Alterations in cortical thickness of frontoparietal regions in patients with social anxiety disorder

Although functional changes of the frontal and (para)limbic area for emotional hyper-reactivity and emotional dysregulation are well documented in social anxiety disorder (SAD), prior studies on structural changes have shown mixed results. This study aimed to identify differences in cortical thickness between SAD and healthy controls (CON). Thirty-five patients with SAD and forty-two matched CON underwent structural magnetic resonance imaging. A vertex-based whole brain and regional analyses were conducted for between-group comparison. The whole-brain analysis revealed increased cortical thickness in the left insula, left superior parietal lobule, left superior temporal gyrus, and left frontopolar cortex in patients with SAD compared to CON, as well as decreased thickness in the left superior/middle frontal gyrus and left fusiform gyrus in patients (after multiple-correction). The results from the ROI analysis did not align with these findings at the statistically significant level after multiple corrections. Changes in cortical thickness were not correlated with social anxiety symptoms. While consistent results were not obtained from different analysis methods, the results from the whole-brain analysis suggest that patients with SAD exhibit distinct neural deficits in areas involved in salience, attention, and socioemotional processing.

Investigation of daily patterns for smartphone keystroke dynamics based on loneliness and social isolation

This study examined the relationship between loneliness levels and daily patterns of mobile keystroke dynamics in healthy individuals. Sixty-six young healthy Koreans participated in the experiment. Over five weeks, the participants used a custom Android keyboard. We divided the participants into four groups based on their level of loneliness (no loneliness, moderate loneliness, severe loneliness, and very severe loneliness). The very severe loneliness group demonstrated significantly higher typing counts during sleep time than the other three groups (one-way ANOVA, F = 3.75, p < 0.05). In addition, the average cosine similarity value of weekday and weekend typing patterns in the very severe loneliness group was higher than that in the no loneliness group (Welch's t-test, t = 2.27, p < 0.05). This meant that the no loneliness group's weekday and weekend typing patterns varied, whereas the very severe loneliness group's weekday and weekend typing patterns did not. Our results indicated that individuals with very high levels of loneliness tended to use mobile keyboards during late-night hours and did not significantly change their smartphone usage behavior between weekdays and weekends. These findings suggest that mobile keystroke dynamics have the potential to be used for the early detection of loneliness and the development of targeted interventions.

CT findings of inferior vena cava trauma according to the level of injury: a retrospective analysis of 19 cases in a single trauma centre

AIM

To analyse the clinicoradiological characteristics of traumatic inferior vena cava (IVC) injury level on preoperative computed tomography (CT).

MATERIALS AND METHODS

This retrospective study evaluated patients from a single trauma centre treated for traumatic IVC injury between January 2014 and January 2021. Data on demographics, mechanism of injury, Injury Severity Score, radiological findings on CT and angiography, IVC injury level in surgical findings, complications, and clinical outcomes were collected.

RESULTS

During the 8-year study period, 36 patients presented with traumatic IVC injury: 19 underwent preoperative CT with 17 (89%) blunt and two (11%) penetrating injuries. The most common primary CT sign was contour abnormality (53%, n=10), followed by intraluminal flap and active extravasation (21%, n=4). Among the secondary signs, hepatic laceration (53%, n=10) and retroperitoneal haemorrhage (53%, n=10) were the most common. Frequencies of primary and secondary signs were higher in the infrarenal and suprarenal than in the retrohepatic vena cava injuries. Diagnostic capability of preoperative CT for IVC injury differed according to the IVC level. The detection rate was the highest for an infrarenal vena cava injury at 100% (n=4), followed by that for a suprarenal, suprahepatic, and retrohepatic vena cava injuries at 75% (n=3), 43% (n=3), and 25% (n=1), respectively.

CONCLUSION

CT findings of traumatic IVC injuries may vary depending on the mechanism and anatomical site of injury. Familiarity with IVC injury imaging features may help in diagnosis and surgical treatment planning.

College students' preferences for tobacco treatment: a discrete choice experiment

The purpose of this study was to elicit preferences for the 'format' and 'content' of tobacco treatment among college student smokers, using an online discrete choice experiment (DCE) survey. A DCE survey, supplemented with a think-aloud method, was conducted among 54 college students who smoked combustible cigarettes and/or e-cigarettes. Conditional logistic regression models were constructed to determine optimal profiles of treatment. Cutting down nicotine rather than quitting 'cold turkey' (P < 0.001) and two-way communication (P < 0.001) were viewed as the most critical attributes for the intervention 'format'; changing behaviors rather than social groups/peers (P < 0.001) and autonomy (P < 0.001) were viewed as the most critical attributes for the intervention 'content'. Some preferences varied based on smoking subgroups. Combustible cigarette users preferred interventions with a longer time commitment (P < 0.05) and without nicotine replacement therapies (NRTs) (P < 0.001). Think-aloud data supported the DCE findings and further revealed a strong desire for cutting down nicotine and keeping social groups/peers and misconceptions regarding NRTs. Our study findings can guide tobacco treatment tailored to college students. These treatments should be tailored to specific smoker subgroups.

Association of executive function with suicidality based on resting-state functional connectivity in young adults with subthreshold depression

Subthreshold depression (StD) is associated an increased risk of developing major depressive disorder (MDD) and suicidality. Suicidality could be linked to distress intolerance and use of context-dependent strategies. We identified neural correlates of executive functioning among the hubs in the resting-state functional connectome (rs-FCN) and examined associations with recent suicidality in StD and MDD. In total, 79 young adults [27 StD, 30 MDD, and 23 healthy controls (HC)] were scanned using magnetic resonance imaging. Neurocognitive measures of the mean latency to correct five moves in the One Touch Stockings of Cambridge (OTSMLC5), spatial working memory between errors (SWMBE), rapid visual information processing A' (RVPA'), and the stop signal reaction time in the stop signal test (SSTSSRT) were obtained. Global graph metrics were calculated to measure the network integration, segregation, and their balance in the rs-FCN. Regional graph metrics reflecting the number of neighbors (degree centrality; DC), participation in the shortcuts (betweenness centrality; BC), and accessibility to intersections (eigenvector centrality; EC) in the rs-FCN defined group-level hubs for StD, HC, and MDD, separately. Global network metrics were comparable among the groups (all P > 0.05). Among the group-level hubs, regional graph metrics of left dorsal anterior insula (dAI), right dorsomedial prefrontal cortex (dmPFC), right rostral temporal thalamus, right precuneus, and left postcentral/middle temporal/anterior subgenual cingulate cortices were different among the groups. Further, significant associations with neurocognitive measures were found in the right dmPFC with SWMBE, and left dAI with SSTSSRT and RVPA'. Shorter OTSMLC5 was related to the lower centralities of right thalamus and suffer of recent 1-year suicidal ideation (all Ps < 0.05 in ≥ 2 centralities out of DC, BC, and EC). Collectively, salience and thalamic networks underlie spatial strategy and planning, response inhibition, and suicidality in StD and MDD. Anti-suicidal therapies targeting executive function and modulation of salience-thalamic network in StD and MDD are required.

The Role of Local Prostate and Metastasis-Directed Radiotherapy in the Treatment of Oligometastatic Prostate Cancer

PURPOSE/OBJECTIVE(S)

The local ablative therapy for oligometastatic disease (OMD) has the potential to delay further metastases and improve survival. However, it has not been fully elucidated how prostate primary radiotherapy (PPR) and metastasis-directed radiotherapy (MDR) affect prognosis in each different OMD scenario. Herein, we tried to provide efficacy and future perspectives for MDR in oligometastatic prostate cancer.

MATERIALS/METHODS

Patients diagnosed with prostate cancer between 2010 and 2019 and treated for OMD (≤5 active lesions), which occurred synchronously or metachronously, were included. All patients received MDR at all detected lesions (OMDRT). OMDRT which was performed as soon as OMD was detected was classified as early, and OMDRT for progressions after hormone therapy was classified as late. The primary endpoint was survival after OMDRT, and timing of progression after RT was also analyzed.

