Primary urachal leiomyosarcoma: a case report and literature review of clinical, pathological, and medical imaging features.

Background: Urachal tumors are exceedingly rare, and adenocarcinoma is the most common malignant urachal neoplasm. Here, an especially rare patient of primary urachal leiomyosarcoma from our hospital was reported, and only five patients have been reported thus far since 1981. Case description: A 24-year-old man was admitted due to urinary tract symptoms. Both urogenital ultrasonography and contrast-enhanced computed tomography showed a mass at the dome of the urinary bladder. Laparoscopic surgical resection was performed, and histopathologic examination of the mass confirmed the diagnosis of urachal leiomyosarcoma. No recurrence was noted after one and a half years. Conclusions: Because the leiomyosarcoma located in the extraperitoneal space of Retzius and may manifest with nonspecific abdominal or urinary symptoms, early and definitive preoperative diagnosis is challenging. Partial cystectomy with complete excision of the urachus is recommended. Because only a few patients have been recorded, clinical outcomes and recurrence risks are difficult to assess.

Effect of Low Tube Voltage (100 kV) Combined with ASIR-V on the Visualization and Image Quality of the Adamkiewicz Artery: A Comparison with 120 kV Protocol.

OBJECTIVE: To evaluate the effect of low tube voltage (100 kV) combined with adaptive statistical iterative reconstruction-V (ASIR-V) on the visualization and image quality of the Adamkiewicz artery (AKA). METHODS: One hundred patients were prospectively enrolled and randomly assigned into two groups (both n = 50). Group A (100 kV) was reconstructed with filtered back projection (FBP) and ASIR-V from 10% to 100% with 10% intervals. Group B (120 kV) was only reconstructed with FBP. The objective image quality was evaluated by using CT values of the aorta (CTAorta), background noise, signal-to-noise ratio of the descending aorta (SNRAorta), and contrast-to-noise ratio of the spinal cord (CNRSpinal cord). The subjective image quality and visualization scores of the AKA were assessed on a 5-point scale. RESULTS: CTAorta was significantly higher in Group A than in Group B (p < 0.001). When ASIR-V weights were ≥60%, significant differences were found in the background noise, SNRAorta, and CNRSpinal cord between the two groups (all p < 0.05). In Group A, compared with FBP, the subjective score gradually increased as ASIR-V increased to 80%, which decreased when ASIR-V exceeded 80%. The visualization scores of the AKA (≥60%) and the ability to detect vessel continuity (≥80%) gradually increased as the ASIR-V weights increased (p < 0.05). The effective radiation dose was reduced by about 40.36% in Group A compared to Group B. CONCLUSIONS: compared with conventional scanning protocol, using a combination of low tube voltage (100 kV) and 80% ASIR-V protocol could not only increase the visualization of the AKA, but also improve image quality and reduce the radiation doses.

Multimodality CT imaging contributes to improving the diagnostic accuracy of solitary pulmonary nodules: a multi-institutional and prospective study.

BACKGROUND: Solitary pulmonary nodules (SPNs) are one of the most common chest computed tomography (CT) abnormalities clinically. We aimed to investigate the value of non-contrast enhanced CT (NECT), contrast enhanced CT (CECT), CT perfusion imaging (CTPI), and dual- energy CT (DECT) used for differentiating benign and malignant SPNs with a multi-institutional and prospective study. PATIENTS AND METHODS: Patients with 285 SPNs were scanned with NECT, CECT, CTPI and DECT. Differences between the benign and malignant SPNs on NECT, CECT, CTPI, and DECT used separately (NECT combined with CECT, DECT, and CTPI were methods of A, B, and C) or in combination (Method A + B, A + C, B + C, and A + B + C) were compared by receiver operating characteristic curve analysis. RESULTS: Multimodality CT imaging showed higher performances (sensitivities of 92.81% to 97.60%, specificities of 74.58% to 88.14%, and accuracies of 86.32% to 93.68%) than those of single modality CT imaging (sensitivities of 83.23% to 85.63%, specificities of 63.56% to 67.80%, and accuracies of 75.09% to 78.25%, all p < 0.05). CONCLUSIONS: SPNs evaluated with multimodality CT imaging contributes to improving the diagnostic accuracy of benign and malignant SPNs. NECT helps to locate and evaluate the morphological characteristics of SPNs. CECT helps to evaluate the vascularity of SPNs. CTPI using parameter of permeability surface and DECT using parameter of normalized iodine concentration at the venous phase both are helpful for improving the diagnostic performance.

