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Laura Medina-Perucha,1 Pablo Gálvez-Hernández,2,3 Ana García-Sangenís,1,4 Ana Moragas,5 Josep María Cots,6 Anna Lanau-Roig,6 Alícia Borrás,2,7 Isabel Amo,2 Nieves Barragán,8 Ramon Monfá,1,4 Carl Llor,1,9 Anna Berenguera1,4,10 1Fundació Institut Universitari per a la recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain; 2Institut Universitari de Pacients (Patients’ University Institut), Universitat Internacional de Catalunya, Barcelona, Spain; 3University of Toronto, IHPME-BFON Collaborative PhD Specialization Program in Health Services and Policy Research, Ontario, Canada; 4Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain; 5Universitat Rovira i Virgili, Jaume I Health Centre, Institut Català de la Salut, Tarragona, Spain; 6La Marina Health Centre, Institut Català de la Salut, Associació d’Infermeria Familiar i Comunitària de Catalunya, Barcelona, Spain; 7Escola Universitària d’Infermeria, Escoles Universitàries Gimbernat, Universitat Autònoma de Barcelona, Sant Cugat del Vallès, Spain; 8Societat Catalana de Medicina Familiar i Comunitària (Camfic), Grupo Programa Comunicación y Salud semFYC. CAP Vallcarca Health Centre, Barcelona, Spain; 9Via Roma Health Centre, Institut Català de la Salut, Barcelona, Spain; 10Departament d’Infermeria, Universitat de Girona, Girona, SpainCorrespondence: Laura Medina-Perucha Gran via de les Corts Catalanes, 587, Attic, Barcelona, 08007, SpainTel +34 93 482 4253 ext. 4761Email lmedina@idiapjgol.infoPurpose: Co-design processes with patients allow developing health education materials, that are adapted to the population’s knowledge and use of language, to reduce inappropriate antibiotic use.Patients and Methods: This study presents a co-design process of educational material with patients (over 18 years old) with a previous diagnosis of acute lower respiratory tract infection. The co-design was framed within a qualitative study (Phase I, interviews; Phase II, focus group) conducted in Barcelona between April and September 2019.Results: Twenty-nine semi-structured interviews were conducted. Six people participated in the focus group. Based on participants’ narratives, educational materials can be useful to support healthcare consultations. Materials should be designed to be accessible in terms of the content and language used.Conclusion: The co-design of educational materials is essential for health promotion. This study presents an example of how materials can be co-developed with patients. The material elaborated in this study is being used for the ISAAC-CAT project and may be useful for future research, practice in health services and health policy.Keywords: health education, co-design, acute respiratory infections, antimicrobial resistance, primary healthcare

Natali Barragan,1 Amanda Batista,1 Deborah L Hall,1 Yasin N Silva2 1School of Social & Behavioral Sciences, Arizona State University, Glendale, AZ, USA; 2Department of Computer Science, Loyola University Chicago, Chicago, IL, USACorrespondence: Deborah L Hall, School of Social & Behavioral Sciences, Arizona State University, 4701 W. Thunderbird Road (MC 3051), Glendale, AZ, 85306, USA, Email d.hall@asu.eduPurpose: Previous research points to a complex relation between social media use and mental health, with open questions remaining with respect to mediation pathways and potential sociodemographic moderators. The present research investigated the extent to which experiences of cyberbullying victimization mediate the link between greater social media use and poorer mental health in adults and whether such indirect effects are moderated by gender or age.Participants and Methods: As part of a larger study, US adults (N = 502) completed an online survey that included measures of degree of social media use, cyberbullying victimization, depression, anxiety, substance use, and sociodemographic characteristics including gender and age.Results: A series of moderated mediation models revealed a robust indirect effect of cyberbullying victimization on the relation between degree of social media use and mental health, such that greater social media use was associated with higher levels of cyberbullying victimization and greater cyberbullying victimization was associated with increased depression, anxiety, and likelihood of substance use. There was no evidence that the mediation effects varied between men and women. Age did, however, moderate the mediation effects for anxiety and likelihood of substance use, with stronger mediation effects emerging for younger compared to older adults.Conclusion: Our findings underscore the importance of empirical investigations that shed a more nuanced light on the complex relation between social media and mental health.Keywords: social media, cyberbullying, depression, anxiety, substance use, gender, age

