微电极导向多靶点毁损术治疗帕金森病

目的　评估微电极导向多靶点毁损术的手术疗效及不同手术方式的适应证选择。方法　应用微电极导向多靶点毁损术治疗帕金森病 83例 ,其中同期双侧苍白球毁损 1 0例 ,同期同侧苍白球加丘脑毁损 3 0例 ,分期双侧多靶点毁损43例。以术前及术后 1周UPDRS积分计算改善率评价疗效。结果　 83例均有显著近期疗效 ,其中同期双侧毁损的改善率为 83 4% ,同期同侧毁损的改善率为 78 5% ,分期双侧毁损的改善率为 85 2 %。术后 3 6%出现轻度并发症。单项症状改善率最高为僵直 (95 7% ) ,余依次为震颤 (95 1 % )、行动迟缓 (90 9% )、步态 (70 % )、平衡 (68% )。平均随访 1年 ,除 1例复发外 ,余疗效均稳定。结论　微电极导向多靶点毁损术是治疗帕金森病的最有效方法 ,根据手术适应证选择手术方案有助于提高疗效。     

Ablative stereotactic surgery improves manual performance time in Parkinson's disease

The objective of this study was to determine the influence of stereotactic ablative surgical interventions on the time required for the performance of manual tasks (i.e. performance time) in patients with Parkinson's disease (PD). We studied 28 patients after pallidotomy and pallido-thalamotomy who were evaluated at four time: before the operation, and 2 days, 3 and 6 months postoperatively. The speed of performance of handwriting and drawing were assessed by means of a chronometer using certain parts of an international standard scale (modified by Fahn). The patients were also assessed according to the Unified Parkinson's Disease Rating Scale (UPDRS) part III. The patients were divided into two groups. Those in group A had relief of all main Parkinsonian symptoms after pallidotomy including tremor. The patients in group B had no relief of tremor straight after pallidotomy. For them the pallidotomy was completed with thalamotomy in the same sitting, which had resulted in cessation of tremor. The time of performance of the manual tasks diminished significantly in all cases in both groups (Student's t-test: p<0.0001). No complications developed following pallidotomy. Pallido-thalamotomy caused transient adverse effects in two patients, and one patient developed permanent adverse effects such as dysarthria and dysequilibrium. Significant improvements were observed in the speed of handwriting and drawing in both groups, but pallido-thalamotomy was accompanied with complications.     

The Penn Parkinson's Daily Activities Questionnaire-15: Psychometric properties of a brief assessment of cognitive instrumental activities of daily living in Parkinson's disease

IntroductionTo describe the psychometric properties of the Penn Parkinson's Daily Activities Questionnaire-15 (PDAQ-15), a 15-item measure of cognitive instrumental activities of daily living for Parkinson's disease (PD) patients derived from the original 50-item PDAQ.MethodsPDAQ-15 items were chosen by expert consensus. Knowledgeable informants of PD participants (n = 161) completed the PDAQ-15. Knowledgeable informants were defined as an individual having regular contact with the PD participant. PD participants were assigned a diagnosis of normal cognition, mild cognitive impairment, or dementia based on expert consensus.ResultsPDAQ-15 scores correlated strongly with global cognition (Dementia Rating Scale-2, r = 0.71, p < 0.001) and a performance-based functional measure (Direct Assessment of Functional Status, r = 0.83; p < 0.001). PDAQ-15 scores accurately discriminated between non-demented PD participants (normal cognition/mild cognitive impairment) and PD with dementia (ROC curve area = 0.91), participants with and without any cognitive impairment (normal cognition versus mild cognitive impairment/dementia, ROC curve area = 0.85) and between participants with mild cognitive impairment and dementia (ROC curve area = 0.84).ConclusionsThe PDAQ-15 shows good discriminant validity across cognitive stages, correlates highly with global cognitive performance, and appears suitable to assess daily cognitive functioning in PD.     

微电极引导立体定向核团毁损和脑深部电刺激治疗帕金森病

目的研究微电极引导立体定向颅内核团毁损和脑深部电刺激手术(deep brain stimulation,DBS)治疗帕金森病的临床疗效。方法分析我院116例应用微电极引导立体定向核团毁损术和85例应用脑深部电刺激术治疗的帕金森病患者的临床资料,获得术前、术后和DBS开启后6个月、1年、3年及5年的不同服药状态下帕金森病联合评分量表(UPDRS)的评分,比较手术前后UPDRS运动评分的差异。结果核团毁损术和DBS在术后6个月、1年和3年的随访中均能显著改善患者术前UPDRS运动评分,在第5年仅DBS组UPDRS运动评分较术前有改善,同时DBS组患者术后抗帕金森病药物用量较术前减少。结论核团毁损和脑深部电刺激手术均能显著改善帕金森病患者的UPDRS运动评分,DBS疗效更为长久。     

Attentional deficits affect activities of daily living in dementia-associated with Parkinson's disease

Objective

To investigate the effects of attentional deficits on activities of daily living (ADL) in patients with dementia associated with Parkinson''s disease (PDD).

