Pharmacochimie et Biologie pour le Développement

We present a clinimetric assessment of the Movement Disorder Society (MDS)-sponsored revision of the Unified Parkinson's Disease Rating Scale (MDS-UPDRS). The MDS-UDPRS Task Force revised and expanded the UPDRS using recommendations from a published critique. The MDS-UPDRS has four parts, namely, I: Non-motor Experiences of Daily Living; II: Motor Experiences of Daily Living; III: Motor Examination; IV: Motor Complications. Twenty questions are completed by the patient/caregiver. Item-specific instructions and an appendix of complementary additional scales are provided. Movement disorder specialists and study coordinators administered the UPDRS (55 items) and MDS-UPDRS (65 items) to 877 English speaking (78% non-Latino Caucasian) patients with Parkinson's disease from 39 sites. We compared the two scales using correlative techniques and factor analysis. The MDS-UPDRS showed high internal consistency (Cronbach's alpha = 0.79-0.93 across parts) and correlated with the original UPDRS (rho = 0.96). MDS-UPDRS across-part correlations ranged from 0.22 to 0.66. Reliable factor structures for each part were obtained (comparative fit index > 0.90 for each part), which support the use of sum scores for each part in preference to a total score of all parts. The combined clinimetric results of this study support the validity of the MDS-UPDRS for rating PD.

The Movement Disorder Society Task Force for Rating Scales for Parkinson's disease (PD) prepared a critique of the Hoehn and Yahr scale (HY). Strengths of the HY scale include its wide utilization and acceptance. Progressively higher stages correlate with neuroimaging studies of dopaminergic loss, and high correlations exist between the HY scale and some standardized scales of motor impairment, disability, and quality of life. Weaknesses include the scale's mixing of impairment and disability and its non-linearity. Because the HY scale is weighted heavily toward postural instability as the primary index of disease severity, it does not capture completely impairments or disability from other motor features of PD and gives no information on nonmotor problems. Direct clinimetric testing of the HY scale has been very limited, but the scale fulfills at least some criteria for reliability and validity, especially for the midranges of the scale (Stages 2-4). Although a "modified HY scale" that includes 0.5 increments has been adopted widely, no clinimetric data are available on this adaptation. The Task Force recommends that: (1) the HY scale be used in its original form for demographic presentation of patient groups; (2) when the HY scale is used for group description, medians and ranges should be reported and analysis of changes should use nonparametric methods; (3) in research settings, the HY scale is useful primarily for defining inclusion/exclusion criteria; (4) to retain simplicity, clinicians should "rate what you see" and therefore incorporate comorbidities when assigning a HY stage; and (5) because of the wide usage of the modified HY scale with 0.5 increments, this adaptation warrants clinimetric testing. Without such testing, however, the original five-point scales should be maintained.

This article presents the revision process, major innovations, and clinimetric testing program for the Movement Disorder Society (MDS)-sponsored revision of the Unified Parkinson's Disease Rating Scale (UPDRS), known as the MDS-UPDRS. The UPDRS is the most widely used scale for the clinical study of Parkinson's disease (PD). The MDS previously organized a critique of the UPDRS, which cited many strengths, but recommended revision of the scale to accommodate new advances and to resolve problematic areas. An MDS-UPDRS committee prepared the revision using the recommendations of the published critique of the scale. Subcommittees developed new material that was reviewed by the entire committee. A 1-day face-to-face committee meeting was organized to resolve areas of debate and to arrive at a working draft ready for clinimetric testing. The MDS-UPDRS retains the UPDRS structure of four parts with a total summed score, but the parts have been modified to provide a section that integrates nonmotor elements of PD: I, Nonmotor Experiences of Daily Living; II, Motor Experiences of Daily Living; III, Motor Examination; and IV, Motor Complications. All items have five response options with uniform anchors of 0 = normal, 1 = slight, 2 = mild, 3 = moderate, and 4 = severe. Several questions in Part I and all of Part II are written as a patient/caregiver questionnaire, so that the total rater time should remain approximately 30 minutes. Detailed instructions for testing and data acquisition accompany the MDS-UPDRS in order to increase uniform usage. Multiple language editions are planned. A three-part clinimetric program will provide testing of reliability, validity, and responsiveness to interventions. Although the MDS-UPDRS will not be published until it has successfully passed clinimetric testing, explanation of the process, key changes, and clinimetric programs allow clinicians and researchers to understand and participate in the revision process.

Most human peripheral blood gamma delta T lymphocytes respond to hitherto unidentified mycobacterial antigens. Four ligands from Mycobacterium tuberculosis strain H37Rv that stimulated proliferation of a major human gamma delta T cell subset were isolated and partially characterized. One of these ligands, TUBag4, is a 5' triphosphorylated thymidine-containing compound, to which the three other stimulatory molecules are structurally related. These findings support the hypothesis that some gamma delta T cells recognize nonpeptidic ligands.