RESULTS

A total of 82 patients with oligometastatic prostate cancer received OMDRT. Among 36 patients with synchronous OMD, 58% received PPR at diagnosis, and 64% received early OMDRT. Among 46 patients with metachronous OMD, 80% received early OMDRT, and 28 received sequential OMDRT for repetitive OMD events. With a median follow-up of 32 months after OMDRT, 54 patients experienced progression and 5-year survival was 78%. Survival was highest in patients with synchronous OMD and early RT (5-year 86%), and 5-year survival of patients with metachronous OMD and early RT was significantly higher than those with late RT (78% vs. 44%, p = 0.003). Survival of patients with synchronous OMD and PPR was significantly higher than those without PPR or with metachronous OMD (5-year 90% vs. 66%, p = 0.030), by delaying progressions (17.9 vs. 7.0 months, p = 0.005).

CONCLUSION

Survival gain could be achieved through OMDRT in oligometastatic prostate cancer, especially in synchronous OMD status. Also, it was possible to improve the prognosis further when OMDRT was performed early and with PPR.

Patient-Specific Deep Learning Model for Clinical Target Volume Delineation on Daily CBCT of Breast Cancer Patients based on Intentional Deep Overfit Learning (IDOL) Framework

PURPOSE/OBJECTIVE(S)

Increasingly complex target volumes and the use of modern irradiation techniques emphasize the importance of daily image guidance more than ever. Significant progress has been made in adjuvant breast cancer radiotherapy (RT) and the need for optimized image guidance is growing. Furthermore, the position of the breast during RT after breast-conserving surgery is highly variable than expected. In this context, cone beam computed tomography (CBCT) is a very effective tool enabling prompt and accurate adaptive radiation therapy (ART). In this study, we aim to develop a deep learning (DL)-based algorithm to segment clinical target volume (CTV) from daily CBCT scans. Also, we validate the optimization of further learning when applying the Intentional Deep Overfit Learning (IDOL) framework.

MATERIALS/METHODS

A total of 240 different CBCT scans obtained from 100 breast cancer patients were used for this study. CTV was defined as whole breast plus margin in all patients. The workflow consists of two training stages: (1) training a novel 'generalized' DL model (Swin_UNETR) to identify and delineate breast CTV on CBCT scans using 90 breast cancer patient cases (2) applying an 'intentional overfitting' to the 'generalized' DL model to generate a 'patient-specific' model using the remaining 10 breast cancer patients. In this study, for the intentionally overfitting stage, we additionally trained with CBCT scans from the patient's 1st fraction to the 14th fractions cases. The results of the proposed method were compared quantitatively with the expert's contours on 1st-15th fractions CBCT scans using Dice Similarity Coefficient (DSC).

RESULTS

The average DSC between the 'generalized' DL model-based breast CTV contours and reference contours for the patient's 15th fraction was 0.9672. When implementing the IDOL framework with the CBCT scan obtained during the patient's 1st treatment, the average DSC was improved to 0.9809. When additional CBCT scans taken during each of the 1st to 6th fractions were used for training, the average DSC could be most effectively raised to 0.9835. The p-value comparison between the 'generalized' DL model and the 1st fraction was found to be 3.62E-04, while the comparison with the 6th fractions resulted in a p-value of 8.36E-05. The average time required for IDOL training using one CBCT scan and six CBCT scans was 107 seconds and 127 seconds, respectively.

CONCLUSION

In this study, we developed a patient-specific DL-based training algorithm to segment CTV in CBCT scans for breast cancer patients. The performance improvement was relatively significant and was confirmed that using continual DL with additional CBCT scans, which are taken every day, can be more accurate and efficient than drawing breast CTV using a general model. Our novel patient-specific model can be effectively applied to various ARTs by not only reducing labor and time but also increasing accuracy.

Comparison of Early Outcomes of Stereotactic Accelerated Partial Breast Irradiation vs. Volumetric Modulated Arc Therapy-Based FAST-FORWARD Whole Breast Irradiation for Breast Cancer

PURPOSE/OBJECTIVE(S)

Despite evidence supporting APBI from 8 published prospective randomized trials enrolling over 10,000 women, the uptake of APBI in clinical practice is surprisingly low. This is being exacerbated by a new, convenient, and safe shortened WBI schedule. Here, we report the dosimetric and early outcome analyses of the first >1000 patients treated at our institution since the first adoption of stereotactic APBI and the ultra-hypofractionated WBI regimen.

MATERIALS/METHODS

From 2016 to 2022, 801 women with breast cancers in the suitable or cautionary categories according to the ASTRO APBI consensus panel guidelines, received 30 Gy in 5 fractions (92%) either using a robotic stereotactic radiation system (83%) or stereotactic volumetric-based arc therapy (VMAT, 17%). Between 2020 and 2022, 468 women, who were not candidates for APBI and not undergoing any regional irradiation received 26 Gy in 5 fractions using VMAT to the whole breast with the addition of cardiac sparing technique in left-sided breast cancer patients. Tumor bed boosts were delivered in 99% of FF-WBI patients. We evaluated dose-volume histogram parameters for target volumes and organs-at-risk and radiation-related toxicities during RT or within 6 months after the end of RT.

RESULTS

Target volume coverage was acceptable in both groups, with mean 96% of the target volumes receiving 95% of the prescribed doses and 0 cm3 within target volumes exceeding 105% of the prescribed doses. S-APBI resulted in small, but statistically significant, reductions in the radiation dose delivered to the ipsilateral breast, contralateral breast, lungs, heart, and coronary artery compared with FF-WBI. Comparing WBI to APBI, the mean contralateral breast dose, ipsilateral lung V20 Gy, mean contralateral lung dose, and mean heart dose, were reduced by 89%, 78%, 73%, and 29%, respectively. With median follow-up periods of 32 months for s-APBI and 19 months for FF-WBI, acute toxicity was assessable in all patients. The risks of any grade acute toxicity were 21% for s-APBI and 25% for FF-WBI (p = .117). Among them, grade 2 rates were 1.3% in both groups and no severe toxicity has been reported.

CONCLUSION

We found s-APBI and VMAT-based FF WBI were associated with favorable dosimetric and acute toxicity profiles. However, considering significantly less irradiated volume in the breast, lungs, and heart, APBI with advanced available technique options should be considered over any WBI-based approach for patients at low risk for local recurrence.

Association of Single Nucleotide Polymorphisms in Transforming Growth Factor-β1 Pathway and Risk of Radiation Pneumonitis in Lung Cancer Patients Treated with Thoracic Radiation Therapy

PURPOSE/OBJECTIVE(S)

Several clinical and dosimetric parameters are known to be associated with radiation-induced lung toxicity, including radiation pneumonitis (RP). Also, single nucleotide polymorphisms (SNPs) of genes in TGF-β1 pathway have a notable association with the RP. However, studies on the predictive value of SNPs for RP are still limited. Herein, we tried to develop a novel integrated predictive model for severe RP in lung cancer patients.

MATERIALS/METHODS

A total of 59 patients who were treated with definitive or preoperative radiotherapy for primary lung cancer and had DNA samples were included. Potentially functional and tagging SNPs of TGF-β1 (rs1800469, rs1800471, rs1982073, and rs11466345), BMP2 (rs235768, rs3178250, rs1979855, and rs170986), and BMP4 (rs17563, rs4898820, and rs762642) were genotyped. Logistic regression was performed to build severe (grade ≥2) RP prediction models, and best subset selection algorithm with L0 and L2 regulations was used for variable selection. Only clinical/dosimetric variables were evaluated in model 1, and those variables as well as SNPs were included in model 2. Using beta coefficient obtained by the logistic regression, a scoring system was also developed.

