Once finished, the table below will be presented to Wikipedia's editors on the Parkinson's disease talk page, so they may incorporate the proposed changes in the article. Some of my (AHC's) comments in the right hand column are aimed at the Wikipedia editors, explaining/arguing for the proposed changes.
Please don't edit the left hand column: I'll add proposed changes.
To join the discussion, create an account here. It takes one minute. Use your name followed by "(BMJ reviewer)" like this: Joe Bloggs (BMJ reviewer). Then
- click the "edit" (not "edit source") tab at the top of the page (between "read" and "view history")
- single-left-click the cell you want to comment in (the cell will go blue)
- double-left-click the cell.
(If you're using Firefox 43 or 44, do 1 and 2 but then hit "return" or "enter" instead of double-clicking.)
Please leave a space between your comment and the preceding one, and initial your comments.
I have only included paragraphs that reviewers have commented on or proposed changes to.
I'm still looking for sources to support proposed changes, and will add them as I find them.
- Reviewing offline
If you'd like to do this on an aeroplane (or anywhere else offline), I'll keep this Word version of this page up to date. Download it before you fly, and email it to me when you're done. I'll add your comments to the conversation here. For a pdf of the full current version of the article (without any of our changes) click here --Anthonyhcole (talk · contribs · email) 10:27, 16 April 2016 (UTC)
Reviewers
edit- David Burn ()
- Mark (MK)
- Anthony Lang (AEL)
- Andrew Lees ()
- Mark Stacy (MS)
Wikipedia facilitators
edit- Anthony Cole (AHC)
- Stuart Ray User:soupvector (SR)
Introduction
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Discussion |
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Paragraph 1 Parkinson's disease (PD, also known as idiopathic |
I think “paralysis agitans” should return to this location. The term cannot fade easily, because it remains a billing code for PD in the American billing lexicon.
MS. I dont agree that paralysis agitans should be replaced. It was always a poor term- there is no paralysis -I would prefer shaking palsy. AJL An editor has moved the alternative names from the introduction to the "infobox" (the list of links and facts in the top right corner) [1] so is this issue resolved? AHC Reviewers: we try to make the language as simple as possible while avoiding ambiguity or loss of nuance - especially in the first, summary, paragraphs. "A progressive reduction in the speed and amplitude of voluntary movement...": Can anyone think of a more accessible form of words than "amplitude"? "In elderly patients there is an increased risk of cognitive impairment and dementia." An alternative to "cognitive impairment"? AHC Perhaps we could use term range of movement instead of amplitude.MK That sounds good to me, Mark. I have replaced "amplitude" with "range" in the left hand column. If anyone objects, please speak up here. AHC Reviewers: Regarding "Parkinson's disease is more common in older people, with most cases occurring after the age of The article presently cites Samii A, Nutt JG, Ransom BR (2004). "Parkinson's disease". Lancet 363 (9423) which says, "The mean age of onset is around 60 years, although 5–10% of cases, classified as young onset PD, begin between the ages of 20 and 50."
I notice Farlow J, Pankratz ND, Wojcieszek J, Foroud T (2004/2014) "Parkinson Disease Overview" GeneReviews also states, "...onset around age 60 years; however, onset can be earlier. Generally, onset before age 20 years is considered to be juvenile-onset Parkinson disease, before age 50 years is considered to be early-onset Parkinson disease, and after age 50 years is considered late-onset Parkinson disease." Can you point to a recent authoritative source that supports the proposed change? Per Wikipedia's guideline on sources for medical information, ideal sources include literature reviews and systematic reviews published in relevant, reputable journals, recognised standard textbooks by experts in the field, and medical guidelines and position statements from national or international expert bodies. AHC
Regarding "young onset PD", a 2010 systematic review by van Rooden et al noted the lack of standardization of this term, i.e. " SR I still don't see such a cutoff in MEDRS. SR
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Paragraph 2 The main motor symptoms are collectively called parkinsonism, or a "parkinsonian syndrome". |
"Depending on age of onset, probably fewer than 5% of cases have a clear genetic origin..." MK Reviewers: Is there a source for this percentage? I've found several sources that talk in this ball-park, but they vary a bit.
say, "Monogenic forms, caused by a single mutation in a dominantly or recessively inherited gene, are well-established, albeit relatively rare types of PD. They collectively account for about 30% of the familial and 3%-5% of the sporadic cases." claim "Approximately 5–10% of PD patients have monogenic forms of the disease, exhibiting a classical Mendelian type of inheritance, however, the majority PD cases are sporadic, probably caused by a combination of genetic and environmental risk factors." They cite Lesage and Brice, 2009 for the figure.