Depression is a common comorbid condition in Parkinson's disease (PD) and a major contributor to poor quality of life and disability. However, depression can be difficult to assess in patients with PD due to overlapping symptoms and difficulties in the assessment of depression in cognitively impaired patients. As several rating scales have been used to assess depression in PD (dPD), the Movement Disorder Society commissioned a task force to assess their clinimetric properties and make clinical recommendations regarding their use. A systematic literature review was conducted to explore the use of depression scales in PD and determine which scales should be selected for this review. The scales reviewed were the Beck Depression Inventory (BDI), Hamilton Depression Scale (Ham-D), Hospital Anxiety and Depression Scale (HADS), Zung Self-Rating Depression Scale (SDS), Geriatric Depression Scale (GDS), Montgomery-Asberg Depression Rating Scale (MADRS), Unified Parkinson's Disease Rating Scale (UPDRS) Part I, Cornell Scale for the Assessment of Depression in Dementia (CSDD), and the Center for Epidemiologic Studies Depression Scale (CES-D). Seven clinical researchers with clinical and research experience in the assessment of dPD were assigned to review the scales using a structured format. The most appropriate scale is dependent on the clinical or research goal. However, observer-rated scales are preferred if the study or clinical situation permits. For screening purposes, the HAM-D, BDI, HADS, MADRS, and GDS are valid in dPD. The CES-D and CSDD are alternative instruments that need validation in dPD. For measurement of severity of depressive symptoms, the Ham-D, MADRS, BDI, and SDS scales are recommended. Further studies are needed to validate the CSDD, which could be particularly useful for the assessment of severity of dPD in patients with comorbid dementia. To account for overlapping motor and nonmotor symptoms of depression, adjusted instrument cutoff scores may be needed for dPD, and scales to assess severity of motor symptoms (e.g., UPDRS) should also be included to help adjust for confounding factors. The HADS and the GDS include limited motor symptom assessment and may, therefore, be most useful in rating depression severity across a range of PD severity; however, these scales appear insensitive in severe depression. The complex and time-consuming task of developing a new scale to measure depression specifically for patients with PD is currently not warranted.

During the past decade, important advances have been made in the understanding of the hydrolytic degradation characteristics of aliphatic polyesters derived from lactic acid (LA) and glycolic acid (GA). Degradation of large poly(LAGA) (PLAGA) polymers is autocatalyzed by carboxyl end groups initially present or generated upon ester bond cleavage. Faster internal degradation and degradation-induced morphological and compositional changes are three of the most important findings deduced from the behaviors of various PLAGA polymers. This review presents the state of the art in this domain. The research efforts are focused on detailing the degradation mechanism and the effects of various factors on the degradation of PLAGA polymers. An attempt is also made to elaborate a scheme that can be used to predict degradation characteristics of these polymers from their initial composition and morphology.

The emergence of disease caused by penicillin-resistant and multidrug-resistant pneumococci has become a global concern, necessitating the identification of the epidemiological spread of such strains. The Pneumococcal Molecular Epidemiology Network was established in 1997 under the auspices of the International Union of Microbiological Societies with the aim of characterizing, standardizing, naming, and classifying antimicrobial agent-resistant pneumococcal clones. Here we describe the nomenclature for 16 pneumococcal clones that have contributed to the increase in antimicrobial resistance worldwide. Guidelines for the recognition of these clones using molecular typing procedures (pulsed-field gel electrophoresis, BOX-PCR, and multilocus sequence typing) are presented, as are the penicillin-binding profiles and macrolide resistance determinants for the 16 clones. This network can serve as a prototype for the collaboration of scientists in identifying clones of important human pathogens and as a model for the development of other networks.

