BACKGROUND/OBJECTIVE:Within-patient comparison of intravenous levodopa and subthalamic nucleus deep brain stimulation effects on neural oscillations and motor function in Parkinson's disease (PD). METHODS:Twelve patients with advanced PD and bilaterally implanted subthalamic electrodes underwent five treatment conditions: medication off/stimulation off, placebo infusion, medication on/stimulation off, medication off/stimulation on, and medication on/stimulation on. For each condition, bilateral local field potentials were recorded, and motor function was evaluated using the Movement Disorder Society Unified Parkinson's Disease Rating Scale Part III. RESULTS:Both levodopa and stimulation improved motor scores (p < 0.01) and reduced low β activity (13-20 Hz). High β activity (21-30 Hz) decreased only during stimulation (p < 0.01). Finely tuned γ (FTG) oscillations (60-90 Hz) appeared most often during combined therapy (68.2%), with peak frequencies entrained to half the stimulation frequency in 93.3% of electrodes, except under 180 Hz stimulation. During intravenous levodopa infusion, FTG emerged with a median latency of 14.3 minutes, frequently before peak plasma levels, and declined in frequency over time. Changes in FTG power correlated with motor improvement (p < 0.05), whereas placebo had no effect. CONCLUSIONS:Levodopa and stimulation exert distinct but complementary effects on oscillatory activity. FTG, rather than β power alone, reflected therapeutic state and was associated with motor improvement without dyskinesia. These findings highlight FTG as a potential biomarker for adaptive stimulation systems in PD. © 2026 International Parkinson and Movement Disorder Society.

INTRODUCTION:Subthalamic nucleus deep brain stimulation (STN-DBS) effectively improves motor symptoms in Parkinson's disease (PD), but long-term survival outcomes and mortality predictors remain unclear. This study aimed to evaluate survival and 10-year clinical outcomes after STN-DBS. METHODS:We retrospectively analyzed 608 patients with PD who underwent bilateral STN-DBS between 2006 and 2023. Kaplan-Meier and Cox regression analyses assessed survival and preoperative predictors. Motor (Movement Disorder Society Unified Parkinson's Disease Rating Scale [MDS-UPDRS Part III]), cognitive (Montreal Cognitive Assessment [MoCA], Mini-Mental State Examination), and medication (levodopa equivalent daily dose [LEDD]) data were compared between baseline and 10 years postoperatively. RESULTS:During a mean follow-up of 4.8 ± 3.5 years, 42 deaths (6.9%) occurred, yielding an age-adjusted mortality rate of 3.3 per 100,000 person-years. The estimated 5- and 10-year survival rates were 95% and 77%, respectively. The most frequent cause of death was aspiration pneumonia (11.9%). In multivariate Cox analysis, lower preoperative MoCA scores (hazard ratio [HR] = 0.83, 95% CI 0.73-0.95, p < 0.01) and higher OFF state MDS-UPDRS Part III scores (HR = 1.03, 95% CI 1.00-1.07, p < 0.05) independently predicted mortality, whereas age at surgery was not significantly associated with survival. Among 118 patients with 10-year follow-up, OFF state motor and cognitive scores worsened significantly (p < 0.01), while ON state motor scores (p = 0.21) and total LEDD (p = 0.06) remained stable, suggesting sustained motor control and medication-sparing effects. CONCLUSION:Long-term survival after STN-DBS in PD was favorable. Preoperative cognitive and motor status, rather than age, determined long-term prognosis, emphasizing the enduring therapeutic value of STN-DBS.

