[How the implementation of a school for people with Parkinson's disease can succeed-Results of a consensus study and a formative evaluation]. / Wie die Umsetzung einer Schule für Menschen mit Parkinson-Krankheit gelingen kann ­ Ergebnisse eines Konsensusverfahrens und einer formativen Evaluation.

BACKGROUND: As the most rapidly increasing neurodegenerative disease worldwide, Parkinson's disease is highly relevant to society. Successful treatment requires active patient participation. Patient education has been successfully implemented for many chronic diseases, such as diabetes and could also provide people with Parkinson's disease with skills to manage the disease better and to participate in shared decision making. MATERIAL AND METHODS: To prepare the implementation of a concept for patient education for people with Parkinson's disease, a structured consensus study was conducted and a pilot project formatively evaluated. The structured consensus study included experts from all over Germany. It consisted of two online surveys and an online consensus conference. The formative evaluation was conducted as three focus groups. Transcripts were evaluated using content-structuring qualitative content analysis. RESULTS: From the consensus procedure 59 consented statements emerged, mainly regarding the contents of a patient school and a group size of 6-8 persons. Only two statements could not be consented. The formative evaluation detected a tendency towards a positive attitude for a digital training format and a very positive evaluation of the contents. DISCUSSION: Overall, important recommendations for a patient school can be drawn from this study. The following subjects require further investigation: format, inclusion criteria, group composition and inclusion of caregivers.

Botulism after intragastric botulinum toxin injections for weight reduction.

Although-considering the risk-benefit ratio-botulinum neurotoxin A (BoNT/A) is unequivocally recommended to treat severe neurological diseases such as dystonia, this has not yet been determined for its endoscopic intragastric injection aimed at weight reduction in obesity. However, severe adverse effects of intragastric BoNT/A had not yet been reported, prompting some European countries to endorse its (off-label) use and treat patients transnationally. We here present three cases of botulism after intragastric BoNT/A injections for obesity treatment in a Turkish hospital. Patients presented with cranial nerve affection, bulbar symptoms, and descending paresis, and benefited from treatment with BoNT antitoxin and pyridostigmine. We assume that iatrogenic botulism was induced by overdosing in combination with toxin spread via the highly vascularized gastric tissue. Of note, within a few weeks, more than 80 cases of iatrogenic botulism were reported across Europe after identical intragastric BoNT/A injections. These cases demonstrate the risks of BoNT/A injections if they are not applied within the limits of evidence-based medicine. There is a need for international guidelines to define the indication and a safe dosing scheme, especially in the context of medical tourism.

Assessment of Affective-Behavioral States in Parkinson's Disease Patients: Towards a New Screening Tool.

BACKGROUND: Assessment of affective-behavioral states in patients with Parkinson's disease (PD) undergoing deep brain stimulation (DBS) is essential. OBJECTIVE: To analyze well-established questionnaires as a pilot-study with the long term aim to develop a screening tool evaluating affective-behavioral dysfunction, including depression, anxiety, apathy, mania, and impulse control disorders, in PD patients screened for DBS. METHODS: Two hundred ninety-seven inpatients with PD underwent standardized neuropsychiatric testing including German versions of Beck Depression Inventory-II, Hospital Anxiety and Depression Scale, Apathy Evaluation Scale, Self-Report Manic Inventory, and Questionnaire for Impulsive-Compulsive Disorders in PD-Rating Scale, to assess appropriateness for DBS. Statistical item reduction was based on exploratory factor analysis, Cronbach's alpha, item-total correlations, item difficulty, and inter-item correlations. Confirmatory factor analysis was conducted to assess factorial validity. An expert rating was performed to identify clinically relevant items in the context of PD and DBS, to maintain content validity. We compared the shortened subscales with the original questionnaires using correlations. To determine cutoff points, receiver operating characteristics analysis was performed. RESULTS: The items of the initial questionnaires were reduced from 129 to 38 items. Results of confirmatory factor analyses supported the validity of the shortened pool. It demonstrated high internal consistency (Cronbach's alpha = 0.72-0.83 across subscales), and the individual subscales were correlated with the corresponding original scales (rs = 0.84-0.95). Sensitivities and specificities exceeded 0.7. CONCLUSION: The shortened item pool, including 38 items, provides a good basis for the development of a screening tool, capturing affective-behavioral symptoms in PD patients before DBS implantation. Confirmation of the validity of such a screening tool in an independent sample of PD patients is warranted.