RESULTS

With median follow-up of 39.7 months, severe RP occurred in 20.3% of patients. In model 1, age (>66) and PTV volume (≥300 cc) were significant factors (p = 0.016, OR 8.820 [95% CI, 1.730-63.800]; and p = 0.024, OR 7.440 [95% CI, 1.460-52.100], respectively). In model 2, the above two factors (p = 0.010, OR 16.200 [95% CI, 2.440-187.000] and p = 0.025, OR 10.100 [95% CI, 1.610-105.000]) and the AG/GG genotype in BMP2 rs1979855 were significant factors (p = 0.031, OR 7.260 [95% CI, 1.380-59.100]). The AUC was significantly higher in model 2 than in model 1 (0.822 vs. 0.741, p = 0.029). According to developed scoring system, patients with a score >2.8 are more likely to experience severe RP (AUC 0.829).

CONCLUSION

BMP2 rs1979855 could serve as a reliable biomarker for predicting RP while significantly improving predictive power compared to when only clinical factors were used.

Distribution and Failure Patterns of Primary Central Nervous System Lymphoma Related to Hippocampus

PURPOSE/OBJECTIVE(S)

Hippocampus (HC) injury by conventional whole brain radiotherapy (C-WBRT) contributes to the neurocognitive decline in primary central nervous system lymphoma (PCNSL). Hippocampal avoidance (HA-WBRT) could minimize neurocognitive impairment by reducing the radiation dose to HC. However, its feasibility in PCNSL has not been examined regarding the incidence of HC involvement and failures. In this retrospective study, we assessed the risk of hippocampal area involvement at diagnosis and after treatments in PCNSL patients.

MATERIALS/METHODS

We identified 278 immunocompetent PCNSL patients diagnosed between 2000 and 2020. After high dose methotrexate-based induction chemotherapy, patients were observed or given consolidation therapy including RT, cytarabine alone, or autologous stem cell transplantation (ASCT). HC was contoured on T1 MRI image and expanded with a 5mm margin, generating hippocampal avoidance region (HAR). The extent of initial and recurrent lesions was evaluated using pre-induction and post-consolidation T1 contrast-enhanced MRI images. HC failure was defined as recurrence or progression at HAR and those who progressed after induction were excluded. The median follow up was 38.7 months (3.1-239.4).

RESULTS

Of 278 patients diagnosed with PCNSL, 39.9% of them had initial lesions at HAR (Figure 1a). After induction therapy, 212 evaluable patients received following treatments: RT (n = 145, 68.4%) consisting of C-WBRT (n = 114), HA-WBRT (n = 23), and focal RT (n = 8), observation (n = 38, 17.9%), cytarabine only (24, 11.3%), and ASCT (n = 5, 2.4%). Intracranial failures occurred in 47.6% (n = 101) of patients, with 33.7% (n = 34) of them in HAR (Figure 1b). The multivariate analysis identified multifocal disease (HR 3.86, 95% CI 1.15-9.73, p = 0.004) as the only factor associated with the risk of HC failure. Those with unifocal lesion outside HAR showed the lowest HC failure rate, 7.0%, while the highest HC failure rate, 25.4% was observed in the subgroup with multifocal disease within HAR at diagnosis (Figure 2a). In the lowest risk group (unifocal lesion outside HAR, n = 66), C-WBRT was not significantly associated with HC failure (HR 0.57, CI 0.09-3.33, P = .572, Figure 2b) or intracranial failure (HR 0.88, CI 0.40-1.91, P = .748).

CONCLUSION

Our data suggest the HA-WBRT could be explored in patients whose lesion is unifocal and located outside HAR. For patients without initial HAR involvement, hippocampal including WBRT did not significantly change HC failure. Further prospective study will be warranted to assess the feasibility of HA-WBRT in the subgroup with low risk of HC failure.

A Photograph-Based Visualization and Prediction Framework for Radiation-Induced Dermatitis

PURPOSE/OBJECTIVE(S)

This study aimed to suggest a photograph-based prediction system for acute radiation-induced dermatitis (RID), which can be applied to notify patients about the risk of the development of skin discomfort during radiotherapy.

MATERIALS/METHODS

The proposed system compared the spatial dose distribution with the RID region using the following methods. Skin photographs of patients were taken using an RGB-depth camera to acquire the shape information of RID. The skin surface data measured from the camera was registered with the shape of the external body contour using an iterative closest point algorithm. Spatial dose distribution of skin was extracted from the external body contour to a depth of 2 mm and projected onto the plane of the skin photograph using a transformation matrix for skin depth data. To compare the spatial distribution of skin dose with the shape of RID, the region of RID in patients' skin was delineated on photographs into three toxicity symptoms referring to the CTCAE criteria grade 1 (skin redness), grade 2 (dry desquamation), and grade 3 (moist desquamation). The degree of overlap between the shape of each RID and skin dose distribution was evaluated using the dice similarity coefficient (DSC). Threshold doses for predicting RID occurrence were estimated by skin isodose lines with the highest DSC. The developed system was validated using data from 19 patients who received volumetric modulated arc therapy for head-neck cancer at a single institution.

RESULTS

Threshold doses for RID grades 1, 2, and 3 were estimated using 18, 18, and 2 individual RID labels delineated on skin photographs, respectively. Isodose lines with the highest DSC for RID grades 1, 2, and 3 were calculated as 26.0 Gy, 36.5 Gy, and 54.0 Gy, respectively. A strong overlap (average DSC > 0.6) was observed between isodose skin lines and the shape of RID labels in all RID grades.

CONCLUSION

Assessing the spatial information of skin dose can be helpful in predicting acute RID. The region of RID shows a strong similarity with the skin dose distribution in head-neck patients. Visualization of skin dose on the patient photograph is potent to patient education for preparing the cosmetic discomfort during radiotherapy, which may lead to the improvement of the patient satisfaction in treatment.

Central metabolites and peripheral parameters associated neuroinflammation in fibromyalgia patients: A preliminary study

To identify central metabolites and peripheral measures associated with neuroinflammation in fibromyalgia (FM), we scanned [11C]-(R)-PK11195 positron emission tomography and magnetic resonance spectroscopy in FM patients. We measured associations between neurometabolite levels measured by magnetic resonance spectroscopy and the extent of neuroinflammation inferred by the distribution volume ratios of [11C]-(R)-PK11195 positron emission tomography in 12 FM patients and 13 healthy controls. We also examined the associations between peripheral parameters, such as creatinine and C-reactive protein, and neuroinflammation. In FM patients, we found negative correlations between neuroinflammation and the creatine (Cr)/total creatine (tCr; Cr + phosphocreatine) ratios in the right (r = -0.708, P = .015) and left thalamus (r = -0.718, P = .008). In FM patients, negative correlations were apparent between neuroinflammation and the glutamate/tCr ratio in the right insula (r = -0.746, P = .005). In FM patients, we found negative correlations between neuroinflammation in the left thalamus (r = -0.601, P = .039) and left insula (r = -0.598, P = .040) and the blood creatinine levels. Additionally, we found significant correlations of other peripheral measures with neuroinflammation in FM patients. Our results suggest that both central metabolites, such as Cr and glutamate, and peripheral creatinine and other parameters are associated with neuroinflammation in patients with FM.

A New Approach to Quantify and Grade Radiation Dermatitis Using Deep-Learning Segmentation in Skin Photographs

AIMS

Objective evaluation of radiation dermatitis is important for analysing the correlation between the severity of radiation dermatitis and dose distribution in clinical practice and for reliable reporting in clinical trials. We developed a novel radiation dermatitis segmentation system based on convolutional neural networks (CNNs) to consistently evaluate radiation dermatitis.