Cognitive-behavioral therapy for insomnia with objective short sleep duration phenotype: A systematic review with meta-analysis.

Cognitive-behavioral therapy for insomnia (CBT-I) has been recommended as the first-line therapy for this condition. However, insomnia disorder with objective short sleep duration (ISS) phenotype is a distinct subtype from insomnia with normal sleep duration (INS) phenotype, and it may have a differential therapeutic response. We searched PubMed, EMBASE, Cochrane Library, and ClinicalTrials.gov using the PICOS principle for studies that examined the efficacy of cognitive-behavioral therapy for those with the ISS phenotype versus the INS phenotype, and identified nine studies with 612 patients with insomnia disorder. This included 270 patients with the ISS phenotype and 342 patients with the INS phenotype. The main outcome was that CBT-I had a better efficacy for the INS phenotype compared with the ISS phenotype, with about 30% higher response and about 20% higher remission. Similar results were indicated in the secondary outcomes. The therapeutic response of the ISS phenotype was significantly different from that of the INS phenotype. In the future, research is needed to clarify how to optimally treat insomnia disorder with the ISS phenotype in prospective randomized clinical trials, and to understand whether decreasing physiologic arousal will be necessary to improve results.

Radiomics and Its Applications and Progress in Pancreatitis: A Current State of the Art Review.

Radiomics involves high-throughput extraction and analysis of quantitative information from medical images. Since it was proposed in 2012, there are some publications on the application of radiomics for (1) predicting recurrent acute pancreatitis (RAP), clinical severity of acute pancreatitis (AP), and extrapancreatic necrosis in AP; (2) differentiating mass-forming chronic pancreatitis (MFCP) from pancreatic ductal adenocarcinoma (PDAC), focal autoimmune pancreatitis (AIP) from PDAC, and functional abdominal pain (functional gastrointestinal diseases) from RAP and chronic pancreatitis (CP); and (3) identifying CP and normal pancreas, and CP risk factors and complications. In this review, we aim to systematically summarize the applications and progress of radiomics in pancreatitis and it associated situations, so as to provide reference for related research.

Pleural effusion volume in patients with acute pancreatitis: a retrospective study from three acute pancreatitis centers.

OBJECTIVE: To assess the value of pleural effusion volume (PEV) quantified on chest computed tomography (CT) in patients with early stage acute pancreatitis (AP). METHODS: Data of PEV, and C-reactive protein (CRP) levels as well as Ranson, bedside index of severity in acute pancreatitis (BISAP), Marshall, acute physiology and chronic health evaluation II (APACHE II), CT severity index (CTSI), and extra-pancreatic inflammation on computed tomography (EPIC) scores in patients with AP were collected. Duration of hospitalization, severity of AP, infection, procedure, intensive care unit (ICU) admission, organ failure, or death were included as the outcome parameters. RESULTS: In 465 patients, the mean PEV was 98.8 ± 113.2 mL. PEV showed strong and significant correlations with the CRP levels, duration of hospitalization as well as the Ranson, BISAP, Marshall, APACHE II, CTSI, and EPIC scores (p < .05). PEV demonstrated significant accuracy in predicting severity, infection, procedure, ICU admission, organ failure, and death (p < .05). CONCLUSION: PEV quantified on chest CT positively associated with the duration of hospitalization, CRP levels, Ranson, BISAP, Marshall, APACHE II, CTSI, and EPIC scores. It can be a reliable radiologic biomarker in predicting severity and clinical outcomes of AP.KEY MESSAGESPleural effusion is a common chest finding in patients with acute pancreatitis.Pleural effusion volume quantified on chest CT examination positively associated with the duration of hospitalization, CRP level, as well as Ranson, BISAP, Marshall, APACHE II, CTSI, and EPIC scoring systems.Pleural effusion volume can be a reliable radiologic biomarker in the prediction of severity and clinical outcomes of acute pancreatitis.

Effects of Noninvasive Brain Stimulation (NIBS) on Cognitive Impairment in Mild Cognitive Impairment and Alzheimer Disease: A Meta-analysis.

