence of SIBO and motor or abdominal symptoms. The following hypothesis was developed with regard to the possibility that intestinal bacterial overgrowth has various effects that are exhibited via bile acid metabolism in Parkinson's disease patients. Serum bilirubin levels become higher as bilirubin metabolism declines with decreases in the intestinal bacteria. At the same time, bile acid is broken down due to increased intestinal bacteria, and lipid absorption decreases. This induces low serum TG levels and leads to weight loss. By a similar mechanism, there is less absorption of vitamin D as bile acid levels decrease, leading to osteoporosis and fractures. The possibility that some of the non-motor manifestations accompanying Parkinson's disease are caused by intestinal dysbiosis needs to be considered.

Normal peripheral circadian phase in the old-old with abnormal circadian behavior.

Almost all organisms maintain a circadian clock from birth to death to synchronize their own physiology and behavior with the earth's rotation. However, extensive studies based on animal experiments have showed that aging results in circadian dysfunction. Human studies have also indicated age-associated abnormal phase, reduced amplitude and enhanced fragmentation in circadian physiology and behavior, thereby strongly implying age-related dysfunction of the clock machinery. Here, we carried out functional assessment of the circadian clock machinery in elderly patients aged 83-94 with severe dementia who showed abnormal circadian behavior. To investigate whether or not the systemic pathway from the circadian input to peripheral clocks functioned normally, the circadian phase in peripheral clock gene expression rhythms was evaluated using plucked hair tissues. Unexpectedly, the phase in all volunteer patients was within a range similar to that of healthy subjects. The circadian pathway from external inputs to peripheral clocks may therefore function normally, even in the old-old with severe dementia.

Postural flexibility during quiet standing in healthy elderly and patients with Parkinson's disease.

Postural instability is one of the predominant symptoms of Parkinson's disease (PD). Despite its significant impact on the deterioration in quality of life in PD patients, mechanistic causes of the instability have not been clarified. Joint inflexibility at ankle and hip joints might be such a major cause, leading to small variability in the center of pressure (CoP) during quiet stance. However, this conjecture is still controversial. Thus, quantitative characterization of CoP patterns during quiet stance in PD patients remains a matter of research. Here we performed a linear discriminant analysis for CoP data in PD patients and age-matched healthy elderly during quiet stance, and showed that CoP variations in PD patients and those in healthy elderly could be well distinguished with an accuracy of about 90%, to which appropriately selected sway indices characterizing aspects of power spectrum for the CoP variations contributed. Specifically, major factors responsible for the discrimination were all associated with increase in the power at a high-frequency band (near and over 1 Hz) along with reduction at the low-frequency regime (lower than about 0.7 Hz). Then, the power-ratio, defined as the relative spectral power in a band around 1 Hz, was examined, since the power in this band reflects postural sway with anti-phase coordinated motions of the ankle and hip joints. We showed that the power-ratio values were significantly smaller in the PD patients than those in the healthy subjects. This difference as well as the results of the linear discriminant analysis suggest joint inflexibility in PD patients, particularly at hip joint, which diminished anti-phase coordination between trunk and lower extremity, leading to postural instability in PD patients.

[A case of limb-girdle muscular dystrophy 2M diagnosed by the occurence of dilated cardiomyopathy].

We report a 24-year-old Japanese man initially suspected to have Becker's muscular dystrophy at the age of 6 years, because of a high level of creatine kinase in serum, though he discontinued visiting the hospital. At the age of 23, he was admitted to the hospital for severe dilated cardiomyopathy, and subsequently diagnosed with limb-girdle muscular dystrophy2M (LGMD2M) based on muscle biopsy and gene analysis. It was recently reported that some patients with fukutinopathy develop LGMD. Most of the cases reported in Japan showed mild skeletal muscle involvement despite serious cardiomyopathy, which may sometimes the initial symptom of the disease. Since muscular dystrophy patients can develop severe cardiac failure, irrespective of the severity of skeletal muscle involvement, regular examinations of cardiopulmonary function are necessary.

Parkinsonian Rigidity Depends on the Velocity of Passive Joint Movement.

Background. It has been long believed that Parkinsonian rigidity is not velocity-dependent based on the neurological examination. However, this has not been verified scientifically. Methods. The elbow joints of 20 Parkinson's disease patients were passively flexed and extended, and two characteristic values, the elastic coefficient (elasticity) and the difference in bias (difference in torque measurements for extension and flexion), were identified from a plot of the angle and torque characteristics. Flexion and extension were done at two different velocities, 60°/s and 120°/s, and a statistical analysis was performed to determine whether the changes in these characteristic values were velocity-dependent. Results. The elastic coefficient was not velocity-dependent, but the difference in bias increased in a velocity-dependent manner (P = 0.0017). Conclusions. The features of rigidity may differ from the conventional definition, which states that they are not dependent on the velocity of joint movement.

