Salbutamol and PD risk

Recently at one of our movement disorders meeting we began to discuss whether people with PD should be prescribed salbutamol. Salbutamol is a drug that has been used to treat asthma and COPD (a smoking related breathing disorder) for a long time. There has been lots of interest in Salbutamol because in epidemiological studies it appears to be protective against developing PD.

Salbutamol works by activating a receptor called the beta-adrenergic receptor which in turn causes the airways to expand; making it easier to breath. There are also medications that do the opposite of this, block the beta-adrenergic receptor. Examples of these medications are bisoprolol, atenolol, propanolol and metoprolol. Interestingly these medications regularly come up as risk factors for PD in similar studies. So based on this data; medications which block the beta-adrenergic receptor increase the risk of PD and medications which activate the beta-adrenergic receptor protect people against PD. This has the potential to be a critical finding as it would mean clinicians may have a simple medication which could prevent Parkinson's disease.

Unfortunately the link between the beta receptor and PD may not be as clear as these studies imply. There are a number of other possible explanations and confounders. As I mentioned earlier is used to treat Asthma and COPD, COPD is a lung disease that is almost exclusively found in smokers. Smoking is known to be associated with a decreased risk of PD. Therefore people who are prescribed salbutamol are much more likely to smoke and subsequently more likely to develop PD. So that could potentially explain why the beta agonists appear to protect people from PD but then why do beta-blockers seem to increase the risk of PD? One of the earliest symptoms of PD is a tremor and patients are often misdiagnosed initially as having an essential tremor. The treatment for essential tremor involves a beta-blocker called propanolol or metoprolol. So it is possible that people with early Parkinson's disease are mistakenly being prescribed beta-blockers so in studies they appear to increase the risk of PD.

A recently published case-control study from Denmark has explored some of these associations. First of all they found again that people with PD are much less likely to take beta-agonists. But they found two key things that indicate that this relationship is driven by smoking rather than beta-agonists. First of all the same reduced odds ratio for PD was found for all medications used to treat COPD in smokers such as anti-cholinergics and inhaled steroids. All of these medications are much more likely to be prescribed in smokers indicating  that beta-agonists are not having a special effect on PD. Also the same reduction in odds ratio for PD was found for people who had been prescribed beta-agonists regardless of the duration of beta-agonist use. The same reduced odds ratio was seen even for people who had been prescribed beta-agonists within the past year which is very unlikely to be having a disease modifying effect on PD as the neurodegeneration typically occurs over years.

With regard to beta-blockers they found that short term beta-blocker prescriptions had a much stronger association with PD than long term beta-blocker prescriptions. This suggests that the association is much more likely to be driven by early PD symptoms being mistaken for essential tremor rather than beta blockers actually causing PD. Also, interestingly, they only found the association for beta-blockers used for treating tremor (such as propanolol and metoprolol) but they did not find an association with other beta blockers such as bisoprolol which can not be used to treat tremor.

This is a really fascinating study which provides important information about the link between beta-adrenergic medication and PD. The data indicates that all of the PD protective effects of beta-agonists are actually mediated by smoking and the risk of beta-blockers is accounted for by attempts to treat the early symptoms of PD.

Neurology. 2019 Jul 9;93(2):e135-e142. doi: 10.1212/WNL.0000000000007694. Epub 2019 May 24.

Use of β2-adrenoreceptor agonist and antagonist drugs and risk of Parkinson disease.

Hopfner F¹, Wod M¹, Höglinger GU¹, Blaabjerg M¹, Rösler TW¹, Kuhlenbäumer G¹, Christensen K¹, Deuschl G¹, Pottegård A².

You are what you eat

You are what you eat!

It is a rare day that reading a scientific report of basic research makes the hairs on my neck stand up, but today is one such day. 

An article published in the prestigious journal Neuroncarries the rather dry title “Transneuronal propagation of pathologic α-synuclein from the gut to the brain models Parkinson’s disease”. In their research the authors at Johns Hopkins in Baltimore injected an abnormal protein (α-synuclein preformed fibrils) into the walls of the stomach and intestines of some mice. They left some to develop, but did an operation (that used to be common in humans) to cut the nerve that supplies the stomach in others.

Within one month, the protein was found within the brainstem. At three months this has progressed and the protein is found in the substantia nigra (the ‘seat’ of Parkinson’s) and at seven months this has progressed further in the brain. What’s more, although not seen at 1 or 3 months, by 7 months there was loss of dopamine neurones in the brain and this progressed by 10 months. These changes were not seen in the mice who had the operation.