AHC Editors: Regarding "...the The two sources cited in the body of the article do not support the claim for pesticides. The second source, does not address this risk factor's relative strength against other risk factors. The first source, says, "the strongest associations with later diagnosis of PD were found for having a first-degree or any relative with PD or any relative with tremor; constipation; or lack of smoking history, each at least doubling the risk of PD."Reviewers: Should we mention constipation and family? AHC
This is a good paper to include and I think it would be worth mentioning constipation as a risk factor. It is a much more robust risk than pesticides. AJL Not family, too? Can someone please propose a change to the current clause, "...the strongest evidence is for a reduced risk in tobacco smokers..." AHC How about: "In addition to genetic/family association, constipation and being a non-smoker each have been associated with increased risk of developing PD later in life (e.g., individuals predisposed to PD may be less prone to smoking addiction)." This adheres to the cited reference, and seems more readable. SR |
Paragraph 3 |
Editors: " AHC Editors: "... "Last resort" is not used in any of the supporting sources. "Research directions include investigations into new animal models of the disease and of the potential usefulness of gene therapy, stem cell transplants and neuroprotective agents.": Perhaps this is not so informative here, it is also quite incomplete. MK. The introductory paragraphs are meant to summarise the most important points of the article, and are covered more fully in the body of the article. I have no opinion on the relevance of "research directions" in the introduction. This is possibly something we could leave up to the wider editing community to decide.AHC choreatiform is incorrect this should be choreiform or choreic. AJL Each of these variants seems to be in use:
Reviewers: How about we say: "...most patients also experience the complication of choreiform dyskinesia (brief, irregular muscle contractions that are not repetitive or rhythmic, but appear to flow from one muscle to the next)" citing this NINDS definition? AHC The following sentence should read : Changes in diet can improve the response to l-dopa treatment and physical therapies can improve gait, balance and posture. AJL I've added it as a proposed change to the left hand column. AHC |
Paragraph 4 |
Classification section
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Discussion |
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Paragraph 1 |
Editors: This is supported by UK Parkinson's Disease Society Brain Bank clinical diagnostic criteria: Step 1. Diagnosis of Parkinsonian Syndrome Muscular rigidity 4-6 Hz rest tremor postural instability not caused by primary visual, vestibular, cerebellar, or proprioceptive dysfunction AHC These criteria are now known as the Queen Square Brain Bank Criteria for Parkinson's diseaseAJL |
Paragraph 2 Parkinson's disease is the most common form of parkinsonism and is usually defined as "primary" parkinsonism, meaning parkinsonism with no external identifiable cause. |
Reviewers: regarding, "There are also cases of parkinsonism where the cause has been identified, including gene mutations."
Could this be incorporated in the earlier addition beginning "These identifiable causes may include..."? I'll do that soon, if there are no objections. AHC |
Paragraph 3 |
I dont think the sentence "The most typical symptom of Alzheimer's disease is dementia" is appropriate. It could be removed or else insert "In contrast to Parkinson's disease, Alzheimer's disease presents most commonly with memory loss, and the cardinal signs of Parkinson's disease (slowness, stiffness and tremor) do not occur." AJL I've replaced the text in the left column. AHC |
Paragraph 4 Dementia with Lewy bodies (DLB) is another synucleinopathy that has close pathological similarities with PD, and especially with the subset of PD cases with dementia. However, the relationship between PD and DLB is complex and still has to be clarified. They may represent parts of a continuum with variable distinguishing clinical and pathological features or they may prove to be separate diseases. |
Signs and symptoms section
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Paragraph 1 The most recognizable symptoms in Parkinson's disease |
Reviewers: regarding, "The most recognizable symptoms in Parkinson's disease affect the initiation and fluency of movements giving rise to motor symptoms" Might this be clearer: "The most recognizable symptoms in Parkinson's disease AHC Yes much better AJL OK. I've changed that. Do we really need "giving rise to motor symptoms"? Aren't "impaired initiation and fluency" the motor symptoms? AHC Last sentence here should read. Some of these non-motor symptoms may be present at the time of diagnosis. AJL OK. I've incorporated that proposed change in the left-hand column. AHC |
Paragraph 2
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Paragraph 3
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I would say here 'A coarse slow tremor of the fingers at rest is the commonest presenting symptom which disappears during voluntary movement of the affected limb and in the deeper stages of sleep' to replace lines 1-5
AJL Done. AHC |
Paragraph 4
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Hypokinesia means reduction in movement not slowness. Bradykinesia is the term most often used to apply to the disabling deficit seen in Parkinson's.
AEL. Reviewers: Can anyone think of a source that supports the remaining changes? AHC Lees, A.J, Hardy, J, Revesz T Parkinsons disease. Lancet 2009;373; 2055-2066 AJL Thank you! AHC |
Paragraph 5 Rigidity is stiffness and resistance to limb movement caused by increased muscle tone, an excessive and continuous contraction of muscles. In parkinsonism the rigidity can be uniform (lead-pipe rigidity) or ratchety (cogwheel rigidity). The combination of tremor and increased tone is considered to be at the origin of cogwheel rigidity. Rigidity may be associated with joint pain; such pain being a frequent initial manifestation of the disease. In early stages of |
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Paragraph 6 Postural instability is typical in |
Editors: Regarding "loss of confidence and reduced mobility"
This is supported by:
AHC Editors: regarding "Instability is often absent in the initial stages, especially in younger people, especially prior to the development of bilateral symptoms." This is supported by |
Paragraph 7 Other recognized motor signs and symptoms include gait and posture disturbances such as festination (rapid shuffling steps and a forward-flexed posture when walking |
Reviewers: "...are other common signs" is redundant. I'll remove it if no one objects.