OBJECTIVE: The purpose of this meta-analysis was to evaluate the beneficial effects and optimal stimulation protocol of noninvasive brain stimulation (NIBS) including repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) on patients with mild cognitive impairment and Alzheimer disease. MATERIALS AND METHODS: PubMed, Web of Science, Embase, and the Cochrane Library were searched until March 2020. The cognitive outcomes were extracted and the standardized mean difference with 95% confidence interval was calculated. RESULTS: Twenty-eight studies were included. The result of NIBS showed significant effect on global cognition (P<0.05). Low-frequency rTMS over right dorsolateral prefrontal cortex (DLPFC), high-frequency rTMS (HF-rTMS) over left DLPFC, and the tDCS over left DLPFC and temporal lobe can significantly improve the memory function (P<0.05). HF-rTMS over left, right, or bilateral DLPFC can significantly improve the language function (P<0.05). Both HF-rTMS and tDCS over left DLPFC can obviously improve the executive function (P<0.05). Multiple sessions of rTMS with 80% to 100% intensity and anode tDCS with 2 mA current density are more suitable for all these functions. CONCLUSIONS: NIBS has a beneficial effect on cognitive performance in both mild cognitive impairment and Alzheimer disease patients. Distinct optimal stimulation parameters were observed for different cognitive functions.

Distinction of High- and Low-Frequency Repetitive Transcranial Magnetic Stimulation on the Functional Reorganization of the Motor Network in Stroke Patients.

Objective: To investigate the functional reorganization of the motor network after repetitive transcranial magnetic stimulation (rTMS) in stroke patients with motor dysfunction and the distinction between high-frequency rTMS (HF-rTMS) and low-frequency rTMS (LF-rTMS). Methods: Thirty-three subcortical stroke patients were enrolled and assigned to the HF-rTMS group, LF-rTMS group, and sham group. Each patient of rTMS groups received either 10.0 Hz rTMS over the ipsilesional primary motor cortex (M1) or 1.0 Hz rTMS over the contralesional M1 for 10 consecutive days. A resting-state functional magnetic resonance imaging (fMRI) scan and neurological examinations were performed at baseline and after rTMS. The motor network and functional connectivities intramotor network with the core brain regions including the bilateral M1, premotor area (PMA), and supplementary motor area (SMA) were calculated. Comparisons of functional connectivities and Pearson correlation analysis between functional connectivity changes and behavioral improvement were calculated. Results: Significant motor improvement was found after rTMS in all groups which was larger in two rTMS groups than in the sham group. The functional connectivities of the motor network were significantly increased in bilateral M1, SMA, and contralesional PMA after real rTMS. These changes were only detected in the regions of the ipsilesional hemisphere in the HF-rTMS group and in the regions of the contralesional hemisphere in the LF-rTMS group. Significantly changed functional connectivities of the intramotor network were found between the ipsilesional M1 and SMA and contralesional PMA, between contralesional M1 and contralesional SMA, between contralesional SMA and ipsilesional SMA and contralesional PMA in the HF-rTMS group in which the changed connectivity between ipsilesional M1 and contralesional PMA was obviously correlated with the motor improvement. In addition, the functional connectivity of the intramotor network between ipsilesional M1 and contralesional PMA was significantly higher in the HF-rTMS group than in the LF-rTMS group. Conclusion: Both HF-rTMS and LF-rTMS have a positive effect on motor recovery in patients with subcortical stroke and could promote the reorganization of the motor network. HF-rTMS may contribute more to the functional connectivity reorganization of the ipsilesional motor network and realize greater benefit to the motor recovery.

White matter changes from mild cognitive impairment to Alzheimer's disease: a meta-analysis.