Not only did they do multiple different kinds of microscopic and imaging experiments to directly detect the spread and progression of this protein, they also looked at the movements and behaviour of the mice. Sure enough, the mice who had the intact nerve (and therefore the spread of the protein to the brain), did worse on movement tests (they were slower and less balanced). They also did significantly worse on memory and decision making tests for mice.

Why is this so (potentially) revolutionary? There are several reasons. 

Firstly, there has been a hypothesis for over 15 years that Parkinson’s starts in the gut and spreads to the brain, and these experiments very strongly support that. This backs up observational data from Scandinavia that showed that humans that had had the nerve-cutting operation (vagotomy) for stomach ulcers were less likely to go on to develop Parkinson’s.

Secondly, not only did these mice show pathological changes on imaging and under the microscope, they behaved like mice with Parkinson’s in many methods of testing. This is all the more novel given that these mice didn’t have any genetic changes that made Parkinson’s more likely – they were ‘ordinary’ mice. Until now animal models of Parkinson’s have been very crude and totally unlike the human form of the pathology (either pure genetic strains or given a toxic compound that causes an ‘instant’ Parkinsons-like picture).

Thirdly, (and leading on from the previous point) with an animal model that is so much more similar to the human form of the disease, it is much more likely that we can identify and try new treatments using this model, that is much more related to human Parkinson’s and therefore much more likely to work for the majority of patients. These treatments need not merely treat the symptoms but genuinely slow, stop or even reverse the condition.

Fourthly (I won’t say finally, because there is so much to unpack from this study), this sheds new light on how Parkinson’s starts, gets to the brain and progresses. The suggestion is that there may be something in the environment that makes its way into individuals and then goes on to cause Parkinson’s. Imagine if we can identify and potentially eliminate that! 

So, for many reasons, this is a truly exciting study, and one that has the potential to revolutionise the field and bring us closer to a cure. One small step for mice, one giant leap for mankind.

The study can be found here.

RNR

More PD genes to discover?

Epidemiological studies involving islands have a long and proud history; they always provide fascinating reading and food for thought. In the Faroe islands there were no reported cases of Multiple Sclerosis until 1943 when british troops occupied the islands. After this there was an epidemic of 21 cases. This pattern led to researchers hypothesising that british troops introduced asymptomatic infection to the islands which could be linked to the development of MS. The island of Crete has also been noted to have a rate of sporadic Creutzfeldt-jakob disease that is 5 times the expected numbers for a population of that size. More relevant to Parkinson's is the island of Guam where a peculiar condition that has signs of Parkinson's and a variant of motor neurone disease (called amyotrophic lateral sclerosis) is endemic and not found anywhere else in the world. 

Again in the Faroe islands researchers have noticed that there are twice the number of people living with Parkinson's that you would normally expect for a population of that size. Analysis of the patterns of Parkinson's in families in the Faroe islands indicated that there was probably a genetic cause for this increased number of people with Parkinson's, rather than an environmental cause. But it is not caused by any of the genes we currently know are associated with Parkinson's.

The researchers had the bright idea to follow up people who had migrated from the Faroe islands to Denmark. They found that despite living in Denmark the Faroese migrants still had a much higher chance of developing Parkinson's, even when they had lived in Denmark for more than 10 years! This indicates that either; the underlying environmental factor that is driving this relationship takes place at a much younger age. Alternatively, and much more likely, is that genetics is the cause of this increased prevalence of Parkinson's disease. But the genes causing this are yet to be discovered...

Mov Disord. 2019 Apr 9. doi: 10.1002/mds.27692.

What does migration between the faroe islands and denmark tell us about the etiology of Parkinson's disease?

Petersen MS^1,2, Lophaven SN³, Lynge E⁴, Weihe P^1,2.

Smelling Parkinson's

In the news this week you might have seen a perplexing story about a lady who can smell Parkinson's! Her husband was diagnosed with Parkinson's and she noticed a strange smell. She only connected the dots when she attended a Parkinson's UK support group and was suddenly surrounded by the smell.

This is not the first report of people being able to smell diseases. Patients with Type 1 diabetes whose sugars have gone very high and blood acidic start to smell like pear drops. There are many reports of nurses who can smell specific types of bacteria.

This phenomena is not limited to humans either! One of my colleagues at medical school presented on the fascinating topic of animals that can smell diseases which included rats which can smell tuberculosis and dogs which can smell cancer. (Also a non-smell related one but equally interesting is that pidgeons can be trained to identify breast cancer on mammograms and pathology slides)

Joy Milne was given 12 t shirts to smell, 6 had been worn by Parkinson's patients and 6 were from people without Parkinson's. She correctly identified the 6 people with Parkinson's and also thought that one of the healthy controls had the smell as well, this person was subsequently diagnosed with Parkinson's so she had 100% accuracy at smelling Parkinson's.