MATERIALS AND METHODS

The radiation dermatitis segmentation system is designed to segment the radiation dermatitis occurrence area using skin photographs and skin-dose distribution. A CNN architecture with a dilated convolution layer and skip connection was designed to estimate the radiation dermatitis area. Seventy-three skin photographs obtained from patients undergoing radiotherapy were collected for training and testing. The ground truth of radiation dermatitis segmentation is manually delineated from the skin photograph by an experienced radiation oncologist and medical physicist. We converted the skin photographs to RGB (red-green-blue) and CIELAB (lightness (L^∗), red-green (a^∗) and blue-yellow (b^∗)) colour information and trained the network to segment faint and severe radiation dermatitis using three different input combinations: RGB, RGB + CIELAB (RGBLAB) and RGB + CIELAB + skin-dose distribution (RGBLAB_D). The proposed system was evaluated using the Dice similarity coefficient (DSC), sensitivity, specificity and normalised Matthews correlation coefficient (nMCC). A paired t-test was used to compare the results of different segmentation performances.

RESULTS

Optimal data composition was observed in the network trained for radiation dermatitis segmentation using skin photographs and skin-dose distribution. The average DSC, sensitivity, specificity and nMCC values of RGBLAB_D were 0.62, 0.61, 0.91 and 0.77, respectively, in faint radiation dermatitis, and 0.69, 0.78, 0.96 and 0.83, respectively, in severe radiation dermatitis.

CONCLUSION

Our study showed that CNN-based radiation dermatitis segmentation in skin photographs of patients undergoing radiotherapy can describe radiation dermatitis severity and pattern. Our study could aid in objectifying the radiation dermatitis grading and analysing the reliable correlation between dosimetric factors and the morphology of radiation dermatitis.

Cluster Analysis of DSC MRI, Dynamic Contrast-Enhanced MRI, and DWI Parameters Associated with Prognosis in Patients with Glioblastoma after Removal of the Contrast-Enhancing Component: A Preliminary Study

BACKGROUND AND PURPOSE

No report has been published on the use of DSC MR imaging, DCE MR imaging, and DWI parameters in combination to create a prognostic prediction model in glioblastoma patients. The aim of this study was to develop a machine learning-based model to find preoperative multiparametric MR imaging parameters associated with prognosis in patients with glioblastoma. Normalized CBV, volume transfer constant, and ADC of the nonenhancing T2 high-signal-intensity lesions were evaluated using K-means clustering.

MATERIALS AND METHODS

A total of 142 patients with glioblastoma who underwent preoperative MR imaging and total resection were included in this retrospective study. From the normalized CBV, volume transfer constant, and ADC maps, the parametric data were sorted using the K-means clustering method. Patients were divided into training and test sets (ratio, 1:1), and the optimal number of clusters was determined using receiver operating characteristic analysis. Kaplan-Meier survival analysis and log-rank tests were performed to identify potential parametric predictors. A multivariate Cox proportional hazard model was conducted to adjust for clinical predictors.

RESULTS

The nonenhancing T2 high-signal-intensity lesions were divided into 6 clusters. The cluster (class 4) with the relatively low normalized CBV and volume transfer constant value and the lowest ADC values was most associated with predicting glioblastoma prognosis. The optimal cutoff of the class 4 volume fraction of nonenhancing T2 high-signal-intensity lesions predicting 1-year progression-free survival was 9.70%, below which the cutoff was associated with longer progression-free survival. Two Kaplan-Meier curves based on the cutoff value showed a statistically significant difference (P = .037). When we adjusted for all clinical predictors, the cluster with the relatively low normalized CBV and volume transfer constant values and the lowest ADC value was an independent prognostic marker (hazard ratio, 3.04; P = .048). The multivariate Cox proportional hazard model showed a concordance index of 0.699 for progression-free survival.

CONCLUSIONS

Our model showed that nonenhancing T2 high-signal-intensity lesions with the relatively low normalized CBV, low volume transfer constant values, and the lowest ADC values could serve as useful prognostic imaging markers for predicting survival outcomes in patients with glioblastoma.

Comparison of trans-radial access and femoral access in cardiogenic shock patient who had undergone primary percutaneous coronary intervention from SMART RESCUE trial

Introduction

Throughout the years of percutaneous coronary intervention (PCI), the debate regarding access route, whether it being trasns-radial or femoral, is an ongoing agenda yet to be solved. Recent guidelines suggest trans-radial approach as an option to be considered in acute coronary syndrome (ACS). However, data on cardiogenic shock patients undergoing PCI is relatively sparse.

Purpose

Compare the clinical implication of trans-radial and femoral approach in cardiogenic shock patients who had undergone PCI.

Method

Cardiogenic shock patients who had undergone PCI from January 2014 to December of 2018 were enrolled. Patients were divided according to their access route respectfully. Primary outcome was composite endpoints including all-cause death, re-admission due to heart failure, myocardial infarction (MI) and cerebrovascular accident.

Result

A total of 694 (572 via femoral approach, 122 via radial approach) cardiogenic shock patients who received PCI were enrolled. Mean age femoral and radial groups was 66.59±12.51 and 66.66±12.8 respectfully. Disease severity was higher for femoral patients compared to radial patients as represented by their LM involvement, mechanical organ support (extracorporeal membrane oxygenation, continuous renal replacement therapy, mechanical ventilation), left ventricular ejection fraction (LVEF) and vasoactive inotropic score. Cox regression analysis after adjusting for conventional risk factors showed that femoral route was a poor prognosticator with respect to composite endpoints (HR=2.059, 95% CI 1.249–3.397, p value = 0.005). Radial approach patients had higher survival probability compared to femoral approach patients (Figure 1).

Conclusion

Radial approach in cardiogenic shock patients who are in need for PCI with relatively less severe clinical condition could be a reasonable option for access route.

Funding Acknowledgement

Type of funding sources: Private hospital(s). Main funding source(s): Inha University Hospital

Prognostic impact of plasma glucose on cardiogenic shock patients with or without diabetes ellitus: smart rescue trial

Background

Even though the presence of hyperglycemia has shown to affect the clinical outcome of cardiogenic shock patients, the extent of hyperglycemia and its association with prognosis have not been fully addressed in large population

Purpose

Investigate the clinical relationship between hyperglycemic status and in-hospital mortality in cardiogenic shock patients

Method

A total of 1,177 consecutive cardiogenic shock patients were enrolled from January 2014 to December of 2018 at 12 hospitals in South Korea. The primary outcome was in-hospital mortality. Patients were divided into four groups according to their initial plasma glucose level in each of diabetes patients (n=752) and non-diabetes patients (n=425); group 1 (≤8 mmol/L), group 2 (8–12 mmol/L), group 3 (12–16 mmol/L) and group 4 (≥16 mmol/L).

Results

The groups with higher admission plasma glucose were associated with lower systolic blood pressure and higher lactic acid level in both diabetic and non-diabetic patients. In-hospital mortality increased in groups with higher admission plasma glucose level in non-diabetic patients (group-1:24.2%, group-2: 28.6%, group-3: 38.1%, group-4: 49.0%, p&lt;0.01) whereas in diabetic patients, mortality and admission plasma glucose level showed no significant association (group-1: 45%, group-2: 35.4%, group-3: 33.3%, group-4: 43.1%, p=0.26). Even after Multivariate analysis, high plasma glucose was an independent predictor of in-hospital mortality in non-diabetic patients

Conclusion

In cardiogenic shock patients, plasma glucose obtained at admission was associated with in-hospital mortality in non-diabetic patients

Funding Acknowledgement

Type of funding sources: Private hospital(s). Main funding source(s): Inha University hospital

Impact of obesity paradox between genders on in-hospital mortality in cardiogenic shock: a retrospective cohort study

Background

In a few studies, obesity was associated with better outcomes in patients with cardiogenic shock (CS). Although this phenomenon, the “obesity paradox”, reportedly manifests differently based on sex in other disease entities, it has not yet been investigated in CS patients.

