Falls in Parkinson's disease: the impact of disease progression, treatment, and motor complications.

The prevalence of Parkinson's disease (PD) tends to increase worldwide in the coming decades. Thus, the incidence of falls is likely to increase, with a relevant burden on the health care system. Objective: The objective of this study was to evaluate clinical factors and drug use associated with falls in PD patients. Methods: We conducted a cross-sectional study at the Movement Disorders outpatient clinic of a tertiary hospital in Northeast Brazil. We performed structured interviews to collect sociodemographic and clinical data. Functional capacity was assessed using the Schwab and England Activities of Daily Living Scale and the modified Hoehn and Yahr Staging Scale. We divided the study sample into non-fallers (no falls) and fallers (≥1 fall), and non-recurrent (≤1 fall) and recurrent fallers (>1 fall). Results: The study population comprised 327 PD patients (48% women), with a mean age of 70 years. The mean disease duration was 9.9±6.9 years. The most prevalent comorbidities were depression (47.2%), hypertension (44.0%), and type 2 diabetes mellitus (21.5%). The logistic regression analysis revealed that hallucinations, amantadine, and catechol-O-methyltransferase inhibitors (entacapone) were independently associated with falls in PD patients. Also, hallucinations, dyskinesia, and the use of amantadine were independently associated with recurrent falls. Conclusions: Health care providers play an essential role in fall prevention in PD patients, particularly by identifying older adults experiencing dyskinesia and visual hallucinations. Prospective studies should investigate the use of amantadine as a risk factor for falls in PD patients.

Estima-se aumento na prevalência da doença de Parkinson (DP) em todo o mundo nas próximas décadas. Dessa forma, espera-se também aumento na incidência de quedas e seu impacto no sistema de saúde. Objetivo: O objetivo deste estudo foi avaliar fatores clínicos e medicamentos associados a quedas em pacientes com DP. Métodos: Trata-se de um estudo observacional transversal, realizado no ambulatório de Distúrbios do Movimento de hospital terciário no Brasil. Os dados sociodemográficos e clínicos foram coletados por meio de entrevista estruturada. A capacidade funcional foi avaliada pela Escala de Atividades de Vida Diária de Schwab e England e o estadiamento por Hoehn e Yahr modificado. A amostra foi dividida em não caidores (0 quedas) e caidores (≥1 queda) e não caidores recorrentes (≤1 queda) e caidores recorrentes (>1 queda). A informação sobre o número de quedas nos últimos seis meses foi confirmada com familiares e cuidadores. Resultados: A população do estudo foi de 327 pacientes (48% mulheres), com idade média de 70 anos e duração média da doença de 9,9±6,9 anos. As comorbidades mais prevalentes foram depressão (47,2%), hipertensão (44%) e diabetes mellitus tipo 2 (21,5%). A análise de regressão logística revelou que alucinações visuais, uso de amantadina e uso de entacapona foram independentemente associadas a quedas. Alucinações visuais, discinesia e uso de amantadina foram independentemente associados a quedas recorrentes neste estudo. Conclusões: Os profissionais de saúde desempenham um papel importante na prevenção de quedas em pacientes com DP, principalmente idosos que apresentam discinesia e alucinações visuais. Estudos prospectivos da amantadina devem ser realizados para investigar sua associação com quedas em pacientes com DP.

Falls in Parkinson's disease: the impact of disease progression, treatment, and motor complications / Quedas na doença de parkinson: impacto da progressão da doença, do tratamento e das complicações motoras

ABSTRACT. The prevalence of Parkinson's disease (PD) tends to increase worldwide in the coming decades. Thus, the incidence of falls is likely to increase, with a relevant burden on the health care system. Objective: The objective of this study was to evaluate clinical factors and drug use associated with falls in PD patients. Methods: We conducted a cross-sectional study at the Movement Disorders outpatient clinic of a tertiary hospital in Northeast Brazil. We performed structured interviews to collect sociodemographic and clinical data. Functional capacity was assessed using the Schwab and England Activities of Daily Living Scale and the modified Hoehn and Yahr Staging Scale. We divided the study sample into non-fallers (no falls) and fallers (≥1 fall), and non-recurrent (≤1 fall) and recurrent fallers (>1 fall). Results: The study population comprised 327 PD patients (48% women), with a mean age of 70 years. The mean disease duration was 9.9±6.9 years. The most prevalent comorbidities were depression (47.2%), hypertension (44.0%), and type 2 diabetes mellitus (21.5%). The logistic regression analysis revealed that hallucinations, amantadine, and catechol-O-methyltransferase inhibitors (entacapone) were independently associated with falls in PD patients. Also, hallucinations, dyskinesia, and the use of amantadine were independently associated with recurrent falls. Conclusions: Health care providers play an essential role in fall prevention in PD patients, particularly by identifying older adults experiencing dyskinesia and visual hallucinations. Prospective studies should investigate the use of amantadine as a risk factor for falls in PD patients.