To address the need to integrate mental health into primary care, Japan introduced a mandatory one-month psychiatry rotation within the two-year postgraduate clinical training program in 2020. However, it remains unclear whether the required rotation improves psychiatric competence, and concerns exist that it might reduce learning opportunities in other fields. This study evaluated the association between the duration of psychiatry rotation and residents' psychiatric and overall clinical competence, measured by a nationwide examination. We conducted a cross-sectional study among 5905 residents taking the General Medicine In-Training Examination (GM-ITE). Using linear mixed-effects models, we examined the association between psychiatry rotation duration (none, 1, 2, ≥3 months) and percentage scores on the psychiatry section (4 questions) and the total examination (80 questions). Models were adjusted for covariates including sex, postgraduate year, hospital settings, and career preference for psychiatry. Compared with residents without psychiatry rotation experience, those with 1, 2, and ≥ 3 months of rotation had significantly higher psychiatry scores, with adjusted mean differences of 5.6% (95% CI: 3.5-7.6), 8.7% (4.4-13.0), and 10.2% (2.8-17.7), respectively. In contrast, no significant difference was observed in total scores regardless of rotation durations. In summary, psychiatry rotations of one month or longer were significantly associated with improved psychiatry scores, without compromising overall clinical learning. These findings support the educational value of required psychiatry rotations and provide an evidence-based perspective for curriculum development and training time allocation in residency programs worldwide.

Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is an effective treatment for Parkinson’s disease (PD). The outcome of DBS varies from patient to patient. We investigated the preoperative changes in the midbrain to predict DBS outcomes. Patients with PD who underwent bilateral STN-DBS at Juntendo University Hospital between June 2019 and October 2020 were included. We compared the Movement Disorders Society Unified Parkinson’s Disease Rating Scale Part III score in the off state 3 months before and 1 year after surgery, and the difference in the score was defined as the motor outcome after DBS. Preoperative magnetic resonance images of the midbrain were evaluated using FreeSurfer and the One-Line Method. A total of 34 patients were enrolled. Multiple regression analysis with least squares indicated that the volume of the midbrain measured using FreeSurfer had no significance as an independent variable (p = 0.16), whereas the midbrain length evaluated using the One-Line Method had significance (p < 0.05) when the outcome of motor symptoms was set as the dependent variable. We showed that midbrain size evaluated using the One-Line Method was a good predictor of the motor outcome after STN-DBS, but volume measured using FreeSurfer was not. The One-Line Method was considered to detect changes in size specifically in the midbrain tegmentum, which is associated with PD motor symptoms. Thus, we present a simple and useful method for predicting poor outcomes after STN-DBS treatment in patients with PD with disease progression.

BACKGROUND:Deep brain stimulation (DBS) is effective for Parkinson's disease (PD); however, its efficacy varies with genetic background, such as the GBA1 variant-the causative gene of Gaucher disease-associated with increased PD risk and cognitive decline after subthalamic nucleus (STN)-DBS. OBJECTIVES:The aim of the study was to examine the relationship between outcomes after STN-DBS and GBA1 variants in PD patients undergoing bilateral STN-DBS. METHODS:Patients were retrospectively analyzed over 5 years, with clinical and genetic assessments, including GBA1 variant status performed at baseline and at 1-, 3-, and 5-years post-DBS. Longitudinal changes in motor, cognitive, and medication outcomes were evaluated using propensity score matching and linear mixed-effects models. RESULTS:A total of 371 PD patients undergoing bilateral STN-DBS were analyzed, including 54 GBA1 variant carriers and 253 noncarriers, after excluding other genetic variants. Propensity score matching yielded 2 groups with balanced baseline characteristics, with 50 patients each. Over time, no significant differences were observed in motor, cognitive, or neuropsychiatric assessments between groups. GBA1 carriers exhibited worsened medication OFF-DBS off state motor symptoms at 5 years postoperatively, whereas cognitive function, assessed by the Mini-Mental State Examination, remained stable in both groups. Levodopa-equivalent daily dose (LEDD) significantly decreased in both groups. Linear mixed-effects models showed progressive motor and cognitive decline and reduced medication use over 5 years, with no significant impact on GBA1 variant status. CONCLUSIONS:Findings from Japan's largest genetic cohort suggest that GBA1 variants may not significantly affect postoperative motor or cognitive trajectories following STN-DBS. Further validation through large-scale multinational and multicenter studies is warranted.