Methods and results

1,227 patients with CS from The REtrospective and prospective observational Study to investigate Clinical oUtcomes and Efficacy of left ventricular assist device for Korean patients with cardiogenic shock (RESCUE) registry in Korea were analyzed. The study population was classified into obese and non-obese groups according to Asian-Pacific criteria (BMI &gt;25.0 kg/m2 for obese). Clinical impact of obesity on in-hospital mortality according to sex was analyzed using logistic regression analysis and restricted cubic spline curves. In-hospital mortality rate was significantly lower in obese men than non-obese men (34.2% vs. 24.1%, p=0.004) while the difference was not significant in women (37.3% vs. 35.8%, p=0.884). As a continuous variable, higher BMI showed a protective effect in men conversely, BMI was not associated with clinical outcomes in women. Comparing to normal-weight patients, obesity was associated with a decreased risk of in-hospital death in men (multivariable-adjusted OR 0.63, CI 0.43–0.92, p=0.016), not in women (multivariable-adjusted OR 0.94, 95% CI 0.55–1.61, p=0.828). Interaction P value for the association between BMI and sex was 0.023.

Conclusions

Obesity paradox exists and apparently occurs in men among CS patients. The differential effect of BMI on in-hospital mortality was observed according to sex.

Funding Acknowledgement

Type of funding sources: None.

Risk factors and clinical effects of late leaflet thrombosis after transcatheter aortic valve replacement

Background

As the indications for trans-catheter aortic valve replacement (TAVR) expand, it is expected that the number of TAVR patients would increase and the follow-up duration would be longer. It is known that the incidence of leaflet thrombosis is higher in TAVR than in surgical aortic valve replacement (SAVR), but not much is known about the risk factors of late leaflet thrombosis in TAVR.

Aim

Therefore, in this study, the incidence and risk factors of late leaflet thrombosis at late term after TAVR and the effect on clinical course of late leaflet thrombosis would be investigated.

Method

There were 176 patients undergone TAVR from January 2015 to October 2020 in one tertiary hospital of south korea. 94 patients had follow-up cardiovascular computed tomography (CT) between 3 months and 2 years after TAVR. Among 94 patients, late leaflet thrombosis was discovered at 20 patients, and risk factors were analyzed by comparing clinical factors, echocardiographic and cardiovascular CT information, and angiographic data between the group with and without late leaflet thrombosis. And the difference in aortic valve hemodynamics between the group with and without leaflet thrombosis was examined and clinical outcomes were compared. Clinical outcome was defined as the composite of all-cause death, stroke, heart failure (HF) admission, redo-aortic valve (AV) replacement and major bleeding after detection of late leaflet thrombosis.

Results

Indexed mean sinus of Valsalva diameter, AV calcium score and post procedure estimated orifice area (EOA) had predictability of late leaflet thrombosis with AUC value of 0.670 (95% CI [0.546–0.795], p value = 0.020), AUC value of 0.698 (95% CI [0.544–0.851], p value = 0.012) and AUC value of 0.665 (95 percent CI [0.548–0.782], p value = 0.031), respectively (Figure 1).

In echocardiography performed at the time of follow-up CT, AV max velocity and AV mean pressure gradient were higher in thrombosis group and EOA and Doppler velocity index were lower in thrombosis group than in no thrombosis group within normal range (Figure 2). Clinical outcome was not significant different between the two groups (log rank p value = 0.560).

Conclusion

Larger indexed sinus of Valsalva diameter, higher AV calcium score and smaller post procedure AV EOA were risk factors for late leaflet thrombosis after TAVR. Subclinical late leaflet thrombosis have a benign course when properly managed.

Funding Acknowledgement

Type of funding sources: None.

Deep Learning-Based Prediction of the 3D Postorthodontic Facial Changes

With the increase of the adult orthodontic population, there is a need for an accurate and evidence-based prediction of the posttreatment face in 3 dimensions (3D). The objectives of this study are 1) to develop a 3D postorthodontic face prediction method based on a deep learning network using the patient-specific factors and orthodontic treatment conditions and 2) to validate the accuracy and clinical usability of the proposed method. Paired sets (n = 268) of pretreatment (T1) and posttreatment (T2) cone-beam computed tomography (CBCT) of adult patients were trained with a conditional generative adversarial network to generate 3D posttreatment facial data based on the patient's gender, age, and the changes of upper (ΔU1) and lower incisor position (ΔL1) as input. The accuracy was calculated with prediction error and mean absolute distances between real T2 (T2) and predicted T2 (PT2) near 6 perioral landmark regions, as well as percentage of prediction error less than 2 mm using test sets (n = 44). For qualitative evaluation, an online survey was conducted with experienced orthodontists as panels (n = 56). Overall, PT2 indicated similar 3D changes to the T2 face, with the most apparent changes simulated in the perioral regions. The mean prediction error was 1.2 ± 1.01 mm with 80.8% accuracy. More than 50% of the experienced orthodontists were unable to distinguish between real and predicted images. In this study, we proposed a valid 3D postorthodontic face prediction method by applying a deep learning algorithm trained with CBCT data sets.

Sex-specific bi‑directional association between osteoporosis and depression from the national representative data of South Korea

Both osteoporosis and depression are major health threats, but their interrelationship is not clear. This study elucidated the associations between osteoporosis and depression while considering the temporal sequence of the diagnoses. In this cross-sectional study, data were extracted from the Korean National Health and Nutrition Examination Surveys (2007–2009 and 2015–2019, n = 29,045). Osteoporosis and depression were defined by diagnoses thereof. The odds ratio (OR) of the incident osteoporosis among depression patients without a history of osteoporosis was calculated by multivariable logistic regression adjusted for potential confounders. A reverse association was also assessed. Participants were additionally stratified by their sex and age. As a result, male depression patients aged under 50 years showed higher ORs for osteoporosis than those without depression (OR 9.16, 95% CI 1.78–47.18). Female osteoporosis patients showed lower ORs for depression than those without osteoporosis (OR 0.71, 95% CI 0.58–0.88), especially in women aged 50 years and older. In the sensitivity analysis, the same results were obtained in women by their menopause status. Depression has a strong positive association with the occurrence of osteoporosis in young male adults, and osteoporosis has a negative association with the occurrence of depression in female adults.

Functional activation of insula and dorsal anterior cingulate for conflict control against larger monetary loss in young adults with subthreshold depression: a preliminary study

Subthreshold depression (StD) is associated with higher risk of later developing major depressive disorder (MDD). Deficits of goal-directed behaviors regarding the motional, motivational, and conflict control are found in MDD. The current study examined neural underpinning of conflict control against monetary punishment in StD compared to MDD and healthy controls (HC). Seventy-one participants (HC, n = 27; StD, n = 21; MDD, n = 23) in their mid-20's completed self-reports. Preprocessing of functional magnetic resonance imaging acquired for the Simon task against larger or smaller monetary punishment was conducted using ENIGMA HALFpipe version 1.2.1. Neural correlates of conflict control against monetary punishment that could vary with either diagnosis or PHQ-9 total score were examined using a general linear model of FSL. Simon effect was effective for reaction time and accuracy in every subgroup of diagnosis and regardless of the size of monetary punishment. Conflict control against larger monetary loss was associated with higher functional activation of left insula in StD than HC and MDD. StD showed lower functional activation of left dorsal anterior cingulate (dACC) than MDD for conflict control against larger monetary loss. For conflict control against smaller monetary loss, StD demonstrated higher functional activation of left paracentral lobule and right putamen compared to HC. Directed acyclic graphs showed directional associations from suicidal ideation, sadness, and concentration difficulty to functional activation of paracentral lobule, ventromedial prefrontal cortex (vmPFC), and thalamus for conflict control against monetary loss. Differential functional activation of insula and dACC for conflict control against larger monetary loss could be a brain phenotype of StD. Item-level depressive symptoms of suicidal ideation, sadness, and concentration difficulty could be reflected in the conflict control-related functional activation of paracentral lobule (against smaller monetary loss), vmPFC and thalamus (against larger monetary loss), respectively.