AHC Editors: This proposed change is supported by
AHC |
Paragraph 8 Parkinson's disease can cause neuropsychiatric disturbances which can range from mild to severe. This includes disorders of |
Usually ("speech") refers to language and language disorders are not seen in Parkinson's. Hypophonia (reduction in speech volume) is a problem and mentioned later and is not a Neuropsychiatric problem so it doesn’t belong in this section.
AEL. |
Paragraph 9 A person with PD has two to six times the risk of dementia compared to the general population. The prevalence of dementia increases with age and to a lesser degree duration of the disease. Dementia is associated with a reduced quality of life in people with PD and their caregivers, increased mortality, and a higher probability of needing nursing home care. |
Reviewers: "The prevalence of dementia increases with age and to a lesser degree duration of the disease.":
Can anyone think of a reliable source that supports this? AHC Perhaps PMID 19733364 or PMID 20522088, though they are a bit dated? LeadSongDog come howl! 21:11, 28 April 2016 (UTC) Actually, PMID 27502301 ("Parkinson Disease and Dementia") was published in 2016 after your comment, User:LeadSongDog, and supports this claim. Anthonyhcole (talk · contribs · email) 08:12, 3 July 2017 (UTC) |
Paragraph 10 Behavior and mood alterations are more common in PD without cognitive impairment than in the general population, and are usually present in PD with dementia. The most frequent mood difficulties are depression, apathy, anhedonia and anxiety. Establishing the diagnosis of depression is complicated by |
"...hallucinations or delusions—occur in This figure (4%) is definitely incorrect. It is much higher than this. For this section I suggest citing:
AEL. Tony, does that source support all of the proposed changes in this paragraph? AHC |
Paragraph 11 Sleep problems are a feature of the disease and can be worsened by medications. Symptoms can manifest as daytime drowsiness, (including sudden sleep attacks resembling narcolepsy), disturbances in REM sleep, or insomnia. REM behavior disorder (RBD), in which patients act out dreams, sometimes injuring themselves or their bed partner, may begin many years before the development of motor or cognitive features of PD or DLB. |
Reviewers: Can anyone suggest a good source for these changes?
AHC |
Paragraph 12 Alterations in the autonomic nervous system can lead to orthostatic hypotension (low blood pressure upon standing), oily skin and excessive sweating, urinary incontinence and altered sexual function. Constipation and gastric dysmotility can be severe enough to cause discomfort and even endanger health. |
Reviewers: A brief explanation of this proposed change?
AHC |
Causes section
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Paragraph 1 Exposure to pesticides and a history of head injury have been linked with PD but the risk is modest. People who have never smoked cigarettes have an increased risk of developing PD while never drinking caffeinated beverages moderately increases risk. A high serum uric acid has also been found to reduce the risk of PD. |
A source supporting this?
AHC The Noyce review referenced earlier covers this. AJL Thank you. AHC |
Paragraph 2 PD traditionally has been considered a non-genetic disorder; however, around 15% of individuals with PD have a first-degree relative who has the disease. |
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Paragraph 3 Mutations in specific genes have been conclusively shown to cause PD. These genes code for alpha-synuclein (SNCA), parkin (PRKN), leucine-rich repeat kinase 2 (LRRK2 or dardarin), PTEN-induced putative kinase 1 (PINK1) |
Remove this gene (ATP13A2). It is not associated with typical Parkinson's disease phenotype.