Adverse drug reactions (ADRs) represent an important medical issue: they result in 3–7% of all hospital admissions and are associated with a substantial increase in morbidity and mortality. Numerous methods can be used to investigate ADRs. Each has its strengths and weakness. The insufficiencies of basic (experimental) pharmacology as well as clinical trials for studying ADRs are well known. Animal physiology often differs from that of humans. Clinical trials, although necessary, do not allow definite conclusions, because they are built to evaluate efficacy more than safety. Thus, spontaneous notifications remain the cornerstone for ADRs despite their mandatory limitations (under-reporting, selective reporting, lack of denominator etc.). Intensive studies could allow quantification of a specific problem of drug safety (i.e. drug admission into hospital for ADRs). For some years, several pharmacoepidemiological methods have been used to identify and also to quantify ADRs. Among thesse methods, case–control or cohort studies are most widely used. However, their setting up requires specific organization, delay, money and also use of large databases, which are not often specifically built for evaluation of ADRs. In the present issue of the journal, clinical pharmacologists and pharmacoepidemiologists from Poitiers University Hospital (France) have used another method, working from the French PharmacoVigilance database. They used disproportionality analysis for identification of memory disorders associated with drugs [1]. The present paper discusses the benefits and strengths of this method. As far as we know, the first time this approach was used was in the early 1980s in the field of drug safety during pregnancy. The question of a possible relation between valproic acid and spina bifida aperta was investigated by Robert [2] after a cluster of case reports in France from the Birth Defects Monitoring system in the Rhone-Alpes region (East France). Robert compared exposure to valproic acid in 146 women with infants suffering from spina bifida aperta and in 6616 other mothers with infants suffering from different malformations. They found a strong significant association, with an odds ratio of 20 and a P value <0.00001. This approach, called ‘case–control study’ in the original paper, was really the first performed case–noncase study. Following this first signal, further studies confirmed the teratogenicity of valproic acid in the first trimester of pregnancy. The second historical example was the investigation of a potential higher risk of serum-sickness-like syndrome related to cefaclor [3]. After the report of several cases in the early 1990s, Stricker and Tijssen performed a ‘nested case–control study’ in the WHO Collaborating Centre for International Drug Monitoring Database, including reports from the USA, UK, Sweden, Canada and Germany for the period 1968–1987. They defined an ADR reporting odds ratio (ROR) as the ratio of the odds of the number of ADR reports of serum sickness in relation to cefaclor and amoxicillin or cephalexin and the odds of other reports on the same drugs. Using this case–noncase approach, they were able to identify that cefaclor had a significantly higher risk for serum-sickness-like syndrome compared with the two other antibiotics. During the 1990s, the databases collecting suspected ADR reports had grown, reaching sizes of more than several thousands or millions, thus making routine and regular quantitative screening a necessity. This data mining in these large databases has become a necessity in order to help pharmacovigilance systems to identify early signals for specific ADRs. Various statistical measures have been proposed for the application of computer-assisted quantitative signal detection procedures. Data mining encompasses a number of statistical techniques, including cluster analysis, link analysis, deviation detection and disproportionality assessment, which can be used to determine the presence of and to assess the strength of ADR signals. The use of a measure of disproportionality is currently applied in various national spontaneous reporting centres, as well as in the WHO Monitoring Centre. Several point estimates, such as ROR and proportional ADR reporting ratio (PRR), have been proposed, in order to analyse, for example, the UK Yellow Card Scheme spontaneous reporting database. Furthermore, the chance of the number of reports being reported in a certain combination with the assumption that no relation exists between the reported suspected ADR and the suspected medication can be calculated by means of the Poisson probability. Another approach is the use of Bayesian logic, specifying the relation between the prior and posterior probability before and after linking data fields, and of adding new data to the database. This method is currently used, for example by the WHO Monitoring Centre in the Bayesian confidence propagation neural network analysis (BCPNN). The statistical measures of disproportionality all express the extent to which the reported ADR is associated with the suspected drug compared with the other drugs in the database. The occurrence of ADRs related to other drugs in the database is used as a proxy for the background incidence of ADRs, when calculating the PRR. Calculations of measures of disproportionality are based upon a two-by-two contingency table (Table 1). Since all the measures of disproportionality are based on the same principles of calculation using the two-by-two table, results should be closely concordant. The abundant literature on this topic underlines that several quantitative methods are now available. However, none is universally better than the others. The different measures of disproportionality have both advantages and disadvantages, and the good choice relies upon on the specific data set and the aims of the screening. In a paper comparing the advantages of the ROR over the PRR, Rothman et al. [4] argued that the best way to deal with the weakness of the spontaneous reporting database should be to treat the data as source data for a case–control study. In this way, this ‘case–noncase’ approach focuses on the importance of the judicious choice of controls for the comparison, and highlights the inherent weakness in spontaneous reporting rata, which is very important for an optimal interpretation of such results. Disproportionality analysis is quick and inexpensive and, with some important precautions, is able to give valuable information on ADRs and drug safety. The main use for this method is to confirm (or not) a potential association based on a pharmacological hypothesis between a specific drug and an ADR. This can be illustrated by the relation between pioglitazone and bladder cancer. Experimental data support a potential association, because glitazones are peroxisome proliferator-activated receptor (PPAR) agonists. Studies in rats exposed to PPAR agonists indicated that tumours occurred in several tissues, with a distribution similar to that of PPARs. Clinical data (clinical trials and case reports) suggested the same association. Finally, a recent case–noncase study in the Food and Drug Administration (FDA) Adverse Event Reporting System (AERS) between 2004 and 2009 found a significant risk for pioglitazone (ROR = 4.30; 95% confidence interval 2.82–6.52). The risk of bladder cancer was less consistent for other hypoglycaemic drugs [5]. In this situation of a pharmacological hypothesis, the advantage of the disproportionality method is the speed of its implementation. For example, we were able to demonstrate that rofecoxib exposure was significantly associated with a high ROR value (4.2) for thrombotic ADRs in the French PharmacoVigilance database, as early as the end of 2001, i.e. only 19 months after rofecoxib marketing [6]. Rofecoxib was only withdrawn from the market in September 2004. Another example of this method to quickly investigate a health problem involving drugs could be severe necrotizing soft-tissue infections and nonsteroidal anti-inflammatory drugs. The case–noncase analysis performed in the French PharmacoVigilance database [7] led to the same conclusions as a case–control study, a method more expensive, longer and more difficult to perform. Thus, this method could be proposed, in a context of signal detection, for testing a working hypothesis before performing larger pharmacoepidemiological studies (case–control or cohort studies). Another important use for this method is validation of a pharmacological hypothesis about the mechanism of occurrence of ADRs. A nice example was the investigation of anti-human ether-a-go-go-related gene (HERG) activity of 52 proarrhythmic drugs and the risk of drug-induced arrhythmias [8]. The study was performed using the database of the WHO International Drug Monitoring Program. A positive association between anti-HERG activity and the risk of severe ventricular arrhythmias and sudden deaths was found. Drugs which bind to HERG potassium channels in concentrations close to therapeutic plasma concentrations were shown to have a high risk of reports of serious ventricular arrhythmias and sudden deaths. This finding facilitates understanding of the mechanism of occurrence of such effects in humans, and could help to predict proarrhythmic effects of drugs by defining the value of preclinical HERG testing. A third application of the disproportionality methods concerns rare and/or nonspecific ADRs. For example, dilated cardiomyopathy is a common disease, which can be either idiopathic or the result of several aetiologies: genetic, viral or immune. Less frequently, it could be related to some toxic agents or drugs. A case–noncase study using the French PharmacoVigilance database was able to describe an association with some already suspected drugs (such as anthracyclines and antiretrovirals), but also with other drugs (antipsychotics, lithium, antidepressants and retinoids) less known to induce such an ADR [9]. This finding represents a pharmacovigilance signal which needs to be investigated by future prospective studies. Memory disorders are another example of a nonspecific ADR with several other nonpharmacological explanations. Thus, the impact of drugs in memory disorders could be minimized. The case–noncase study published by the French team of pharmacoepidemiology from Poitiers University Hospital in the present issue and performed using the French PharmacoVigilance database confirmed an association between memory disorders and some drugs, such as benzodiazepines or anticonvulsants, but also found an association with other drugs, such as ‘benzodiazepine-like’ hypnotics (zolpidem and zopiclone), newer anticonvulsants, serotoninergic antidepressants, isotretinoin or cyclosporine [1]. The final application of disproportionality methods could be to generate automatic signals from large postmarketing or pharmacovigilance databases. As the complete safety profile of a drug can be described only after its marketing approval, surveillance systems are needed, and suspected ADRs are now collected in very large databases. As the volume of these data is continuously growing, data mining with measures of disproportionality is being used more and more in order to detect new, previously unknown, ADRs as soon as possible after a drug is marketed. For example, such a method was used to detect the pregabalin dependence potential in the Swedish national register of adverse drug reactions (SWEDIS) [10]. This study led to the addition of warnings on pregabalin abuse potential in the Summary of Product Characteristics in April and June 2010. However, this conclusion should be challenged. Several experiments have recently shown clearly that use of this approach to automatically generate signals on drug safety is not always satisfactory. In fact, a case–noncase analysis necessitates a double analysis: firstly, a pharmacological one and secondly, a medical one. All disproportionality analysis in a pharmacovigilance database requires a clear pharmacodynamic hypothesis established on basic properties of drugs. Several examples are given in the present paper, such as the carcinogenic properties of pioglitazone on bladder [5], the thrombotic risk of coxibs [6] and the involvement of nonsteroidal anti-inflammatory drugs in necrotizing soft-tissue infections [7]. This case–noncase method cannot be used for investigating all risks of all drugs without a strong basic pharmacodynamic hypothesis. For example, a systematic investigation of a cancer or depression risk for drugs (whatever their class) using this approach in such a database without a biological hypothesis has no sense and could lead (and does lead) to false findings. Another comment about this disproportionality analysis concerns validation of cases. In order to obtain valid results, it is necessary that, before analysis, each ADR report is validated once again in the context of the pharmacological and medical questions of the study. If not, it could induce false results without clinical meaning. Finally, it is important to recall that these disproportionality studies should be only considered as exploratory in a context of signal detection. They do not allow quantification of the true risk. For example, ROR only investigates an increased risk of ADR reporting and not risk of ADR occurrence in absolute terms. Despite its inherent limits, disproportionality analysis in pharmacovigilance databases is now a validated method in drug safety research and surveillance, although this kind of approach should only be considered as exploratory to generate signals. Finding of a disproportionality ratio for a drug should lead to a new reinvestigation of data from experimental pharmacology and randomized clinical trials. It should also stimulate specific case–control or cohort analysis to confirm the signal. This paper clearly underlines that none of the methods described above and taken alone (experimental data, clinical trials, spontaneous notifications, case–control studies, cohort studies and data mining) should be considered as definitive for evaluating drug risk. It is only the convergence of proofs which allows final conclusions and decisions in pharmacovigilance. Thus, the notion of ‘levels of evidence’, widely used for evaluating drug efficacy, cannot be applied in the field of ADRs; all methods are of interest for evaluation of ADRs. Finally, the ease with which disproportionality studies can be performed appears to be important today, when there is a growing demand for more safe drugs. There are no competing interests to declare.