Greater variability in daily sleep efficiency predicts depression and anxiety in young adults: Estimation of depression severity using the two-week sleep quality records of wearable devices

OBJECTIVES

Sleep disturbances are associated with both the onset and progression of depressive disorders. It is important to capture day-to-day variability in sleep patterns; irregular sleep is associated with depressive symptoms. We used sleep efficiency, measured with wearable devices, as an objective indicator of daily sleep variability.

MATERIALS AND METHODS

The total sample consists of 100 undergraduate and graduate students, 60% of whom were female. All were divided into three groups (with major depressive disorder, mild depressive symptoms, and controls). Self-report questionnaires were completed at the beginning of the experiment, and sleep efficiency data were collected daily for 2 weeks using wearable devices. We explored whether the mean value of sleep efficiency, and its variability, predicted the severity of depression using dynamic structural equation modeling.

RESULTS

More marked daily variability in sleep efficiency significantly predicted levels of depression and anxiety, as did the average person-level covariates (longer time in bed, poorer quality of life, lower extraversion, and higher neuroticism).

CONCLUSION

Large swings in day-to-day sleep efficiency and certain clinical characteristics might be associated with depression severity in young adults.

Neural Changes in Reward Processing Following Approach Avoidance Training for Depression

Altered approach motivation is hypothesized to be critical for the maintenance of depression. Computer-administered approach-avoidance training programs to increase approach action tendencies toward positive stimuli produce beneficial outcomes. However, there have been few studies examining neural changes following approach-avoidance training. Participants with Major Depressive Disorder were randomized to an Approach Avoidance Training (AAT) manipulation intended to increase approach tendencies for positive social cues (n=13) or a control procedure (n=15). We examined changes in neural activation (primary outcome) and connectivity patterns using Group Iterative Multiple Model Estimation during a social reward anticipation task (exploratory). A laboratory-based social affiliation task was also administered following the manipulation to measure affect during anticipation of real-world social activity. Individuals in the AAT group demonstrated increased activation in reward processing regions during social reward anticipation relative to the control group from pre to post-training. Following training, connectivity patterns across reward regions were observed in the full sample and connectivity between the medial PFC and caudate was associated with anticipatory positive affect before the social interaction; preliminary evidence of differential connectivity patterns between the two groups also emerged. Results support models whereby modifying approach-oriented behavioral tendencies with computerized training leads to alterations in reward circuitry. (NCT02330744).

Review: The development of the gastrointestinal tract microbiota and intervention in neonatal ruminants

The complex microbiome colonizing the gastrointestinal tract (GIT) of ruminants plays an important role in the development of the immune system, nutrient absorption and metabolism. Hence, understanding GIT microbiota colonization in neonatal ruminants has positive impacts on host health and productivity. Microbes rapidly colonize the GIT after birth and gradually develop into a complex microbial community, which allows the possibility of GIT microbiome manipulation to enhance newborn health and growth and perhaps induce lasting effects in adult ruminants. This paper reviews recent advances in understanding how host-microbiome interactions affect the GIT development and health of neonatal ruminants. Following initial GIT microbiome colonization, continuous exposure to host-specific microorganisms is necessary for GIT development and immune system maturation. Furthermore, the early GIT microbial community structure is significantly affected by early life events, such as maternal microbiota exposure, dietary changes, age and the addition of prebiotics, probiotics and synbiotics, supporting the idea of microbial programming in early life. However, the time window in which interventions can optimally improve production and reduce gastrointestinal disease as well as the role of key host-specific microbiota constituents and host immune regulation requires further study.

Impaired Performance in Mental Rotation of Hands and Feet and Its Association with Social Cognition in Patients with Complex Regional Pain Syndrome

Objectives. 

So far, dysfunction in mental rotation has been assessed in relation to the left- or right-sided CRPS. Here we examined mental rotation in patients with upper or lower limb CRPS. Considering the potential role of socio-emotional functioning on the perception of body image, we further investigated the association between performance on mental rotation and socio-emotional characteristics.

Methods. 

We examined the performance of 36 patients with upper or lower limb CRPS on the limb laterality recognition. Accuracy and response times for pictures of hands and feet at 4 rotation angles were evaluated. Socio-emotional functioning was measured by the Interpersonal Reactivity Scale and the Toronto Alexithymia Scale.

Results. 

Patients with upper limb pain showed longer RTs to recognize the laterality of hands than feet (P = 0.002), whereas patients with lower limb pain showed longer RTs for feet than hands (P = 0.039). Exploratory correlation analyses revealed that RTs for feet were negatively correlated with the levels of empathic ability to take another’s perspective (P = 0.006) and positively correlated with the level of emotional difficulty in identifying feelings (P = 0.006).

Conclusions. 

This study is the first to report selectively impaired mental rotation of hands vs feet in patients with upper or lower limb CRPS. The findings suggest that impaired mental rotation derives from relative deficits in the representation of the affected limb. Correlations between impaired mental rotation and socio-emotional inability indicate that an altered body schema may be closely associated with impaired social cognitive aspects in CRPS patients.

Dysfunctional energy metabolisms in fibromyalgia compared with healthy subjects

This study aimed to investigate the levels of creatine (Cr) metabolites in the anterior cingulate cortex (ACC), thalamus, and insula of patients with fibromyalgia (FM) using proton magnetic resonance spectroscopy (MRS). The levels of Cr and phosphocreatine (PCr) relative to total Cr (tCr), which includes Cr and PCr, in the ACC, thalamus, and insula were determined using MRS in 12 patients with FM and in 13 healthy controls. The FM group had lower levels of PCr/tCr in the ACC and right insula compared to healthy controls. There was a negative correlation between Cr/tCr in the ACC and total pain levels (McGill Pain Questionnaire-Total; r = −0.579, p = 0.049) and between Cr/tCr in the left insula and affective pain levels (McGill Pain Questionnaire-Affective; r = −0.638, p = 0.047) in patients with FM. In addition, there were negative correlations between stress levels (Stress Response Inventory) and Cr/tCr in the right (r = −0.780, p = 0.005) and left thalamus (r = −0.740, p = 0.006), as well as in the right insula (r = −0.631, p = 0.028) in patients with FM. There were negative correlations between symptom levels of post-traumatic stress disorder (PTSD; PTSD checklist) and Cr/tCr in the right (r = −0.783, p = 0.004) and left thalamus (r = −0.642, p = 0.024) of patients with FM. These findings are paramount to understanding the decisive pathologies related to brain energy metabolism in patients with FM.

MGMT Promoter Methylation Status in Initial and Recurrent Glioblastoma: Correlation Study with DWI and DSC PWI Features

BACKGROUND AND PURPOSE

O⁶-methylguanine-DNA methyltransferase (MGMT) promoter methylation status in primary and recurrent glioblastoma may change during treatment. The purpose of this study was to correlate MGMT promoter methylation status changes with DWI and DSC PWI features in patients with recurrent glioblastoma after standard treatment.

MATERIALS AND METHODS

Between January 2008 and November 2016, forty patients with histologically confirmed recurrent glioblastoma were enrolled. Patients were divided into 3 groups according to the MGMT promoter methylation status for the initial and recurrent tumors: 2 groups whose MGMT promoter methylation status remained, group methylated (n = 13) or group unmethylated (n = 18), and 1 group whose MGMT promoter methylation status changed from methylated to unmethylated (n = 9). Normalized ADC and normalized relative CBV values were obtained from both the enhancing and nonenhancing regions, from which histogram parameters were calculated. The ANOVA and the Kruskal-Wallis test followed by post hoc tests were performed to compare histogram parameters among the 3 groups. The t test and Mann-Whitney U test were used to compare parameters between group methylated and group methylated to unmethylated. Receiver operating characteristic curve analysis was used to measure the predictive performance of the normalized relative CBV values between the 2 groups.

