The role of the gut and the gastrointestinal microbiome in Parkinson’s disease

INTRODUCTION: Parkinson’s disease (PD) is a disabling and progressive neurodegenerative disorder that is increasing in prevalence with the aging and urbanisation of the global population. The mechanisms underlying PD pathogenesis and progression are incompletely understood. Improved clinical recognition of early and prodromal non-motor symptoms (NMS), namely gastrointestinal (GI) dysfunction, has focused research over the last two decades on the roles of the gut. More recently, the influences of the microbiota-gut-brain-axis (MGBA) in the development and progression of PD have become an intensive area of research. Studies have demonstrated an association between the GM and a variety of PD-related characteristics, identifying important impacts on levodopa metabolism by certain microbiota. Importantly, the effect of device-assisted therapies (DATs) on the GM and the robustness of microbiota compositional differences between PD patients and household controls (HCs) has not been well defined. The aims of this thesis were to 1) investigate GI dysfunction and nutritional patterns in PD, 2) determine if the GM is a biomarker of PD, and 3) investigate the temporal stability of the GM in PD patients receiving standard therapies and those initiating DATs. METHODS: 103 PD patients and 81 HCs were recruited and participants with PD were considered in two sub-cohorts; 1) PD patients initiating DAT; either Deep Brain Stimulation (DBS) (n=10), or levodopa-carbidopa intestinal gel (LCIG) (n=11), who had GM sampling from stool at -2, 0, 2 and 4 weeks around initiation of DAT and baseline, 6 and 12 months following DAT initiation, 2) 82 PD patients receiving standard PD therapies, who had GM sampling from stool at baseline, 6 and 12 months. Validated PD questionnaire metadata ascertaining motor characteristics and NMS, as well as nutritional data in the form of a Food Frequency Questionnaire, were collected for all participants at baseline, 6 and 12 months. Total DNA was isolated from stool before sequencing the V3-V4 region of 16S rRNA. Relative bacterial abundances, diversity measures, compositional differences and clinical-microbiome associations were determined, as well as developing predictive modelling to identify PD patients and assess disease progression. RESULTS: PD patients reported more prevalent and severe GI dysfunction, especially constipation, which was almost three-times more common compared to HC subjects, (78.6% vs 28.4%, p<0.001). PD patients had a higher intake of total carbohydrates (279 g/day vs 232 g/day; p=0.034), which was largely attributable to an increased daily sugar intake (153 g/day vs 119 g/day; p=0.003), particularly of free sugars (61 g/day vs 41 g/day; p=0.001). Significant GM compositional differences across several taxonomic levels were apparent between PD patients and HCs and associated with a number of PD motor and NMS features, as well as certain therapies. Predictive models to distinguish PD from HCs were developed considering global GM profiles, achieving an area under the curve (AUC) of 0.71, which was improved by addition of data on carbohydrate intake (AUC 0.74). Longitudinal analysis demonstrated persistent underrepresentation of known short-chain fatty acid producing bacteria in PD patients, particularly those concerned with butyrate production; Butyricicoccus, Fusicatenibacter, Lachnospiraceae ND3007 group and Erysipelotrichaceae UCG−003. Taxa differences observed over the short-term (four week) sampling period around DAT (DBS and LCIG) initiation, were not sustained at 6 and 12 months. Despite this, persistent longer-term overrepresentation of Prevotella was observed after DBS initiation, and a trend was found that was suggestive of overrepresentation of Roseburia after LCIG initiation. These results suggest that there may be variable shorter and longer-term DBS and LCIG influences on the GM, which are complex and multifactorial. PD progression analysis did not identify distinct persisting GM compositional differences between faster and slower progressing patients, although predictive modelling was strengthened by the consideration of nutritional data, specifically protein intake, and improved the predictive capacity for PD progression. CONCLUSION: This thesis demonstrates that there are numerous clinically significant associations between the gut, GM and PD. GI dysfunction is common, and carbohydrate nutritional intake appears to be different from the general population in PD. Persistent alterations of GM composition in PD compared to HCs were found. These findings provide support for the existence of disturbances of gut homeostatic pathways, which may disrupt intestinal barrier permeability and lead to gut leakiness, in the pathogenesis of PD. This thesis also highlights the potential to use the GM in the identification of PD and the characterisation of disease progression

Hospitalisation and comorbidities in Parkinson\u27s disease: A large Australian retrospect study