Previous diffusion tensor imaging (DTI) studies have reported that both mild cognitive impairment (MCI) and Alzheimer's disease (AD) revealed microstructural changes [fractional anisotropy (FA)]. However, these results were not conclusive. The purpose of this meta-analysis was to identify the consistent FA alterations and the differences between MCI and AD. Case-control studies investigating MCI and AD using FA were searched in the online databases. The quantitative FA value of cognition-related brain regions was extracted and the standardized mean difference (SMD) with 95% confidence interval (CI) was calculated using fixed or random effect models. Twenty six studies with a total of 1,021 patients were included in this meta-analysis. Significantly decreased FA in patients with AD were identified in the left frontal lobe, corpus callosum (CC), fornix, hippocampus (HP), cingulate gyrus (CG), cingulate bundle (CB), uncinate fasciculus (UF), superior longitudinal fasciculus(SLF), the inferior fronto-occipital fascicles (IFOF), and the inferior longitudinal fasciculus(ILF) relative to MCI in this meta-analysis. This study provides objective and quantitative evidence that AD is associated with FA alteration within left frontal lobe, CC, FX, HP, CG, CB, and UF may suggest the key regions of the process from MCI to AD.

Effect of rTMS on Parkinson's cognitive function: a systematic review and meta-analysis.

BACKGROUND: To evaluate the effects and optimal parameters of repetitive transcranial magnetic stimulation (rTMS) on cognition function of patients with Parkinson's disease (PD) and to estimate which cognitive function may obtain more benefits from rTMS. METHOD: The articles dealing with rTMS on cognitive function of PD patients were retrieved from the databases until April 2019. Outcomes of global cognitive function and different cognitive domains were extracted. The standardized mean differences (SMDs) with 95% confidence interval (CI) of cognitive outcome for different parameters, scales, and cognitive functions were estimated. RESULTS: Fourteen studies involving 173 subjects were included in this meta-analysis. A significant effect size was observed with the mini-mental state examination (MMSE) for the global cognitive outcome based on the evidence of four published articles. Further subtests for different cognitive domains demonstrated prominent effect for the executive function. The significant effect sizes for executive function were found with multiple sessions of high-frequency rTMS over frontal cortex; especially over dorsolateral prefrontal cortex (DLPFC). All of the other cognitive domains, which included memory, attention, and language ability, did not obtain significant effects. CONCLUSIONS: Multiple sessions of high-frequency rTMS over the DLPFC may have positive effect on executive function in PD patients. Further well designed studies with large sample sizes are needed to verify our results and ascertain the long-term effects of rTMS.

Insomnia Disorder Increases the Risk of Mortality: Pooled Analysis of Annual Cumulative Time-to-Event Data.

The association of mortality risk and insomnia disorder with daytime impairments has been plausible. The purpose of this study was to evaluate the strength of evidence for this relationship. We performed a comprehensive literature search for clinical Cohort trials including annual cumulative time-to-event data that evaluated the risk of mortality in insomnia disorder patients with daytime impairments. We used pooled hazard ratio (HR) as the main outcome measure and Kaplan-Meier survive curve to display outcome measures. The weighted cumulative mortality of 4.5% for patients with insomnia disorder was higher than that of 2.6% for those without insomnia (p<0.001). Higher risk of mortality presented in patients with insomnia disorder when compared to those without insomnia (HR = 1.66, 95% CI = 1.25-2.19, p<0.001). Patients with duration of more than 10 years were at a greater risk of annual cumulative mortality (R2 = 0.891, p<0.001). Insomnia disorder with daytime impairments increased the risk of mortality, and patients with duration of more than 10 years were at a greater risk of annual cumulative mortality.

Biphasic feature of placebo response in primary insomnia: pooled analysis of data from randomized controlled clinical trials of orexin receptor antagonists.

OBJECTIVES: The placebo response to orexin receptor antagonists in primary insomnia is little-known. Our aim was, therefore, to conduct a systematic review of placebo-controlled randomized clinical trials to characterize placebo response. METHODS: We performed a comprehensive literature search for randomized, placebo-controlled, double-blind clinical trials evaluating the efficacy of orexin receptor antagonists addressing primary insomnia. To pool effect size estimates (Cohen's d) of placebo and orexin receptor antagonists across trials for outcome measures, a meta-analysis was done according to the Cochrane guideline. RESULTS: The placebo response was significant and robust to improve the symptoms of insomnia in terms of objective and subjective measures, and the effects (0.70 ± 0.51) in subjective measures were smaller than that (1.10 ± 1.14) in objective measures (p = 0.027). The biphasic feature of placebo response showed an initial short-term increase of placebo effect and subsequent changeless long-term effect. CONCLUSION: The biphasic feature of placebo response is clinically useful, and neuroimaging is essential to clarify the long-term mechanism in the future.