SNCA, LRRK2, VPS35, EIF4G1, DNAJC13, and CHCHD2 are the dominant genes associated with this while parkin, PINK1 and DJ-1 are the recessively inherited genes that need to be mentioned here. We have reviewed all of this in a recent major review paper that you could cite here and elsewhere (for example the sections on Brain cell death, Diagnosis, Prevention):
AEL. ATP13A2 is not a typical Parkinson’s disease gene, it is mainly associated with rapid onset dystonia and parkinsonism. Should be removed here. MK. Agree this should be removed. AJL Done. Reviewers: We don't yet mention VPS35, EIF4G1, DNAJC13, and CHCHD2. Would someone like to propose language to incorporate them? AHC |
Paragraph 4 The LRRK2 gene (PARK8) encodes a protein called dardarin. The name dardarin was taken from a Basque word for tremor, because this gene was first identified in families from England and the north of Spain. Mutations in LRRK2 are the most common known cause of familial and sporadic PD, accounting for approximately 5% of individuals with a family history of the disease and 3% of sporadic cases. There are many mutations described in LRRK2, however unequivocal proof of causation only exists for a few. LRRK2 mutation, especially the commonest (G2019S), may have penetrance as low as 26% in some populations, for example Ashkenazi Jews. |
AEL. I'm not seeing the relevance of this detail for a broad overview article. AHC |
Paragraph 4 The basal ganglia, a group of brain structures innervated by the dopaminergic system, are the most seriously affected brain areas in PD. The |
"...affecting up to 70% of the cells by the time death occurs.":
This should probably be revised – its typically stated that there is greater than 50% cell loss at the time of clinical presentation. Usually the cell loss at death would be considerably higher than 70%. AEL. Reviewers: A source for greater than 50% at presentation and higher than 70% at death? AHC "The Reviewers: Can we find a more accessible term than "lesion"? AHC Reviewers: "...the ventral (front) part ..." I thought "ventral" meant underside in the brain? AHC Reviewers: Are we talking about 70% of the substantia nigra or of the ventral pars compacta? AHC |
Paragraph 5 Macroscopic alterations can be noticed on cut surfaces of the brainstem, where neuronal loss can be inferred from a reduction of neuromelanin pigmentation in the substantia nigra and locus coeruleus. |
"Neuronal loss is accompanied by death of astrocytes...":
Generally there is overgrowth of astrocytes (“astrocytosis”); what is the evidence that there is death of astrocytes? To my knowledge this is never highlighted as a pathological feature and should probably be deleted. AEL. Editors: On page 273, the cited source,
says "Neuronal loss in the substantia nigra is accompanied by astrocytosis and microglial activation." So the editor who added this appears to have misunderstood the source.In the left hand column, I've proposed deletion of the entire sentence beginning "Neuronal loss is accompanied..." AHC |
Pathology section
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Paragraph 1 There is speculation of several mechanisms by which the brain cells could be lost. One mechanism consists of an abnormal accumulation of the protein alpha-synuclein bound to ubiquitin in the damaged cells. This insoluble protein accumulates inside neurones forming inclusions called Lewy bodies. According to the Braak staging, a classification of the disease based on pathological findings, Lewy bodies first appear in the olfactory bulb, medulla oblongata and pontine tegmentum; |
Reviewers: A source or sources for these additions?
AHC |
Diagnosis section
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Illustration caption Fluorodeoxyglucose (18F) (FDG) PET scan of a healthy brain. Hotter areas reflect higher glucose uptake. A decreased activity in the basal ganglia can aid in diagnosing Parkinson's disease. |
MAJOR revision required: This figure should be replaced with a scan of the pre-synaptic dopamine system (eg DAT scan of F-dopa scan. FDG scans are not routinely done in PD and without very complex analysis that is done by only one group of researchers are NEVER useful in diagnosing PD.
AEL. Reviewers: Do any of you know where we can get such an image? The copyright owner would have to be willing to relinquish most rights, but they'd be credited on the image's file in our media repository, and reusers would have to credit them.AHC |
Paragraph 1 A physician will diagnose |
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Paragraph 2 Other causes that can secondarily produce a parkinsonian syndrome are |
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Paragraph 3 Medical organizations have created diagnostic criteria to ease and standardize the diagnostic process, especially in the early stages of the disease. The most widely known criteria come from the UK |
"The most widely known criteria come from the UK Andrew, can you please briefly explain these changes? AHC The criteria were developed by Bill Gibb and me at the Queen Square Brain Bank in the eighties and they have been very widely used by researchers. The attachment of PD Society to the name was related to funding at the time they were devised but in the last 10 years the criteria have been referred to as UK Brain Bank or better Queen Square Brain Bank. It will important to have the reference in too to balance the Postuma one below and is Gibb, W.R.G and Lees, A.J. The relevance of the Lewy body to the pathogenesis of Parkinsons disease. J. Neurol. Neurosurg. Psychiat. 1988;51;745-752 "Very recently, a task force of the International Parkinson and Movement Disorder Society (MDS) has proposed diagnostic criteria for Parkinson’s disease as well as research criteria for the diagnosis of prodromal disease, but these will require validation against the more established criteria.":
AEL. |
Paragraph 4 Computed tomography (CT) and conventional magnetic resonance imaging (MRI) brain scans of people with PD usually appear normal. These techniques are nevertheless useful to rule out other diseases that can be secondary causes of parkinsonism, such as basal ganglia tumors, vascular pathology and hydrocephalus. A specific technique of MRI, diffusion MRI, has been reported to be useful at discriminating between typical and atypical parkinsonism, although its exact diagnostic value is still under investigation. Dopaminergic function in the basal ganglia can be measured with different PET and SPECT radiotracers. Examples are ioflupane (123I) (trade name DaTSCAN) and iometopane (Dopascan) for SPECT or |
Prevention section
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Paragraph 1 Exercise in middle age |
"However, recently it has been suggested that the negative association with smoking is not protective but is due to an inherent difference in the propensity of patients destined to develop PD to become addicted to nicotine.":
AEL. Reviewers: This is a primary source. Has anyone, independent of the authors, reviewed their results and supported this suggestion? Belay that. Found:
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Paragraph 2 Antioxidants, such as vitamins C and |
"...certain calcium channel blocking drugs () and higher levels of uric acid.":
You could cite the Kalia and Lang Lancet paper here as a review that covers this material. AEL.