A prospective, controlled study of non-motor effects of subthalamic stimulation in Parkinson's disease: results at the 36-month follow-up.

OBJECTIVE: To examine 36-month effects of bilateral subthalamic nucleus deep brain stimulation (STN-DBS) on non-motor symptoms (NMS) compared with standard-of-care medical treatment (MED) in Parkinson's disease (PD). METHODS: Here we report the 36-month follow-up of a prospective, observational, controlled, international multicentre study of the NILS cohort. Assessments included NMSScale (NMSS), PDQuestionnaire-8 (PDQ-8), Scales for Outcomes in PD (SCOPA)-motor examination, -activities of daily living, and -complications, and levodopa equivalent daily dose (LEDD). Propensity score matching resulted in a pseudo-randomised sub-cohort balancing baseline demographic and clinical characteristics between the STN-DBS and MED groups. Within-group longitudinal outcome changes were analysed using Wilcoxon signed-rank and between-group differences of change scores with Mann-Whitney U test. Strength of clinical responses was quantified with Cohen's effect size. In addition, bivariate correlations of change scores were explored. RESULTS: Propensity score matching applied on the cohort of 151 patients (STN-DBS n=67, MED n=84) resulted in a well-balanced sub-cohort including 38 patients per group. After 36 months, STN-DBS significantly improved NMSS, PDQ-8, SCOPA-motor examination and -complications and reduced LEDD. Significant between-group differences, all favouring STN-DBS, were found for NMSS, SCOPA-motor complications, LEDD (large effects), motor examination and PDQ-8 (moderate effects). Furthermore, significant differences were found for the sleep/fatigue, urinary (large effects) and miscellaneous NMSS domains (moderate effects). NMSS total and PDQ-8 change scores correlated significantly. CONCLUSIONS: This study provides Class IIb evidence for beneficial effects of STN-DBS on NMS at 36-month follow-up which also correlated with quality of life improvements. This highlights the importance of NMS for DBS outcomes assessments.

Circadian rhythms and influencing factors of xerostomia among Parkinson's disease patients.

OBJECTIVES: Parkinson's disease (PD) patients suffer from xerostomia, but limited information exists regarding associations with dysphagia, drooling, daily habits, PD characteristics, or possible circadian rhythms. SUBJECTS AND METHODS: A questionnaire was administered, including (a) clinical characteristics (comorbidities, prescribed medications, levodopa equivalent daily dose [LEDD], disease duration); (b) self-assessment of dysphagia, xerostomia, drooling (10-cm visual analogue scale [VAS]); (c) 24-hr diary of motor impairment, dyskinesia, xerostomia, dysphagia, drooling, daily habits. RESULTS: Of 75 PD patients who completed the study, 67% reported dysphagia (mean ± standard deviation VAS 4 ± 2), 76% drooling (5 ± 2), 77% xerostomia (5 ± 2). Xerostomia was associated with comorbidities (p = 0.021) and smoking (p = 0.010) and affected by tremor (p = 0.003), dyskinesia (p = 0.010), dysphagia (p < 0.001), food intake (p = 0.005), sleep (p = 0.011), age (p = 0.018), medication intake (p = 0.063), LEDD (p = 0.052), daytime (p = 0.075), disease duration (p = 0.004). Xerostomia peaked at 9 a.m. and 9 p.m. CONCLUSIONS: PD patients suffer from xerostomia, dysphagia, and drooling. Subjective dysphagia is associated with drooling and xerostomia, but drooling prevalence or intensity does not influence xerostomia symptoms. Tremor, dyskinesia, and disease duration, which characterise PD, affect xerostomia. Additionally, food intake, sleep, age, LEDD, and daytime (peaks at 9 a.m. and 9 p.m.) increase xerostomia occurrence. This knowledge may improve dentists' advice to patients and aid development of patient-centred, symptom-relieving products.

Unstable impedance of a single electrode contact resulting in loss of DBS therapy-a case report.