RESULTS

Group methylated to unmethylated showed significantly higher means and 90th and 95th percentiles of the cumulative normalized relative CBV values of the nonenhancing region of the initial tumor than group methylated and group unmethylated (all P < .05). The mean normalized relative CBV value of the nonenhancing region of the initial tumor was the best predictor of methylation status change (P < .001), with a sensitivity of 77.78% and specificity of 92.31% at a cutoff value of 2.594.

CONCLUSIONS

MGMT promoter methylation status might change in recurrent glioblastoma after standard treatment. The normalized relative CBV values of the nonenhancing region at the first preoperative MR imaging were higher in the MGMT promoter methylation change group from methylation to unmethylation in recurrent glioblastoma.

Abnormal neurometabolites in fibromyalgia patients: Magnetic resonance spectroscopy study

This study aimed to investigate distinct neurometabolites in the anterior cingulate cortex (ACC), right and left thalamus, and insula of patients with fibromyalgia (FM) compared with healthy controls using proton magnetic resonance spectroscopy (MRS). Levels of N-acetylaspartate (NAA), N-acetylaspartylglutamate (NAAG), total NAA (tNAA = NAA + NAAG), myo-inositol (ml), glutamine (Gln), glutamate (Glu), Glx (Glu + Gln), glycerophosphocholine (GPC), total choline (tCho = GPC + phosphocholine) and glutathione (GSH) levels relative to total creatine (tCr) levels including creatine (Cr) and phosphocreatine (PCr) and relative to Cr levels were determined in the ACC, right and left thalamus, and insula in 12 patients with FM and 13 healthy controls using MRS. In the ACC, NAA/tCr (P = 0.028) and tCho/tCr (P = 0.047) were higher in patients with FM. In the right and left insula, tNAA/tCr (P = 0.019, P = 0.007, respectively) was lower in patients with FM. Patients with FM showed lower levels of ml/Cr (P = 0.037) in the right insula than healthy controls. These findings are paramount to understand decisive pathophysiological mechanisms related to abnormal features in the brain and parasympathetic nervous systems in FM. We suggest that the results presented herein may be essential to understand hidden pathological mechanisms and also life system potential as protective and recovering metabolic strategies in patients with FM.

Irisin promotes odontogenic differentiation and angiogenic potential in human dental pulp cells

AIM

To determine whether irisin, a newly discovered myokine that links exercise-induced and metabolic homeostasis, is able to promote odontogenic differentiation and angiogenesis in human dental pulp cells (HDPCs).

METHODOLOGY

Cell viability in the presence of irisin was measured. Real-time PCR and Western blot analysis were performed to evaluate the expression levels of irisin, odontogenic and angiogenic markers. The involvement of mitogen-activated protein kinase (MAPK) and the protein kinase B (Akt) signalling pathway was evaluated by Western blot. To evaluate mineralization nodule formation, alkaline phosphatase (ALP) staining and alizarin red S staining were performed. Scratch wound assays were performed to evaluate the effects of irisin on cell migration. The data were analysed using one-way analysis of variance (anova) followed by Tukey post hoc test and Student's t-test. Statistical significance was considered at P < 0.05.

RESULTS

Irisin significantly promoted odontogenic differentiation as evidenced by formation of mineralized nodules, induction of ALP activity and upregulation of odontogenic and angiogenic markers (P < 0.05). Scratch wound assays revealed that irisin significantly increased migration of HDPCs (P < 0.05). Phosphorylation of both MAPK and Akt was increased by irisin. MAPK and Akt inhibitors inhibited mineralization, cell migration and the increased expression of odontogenic and angiogenic markers.

CONCLUSIONS

Irisin promoted odontogenic differentiation and mineralization and has the potential for angiogenesis through activation of the MAPK and Akt signalling pathways in HDPCs.

Long-term beneficial effects of an online mind-body training program on stress and psychological outcomes in female healthcare providers: A non-randomized controlled study

Mind-body training (MBT) programs are effective interventions for relieving stress and improving psychological capabilities. To expand our previous study which demonstrated the short-term effects of an 8-week online MBT program, the present study investigated whether those short-term effects persist up to a month after the end of the intervention.Among previous participants, 56 (64%) participated in this follow-up study, 25 in the MBT group and 31 in the control group. Outcome measures included the stress response, emotional intelligence, resilience, coping strategies, positive and negative affect, and anger expression of both groups at baseline, at 8 weeks (right after the training or waiting period), and at 12 weeks (a month after the training or waiting period).The MBT group showed a greater decrease in stress response at 8 weeks, and this reduction remained a month after the end of the intervention. The effect of MBT on resilience and effective coping strategies was also significant at 8 weeks and remained constant a month later. However, the improvement to emotional intelligence and negative affect did not persist a month after training.These findings suggest that the beneficial short-term effects of MBT may last beyond the training period even without continuous practice, but the retention of these benefits seems to depend on the outcome variables. Through a convenient, affordable, and easily accessible online format, MBT may provide cost-effective solutions for employees at worksites.

Effects of Paliperidone Palmitate on Healthcare Utilization and Costs for Patients with Schizophrenia: A Claim-based Mirror-image Study in South Korea

Objective

Long-acting injectable (LAI) antipsychotics, such as paliperidone palmitate (PP), are known to improve treatment adherence in patients with schizophrenia, which can lead to reductions in relapse and hospitalization rates. However, relatively few studies have demonstrated the economic impact of LAIs, especially in Asian populations.

Methods

We conducted a claim-based mirror-image study to explore changes in healthcare utilization and associated costs, among 1,272 South Korean patients with schizophrenia (ICD-10-CM code F20), between the 1-year periods before and after the initiation of PP treatment.

Results

Patients accessed outpatient services more frequently after versus before starting PP treatment, with the number of prescription days increasing by 133.45 (p < 0.0001) and the associated costs increasing by USD 1,497.15 (p < 0.0001). The number of admission days was reduced by 11.33 after starting PP treatment (p < 0.0001) and the associated costs were reduced by USD 1,220.75 (p < 0.0001). However, admission cost savings were different according to patients’ oral drug compliance. The daily dosages for benztropine, procyclidine, and propranolol decreased, showing that there were fewer side-effects after PP-treatment (p < 0.0001).

Conclusion

Although the high acquisition cost of PP has been regarded as an obstacle to its clinical use, our results imply that the high prescription costs for PP may be counterbalanced by the reduced admission costs associated with its use. Economic outcomes for patients treated with LAIs should be investigated further to help healthcare decision-makers and providers to determine the value of LAIs relative to other treatment medications.

Sex-Specific Differences in Severity of Depressive Symptoms, Heart Rate Variability, and Neurocognitive Profiles of Depressed Young Adults: Exploring Characteristics for Mild Depression

Mild depressive symptoms (MDS) reflect vulnerability to major depression that does not meet the criteria for a major depressive disorder (MDD). Previous research indicates that it is difficult to identify MDS in young adults, and they exhibit diverse aspects of depressive symptoms caused by clinical depression, which can lead to poor academic performance, relationship difficulties, and even suicide. Additionally, many young adults remain unaware of their depressive symptoms during the early stages of MDD. Thus, the present study investigated clinical, neurocognitive, and physiological characteristics of young adults with various symptoms of depression and explored sex-specific differences. A total of 113 students aged 18-35 (MDD: n = 32; MDS: n =37; control [CON]: n = 44) participated in the study. Self-report clinical measures, short-term cardiac activity measured by finger sensors, and neurocognitive data were collected. Pearson's correlations, two-way analysis of variance (ANOVA), principal component analysis, and exploratory structural equation modeling were conducted for the statistical analyses. Furthermore, the measurement invariance of the latent factor model was tested, and fit indices were compared according to sex. The results revealed that male students showed greater sympatho-vagal activity than female students. Additionally, male MDS students tended to exhibit decreased performance levels in neurocognitive function tasks compared with MDD and CON males, whereas female MDS students showed distinct characteristics compared to MDD and CON females on self-report measures of anxiety. Correlation analyses identified a positive association between the level of anger perception and latency in the executive function test among both males and females. Additionally, the use of a structured model revealed significant sex-specific differences in factor estimates. The present results suggest that recognizing the early signs of MDS that account for sex-specific differences in both subjective and objective measures may improve the diagnosis and monitoring of young adults with MDS.