Between Fall 2017 and Spring 2018, the Los Angeles County Sodium Reduction Initiative interviewed food service management leaders and staff from eight public and private institutions in Southern California (three universities, four hospitals, and one senior meal program) to identify opportunities and challenges in reducing sodium content for the foods they sell, serve, and produce. Interviews were transcribed, collated, and analyzed using content analysis with thematic sorting and coding. Interviewees identified several opportunities: (1) group purchasing through a large organizational membership; (2) a supportive organizational culture; (3) organized strategies to replace high-sodium products; and (4) access to software resources to manage food inventories. Challenges included (1) negative customer/staff receptivity to low-sodium options; (2) lack of kitchen infrastructure/equipment; (3) low availability of healthy foods; and (4) limited program evaluation capacity. Collectively, these findings provide practice-based insights into how these factors contributed to sodium reduction efforts in these institutions.

Oligoclonal IgM bands (OCMB) against myelin lipids predict an aggressive multiple sclerosis (MS) course. However, the clinical significance of OCMB without lipid specificity, present in other MS patients, remains unknown. We describe here a characterization of these antibodies and study their role in MS progression. Fifty-four MS patients showing CSF-restricted OCMB were included in this study at disease onset and followed-up during 61.1 ± 2.7 months. The specificity of OCMB and the CSF B-cell profile were investigated. A second CSF IgM study was performed in a group of eight patients. Thirty-eight patients showed OCMB against myelin lipids (M+L+) and other sixteen had OCMB lacking this specificity (M+L-). The CD5+ B cell subpopulation, responsible for most persistent IgM responses, was considerably higher in M+L+ than in M+L- patients (3.3 ± 0.6% versus 0.8 ±0.2, P =0.009). In addition, M+L+ bands persisted during disease course, while M+L- disappeared during follow-up. M+L+ patients suffered more relapses (4.2 ± 0.6 versus 1.6 ± 0.3, P = 0.002) and reached higher disability (EDSS score of 2.2 ± 0.2 versus 1.2 ± 0.2, P = 0.02) than M+L- group. These data corroborate that anti-lipid OCMB associate with an aggressive MS course and show that OCMB that do not recognize myelin lipids represent a transient immune response related to a more benign disease course. [ABSTRACT FROM AUTHOR]

Abstract Background The non-pharmacological approach to cholesterol control in patients with hyperlipidemia is based on the promotion of a healthy diet and physical activity. Thus, to help patients change their habits, it is essential to identify the most effective approach. Many efforts have been devoted to explain changes in or adherence to specific health behaviors. Such efforts have resulted in the development of theories that have been applied in prevention campaigns, and that include brief advice and counseling services. Within this context, Motivational Interviewing has proven to be effective in changing health behaviors in specific cases. However, more robust evidence is needed on the effectiveness of Motivational Interviewing in treating chronic pathologies -such as dyslipidemia- in patients assisted by general practitioners. This article describes a protocol to assess the effectiveness of MI as compared with general practice (brief advice), with the aim of improving lipid level control in patients with dyslipidemia assisted by a general practitioner. Methods/Design An open, two-arm parallel, multicentre, cluster, controlled, randomized, clinical trial will be performed. A total of 48-50 general practitioners from 35 public primary care centers in Spain will be randomized and will recruit 436 patients with dyslipidemia. They will perform an intervention based either on Motivational Interviewing or on the usual brief advice. After an initial assessment, follow-ups will be performed at 2, 4, 8 and 12 months. Primary outcomes are lipid levels (total cholesterol, HDL cholesterol, LDL cholesterol, triglycerides) and cardiovascular risk. The study will assess the degree of dietary and physical activity improvement, weight loss in overweight patients, and adherence to treatment guidelines. Discussion Motivational interview skills constitute the primary strategies GPs use to treat their patients. Having economical, simple, effective and applicable techniques is essential for primary care professionals to help their patients change their lifestyle and improve their health. This study will provide scientific evidence on the effectiveness of Motivational interviewing, and will be performed under strict control over the data collected, ensuring the maintenance of therapeutic integrity. Trials Registration ClinicalTrials.gov (NCT01282190).

