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Conway Kleven B, Chien LC, Young DL, Cross CL, Labus B, Bernick C. Repetitive head impacts among professional fighters: a pilot study evaluating Traumatic Encephalopathy Syndrome and postural balance. PHYSICIAN SPORTSMED 2024:1-7. [PMID: 38418380 DOI: 10.1080/00913847.2024.2325331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 02/27/2024] [Indexed: 03/01/2024]
Abstract
OBJECTIVES Clinical criteria for Traumatic Encephalopathy Syndrome (ccTES) were developed for research purposes to reflect the clinical symptoms of Chronic Traumatic Encephalopathy (CTE). The aims of this study were to 1) determine whether there was an association between the research diagnosis of TES and impaired postural balance among retired professional fighters, and 2) determine repetitive head impacts (RHI) exposure thresholds among both TES positive and TES negative groups in retired professional fighters when evaluating for balance impairment. METHODS This was a pilot study evaluating postural balance among participants of the Professional Athletes Brain Health Study (PABHS). Among the cohort, 57 retired professional fighters met the criteria for inclusion in this study. A generalized linear model with generalized estimating equations was used to compare various balance measures longitudinally between fighters with and without TES. RESULTS A significant association was observed between a TES diagnosis and worsening performance on double-leg balance assessments when stratifying by RHI exposure thresholds. Additionally, elevated exposure to RHI was significantly associated with increased odds of developing TES; The odds for TES diagnosis were 563% (95% CI = 113, 1963; p-value = 0.0011) greater among athletes with 32 or more professional fights compared to athletes with less than 32 fights when stratifying by balance measures. Likewise, the odds for TES diagnosis were 43% (95% CI = 10, 102; p-value = 0.0439) greater with worsening double leg stance balance in athletes exposed to 32 or more fights. CONCLUSION This pilot study provides preliminary evidence of a relationship between declining postural balance and a TES diagnosis among retired professional fighters with elevated RHI exposure. Further research exploring more complex assessments such as the Functional Gait Assessment may be of benefit to improve clinical understanding of the relationship between TES, RHI, and balance.
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Affiliation(s)
- Brooke Conway Kleven
- Sports Innovation Institute, University of Nevada, Las Vegas, Las Vegas, NV, USA
- School of Public Health, Department of Epidemiology and Biostatistics, University of Nevada, Las Vegas, Las Vegas, NV, USA
| | - Lung-Chang Chien
- School of Public Health, Department of Epidemiology and Biostatistics, University of Nevada, Las Vegas, Las Vegas, NV, USA
| | - Daniel L Young
- School of Integrated Health Sciences, Department of Physical Therapy, University of Nevada, Las Vegas, Las Vegas, NV, USA
| | - Chad L Cross
- School of Public Health, Department of Epidemiology and Biostatistics, University of Nevada, Las Vegas, Las Vegas, NV, USA
| | - Brian Labus
- School of Public Health, Department of Epidemiology and Biostatistics, University of Nevada, Las Vegas, Las Vegas, NV, USA
| | - Charles Bernick
- Department of Neurology, Cleveland Clinic Lou Ruvo Center for Brain Health, Las Vegas, NV, USA
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Conway Kleven BD, Chien LC, Labus B, Cross CL, Ritter A, Randall R, Montes A, Bernick C. Longitudinal Changes in Regional Brain Volumes and Cognition of Professional Fighters With Traumatic Encephalopathy Syndrome. Neurology 2023; 101:e1118-e1126. [PMID: 37380429 PMCID: PMC10513890 DOI: 10.1212/wnl.0000000000207594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 05/12/2023] [Indexed: 06/30/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Due to current limitations in diagnosing chronic traumatic encephalopathy (CTE) clinically, traumatic encephalopathy syndrome (TES) has been proposed as the clinical presentation of suspected CTE. This study aimed to determine whether there was an association between a clinical diagnosis of TES and subsequent temporal