RESUMO. Estima-se aumento na prevalência da doença de Parkinson (DP) em todo o mundo nas próximas décadas. Dessa forma, espera-se também aumento na incidência de quedas e seu impacto no sistema de saúde. Objetivo: O objetivo deste estudo foi avaliar fatores clínicos e medicamentos associados a quedas em pacientes com DP. Métodos: Trata-se de um estudo observacional transversal, realizado no ambulatório de Distúrbios do Movimento de hospital terciário no Brasil. Os dados sociodemográficos e clínicos foram coletados por meio de entrevista estruturada. A capacidade funcional foi avaliada pela Escala de Atividades de Vida Diária de Schwab e England e o estadiamento por Hoehn e Yahr modificado. A amostra foi dividida em não caidores (0 quedas) e caidores (≥1 queda) e não caidores recorrentes (≤1 queda) e caidores recorrentes (>1 queda). A informação sobre o número de quedas nos últimos seis meses foi confirmada com familiares e cuidadores. Resultados: A população do estudo foi de 327 pacientes (48% mulheres), com idade média de 70 anos e duração média da doença de 9,9±6,9 anos. As comorbidades mais prevalentes foram depressão (47,2%), hipertensão (44%) e diabetes mellitus tipo 2 (21,5%). A análise de regressão logística revelou que alucinações visuais, uso de amantadina e uso de entacapona foram independentemente associadas a quedas. Alucinações visuais, discinesia e uso de amantadina foram independentemente associados a quedas recorrentes neste estudo. Conclusões: Os profissionais de saúde desempenham um papel importante na prevenção de quedas em pacientes com DP, principalmente idosos que apresentam discinesia e alucinações visuais. Estudos prospectivos da amantadina devem ser realizados para investigar sua associação com quedas em pacientes com DP.

Stiff-Eye Syndrome-Anti-GAD Ataxia Presenting with Isolated Ophthalmoplegia: A Case Report.

Anti-GAD ataxia is one of the most common forms of immune-mediated cerebellar ataxias. Many neurological syndromes have been reported in association with anti-GAD. Ophthalmoparesis has been described in stiff person syndrome. We report a case of anti-GAD ataxia presenting initially with isolated ophthalmoplegia and showing complete resolution after immunotherapy. A 26-year-old male patient presented with ophthalmoparesis characterized by tonic upwards deviation of the right eye. In the following month, he developed progressive ataxia with anti-GAD titers of 1972 UI/mL. After treatment with methylprednisolone and immunoglobulin, there was complete resolution of symptoms and anti-GAD titers decreased. This is the first report of isolated ophthalmoparesis due to tonic eye deviation associated with anti-GAD antibodies without stiff-person syndrome. Tonic eye deviation has been reported in SPS, possibly secondary to continuous discharge in gaze holding neurons in the brainstem (similar to what occurs in spinal motor neurons). With growing evidence for ocular abnormalitites in SPS, anti-GAD associated neurological syndromes should be included in the differential diagnosis of isolated ophthalmoplegia.

Intracranial mass lesions and skin discoloration in the armpits as unusual clues to Erdheim-Chester disease: a case report.

BACKGROUND: Erdheim-Chester disease (ECD) is a non-Langerhans histiocytosis that results in multi-organ disease involving the skin, bones, lungs and kidneys. Central nervous system (CNS) involvement occurs in about 50 % of patients, and diabetes insipidus, visual disturbances, and cerebellar ataxia are the most frequent neurological signs. We report a case of Erdheim-Chester disease with central nervous system involvement in the form of enhancing intracranial mass lesions with massive edema. CASE PRESENTATION: The patient presented with vertigo, ataxia, encephalopathy and pyramidal signs. Diagnosis was suggested by xanthomatous skin lesions and a biopsy was compatible with Erdheim-Chester disease demonstrating xanthogranulomas CD68 positive (clone KP1) and CD1a and S100 negative. Testing for BRAF mutation was negative, which precluded treatment with Vemurafenib. Treatment with steroids and interferon resulted in improvement of neurological signs and regression of edema on MRI. CONCLUSIONS: The diagnosis of Erdheim-Chester disease should be considered in intracranial mass lesions. Xanthomatous skin lesions are a clue to the diagnosis.