The research-practice gap between evidence-based intervention efficacy and its uptake in real-world contexts remains a central challenge for prevention and implementation science. Providing technical assistance (TA) is considered a crucial support mechanism that can help narrow the gap. However, empirical measurement of TA strategies and their variation is often lacking. The current study unpacks the black box of TA, highlighting different TA strategies, amounts, and their relation to intervention characteristics. First, we qualitatively categorized interactions between TA providers and implementers. Second, we explored how characteristics of implementing organizations and the intervention related to variations in the amount of TA delivered. Using data spanning six years, we analyzed over 10,000 encounters between TA providers and implementers. Content analysis yielded four distinct strategies: Consultation (27.2%), Coordination Logistics (24.5%), Monitoring (16.5%), and Resource Delivery (28.2%). Organizations with prior experience required less monitoring and resource delivery. Additionally, characteristics of the intervention were significantly associated with the amount of consultation, monitoring, coordination logistics, and resource delivery provided. The specific features of the intervention showed significant variation in their relation to TA strategies. These findings provide initial insights into the implications of intervention characteristics in determining how much of which TA strategies are needed to support implementations in real-world settings., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Rheumatoid meningitis (RM) is a rare complication of rheumatoid arthritis that can manifest as stroke-like episodes. We present the case of a 63-year-old woman with a past history of overlap syndrome and clinical manifestations suggestive of amyopathic dermatomyositis, rheumatoid arthritis, and systemic lupus erythematosus. She presented to the emergency department with sudden onset right-sided clumsiness and numbness, as well as a 2-week history of left hemicranial headache. Laboratory workup revealed positive serum antinuclear antibodies, anti-Ro antibodies, anti-citrullinated peptide antibodies (ACPA), and elevated rheumatoid factor. Lymphocytic pleocytosis, positive ACPA and anti-Ro antibodies with passive diffusion pattern, and negative microbiological studies were demonstrated in the CSF. Brain magnetic resonance imaging showed predominant left fronto-parieto-occipital leptomeningeal and pachimeningeal enhancement. She was diagnosed with RM and received methylprednisolone IV mg/kg once daily. Stroke-like episodes in the setting of a patient with lymphocytic pleocytosis in the cerebrospinal fluid (CSF) and meningeal enhancement should raise suspicion of RM. In this context, serum rheumatoid factor and ACPA levels should always be measured and ACPA should also be measured in CSF. To our knowledge, this is the first reported case of RM in the context of an overlap syndrome. ACPA levels in CSF could be a relevant diagnostic clue in the setting of central nervous system disturbance and overlapping autoimmune conditions that include rheumatoid arthritis. In our case, the presence of a suggestive clinical scenario of RM reinforces the probable pathogenic role of ACPA when it is present in the central nervous system, even without intrathecal synthesis evidence., (© Japan College of Rheumatology 2023. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Ageing and its consequences on quality of life is one of the main issues to be addressed by public organizations; therefore the development of tools for its evaluation is a priority issue to orientate lines of action. Therefore, the objective of this research is to carry out cross-cultural adaptation and present the psychometric properties of the Spanish version of the Older People's Quality of Life Questionnaire-Brief (OPQOL-Brief)., Methods: a cross-cultural adaptation was carried out together with a process of translation and back-translation of the scale. The OPQOL-Brief and a sociodemographic questionnaire were administered to 120 older adults aged over 65 from a healthcare setting in the region of Extremadura., Results: the exploratory analysis revealed a factor structure through a matrix of polychoric correlations divided in two intercorrelated factors, consisting of 12 items and with excellent sample adequacy indices (KMO = 0.846'; Bartlett test = 1268.1; p = 0.000). Then, the confirmatory factor analysis established the definitive model with exceptional goodness-of-fit indices (NNFI = 0.99; CFI = 0.99; CMIN/DF = 0.96; Ρ ( χ 2 ) = 0.22; RMSEA = 0.037 and RMSR = 0.040). Finally, Cronbach's alpha and McDonald's omega for internal consistency reported good values of 0.830 and 0.851, respectively., Conclusion: our findings show that the OPQOL-Brief exhibits a solution with 12 elements and related constructs, providing stable goodness-of-fit indicators as well as good and remarkable consistency ratings.