Different Therapeutic Effects of Transcranial Direct Current Stimulation on Upper and Lower Limb Recovery of Stroke Patients with Motor Dysfunction: A Meta-Analysis.

Objective: To explore the effects of transcranial direct current stimulation (tDCS) on the motor recovery of stroke patients and the effect differences between the upper limb and lower limb. Methods: Randomized control trials published until January 2019 were searched from PubMed, Embase, ScienceDirect, and Cochrane Library databases. The standardized mean difference (SMD) with 95% confidence interval (CI) was estimated separately for upper and lower limb motor outcomes to understand the mean effect size. Results: Twenty-nine studies with 664 subjects were included in this meta-analysis. The overall analyses of tDCS demonstrated significant effect size both for the upper limb (SMD = 0.26, P = 0.002) and the lower limb (SMD = 0.47, P = 0.002). Compared with acute and subacute stroke patients, chronic stroke patients obtained significant effects after tDCS (SMD = 0.25, P = 0.03) in upper limb function. Furthermore, both anode and cathode stimulations produced significant effect size for stroke patients after ≤10 sessions of tDCS (anode: SMD = 0.40, P = 0.001; cathode: SMD = 0.79, P < 0.0001) with >0.029 mA/cm2 of density (anode: SMD = 0.46, P = 0.002; cathode: SMD = 0.79, P < 0.0001). But for lower limb function, more prominent effects were found in subacute stroke patients (SMD = 0.56, P = 0.001) with bilateral tDCS (SMD = 0.59, p = 0.009). Conclusion: tDCS is effective for the recovery of stroke patients with motor dysfunction. In addition, upper limb and lower limb functions obtain distinct effects from different therapeutic parameters of tDCS at different stages, respectively.

Effects of High-Frequency Transcranial Magnetic Stimulation for Cognitive Deficit in Schizophrenia: A Meta-Analysis.

Objective: Repetitive transcranial magnetic stimulation (rTMS) has been applied to dorsolateral prefrontal cortex (DLPFC) to improve cognitive function of patients with schizophrenia (SZs). The aim of this meta-analysis was to evaluate whether a high-frequency rTMS course could enhance cognitive function in SZs. Methods: Studies published in PubMed, Cochrane Library, Embase, ScienceDirect, and Web of science were searched until April 2018. The search terms included: "repetitive transcranial magnetic stimulation" or "Rtms," "SZ," or "schizophrenia," and "neuro-cognition" or "neurocognitive performance" or "cognitive effects" or "cognitive" or "cognition" or "working memory" or "executive function" or "language function" or "processing speed," After screening the literatures according to inclusion and exclusion criteria, extracting data, and evaluating the methodological quality of the included studies, a meta-analysis was performed using RevMan 5.3 software (The Cochrane Collaboration, USA). Results: A total of 9 studies on cognitive dysfunction of SZs were included and involved 351 patients. A significant efficacy of high-frequency rTMS on working memory in SZs was found compared to sham stimulation [p = 0.009, standardized mean difference (SMD) = 0.34]. Specifically, rTMS treatment positioned on the left DLPFC, with a total pluses <30,000 was more significantly more effective in improving the working memory (SMD = 0.33, p = 0.03). No improvement was found in other cognitive domains such as executive function, attention, processing speed, and language function. For the follow-up observations, high-frequency rTMS had long-lasting sustained effects on working memory (SMD = 0.45, p = 0.01) and language function (SMD = 0.77, p = 0.02) in SZs. Conclusions: High-frequency rTMS over the left DLPFC with a total pulses <30,000 stimulation could significantly improve working memory in SZs for an extended period of time.

Transcranial Direct Current Stimulation Improves Cognitive Function in Mild to Moderate Alzheimer Disease: A Meta-Analysis.