Method

461 patients were assessed neuropsychologically. Factor analyses were used to differentiate attention from other cognitive functions and to differentiate different aspects of ADL functions. The effects of the attentional measure on ADL were examined using sequential multiple regression, controlling for age, sex, education, severity of motor symptoms and other cognitive functions.

Results

Three cognitive factors were identified, with one factor emerging as a measure of vigilance and focused attention. This factor predicted different aspects of ADL status even after controlling for motor functions and other cognitive factors. The attention factor was the single strongest cognitive predictor of ADL status, matching the strength of the effects of motor functions on ADL status.

Conclusion

Impaired attention is an important determinant of ADL functions in patients with PDD.Dementia among patients with Parkinson''s disease (PDD) has an average prevalence of 31% in cross‐sectional studies,¹ a cumulative prevalence approaching 80%,² and is associated with rapid motor³ and functional decline.⁴ Deficits in activities of daily living (ADL) develop in Parkinson''s disease due to the motor symptoms, and also in PDD due to cognitive deficits. ADL deficits are associated with reduced quality of life for patients⁵ and care givers,⁶ and in general, with high nursing costs in nursing homes.⁷ Thus, it is of vital importance to understand the causes of ADL deficits in patients with Parkinson''s disease and to target treatment against these causes.Attention deficit is increasingly acknowledged as an important cognitive symptom in Parkinson''s disease.^{8,9,10,11,12,13} The attention construct is heterogeneous, encompassing executive control functions, selective attention and sustained attention.¹⁴ The executive control functions are complex, and include functions such as planning, sequencing, self‐monitoring, response inhibition, set shifting, and in multitasking by coordinating cognitive resources between different simultaneous task demands. Selective attention refers to the selection of a limited aspect of environmental stimuli for full cognitive processing at the cost of the exclusion of other aspects. Listening to a conversation partner in a noisy environment is an example of selective attention. Sustained attention is often named “vigilance”. It usually refers to the ability to detect and respond to stimuli over time.¹⁵ Drowsiness and reduced arousal will usually be measurable as decreased vigilance.The literature indicates that executive functions are often compromised even in early Parkinson''s disease,^16,17 especially set shifting between task demands. Evidence also suggests a deficit in auditory¹⁸ and visual selective attention.¹³ The concept of “fluctuating” attention in patients with PDD and in those with dementia with Lewy bodies (DLB)⁸ is probably closely related to vigilance deficits. Thus, there is evidence that a broad range of attentional phenomena is compromised in PDD.Deficit in executive functions has been proposed as the most important cognitive predictor of ADL deficit in patients with Parkinson''s disease.¹⁹ However, not much work has been carried out on the effect of changes in vigilance and selective attention. Given the fundamental role of vigilance and selective attention for sustained goal‐directed activity and the variable vigilance level of patients with PDD, we hypothesise that vigilance and selective attention, hereby just referred to as “attention”, are major factors in explaining ADL deficits.We are not aware of any previous published studies on the relationship between ADL and attention in patients with PDD, but the trail making B test¹⁹ and a visuoconstruction task²⁰ has been proposed as a major predictor of ADL status in Parkinson''s disease. Fluctuating attention among patients with DLB correlates with ADL deficits.²¹ However, these studies have used small samples and limited cognitive testing.To test the hypothesis that attentional deficit is related to ADL, we investigated the baseline data from a recent study²² that investigated the effects of rivastigmine on patients with PDD, in which a large sample of patients with PDD was examined using several cognitive tests, some designed specifically to measure attention. The size of the sample made it possible to choose a factor‐analytical approach to generate compound measures that represented the underlying attentional processes better than isolated neuropsychological tests, and to compare the effect of attention with that of other cognitive measures. Thus, our study aimed to investigate the effect of attention on level of ADL functions, and to compare this effect with other cognitive functions and with measures of motor function.     