Background: Excessive and inappropriate use of antibiotics is the most important driver of antimicrobial resistance. The aim of the HAPPY PATIENT project is to evaluate the adaptation of European Union (EU) recommendations on the prudent use of antimicrobials in human health by evaluating the impact of a multifaceted intervention targeting different categories of healthcare professionals (HCPs) on common community-acquired infectious diseases, especially respiratory and urinary tract infections., Methods/design: HAPPY PATIENT was initiated in January 2021 and is planned to end in December 2023. The partners of this project include 15 organizations from 9 countries. Diverse HCPs (doctors, nurses, pharmacists, and pharmacy technicians) will be audited by the Audit Project Odense (APO) method before and after an intervention in four different settings: general practice, out of hours services, nursing homes and community pharmacies in four high antibiotic prescribing countries (France, Poland, Greece, and Spain) and one low prescribing country (Lithuania). About 25 individuals from each professional group will be recruited in each country, who will register at least 25 patients with community-acquired infections during each audit period. Shortly before the second registration participants will undertake a multifaceted intervention and will receive the results from the first registration to allow the identification of possible quality problems. At these meetings participants will receive training courses on enhancement of communication skills, dissemination of clinical guidelines with recommendations for diagnosis and treatment, posters for the waiting rooms, and leaflets for patients. The results of the second registration will be compared with those obtained in the first audit., Discussion: HAPPY PATIENT is an EU-funded project aimed at contributing to the battle against antibiotic resistance through improvement of the quality of management of common community-acquired infections based on interventions by different types of HCPs. It is hypothesized that the use of multifaceted strategies combining active intervention will be effective in reducing inappropriate prescribing and dispensing of antibiotics., Study Registration: EU Health programmes project database https://webgate.ec.europa.eu/chafea_pdb/health/projects/900024/summary ; date of registration: 1 January 2021., (© 2022. The Author(s).)

The role of immunosuppression among coronavirus disease 2019 (COVID-19) patients has not been elucidated and management may be challenging. This observational study included confirmed COVID-19 patients. The primary endpoint was the development of moderate-severe acute respiratory distress syndrome (ARDS). Time to moderate-severe ARDS, the need for mechanical or noninvasive ventilation (MV/NIV), death, and a composite of death or MV/NIV were secondary endpoints. Of 138 patients included, 27 (19.6%) were immunosuppressed (IS) and 95 (68.8%) were male, with a median (IQR) age of 68 (54-78) years. A significantly lower proportion of IS patients (25.9%) compared to non-IS patients (52.3%) developed moderate-severe ARDS, in both unadjusted (0.32; 95% CI, 0.13-0.83; p = .017) and adjusted (aOR, 0.25; 95% CI, 0.08-0.80; p = .019) analyses. After stratifying by pathologies, only IS patients with autoimmune diseases remained significant (aOR 0.25; 95% CI, 0.07-0.98; p = .046). Nonsignificant trends toward a longer time to moderate or severe ARDS, a lower need for MV/NIV, and a lower risk of death or MV/NIV were detected among IS. In our cohort of COVID-19 patients, nonsevere immunosuppression was associated with a lower risk of moderate-severe ARDS, especially among AD. This suggests a potential protective effect from a hypothesized hyper-inflammatory response., (© 2020 Wiley Periodicals LLC.)