OBJECTIVE: The purpose of this meta-analysis was to evaluate the therapeutic effect of transcranial direct current stimulation (tDCS) on mild to moderate Alzheimer disease (AD) patients. MATERIALS AND METHODS: PubMed, Embase, Web of Science, and Cochrane Library were searched until April 2018. The primary cognitive outcomes were extracted from included articles. A crude standardized mean difference with 95% CI was calculated by using fixed or random effect models. RESULTS: Seven studies with 146 patients were included in this meta-analysis. The pooled result showed that tDCS significantly improved cognitive function of AD patients (standardized mean difference=0.37; 95% CI, 0.09-0.65; P=0.01). Subgroup analyses showed that: a single session of tDCS was significantly effective (P<0.05) whereas repeated sessions of tDCS was not lower current density (0.06 mA/cm) (P>0.05) but not higher current density (0.08 mA/cm) significantly improved cognitive performance; stimulating the temporal cortex (P<0.05) but not the left dorsal lateral prefrontal cortex significantly improved cognitive function of AD patients; and improved cognitive function occurred in the group with higher education (P<0.05) but not in the group with lower education. CONCLUSIONS: Current evidence suggests that tDCS has a beneficial effect in mild to moderate AD patients. We must be cautious about the results of subgroup analysis given small sample sizes, and further well-designed studies with larger sample size are required to verify these results.

High-Frequency Repetitive Transcranial Magnetic Stimulation Could Improve Impaired Working Memory Induced by Sleep Deprivation.

Objective: To investigate whether and how the working memory impairment induced by sleep deprivation (SD) could be recovered by using repetitive transcranial magnetic stimulation (rTMS), as well as to clarify the corresponding brain activity changes. Methods: Seventeen healthy adults received one session of 5.0 Hz rTMS over the left dorsolateral prefrontal cortex (DLPFC) following 24 hours of SD. Resting state functional magnetic resonance imaging (fMRI) and working memory test were performed during a rested waking period, after SD and rTMS. The amplitude of low-frequency fluctuations (ALFF) was used to detect the spontaneous neural activity changes after both SD and rTMS. The relationship between ALFF and the performance of working memory was also assessed by using correlation analysis. Results: After SD, the participants exhibited lower response accuracies and longer reaction times on the working memory tests of letters and numbers. The decreased response accuracy of numbers was significantly improved after rTMS similarly to the state of the rested waking period after a normal night of sleep. ALFF values decreased from the rested waking period state to the state of SD in the brain regions involving the frontal gyrus, precuneus, angular gyrus, and parietal lobe which showed significantly increased ALFF after rTMS. Furthermore, significantly positive correlations were observed between changes of response accuracy and the changes of ALFF value of the inferior frontal gyrus and supramarginal gyrus. Conclusion: These results indicate that high-frequency rTMS applied over left DLPFC may contribute to the recovery of the impaired working memory after SD by modulating the neural activity of related brain regions.

Efficacy and safety of thermal ablation of lung malignancies: A Network meta-analysis.

OBJECTIVE: The objective of this study was to compare the efficacy and safety of radiofrequency ablation (RFA), cryoablation, and microwave ablation (MWA) for patients with lung malignancies. METHODS: We performed a network meta-analysis to identify both direct and indirect evidence from relevant trials by searching PubMed, Embase, and the Cochrane Library to December 31, 2017, for the treatment of malignant lung tumors with the use of RFA, MWA, or cryoablation. We extracted the relevant information from the published studies with a predefined data sheet and assessed the risk of bias with the Cochrane risk of bias tool. The primary outcomes were efficacy (local progression rate and overall survival rate) and safety (major complications rate). We did a random-effects network meta-analysis within a Bayesian framework as well as assessed the quality of evidence contributing to each network estimate using GRADE framework. RESULTS: We collected 34 studies eligible which included 1840 participants and 2520 lung malignancies (1318 primary lung cancer and 1202 pulmonary metastatic tumors). The quality of evidence was rated as very low in most comparisons. From the point of local progression rate, RFA and MWA were significantly more effective than cryoablation with odds ratio (OR) of 0.04 (95% confidence interval [CI]: 0.004, 0.38; P = 0.005) and 0.02 (95% CI: 0.002, 0.24; P = 0.001), respectively. No significant difference was found between MWA and RFA with an OR of 0.63 (95% CI: 0.04, 10.39; P = 0.745). Regarding the major complications, RFA, MWA, and cryoablation showed the comparable safety (P > 0.05). CONCLUSION: RFA and MWA offer an advantage over cryoablation for patients with malignant lung tumors.

Repetitive transcranial magnetic stimulation therapy for motor recovery in Parkinson's disease: A Meta-analysis.