PURPOSE:We developed a Japanese version of the Patient Safety Screener-3 (PSS-3) and applied it to stratify suicide risk in hospitalized patients. Additionally, we tested the hypothesis that PSS-3-assessed depressed mood and suicide risk are independently associated with length of stay (LOS) among hospitalized patients. METHODS:A cross-sectional study was conducted at a university hospital in Tokyo from January to December 2023. The Japanese version of the PSS-3 was used to screen hospitalized patients with advanced cancer. Data were collected from medical charts and Diagnosis Procedure Combination records. Linear mixed-effects models with patient-level random intercepts were used to examine associations among depressed mood, suicide risk, and LOS, adjusting for age, sex, cancer diagnosis, Charlson Comorbidity Index, activities of daily living (ADL), and disturbance of consciousness. RESULTS:Among 2077 screenings, 2019 first assessments on admission were analyzed, of which 90.8 % were performed on admission day. Depressed mood was present in 308 patients (15.3 %), and 26 patients (1.3 %) were assessed as having high suicide risk. Depressed mood prolonged LOS (reference geometric mean: 8.44 days) by 18 % (1.18; 95 % CI, 1.07-1.30), while high suicide risk prolonged it by 40 % (1.40; 95 % CI, 1.03-1.90), in a clinically and statistically balanced model adjusted for age, sex, and cancer diagnosis. CONCLUSIONS:The PSS-3 stratified hospitalized patients by depressed mood and suicide risk, both of which were independently associated with prolonged hospitalization. This simple screening tool may facilitate early identification of high-risk patients, optimize resource allocation, and improve patient care.

Abstract Background Psychosis is known as one of the non-motor symptoms of Parkinson’ s disease (PD). Psychosis is typically associated with an increased burden regarding living activities in PD and thus constitutes a serious public health problem. Aims & Objectives We hypothesized that the visual hallucinations associated with PD would be predicted by neurodegeneration of specific regions. We consecutively enrolled 228 patients with PD between October 2016 and March 2021 at Juntendo University Hospital in Japan. Method All patients were assessed for motor function, cognition, mental state, and REM sleep-related events using the REM sleep behavior disorder (RBD) Single-Question Screen (RBD1Q), and for regional cerebral blood flow (rCBF) using N-isopropyl-p-123I-iodoamphetamine single photon emission tomography. Results The patients were divided into two groups: one with a history of visual hallucinations (Hal-PD; n = 119) and one without (nHal-PD; n = 109). Three factors were associated with Hal-PD: sex and scores on both the RBD1Q and Odor Stick Identification Test for Japanese (OSIT-J). In single photon emission tomography data, rCBF in the bilateral posterior cingulate (PC) and right cuneus were significantly lower in the Hal-PD than in the nHal-PD group. RBD1Q scores were associated with rCBF in the bilateral PC. Discussion & Conclusions Visual hallucinations were associated with rCBF in the bilateral PC and OSIT-J scores. Especially, rCBF in the left PC was an independent risk factor. RBD1Q scores were significantly associated with Hal-PD. RBD1Q scores may be an easy surrogate factor for visual hallucinations in settings where rCBF cannot be measured.

Abstract Background Approximately 10 - 20 % pregnant women have been diagnosed with depression, and 3 - 6% pregnant women receive SSRI treatment. In Japan, it reported that approximately 1% of pregnant women (105 out of 10,000 births) were prescribed SSRIs during the perinatal period. Importantly, SSRIs crossed the placenta and may affect perinatal outcomes in infants exposed to these drugs during pregnancy in human. Several large cohort studies have been conducted, some finding significant differences in the risk of ASD and others not. In the present study, we created an animal model of a patient receiving medication during pregnancy and examined changes in the offspring`s behavior and brain structure. Aims & Objectives We created an animal model of a patient receiving medication during pregnancy and examined changes in the offspring`s behavior and brain structure in rats. Methods We used pregnant female Wistar rats. Paroxetine was administered daily from ED12.5 to ED21.5, covering the last 9–12 days of pregnancy. Oral sondes were used to keep rodents at a constant daily dose, and paroxetine 1 mg / kg / day or paroxetine 2.5 mg / kg / day or saline was given to the control group. The control group received saline daily. We evaluated spontaneous locomotor activity using the open field test (OF), spontaneous alternation behavior using the Y-maze test, and anxiety behavior using the elevated plus maze test (EPM) in male offspring at PD30. BrdU-positive cells in hippocampus were counted by fluorescence microscope. Results Locomotor activities significantly increase in paroxetine 2.5 mg group compare to a control group. The paroxetine 2.5 mg group spent less time in the closed arm compared to the control and paroxetine 1 mg groups in EPM. The number of BrdU-positive cells was significantly increased in the paroxetine 2.5 mg group compared to the control group. There was tendency to be a positive correlation between spontaneous activity and the number of BrdU-positive cells. Discussion & Conclusions In this study, it was revealed that oral administration of paroxetine during pregnancy induces hyperactivities and impulsivities in offspring, and increased neurogenesis in hippocampus of rats. There was a positive correlation between locomotor activity and the amount of neurogenesis. SSRI administration during pregnancy may affect the neurodevelopment of the newborn infant.