Breast cancer is the cancer with the most incidence and mortality in women. microRNAs are emerging as novel prognosis/diagnostic tools. Our aim was to identify a serum microRNA signature useful to predict cancer development. We focused on studying the expression levels of 30 microRNAs in the serum of 96 breast cancer patients vs . 92 control individuals. Bioinformatic studies provide a microRNA signature, designated as a predictor, based on the expression levels of five microRNAs. Then, we tested the predictor in a group of 60 randomly chosen women. Lastly, a proteomic study unveiled the overexpression and downregulation of proteins differently expressed in the serum of breast cancer patients vs . that of control individuals. Twenty-six microRNAs differentiate cancer tissue from healthy tissue, and 16 microRNAs differentiate the serum of cancer patients from that of the control group. The tissue expression of miR-99a, miR-497, miR-362, and miR-1274, and the serum levels of miR-141 correlated with patient survival. Moreover, the predictor consisting of miR-125b, miR-29c, miR-16, miR-1260, and miR-451 was able to differentiate breast cancer patients from controls. The predictor was validated in 20 new cases of breast cancer patients and tested in 60 volunteer women, assigning 11 out of 60 women to the cancer group. An association of low levels of miR-16 with a high content of CD44 protein in serum was found. Circulating microRNAs in serum can represent biomarkers for cancer prediction. Their clinical relevance and the potential use of the predictor here described are discussed., (Copyright © 2020 Feliciano, González, Garcia-Mayea, Mir, Artola, Barragán, Martín, Altés, Castellvi, Benavente, Ramón y Cajal, Espinosa-Bravo, Cortés, Rubio and LLeonart.)

Objective: To assess the effectiveness and tolerability of perampanel (PER) monotherapy in routine clinical practice for the treatment of focal onset and generalized tonic-clonic seizures (GTCS)., Methods: This multicenter, retrospective, observational study was conducted in patients aged ≥12 years treated with PER as primary monotherapy or converted to PER monotherapy by progressive reduction of background antiepileptic drugs. Outcomes included retention, responder, and seizure-free rate after 3, 6, and 12 months and tolerability throughout the follow-up., Results: A total of 98 patients (mean age = 49.6 ± 21.7 years, 51% female) with focal seizures and/or GTCS were treated with PER monotherapy for a median exposure of 14 months (range = 1-57) with a median dose of 4 mg (range = 2-10). The retention rates at 3, 6, and 12 months and last follow-up were 93.8%, 89.3%, 80.9%, and 71.4%, respectively. The retention rates according to the type of monotherapy (primary vs conversion) did not differ (log-rank P value = .57). Among the 98 patients, 61.2% patients had seizures throughout the baseline period, with a median seizure frequency of 0.6 seizures per month (range = 0.3-26). Responder rates at 3, 6, and 12 months were 79.6%, 70.1%, and 52.8%, respectively, and seizure freedom rates at the same points were 62.7%, 56.1%, and 41.5%. Regarding the 33 patients who had GTCS in the baseline period, 87.8% were seizure-free at 3 months, 78.1% at 6 months, and 55.1% at 12 months. Over the entire follow-up, PER monotherapy was generally well tolerated, and only 16% of patients discontinued PER due to adverse events (AEs). Female patients were found to be at a higher risk of psychiatric AEs (female vs male odds ratio = 2.85, 95% confidence interval = 1-8.33, P = .046)., Significance: PER demonstrated good effectiveness and a good safety profile when used as primary therapy or conversion to monotherapy at relatively low doses, in a clinical setting with patients with focal seizures and GTCS., (© 2020 International League Against Epilepsy.)

The Americas have an elevated number of leishmaniasis cases (accounting for two-thirds of the worldwide disease burden) and circulating Leishmania species, and are therefore of interest in terms of epidemiological surveillance. Here, we present a systematic review of Leishmania parasite species circulating in the countries of the American continent, together with complementary information on epidemiology and geospatial distribution. A database was built from data published between 1980 and 2018 on Leishmania species identified in most of the American countries. A total of 1499 georeferenced points were extracted from published articles and subsequently located to 14 countries in the Americas. This database could be used as a reference when surveilling the occurrence of Leishmania species in the continent.