decline in cognitive or MRI volumetric measures. METHODS This was a secondary analysis of the Professional Athletes Brain Health Study (PABHS), inclusive of active and retired professional fighters older than 34 years. All athletes were adjudicated as TES positive (TES+) or TES negative (TES-) based on the 2021 clinical criteria. General linear mixed models were used to compare MRI regional brain volumes and cognitive performance between groups. RESULTS A total of 130 fighters met inclusion criteria for consensus conference. Of them, 52 fighters (40%) were adjudicated as TES+. Athletes with a TES+ diagnosis were older and had significantly lower education. Statistically significant interactions and between-group total mean differences were found in all MRI volumetric measurements among the TES+ group compared with those among the TES- group. The rate of volumetric change indicated a significantly greater increase for lateral (estimate = 5,196.65; 95% CI = 2642.65, 7750.66) and inferior lateral ventricles (estimate = 354.28; 95% CI = 159.90, 548.66) and a decrease for the hippocampus (estimate = -385.04, 95% CI = -580.47, -189.62), subcortical gray matter (estimate = -4,641.08; 95% CI = -6783.98, -2498.18), total gray matter (estimate = -26492.00; 95% CI = -50402.00, -2582.32), and posterior corpus callosum (estimate = -147.98; 95% CI = -222.33, -73.62). Likewise, the rate of cognitive decline was significantly greater for reaction time (estimate = 56.31; 95% CI = 26.17, 86.45) and other standardized cognitive scores in the TES+ group. DISCUSSION The 2021 TES criteria clearly distinguishes group differences in the longitudinal presentation of volumetric loss in select brain regions and cognitive decline among professional fighters 35 years and older. This study suggests that a TES diagnosis may be useful in professional sports beyond football, such as boxing and mixed martial arts. These findings further suggest that the application of TES criteria may be valuable clinically in predicting cognitive decline.
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Affiliation(s)
- Brooke D Conway Kleven
- From the School of Public Health (B.D.C.K., L.-C.C., B.L., C.L.C., A.M.), University of Nevada, Las Vegas; and Cleveland Clinic Lou Ruvo Center for Brain Health (A.R., R.R., A.M., C.B.), Las Vegas, NV.
| | - Lung-Chang Chien
- From the School of Public Health (B.D.C.K., L.-C.C., B.L., C.L.C., A.M.), University of Nevada, Las Vegas; and Cleveland Clinic Lou Ruvo Center for Brain Health (A.R., R.R., A.M., C.B.), Las Vegas, NV
| | - Brian Labus
- From the School of Public Health (B.D.C.K., L.-C.C., B.L., C.L.C., A.M.), University of Nevada, Las Vegas; and Cleveland Clinic Lou Ruvo Center for Brain Health (A.R., R.R., A.M., C.B.), Las Vegas, NV
| | - Chad L Cross
- From the School of Public Health (B.D.C.K., L.-C.C., B.L., C.L.C., A.M.), University of Nevada, Las Vegas; and Cleveland Clinic Lou Ruvo Center for Brain Health (A.R., R.R., A.M., C.B.), Las Vegas, NV
| | - Aaron Ritter
- From the School of Public Health (B.D.C.K., L.-C.C., B.L., C.L.C., A.M.), University of Nevada, Las Vegas; and Cleveland Clinic Lou Ruvo Center for Brain Health (A.R., R.R., A.M., C.B.), Las Vegas, NV
| | - Rebekah Randall
- From the School of Public Health (B.D.C.K., L.-C.C., B.L., C.L.C., A.M.), University of Nevada, Las Vegas; and Cleveland Clinic Lou Ruvo Center for Brain Health (A.R., R.R., A.M., C.B.), Las Vegas, NV
| | - Arturo Montes
- From the School of Public Health (B.D.C.K., L.-C.C., B.L., C.L.C., A.M.), University of Nevada, Las Vegas; and Cleveland Clinic Lou Ruvo Center for Brain Health (A.R., R.R., A.M., C.B.), Las Vegas, NV
| | - Charles Bernick
- From the School of Public Health (B.D.C.K., L.-C.C., B.L., C.L.C., A.M.), University of Nevada, Las Vegas; and Cleveland Clinic Lou Ruvo Center for Brain Health (A.R., R.R., A.M., C.B.), Las Vegas, NV
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Chen YT, Yu CC, Lin YC, Chan SH, Lin YY, Chen NC, Lin WC. Brain CT can predict low lean mass in the elderly with cognitive impairment: a community-dwelling study. BMC Geriatr 2022; 22:3. [PMID: 34979925 PMCID: PMC8722183 DOI: 10.1186/s12877-021-02626-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 11/11/2021] [Indexed: 12/28/2022] Open
