A focus on Rome III criteria for the assessment of constipation in Parkinson's disease

A randomized double-blind placebo-controlled multicenter trial of Bushen Yisui and Ziyin Jiangzhuo formula for constipation in Parkinson disease

INTRODUCTION

Constipation is a common nonmotor symptom of Parkinson disease (PD). Constipation can also impact patient's quality of life. Chinese herbal medicines have been used for the treatment of constipation in PD. This trial will evaluate the efficacy and safety of a Chinese herbal formula Bushen Yisui and Ziyin Jiangzhuo (BYZJ) for the treatment of constipation in PD.

METHODS AND ANALYSIS

This randomized, double-blind, placebo-controlled, multicenter clinical trial will involve 4 hospitals in Beijing, China. The study will aim to recruit 90 PD patients with constipation between 30 and 80 years-of age with a score of 1 - 4 on the Hoehn and Yahr scale. Once recruited, Patients will be randomized into a BYZJ group or a placebo group in a 2:1 ratio. The trial will include a 1-week run-in period, a 4-week double-blind treatment period, a 4-week and a 12-week follow-up period. All patients will be educated about PD-related constipation during the run-in period. BYZJ granules and simulated granules will be administered twice daily for 4 weeks to the BYZJ group and the placebo group respectively. Assessments will be performed during run-in period, before the start of treatment (baseline, week 0), and at 4, 8, and 16 weeks. The primary outcome will be measured with the Constipation Severity Instrument, and secondary outcomes will be evaluated with the Patient Assessment of Constipation Quality of Life questionnaire, Bristol Stool Form Scale, Movement Disorders-Unified Parkinson Disease Rating Scale, Nonmotor Symptoms Scale, PD Sleep Scale, Parkinson Fatigue Scale-16. Laxative use (dose and frequency) will also be recorded. Intention-to-treat and per-protocol set analyses will be used to compare symptom improvement between the 2 groups. Any adverse events will be recorded.

DISCUSSION

If found effective and safe, BYZJ formula will be one of Chinese herb to treat constipation and even other nonmotor or motor symptoms in PD patients. The results will sustain the broader use of BYZJ formula in PD.

α-Synuclein oligomers in skin biopsy of idiopathic and monozygotic twin patients with Parkinson's disease

A variety of cellular processes, including vesicle clustering in the presynaptic compartment, are impaired in Parkinson’s disease and have been closely associated with α-synuclein oligomerization. Emerging evidence proves the existence of α-synuclein-related pathology in the peripheral nervous system, even though the presence of α-synuclein oligomers in situ in living patients remains poorly investigated. In this case-control study, we show previously undetected α-synuclein oligomers within synaptic terminals of autonomic fibres in skin biopsies by means of the proximity ligation assay and propose a procedure for their quantification (proximity ligation assay score). Our study revealed a significant increase in α-synuclein oligomers in consecutive patients with Parkinson’s disease compared to consecutive healthy controls (P < 0.001). Proximity ligation assay score (threshold value > 96 using receiver operating characteristic) was found to have good sensitivity, specificity and positive predictive value (82%, 86% and 89%, respectively). Furthermore, to disclose the role of putative genetic predisposition in Parkinson’s disease aetiology, we evaluated the differential accumulation of oligomers in a unique cohort of 19 monozygotic twins discordant for Parkinson’s disease. The significant difference between patients and healthy subjects was confirmed in twins. Intriguingly, although no difference in median values was detected between consecutive healthy controls and healthy twins, the prevalence of healthy subjects positive for proximity ligation assay score was significantly greater in twins than in the consecutive cohort (47% versus 14%, P = 0.019). This suggests that genetic predisposition is important, but not sufficient, in the aetiology of the disease and strengthens the contribution of environmental factors. In conclusion, our data provide evidence that α-synuclein oligomers accumulate within synaptic terminals of autonomic fibres of the skin in Parkinson’s disease for the first time. This finding endorses the hypothesis that α-synuclein oligomers could be used as a reliable diagnostic biomarker for Parkinson’s disease. It also offers novel insights into the physiological and pathological roles of α-synuclein in the peripheral nervous system.