BACKGROUND:Although the use of antidepressants during pregnancy has increased over the last several decades, their safety has remained a topic of debate. Selective serotonin reuptake inhibitors (SSRIs) can cross the placenta and affect perinatal outcomes in infants exposed during pregnancy. Recent studies suggest new risks for not only for structural malformations, but also long-term behavioral, developmental, and emotional disorders in offspring. AIM:We aimed to elucidate the effects by which in utero paroxetine exposure may affect the behavior and hippocampus of the offspring of paroxetine-treated rodent mothers. METHODS:Paroxetine was administered daily to pregnant female Wistar rats from embryonic day (ED) 12.5 to ED 21 with oral sondes. Paroxetine 1 mg/kg/day or paroxetine 2.5 mg/kg/day or saline was given to the control group. We evaluated spontaneous locomotor activity, spontaneous alternation behavior using the Y-maze test, and anxiety behavior using the elevated plus maze (EPM) in male offspring at postnatal day 30. Bromodeoxyuridine (BrdU)-positive cells in the hippocampus were counted using a fluorescence microscope. RESULTS:Locomotor activities significantly increased in the paroxetine 2.5 mg compared with the control group. The paroxetine 2.5 mg group spent less time in the closed arm than did the control and paroxetine 1 mg groups in the EPM. The number of BrdU-positive cells in the dentate gyrus was significantly increased in the paroxetine 2.5 mg compared with the control group. CONCLUSIONS:These findings suggest that oral administration of paroxetine during pregnancy induces hyperactivity, decreases anxiety, and increases cell proliferation in the hippocampus of male offspring.

Patients with bipolar disorder often report self-perceived treatment resistance. However, it is not known to what extent it is due to actual treatment resistance. The Juntendo University provides "Bipolar Disorder Treatment Rebuilding Program," in which patients with self-reported treatment resistant bipolar disorder are hospitalized for 2 weeks and undergo detailed examinations. In this study, we report our experience with the initial 43 patients hospitalized during the one and half years after the launch of the program. Among the patients who underwent full assessment, only one was regarded as having genuine treatment-resistant bipolar disorder without comorbidity. In other cases, ten were not diagnosed with bipolar disorder, 3 had organic brain diseases, 12 had comorbid mental disorders and its symptoms were regarded as treatment-resistant bipolar symptoms by the patients, and 18 did not receive adequate treatment because attendant physicians did not adhere to the treatment guidelines or patients did not adhere to the treatment because of lack of insight. The number of participants was not large, and selection bias hampered the generalization of the findings. Insight and adherence were assessed without the use of validated tools. We could not verify recovery after adequate treatment because of the limited hospitalization period. The findings suggest that most patients with self-perceived treatment-resistant bipolar disorder may not have genuine treatment-resistant bipolar disorder. These results shed light on the difficulties of public education of bipolar disorder and importance of providing appropriate services for diagnosis and treatment of bipolar disorder in the community.