Mesial temporal lobe epilepsy (mTLE) is a neurological disorder associated with histopathological changes in different subfields of the hippocampus. These alterations have been associated with memory difficulties. In this study, we tested the hypothesis that these difficulties stem on mnemonic discrimination impairment due to a reduced ability to make similar representations more distinct, leading to an increased susceptibility to interference. With this aim, we used a visual mnemonic discrimination task and evaluated the ability of a group of patients with unilateral mTLE, relative to controls, to discriminate between a studied item and a new foil item, as a function of the similarity between them, and of the number of exemplars from a category stored in memory. We found that patients performed worse than controls when the studied item had to be discriminated from a physically similar new object from the same basic-level category. Crucially, reliable differences between groups were observable in the conditions in which more exemplars from a category were held in memory. In the conditions in which the studied item had to be discriminated from a foil from a different basic-level category, there were no differences between groups, with one exception. Neither a general cognitive impairment nor a general memory impairment could account for this pattern of results. Current findings indicate that patients found more difficulties in conditions with higher interference, which poses greater demands for pattern separation. A disruption of pattern separation processes resulting from hippocampal damage provides a reasonable interpretation for these results. Future studies should explore the causal relationship between hippocampal subfields integrity and mnemonic discrimination capacity in mTLE patients., (Copyright © 2020. Published by Elsevier Inc.)

Background: Despite their marginal benefit, about 60% of acute lower respiratory tract infections (ALRTIs) are currently treated with antibiotics in Catalonia. This study aims to evaluate the effectiveness and efficiency of a continuous disease-focused intervention (C-reactive protein [CRP]) and an illness-focused intervention (enhancement of communication skills to optimise doctor-patient consultations) on antibiotic prescribing in patients with ALRTIs in Catalan primary care centres., Methods/design: A cluster randomised, factorial, controlled trial aimed at including 20 primary care centres (N = 2940 patients) with patients older than 18 years of age presenting for a first consultation with an ALRTI will be included in the study. Primary care centres will be identified on the basis of socioeconomic data and antibiotic consumption. Centres will be randomly assigned according to hierarchical clustering to any of four trial arms: usual care, CRP testing, enhanced communication skills backed up with patient leaflets, or combined interventions. A cost-effectiveness and cost-utility analysis will be performed from the societal and national healthcare system perspectives, and the time horizon of the analysis will be 1 year. Two qualitative studies (pre- and post-clinical trial) aimed to identify the expectations and concerns of patients with ALRTIs and the barriers and facilitators of each intervention arm will be run. Family doctors and nurses assigned to the interventions will participate in a 2-h training workshop before the inception of the trial and will receive a monthly intervention-tailored training module during the year of the trial period. Primary outcomes will be antibiotic use within the first 6 weeks, duration of moderate to severe cough, and the quality-adjusted life-years. Secondary outcomes will be duration of illness and severity of cough measured using a symptom diary, healthcare re-consultations, hospital admissions, and complications. Healthcare costs will be considered and expressed in 2021 euros (year foreseen to finalise the study) of the current year of the analysis. Univariate and multivariate sensitivity analyses will be carried out., Discussion: The ISAAC-CAT project will contribute to evaluate the effectiveness and efficiency of different strategies for more appropriate antibiotic prescribing that are currently out of the scope of the actual clinical guidelines., Trial Registration: ClinicalTrials.gov, NCT03931577.

We report a new transthyretin (ATTR) gene c.272C>G mutation and variant protein, p.Leu32Val, in a kindred of Bolivian origin with a rapid progressive peripheral neuropathy and cardiomyopathy. Three individuals from a kindred with peripheral nerve and cardiac amyloidosis were examined. Analysis of the TTR gene was performed by Sanger direct sequencing. Neuropathologic examination was obtained on the index patient with mass spectrometry study of the ATTR deposition. Direct DNA sequence analysis of exons 2, 3, and 4 of the TTR gene demonstrated a c.272 C>G mutation in exon 2 (p.L32V). Sural nerve biopsy revealed massive amyloid deposition in the perineurium, endoneurium and vasa nervorum. Mass spectrometric analyses of ATTR immunoprecipitated from nerve biopsy showed the presence of both wild-type and variant proteins. The observed mass results for the wild-type and variant proteins were consistent with the predicted values calculated from the genetic analysis data. The ATTR L32V is associated with a severe course. This has implications for treatment of affected individuals and counseling of family members., (© 2017 Peripheral Nerve Society.)

