Hyperhomocysteinemia Due to Levodopa Treatment as a Risk Factor for Osteoporosis in Patients with Parkinson’s Disease

Parkinson’s disease (PD) patients have been reported to have lower bone mineral density (BMD) and higher fracture risk than individuals without PD. We assessed the association between hyperhomocysteinemia due to levodopa intake and BMD in PD patients. We measured serum homocysteine (Hcy) concentrations and BMD in the proximal femur and lumbar spine of PD patients aged 55 years or older (n = 95) and three age-/gender-matched control subjects (n = 285). The prevalence of osteoporosis was higher in both men (2.5-fold) and women (1.7-fold) with PD than in controls, and adjusted odds ratios for osteoporosis were 3.57 (95% confidence interval [CI], 1.25–10.20) for men and 2.54 for women (95% CI, 1.31–4.93) with PD. Serum Hcy concentrations were significantly higher in PD patients (median = 13.0 μmol/l) than controls (median = 11.5 μmol/l) (P = 0.005). Serum Hcy concentrations were independently associated with BMD values at all proximal femur sites in all subjects (P = 0.005 to 0.012). In PD patients, higher serum Hcy concentrations were independently associated with higher fracture risk (P = 0.029). PD patients taking higher doses of levodopa had significantly higher serum Hcy concentrations (P = 0.013), and greater levodopa intake was associated with lower BMD values in some areas (P = 0.008 to 0.029). In conclusion, these findings indicate that hyperhomocysteinemia due to levodopa intake may be one additional risk factor for osteoporosis and fracture in PD patients. Reducing Hcy may be a therapeutic modality for treating osteoporosis in PD patients taking levodopa.     

Treatment Options for Sleep Dysfunction in Parkinson’s Disease

Sleep disturbance is an important feature of Parkinson’s disease (PD) that deserves clinical attention. Various disorders need to be considered and treatment should be customized to the patient’s specific symptoms and lifestyle. Evaluation of a PD patient complaining of difficulty sleeping begins with a detailed history from the patient and bed partner about the specific problem the patient is experiencing. It is important to inquire about difficulties with sleep onset, frequent awakenings, increased movements during sleep, acting out dreams, uncomfortable motor symptoms, disordered breathing, and nocturia. Current medications should be reviewed to determine whether the recent addition of a drug or a change in dose may be contributing to sleep difficulties, and one should ask about daytime sleepiness, frequent daytime naps, and sleep hygiene in the evening that can contribute to problems sleeping at night. The goal of therapy is to restore quality nighttime sleep without excessive daytime sedation and to improve the patient’s daily mental and physical function and overall quality of life.     

Treatment of Irritability in Huntington’s Disease

Irritability is a common neuropsychiatric feature of Huntington’s disease (HD), with prevalences varying from 38% to 73%. Similar prevalences of irritability are reported in other neurodegenerative disorders and traumatic brain injury, especially when the frontal lobe is involved. Before therapeutic interventions are initiated, the clinician should analyze the severity and frequency of the irritable behavior. By examining irritability in a broader spectrum, a tailor-made treatment can be provided.     

Behcet’s Disease: Treatment of Popliteal Pseudoaneurysm by an Endovascular Stent Graft Implantation

Behçet disease is a multisystemic chronic autoimmune process that can be responsible for some vascular lesions, in addition to its typical dermatologic lesions. Arterial pseudoaneurysm formation can be diagnosed in this group of patients and generally surgery is indicated. In this report, we discuss an alternative endovascular intervention and its advantages. An endovascular stent graft was placed in the popliteal artery pseudoaneurysm of a 37-year-old male with Behçet disease. Early results of this procedure are good thus far. Implantation of an endovascular stent graft, an alternative modality in the treatment of pseudoaneurysms, can result in a shorter hospital stay and a significantly shorter period before returning to normal life. General anesthesia and surgical dissection are avoided, thus diminishing morbidity.     

One-Stage Transanal Endorectal Pull-through for Treatment of Hirschsprung’s Disease in Adolescents and Adults

Background  

One-stage pull-through operation has become increasingly popular for treatment of Hirschsprung’s disease. The one-stage transanal pull-through was introduced in the late 1990s and has rapidly replaced traditional procedures in infants and young children in many surgical centers.     

Contemporary Review of Peyronie’s Disease Treatment

Purpose

To analyze the literature on the current treatment options for Peyronie’s disease (PD).

Recent Findings

Intracavernosal injection therapy using collagenase clostridium histolyticum (CCH) has been widely adopted since its FDA approval in 2013. Based on the current evidence, it appears to be moderately efficacious for men with mild curvatures. Although a recent study has shown similar outcomes using a modified protocol requiring fewer injections, CCH remains an expensive medication. Surgery provides the most definitive treatment. The most common adverse effect following surgery is perceived loss of length. Length restoration procedures have recently been developed to address this with promising results reported in small series.

Summary

There are a variety of medical treatment options for PD, with CCH getting the most attention for being the first drug to be FDA approved for PD treatment. It is the authors’ opinion that the non-surgical therapy most likely to provide meaningful results is combination therapy utilizing oral, intralesional, and external traction therapy. Surgery remains the gold standard for definitive treatment.