Abstract
Background The coexistence of sarcopenia and dementia in aging populations is not uncommon, and they may share common risk factors and pathophysiological pathways. This study aimed to evaluate the relationship between brain atrophy and low lean mass in the elderly with impaired cognitive function. Methods This cross-sectional study included 168 elderly patients who visited the multi-disciplinary dementia outpatient clinic at Kaohsiung Chang Gung Memorial Hospital for memory issues, between 2017 and 2019. The body composition was assessed by dual energy X-ray absorptiometry (DEXA) and CT based skeletal muscle index including L3 skeletal muscle index (L3SMI) and masseter muscle mass index (MSMI). The brain atrophy assessment was measured by CT based visual rating scale. Possible predictors of low lean mass in the elderly with cognitive impairement were identified by binary logistic regression. ROC curves were generated from binary logistic regression. Results Among the 81 participants, 43 (53%) remained at a normal appendicular skeletal muscle index (ASMI), whereas 38 (47%) showed low ASMI. Compared with the normal ASMI group, subjects with low ASMI exhibited significantly lower BMI, L3SMI, and MSMI (all p < 0.05), and showed significant brain atrophy as assessed by visual rating scale (p < 0.001). The accuracy of predictive models for low ASMI in the elderly with cognitive impairment were 0.875, (Area under curve (AUC) = 0.926, 95% confidence interval [CI] 0.844–0.972) in model 1 (combination of BMI, GCA and L3SMI) and 0.885, (Area under curve (AUC) = 0.931, [CI] 0.857–0.979) in model 2 (combination of BMI, GCA and MSMI). Conclusions Global cortical atrophy and body mass index combined with either L3 skeletal muscle index or masseter skeletal muscle index can predict low lean mass in the elderly with cognitive impairment. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-021-02626-8.
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Affiliation(s)
- Yun-Ting Chen
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123 Ta-Pei Road, Niao-Sung Dist, Kaohsiung City, 83305, Taiwan
| | - Chiun-Chieh Yu
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123 Ta-Pei Road, Niao-Sung Dist, Kaohsiung City, 83305, Taiwan
| | - Yu-Ching Lin
- Department of Medical Imaging and Intervention, Keelung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 222, Maijin Road, Anle Dist, Keelung City, 204201, Taiwan
| | - Shan-Ho Chan
- Department of Medical Imaging and Radiology, Shu-Zen Junior College of Medicine and Management, No. 452, Hwan-chio Road, Luju Dist, Kaohsiung City, 821004, Taiwan
| | - Yi-Yun Lin
- School of Nursing, Shu Zen College of Medicine and Management, No.452, Hwan-chio Road, Luju Dist, Kaohsiung, 821004, Taiwan
| | - Nai-Ching Chen
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Ta-Pei Road, Niao-Sung Dist, Kaohsiung City, 83305, Taiwan.
| | - Wei-Che Lin
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123 Ta-Pei Road, Niao-Sung Dist, Kaohsiung City, 83305, Taiwan.
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Duc Nguyen H, Pal Yu B, Hoang NHM, Jo WH, Young Chung H, Kim MS. Prolactin and Its Altered Action in Alzheimer's Disease and Parkinson's Disease. Neuroendocrinology 2022; 112:427-445. [PMID: 34126620 DOI: 10.1159/000517798] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 06/10/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Prolactin (PRL) is one of the most diverse pituitary hormones and is known to modulate normal neuronal function and neurodegenerative conditions. Many studies have described the influence that PRL has on the central nervous system and addressed its contribution to neurodegeneration, but little is known about the mechanisms responsible for the effects of PRL on neurodegenerative disorders, especially on Alzheimer's disease (AD) and Parkinson's disease (PD). SUMMARY We review and summarize the existing literature and current understanding of the roles of PRL on various PRL aspects of AD and PD. KEY MESSAGES In general, PRL is viewed as a promising molecule for the treatment of AD and PD. Modulation of PRL functions and targeting of immune mechanisms are needed to devise preventive or therapeutic strategies.