Aim:The aim of this study was to develop quantitative outcome indicators for psychiatric training programs integrated into the General Medicine In-Training Examination (GM-ITE) and to investigate which characteristics correlate with high scores in psychiatry. Methods:A nationwide cross-sectional study was conducted over 3 fiscal years (2021-2023). An anonymous online questionnaire was distributed to postgraduate year 1 and 2 residents who completed the GM-ITE. The primary outcome was GM-ITE score, with a particular focus on psychiatry. Multiple-choice questions for the psychiatry field were created by board-certified psychiatrists with various subspecialties, then reviewed and piloted. Multiple regression analysis examined correlations between GM-ITE score and various resident and facility characteristics. Results:A total of 18,226 residents participated over the 3 years, of whom 5%-6% aspired to specialize in psychiatry. Quantitative scores were effective in the psychiatry field across all 3 years. Psychiatry aspirants had lower scores in internal medicine, emergency, and total scores but higher scores in psychiatry. Residents from university hospitals had lower psychiatry scores, while the number of psychiatry beds and supervising psychiatrists did not correlate with higher psychiatry scores. These findings indicate the need for psychiatric training programs distinct from general internal medicine and emergency training. Conclusion:Based on these quantitative psychiatry scores, this study highlights the necessity of improving physical assessment skills during residency for psychiatry aspirants, who score higher in psychiatry. Future research should identify effective training programs and facility practices that lead to higher psychiatry scores among residents, and thereby better integrate psychiatry into basic clinical skills.

Introduction: Monoamine oxidase type B inhibitors, including selegiline, are established as anti-Parkinsonian Drugs. Inhibition of monoamine oxidase type B enzymes might suppress the inflammation because of inhibition to generate reactive oxygen species. However, its effect on brain microstructure remains unclear. The aim of this study is to elucidate white matter and substantia nigra (SN) microstructural differences between Patients with Parkinson's disease with and without selegiline treatment by two independently recruited cohorts. Methods: Diffusion tensor imaging and free water imaging indices of WM and SN were compared among 22/15 Patients with Parkinson's disease with selegiline (PDselegiline(+)), 33/23 Patients with Parkinson's disease without selegiline (PDselegiline(-)), and 25/20 controls, in the first/second cohorts. Two cohorts were analyzed with different MRI protocols. Results: Diffusion tensor imaging and free-water indices of major white matter tracts were significantly differed between the PDselegiline(-) and controls in both cohorts, although not between the PDselegiline(+) and controls except for restricted areas. Compared with the PDselegiline(+), free-water was significantly higher in the PDselegiline(-) in the inferior fronto-occipital fasciculus, superior longitudinal fasciculus, and superior and posterior corona radiata (first cohort) and the forceps major and splenium of the corpus callosum (second cohort). There were no significant differences in free -water of anterior or posterior substantia nigra between PDselegiline(+) and PDselegiline(-). Conclusions: Selegiline treatment might reduce the white matter microstructural abnormalities detected by freewater imaging in Parkinson's disease.

Aim:To investigate the real-world effectiveness and safety of lemborexan for treating comorbid insomnia associated with other psychiatric disorders, and whether lemborexant helps reduce the dose of benzodiazepines (BZs).Methods:This retrospective observational study was conducted on outpatients and inpatients treated by physicians of Juntendo University Hospital Mental Clinic between April 2020 and December 2021.Results:Data of 649 patients who were treated with lemborexant were eventually enrolled. About 64.5% of patients were classified as the responder group. Response rates of ≥60% were recorded for most psychiatric disorders. Upon administration of lemborexant, diazepam-equivalent dose of BZs had been significantly reduced in participants (3.7 ± 8.2 vs. 2.9 ± 7.9, p < 0.001). The results of logistic regression analysis showed that outpatient (odds ratios: 2.310; 95% confidence interval [CI]: 1.32-4.05), shorter duration of BZ use (<1 year) (odds ratios: 1.512; 95% CI: 1.02-2.25), no adverse events (odds ratios: 10.369; 95% CI: 6.13-17.54), larger reduction of diazepam-equivalent dose of BZs upon introducing lemborexant prescription (odds ratios: 1.150; 95% CI: 1.04-1.27), and suvorexant was the replacement drug (odds ratios: 2.983; 95% CI: 1.44-6.19), which were significant predictors of good response.Conclusion:Although this is a retrospective and observational study with many limitations, our study results suggest that lemborexant is effective and safe.