From a scientific point of view, there must be a particular chemical that she is smelling and she has been working with a team in Manchester to try to identify the chemical that she is smelling. Fortunately they have found two chemicals that could be the source of this smell. This is a really important finding because it can lead to a potential quick test to diagnose Parkinson's. This test could even be used to diagnose Parkinson's earlier.

Discovery of volatile biomarkers of Parkinson’s disease from sebum

Drupad K Trivedi, Eleanor Sinclair, Yun Xu, Depanjan Sarkar, Camilla Liscio, Phine Banks, Joy Milne, Monty Silverdale, Tilo Kunath, Royston Goodacre, Perdita Barran

Parkinson’s disease (PD) is a progressive, neurodegenerative disease that presents with significant motor symptoms, for which there is no diagnostic test. We have serendipitously identified a hyperosmic individual, a ‘Super Smeller’ that can detect PD by odor alone, and our early pilot studies have indicated that the odor was present in the sebum from the skin of PD subjects. Here, we have employed an unbiased approach to investigate the volatile metabolites of sebum samples obtained noninvasively from the upper back of 64 participants in total (21 controls and 43 PD subjects). Our results, validated by an independent cohort, identified a distinct volatiles-associated signature of PD, including altered levels of perillic aldehyde and eicosane, the smell of which was then described as being highly similar to the scent of PD by our ‘Super Smeller’

Crying out for a new biomarker

The hunt for a biomarker for Parkinson's has led researchers to investigate a lot of different bodily fluids and techniques! A biomarker is a test that can diagnose Parkinson's, at the moment the only way to diagnose Parkinson's is by using your eyes and your ears. Previously people have tested blood, CSF (the fluid around your brain), skin, saliva, MRI scans, skin samples and even samples of colon. But this pilot study is about a potential location for a biomarker that I had not yet heard of: Tears.

Its well known already that people with Parkinson's have reduced amounts of tears and a lower blink rate. And the researchers point out the the nerves that control the tear gland (lacrimal gland) connect to the brainstem. The brainstem is where a lot of the changes in early Parkinson's take place.

In this study they took 36 people with Parkinson's and 18 healthy people without Parkinson's and collected their tears by using some filter paper to absorb them. They then extracted the proteins from the collected tears.

They found that the Parkinson's participants had a smaller volume of tears but the protein concentration in the tears was about the same as healthy controls. They also identified 21 proteins that people with Parkinson's had significantly higher amounts of and 19 that were significantly reduced in Parkinson's too.

This is only a very small pilot study so we need some further studies in larger groups of patients before we draw any conclusions. But tears are a very attractive biomarker simply because they are so accessible. So this is definitely one to keep in mind and watch out for any further studies about.

Parkinsonism Relat Disord. 2019 Mar 6. pii: S1353-8020(19)30094-X. doi:

Proteomic analysis of tear fluid reveals disease-specific patterns in patients with Parkinson's disease - A pilot study.

Boerger M¹, Funke S², Leha A³, Roser AE⁴, Wuestemann AK⁵, Maass F⁶, Bähr M⁷, Grus F⁸, Lingor P⁹.

Abstract

BACKGROUND:

The diagnosis of Parkinson's disease (PD) is still challenging and biomarkers could contribute to an improved diagnostic accuracy. Tear fluid (TF) is an easily accessible body fluid reflecting pathophysiological changes in systemic and ocular diseases and is already used as a biomarker source for several ophthalmological disorders. Here, we analyzed the TF of patients with PD and controls (CTR) to describe disease-related changes in TF and identify putative biomarkers for the diagnosis of PD.

METHODS:

Unstimulated TF samples of a pilot cohort with 36 PD patients and 18 CTR were collected via Schirmer tear test strips and then analyzed via a Bottom-up liquid chromatography electrospray ionization tandem mass spectrometry (BULCMS) workflow, followed by functional analysis encompassing protein-protein interaction as well as cellular component and pathway analysis.

RESULTS:

BULCMS analysis lead to the identification of 571 tear proteins (false discovery rate, FDR < 1%), whereby 31 proteins were exclusively detected in the PD group and 7 only in the CTR group. Whereas 21 proteins were significantly increased in the PD versus CTR groups, 19 proteins were significantly decreased. Core networks of proteins involved in immune response, lipid metabolism and oxidative stress were distinctly altered in PD patients.

CONCLUSIONS:

To our best knowledge, this is the first description of TF proteome in PD patients. Tear protein level alterations suggest the contribution of different disease-related mechanisms in ocular pathology in PD and propose candidate proteins to be validated as potential biomarkers in larger cohorts.

