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You S, Lv T, Qin R, Hu Z, Ke Z, Yao W, Zhao H, Bai F. Neuro-Navigated rTMS Improves Sleep and Cognitive Impairment via Regulating Sleep-Related Networks' Spontaneous Activity in AD Spectrum Patients. Clin Interv Aging 2023; 18:1333-1349. [PMID: 37601952 PMCID: PMC10439779 DOI: 10.2147/cia.s416992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 08/03/2023] [Indexed: 08/22/2023] Open
Abstract
Study Objectives By examining spontaneous activity changes of sleep-related networks in patients with the Alzheimer's disease (AD) spectrum with or without insomnia disorder (ID) over time via neuro-navigated repetitive transcranial magnetic stimulation (rTMS), we revealed the effect and mechanism of rTMS targeting the left-angular gyrus in improving the comorbidity symptoms of the AD spectrum with ID. Methods A total of 34 AD spectrum patients were recruited in this study, including 18 patients with ID and the remaining 16 patients without ID. All of them were measured for cognitive function and sleep by using the cognitive and sleep subscales of the neuropsychiatric inventory. The amplitude of low-frequency fluctuation changes in sleep-related networks was revealed before and after neuro-navigated rTMS treatment between these two groups, and the behavioral significance was further explored. Results Affective auditory processing and sensory-motor collaborative sleep-related networks with hypo-spontaneous activity were observed at baseline in the AD spectrum with ID group, while substantial increases in activity were evident at follow-up in these subjects. In addition, longitudinal affective auditory processing, sensory-motor and default mode collaborative sleep-related networks with hyper-spontaneous activity were also revealed at follow-up in the AD spectrum with ID group. In particular, longitudinal changes in sleep-related networks were associated with improvements in sleep quality and episodic memory scores in AD spectrum with ID patients. Conclusion We speculated that left angular gyrus-navigated rTMS therapy may enhance the memory function of AD spectrum patients by regulating the spontaneous activity of sleep-related networks, and it was associated with memory consolidation in the hippocampus-cortical circuit during sleep. Clinical Trial Registration The study was registered at the Chinese Clinical Trial Registry, registration ID: ChiCTR2100050496, China.
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Affiliation(s)
- Shengqi You
- Department of Neurology, Nanjing Drum Tower Hospital Clinical College of Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, 210008, People’s Republic of China
| | - Tingyu Lv
- Department of Neurology, Nanjing Drum Tower Hospital Clinical College of Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, 210008, People’s Republic of China
| | - Ruomeng Qin
- Department of Neurology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, 210008, People’s Republic of China
| | - Zheqi Hu
- Department of Neurology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, 210008, People’s Republic of China
| | - Zhihong Ke
- Department of Neurology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, 210008, People’s Republic of China
| | - Weina Yao
- Department of Neurology, Nanjing Drum Tower Hospital Clinical College of Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, 210008, People’s Republic of China
| | - Hui Zhao
- Department of Neurology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, 210008, People’s Republic of China
| | - Feng Bai
- Department of Neurology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, 210008, People’s Republic of China
- Geriatric Medicine Center, Taikang Xianlin Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, 210008, People’s Republic of China
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Song T, Yu K, Wang L, Xu L, Xu M, Peng Z, Dai C, Wang H, Yang T, Shao Y, Wang X, Lv J. Total Sleep Deprivation Triggers Greater Activation in the Parietal Brain in the Visual Working Memory Updating Processes: An Event-Related Potentials Study. Front Neurosci 2022; 16:736437. [PMID: 35368284 PMCID: PMC8966886 DOI: 10.3389/fnins.2022.736437] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 02/17/2022] [Indexed: 12/21/2022] Open
Abstract
Working memory functions are known to be altered after total sleep deprivation (TSD). However, few studies have explored the deficits of working memory updating (WMU) after TSD, or the underlying electrophysiological mechanisms of these alterations. In the current exploratory study, we enrolled 14 young male volunteers who performed two kinds of WMU tasks—spatial and object two-back tasks—with simultaneous electroencephalography recordings under two sleep conditions: a normal sleep baseline condition and after 36 h of TSD. Repeated-measures analysis of variance showed that compared with those at baseline, the rates of correct responses in the WMU tasks decreased significantly after TSD. Analysis of event-related potentials revealed that the average amplitude of P3 components decreased significantly in the frontal and central brain regions and increased significantly in the parietal brain regions. Our findings suggest that TSD damages WMU behavior, impairs cognitive functions in the frontal and central brain regions, and triggers greater activation in the parietal brain regions. This is the first study to report the existence of event-related compensatory neural activity. This event-related compensatory effect may provide a new perspective for understanding the mechanisms underlying the influences triggered by sleep loss.