AHC |
Management section
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Paragraph 1 There is no cure for |
Editors: "...medications, surgery and The cited source (NICE 2006 guidelines, page 141) supports this change. AHC "L-DOPA ( AHC Reviewers: " AHC "However, levodopa remains the most effective treatment for PD and should not be delayed in patients whose quality of life is impaired. Indeed, dyskinesias correlate more strongly with duration and severity of the disease than duration of levodopa treatment, so delaying this therapy may not really provide much longer dyskinesia-free time than earlier use ()." We'll need a source for this.AHC
AHC "When medications are not enough to adequately control symptoms, surgery AHC Should read 'when oral medications' and then remove infusion and put subcutaneous waking day apomorphine infusion and enteral dopa pumps AJL Done. AHC Insert references for apomorphine the seminal paper is:
Thank you. Wikipedia insists we cite secondary sources so I've cited the following review which cites the 1988 Lancet article and makes the point.:
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Paragraph 2 Levodopa has been the most widely used treatment for over 30 years. L-DOPA is converted into dopamine in the dopaminergic and possibly other (e.g., serotonergic) neurons by dopa decarboxylase. Since motor symptoms are produced by a lack of dopamine in the substantia nigra, the administration of L-DOPA temporarily diminishes the motor symptoms. |
Reviewers: Can you suggest a source for this?
AHC |
Paragraph 3 Only 5–10% of L-DOPA crosses the blood–brain barrier. The remainder is often metabolized to dopamine elsewhere, causing a variety of side effects including nausea, |
" AEL. Editors: The cited source, reference 54,
AHC Reviewers: It would be nice to have a source attributing nausea, vomiting and orthostatic hypotension to peripheral metabolism of levodopa. AHC Got it:
AHC. "There are controlled release versions of levodopa. Intravenous infusions of levodopa are not used clinically – they are only a research tool. AEL. "A newer extended-release levodopa preparation does seem to be more effective in controlling motor fluctuations but in many patients problems persist."
AEL. Reviewers: We should cite someone who has reviewed this (Connolly & Lang, 2014?). We can cite the trial report, too, but we really should show it has been evaluated and contextualised by independent expert authors.AHC "Intestinal infusions of levodopa (Duodopa) can result in striking improvements in motor fluctuations.":
AEL. Reviewers: Has this been discussed in an independent review?AHC |
Paragraph 4 Tolcapone inhibits the COMT enzyme, which degrades dopamine, thereby prolonging the effects of levodopa. It has been used to complement levodopa; however, its usefulness is limited by possible side effects such as liver damage. |
Entacapone is generally believed to be less effective than tolcapone.
AEL. Editors: The following source,
AHC |
Paragraph 5 Levodopa preparations frequently lead in the long term to the development of motor complications characterized by involuntary movements called dyskinesias and fluctuations in the response to medication. When this occurs a person with PD can change from phases with good response to medication and few symptoms ("on" state), to phases with no response to medication and significant motor symptoms ("off" state). For this reason, levodopa doses are kept as low as possible while maintaining functionality. |
" This approach is being used much less now. There is no good evidence that there is important advantage in delaying levodopa except in young patients where dyskinesia can become problematic. Rather than citing reference numeral 54 repeatedly (somewhat outdated and in some cases clearly wrong) I would suggest citing a large review that we wrote for JAMA (evidence-based studies were emphasized in all of the sections of this paper):
AEL. |
Paragraph 6 Several dopamine agonists that bind to dopaminergic post-synaptic receptors in the brain have similar effects to levodopa. These were initially used for individuals experiencing on-off fluctuations and dyskinesias as a complementary therapy to levodopa; they are now mainly used on their own as an initial therapy for motor symptoms with the aim of delaying motor complications. Like levodopa, these can improve all of the dopaminergic motor symptoms but they are generally less effective than levodopa.When used in late PD they are useful at reducing the off periods. Dopamine agonists include bromocriptine, pergolide, pramipexole, ropinirole, piribedil, cabergoline, apomorphine, lisuride and rotigotine. The most commonly used oral dopamine agonists are pramipexole and ropinirole. Rotigotine is used as a transdermal patch. |
Editors: A source supporting the inclusion of Rotigotine:
Quote: "In conclusion, the preclinical and clinical development of the rotigotine transdermal system has established this system as an effective method for providing continuous delivery of a dopamine agonist across the skin, and may have clinical advantages compared with other agents." AHC |
Paragraph 7 Dopamine agonists can produce significant |
"... AEL.