Prevalence of Malnutrition in Parkinson's Disease and Correlation with Gastrointestinal Symptoms

Background:

Parkinson's disease (PD) patients are at a higher risk of malnutrition with the overall prevalence estimated to be 3%–60%, but there are limited data in India regarding nutritional assessment of PD.

Aim:

This study aims to assess nutritional status of PD patients and correlate the disease factors and gastrointestinal tract (GIT) symptoms with nutritional status.

Materials and Methods:

The PD cohort was assessed for demographic factors, nutritional assessment was done by Mini-Nutritional Assessment (MNA) Scale, and GI symptoms were assessed by validated scales. Age- and gender-matched cohort controls were randomly selected to correlate the GIT symptoms influencing nutritional status. The study population was divided into two groups according to the MNA score; Group I malnourished/at risk of malnutrition (score <23.5) or Group II normal nutrition (>23.5). The two subgroups were then compared.

Results:

We assessed 75 patients of PD and 35 age- and gender-matched controls. According to anthropometric criteria, 23% of the PD population was underweight, and according to biochemical assessment, 17.3% had hypoalbuminemia along with anemia. According to MNA scale, 12% were malnourished and 45.3% were at risk of malnutrition. Hence, a total of 57.3% patients in Group I (with abnormal nutrition) as compared to 14% of the controls were at risk of malnutrition while none was found to be malnourished. In our study, GIT symptoms, such as sialorrhea and dysphagia was reported by 29.3% each and constipation by 41.3% patients. While comparing GI symptoms within the two MNA groups, there was statistically significant relationship of all GI manifestations, sialorrhea (P = 0.041), dysphagia (P = 0.00081), and constipation (P = 0.0042) with malnutrition. There was no statistical significant difference between groups for age (P = 0.54), gender (P = 0.903), and duration of disease (P = 0.743).

Conclusions:

The data suggest that about 45% of PD patients are at risk of malnourishment. MNA Score is a validated nutritional assessment tool and anthropometric or biochemical measures alone cannot identify all the malnourished population. PD patients at risk of malnutrition or malnourished do have symptoms of dysphagia, sialorrhea, and constipation as compared to PD patients with normal nutrition.

A survey of subjective constipation in Parkinson's disease patients in shanghai and literature review

Background

Constipation is one of the most frequent non-motor symptoms (NMS) in Parkinson’s disease (PD) and the prevalence of constipation in PD patients varies among different studies. We designed this study to survey the prevalence and clinical characteristics of subjective constipation and the appearance chronology between the emergence of constipation and onset of motor symptoms in PD patients from Shanghai, China.

Methods

268 PD patients were continuously recruited into this study. Parkinson’s related clinical information of the participants was collected. A spectrum of motor and nonmotor features was assessed with scales and questionnaires. Subjective constipation was defined by ROME III criteria.

Results

54.10% PD patients suffer from constipation. Among them, there was 47.59% having constipation before onset of motor symptoms. Compared with patients without constipation, patients with constipation reported lower daily water intake and less exercise, and were dominated by bradykinetic-rigid motor phenotype at onset and were prone to have anxiety, depression and insomnia. The time span between constipation and the onset of motor symptoms was (6.62 ± 9.32) years. Constipation occurred more frequently between 2 and 10 years before onset of motor symptoms. Patients suffering with constipation were then divided into two groups according to the time sequence of constipation and motor onset: ‘constipation pre-motor sign’ group and ‘constipation post-motor sign’ group. Total timespan from earliest initial symptoms to present was similar. Compared with ‘constipation post-motor sign’ group, the patients in ‘constipation pre-motor sign’ group experienced an older motor symptoms onset age, less serious motor symptoms, more serious constipation and less daily levodopa dosage.

Conclusions

Our results supported that constipation could be a pre-motor symptom of PD. Different clinical characteristics were found in different constipation-loading time relative to motor symptoms. Research of constipation may be useful to better understand the early stages of PD and assessment of constipation with validated criteria may have utility as a risk factor for predicting PD in the prodromal phase.