The evolution of diagnosis in early Parkinson disease
The evolution of diagnosis in early Parkinson disease
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DOI：
10.1001/archneur.57.3.369
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发表时间：
2000-03-01
影响因子：
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通讯作者：
Perl, DP
中科院分区：
文献类型：
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作者：
Jankovic, J;Rajput, AH;Perl, DP
背景：由于帕金森病（PD）没有诊断性生物学标志物，诊断基于临床评估结果。随着时间推移和反复评估，诊断准确性会提高。仅要求纳入帕金森病早期病例的研究存在诊断难题。先前的研究得出结论，当患者在尸检时接受检查，普通神经科医生对帕金森病的初始诊断在24% - 35%的病例中是不正确的。运动障碍专家对帕金森病的初始诊断预计具有更高的准确性。
目的：确定由帕金森病专家最初做出的早期帕金森病患者临床诊断的演变。
设计：800名有轻度帕金森症状（霍恩和亚尔分级为1级或2级）且在研究开始前不到5年被诊断为帕金森病的患者被纳入最初的帕金森病司来吉兰和生育酚抗氧化治疗研究。对这些患者进行前瞻性随访并反复进行临床评估。使用以下临床标准重新评估初始诊断：研究者对帕金森病诊断的信心、非典型临床特征的存在、影像学研究结果、对左旋多巴的反应以及尸检结果。
结果：800例患者入组时患病的平均±标准差病程为2.2±1.3年，平均±标准差霍恩和亚尔分级为1.6±0.5。平均±标准差随访时间为6.0±1.4年（范围为0.2 - 7.6年）。5例患者尸检未确诊帕金森病，15例患者影像学研究结果显示存在其他病理状况。在550例接受左旋多巴治疗的患者中，49例（8.9%）改善甚微或无改善；其中6例与尸检或影像学研究排除标准有重叠。另外2例至少有6项非典型临床特征中的4项，不支持帕金森病诊断。因此，根据研究标准，800例患者中有65例（8.1%）没有患帕金森病。与最终诊断为帕金森病的患者相比，在60例未进行尸检的诊断中，症状持续时间（平均±标准差，7.2±2.0年对8.3±1.9年；P <.001）和随访持续时间（5.3±1.6年对6.1±1.3年；P <.001）更短。
结论：我们发现，最初被诊断为帕金森病的患者中有65例（8.1%）后来根据多因素临床诊断标准被发现有其他诊断。这种其他诊断表明，在7.6年的随访期间，帕金森病专家很少改变他们的诊断。
Context: Since there is no diagnostic biological marker for Parkinson disease (PD), the diagnosis is based on the results of clinical assessment. The accuracy of diagnosis improves with time and repeated assessments. Studies that require only inclusion of early cases of PD present a diagnostic challenge. Previous studies concluded that initial diagnoses of PD made by general neurologists were incorrect in 24% to 35% of the cases when patients were examined at autopsy. Experts in movement disorders are expected to have greater accuracy of initial diagnosis of PD.Objective: To determine the evolution of clinical diagnosis in patients with early PD made initially by experts in PD.Design: Eight hundred patients with mild parkinsonian symptoms (Hoehn and Yahr stage 1 or 2) who received a diagnosis of PD less than 5 years before the beginning of the study were included in the original Deprenyl and Tocopherol Antioxidative Therapy for Parkinson's Disease study. These patients were followed up prospectively with repeated clinical assessments. The following clinical criteria were used to reassess the initial diagnosis: investigator's confidence in the diagnosis of PD, presence of atypical clinical features, findings of imaging studies, response to levodopa, and results of autopsy examinations.Results: The mean +/- SD duration of illness in the 800 cases at enrollment was 2.2 +/- 1.3 years, and the mean +/- SD Hoehn and Yahr stage was 1.6 +/- 0.5. The mean +/- SD follow-up was 6.0 +/- 1.4 years (range, 0.2-7.6 years). In 5 cases, PD was not confirmed at autopsy, and in 15 patients, the results of imaging studies indicated the presence of other pathological conditions. Of the 550 cases treated with levodopa, 49 (8.9%) had little or no improvement; 6 of these cases overlap with either autopsy or imaging study exclusion criteria. Two other cases had at least 4 of the 6 atypical clinical features arguing against the diagnosis of PD. Thus, of the 800 patients, 65 (8.1%) did not have PD according to the study criteria. Compared with those patients with the final diagnosis of PD, in the diagnoses of 60 patients without autopsy, the duration of symptoms (mean +/- SD, 7.2 +/- 2.0 years vs 8.3 +/- 1.9 years; P < .001) and the duration of follow-up (5.3 +/- 1.6 years vs 6.1 +/- 1.3 years; P(.001) were shorter.Conclusions: We found that 65 (8.1%) of patients initially diagnosed as having PD were later found to have an alternate diagnosis based on multifactorial clinical diagnostic criteria. This alternate diagnosis indicated that experts in PD changed their diagnoses infrequently during the 7.6-year follow-up.