Editors: The source cited for this is page 63 of the NICE 2006 guideline. It says: "However, agonists generate significant dopaminergic adverse events. The latter do not lead to drug withdrawal, which suggests that they are mild and that tolerance develops. These conclusions apply to the relatively young people included in these studies. Further work on the efficacy and safety of dopamine agonists in older people is required." So Wikipedia's assertion that side effects are usually mild misinterprets the source.AHC "However, recent studies have emphasized little advantage to so-called "levodopa sparing" approaches (e.g., dopamine agonists, MAO-B inhibitors) in early disease":
AEL. Reviewers: Per our medical sources guideline, we prefer to cite secondary sources. I don't have access to the following. Does it support this change?
AHC
"...and discontinuing dopamine agonists may be associated with "dopamine agonist withdrawal syndrome":
AEL. Reviewers: Where possible, we prefer to cite topic overviews, rather than individual studies. Would this source be adequate support for the claim?
AHC "...with symptoms similar to withdrawal from narcotics, and apathy"
AEL. " MS.
Editors: The source cited for this is
It does not comment on the prevalence of dyskinesias due to dopamine agonists in younger people. AHC |
Paragraph 9 MAO-B inhibitors (selegiline and rasagiline) increase the level of dopamine in the basal ganglia by blocking its metabolism. |
"...but AEL. Reviewers and editors: The source (the NICE guideline) says on p. 71, "The trial evidence supports the ability of MAOB inhibitors in PD to improve motor symptoms, improve activities of daily living and delay the need for levodopa. ... This is at the expense of more dopaminergic adverse events and, as a result, more withdrawals from treatment". But it's a very old source. (It's being re-written now, for publication in 2017(?) I think.) Given the age of the source and the relatively thin evidence they based the claim on, the simple act of challenging the claim should be sufficient to see it removed. But if you know of a recent source that compares the adverse event profiles of levodopa and MAO-B inhibitors, it would be nice to have. AHC |
Paragraph 10 Other drugs such as amantadine and anticholinergics may be useful as treatment of motor symptoms. However, because they are old drugs the evidence from modern clinical trials supporting them lacks quality, so they are |
"...clozapine...": Much more effective than quetiapine and clearly proven in RTCs whereas quetiapine has not.
AEL. Tony, is this covered in a review? AHC |
Paragraph 11 Treating motor symptoms with surgery was once a common practice, but since the |
"Studies in the past few decades have led to great improvements in surgical techniques, so that surgery is again being used in people with advanced PD for whom drug therapy
MK.
Ah. Sorry. I'm misreading. The old source doesn't say that surgery is used increasingly in patients with less advanced disease and I'm not seeing it in Sheupbach et al. either. Can you think of a review, position statement or guideline that supports that claim? AHC "New developments in DBS include manufacturing closed loop systems in which deep brain electrodes simultaneously pick up local field potentials to respond with the appropriate electrical signal.":
MK. I realise it's sometimes just not possible, but is there any way we can say this so it's understandable by the intelligent lay reader? AHC |
Paragraph 13 Palliative care is specialized medical care for people with serious illnesses, including |
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Paragraph 14 Along with offering emotional support to both the patient and family, palliative care serves an important role in addressing goals of care. People with |
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Paragraph 15 Muscles and nerves that control the digestive process may be affected by PD, resulting in constipation and gastroparesis (food remaining in the stomach for a longer period than normal). A balanced diet, based on periodical nutritional assessments, is recommended and should be designed to avoid weight loss or gain and minimize consequences of gastrointestinal dysfunction. As the disease advances, swallowing difficulties (dysphagia) may appear. In such cases it may be helpful to use thickening agents for liquid intake and an upright posture when eating, both measures reducing the risk of choking. Gastrostomy to deliver food directly into the stomach is possible in severe cases. |
A very good review paper on GI issues in PD has been recently published in Lancet Neurology by
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Paragraph 16 |
" Food in the stomach and constipation both slow stomach emptying which delays or reduces L-DOPA access to the upper small intestine where it is absorbed, resulting in poorer responses to individual doses."
Reviewers: A source for this? Does Fasano et al. 2015 support this?
AHC |
Paragraph 17 Repetitive transcranial magnetic stimulation temporarily improves levodopa-induced dyskinesias. Its usefulness in PD is an open research topic, although recent studies have shown no effect by rTMS. Several nutrients have been proposed as possible treatments; however there is no evidence that vitamins, |
"...or orally ingested and intravenous glutathione..."