Parkinson’s disease (PD) is a progressive and disabling neurological disorder that affects approximately 1% of the adult population aged over 65 years in Australia. Parkinson’s disease, as with many other chronic illnesses, results in frequent patient hospitalisations. There is a paucity of information on the causes and related co-morbidities that lead to hospitalisation among these patients in an Australian setting. The aim of this study was to examine patterns of hospitalisation of Parkinson’s disease patients with regards to demographic factors, co-morbidities and aspects relating to clinical management. In this study, data was extracted from the NSW Ministry of Health’s Admitted Patient Data Collection (APDC), to examine patterns of the patient admission over a five-year period. A comparison group (patients without Parkinson’s disease) was used to strengthen the study and to compare the epidemiological, demographic and clinical features if the Parkinson’s disease patients with those of patients without Parkinson’s disease. Statistical analysis of patterns of disease that may predispose Parkinson’s disease patients to hospitalisation was undertaken. The results of this retrospective study were used to inform patient groups and health care providers about the possibilities for improved health outcomes for patients and their carers and were published in the Journal of Neurology, Neurosurgery and Psychiatry in 2014

Isolated intractable nausea and vomiting with hiccups heralds a neuromyelitis optica area postrema syndrome

No abstract is available for this article

Gastrointestinal dysfunction in Parkinson\u27s disease

Background: Gastrointestinal (GI) dysfunction is prevalent in Parkinson’s disease (PD). Symptoms are evident throughout the disease course, affect the length of the GI tract and impact on patient quality of life and management. We clarify real-life differences in the frequency and severity of GI symptoms in a cohort of PD and healthy control (HC) subjects. Methods: 103 PD patients were compared to 81 HC subjects. Outcome measures collected from validated questionnaires included constipation severity, upper and lower GI symptoms and physical activity. Results: PD patients were three-times more likely to experience constipation than HC subjects, (78.6% vs 28.4%), exhibited a fourfold increase in constipation severity and formed harder stools. PD patients also reported increased symptoms of indigestion, nausea, excessive fullness and bloating, compared to the HCs. A higher mean Leeds Dyspepsia Questionnaire score for PD patients (8.3 (standard deviation (SD) 7.7) vs 4.6 (SD 6.1), p=0.001)) indicated increased symptom severity. Chronic pain was more frequently reported and correlated with constipation and upper GI dysfunction, being more prevalent and severe in women. Physical activity was notably decreased in the PD cohort (1823.6 (±1693.6) vs 2942.4 (±2620.9) metabolic equivalent-minutes/week, p=0.001) and correlated with constipation severity. PD therapies were associated with increased fullness and bloating and harder stools. Conclusions: PD patients report more prevalent and severe GI dysfunction, although our cohort comprised of many later stage participants. Earlier recognition of GI dysfunction in PD provides the opportunity to direct treatment for chronic pain and constipation, promote physical activity and rationalise PD therapies for optimal patient care

Depression in Parkinson\u27s disease: Perspectives from an Australian cohort

Introduction: Depression is often an under-recognised feature of Parkinson\u27s disease (PD). It is detrimental to physical and interpersonal functioning, negatively impacting a patient\u27s clinical management, quality of life and well-being. We aimed to identify clinical predictors and management implications of depression in Australian PD patients. Methods: 103 PD and 81 Healthy Control (HC) subjects were evaluated using the Beck Depression Inventory (BDI) and other validated PD motor and non-motor symptom (NMS) tools. Results: Nearly twice as many PD patients were depressed, (38.9% vs 20.1%, p = 0.009), with a corresponding increase in depression severity on the BDI (11.9; standard deviation (SD) 8.8 vs 5.2; SD 5.5, p\u3c0.001), and an odds ratio of 2.4 (95% confidence interval 1.2 - 4.7). Employment appeared to be a relative protective factor for depression, whilst patients requiring support services seemed to be more vulnerable to depression. Rapid Eye Movement Sleep Behaviour Disorder, dyskinesias, impulse control disorder, higher daily levodopa equivalent dose, increased motor severity, as well as catechol-O-methyltransferase inhibitor and amantadine use, all showed associations with depression (p\u3c0.05). Chronic pain, decreased physical activity, constipation and upper gastrointestinal dysfunction presented with an apparent increase in risk for developing depression and increased depression severity. Other NMS were also found to be associated with PD-related depression. Limitations: Potential selection bias of self-reporting data collection from specialist PD clinics in a single metropolitan area. Conclusion: Our findings provide novel insight into the prevalence of depression in PD, possible contributory factors and future treatment strategies targeting depression in PD

Actinomyces cavernous sinus infection: A case and systematic literature review

A 63-year-old man presented with a 2-month history of progressive right-sided exophthalmos, painful ophthalmoplegia and fevers. As more features developed, he was diagnosed with giant cell arteritis then Tolosa-Hunt syndrome and transiently responded to corticosteroids. A bland cerebrospinal fluid and highly metabolically active brain (18F)-fluoro-D-glucose-positron emission tomography suggested lymphoma. Biopsy of the mass showed sulphur granules with Gram-positive filamentous bacteria with Actinomyces-like colonies. Actinomyces cavernous sinus infections are rare and indolent. They often mimic non-infective causes including other inflammatory and infiltrative conditions, vascular and neoplastic causes, particularly lymphoma. Clinicians should consider infective cavernous sinus syndromes in people with a fluctuating painful ophthalmoplegia that responds poorly to corticosteroids. The term Tolosa-Hunt syndrome is problematic and should be retired or used only with reservation