PLAIN ENGLISH: Organ transplants and risk of Parkinson's

This is another interesting study borne out of large USA health insurance databases (Medicare database). The team from Washington noticed, whilst using the same data to see if they could identify people at high risk of Parkinson’s, that people with Parkinson’s were less likely to have received an organ transplant than someone without Parkinson’s. This implies that people who have had organ transplants have a reduced risk of Parkinson’s. They decided to investigate this further because it could important implications in developing a medication to prevent Parkinson’s.

They identified 94,155 people with Parkinson’s and then they randomly selected 118,295 people without Parkinson’s in a similar age group. Overall 278 people with Parkinson’s had also had a tissue transplant and 302 of the people without Parkinson’s had a tissue transplant. They found that the odds of having Parkinson’s after a tissue transplant were reduced.

It’s unclear what is causing this effect but one of the possibilities is the medication that transplant patients are on. People who have received transplants are usually started on medication that lowers the body’s immune system to prevent the body rejecting the transplant. It is possible that these medications could be protecting the brain in some way from Parkinson’s. Unfortunately we cannot be sure at the moment and more research is needed to understand the science underlying this!

Parkinsonism Relat Disord. 2019 Feb 14. pii: S1353-8020(19)30059-8. doi: 10.1016/j.parkreldis.2019.02.013. [Epub ahead of print]

Transplant and risk of Parkinson disease.

Fan J¹, Searles Nielsen S², Faust IM³, Racette BA⁴.

Author information

Abstract

INTRODUCTION:

The pathophysiology of Parkinson's disease (PD) remains unclear, but growing evidence supports a role of neuroinflammation. The purpose of this study was to investigate the association between tissue transplantation and PD risk, given the importance of immunosuppressants in post-transplant management.

METHODS:

We performed a case-control study among Medicare beneficiaries age 66-90 using claims from 2004 to 2009. We used International Classification of Diseases, Ninth Edition (ICD-9) and Current Procedural Terminology (CPT) codes to identify PD (89,790 incident cases, 118,095 population-based controls) and history of tissue transplant (kidney, heart, liver, lung, and bone marrow). We investigated risk of PD in relation to tissue transplant in logistic regression models, adjusting for age, sex, race, smoking, and overall use of medical care.

RESULTS:

Beneficiaries who had received a tissue transplant at least five years prior to PD diagnosis or reference had a lower risk of PD (odds ratio [OR] 0.63, 95% confidence interval [CI] 0.53, 0.75) than those without tissue transplant. This inverse association was observed for kidney (OR 0.63, 95% CI 0.47, 0.84), heart (OR 0.58, 95% CI 0.40, 0.83), lung (OR 0.41, 95% CI 0.21, 0.77), and bone marrow (OR 0.57, 95% 0.38, 0.85) transplants. Associations were attenuated, but remained, following adjustment for indications for the respective type of transplant. Liver transplant was not associated with PD risk.

CONCLUSIONS:

Patients undergoing tissue transplant may have a lower risk of developing PD than the general population. Further studies are needed to determine if this association is causal and if immunosuppressants mediate this association.

The Parkinson’s Drug Trial: A Miracle Cure?

I’m sure many of you have seen the programme about a landmark Parkinson’s study, that was aired on the BBC last night (28^th February 2019). It is a very well-produced fly-on-the-wall documentary that follows the investigators, inventors and some participants that have pioneered a truly ‘disruptive’ trial. If you haven’t seen it, stop reading and watch now (UK readers only).

The inimitable Tom Isaacs, who was one of the first patients into the study, and who's charity the Cure Parkinson's Trust funded this study.

What made it so unique – after all, there are thousands of drug studies that take place across the UK every day. Usually a study is designed to test one thing – most often a drug. In this study, they didn’t just test if the new drug worked. They had to invent new hardware – that needed to be tested. They had to invent a new kind of brain surgery – that needed to be tested. They had to persuade fairly risk-averse regulatory bodies and ethics panels that doing all three, together, at once was fair, safe and acceptable. Regardless of the outcomes of the study, I can only marvel at the courage and dedication shown by every person involved, from the chief investigator and the whole study team, to each and every participant and their families. Medicine usually progresses by small evolution, this study was a major revolution.

So what did the study show? ***Spoiler alert*** (The second part of the documentary is due to be aired next week. Here I will review the peer-reviewed scientific data that was published in two papers this year)

The one sentence summary from the first paper might, on the surface, appear to indicate defeat, “At the 40-week point, however, we have not shown clinical benefit despite this putamen-wide tissue engagement.” However, despite the headline ‘failure’, there is so much to celebrate.

Firstly, the managed to recruit (in fact, for 42 study ‘spots’, they had over 200 people volunteer). This is no small challenge, especially when there is the very real risk of making people worse off, and asking people with Parkinson’s to travel to Bristol every month for nearly a year.