Introduction: Response to drug withdrawal in patients with suspected drug-induced parkinsonism (DIP) is of prognostic and therapeutic importance, but cannot be predicted solely on clinical information. The aim of this study was to validate SN hyperechogenicity (SN+) assessed by transcranial sonography as a predictor of response to drug withdrawal in this group of patients., Methods: Patients were diagnosed according to previously published criteria and prospectively included in the study. All patients were followed until complete recovery of parkinsonian symptoms or at least for 6 months after discontinuation of the offending drug and then diagnosed as DIP or parkinsonism following neuroleptic exposure (PFNE). Transcranial sonography (TCS) findings were compared with the clinical diagnosis., Results: Sixty patients comprised the group for the final analysis. Sixteen patients were classified as PFNE and 44 as DIP. The area of SN echogenicity was significantly increased in the PFNE group (0.23 cm 2 ; standard deviation [SD]: 0.04), compared to the DIP group (0.14 cm 2 ; SD, 0.05; one-way analysis of variance; P < 0.001). Normal SN was significantly associated with complete recovery after withdrawal of the parkinsonism-inducing drug ( P < 0.0005). Accuracy of SN+ to distinguish PFNE from DIP was: sensitivity 81.2%; specificity 84.1%; positive predictive value 47.4%; and negative predictive value 96.2%., Conclusions: We believe that SN+ assessed with TCS is a valid prognostic marker in the setting of suspected DIP. It is a nonexpensive, feasible technique that can be implemented for proper counseling and guidance of treatment decisions.

Objectives: Hyperechogenicity of the substantia nigra on transcranial sonography is used for diagnosing Parkinson disease (PD). Cutoff values for the substantia nigra echogenic area, defining substantia nigra hyperechogenicity, vary among ultrasound systems from different manufacturers. In this study we wanted to determine the cutoff criterion for a Toshiba (Tokyo, Japan) system and to assess its diagnostic value., Methods: Three hundred participants (controls, n = 138; patients with PD, n = 105; and patients with essential tremor, n = 57) underwent transcranial sonography following a standardized protocol., Results: The substantia nigra was assessable in 92.7% of all participants. The substantia nigra echogenic area (larger of bilateral measurements) was larger in patients with PD (mean ± SD, 0.24 ± 0.05 cm(2)) than controls (0.14 ± 0.05 cm(2); P < .001) and patients with essential tremor (0.14 ± 0.04 cm(2); P < .001). Substantia nigra echogenicity was larger in male participants (0.20 ± 0.07 cm(2)) than female participants (0.15 ± 0.06 cm(2); P< .001). Age did not correlate with substantia nigra echogenicity in any group. Frontal horn width was larger and lenticular nucleus hyperechogenicity and a discontinuous raphe were more frequent in the PD group than the other groups. On multivariate analysis, only substantia nigra hyperechogenicity was associated with the diagnosis of PD. The 90th-percentile substantia nigra echogenic area in the control group, which defined marked substantia nigra hyperechogenicity, also represented the optimum cutoff value for discrimination of PD from non-PD participants on receiver operating characteristic curve analysis (area under the curve, 0.913; Youden index, 0.73). This cutoff value (≥0.21 cm(2), larger of bilateral measurements) yielded sensitivity of 83% and specificity of 90% for the diagnosis of PD., Conclusions: Transcranial sonography shows good diagnostic validity for diagnosis of PD when implemented according to a strictly standardized protocol., (© 2013 by the American Institute of Ultrasound in Medicine.)