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Affiliation(s)
- Tao Song
- School of Psychology, Beijing Sport University, Beijing, China
| | - Ke Yu
- Department of General Practice, The General Hospital of Western Theater Command, Chengdu, China
| | - Letong Wang
- School of Psychology, Beijing Sport University, Beijing, China
| | - Lin Xu
- School of Psychology, Beijing Sport University, Beijing, China
| | - Mengmeng Xu
- School of Psychology, Beijing Sport University, Beijing, China
| | - Ziyi Peng
- School of Psychology, Beijing Sport University, Beijing, China
| | - Cimin Dai
- School of Psychology, Beijing Sport University, Beijing, China
| | - Haiteng Wang
- School of Psychology, Beijing Sport University, Beijing, China
| | - Tianyi Yang
- School of Psychology, Beijing Sport University, Beijing, China
| | - Yongcong Shao
- School of Psychology, Beijing Sport University, Beijing, China
- *Correspondence: Yongcong Shao,
| | - Xiaoming Wang
- Tianjin Institute of Environmental and Operational Medicine, Tianjin, China
- Xiaoming Wang,
| | - Jing Lv
- Department of Psychology, The Second Medical Center, Chinese PLA General Hospital, Beijing, China
- Jing Lv,
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Qi J, Li BZ, Zhang Y, Pan B, Gao YH, Zhan H, Liu Y, Shao YC, Weng XC, Zhang X. Disrupted Small-world Networks are Associated with Decreased Vigilant Attention after Total Sleep Deprivation. Neuroscience 2021; 471:51-60. [PMID: 34293415 DOI: 10.1016/j.neuroscience.2021.07.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 07/02/2021] [Accepted: 07/12/2021] [Indexed: 02/06/2023]
Abstract
Sleep deprivation critically affects vigilant attention. Previous neuroimaging studies have revealed altered inter-regional functional connectivity after sleep deprivation, which may disrupt topological properties of brain functional networks. However, little is known about alterations in the topology of intrinsic connectivity and its involvement in attention performance after sleep deprivation. In the current study, we investigated the topological properties of brain networks derived from resting-state functional magnetic resonance imaging of 26 healthy men in rested wakefulness (RW) state and after 36 h of total sleep deprivation (TSD). In the predefined sparsity threshold range, both global and nodal network properties were evaluated based on graph theory analysis. Vigilant attention was assessed using the psychomotor vigilance test (PVT) before and after TSD. Furthermore, Pearson's correlation analyses were conducted to explore the association between altered network properties and changed PVT performance after TSD. At the global level, the brain functional networks in the TSD state showed a significantly lower small-world coefficient than RW, with decreased global efficiency. At the nodal level, the altered regions were selectively distributed in frontoparietal networks, sensorimotor networks, temporal regions, and salience networks. More specifically, the altered clustering coefficient in the posterior superior temporal sulcus (pSTS) and insula, and altered local efficiency in pSTS were further associated with PVT performance after TSD. Our results suggest that the topological properties of brain functional networks are disrupted, and aberrant topology of temporal networks and salience networks may act as neural signatures underlying the vigilant attention impairments after TSD.
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Affiliation(s)
- Jing Qi
- School of Medicine, Nankai University, Tianjin 300071, China; Department of Neurology, The Second Medical Center, Sleep Medicine Research Center, National Clinical Research Centre for Geriatric Diseases, Chinese PLA General Hospital, Beijing 100853, China
| | - Bo-Zhi Li
- Department of Neurology, The Second Medical Center, Sleep Medicine Research Center, National Clinical Research Centre for Geriatric Diseases, Chinese PLA General Hospital, Beijing 100853, China
| | - Ying Zhang
- The Eighth Medical Center of the General Hospital of People's Liberation Army, Beijing 100091, China
| | - Bei Pan
- Airforce Medical Center, PLA, Beijing 100142, China
| | - Yu-Hong Gao
- National Clinical Research Centre for Geriatric Diseases, Second Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Hao Zhan
- Airforce Medical Center, PLA, Beijing 100142, China
| | - Yong Liu
- Brainnetome Center, Institute of Automation, Chinese Academy of Sciences, Beijing 100190, China; National Laboratory of Pattern Recognition, Institute of Automation, Chinese Academy of Sciences, Beijing 100190, China; CAS Center for Excellence in Brain Science and Intelligence Technology, Institute of Automation, Chinese Academy of Sciences, Beijing 100190, China; University of Chinese Academy of Sciences, Beijing 100049, China
| | - Yong-Cong Shao
- School of Psychology, Beijing Sport University, Beijing 100084, China; School of Biological Science and Medical Engineering, Beihang University, Beijing 100191, China
| | - Xie-Chuan Weng
- Beijing Institute of Basic Medical Sciences, Beijing 100850, China.