Secondly, they proved that the hardware and surgery worked, and worked safely. 

Image from BBC.com

Thirdly, and very importantly, they showed that after 40 weeks, there was no change in the dopamine-scan in those who’d had placebo; but in the GDNF group there was a marked change that took the appearances back to those expected at the early stage of Parkinson’s. Bear in mind that on average, the participants had had symptoms of Parkinson’s for over 10 years, and in some for well over 15 years!

Fourthly, at the end of 40 weeks, no patients in the placebo group had movement scores that improved by 10 or more points. However, 9 out of the 17 participants given GDNF improved by between 10 and 16 points. This was not only statistically significant (albeit as a post hoc analysis), but most definitely clinically significant.

So what else can be said? Well, firstly, there was a very strong placebo effect. At one point in the film, the mother of one of the participants says, “To have a huge operation like that, and then have to have a placebo. Is that human? Not really, is it!” The BBC have produced a very good summary on the placebo (and nocebo) effects. The fact that the placebo group did improve so much, means that there is much less of a difference between the two groups. This doesn’t necessarily mean that the GDNF didn’t work, it means that the effect is ‘lost’ in the statistical analysis. 

Furthermore, the numbers in the study were very small, with only 41 patients in total, (21 GDNF, 20 placebo.) This further reduces the chance of finding statistical differences.

A - model showing the novel equipment that was designed and made specifically for this study. B - the port that participants lived with, with which they were 'hooked up' to treatment. C - brain scan showing that the drug delivery worked exactly where it needed to. D - patient sat being infused with treatment via the 'head port'. E - A (not-so) ordinary infusion suite. (image from linked Brain paper)

After the original 40 week study, both groups continued to get another 40 weeks treatment, this time with everyone getting the GDNF. At the end of this phase, there was still no overall group differences from the very beginning to the very end between those who had 80 weeks vs 40 weeks of GDNF treatment, in terms of the movement scores off all treatment. However, those who’d had GDNF all along had fewer increases in their regular medication (to a tune of nearly 5 tablets-worth per day (59mg vs 289mg)). There was also ongoing improvement in the ability to do daily activities in those having GDNF for 80 weeks, and a continued improvement in the proportion of the day when the medication was working well.

There are several other factors that need to be borne in mind. The study cost £3m. Divided over each of the participants amounts to over £73,000 per person. Although this seems like a lot, the actual treatment cost, should this every come to clinical practice would likely be much lower, as it includes all the extra costs associated with running a complex clinical trial. Furthermore, if GDNF is ultimately shown to slow the progression of the condition, if it means that someone maintains their independence and can either carry on working (and paying tax), or stay in their own home independently, rather than take early retirement or move to a nursing home, this really is small change – and when you factor in Quality of Life benefits, must surely be a price worth paying.

Finally (and thank you for bearing with me to this point), all these patients had a diagnosis of Parkinson’s disease for around 8 years. This means that they had the pathology for approaching 20 years. Many were profoundly affected by their symptoms. To use a metaphor I’ve used previously on this blog, it is easier to blow out a match than fight a forest fire. The brain of someone with advanced Parkinson’s is vastly more effected than at the early, or even pre-symptomatic stages. Any restorative attempts are far more likely to work if you can catch it early and intervene early. This is the overwhelming conclusion from treating infections and the whole concept of cancer treatment. 

Hopefully, you and your friends will help us reach that goal with Parkinson’s. You can do your bit by helping us to identify the very earliest phase of Parkinson’s: www.predictpd.com. Taking part involves 25 minutes in front of your own computer at home, and certainly doesn’t pose any of the risks that this study did!

As a final note, I would like to say that this programme reminded me how much of a privilege it is to look after people with Parkinson’s in the clinics of the Royal Free and Luton & Dunstable Hospital; how much of a privilege it is to be at the forefront of Parkinson’s research, funded by Parkinson’s UK, and how much this motivates me while training for the London Landmarks half-marathon and Virgin Money London Marathon.

RNR 

PLAIN ENGLISH - Risk scoring for future Parkinson's in General Practice Records

It has been a quiet month on the blog, but it is a consequence of us working hard, rather than having too much leisure time 😇

In this post we are looking at some of our own work, led by Professor Anette Schrag from the PREDICT-PD study.

Here Anette and colleagues looked at routinely collected data from General Practice medical records. They identified >8000 people who had been diagnosed with Parkinson's and >46,000 people who had not been diagnosed with Parkinson's. Then they looked back in time (in the records) to build a risk score based on the various events that occurred prior to the diagnosis of Parkinson's. As we have reported previously on this blog, things like tremor, constipation, depression, and urinary problems (and many more things) contributed to the score. The scoring process worked well overall. 