Parkinson\u27s disease and the gastrointestinal microbiome

Recently, there has been a surge in awareness of the gastrointestinal microbiome (GM) and its role in health and disease. Of particular note is an association between the GM and Parkinson’s disease (PD) and the realisation that the GM can act via a complex bidirectional communication between the gut and the brain. Compelling evidence suggests that a shift in GM composition may play an important role in the pathogenesis of PD by facilitating the characteristic ascending neurodegenerative spread of α-synuclein aggregates from the enteric nervous system to the brain. Here, we review evidence linking GM changes with PD, highlighting mechanisms supportive of pathological α-synuclein spread and intestinal inflammation in PD. We summarise existing patterns and correlations seen in clinical studies of the GM in PD, together with the impacts of non-motor symptoms, medications, lifestyle, diet and ageing on the GM. Roles of GM modulating therapies including probiotics and faecal microbiota transplantation are discussed. Encouragingly, alterations in the GM have repeatedly been observed in PD, supporting a biological link and highlighting it as a potential therapeutic target

Rheumatoid leptomeningitis presenting with an acute neuropsychiatric disorder

Leptomeningitis is a rare central nervous system manifestation of rheumatoid arthritis, generally in patients with established chronic rheumatoid disease. We report a 41-year-old man without previous rheumatoid arthritis or psychiatric disorder who presented with an acute neuropsychiatric disturbance and polyarthralgia. His MR scan of brain showed asymmetric bifrontal leptomeningitis, confirmed on (18F)-fluoro-D-glucose-positron emission tomography. Other investigations showed highly positive serum and cerebrospinal fluid anti-cyclic citrullinated peptide. A leptomeningeal biopsy showed necrotising leptomeningeal inflammation with ill-defined granulomas and lymphoplasmacytic infiltrate without organisms. Prolonged high-dose corticosteroids and then rituximab resulted in recovery. Chronic leptomeningitis can present with an acute neuropsychiatric disorder. We highlight that early rheumatoid disease can, rarely, cause a chronic leptomeningitis, reversible with immunotherapy

Cognitive influences in Parkinson\u27s disease patients and their caregivers: Perspectives from an Australian cohort

Objectives: Cognitive impairment impacts negatively on Parkinson\u27s disease (PD) patient and caregiver quality of life (QoL). We examined cognitive impairment in PD patients and their caregivers to determine if caregiver cognition affected their PD relative. Methods: Validated cognition and clinical outcome measures were assessed in 103 PD patients and 81 caregivers. Results: PD patients showed more cognitive impairment than their carers, with 48.6% having possible Mild Cognitive Impairment (MCI) and 16.5% having PD dementia. Increasing age, male gender, lower education level, various non-motor symptoms and certain therapies, associated with poorer cognition in PD. Eighteen and a half percent of caregivers were found to have MCI, in association with a lower physical and mental QoL. This reflected in lower QoL and mood for the respective PD patients. Conclusion: Impaired cognition and QoL in caregivers was associated with decreased QoL and mood for respective PD patients, suggesting MCI in caregivers is an important consideration for the management of PD

Health-related quality of life for Parkinson’s disease patients and their caregivers

Objective: Motor and non-motor symptoms (NMS) negatively impact the health-related quality of life (HRQoL) for individuals with Parkinson’s disease (PD), as well as their caregivers. NMS can emerge decades prior to the manifestation of motor symptoms but often go unrecognized and therefore untreated. To guide clinical management, we surveyed differences and identified factors that influence HRQoL in a cohort of PD patients and family caregivers. Methods: A total of 103 PD patients were compared with 81 caregivers. Outcome measures collected from validated questionnaires included generic and disease-specific HRQoL assessments, depression frequency and severity, constipation severity, upper and lower gastrointestinal symptoms, physical activity and motor symptom severity. Results: PD patients reported significantly decreased physical and mental HRQoL compared to their caregivers (both p \u3c 0.001). Unemployment, the need for social support services, rehabilitation use, REM sleep behavior disorder, impulse control disorders and features suggestive of increasing disease severity hallmarked by increasing PD duration, higher MDS UPDRS-III (Movement Disorder Society–Unified Parkinson’s Disease Rating Scale–Part III) scores, higher daily levodopa equivalence dose and motor fluctuations were consistent with a lower HRQoL in our PD cohort. Furthermore, decreased physical activity, chronic pain, depression, constipation and upper gastrointestinal dysfunction (particularly indigestion, excess fullness and bloating) suggested vulnerability to reduced HRQoL. Overall, PD patients perceived their health to decline by 12% more than their caregivers did over a 1-year period. Conclusion: PD patients reported decreased HRQoL, with both motor symptoms and NMS negatively impacting HRQoL. Our findings support the routine clinical screening of HRQoL in PD patients to identify and address modifiable factors