| | - Xi Zhang
- Department of Neurology, The Second Medical Center, Sleep Medicine Research Center, National Clinical Research Centre for Geriatric Diseases, Chinese PLA General Hospital, Beijing 100853, China; School of Medicine, Nankai University, Tianjin 300071, China.
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Meigal AY, Tretjakova OG, Gerasimova-Meigal LI, Sayenko IV. Program of Seven 45-min Dry Immersion Sessions Improves Choice Reaction Time in Parkinson's Disease. Front Physiol 2021; 11:621198. [PMID: 33519524 PMCID: PMC7841462 DOI: 10.3389/fphys.2020.621198] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 12/11/2020] [Indexed: 01/26/2023] Open
Abstract
The study hypothesis held that in subjects with Parkinson's disease (PD), the reaction time (RT) tests of the higher cognition demand would have more readily improved under the program of analog microgravity (μG) modeled with "dry" immersion (DI). To test this hypothesis, 10 subjects with PD have passed through a program of seven DI sessions (each 45 min long) within 25-30 days, with overall μG dose 5 1/4 h. Five patients were enrolled as controls, without DI (noDI group). Simple RT (SRT), disjunctive RT (DRT), and choice RT (CRT) were assessed in four study points: before the DI program (preDI), 1 day after the DI program (postDI), 2 weeks after the DI program (DI2w), and 2 months after the DI program (DI2m). The motor time (MT) was assessed with the tapping test (TT). Additionally, signal detection time (SDT) and central processing time (CPT) were extracted from the data. Before the program of DI, the RT tests are in accordance with their cognition load: SRT (284 ± 37 ms), DRT (338 ± 38 ms), and CRT (540 ± 156 ms). In accordance with the hypothesis, CRT and DRT have improved under DI by, respectively, 20 and 8% at the study point "DI2w," whereas SRT, SDT, and MT did not change (<5% in the preDI point, p > 0.05). Thus, the program of DI provoked RT improvement specifically in the cognitively loaded tasks, in a "dose of cognition-reaction" manner. The accuracy of reaction has changed in none of the RT tests. The neurophysiologic, hormonal/neuroendocrine, behavioral, neural plasticity, and acclimation mechanisms may have contributed to such a result.
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Affiliation(s)
- Alexander Yu Meigal
- Laboratory of Novel Methods in Physiology, Institute of Higher Biomedical Technologies, Petrozavodsk State University, Petrozavodsk, Russia
| | - Olesya G Tretjakova
- Laboratory of Novel Methods in Physiology, Institute of Higher Biomedical Technologies, Petrozavodsk State University, Petrozavodsk, Russia
| | - Liudmila I Gerasimova-Meigal
- Laboratory of Novel Methods in Physiology, Institute of Higher Biomedical Technologies, Petrozavodsk State University, Petrozavodsk, Russia
| | - Irina V Sayenko
- State Scientific Center, "Institute of Biomedical Problems," Russian Academy of Sciences, Moscow, Russia
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The connectivity between the olfactory and auditory cortex predicts an individual's sleep quality. Neuroreport 2021; 32:99-104. [PMID: 33395187 DOI: 10.1097/wnr.0000000000001567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Sleep disorders and multiple sensory impairments have been noticed as the potential first sign of neurodegenerative diseases such as the Parkinson disease. The relationship between sleep quality and the sensory neural basis would help us consider their combination in early diagnosis. In the present study, 32 out of 45 healthy subjects' resting-state functional magnetic resonance imaging data survived from motion correction and entered into the connectivity analysis. We found that the connectivity between two regions of interest (the left olfactory gyrus and the left superior temporal pole) and the regional homogeneity in the left middle temporal gyrus were negatively correlated with their Pittsburgh sleep quality index. These results suggest that these sensory-related brain regions are related to sleep quality and they may together predict the diseases.