Polypharmacy simulation and pharmacotherapy perceptions among students from a university in Ceará: a pilot study / Simulação de polimedicação e percepções sobre farmacoterapia em estudantes de universidade no Ceará: estudo-piloto

Abstract: Introduction: Given the high prevalence of polypharmacy patients, it is paramount that they be handled with an effective therapeutic alliance and with safe and feasible treatments. Empathy towards the patient is essential, and the lack of prescriber experience may hamper such bond. Objectives: This study simulates a polypharmacy regimen among medical students, aiming to promote reflections about the daily challenges faced by patients. Methods: It is a prospective study in a single, non-blind group. The participants were medical students and residents from our institution, all of whom followed a 7-day placebo prescription. They answered questionnaires on their perceptions of medication adherence and concordance before and after the simulation. Results: twenty-eight volunteers participated, 27 of which (96.4%) forgot to take at least one pill during the experiment. Among the lower undergraduates, 28.57% interrupted at least one medication. As for the higher undergraduates and residents, this happened with 71.43% of them. There were more adherence failures than predicted by the participants themselves. In realistic dosages, levothyroxine, angiotensin-converting enzyme inhibitors and metformin were the drugs reported to be the most difficult. 96% of the volunteers strongly agreed that doctor and patient's agreement regarding the treatment correlates with good adherence. Conclusion: Understanding the factors that affect adherence and how to handle them is essential for a doctor, as well as a good bond with the patient. The teaching of these abilities is very necessary. Further studies are needed to reach more undergraduate students and to highlight the relevance of simulations in the medical education setting.

Resumo: Introdução: Com a prevalência de pacientes polimedicados, é essencial que estes sejam manejados com aliança terapêutica efetiva e tratamentos factíveis e seguros. A empatia com o paciente é indispensável, e a falta de experiência dos prescritores pode impedir esse vínculo. Objetivo: O presente estudo simula um regime polimedicamentoso com acadêmicos de Medicina, para promover reflexões sobre as dificuldades vivenciadas pelos pacientes. Método: É estudo prospectivo em grupo único e não cego. Participaram estudantes de Medicina dos semestres 5 a 7, internos e residentes da nossa instituição, que seguiram regime placebo por sete dias. Antes e depois do período, os voluntários responderam a questionários de percepções sobre aderência medicamentosa e concordância terapêutica. Resultado: Participaram 28 voluntários, dos quais 27 (96,4%) esqueceram-se de utilizar pelo menos uma medicação durante o período. Dos graduandos, 28,57% referiram interrupção do uso de pelo menos uma. Do grupo de internos e residentes, essa porcentagem foi de 71,43%. Houve mais perdas de dose do que o previsto pelos participantes. Seguindo posologias realistas, levotiroxina sódica, inibidor de enzima conversora da angiotensina e metformina foram os fármacos referidos como de maior dificuldade. Do total de participantes, 96% afirmaram com veemência que o tratamento acordado entre médico e paciente deve se correlacionar com a boa aderência terapêutica. Conclusão: A compreensão sobre os fatores que influenciam na aderência e em seus manejos é indispensável na capacitação do médico, bem como o bom vínculo entre médico e paciente. O ensino dessas habilidades é necessário. São necessários estudos adicionais, a fim de alcançar mais graduandos e ressaltar a relevância de simulações no ensino médico.

Effects of a power strength training using elastic resistance exercises on the motor and non-motor symptoms in patients with Parkinson's disease H&Y 1-3: study protocol for a randomised controlled trial (PARK-BAND Study).

INTRODUCTION: Parkinson's disease (PD) is the second most common neurodegenerative disorder in Brazil. Physical activity is a complementary intervention in managing inherent declines associated with the disease like strength, balance, gait, and functionality and benefit health-related outcomes. Here, we report the PARK-BAND Study protocol, which aims to investigate potential benefits of power training using elastic devices in participants with PD. Our intervention will be provided in patients with PD using elastic devices like elastic bands and tubes. Therefore, we used the term Park from Parkinson's disease and band from elastic bands. METHODS AND ANALYSIS: This randomised single-blind single-centre two-arm parallel, superiority trial will include 50 participants with PD attending the clinical setting. Those who meet the eligibility criteria and provide consent to participate will be randomised in a 1:1 ratio to either the exercise group, which will receive power training programme or the health education group, which will receive the education programme. Randomisation will be performed by permuted block randomisation with a block size of eight. Both groups will receive a 12-week intervention. The exercise group will have two sessions per week and the health education group will have one session per week. Changes from baseline in bradykinesia, as assessed by the Unified Parkinson's Disease Rating Scale motor examination subscore and physical functional performance, will be the primary outcomes. Secondary outcomes include other neurological, neurophysiological and physical variables, as well as the quality of life, depression, cognition, sleep quality and disturbances, assessed before and after interventions. We hypothesise that the exercise group will have greater improvement in primary and secondary outcomes than the health education group. ETHICS AND DISSEMINATION: The study is approved by the Research Ethics Committee of Hospital Universitário Walter Cantidio and all participants will provide their written informed consent (register number 91075318.1.0000.5045).Trial results will be disseminated via peer reviewed journal articles and conference presentations, reports for organisations involved with PD and for participants. TRIAL REGISTRATION NUMBER: Registro Brasileiro de Ensaios Clínicos Registry (RBR-5w2sqt); Pre-results.