Of course we do something very similar in the PREDICT-PD, except here people take part online and answer questionnaires and complete online tests that all contribute to an individual score... we are actively recruiting and you can take part at predictpd.com.

- Alastair Noyce

Predicting diagnosis of Parkinson's disease: A risk algorithm based on primary care presentations.

Mov Disord. 2019 Feb 8. doi: 10.1002/mds.27616. [Epub ahead of print] 

Schrag A, Anastasiou Z, Ambler G, Noyce A, Walters K. 

BACKGROUND: Diagnosis of Parkinson's disease (PD) is typically preceded by nonspecific presentations in primary care. OBJECTIVES: The objective of this study was to develop and validate a prediction model for diagnosis of PD based on presentations in primary care. 

SETTING: The settings were general practices providing data for The Health Improvement Network UK primary care database. 

METHODS: Data from 8,166 patients aged older than age 50 years with incident diagnosis of PD and 46,755 controls were analyzed. Likelihood ratios, sensitivity, specificity, and positive and negative predictive values for individual symptoms and combinations of presentations were calculated. An algorithm for risk of diagnosis of PD within 5 years was calculated using multivariate logistic regression analysis. Split sample analysis was used for model validation with a 70% development sample and a 30% validation sample. 

RESULTS: Presentations independently and significantly associated with later diagnosis of PD in multivariate analysis were tremor, constipation, depression or anxiety, fatigue, dizziness, urinary dysfunction, balance problems, memory problems and cognitive decline, hypotension, rigidity, and hypersalivation. The discrimination and calibration of the risk algorithm were good with an area under the curve of 0.80 (95% confidence interval 0.78-0.81). At a threshold of 5%, 37% of those classified as high risk would be diagnosed with PD within 5 years and 99% of those who were not classified as high risk would not be diagnosed with PD. 

CONCLUSION: This risk algorithm applied to routine primary care presentations can identify individuals at increased risk of diagnosis of PD within 5 years to allow for monitoring and earlier diagnosis of PD. 

Percentage patients with Parkinson's and non-patients with various potential early symptoms.

© 2019 The Authors. Movement Disorders published by Wiley Periodicals, Inc. on behalf of International Parkinson and Movement Disorder Society.

A horse from our own stable: In memory of Tom Isaacs

We are delighted that one of our reviews has been published by the European Journal of Neuroscience: The Prodromes of Parkinson's.

This article is part of a special edition dedicated to the memory of Tom Isaacs. He was a shining light in the Parkinson's community. Having Parkinson's himself, he grew frustrated with the slow progress of research, and set up his own charity - The Cure Parkinson's Trust. The aim of the Cure Parkinson's Trust is to slow, halt or cure Parkinson's and only fund research that has the potential to do that. Tom's vision in creating and leading the Trust has changed the landscape of Parkinson's research and we are getting closer to achieving his dream. 

We are honoured to have been part of this evidence-based memorial to Tom. In this article we highlight the evidence of the stage before Parkinson's symptoms lead to a positive diagnosis - the prodromal phase. We look in particular at people with smell loss, individuals who have a particular sleep disorder (Rapid Eye Movement Sleep Behavioural Disorder) and some genetic causes of Parkinson's. 

It is increasingly clear that Parkinson's is an umbrella term for different sub-types of the pathology - in a group of people with Parkinson's, very few will have exactly the same features as each other. Even tremor - what most people think is the quintessential feature of Parkinson's, is totally absent in some individuals. Therefore, it stands to reason that there are different prodromal phases too. This is work that we are currently exploring, especially with our work with people with smell loss and with this sleep disorder. We hope to find out what are the markers that separate these groups, and what might shape the kind of Parkinson's that different people get.

The article is open access, thanks to the generous support of Parkinson's UK and can be found here.

Housekeeping

Dear reader, 

Unfortunately we've been targeted by a spam bot. We have deleted over 2000 spam messages and we apologise if we have inadvertently deleted any of your genuine messages in the process.

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Thank you for your understanding.

Please can we take this opportunity to thank you for your participation in our research, and if you know anyone who is age 60-80, lives in the UK and doesn't have Parkinson's, please encourage them to take part in the study at www.predictpd.com

Predict-PD

A scan to predict dementia?

We know that Parkinson's is caused by damage to a small area at the base of the brain known as the Substantia Nigra, which contains cells that produce the chemical messenger dopamine. However, this is not the entire picture, and we believe that other brain structures and chemicals may be involved in causing the variety of different symptoms we see in patients. 

One of the key questions for us in predicting what might happen to patients in the future is whether there is damage that can be found at an early stage, before patients start having problems.  A recent study used hundreds of MRI scans from people with Parkinson's to look at another small structure deep in the brain, named the Nucleus Basalis of Meynert. This is shown in the MRI image below.