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Zhang L, Li D, Yin H. How is psychological stress linked to sleep quality? The mediating role of functional connectivity between the sensory/somatomotor network and the cingulo-opercular control network. Brain Cogn 2020; 146:105641. [PMID: 33142162 DOI: 10.1016/j.bandc.2020.105641] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 10/17/2020] [Accepted: 10/20/2020] [Indexed: 12/20/2022]
Abstract
How the functional connectivity of brain networks affects the relationship between psychological stress and sleep quality remains unclear. To better understand the associations between psychological stress, resting-state functional connectivity (RSFC), and sleep quality, we used the RSFC, Pittsburgh Sleep Quality Index (PSQI), and Psychosomatic Tension Relaxation Inventory (PSTRI) to investigate the relationship between psychological stress, sleep quality, and RSFC in four brain networks, the sensory/somatomotor (SM) network, cigulo-opercular control (CO) network, default mode (DM) network, and dorsal attention (DA) network, in a large healthy sample of 315 college students from Southwest University. Results showed that the brain functional connectivity in the SM, CO, DM, and DA networks was significantly correlated to sleep quality. Meanwhile, we also found that the brain functional connectivity between the SM and CO networks partially mediated the relationship between psychological stress and sleep quality, suggesting that psychological stress has an important effect on individuals' sleep quality, and increased functional connectivity between the SM and CO networks provides a neural basis for the association between psychological stress and poor sleep quality.
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Affiliation(s)
- Li Zhang
- School of Education Science, Hunan Normal University, Chang Sha, 410081, China; Cognition and Human Behavior Key Laboratory of Hunan Province, Hunan Normal University, Chang Sha 410081, China
| | - Dan Li
- School of Education Science, Hunan Normal University, Chang Sha, 410081, China; Cognition and Human Behavior Key Laboratory of Hunan Province, Hunan Normal University, Chang Sha 410081, China
| | - Huazhan Yin
- School of Education Science, Hunan Normal University, Chang Sha, 410081, China; Cognition and Human Behavior Key Laboratory of Hunan Province, Hunan Normal University, Chang Sha 410081, China.
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Wu YJ, Wu N, Huang X, Rao J, Yan L, Shi L, Huang H, Li SY, Zhou FQ, Wu XR. Evidence of cortical thickness reduction and disconnection in high myopia. Sci Rep 2020; 10:16239. [PMID: 33004887 PMCID: PMC7530748 DOI: 10.1038/s41598-020-73415-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 08/21/2020] [Indexed: 01/22/2023] Open
Abstract
High myopia (HM) is associated with impaired long-distance vision. accumulating evidences reported that abnormal visual experience leads to dysfunction in brain activity in HM even corrected. However, whether the long-term of abnormal visual experience lead to neuroanatomical changes remain unknown, the aim at this study is to investigate the alternation of cortical surface thickness in HM patients. 82 patients with HM (HM groups), 57 healthy controls (HC groups) were recruited. All participants underwent high-resolution T1 and resting-state functional magnetic resonance imaging (MRI) scans. The cortical thickness analysis was preformed to investigate the neuroanatomical changes in HM patients using computational anatomy toolbox (CAT 12) toolbox. Compare with HCs, HM patients showed decreased the cortical surface thickness in the left middle occipital gyrus (MOG), left inferior parietal lobule (IPL), right inferior temporal gyrus (ITG), right precuneus, right primary visual area 1 (V1), right superior temporal gyrus (STG), right superior parietal lobule (SPL), right occipital pole, and right the primary motor cortex (M1), and increased to the parietal operculum (OP4) (P < 0.01, FWE-corrected), the mean cortical thickness of right orbitofrontal cortex (OFC), right dorsolateral prefrontal cortex (DLPFC) and right subcallosal cortex showed negatively correlation between clinical variables (axis length (ALM), the average macular thickness (AMT), keratometer (KER) 1, KER2, the mean KER, the mean macular fovea thickness (MFK), the refractive diopter) in HM patients. Our result mainly provided an evidence of cortical thickness reduction and disconnection in visual center and visual processing area, and cortical thickness increase in left multimodal integration region in HM patients. This may provide important significance of the study of the neural mechanism of HM.