Open and short circuits of electrode contacts are important technical dysfunctions of DBS. Here, we report on another type of dysfunction restricted to a single electrode contact: impedance instability within regular absolute values. After 9-year subthalamic DBS, a Parkinson patient developed unilateral motor symptoms and intermittent dysaesthesia due to impedance instability of the active contact. DBS efficacy could be restored without surgical revision by activation of the neighboring contact. During 3-year-follow-up, impedances of the dysfunctional contact varied between 1 and 3 kΩ whereas the other three contacts remained stable. Impedance documentation is crucial to identify such dysfunctions.

Contusion of the cervical spinal cord following dental treatment of a patient at risk to stroke: A case report.

OBJECTIVES: It is essential that especially elderly patients are correctly positioned in dental chairs, based on medical history and careful observation. METHOD: We report a case where reclination of the patient's head resulted in weakness of the limbs. RESULTS: Subsequent investigation determined traumatic contusion of the cervical spinal cord. CONCLUSIONS: This case highlights the need for accurate anamnesis, close observation and interdisciplinary communication to determine correct positioning. Exceptional circumstances necessitate speedy response to minimise adverse events in elderly patients.

Pulse duration settings in subthalamic stimulation for Parkinson's disease.

BACKGROUND: Stimulation parameters in deep brain stimulation (DBS) of the subthalamic nucleus for Parkinson's disease (PD) are rarely tested in double-blind conditions. Evidence-based recommendations on optimal stimulator settings are needed. Results from the CUSTOM-DBS study are reported, comparing 2 pulse durations. METHODS: A total of 15 patients were programmed using a pulse width of 30 µs (test) or 60 µs (control). Efficacy and side-effect thresholds and unified PD rating scale (UPDRS) III were measured in meds-off (primary outcome). The therapeutic window was the difference between patients' efficacy and side effect thresholds. RESULTS: The therapeutic window was significantly larger at 30 µs than 60 µs (P = ·0009) and the efficacy (UPDRS III score) was noninferior (P = .00008). INTERPRETATION: Subthalamic neurostimulation at 30 µs versus 60 µs pulse width is equally effective on PD motor signs, is more energy efficient, and has less likelihood of stimulation-related side effects. © 2017 The Authors. Movement Disorders published by Wiley Periodicals, Inc. on behalf of International Parkinson and Movement Disorder Society.

Rapid battery depletion and loss of therapy due to a short circuit in bipolar DBS for essential tremor.

Technical dysfunctions have been reported reducing efficacy of deep brain stimulation (DBS). Here, we report on an essential-tremor patient in whom a short circuit in bipolar DBS resulted not only in unilateral loss of therapy but also in high current flow and thereby rapid decline of the impulse-generator battery voltage from 2.83 V a week before the event to 2.54 V, indicating the need for an impulse-generator replacement. Immediate re-programming restored therapeutic efficacy. Moreover, the reduction in current flow allowed the battery voltage to recover without immediate surgical intervention to 2.81 V a week later.

Dopamine replacement modulates oscillatory coupling between premotor and motor cortical areas in Parkinson's disease.

Efficient neural communication between premotor and motor cortical areas is critical for manual motor control. Here, we used high-density electroencephalography to study cortical connectivity in patients with Parkinson's disease (PD) and age-matched healthy controls while they performed repetitive movements of the right index finger at maximal repetition rate. Multiple source beamformer analysis and dynamic causal modeling were used to assess oscillatory coupling between the lateral premotor cortex (lPM), supplementary motor area (SMA), and primary motor cortex (M1) in the contralateral hemisphere. Elderly healthy controls showed task-related modulation in connections from lPM to SMA and M1, mainly within the γ-band (>30 Hz). Nonmedicated PD patients also showed task-related γ-γ coupling from lPM to M1, but γ coupling from lPM to SMA was absent. Levodopa reinstated physiological γ-γ coupling from lPM to SMA and significantly strengthened coupling in the feedback connection from M1 to lPM expressed as ß-ß as well as θ-ß coupling. Enhancement in cross-frequency θ-ß coupling from M1 to lPM was correlated with levodopa-induced improvement in motor function. The results show that PD is associated with an altered neural communication between premotor and motor cortical areas, which can be modulated by dopamine replacement.