     

Treatment of Apathy in Huntington’s Disease and Other Movement Disorders

Apathy is one of the most prevalent neurobehavioral symptoms in Huntington’s disease (HD), occurring in approximately 70% of the symptomatic HD population. Apathy scores in patients with HD are highly correlated with duration of illness, suggesting that apathy is an inevitable consequence of advanced disease. Although less distressing than symptoms like depression and less disruptive than irritability or aggression, apathy has a considerable adverse impact on those affected with HD because it leads to a decrease of the goal-directed behaviors that contribute much to the day-to-day quality of life. As a neuropsychiatric syndrome, apathy is also common in patients with other neuropsychiatric disorders such as Parkinson’s disease, traumatic brain injury, cerebrovascular accident, dementia, and other neurodegenerative conditions. The nosologic status of apathy and lack of a clear definition has probably contributed to the paucity of therapeutic evidence in this area. Several different scales are available to measure apathy, including the Apathy Evaluation Scale, Apathy Inventory, Lilles Apathy Rating Scale, and the apathy items from the Unified HD Rating Scale, the Problem Behaviours Assessment for HD, and the Neuropsychiatric Inventory, but all are based on slightly different definitions of apathy, so the scores obtained may not be directly comparable. Assessment may also be complicated by overlap between the manifestations of apathy and other complications of HD such as depression, so the identification and treatment of these comorbid conditions is important. No adequate evidence currently supports any specific pharmacologic or psychological intervention for apathy in HD. Evidence can only be extrapolated from interventional studies done in other basal ganglia disorders such as Parkinson’s disease or other neurodegenerative disorders such as dementia. The neurobiology of apathy points towards three areas of functional connectivity: connections between the dorsolateral prefrontal cortex (PFC) and basal ganglia, orbitomedial PFC and basal ganglia, and dorsomedial PFC and basal ganglia. Pharmacologic interventions such as cholinesterase inhibitors, the dopaminergic antidepressant bupropion, amantadine, levodopa, bromocriptine, methylphenidate, and atypical antipsychotics have all been tried in other neurodegenerative disorders, but not in HD. Psychosocial interventions such as cognitive stimulation therapy and multisensory stimulation, which have been used in patients with dementia, have not been properly studied in HD. Individualized treatment should be considered, using a combination of methods, as there is no evidence to support one particular type of treatment. Multidisciplinary input, environmental modifications, improved psychosocial support, and psychoeducation programs designed to help caregivers to understand and compensate for the deficits caused by this symptom may all have a role to play in the treatment of apathy.     

Surgical Considerations in the Treatment of Small Bowel Crohn’s Disease

Journal of Gastrointestinal Surgery - Surgery remains a cornerstone of the management of Crohn’s disease (CD). Despite the rise of biologic therapy, most CD patients require surgery for...     

β-Catenin Overexpression in Dupuytren’s Disease Is Unrelated to Disease Recurrence

Recurrence of Dupuytren's contracture is common yet unpredictable, compromising surgical outcome. The alpha-smooth muscle actin-containing myofibroblast is the active contractile cellular component. Based on recent reports on beta-catenin accumulation in Dupuytren's disease, we investigated a possible relation with disease recurrence. We divided a collection of 143 nodules into those from patients with recurrent or nonrecurrent nodules and with a minimal 3-year followup. We randomly selected 12 and 11 samples of each group, respectively. We looked at Dupuytren's diathesis, immunohistologic staining for beta-catenin and alpha-smooth muscle actin, and Luck's histologic stages (zones). The expression of selected Wnt genes was examined with TaqMan PCR in separate histologic zones. All samples showed cytoplasmic and nuclear beta-catenin accumulation in myofibroblasts in involutional zones. The risk score of Abe et al. and Dupuytren's diathesis were greater in the recurrent group. Greater Wnt5a expression in the beta-catenin-accumulating involutional zone was seen. We conclude intracellular beta-catenin accumulation, possibly regulated by upstream Wnt signaling pathway activation and confined in myofibroblasts in the involutional zone of Dupuytren's diathesis, is unrelated to disease recurrence. Clinical parameters for Dupuytren's diathesis remain the best way to predict recurrence risk.     

Treatment of Peyronie’s Disease: 2012 Update

Peyronie’s disease (PD) is the occurrence of a fibrous inelastic scar of the tunica albuginea of the penis. It is a relatively common disorder among men, with a reported prevalence of 3% to 8%. It is often associated with penile pain, anatomical deformities in the erect state, and difficulty with intromission. Because the exact pathophysiology of PD remains unknown and standards for evaluating or reporting treatment outcomes are unclear, research on effective therapies has been limited. The benefits of nonsurgical treatment options are conflicting and further controlled studies are required before any therapy can be fully recommended. The success of surgery has been well documented; however, surgery is invasive and costly and carries potential side effects. Patients who report stable disease that has been present for longer than 12 months and who experience penile deformity preventing satisfactory sexual intercourse are best suited for surgery. Additionally, failed conservative management and a patient’s preference for definitive correction are important additional indications for surgical treatment.