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Affiliation(s)
- Ya-Jun Wu
- Department of Ophthalmology, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, China
| | - Na Wu
- Department of Ophthalmology, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, China
| | - Xin Huang
- Department of Ophthalmology, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, China
| | - Jie Rao
- Department of Ophthalmology, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, China
| | - Li Yan
- Department of Ophthalmology, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, China
| | - Ling Shi
- Department of Ophthalmology, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, China
| | - Hui Huang
- Department of Ophthalmology, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, China
| | - Si-Yu Li
- Department of Ophthalmology, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, China
| | - Fu-Qing Zhou
- Department of Radiology, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, China.
| | - Xiao-Rong Wu
- Department of Ophthalmology, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, China.
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Zhu DM, Zhang C, Yang Y, Zhang Y, Zhao W, Zhang B, Zhu J, Yu Y. The relationship between sleep efficiency and clinical symptoms is mediated by brain function in major depressive disorder. J Affect Disord 2020; 266:327-337. [PMID: 32056895 DOI: 10.1016/j.jad.2020.01.155] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 12/29/2019] [Accepted: 01/26/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Sleep disturbance is a common and key symptom that affects most of patients with major depressive disorder (MDD). However, neural substrates underlying sleep disturbance and their clinical relevance in depression remain unclear. METHODS Ninety-six MDD patients underwent resting-state functional MRI. Fractional amplitude of low-frequency fluctuation (fALFF) and resting-state functional connectivity (rsFC) were used to measure brain function. Overnight polysomnography was performed to objectively measure sleep efficiency (SE), which was used to classify patients into normal sleep efficiency (NSE) and low sleep efficiency (LSE) groups. Between-group differences in fALFF and rsFC were examined using two-sample t-tests. Moreover, correlation and mediation analyses were conducted to test for potential associations between SE, brain functional changes, and clinical variables. RESULTS LSE group showed decreased fALFF in right cuneus, thalamus, and middle temporal gyrus compared to NSE group. MDD patients with low SE also exhibited lower rsFC of right cuneus to right lateral temporal cortex, which was associated with more severe depression and anxiety symptoms. More importantly, mediation analyses revealed that the relationships between SE and severity of depression and anxiety symptoms were significantly mediated by the altered rsFC. In addition, these low SE-related brain functional alterations were not affected by antidepressant medication and were independent of structural changes. LIMITATIONS The lack of healthy controls because of "first-night effect". CONCLUSION These findings not only may expand existing knowledge about neuropathology of sleep disturbance in depression, but also may inform real-world clinical practice by improving depression and anxiety symptoms through sleep regulation.
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Affiliation(s)
- Dao-Min Zhu
- Department of Sleep Disorders, Affiliated Psychological Hospital of Anhui Medical University, Hefei 230022, China; Hefei Fourth People's Hospital, Hefei 230022, China; Anhui Mental Health Center, Hefei 230022, China
| | - Cun Zhang
- Department of Radiology, The First Affiliated Hospital of Anhui Medical University, No. 218, Jixi Road, Shushan District, Hefei 230022, China
| | - Ying Yang
- Department of Radiology, The First Affiliated Hospital of Anhui Medical University, No. 218, Jixi Road, Shushan District, Hefei 230022, China
| | - Yu Zhang
- Department of Sleep Disorders, Affiliated Psychological Hospital of Anhui Medical University, Hefei 230022, China; Hefei Fourth People's Hospital, Hefei 230022, China; Anhui Mental Health Center, Hefei 230022, China
| | - Wenming Zhao
- Department of Radiology, The First Affiliated Hospital of Anhui Medical University, No. 218, Jixi Road, Shushan District, Hefei 230022, China
| | - Biao Zhang
- Department of Radiology, The First Affiliated Hospital of Anhui Medical University, No. 218, Jixi Road, Shushan District, Hefei 230022, China
| | - Jiajia Zhu
- Department of Radiology, The First Affiliated Hospital of Anhui Medical University, No. 218, Jixi Road, Shushan District, Hefei 230022, China.
| | - Yongqiang Yu
- Department of Radiology, The First Affiliated Hospital of Anhui Medical University, No. 218, Jixi Road, Shushan District, Hefei 230022, China.
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