P arkinson disease is chronic and progressive in nature, decreasing the quality of life for both patients with the disease and their caregivers and placing an onerous economic burden on society. 1 The first Canadian guideline on Parkinson disease was published in 2012. 2 Since that guideline, there have been substantial advances in the literature on the disease, particularly with respect to diagnostic criteria and treatment options. Parkinson Canada undertook to update the existing guideline to reflect these advances, as well as to add information on palliative care. With the aim of enhancing care for all Canadians with Parkinson disease, this guideline is based on the best published evidence, involves expert consensus when there is a lack of evidence, offers practical clinical advice, takes patient choice and informed decision-making into account and is relevant to the Canadian health care system. The guideline has been divided into 5 main sections to improve the ease of use: communication, diagnosis and progression, treatment, nonmotor features and palliative care. The full guideline is available in Appendix 1, at www.cmaj.ca/lookup/ suppl/
There is limited evidence for the treatment of orthostatic hypotension in idiopathic Parkinson's disease. The objective of this study was to determine the efficacy of three treatments (nonpharmacological therapy, fludrocortisone, and domperidone). Phase I assessed the compliance, safety, and efficacy of nonpharmacological measures. Phase II was a double-blind randomized controlled crossover trial of the two medications. Primary outcome measures consisted of the orthostatic domain of the Composite Autonomic Symptom Scale (COMPASS-OD), a clinical global impression of change (CGI), and postural blood pressure testing via bedside sphygmomanometry (Phase I) or tilt table testing (Phase II). For the 17 patients studied, nonpharmacological therapy did not significantly alter any outcome measure. Both medications improved the CGI and COMPASS-OD scores. There was a trend towards reduced blood pressure drop on tilt table testing, with domperidone having a greater effect.
Originally named "aliquorrhea" by Schaltenbrand 1 in 1938, spontaneous intracranial hypotension (SIH) is an increasingly recognized syndrome characterized by a triad of low CSF pressure, postural headache, and magnetic resonance imaging (MRI) abnormalities. 2 The classic MRI finding of diffuse pachymeningeal enhancement, 3 with leptomeningeal sparing, is thought to be a result of engorgement of dural bridging veins secondary to decreased CSF pressure.4 This is such a hallmark feature that its absence has been suggested to exclude the diagnosis. 2 There have been only a few reported cases of SIH with absent MRI findings. 5 We report four cases of SIH that presented to our institution ABSTRACT: Background: Spontaneous intracranial hypotension (SIH) is a neurologic syndrome of unknown etiology, characterized by features of low cerebral spinal fluid (CSF) pressure, postural headache and magnetic resonance imaging (MRI) abnormalities. Methods: Four symptomatic cases of SIH presented to our institution over a six-month period. Magnetic resonance imaging studies were performed in all four cases. Diagnostic lumbar puncture was done in all except one case. Results: All of the patients on whom lumbar punctures were performed demonstrated low CSF pressure and CSF protein elevation with negative cultures and cytology. Three out of the four patients exhibited MRI findings of diffuse spinal and intracranial pachymeningeal gadolinium enhancement and extradural or subdural fluid collections. One patient had no MRI abnormalities despite prominent postural headache and reduced CSF pressure at lumbar puncture. All patients recovered with intravenous fluids and conservative treatment. Conclusions: Magnetic resonance imaging abnormalities are found in most, but not all patients, with SIH. Cerebral spinal fluid abnormalities can be detected even in patients with normal MRI studies. It is important to recognize the variability of imaging results in this usually benign disorder.
Digital still cameras capable of filming short video clips are readily available, but the quality of these recordings for telemedicine has not been reported. We performed a blinded study using four commonly available digital cameras. A simulated patient with a hemiplegic gait pattern was filmed by the same videographer in an identical, brightly lit indoor setting. Six neurologists viewed the blinded video clips on their PC and comparisons were made between cameras, between video clips recorded with and without a tripod, and between video clips filmed on high- or low-quality settings. Use of a tripod had a smaller effect than expected, while images taken on a high-quality setting were strongly preferred to those taken on a low-quality setting. Although there was some variability in video quality between selected cameras, all were of sufficient quality to identify physical signs such as gait and tremor. Adequate-quality video clips of movement disorders can be produced with low-cost cameras and transmitted by email for teleneurology purposes.
Parkinson's disease (PD) is a progressive neurological disorder characterized by motor symptoms as well as severe deficits in olfactory function and microstructural changes in olfactory brain regions. Because of the evidence of asymmetric neuropathological features in early-stage PD, we examined whether lateralized microstructural changes occur in olfactory brain regions and the substantia nigra in a group of early-stage PD patients. Using diffusion tensor imaging (DTI) and the University of Pennsylvania Smell Identification Test (UPSIT), we assessed 24 early-stage PD patients (Hoehn and Yahr stage 1 or 2) and 26 healthy controls (HC). We used DTI and a region of interest (ROI) approach to study the microstructure of the left and right anterior olfactory structures (AOS; comprising the olfactory bulbs and anterior end of the olfactory tracts) and the substantia nigra (SN). PD patients had reduced UPSIT scores relative to HC and showed increased mean diffusivity (MD) in the SN, with no lateralized differences. Significant group differences in fractional anisotropy (FA) and MD were seen in the AOS, but these differences were restricted to the right side and were not associated with the primary side of motor symptoms amongst PD patients. No associations were observed between lateralized motor impairment and lateralized microstructural changes in AOS. Impaired olfaction and microstructural changes in AOS are useful for early identification of PD but asymmetries in AOS microstructure seem unrelated to the laterality of PD motor symptoms.
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