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Affiliation(s)
- Hai Duc Nguyen
- Department of Pharmacy, College of Pharmacy and Research Institute of Life and Pharmaceutical Sciences, Sunchon National University, Suncheon, Republic of Korea
| | - Byung Pal Yu
- Department of Physiology, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Ngoc Hong Minh Hoang
- Department of Pharmacy, College of Pharmacy and Research Institute of Life and Pharmaceutical Sciences, Sunchon National University, Suncheon, Republic of Korea
| | - Won Hee Jo
- Department of Pharmacy, College of Pharmacy and Research Institute of Life and Pharmaceutical Sciences, Sunchon National University, Suncheon, Republic of Korea
| | - Hae Young Chung
- Department of Pharmacy, College of Pharmacy, Pusan National University, Busan, Republic of Korea
| | - Min-Sun Kim
- Department of Pharmacy, College of Pharmacy and Research Institute of Life and Pharmaceutical Sciences, Sunchon National University, Suncheon, Republic of Korea
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Xu K, Zhou XX, He RC, Zhou Z, Liu ZH, Xu Q, Sun QY, Yan XX, Wu XY, Guo JF, Tang BS. Constructing Prediction Models for Freezing of Gait by Nomogram and Machine Learning: A Longitudinal Study. Front Neurol 2021; 12:684044. [PMID: 34938251 PMCID: PMC8686836 DOI: 10.3389/fneur.2021.684044] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 11/01/2021] [Indexed: 12/22/2022] Open
Abstract
Objectives: Although risk factors for freezing of gait (FOG) have been reported, there are still few prediction models based on cohorts that predict FOG. This 1-year longitudinal study was aimed to identify the clinical measurements closely linked with FOG in Chinese patients with Parkinson's disease (PD) and construct prediction models based on those clinical measurements using Cox regression and machine learning. Methods: The study enrolled 967 PD patients without FOG in the Hoehn and Yahr (H&Y) stage 1-3 at baseline. The development of FOG during follow-up was the end-point. Neurologists trained in movement disorders collected information from the patients on a PD medication regimen and their clinical characteristics. The cohort was assessed on the same clinical scales, and the baseline characteristics were recorded and compared. After the patients were divided into the training set and test set by the stratified random sampling method, prediction models were constructed using Cox regression and random forests (RF). Results: At the end of the study, 26.4% (255/967) of the patients suffered from FOG. Patients with FOG had significantly longer disease duration, greater age at baseline and H&Y stage, lower proportion in Tremor Dominant (TD) subtype, a higher proportion in wearing-off, levodopa equivalent daily dosage (LEDD), usage of L-Dopa and catechol-O-methyltransferase (COMT) inhibitors, a higher score in scales of Unified Parkinson's Disease Rate Scale (UPDRS), 39-item Parkinson's Disease Questionnaire (PDQ-39), Non-Motor Symptoms Scale (NMSS), Hamilton Depression Rating Scale (HDRS)-17, Parkinson's Fatigue Scale (PFS), rapid eye movement sleep behavior disorder questionnaire-Hong Kong (RBDQ-HK), Epworth Sleepiness Scale (ESS), and a lower score in scales of Parkinson's Disease Sleep Scale (PDSS) (P < 0.05). The risk factors associated with FOG included PD onset not being under the age of 50 years, a lower degree of tremor symptom, impaired activities of daily living (ADL), UPDRS item 30 posture instability, unexplained weight loss, and a higher degree of fatigue. The concordance index (C-index) was 0.68 for the training set (for internal validation) and 0.71 for the test set (for external validation) of the nomogram prediction model, which showed a good predictive ability for patients in different survival times. The RF model also performed well, the C-index was 0.74 for the test set, and the AUC was 0.74. Conclusions: The study found some new risk factors associated with the FOG including a lower degree of tremor symptom, unexplained weight loss, and a higher degree of fatigue through a longitudinal study, and constructed relatively acceptable prediction models.
