Sensitivity and specificity are two components that measure the inherent validity of a diagnostic test for dichotomous outcomes against a gold standard. Receiver operating characteristic (ROC) curve is the plot that depicts the trade-off between the sensitivity and (1-specificity) across a series of cut-off points when the diagnostic test is continuous or on ordinal scale (minimum 5 categories). This is an effective method for assessing the performance of a diagnostic test. The aim of this article is to provide basic conceptual framework and interpretation of ROC analysis to help medical researchers to use it effectively. ROC curve and its important components like area under the curve, sensitivity at specified specificity and vice versa, and partial area under the curve are discussed. Various other issues such as choice between parametric and non-parametric methods, biases that affect the performance of a diagnostic test, sample size for estimating the sensitivity, specificity, and area under ROC curve, and details of commonly used softwares in ROC analysis are also presented.

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A Randomized Clinical Trial of High-Dosage Coenzyme Q10 in Early Parkinson Disease No Evidence of Benefit The Parkinson Study Group QE3 Investigators IMPORTANCE Coenzyme Q10 (CoQ10), an antioxidant that supports mitochondrial function, has been shown in preclinical Parkinson disease (PD) models to reduce the loss of dopamine neurons, and was safe and well tolerated in early-phase human studies. A previous phase II study suggested possible clinical benefit. OBJECTIVE To examine whether CoQ10 could slow disease progression in early PD. DESIGN, SETTING, AND PARTICIPANTS A phase III randomized, placebo-controlled, double-blind clinical trial at 67 North American sites consisting of participants 30 years of age or older who received a diagnosis of PD within 5 years and who had the following inclusion criteria: the presence of a rest tremor, bradykinesia, and rigidity; a modified Hoehn and Yahr stage of 2.5 or less; and no anticipated need for dopaminergic therapy within 3 months. Exclusion criteria included the use of any PD medication within 60 days, the use of any symptomatic PD medication for more than 90 days, atypical or drug-induced parkinsonism, a Unified Parkinson's Disease Rating Scale (UPDRS) rest tremor score of 3 or greater for any limb, a Mini-Mental State Examination score of 25 or less, a history of stroke, the use of certain supplements, and substantial recent exposure to CoQ10. Of 696 participants screened, 78 were found to be ineligible, and 18 declined participation. INTERVENTIONS The remaining 600 participants were randomly assigned to receive placebo, 1200 mg/d of CoQ10, or 2400 mg/d of CoQ10; all participants received 1200 IU/d of vitamin E. MAIN OUTCOMES AND MEASURES Participants were observed for 16 months or until a disability requiring dopaminergic treatment. The prospectively defined primary outcome measure was the change in total UPDRS score (Parts I-III) from baseline to final visit. The study was powered to detect a 3-point difference between an active treatment and placebo. RESULTS The baseline characteristics of the participants were well balanced, the mean age was 62.5 years, 66% of participants were male, and the mean baseline total UPDRS score was 22.7. A total of 267 participants required treatment (94 received placebo, 87 received 1200 mg/d of CoQ10, and 86 received 2400 mg/d of CoQ10), and 65 participants (29 who received placebo, 19 who received 1200 mg/d of CoQ10, and 17 who received 2400 mg/d of CoQ10) withdrew prematurely. Treatments were well tolerated with no safety concerns. The study was terminated after a prespecified futility criterion was reached. At study termination, both active treatment groups showed slight adverse trends relative to placebo. Adjusted mean changes (worsening) in total UPDRS scores from baseline to final visit were 6.9 points (placebo), 7.5 points (1200 mg/d of CoQ10; P = .49 relative to placebo), and 8.0 points (2400 mg/d of CoQ10; P = .21 relative to placebo). CONCLUSIONS AND RELEVANCE Coenzyme Q10 was safe and well tolerated in this population, bu...