INTRODUCTION: Therapeutic effects of repetitive transcranial magnetic stimulation (rTMS) on motor recovery of Parkinson's disease (PD) have been reported; however, the protocols of these studies varied greatly. The aim of this meta-analysis was to evaluate the optimal rTMS parameters for motor recovery of PD. METHODS: Electronic databases were searched for studies investigating the therapeutic effects of rTMS on motor function in patients with PD. The section III of the Unified Parkinson's Disease Rating Scale (UPDRS) was extracted as the primary outcome, and the standardized mean difference (SMD) with 95% confidence interval (CI) was calculated. RESULTS: Twenty-three studies with a total of 646 participants were included. The pooled estimates of rTMS revealed significant short-term (SMD, 0.37; p < 0.00001) and long-term (SMD, 0.39; p = 0.005) effects on motor function improvement of PD. Subgroup analysis observed that high-frequency rTMS (HF-rTMS) was significant in improving motor function (SMD, 0.48; p < 0.00001), but low-frequency rTMS (LF-rTMS) was not. In particular, when HF-rTMS targeted over the primary motor cortex (M1), in which the bilateral M1 revealed a larger effect size than unilateral M1. Compared to single-session, multi-session of HF-rTMS over the M1 showed significant effect size. In addition, HF-rTMS over the M1 with a total of 18,000-20,000 stimulation pulses yielded more significant effects (SMD, 0.97; p = 0.01) than other dosages. CONCLUSIONS: In conclusion, multi-session of HF-rTMS over the M1 (especially bilateral M1) with a total of 18,000-20,000 pulses appears to be the optimal parameters for motor improvement of PD.

Antidepressant Effects of Repetitive Transcranial Magnetic Stimulation Over Prefrontal Cortex of Parkinson's Disease Patients With Depression: A Meta-Analysis.

Objective: The purpose of this meta-analysis was to investigate the antidepressant effects of repetitive transcranial magnetic stimulation (rTMS) over the prefrontal cortex (PFC) of patients with Parkinson's disease (PD) and to determine the optimal rTMS parameters, such as the intensity, frequency and the delivered pattern of rTMS stimulation. Methods: EMBASE, PubMed, Web of Science, MEDLINE, and Cochrane data bases were researched for papers published before March 12, 2018. Studies investigating the anti-depression effects of rTMS over PFC in patients with PD were considered. The main outcomes of pre- and post-rTMS treatment as well as score changes were all extracted. The mean effect size was estimated by calculating the standardized mean difference (SMD) with 95% confidence interval (CI) by using fixed or random effect models as appropriate. Results: Nine studies containing 137 PD patients with depression were included. The pooled results showed significant pre-post anti-depressive effects of rTMS over PFC in PD patients with depression (SMD = -0.80, P < 0.00001). The subgroup analyses of stimulation intensity, frequencies, and models also revealed significant effects (Intensities: 90% RMT: SMD = -1.16, P = 0.0006; >100% RMT: SMD = -0.82, P < 0.0001. Frequencies: < 1.0 Hz: SMD = -0.83, P = 0.03; 5.0 Hz: SMD = -1.10, P < 0.0001; ≥10.0 Hz: SMD = -0.55, P = 0.02. Models: Continuous: SMD = -0.79, P < 0.0001; Discontinuous: SMD = -0.84, P = 0.02). But the results of the studies with place-controlled designs were not significant (Overall: SMD = -0.27, P = 0.54. Intensities: 90% RMT: SMD = 0.27, P = 0.68; 100% RMT: SMD = -0.32, P = 0.33. Frequencies: 5.0 Hz: SMD = -0.87, P = 0.10; ≥10.0 Hz: SMD = 0.27, P = 0.66. Models: Continuous: SMD = -0.28, P = 0.68; Discontinuous: SMD = -0.32, P = 0.33). The greater effect sizes of rTMS with 90% RMT, 5.0 Hz in discontinuous days can be observed rather than the other parameters in both kinds of analyses across study design. Conclusions: rTMS may have a significant positive pre-post anti-depressive effect over PFC on patients with depression, especially by using 5.0 Hz frequency with 90% RMT intensity in discontinuous days, which may produce better effects than other parameters. The real effect, though, was not different from that of the placebo. Future studies with larger sample sizes and high-quality studies are needed to further corroborate our results and to identify the optimal rTMS protocols.