Background Holmes tremor (HT) is a refractory tremor associated with cortico-basal ganglia loops and cerebellothalamic tract abnormalities. Various drug treatments have been attempted; however, no treatment method has yet been established. Historically, thalamic deep brain stimulation (DBS) has been performed in medically refractory cases. Recently, the posterior subthalamic area (PSA) has been used for HT. Here, we report cases of HT and review the effectiveness and safety of PSA-DBS for HT. Cases We conducted a retrospective chart review of two patients with HT who underwent PSA-DBS. Improvement in tremors was observed 1 year after surgery without apparent complications. Literature review We identified 12 patients who underwent PSA-DBS for HT, including our cases. In six patients, PSA was targeted alone; for the rest, the ventralis intermediate nucleus (Vim) of the thalamus and PSA were simultaneously targeted. The Fahn–Tolosa–Marin Tremor Rating Scale improvement rates were 56.8% (range, 33.9–82.1%; n = 6) and 77.8% (range, 42.6–100%; n = 5) for the PSA-DBS and PSA+Vim-DBS, respectively. Conclusion Reasonable improvements in HT were observed after PSA-DBS. PSA might be an appropriate target for improving the symptoms of HT. Long-term observations, accumulation of cases, and randomized studies are required in future.

BACKGROUND:Impulse control behaviors (ICBs) in Parkinson's disease (PD) are thought to be caused by an overdose of dopaminergic therapy in the relatively spared ventral striatum, or by hypersensitivity of this region to dopamine. Alterations in brain networks are now also thought to contribute to the development of ICBs.OBJECTIVE:To comprehensively assess white matter microstructures in PD patients with ICBs using advanced diffusion MRI and magnetization transfer saturation (MT-sat) imaging.METHODS:This study included 19 PD patients with ICBs (PD-ICBs), 18 PD patients without ICBs (PD-nICBs), and 20 healthy controls (HCs). Indices of diffusion tensor imaging (DTI), diffusion kurtosis imaging, neurite orientation dispersion and density imaging, and MT-sat imaging were evaluated using tract-based spatial statistics (TBSS), regions of interest (ROIs), and tract-specific analysis (TSA).RESULTS:Compared with HCs, PD-nICBs had significant alterations in many major white matter tracts in most parameters. In contrast, PD-ICBs had only partial changes in several parameters. Compared with PD-ICBs, TBSS, ROI, and TSA analyses revealed that PD-nICBs had lower axial kurtosis, myelin volume fraction, and orientation dispersion index in the uncinate fasciculus and external capsule, as well as in the retrolenticular part of the internal capsule. These are components of the reward system and the visual and emotional perception areas, respectively.INTERPRETATION:Myelin and axonal changes in fibers related to the reward system and visual emotional recognition might be more prominent in PD-nICBs than in PD-ICBs.

Abstract Aim To clarify the association between changes in the number of foundational medications for heart failure (FMHF) during hospitalization for worsening heart failure and post-discharge prognosis. Methods and results We retrospectively analyzed a combined dataset of three large-scale registries of hospitalized patients with heart failure in Japan (NARA-HF, WET-HF, and REALITY-AHF) and included patients already diagnosed with heart failure with reduced or mildly reduced left ventricular ejection fraction (HFr/mrEF) before admission. Patients were stratified by changes in the number of prescribed FMHF classes, namely angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, beta blockers, and mineralocorticoid receptor blockers, from admission to discharge. The primary endpoint was defined as the combined endpoint of heart failure rehospitalization and all-cause death within 1-year of discharge. The cohort consisted of 1,113 patients, and 482 combined endpoints were observed. In total, 413 (37.1%) patients were on increased FMHF (increased group), 607 (54.5%) remained unchanged (unchanged group), and 93 (8.4%) had a decreased number of FMHF (decreased group) at discharge compared to the time of admission. In multivariable analysis, the increased group was associated with a significantly lower incidence of the primary endpoint compared with the unchanged group (hazard ratio 0.56, 95% confidence interval 0.45–0.60; P<0.001) and decreased group (hazard ratio 0.58, 95% confidence interval 0.40–0.84; P=0.004). Conclusion Increasing the number of FMHF cases during heart failure hospitalization is associated with a better prognosis in patients with HFr/mrEF. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): REALITY registry was funded by the Cardiovascular Research Fund of Japan.WET-HF registry was supported by a Grant-in-Aid for Young Scientists (Y.S. JSPS KAKENHI, 18K15860).