Nucleus Basalis of Meynert

When this team looked at many different brain structures, it was only the size of this part of the brain that could predict whether patients would go on to develop problems with thinking and processing information. This ties in with other work showing this part of the brain plays a key role in different types of dementia as well as our knowledge that a drug which targets the main chemical found in this part of the brain, acetylcholine, is effective in Parkinson's Disease with dementia. 

As researchers continue to put together these kinds of findings, we can develop increasingly accurate ways to predict disease and ultimately ensure that the right people have access to treatments at the earliest stages. 

If you're interested in reading more, here is the link to the article https://academic.oup.com/brain/article/141/5/1501/4944714 

-Anna

 

Great Debates

While there are many great debates happening this week in the UK, perhaps the most interesting happened at today’s biannual meeting of the Association of British Neurologists Movement Disorders Special Interest Group, held in the beautiful Oxford Town Hall. The opening session of the meeting was a debate between two giants of the international Parkinson’s world: Professor Donald Grosset from Glasgow, and Professor Ron Postuma from Montreal.

The topic they were debating was “Should research focus on prodromal disease prevention or improving symptomatic therapies?” Professor Grosset set out the reasons for focussing on better treatments in the complex phase of the disease – when the treatments that we have either fail to work or side effects become increasingly troublesome and diffucult to manage. He also pointed out the near-total lack of well-proven treatments for many of the non-motor aspects of Parkinson’s (a point we have laboured in previous blog posts here). He suggested that detection of the prodromal stage was hit-and-miss and that the best case scenario was that trials in this group would costs hundreds of millions of pounds which would be better served investing in treatments for people with definite Parkinson’s.

Ron Postuma countered his argument and opened with the metaphor central to preventive medicine: people are falling over a waterfall and nearly drowning in the pool below. A man is pulling them out one by one and calls to a bystander to help. The bystander walks away, but returns at the top of the waterfall to stop people from falling down in the first place. Although  this metaphor may seem simplistic, it highlights the importance of focussing on the earliest stages. He went on to simplify the drug treatment of established Parkinson’s as “playing with neurotransmitters” – and no matter how successful one might be at doing that, there is an underlying progression of brain death. To deal with that means to effect a change before disease causing cascade of events has become unstoppable – i.e. in the earliest (prodromal) stages. Finally, he highlighted the seismic changes that have occurred in medicine in the last two generations. Penicillin used to be so expensive that patients given penicillin had their urine collected, the excreted penicillin extracted and given back to the patients to make each vial go further. Wards for women with infected wombs after miscarriages who would almost inevitably succumb to their infections closed within weeks. The AIDS wards that were in most hospitals in the 70s and 80s were empty just a few years after HIV medication started being used. New treatments for advanced cancer have changed the landscape for some of these diseases (including nilotonib which is currently being trialed in Parkinson’s), and the last two years has brought these game-changing experiences to neurological diseases with drugs such as Nucinercin – effectively curing an incurable genetic condition that killed children in their first few years. The message, he said, was clear – things we now take for granted were once hard and very expensive, and for Parkinson’s there is change on the horizon.

The rest of the meeting continued with many other fascinating and useful talks from some of the leaders of British neurology, and has offered many insights and ideas that we at Predict-PD can use to help bring us closer to a robust identificaiton of prodromal Prkinson’s and therefore, another step closer to a cure.

RNR

PLAIN ENGLISH: Gout and the risk of Parkinson's disease in older adults

First blog post of the year from me and, after feedback from literally everyone, I will be making a concerted effort to make them easy (easier) to understand. I can't get rid of the science I'm afraid... after all this is a research blog. But I (and we) can make bigger efforts to keep the focus on predicting Parkinson's, the PREDICT-PD study (predictpd.com) and related projects. 

The reason this blog was started was to help researchers, patients and the public understand how we use and weigh emerging research, which in turn informs our approach to our work on Parkinson's.

Take this study as an example... it looked at health insurance claims data from the USA over a 6 year period. The researchers looked at the link between claims for gout and subsequent claims for Parkinson's. They observed that, compared to people that made claims for other illnesses, people that claimed for gout were more likely to claim for Parkinson's in subsequent years. This in turn offers a weak suggestion that gout might be in some way linked with a higher risk of Parkinson's. However... we also know that this is only part of a much bigger story.

The biggest determinant of gout is the amount of a chemical in the blood known as uric acid. Generally speaking, people with higher levels of uric acid are more likely to have gout. It has also been noted on multiple occasions that people with Parkinson's tend to have lower levels of uric acid (both after diagnosis and in the years before)... which in turn has led to strategies to try and boost uric acid levels to treat Parkinson's (without introducing gout). 