磁共振结合微电极记录技术定位治疗帕金森病

目的：探讨磁共振扫描（ＭＲＩ）定位结合微电极记录技术在帕金森病（ＰＤ）立体定向手术治疗中的作用。方法：ＭＲＩ定位结合微电极记录技术,定向毁损法治疗ＰＤ２７０例,分析术中靶点更换,手术治疗效果和并发症发生情况。总结应用体会。结果：ＭＲＩ定位结合应用微电极记录技术,ＰＤ的立体定向外科手术治疗疗效优良,并发症少,无永久性并发症：脑内出血发生率为１．８６％,结论：ＭＲＩ定位结合微电极记录技术提高了ＰＤ的手     

Gender differences in disability and health-related quality of life in patients with Parkinson's disease treated with stereotactic surgery

OBJECTIVES: To investigate eventual differences between women and men with Parkinson's disease (PD) before and after surgery, with respect to clinical status, disability and health-related quality of life (HRQoL). MATERIAL AND METHODS: Twenty-four men and 14 women with PD received a total of 46 surgical procedures (pallidotomy, thalamotomy and deep brain stimulation of the thalamus, pallidum or subthalamic nucleus). The impact of PD on disability and other aspects of HRQoL was analysed separately in men and women before and at a mean of 11 months after surgery, using the following assessment tools: The Unified Parkinson's Disease Rating Scale (UPDRS), the ADL Taxonomy, the Nottingham Health Profile, the Life Satisfaction Questionnaire and a Visual Analogue Scale. RESULTS: At surgery, women had a significantly longer duration of disease than men (mean: 15 vs. 10 years, P < 0.01). They had a higher stage on the Hoehn and Yahr scale and worse scores on UPDRS parts II (ADL) and IV (complications), as well as on the Schwab and England scale and on the ADL Taxonomy. Following surgery, both men and women showed improvement, but women experienced greater benefit than men in ADL, in emotions, and in social life. CONCLUSIONS: Perhaps women with PD should be offered surgery more often and earlier in the course of their disease.     

Impairments in activities of daily living in Parkinson's disease: implications for management

Parkinson's disease (PD) is a neurodegenerative disorder with progressive impairment in motor and cognitive functioning. A review of past research shows that individuals experience not only physical discomfort brought on by the illness, but also considerable psychological distress. Increased dependency on a caregiver due to impairments in activities of daily living (e.g., walking, eating, dressing) may bring on feelings of being a burden and strain relationships. However, since PD is a chronic illness, it necessitates family caregiving throughout the life-span. This has implications for the family members who need to redefine their roles within the family to manage the circumstances brought on by the illness. Such strains may include finances, threats to employment, social isolation or health strain. Thus, it becomes imperative to provide unrelenting support to the affected family and individual, to enable them to refocus and learn to manage new illness-related, task-oriented, and affective roles. This enhances the integrity and self-esteem of the patient and helps the family's adjustment to illness of a member. This paper outlines, the role of mental health professionals in providing counseling and psychoeducational approaches to helping patients and their families.     

Clinical phenotype in patients with alpha-synuclein Parkinson's disease living in Greece in comparison with patients with sporadic Parkinson's disease

OBJECTIVE: An Ala53Thr mutation of the alpha-synuclein gene has been recently identified as a rare cause of autosomal Parkinson's disease (PD). The clinical characteristics of 15 patients with PD living in Greece with the Ala53Thr alpha-synuclein mutation (alpha-synPD) were compared with patients with sporadic Parkinson's disease (sPD). METHODS: An investigator, blind to the results of the genetic analysis, examined 15 patients with alpha-synPD and 52 consecutive patients with sPD. Demographic data, age at onset of the illness, modality of presentation, and duration of PD were collected. The unified Parkinson's disease rating scale, the Hoehn and Yahr scale, and the Schwab-England scale were completed. The patients with alpha-synPD were matched for duration of disease with 32 of the 52 patients with sporadic PD (MsPD group). RESULTS: Patients with the alpha-synuclein mutation were significantly younger (mean 7.6 years), showed the first sign of the disease significantly earlier in life (mean 10.8 years), and had significantly longer duration of the disease compared with patients with sPD. Tremor at onset of the disease was present in only one (6.7%) of the patients with alpha-synPD, whereas it was present in 32 (61.5%) of the patients with sPD (p=0.0006). During the course of the disease one patient in the alpha-synPD group went on to develop tremor compared with six patients in the sPD group. Rigidity, bradykinesia, postural instability, orthostatic hypotension, intellectual impairment, depression, complications of therapy, and clinical severity of the disease at the time of examination did not differ significantly between patients with alpha-synPD and those with sPD, or between patients with alpha-synPD and the MsPD group. CONCLUSION: The younger age at onset of the illness, the much lower prevalence of tremor, and the longer duration of the disease characterise the clinical phenotype in this sample of patients with alpha-synPD. The other symptoms and signs of the illness did not seem to differentiate the patients with alpha-synPD from those with sPD.     

