Happy Summer! We are very pleased to welcome Dr. Don Higgins and his team at the Albany VA to the Consortium Center Network…making #50 on our referral map!
The PADRECC/EES Tele-Broadcast Series continues to be an overwhelming success, with audiences from all corners of the healthcare system. While the 2008/2009 series will soon wrap, the PADRECC Educators have initiated measures to secure support for continuation of the program. We would like to thank Lynn Klanchar of the Richmond PADRECC for spearheading this innovative project. Please see the calendar of events for upcoming dates and topics.
The next Consortium Conference has been tentatively postponed until fall 2010. We look forward to another opportunity to gather our expanding network of devoted VA movement disorder specialists. In the meantime, please take advantage of the Consortium Outreach Program for training opportunities with your designated PADRECC. For more information, please contact your PADRECC Associate Director of Education.
The outcome of the Consortium Center proposal continues to be under review in the Office of Patient Care Services. PADRECC and Consortium leaders continue to endorse the implications of this request and will share information as it becomes available.
Prepared by Aliya Sarwar, MD Houston PADRECC.
(+) Dopamine dysregulation syndrome, impulse control disorder and punding after deep brain stimulation surgery for Parkinson's disease.(click here)
Data regarding the effect of deep brain stimulation (DBS) surgery on the dopamine dysregulation syndrome (DDS), impulse control disorders (ICDs) and punding in Parkinson's disease (PD) are limited. In this study the authors presented a case series of 21 operated PD patients who had exhibited DDS, ICDs or punding at some stage during the disease. DDS remained unimproved or worsened post-operatively in 12/17 patients with pre-operative DDS (71%) (nine bilateral subthalamic nucleus [STN], one right-sided STN, two bilateral globus pallidus internus [GPi] DBS). DDS improved or resolved after bilateral STN DBS in 5/17 patients with pre-operative DDS. DDS apparently developed for the first time after bilateral STN DBS in two patients, although only after a latency of eight years in one case. One patient without reported pre-operative DDS or ICDs developed pathological gambling post-STN DBS. One patient had pathological gambling which resolved pre-operatively, and did not recur post-DBS.
It was concluded that, DDS, ICDs and punding may persist, worsen or develop for the first time after DBS surgery, although a minority of patients improved dramatically. Predictive factors may include physician vigilance, motor outcome and patient compliance.
(+) Efficacy of rivastigmine for cognitive symptoms in Parkinson disease with dementia.(click here)
This study explored whether oral cholinesterase inhibitors improve measures of cognitive outcome and are tolerated by people with PDD. The question was addressed through the development of a critically appraised topic. Participants included consultant and resident neurologists, clinical epidemiologists, a medical librarian, and behavioral neurology and movement disorder specialists. Participants began with a structured clinical question, devised search strategies, compiled the best evidence, performed a critical appraisal, summarized the evidence, provided commentary, and declared bottom-line conclusions. A randomized controlled trial (n = 541) showed that, compared with placebo, rivastigmine (mean, 8.6 mg/d) significantly improved scores on 2 coprimary cognitive outcome scales in PDD, including the Alzheimer disease Cooperative Study-Clinician's Global Impression of Change. When dichotomized to evaluate clinically significant benefit (moderate or marked improvement), this outcome was not significant (risk difference = 5.3%; 95% confidence interval (CI) = -1.6 to 12.1). The number needed to treat (NNT) to avoid clinically significant worsening of cognition was 10 (95% CI = 6-28). The NNT for the combined outcome of either achieving clinically significant benefit or avoiding significant worsening was 7. The numbers needed to harm for cholinergic side effects were 9 (95% CI = 5-24) for parkinsonian symptoms and 11 (95% CI = 6-32) for rivastigmine discontinuation due to any side effect.
The authors concluded that Rivastigmine therapy for PDD is associated with significant tradeoffs in efficacy and adverse effects and that carefully monitored trials of rivastigmine may provide meaningful benefits for a minority of PDD patients.
(+) Deep brain stimulation and cognitive functions in Parkinson's disease: A three year controlled study(click here)
The study evaluated the cognitive effects deep brain stimulation (DBS) of the subthalamic nucleus (STN) in advanced Parkinson’s disease. The authors performed a prospective, naturalistic controlled, 3-year follow-up study. A total of 65 PD patients were enrolled, of whom 32 underwent STN-DBS (PD-DBS) and 33, even though eligible for this treatment, declined surgery and chose other therapeutic procedures (PD-control). Motor and neuropsychological functions were assessed in all the subjects at baseline (T0) and 36 months (T36). The PD-DBS patients were also evaluated at 1, 6, 12, and 24 months after surgery (T1, T6, T12, and T24). At T1, compared with T0, the PD-DBS patients recorded worse logical executive function task and verbal fluency (FAS) scores, whereas their performance of memory tasks remained stable. At T12, their cognitive profile had returned within the pre-DBS range, thereafter remaining stable until T36. FAS scores at T36 were significantly worse in the PD-DBS compared with the PD-control patients.
Per the authors this is the first long-term naturalistic controlled study of cognitive functions in PD patients submitted to STN-DBS. According to the authors their results confirm previous reports of a worsening of verbal fluency after DBS, but show that STN-DBS seems to be relatively safe from a cognitive standpoint, as the short-term worsening of frontal-executive functions was found to be transient.
Standardization of Care:Worked collaboratively to create a Criteria for Use for Tetrabenazine, which was submitted to the National Pharmacy Benefits Management Group
Pocket Card:The Committee is now working on revising the PADRECC pocket card, which outlines initial management of PD to be used by general practitioners.
PADRECC Transmitter:The Clinical Care Committee continues to provide reviews of recent movement disorder publications that are included in the PADRECC Transmitter.
Research:Exploring a Requip XL study for possible VA PADRECC study.
EES/PADRECC Educational Series:The 1st series of audio conferences are wrapping with the last audio conference being held on September 10th,, 2009 at 12pm EST and repeated at 3pm EST. The Topic will be Caregiving and Psychosocial Issues in PD. The education committee continues to monitor these conferences and with the help of EES and VANTS are tracking participation on the calls. Application has been submitted to EES for approval of a 2nd EES/PADRECC audio conference series for FY10.
PADRECC Transmitter:The Education Committee continues to put together the PADRECC Transmitter every other month and distribute to the PADRECC Consortium Centers.
Patient Education Materials:The Committee is exploring the possibility of developing a newly diagnosed patient education handout that will provide key information on Parkinson's disease.
The VA Parkinson Report:The annual newsletter is in the process of being developed.