Atrial natriuretic peptide (ANP) receptors have been described on rodent adipocytes and expression of their mRNA is found in human adipose tissue. However, no biological effects associated with the stimulation of these receptors have been reported in this tissue. A putative lipolytic effect of natriuretic peptides was investigated in human adipose tissue. On isolated fat cells, ANP and brain natriuretic peptide (BNP) stimulated lipolysis as much as isoproterenol, a nonselective beta-adrenergic receptor agonist, whereas C-type natriuretic peptide (CNP) had the lowest lipolytic effect. In situ microdialysis experiments confirmed the potent lipolytic effect of ANP in abdominal s.c. adipose tissue of healthy subjects. A high level of ANP binding sites was identified in human adipocytes. The potency order defined in lipolysis (ANP > BNP > CNP) and the ANP-induced cGMP production sustained the presence of type A natriuretic peptide receptor in human fat cells. Activation or inhibition of cGMP-inhibited phosphodiesterase (PDE-3B) (using insulin and OPC 3911, respectively) did not modify ANP-induced lipolysis whereas the isoproterenol effect was decreased or increased. Moreover, inhibition of adenylyl cyclase activity (using a mixture of alpha(2)-adrenergic and adenosine A1 agonists receptors) did not change ANP- but suppressed isoproterenol-induced lipolysis. The noninvolvement of the PDE-3B was finally confirmed by measuring its activity under ANP stimulation. Thus, we demonstrate that natriuretic peptides are a new pathway controlling human adipose tissue lipolysis operating via a cGMP-dependent pathway that does not involve PDE-3B inhibition and cAMP production.