髋关节置换后生活活动能力与效果评价：社区回访

背景：髋关节置换是一种重建髋关节功能且疗效十分显著的骨科手术，但如果置换后卧床时间过长，未及早地进行康复治疗，患者可出现不同程度的肌力减退及关节挛缩，影响关节功能的恢复及手术的疗效。 目的：探讨髋关节置换后回访社区继续康复治疗的生活活动能力与效果评价。 方法：选择髋关节置换患者28例，年龄78.1(68~81)岁；男16例，女12例。将患者随机分为治疗组与对照组。治疗组患者于髋关节置换后15 d出院转入本社区卫生服务中心进行继续跟踪康复锻炼，根据假体的稳定性、患者的年龄、体质、置换后时间的长短等制定康复训练计划，训练1个月。对照组只定期随访，未进行相关的康复训练。两组患者在社区卫生服务中心进行入院第1天、1个月、6个月跟踪随访，通过Harris评定和Barthel评定肌力变化。 结果与结论：治疗组患者均按时回访，对照组患者中1例因摔倒骨折入中心医院，1例心脏病发作死亡，2例因外出未回无法取得联系，脱落复诊4例。两组患者置换后到社区卫生中心第1天、1个月、6个月的日常生活活动能力指数、Harris评定与Barthel指数评分均明显提高，且1，6个月治疗组上述指标高于对照组(P < 0.01)。结果说明髋关节置换后患者通过转入社区卫生服务中心继续进行功能训练有助于日常生活活动能力与功能疗效的提高。     

Using the Internet to assess activities of daily living and hand function in people with Parkinson's disease

The ability to measure activities of daily living (ADL) and hand function for people with Parkinson's disease via an Internet-based telerehabilitation system would have a significant impact on the equity, accessibility, and management of the condition for patients who live in rural and remote communities. A low-bandwidth computer-based telerehabilitation system, which incorporates videoconferencing with calibrated assessment tools, has been recently developed at the University of Queensland. This study aimed to determine the validity, intra- and inter-rater reliability of the telerehabilitation system in measuring ADL and hand function in 12 people with Parkinson's disease. ADL status was assessed using the motor component of the Functional Independence Measure (FIM) and selected items from the Unified Parkinson's Disease Rating Scale (UPDRS). The Nine Hole Peg Test, Jamar dynamometer and Preston pinch gauge were also used to assess hand function. For half of the participants, an assessor administered assessments in the traditional face-to-face manner while another assessor simultaneously scored the same assessments via the telerehabilitation system. For the remaining participants, the telerehabilitation assessor administered the assessments via the telerehabilitation system while a face-to-face assessor simultaneously scored the assessments. The telerehabilitation system was found to be a valid measure of ADL status and hand function in people with Parkinson's disease and to have a high level of intra- and inter-rater reliability (all ICCs > 0.80). These results suggest that therapists can confidently use a low-bandwidth telerehabilitation system to assess ADL status and hand function in people with Parkinson's disease.     

Subjective report versus objective measurement of activities of daily living in Parkinson's disease.

We compared subjective self-reports with objective performance ratings of activities of daily living (ADLs) and instrumental ADLs (IADLs) in patients with Parkinson's disease (PD) and identified variables associated with discordance of ratings between these two methods. Seventy-six PD patients completed a modified Older Americans Resources and Services scale, assessing ADLs and IADLs. These results were compared with structured performance tests of walking, eating, dressing, money, and medicine management administered in the clinic. Patient performance was rated on a five-point Likert-type scale, ranging from 1 = no difficulty to 5 = completely unable to perform task. Significant differences were found between patients and clinicians' ratings on all tasks except walking. On the other four tasks, paired group t tests showed that patients reported better function compared with the clinician rating of medication management (1.33 vs. 2.80), eating (1.53 vs. 1.76), dressing (1.64 vs. 1.86), and managing money (1.44 vs. 2.06). A discrepancy was found between patients subjective reporting of ADL and IADL function and objective ratings. Patients overestimated their function on four of five tasks. Further study is necessary to identify whether subjective or objective performance ratings are more reflective of actual daily function.     