Parkinsonian rigidity shows variable properties depending on the elbow joint angle.

Parkinsonian rigidity has been thought to be constant through a full range of joint angle. The aim of this study was to perform a detailed investigation of joint angle dependency of rigidity. We first measured muscle tone at the elbow joint in 20 healthy subjects and demonstrated that an angle of approximately 60° of flexion marks the division of two different angle-torque characteristics. Then, we measured muscle tone at the elbow joint in 24 Parkinson's Disease (PD) patients and calculated elastic coefficients in flexion and extension in the ranges of 10°-60° (distal) and 60°-110° (proximal). Rigidity as represented by the elastic coefficient in the distal phase of elbow joint extension was best correlated with the UPDRS rigidity score (r = 0.77). A significant difference between the UPDRS rigidity score 0 group and 1 group was observed in the elastic coefficient in the distal phase of extension (P < 0.0001), whereas no significant difference was observed in the proximal phase of extension and in each phase of flexion. Parkinsonian rigidity shows variable properties depending on the elbow joint angle, and it is clearly detected at the distal phase of elbow extension.

L-threo-3,4-dihydroxyphenylserine (L-DOPS) co-administered with entacapone improves freezing of gait in Parkinson's disease.

Parkinson's disease (PD) is a neurodegenerative disorder characterized by a variety of motor symptoms including freezing of gait (FOG), in which walking is transiently halted as if the patient's feet were 'glued to the ground'. Treatment of FOG is still challenging. Although L-threo-3,4-dihydroxyphenylserine (L-DOPS), a precursor of noradrenaline, has been on the market in Japan because of its beneficial effect for FOG, clinical use of L-DOPS has been far from satisfying. However, the fact that there were some responders to L-DOPS encouraged us to hypothesize that the enhancement of L-DOPS concentration in the brain by the co-administration of L-DOPS and a catechol-O-methyl transferase (COMT) inhibitor, which is expected to interrupt L-DOPS metabolism in the peripheral circulation, would be beneficial for FOG. Based on our hypothesis, we conducted a preliminary study with a small number of participants with FOG. Of the 16 PD patients with FOG who completed this study, group 1 (n=6) received L-DOPS co-administered with entacapone, which is a COMT inhibitor used worldwide as an anti-parkinson drug, group 2 (n=5) received entacapone alone, and group 3 (n=5) received L-DOPS alone. Only the patients in group 1 showed a significant improvement in FOG. Moreover, the beneficial effect was observed only in patients with levodopa-resistant FOG. This result supports our hypothesis, at least in patients with levodopa-resistant FOG, and shows that the co-administration of L-DOPS and entacapone could be a new strategy for FOG treatment.

Noisy interlimb coordination can be a main cause of freezing of gait in patients with little to no parkinsonism.

Freezing of gait in patients with Parkinson's disease is associated with several factors, including interlimb incoordination and impaired gait cycle regulation. Gait analysis in patients with Parkinson's disease is confounded by parkinsonian symptoms such as rigidity. To understand the mechanisms underlying freezing of gait, we compared gait patterns during straight walking between 9 patients with freezing of gait but little to no parkinsonism (freezing patients) and 11 patients with Parkinson's disease (non-freezing patients). Wireless sensors were used to detect foot contact and toe-off events, and the step phase of each foot contact was calculated by defining one stride cycle of the other leg as 360°. Phase-resetting analysis was performed, whereby the relation between the step phase of one leg and the subsequent phase change in the following step of the other leg was quantified using regression analysis. A small slope of the regression line indicates a forceful correction (phase reset) at every step of the deviation of step phase from the equilibrium phase, usually at around 180°. The slope of this relation was smaller in freezing patients than in non-freezing patients, but the slope exhibited larger step-to-step variability. This indicates that freezing patients executed a forceful but noisy correction of the deviation of step phase, whereas non-freezing patients made a gradual correction of the deviation. Moreover, freezing patients tended to show more variable step phase and stride time than non-freezing patients. Dynamics of a model of two coupled oscillators interacting through a phase resetting mechanism were examined, and indicated that the deterioration of phase reset by noise provoked variability in step phase and stride time. That is, interlimb coordination can affect regulation of the gait cycle. These results suggest that noisy interlimb coordination, which probably caused forceful corrections of step phase deviation, can be a cause of freezing of gait.