To revalidate the Freezing of Gait Questionnaire (FOG-Q), patients with Parkinson's disease (PD) were randomly assigned to receive rasagiline (1 mg/day) (n = 150), entacapone (200 mg with each dose of levodopa) (n = 150), or placebo (n = 154). Patients were assessed at baseline and after 10 weeks using the FOG-Q, Unified Parkinson's Disease Rating Scale (UPDRS), Beck Depression Inventory (BDI), and Parkinson's Disease Questionnaire (PDQ-39). FOG-Q dimensionality, test-retest reliability, and internal reliability were examined. Convergent and divergent validities were assessed by correlating FOG-Q with UPDRS, BDI, and PDQ-39. Comparisons between FOG-Q item 3 and UPDRS item 14 were also made. Principal component analysis indicated that FOG-Q measures a single dimension. Test-retest reliability and internal reliability of FOG-Q score was high. FOG-Q was best correlated to items of the UPDRS relating to walking, general motor issues, and mobility. Correlations between baseline and endpoint suggested that FOG-Q item 3 is at least as reliable as UPDRS item 14. At baseline, 85.9% of patients were identified as "Freezers" using FOG-Q item 3 (> or =1) and 44.1% using UPDRS item 14 (> or =1) (P < 0.001). FOG-Q was a reliable tool for the assessment of treatment intervention. FOG-Q item 3 was effective as a screening question for the presence of FOG.

Preparation of a propolis extract was codified, conditions of pulverization, extraction and treatment of the extractive solution are specified. The wounds healing properties of this extract are related to flavonoids and phenolic acids, which were identified by TLC.