Would ask other authors to comment on whether this should be stated. MS. From Wikipedia's perspective, it's appropriate to mention prominent fringe treatments and the strength (or weakness) of the evidence supporting their use. AHC You need a source for Mucuna bean use; Katzenschlager R Evans A Manson A et al Mucuna pruriens in Parkinsons disease a double blind clinical and pharmacological study. Journal of Neurology, Neurosurgery and Psychiatry 2004 75 1672-1677 AJL |
Prognosis section
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Paragraph 1 PD invariably progresses with time. A severity rating method known as the Unified Parkinson's Disease Rating Scale (UPDRS) is the most commonly used metric for clinical study. A modified version known as the MDS-UPDRS is |
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Paragraph 2 Motor symptoms, if not treated, advance |
"Motor symptoms, if not treated, advance Reviewers: The cited source for the original claim is
I'm awaiting access to that. Can anyone provide a source that supports a linear course? I've got that 2006 article now and it says:
"Likely". So, at the very least, we should make the claim less categorical. Given the age of the source and the "likely", in the absence of a stronger, more recent source, I think simply challenging the claim should be enough to warrant its removal. To change the language to "in linear fashion" we'll need a good source supporting that. AHC |
Paragraph 3 Since current therapies improve many of the motor symptoms, disability at present is mainly related to non-motor features of the disease as well as the non-dopaminergic motor features. Nevertheless, the relationship between disease progression and disability is not linear. Disability is initially related to motor symptoms. As the disease advances, disability is more related to motor symptoms that do not respond adequately to medication, such as swallowing/speech difficulties, and gait/balance problems; and also to motor complications, which appear in up to 50% of individuals after 5 years of levodopa usage. Finally, after ten years most people with the disease have autonomic disturbances, sleep problems, mood alterations and cognitive decline. All of these symptoms, especially cognitive decline, greatly increase disability. |
Epidemiology section
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Paragraph 1 PD is the second most common neurodegenerative disorder after Alzheimer's disease and affects approximately seven million people globally and one million people in the United States. The proportion in a population at a given time is about 0.3% in industrialized countries. PD is more common in the elderly and rates rises from 1% in those over 60 years of age to 4% of the population over 80. The mean age of onset is around 60 years, although 5–10% of cases, classified as young onset PD, begin between the ages of 20 and 50. There is also some evidence that the incidence of the disease reduces in the ninth decade of life. PD may be less prevalent in those of African and Asian ancestry, although this finding is disputed. |
Suggest citing this paper for this section:
AEL. |
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Reviewers: A few words explaining this deletion would be helpful.
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Paragraph 1 Several early sources, including an Egyptian papyrus, an Ayurvedic medical treatise, the Bible, and Galen's and Leonardo da Vinci's writings, describe symptoms |
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Paragraph 2 In 1817 an English doctor, James Parkinson, published his essay reporting six cases of paralysis agitans. An Essay on the Shaking Palsy described the characteristic resting tremor, abnormal posture and gait, paralysis and diminished muscle strength, and the way that the disease progresses over time. Early neurologists who made further additions to the knowledge of the disease include Trousseau, Gowers, Kinnier Wilson and Erb, and |
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Paragraph 3 Anticholinergics and surgery (lesioning of the corticospinal pathway or some of the basal ganglia structures) were the only treatments until the arrival of levodopa, which reduced their use dramatically. Levodopa was first synthesized in 1911 by Casimir Funk, but it received little attention until the mid 20th century. It entered clinical practice in 1967 and brought about a revolution in the management of PD. |
Reviewers: A few words explaining the deletion?
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Society and culture section
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Paragraph 1 11 April, the birthday of James Parkinson, has been designated as Parkinson's disease day. A red tulip was chosen by international organizations as the symbol of the disease in 2005: it represents the James Parkinson Tulip cultivar, registered in 1981 by a Dutch horticulturalist. Advocacy organizations include the National Parkinson Foundation, which has provided more than $180 million in care, research and support services since 1982, Parkinson's Disease Foundation, which has distributed nearly $110 million for research and nearly $47 million for education and advocacy programs since its founding in 1957 by William Black; the American Parkinson Disease Association, founded in 1961; Parkinson’s UK, which has been helping people with Parkinson’s in the UK for over 40 years; and the European Parkinson's Disease Association, founded in 1992. |
Need to add reference to weblink for Parkinson’s UK: www.parkinsons.org.uk.
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Paragraph 2 Actor Michael J. Fox has PD and has greatly increased the public awareness of the disease. After diagnosis, Fox embraced his Parkinson's in television roles, sometimes acting without medication, in order to further illustrate the effects of the condition. He has written two autobiographies in which his fight against the disease plays a major role, and appeared before the United States Congress without medication to illustrate the effects of the disease. The Michael J. Fox Foundation aims to develop a cure for Parkinson's disease. Fox received an honorary doctorate in medicine from Karolinska Institutet for his contributions to research in Parkinson's disease. |
Reviewers: The editors of the article have left this note embedded in the source code for anyone editing this section:
"Parkinson's is a common disease, so lots of notable people have it. Please only add people here who have played a MAJOR role in supporting research or public understanding of the disease. All others can be listed at the main article about people diagnosed with Parkinson's disease." Who should be included, and how, can probably be easily resolved in a conversation with the editors. AHC "... sometimes acting without medication to illustrate the effects of the condition.": This needs to be checked carefully. As I understood it, he was criticized for doing that when in fact people misinterpreted his dyskinesia (due to his medication) for the primary symptoms of the disease and claimed that he had withheld his medication to get sympathy. This clearly indicated a lack of understanding on the part of the congressional members who criticized him. (At least that is my understanding what took place but perhaps I am wrong). AEL. "The Michael J. Fox Foundation aims to develop a cure for Parkinson's disease.": I would add something about how much they have raised for research emphasizing that this has been an extremely effective organization. AEL. |
Paragraph 3 Muhammad Ali showed signs of Parkinson's when he was 38, but was not diagnosed until he was 42, and has been called the "world's most famous Parkinson's patient". Whether he has PD or a parkinsonism related to boxing is unresolved. Ray Kennedy the Arsenal and Liverpool football player developed PD towards the end of his professional football career at the age of 35. Retrospective examination of television footage confirmed that he had physical signs in one arm while he was still playing football at a high level(Lees 1992). |
"Whether he has PD or a parkinsonism related to boxing is unresolved.":
We cannot really resolve the dx of lewy body parkinsonism in anyone prior to autopsy. Does it help any reader to think about parkinsonism and boxing? Muhammad was certainly not demented when I ran the Ali Center, and that was 20 years after diagnosis. MS. Do we include a link to Robin Williams? Others? DB. |
Research section
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Paragraph 1 There is little prospect of dramatic new PD treatments expected in |
Reviewers: A brief explanation?