OBJECTIVETo review and synthesize qualitative research studies of women's perceptions of professional labor support.DATA SOURCESJournal articles dated from 1990 to 2001. Search terms included labor support, labor and delivery, childbirth, birth, and caring during labor. Qualitative studies and combined quantitative/qualitative studies with open-ended questions were included.STUDY SELECTIONThe focus of the 17 studies was laboring women's rather than nurses' perceptions of labor support or care during labor.DATA EXTRACTIONData describing methods, samples, and findings were extracted from study reports.DATA SYNTHESISSimilarities reported in the study findings were synthesized using a model of labor support. Synthesis of the study findings was reported using exemplary statements in the words of women who experienced labor support. Categories included expectations of labor support, physical comfort, caring and emotional support, interpersonal communication style, communication of information and instructions, advocacy, and competence of the professional.CONCLUSIONSThere were a limited number of qualitative studies of labor support. Professional labor support was influenced by the interpersonal communication style of the caregiver. Cultural differences existed in caregiver actions considered supportive.

INTRODUCTION:Levodopa-induced dyskinesia is a complication of levodopa therapy and negatively impacts the quality of life of patients. We aimed to elucidate white matter alterations in Parkinson's disease with levodopa-induced dyskinesia using advanced diffusion magnetic resonance imaging techniques.METHODS:The enrolled subjects included 26 clinically confirmed Parkinson's disease patients without levodopa-induced dyskinesia, 25 Parkinson's disease patients with levodopa-induced dyskinesia, and 23 healthy controls. Subjects were imaged using a 3-T magnetic resonance scanner. Diffusion tensor imaging, diffusion kurtosis imaging, and neurite orientation dispersion and density imaging findings were compared between groups with a group-wise whole brain approach and a region-of-interest analysis for each white matter tract. Additionally, logistic regression analysis was used to calculate odds ratios for levodopa-induced dyskinesia.RESULTS:Group-wise tract-based spatial statistical analysis revealed significant white matter differences in isotropic diffusion, complexity, or heterogeneity, and neurite density between healthy controls and Parkinson's disease patients without levodopa-induced dyskinesia and between patients with and without levodopa-induced dyskinesia. Region-of-interest analysis revealed similar alterations using a group-wise whole-brain approach in the external capsule, inferior fronto-occipital fasciculus, inferior longitudinal fasciculus, and uncinate fasciculus. These tracts had an odds ratio of approximately 2.3 for the presence of levodopa-induced dyskinesia.CONCLUSIONS:Our findings suggest that Parkinson's disease with levodopa-induced dyskinesia produces less white matter microstructural disruption, especially in temporal lobe fibers, than Parkinson's disease without levodopa-induced dyskinesia. These fibers has a more than 2-fold odds ratio for the presence of levodopa-induced dyskinesia and might be associated with the pathogenesis of the sequela.

Multiple system atrophy (MSA) is classified into two main types: parkinsonian and cerebellar ataxia with oligodendrogliopathy. We examined microstructural alterations in the white matter and the substantia nigra pars compacta (SNc) of patients with MSA of parkinsonian type (MSA-P) using multishell diffusion magnetic resonance imaging (dMRI) and myelin sensitive imaging techniques. Age- and sex-matched patients with MSA-P ( n = 21, n = 10 first and second cohorts, respectively), Parkinson’s disease patients ( n = 19, 17), and healthy controls ( n = 20, 24) were enrolled. Magnetization transfer saturation imaging (MT-sat) and dMRI were obtained using 3-T MRI. Measurements obtained from diffusion tensor imaging (DTI), free-water elimination DTI, neurite orientation dispersion and density imaging (NODDI), and MT-sat were compared between groups. Tract-based spatial statistics analysis revealed differences in diffuse white matter alterations in the free-water fractional volume, myelin volume fraction, and intracellular volume fraction between the patients with MSA-P and healthy controls, whereas free-water and MT-sat differences were limited to the middle cerebellar peduncle in comparison with those with Parkinson’s disease. Region-of-interest analysis of white matter and SNc revealed significant differences in the middle and inferior cerebellar peduncle, pontine crossing tract, corticospinal tract, and SNc between the MSA-P and healthy controls and/or Parkinson’s disease patients. Our results shed light on alterations to brain microstructure in MSA.