Highlights This prospective study is one of the largest clinical trials in essential tremor to date. Study findings suggest that individualized non-invasive neuromodulation therapy used repeatedly at home over three months results in safe and effective hand tremor reduction and improves quality of life for many essential tremor patients. Background: Two previous randomized, controlled, single-session trials demonstrated efficacy of non-invasive neuromodulation therapy targeting the median and radial nerves for reducing hand tremor. This current study evaluated efficacy and safety of the therapy over three months of repeated home use. Methods: This was a prospective, open-label, post-clearance, single-arm study with 263 patients enrolled across 26 sites. Patients were instructed to use the therapy twice daily for three months. Pre-specified co-primary endpoints were improvements on clinician-rated Tremor Research Group Essential Tremor Rating Assessment Scale (TETRAS) and patient-rated Bain & Findley Activities of Daily Living (BF-ADL) dominant hand scores. Other endpoints included improvement in the tremor power detected by an accelerometer on the therapeutic device, Clinical and Patient Global Impression scores (CGI-I, PGI-I), and Quality of Life in Essential Tremor (QUEST) survey. Results: 205 patients completed the study. The co-primary endpoints were met (p≪0.0001), with 62% (TET-RAS) and 68% (BF-ADL) of 'severe' or 'moderate' patients improving to 'mild' or 'slight'. Clinicians (CGI-I) reported improvement in 68% of patients, 60% (PGI-I) of patients reported improvement, and QUEST improved (p = 0.0019). Wrist-worn accelerometer recordings before and after 21,806 therapy sessions showed that 92% of patients improved, and 54% of patients experienced ≥50% improvement in tremor power. Device-related adverse events (e.g., wrist discomfort, skin irritation, pain) occurred in 18% of patients. No device-related serious adverse events were reported. Discussion: This study suggests that non-invasive neuromodulation therapy used repeatedly at home over three months results in safe and effective hand tremor reduction in many essential tremor patients.

The carbocationic polymerization of isobutylene (IB), co-initiated by GaCl 3 or FeCl 3 ·dialkyl ether 1:1 complexes has been investigated in hexanes in the −20 to 10°C temperature range. In contrast to AlCl 3 ·diisopropyl ether (AlCl 3 ·i-Pr 2 O) complexes, 1 GaCl 3 ·i-Pr 2 O and FeCl 3 ·i-Pr 2 O readily co-initiate polymerization with 2-chloro-2,4,4-trimethylpentane (TMPCl) or tert-butyl chloride (t-BuCl) in the presence or absence of proton trap. In the absence of proton trap, chain transfer to monomer readily proceeded, resulting in close to complete monomer conversion and up to 85% exo-olefinic end group content. Diisopropyl ether complexes gave the highest polymerization rates, while nonbranched alkyl ether complexes were completely inactive. A polymerization mechanism is proposed to involve ether-assisted proton elimination to yield PIB exo-olefin, and the abstracted proton can subsequently start a new polymer chain by protonation of IB. Alternatively PIB + may be deactivated by ion collapse to yield PIBCl, which can be reactivated by the Lewis acid. The reasons for the difference in behavior between the Ga and Fe catalysts and the Al-based catalysts are described. ■ INTRODUCTIONLow molecular weight (M n ∼ 500−5000 g/mol) olefin end functional PIB is a precursor to motor oil and fuel additives. Currently two major industrial methods are utilized to produce low molecular weight IB homo or copolymers with olefinic end groups. The "conventional" method uses a C4 mixture and AlCl 3 or EtAlCl 2 based catalyst systems, which provides polybutenes with high trisubstituted olefinic content. 2,3 The other method employs pure IB and uses BF 3 complexes with either alcohols or ethers as catalysts, yielding highly reactive PIB (HR PIB) with high exo-olefinic end-group content. 4 In contrast to the trisubstituted olefins of conventional polybutenes, PIB exo olefins readily react with maleic anhydride in a thermal ene reaction to produce PIB succinic anhydride and subsequently polyisobutenyl succinimide ashless dispersants. Since chlorination is not necessary for maleation of HR PIB, the final product does not contain any chlorine, making HR PIB more desirable than conventional polybutenes.In recent decades, several new methods for the synthesis of HR PIB have been reported. For example, PIBCl was selectively dehydrochlorinated by a bulky base, e.g., potassium tertbutoxide to yield HR PIB. 5 Storey et al. used living cationic polymerization of IB at −80°C to obtain living PIB, which was then end-quenched with sterically hindered bases 6 or sulfides. 7 Another method used to produce HR PIB, developed by Kuhn and co-workers, involves inorganic/organometallic catalysts with weakly coordinating anions in dichloromethane (DCM). 8 Recently, Kostjuk and Wu independently reported that at moderate temperatures AlCl 3 ·dibutyl ether 9 (AlCl 3 ·Bu 2 O) and AlCl 3 ·i-Pr 2 O 10 complexes in DCM or DCM/hexanes 80/20 (v/ v) mixtures give HR PIB with exo-olefinic end-groups in excess of 90%. Shortly thereafter, Wu and co-workers also rep...