The alpha-isoform of the peroxisome proliferator-activated receptor (PPARalpha) is a nuclear transcription factor activated by structurally diverse chemicals referred to as peroxisome proliferators. Activators can be endogenous molecules (fatty acids/steroids) or xenobiotics (fibrate lipid-lowering drugs). Upon pharmacological activation, PPARalpha modulates target genes encoding lipid metabolism enzymes, lipid transporters, or apolipoproteins, suggesting a role in lipid homeostasis. Transgenic mice deficient in PPARalpha were shown to lack hepatic peroxisomal proliferation and have an impaired expression and induction of several hepatic target genes. Young adult males show hypercholesterolemia but normal triglycerides. Using a long term experimental set up, we identified these mice as a model of monogenic, spontaneous, late onset obesity with stable caloric intake and a marked sexual dimorphism. Serum triglycerides, elevated in aged animals, are higher in females that develop a more pronounced obesity than males. The latter show a marked and original centrilobular-restricted steatosis and a delayed occurrence of obesity. Fat cells from their liver express substantial levels of PPARgamma2 transcripts when compared with lean cells. These studies demonstrate, in rodents, the involvement of PPARalpha nuclear receptor in lipid homeostasis, with a sexually dimorphic control of circulating lipids, fat storage, and obesity. Characterization of this pathological link may help to delineate new molecular targets for therapeutic intervention and could lead to new insights into the etiology and heritability of mammalian obesity.

OBJECTIVES: To investigate the prevalence of orthostatic hypotension and the nature of the postural events related to a fall in blood pressure in patients with Parkinson's disease. METHODS: Blood pressure was measured first in a supine position after a rest of at least 15 minutes and every minute during 10 minutes of an active standing up procedure. Orthostatic hypotension was considered as present when a fall of at least 20 mm Hg of systolic blood pressure was recorded. Postural events which occurred during the standing test were identified from a questionnaire and self reporting. Statistical analysis was performed to determine the relation between orthostatic hypotension and disease characteristics (duration, severity) and the use of antiparkinsonian drugs. Ninety one consecutive patients with Parkinson's disease (48 women, 43 men, mean age 66 (SD 9) years) participated to the study. RESULTS: A fall of at least 20 mm Hg of systolic blood pressure was found in 58.2% of the patients. Orthostatic hypotension was asymptomatic in 38.5% and associated with postural events in 19.8% of the patients. Symptomatic (but not asymptomatic) orthostatic hypotension was related to duration and severity of the disease and with the use of higher daily levodopa and bromocriptine doses. The analysis of the relation between the postural symptoms (and the need for standing test abortion) with the fall in systolic blood pressure allowed the identification of six clinical criteria specific of orthostatic hypotension. A direct relation between the postural changes in systolic blood pressure and the number of clinical events in this clinical scale was found. CONCLUSION: The frequency of orthostatic hypotension in Parkinson's disease is high and it is possible to establish a clinical rating scale which could be used to assess the effects of drugs employed in the management of orthostatic hypotension.

Patients suffering from Parkinson's disease (PD) frequently experienced painful sensations that could be in part due to central modification of nociception. We compared pain threshold before and after administration of levodopa in PD patients and in controls, and investigated cerebral activity with positron emission tomography (PET) during experimental nociceptive stimulation. Pain threshold was determined using thermal stimulation during two randomized conditions: off and on. We performed H(2) (15)O PET analysis of regional cerebral blood flow on subjects while they received alternate randomized noxious and innocuous stimuli during off and on conditions. In off condition, pain threshold in nine PD patients was significantly lower than in nine controls. Administration of levodopa significantly raised pain threshold in PD patients but not in controls. During off condition, there was a significant increase in pain-induced activation in right insula and prefrontal and left anterior cingulate cortices in PD compared to control group. Levodopa significantly reduced pain-induced activation in these areas in PD. This study shows that pain threshold is lower in PD patients but returns to normal ranges after levodopa administration. Moreover, PD patients have higher pain-induced activation in nociceptive pathways, which can be reduced by levodopa.

The X-ray structure of Escherichia coli TEM1 beta-lactamase has been refined to a crystallographic R-factor of 16.4% for 22,510 reflections between 5.0 and 1.8 A resolution; 199 water molecules and 1 sulphate ion were included in refinement. Except for the tips of a few solvent-exposed side chains, all protein atoms have clear electron density and refined to an average atomic temperature factor of 11 A2. The estimated coordinates error is 0.17 A. The substrate binding site is located at the interface of the two domains of the protein and contains 4 water molecules and the sulphate anion. One of these solvent molecules is found at hydrogen bond distance from S70 and E166. S70 and S130 are hydrogen bonded to K73 and K234, respectively. It was found that the E. coli TEM1 and Staphylococcus aureus PC1 beta-lactamases crystal structures differ in the relative orientations of the two domains composing the enzymes, which result in a narrowed substrate binding cavity in the TEM1 enzyme. Local but significant differences in the vicinity of this site may explain the occurrence of TEM1 natural mutants with extended substrate specificities.