Levodopa pharmacokinetics and motor performance during activities of daily living in patients with Parkinson's disease on individual drug combinations

Pharmacokinetics and pharmacodynamics of levodopa were evaluated at a high-resolution level in a heterogeneous group of 10 patients with idiopathic Parkinson's disease during their normal daily activity. A physician and a nurse spent 10 hours with each patient from the first morning dose of levodopa during daily activities at home and at work. Plasma samples were obtained every 20 minutes for analysis of levodopa and 3-O-methyldopa by high-performance liquid chromatography. To assess clinical response, mobility was rated on every test occasion by patients and by investigators. Food and fluid intake and physical activity were also monitored. There was a large intra- and interindividual variability in the pharmacokinetics of levodopa regardless of the different drug combinations used. Mean plasma levodopa concentration ranged between 0.45 to 7.07 microg/mL and peak concentrations between 0.95 to 13.75 microg/mL. In 44 of 58 dosing events, an oral dose of levodopa was related to a peak in plasma concentration. Assessment of the clinical effects was more sensitive when given by patients than when given by the investigators. The fluctuations of the levodopa concentration in plasma had a clear effect on the clinical parameters assessed, even during early disease stages. Variation in levodopa concentration is the determining factor for motor fluctuations also in patients on clinically optimized combinations with dopamine agonists and enzyme inhibitors.     

Respiratory chain enzyme activities in spermatozoa from untreated Parkinson's disease patients

We studied respiratory chain enzyme activities in spermatozoa homogenates from 12 untreated Parkinson's disease (PD) male patients and from 23 age matched healthy male controls. When compared with controls, PD patients showed significantly lower specific activities for complexes I+ III, II+III, and IV. However, citrate synthase corrected activities were similar in patients and controls. Values for enzyme activities in the PD group did not correlate with age at onset, duration, scores of the Unified Parkinson's Disease Rating Scales and Hoehn and Yahr staging. These results suggest that this tissue cannot be used to develop a diagnostic test for PD.     

Daily energy expenditure,physical activity,and weight loss in Parkinson's disease patients

Patients with Parkinson's disease (PD) commonly exhibit weight loss (WL) which investigators attribute to various factors, including elevated energy expenditure. We tested the hypothesis that daily energy expenditure (DEE) and its components, resting energy expenditure (REE) and physical activity (PA) energy expenditure (PAEE), are elevated in WL compared with weight stable (WS) PD patients. We measured DEE in 10 PD WL patients and 10 PD WS patients using doubly labeled water (DLW). PAEE was estimated with DLW, activity monitors, and activity questionnaires. REE was measured with indirect calorimetry. We evaluated energy intake (EI) with a patient's 3‐day food diary. Data was assessed employing SPSS, Spearman correlation coefficients, and Bland and Altman plots. There was no difference in DEE between the WL and WS groups measured with DLW. There were no differences in REE and EI between groups. DEE (r = 0.548, P < 0.05) and PAEE (r = 0.563, P < 0.01) are related with caloric intake. The WL group had higher PA than the WS group (P < 0.042) only when measured with wrist activity monitors. Results suggest that WL in PD patients cannot be fully explained by an increase in DEE. Large longitudinal studies to examine multiple relationships between variables might provide us with a better understanding of WL among PD patients. © 2008 Movement Disorders Society     

伏隔核毁损术戒毒术后患者复吸原因研究

目的 调查伏隔核毁损术后患者复吸原因,比较手术戒毒与保守治疗的效果,评价手术戒毒疗效.方法 回顾性调查手术后观察期2年以上的复吸患者43例,通过家庭走访、门诊、电话、书信、问卷等方式,调查复吸原因,操守时间,术前、术后吸食毒品量变化、对毒品的心理渴求感及吸食毒品后的主观感觉变化,通过自身对比,分析比较手术与以往保守治疗戒毒的效果及复吸原因.结果 失随访9例,主要复吸原因为接触与原成瘾相关的情境(28例,占82.4%)和生活负性事件的应激反应(6例,占17.6%);手术后的操守时间明显长于以往保守治疗后的操守时间;手术后每日吸食毒品量明显少于以往保守治疗后的吸食量;以手术组为研究对象,对操守时间及每日吸食毒品量按复吸原因分组进行成组t检验均无显著性差异(P＞0.05).结论 手术戒毒与保守治疗相比,操守时间长,复吸后每日吸食毒品量明显减少,对毒品的心理渴求感降低.     

立体定向苍白球毁损术对难治性帕金森病的疗效观察

目的：探讨“难治性”帕金森病的手术治疗效果。方法：对３０例难治性帕金林病患者行立体定向苍白球毁损术治疗,观察术前术后对药物反应情况和症状改善程度。结果：苍白球毁损术对“难治性”帕金森病患者的僵直改善率为９２．０％,对运动迟缓改善率为８７．５％,对震颤改善率为７５．０％。Ｈｏｅｈｎ－Ｙａｈｒ分级显著改善。结论：苍白球毁损术对治疗“难治性”帕金森病有良好的治疗效果。