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Background: Exposure to pesticides has been linked to Parkinson's disease (PD), although associations between specific pesticides and PD have not been well studied. Residents of rural areas can be exposed through environmental drift and volatilization of agricultural pesticides. Objectives: Our aim was to investigate the association between lifetime environmental exposure to individual pesticides and the risk of PD, in a national case-control study. Methods: Environmental exposure to pesticides was estimated using a spatio-temporal model, based on agricultural crops around the residential address. Distance up to 100m from the residence was considered most relevant, considering pesticide drift potential of application methods used in the Netherlands. Exposure estimates were generated for 157 pesticides, used during the study period, of which four (i.e. paraquat, maneb, lindane, benomyl) were considered a priori relevant for PD. Results: A total of 352 PD cases and 607 hospital-based controls were included. No significant associations with PD were found for the a priori pesticides. In a hypothesis generating analysis, including 153 pesticides, increased risk of PD was found for 21 pesticides, mainly used on cereals and potatoes. Results were suggestive for an association between bulb cultivation and PD. Conclusions: For paraquat, risk estimates for the highest cumulative exposure tertile were in line with previously reported elevated risks. Increased risk of PD was observed for exposure to (a cluster of) pesticides used on rotating crops. High correlations limited our ability to identify individual pesticides responsible for this association. This study provides some evidence for an association between environmental exposure to specific pesticides and the risk of PD, and generates new leads for further epidemiological and mechanistic research. Keywords: Environmental exposure, Pesticides, Parkinson's Disease, Case-control study

De eerste beschrijving van de ziekte van Parkinson, ‘On the shaking palsy’ van James Parkinson in 1817,1 deed achteraf niet helemaal recht aan het ziektebeeld, omdat Parkinson vooral de tremor beschreef. Ook sprak hij van ‘intact intellect’. Ruim 50 jaar later, in 1872, voegde Jean-Martin Charcot bradykinesie en rigiditeit aan dit ziektebeeld toe.2 Dit was reden voor Charcot om de term ‘shaking palsy’ (paralysis agitans) te vervangen door ‘de ziekte van Parkinson’. Deze trias – tremor, bradykinesie en rigiditeit – bleef tot in de jaren 60 van de vorige eeuw de kern van de definitie van de ziekte van Parkinson.

Stephen W Pedersen,1 Martin Suedmeyer,2 Louis W C Liu,3 Dirk Domagk,4 Alison Forbes,5 Lars Bergmann,6 Koray Onuk,6 Ashley Yegin,6 Teus van Laar7 1Department of Neurology, Glostrup Hospital, University of Copenhagen, Glostrup, Copenhagen, Denmark; 2Department of Neurology, University of Düesseldorf, Düesseldorf, Germany; 3Division of Gastroenterology, Department of Medicine, University of Toronto, University Health Network, Toronto, ON, Canada; 4Department of Medicine I, Josephs-Hospital Warendorf, Academic Teaching Hospital, University of Muenster, Warendorf, Germany; 5PDNS consultant, AbbVie Inc., Roswell, GA, USA; 6Global Medical Affairs, AbbVie Inc., North Chicago, IL, USA; 7Department of Neurology, University Medical Center Groningen, Groningen, The Netherlands Abstract: A multidisciplinary team (MDT) approach is increasingly recommended in Parkinson’s disease (PD) treatment guidelines, but no standard of care exists for such an approach, and the guidelines do not provide clarification on how it should be implemented. This paper reviews evidence of MDT interventions in people with PD and provides expert clinical perspectives for an MDT approach, with a focus on advanced PD and levodopa–carbidopa intestinal gel (carbidopa–levodopa enteral suspension in the USA). The key recommendations are to enable the best possible treatment of people with PD locally by facilitating a close structured collaboration of different health care professionals working in a fixed network structure; to refer people with PD to established MDT centers in a timely manner; to establish regular meetings for the MDT enabling interdisciplinary exchange and learning; to optimize individual treatment and carefully evaluate available treatment options; to ensure treatment decisions are agreed jointly between people with PD, their caregivers, family, and health care professional; and to include specialists outside of neurology from adjuvant medical departments as necessary when implementing advanced therapies. Keywords: Parkinson’s disease, multidisciplinary team, advanced therapy, levodopa–carbidopa intestinal gel, carbidopa–levodopa enteral suspension