Apathy is a common condition in Parkinson's disease (PD) and is generally defined as a lack of motivation. It is associated with more severe cognitive dysfunction and a decrease in activities of daily living (ADL) performance. Anhedonia, the inability to experience pleasure, can be a symptom of both depressive and apathetic syndromes. The Movement Disorder Society (MDS) commissioned a task force to assess the clinimetric properties of apathy and anhedonia scales in PD patients. A systematic literature review was conducted to identify scales that have either been validated or used in PD patients. Apathy scales identified for review include the Apathy Evaluation Scale (AES), the Apathy Scale (AS), the Apathy Inventory (AI), and the Lille Apathy Rating Scale (LARS). In addition, item 4 (motivation/initiative) of the Unified Parkinson's Disease Rating Scale (UPDRS) and item 7 (apathy) of the Neuropsychiatric Inventory (NPI) were included. Anhedonia scales identified for review were the Snaith-Hamilton Pleasure Scale (SHAPS) and the Chapman scales for physical and social anhedonia. Only the AS is classified as "recommended" to assess apathy in PD. Although item 4 of the UPDRS also meets the criteria to be classified as recommended, it should be considered for screening only because of the obvious limitations of a single item construct. For the assessment of anhedonia, only the SHAPS meets the criteria of "Suggested." Information on the validity of apathy and anhedonia scales is limited because of the lack of consensus on diagnostic criteria for these conditions.

French health insurance databases are organized since 2003 into a huge digital data warehouse, the Système national d’information inter-régime de l’assurance maladie (SNIIR-AM). It covers the entire French population (65 million inhabitants). In order to facilitate studies on more frequent conditions, a random sample of 1/97th of national health system beneficiaries has been built since 2005, called the échantillon généraliste des bénéficiaires (EGB). The aim of this article is to describe the main characteristics of the SNIIR-AM and the EGB, to detail their accessibility according to French law, and to present their strengths and limits. It is illustrated with the most recent studies conducted in these databases. These databases include demographic, out-hospital reimbursement (including drug dispensing), medical (costly long-term diseases, occupational diseases, sick-leaves…), and in-hospital data. All these data are prospectively recorded, individualized, made anonymous and linkable. Consequently, the SNIIR-AM is a very useful data source for epidemiological, pharmacoepidemiological and health economics studies, particularly for rare diseases. The EGB is appropriate for long-term research on more frequent diseases. Les bases de données de l’assurance maladie sont collectées depuis 2003 dans un vaste entrepôt numérique, le Système national d’information inter-régime de l’assurance maladie (SNIIR-AM). La résultante en est une des plus grandes bases médico-administratives au monde, couvrant 65 millions de personnes. Afin de faciliter l’étude de cohortes de patients atteints de maladies plus fréquentes, un échantillon au 1/97e des assurés à l’assurance maladie a été constitué depuis 2005 : l’échantillon généraliste des bénéficiaires (EGB). L’objectif de cette mise au point est de présenter les grandes lignes de l’architecture du SNIIR-AM et de l’EGB, leurs modalités d’accès, leurs intérêts et leurs limites. Leur potentiel en recherche médicale est illustré par les publications les plus récentes. Ces bases de données contiennent des données démographiques, les données de remboursements des prestations ambulatoires (dont les délivrances de médicaments), les données médicales des régimes de l’assurance maladie (affections de longue durée, maladies professionnelles, arrêts de travail…) et les données hospitalières issues du programme de médicalisation des systèmes d’information. Toutes ces données sont individuelles, prospectivement recueillies, anonymisées et chaînables. Tout cela fait du SNIIR-AM une source de données très intéressante pour la recherche épidémiologique, pharmacoépidémiologique et en économie de la santé, particulièrement pour les maladies rares. L’EGB est particulièrement utile à l’étude des maladies plus fréquentes et sur le long terme.