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Affiliation(s)
- Kun Xu
- Collaborative Innovation Center for Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China.,Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Xiao-Xia Zhou
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Run-Cheng He
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Zhou Zhou
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Zhen-Hua Liu
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Qian Xu
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Qi-Ying Sun
- Department of Geriatrics, Xiangya Hospital, Central South University, Changsha, China
| | - Xin-Xiang Yan
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Xin-Yin Wu
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
| | - Ji-Feng Guo
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China.,Centre for Medical Genetics, Hunan Key Laboratory of Medical Genetics, School of Life Sciences, Central South University, Changsha, China.,Key Laboratory of Hunan Province in Neurodegenerative Disorders, Central South University, Changsha, China
| | - Bei-Sha Tang
- Collaborative Innovation Center for Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China.,Department of Neurology, Xiangya Hospital, Central South University, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China.,Centre for Medical Genetics, Hunan Key Laboratory of Medical Genetics, School of Life Sciences, Central South University, Changsha, China.,Key Laboratory of Hunan Province in Neurodegenerative Disorders, Central South University, Changsha, China
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Levodopa-Induced Ocular Dyskinesia in an Early-Onset Parkinson Disease Patient With GBA Mutation. Clin Neuropharmacol 2021; 44:201-204. [PMID: 34654015 PMCID: PMC8594500 DOI: 10.1097/wnf.0000000000000484] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Supplemental digital content is available in the text. Objectives The aim of this study was to report a case of levodopa-induced ocular dyskinesia in an early-onset Parkinson disease patient and to investigate the pathogenic gene. Methods We report the case of a 49-year-old male patient with a 13-year history of Parkinson disease. Involuntary eye movements were noticed after treatment with amantadine for limb dyskinesias. Levodopa-induced ocular dyskinesias involving repetitive, transient, and stereotyped rightward deviations of gaze appeared after intake of an antiparkinsonian drug. Limb dyskinesias also occurred simultaneously. We used a next-generation sequencing targeted gene panel and found a heterozygous missense mutation (p.R535H) in GBA. Direct Sanger sequencing verified the missense mutation. Conclusions We report the case of an uncommon early-onset PD patient carrying a GBA mutation presenting ocular dyskinesia. Genetic screening may provide a better mechanistic insight into dyskinesias.
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Liu H, Deng B, Xie F, Yang X, Xie Z, Chen Y, Yang Z, Huang X, Zhu S, Wang Q. The influence of white matter hyperintensity on cognitive impairment in Parkinson's disease. Ann Clin Transl Neurol 2021; 8:1917-1934. [PMID: 34310081 PMCID: PMC8419402 DOI: 10.1002/acn3.51429] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 06/05/2021] [Accepted: 07/02/2021] [Indexed: 01/11/2023] Open
Abstract
The aim of this meta‐analysis was to review systematically and to identify the relationship between the severity and location of white matter hyperintensities (WMHs) and the degree of cognitive decline in patients with Parkinson’s disease (PD). We searched the PubMed, EMBASE, Web of Science, Ovid, and Cochrane Library databases for clinical trials of the severity and location of WMHs on the degree of cognitive impairment in PD through October 2020. We conducted the survey to compare the association of WMH burden in patients with PD with mild cognitive impairment (PD‐MCI) versus those with normal cognition (PD‐NC) and in patients with PD with dementia (PDD) versus those with PD without dementia (PD‐ND). Nine studies with PD‐MCI versus PD‐NC and 10 studies with PDD versus PD‐ND comparisons were included. The WMH burden in PD‐MCI patients was significantly different compared to that in PD‐NC patients (standard mean difference, SMD = 0.39, 95% CI: 0.12 to 0.66, p = 0.005), while there was no correlation shown in the age‐matched subgroup of the comparison. In addition, PDD patients had a significantly higher burden of WMHs (SMD = 0.8, 95% CI: 0.44 to 1.71, p < 0.0001), especially deep white matter hyperintensities (SMD = 0.54, 95% CI: 0.36 to 0.73, p < 0.00001) and periventricular hyperintensities (SMD = 0.70, 95% CI: 0.36 to 1.04, p < 0.0001), than PD‐NC patients, regardless of the adjustment of age. WMHs might be imaging markers for cognitive impairment in PDD but not in PD‐MCI, regardless of age, vascular risk factors, or race. Further prospective studies are needed to validate the conclusions.
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Affiliation(s)
- Hailing Liu
- Department of Neurology, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong, 510282, P.R. China.,Department of Neurology, Maoming People's Hospital, Maoming, Guangdong, China
| | - Bin Deng
- Department of Neurology, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong, 510282, P.R. China
| | - Fen Xie
- Department of Neurology, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong, 510282, P.R. China
| | - Xiaohua Yang
- Department of Neurology, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong, 510282, P.R. China
| | - Zhenchao Xie
- Department of Neurology, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong, 510282, P.R. China
| | - Yonghua Chen
- Department of Neurology, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong, 510282, P.R. China
| | - Zhi Yang
- Department of Neurology, Maoming People's Hospital, Maoming, Guangdong, China
| | - Xiyan Huang
- Department of Rehabilitation, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong, 510282, P.R. China
| | - Shuzhen Zhu
- Department of Neurology, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong, 510282, P.R. China
| | - Qing Wang
- Department of Neurology, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong, 510282, P.R. China
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