AHC |
Paragraph 2 PD is not known to occur naturally in any species other than humans, although animal models which show some features of the disease are used in research. The appearance of parkinsonian symptoms in a group of drug addicts in the early 1980s who consumed a contaminated batch of the synthetic opiate MPPP led to the discovery of the chemical MPTP as an agent that causes a parkinsonian syndrome in non-human primates as well as in humans. Other predominant toxin-based models employ the insecticide rotenone, the herbicide paraquat and the fungicide maneb. Models based on toxins are most commonly used in primates. Transgenic rodent models that replicate various aspects of PD have been developed. |
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Paragraph 3 Gene therapy typically involves the use of a non-infectious virus (i.e., a viral vector such as the adeno-associated virus) to shuttle genetic material into a part of the brain. The gene used leads to the production of |
"More recently, gene therapy for the trophic factor neurturin, injected into both the striatum and substantia nigra, failed to show benefit in a well-designed randomized controlled clinical trial":
AEL. Tony, can you think of a source (if Warren Olanow doesn't) that supports the earlier addition beginning with "...proteins that could affect symptoms..."? AHC |
Paragraph 4 Investigations on neuroprotection are at the forefront of PD research. Several molecules have been proposed as potential treatments. However, none of them have been conclusively demonstrated to reduce degeneration. Agents currently under investigation include |
"...neuroprotection...":
Me – look up Kalia recent MDJ paper and edit. AEL. "Several molecules have been proposed as potential treatments.": Suggest adding the following reference in which we reviewed this area in considerable detail very recently so it is the most up to date reference on the topic:
AEL. Presently we cite
AHC "Both active and passive methods of immunizing against alpha-synuclein are being actively pursued." Reviewers: Is there a one or two sentence layman's explanation for "active and passive methods"? AHC |
Paragraph 5 Since early in the 1980s, fetal, porcine, carotid or retinal tissues have been used in cell transplants, in which |
" Only one group has injected them into the substantia nigra; all other studies that use the striatum. AEL. "Although there was initial evidence of mesencephalic dopamine-producing cell transplants being beneficial, double-blind trials to date indicate that cell transplants Reviewers: I don't understand "particularly in these trials". What trials? The article presently cites
AHC "although individual patients (often younger and with milder disease) have shown marked prolonged improvement." Reviewers: Can we have a source that supports this? AHC "It remains uncertain whether early 'physiological' replacement of the damaged nigrostriatal dopamine pathway will correct all the symptoms and signs of Parkinson’s disease.":
AEL. |
References
edit- ^ C. Warren Olanow; Anthony H.V. Schapira; Jose A. Obeso. "449: Parkinson's Disease and Other Movement DIsorders". In Kasper, Dennis; Fauci, Anthony; Hauser, Stephen; Longo, Dan; Jameson, J. Larry; Loscalzo, Joseph (eds.). Harrison's Principles of Internal Medicine (19 ed.). McGraw-Hill. ISBN 9780071802154.
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(help) - ^ Goetz, CG; Pal, G (19 December 2014). "Initial management of Parkinson's disease". BMJ (Clinical research ed.). 349: g6258. PMID 25527341. Retrieved 23 May 2016.
- ^ de Lau, LM; Breteler, MM (June 2006). "Epidemiology of Parkinson's disease". The Lancet. Neurology. 5 (6): 525–35. doi:doi:10.1016/S1474-4422(06)70471-9. PMID 16713924.
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value (help) - ^ van Rooden, SM; Heiser, WJ; Kok, JN; Verbaan, D; van Hilten, JJ; Marinus, J (15 June 2010). "The identification of Parkinson's disease subtypes using cluster analysis: a systematic review". Movement disorders : official journal of the Movement Disorder Society. 25 (8): 969–78. PMID 20535823.