IMPORTANCE: Freezing of gait (FOG) is a common axial symptom of Parkinson disease (PD). OBJECTIVE: To determine the prevalence of FOG in a large group of PD patients, assess its relationship with quality of life and clinical and pharmacological factors, and explore its changes from the off to on conditions in patients with motor fluctuations. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional survey of 683 patients with idiopathic PD. Scores for FOG were missing in 11 patients who were not included in the analysis. Patients were recruited from referral centers and general neurology clinics in public or private institutions in France. EXPOSURE: Patients with FOG were identified as those with a score of 1 or greater on item 14 of the Unified Parkinson's Disease Rating Scale (UPDRS) in the on condition. Item 14 scores for FOG in the off condition were also collected in patients with fluctuating motor symptoms. MAIN OUTCOMES AND MEASURES: Quality of life (measured by the 39-item Parkinson's Disease Questionnaire and 36-Item Short Form Health Survey), anxiety and depression (Hospital Anxiety and Depression Scale), clinical features (UPDRS), and drug consumption. RESULTS: Of 672 PD patients, 257 reported FOG during the onstate (38.2%), which was significantly related to lower quality of life scores (P < .01). Freezing of gait was also correlated with longer PD duration (odds ratio, 1.92 [95% CI, 1.28-2.86]), higher UPDRS parts II and III scores (4.67 [3.21-6.78]), the presence of apathy (UPDRS item 4) (1.94 [1.33-2.82]), a higher levodopa equivalent daily dose (1.63 [1.09-2.43]), and more frequent exposure to antimuscarinics (3.07 [1.35-6.97]) (logistic regression). The FOG score improved from the off to on states in 148 of 174 patients with motor fluctuations (85.1%) and showed no change in 13.8%. The FOG score improved by more than 50% in 43.7% of patients. Greater improvement in the on state was observed in younger patients (r = -0.25; P < .01) with lower UPDRS II and III scores (r = -0.50; P < .01) and no antimuscarinic use (r = -0.21; P < .01). CONCLUSIONS AND RELEVANCE: Freezing of gait in PD patients correlates with poor quality of life, disease severity, apathy, and exposure to antimuscarinics. Dopaminergic therapy improved FOG in most patients with motor fluctuations, especially younger ones with less severe disease and no antimuscarinic use. This finding suggests that quality of life is impaired in PD patients with FOG and that optimizing dopaminergic therapy and avoiding antimuscarinics should be considered.

Amongst the various routes of drug delivery, the field of ocular drug delivery is one of the most interesting and challenging endeavors facing the pharmaceutical scientist. Recent research has focused on the characteristic advantages and limitations of the various drug delivery systems, and further research will be required before the ideal system can be developed. Administration of drugs to the ocular region with conventional delivery systems leads to short contact time of the formulations on the epithelium and fast elimination of drugs. This transient residence time involves poor bioavailability of drugs which can be explained by the tear production, non-productive absorption and impermeability of corneal epithelium. Anatomy of the eye is shortly presented and is connected with ophthalmic delivery and bioavailability of drugs. In the present update on ocular dosage forms, chemical delivery systems such as prodrugs, the use of cyclodextrins to increase solubility of various drugs, the concept of penetration enhancers and other ocular drug delivery systems such as polymeric gels, bioadhesive hydrogels, in-situ forming gels with temperature-, pH-, or osmotically induced gelation, combination of polymers and colloidal systems such as liposomes, niosomes, cubosomes, microemulsions, nanoemulsions and nanoparticles are discussed. Novel ophthalmic delivery systems propose the use of many excipients to increase the viscosity or the bioadhesion of the product. New formulations like gels or colloidal systems have been tested with numerous active substances by in vitro and in vivo studies. Sustained drug release and increase in drug bioavailability have been obtained, offering the promise of innovation in drug delivery systems for ocular administration. Combining different properties of pharmaceutical formulations appears to offer a genuine synergy in bioavailability and sustained release. Promising results are obtained with colloidal systems which present very comfortable conditions of use and prolonged action.

Health-related quality of life is an important patient-reported outcome used in intervention trials and for monitoring the consequences of health status on physical, mental, and social domains. Parkinson's disease is a complex disorder that strongly affects patients' quality of life. Several health-related quality of life tools have been used in Parkinson's disease. A Movement Disorder Society Task Force was commissioned to rate the psychometric quality of available health-related quality of life scales as applied to Parkinson's disease. Following the methodology adopted by previous work of the Movement Disorder Society Task Force, a review of generic and specific health-related quality of life scales applied in studies on Parkinson's disease was completed. Considering the scales from 3 perspectives-use in Parkinson's disease, use by multiple research groups, and clinimetric properties-a final classification as "recommended," "suggested," or "listed" was applied to each reviewed instrument. Four generic scales (EuroQoL, Nottingham Health Profile, 36-Item Short-Form Health Survey, and Sickness Impact Profile) and 5 specific scales (39-Item Parkinson's Disease Questionnaire, Parkinson's Disease Questionnaire Short Form, Parkinson's Disease Quality of Life Questionnaire, Parkinson's Impact Scale, and Scales for Outcomes in Parkinson's Disease-Psychosocial) reached the level of "recommended." The 39-item Parkinson's Disease Questionnaire is the most thoroughly tested and applied questionnaire. Three other generic measures (Quality of Life Questionnaire 15D, Schedule for the Evaluation of Individual Quality of Life-Direct Weighting, and World Health Organization Quality of Life Assessment Short Version) and the specific Parkinson's Disease Quality of Life Scale are "suggested." With a little additional effort in completing the stipulated requirements, they could reach the "recommended" level. At present there is a wide variety of health-related quality of life measures for application in the Parkinson's disease setting, and the task force does not recommend the development of a new scale. Selection of the most appropriate instrument for a particular objective requires consideration of the characteristics of each scale and the goals of the assessment.