So how does that make any sense at all?? High uric acid is associated with an increase in gout, gout is associated with an increase of Parkinson's, but Parkinson's is associated with low uric acid levels...?? We seem to be going in circles. 

But what if the explanation is simple... what if Parkinson's disease consumes uric acid and makes it look like low levels of uric acid are causing Parkinson's, when in fact it is the other way around? There have been similar examples in cancer where vitamin E was noted to be low in people that had prostate cancer, leading to the suggestion of supplementing vitamin E to reduce cancer. Instead the cancer rates appeared to increase... so it wasn't that low vitamin E was causing cancer... it was cancer consuming vitamin E and supplementing vitamin E only added more fuel to the fire.

If for some reason Parkinson's consumes uric acid, then gout may actually increase the risk of being diagnosed with Parkinson's and strategies to boost uric acid to treat or protect against Parkinson's may not lead to benefit and have the opposite effect...

Of course, this is speculation and certainly not the final say on the matter. Further research will likely reveal the truth over time...

- Alastair Noyce


BMC Neurol. 2019 Jan 5;19(1):4. doi: 10.1186/s12883-018-1234-x.
Singh JA, Cleveland JD.

BACKGROUND: In the presence of limited available data, our objective was to assess the association of gout with the risk of incident Parkinson's disease (PD) in adults 65 years or older.

METHODS: We used the 5% random sample of Medicare claims data from 2006 to 2012 to examine the association of gout with incident PD. The multivariable Cox regression model adjusted for demographics, comorbidity, and common cardiovascular disease and gout medications. We calculated hazard ratios (HR) and 95% confidence interval (CI). Sensitivity analyses adjusted for comorbidity categorically, or individually and for additional cardiovascular comorbidities.

RESULTS: In a cohort study, 1.72 million Medicare beneficiaries were eligible. The mean age was 75 years (standard deviation [SD], 7.6), 58% were female, 86% were White and 37% had Charlson-Romano comorbidity index score of ≥2. We found that 22,636 people developed incident PD, 1129 with gout and 21,507 without gout. The respective crude incidence rates of incident PD were 3.7 vs. 2.2 per 1000 person-years. We found that gout was associated with 1.14-times higher hazard ratio (95% CI, 1.07, 1.21) of PD in the main analysis; findings were confirmed in sensitivity analyses. We noted that the risk differed slightly by age; ages 65-75, 75-85 and > 85 had hazard ratios of incident PD with gout of 1.27 (95% CI, 1.16, 1.39), 1.07 (95% CI, 0.97, 1.16) and 0.97 (95% CI, 0.79, 1.20), respectively, but no gender or race differences were noted.

CONCLUSIONS: Gout was associated with a higher risk of incident PD in older adults, with the risk being significant in the age group 65-75 years. Future studies need to assess the mechanisms of this increased risk.

The hard miles

Happy new year to you all. I hope you have had a good start to the year.

2018 was a busy year for us. In this map, we have highlighted all the participants we have visited at their homes. The red markers are our participants with idiopathic anosmia (smell loss) and the blue markers are regular members of the Predict-PD study. Between us we have travelled literally thousands of miles.

The information we have collected will be vital in helping to define the 'prodromal phase' of Parkinson's, and potentially identifying key features that might allow identification of early Parkinson's. This will be vital in getting the right people into trials of potentially disease modifying treatments.

This study is funded by Parkinson's UK. Many of us in the research team are also movement disorders neurologists and see people with Parkinson's in clinic, and we see the benefits that Parkinson's UK also provide to individuals and even at a national policy level. I am running the 2019 Virgin Money London Marathon for Parkinson's UK, and training is going well. This weekend the charity held a 'preparation day' for its runners in the London and Brighton marathons. I had the wonderful opportunity to spend a few minutes telling them about the world-leading research we are doing at Predict-PD, and encouraging them to tell all their friends and family age 60-80 years about the study. It was very special to share the study with a group of such motivated and interested people, and showcase the work that we do. They were a mix of men and women of all ages, some of whom are running their first marathon (having never run 5km before), others are running their 30th full marathon this year. Some had relatives or friends with Parkinson's, others had Parkinson's themselves - all had a deep connection with the condition. I wish them all the best of luck with their training and look forward to seeing them at the finish line on the 28th April.

Because this post is getting perilously close to having no stats, here are some of mine since starting my training programme on Christmas day:
Total miles: 114.26
Total time running:  15 hours 8 minutes
Total calories burned: 11,206

2019 is another year of progress - please help us by encouraging everyone you know, age 60-80 to go to www.predictpd.com and take part!

RNR