Commonalities and differences in abnormal peripheral metabolites between patients with fibromyalgia and complex regional pain syndrome

Background: Fibromyalgia (FM) and complex regional pain syndrome (CRPS) share many pathological mechanisms related to chronic pain that could contribute to multifactorial pathological mechanisms.Methods: We investigated peripheral metabolites in FM and CRPS patients compared to healthy controls based on cross-sectional study.Results: Mean corpuscular hemoglobin (p < 0.001), mean corpuscular volume (p = 0.014), and total bilirubin levels (p = 0.017) were lower in FM patients than in healthy controls. On the other hand, CRPS patients showed lower levels of total bilirubin than healthy controls (p = 0.037). Creatinine level was lower in FM patients (p = 0.057) compared to healthy controls, particularly when comparing the low-hemoglobin subgroup among FM patients (p = 0.035) with the low-hemoglobin subgroup among healthy controls. Red blood cell count (r = -0.620, p = 0.031), hematocrit (r = -0.593, p = 0.042), and creatinine level (r = -0.598, p = 0.040) showed negative correlations with McGill Pain Questionnaire-Affective (MPQ-A) scores in FM patients. A negative correlation was observed between MCV and McGill Pain Questionnaire-Sensory scores (r = -0.680, p = 0.015) in CRPS patients.Conclusion: We found specific peripheral metabolites that may exhibit different tendency between FM and CRPS patients as well as some common metabolites, which may be associated with peripheral pathology in the patients. Considering this study had a few limitations such as a small sample sizes and using a liberal threshold of significance in the correlation analysis, future studies with larger sample sizes may be needed to generalize these findings.

Dynamic Contrast-Enhanced MR Imaging of Nonenhancing T2 High-Signal-Intensity Lesions in Baseline and Posttreatment Glioblastoma: Temporal Change and Prognostic Value

BACKGROUND AND PURPOSE

The prognostic value of dynamic contrast-enhanced MR imaging on nonenhancing T2 high-signal-intensity lesions in patients with glioblastoma has not been thoroughly elucidated to date. We evaluated the temporal change and prognostic value for progression-free survival of dynamic contrast-enhanced MR imaging-derived pharmacokinetic parameters on nonenhancing T2 high-signal-intensity lesions in patients with glioblastoma before and after standard treatment, including gross total surgical resection.

MATERIALS AND METHODS

This retrospective study included 33 patients who were newly diagnosed with glioblastoma and treated with gross total surgical resection followed by concurrent chemoradiation therapy and adjuvant chemotherapy with temozolomide in a single institution. All patients underwent dynamic contrast-enhanced MR imaging before surgery as a baseline and after completion of maximal surgical resection and concurrent chemoradiation therapy. On the whole nonenhancing T2 high-signal-intensity lesion, dynamic contrast-enhanced MR imaging-derived pharmacokinetic parameters (volume transfer constant [K ^trans], volume of extravascular extracellular space [v _e]_, and blood plasma volume [v_p ]) were calculated. The Cox proportional hazards regression model analysis was performed to determine the histogram features or percentage changes of pharmacokinetic parameters related to progression-free survival.

RESULTS

Baseline median K ^trans, baseline first quartile K ^trans, and posttreatment median K ^trans were significant independent variables, as determined by univariate analysis (P < .05). By multivariate Cox regression analysis including methylation status of O⁶-methylguanine-DNA methyltransferase, baseline median K ^trans was determined to be the significant independent variable and was negatively related to progression-free survival (hazard ratio = 1.48, P = .003).

CONCLUSIONS

Baseline median K ^trans from nonenhancing T2 high-signal-intensity lesions could be a potential prognostic imaging biomarker in patients undergoing gross total surgical resection followed by standard therapy for glioblastoma.

Prognostic Predictions for Patients with Glioblastoma after Standard Treatment: Application of Contrast Leakage Information from DSC-MRI within Nonenhancing FLAIR High-Signal-Intensity Lesions

BACKGROUND AND PURPOSE

Attempts have been made to quantify the microvascular leakiness of glioblastomas and use it as an imaging biomarker to predict the prognosis of the tumor. The purpose of our study was to evaluate whether the extraction fraction value from DSC-MR imaging within nonenhancing FLAIR hyperintense lesions was a better prognostic imaging biomarker than dynamic contrast-enhanced MR imaging parameters for patients with glioblastoma.

MATERIALS AND METHODS

A total of 102 patients with glioblastoma who received a preoperative dynamic contrast-enhanced MR imaging and DSC-MR imaging were included in this retrospective study. Patients were classified into the progression (n = 87) or nonprogression (n = 15) groups at 24 months after surgery. We extracted the means and 95th percentile values for the contrast leakage information parameters from both modalities within the nonenhancing FLAIR high-signal-intensity lesions.

RESULTS

The extraction fraction 95th percentile value was higher in the progression-free survival group of >24 months than at ≤24 months. The median progression-free survival of the group with an extraction fraction 95th percentile value of >13.32 was 17 months, whereas that of the group of ≤13.32 was 12 months. In addition, it was an independent predictor variable for progression-free survival in the patients regardless of their ages and genetic information.

CONCLUSIONS

The extraction fraction 95th percentile value was the only independent parameter for prognostic prediction in patients with glioblastoma among the contrast leakage information, which has no statistically significant correlations with the DCE-MR imaging parameters.

Frequency and Clinical Associating Factors of Valvular Heart Disease in Asymptomatic Korean Adults

Limited information is available on the prevalence and clinical determinants of valvular heart disease (VHD) in apparently healthy people. This study sought to assess the frequency and clinical associating factors of aortic stenosis (AS), aortic regurgitation (AR), mitral stenosis (MS), mitral regurgitation (MR), tricuspid regurgitation (TR) in asymptomatic individuals with health check-up examination. We included 23,254 subjects ≥50 years of age who underwent a health check-up examination with transthoracic echocardiography (TTE) between 2012 and 2016 in a single tertiary-care hospital in Korea. Among a total of 23,254 subjects, 15,358 men (66.0%) and 7,896 women (34.0%) underwent TTE. Newly identified (predominantly mild) VHD was detected in 9.4% of subjects. The most common VHD were TR (4.6%), AR (3.0%) and MR (2.4%). Clinically significant (more than moderate) VHD was identified in 176 subjects (0.8%). Age ≥75 years was associated with all clinically significant VHD, and female gender was associated with AR, MS and TR. Korea has been very active in the health check-up examination including echocardiography. We find that VHD in apparently healthy people is not uncommon than believed; all VHD except MS were more frequent in elderly over 75 years of age in a large population-based study.

The relationship between levels of self-esteem and the development of depression in young adults with mild depressive symptoms

Little is known about the relationship between levels of self-esteem and the development of depression in young adults. The present study investigated the relationship between self-esteem and depression to determine whether self-esteem levels are a risk factor for the development of depression in young adults. This study was conducted with 113 college students aged 19 to 35 (major depressive disorder (MDD) n = 44, Mild Depressive Symptoms (MDS) n = 37, Healthy Control n = 32). The levels of clinical symptoms, self-esteem, resilience, social support, and quality of life, as well as personality traits, were assessed (by Patient Health Questionnaire-9, generalized anxiety disease-7, State-Trait Anxiety Inventory-S, Resilience Appraisal Scale, Rosenberg Self-Esteem Scale, Quality of Life, and NEO-personality inventory (NEO-PI)). The MDS group with high self-esteem reported having the lowest levels of social support, resilience, agreeableness, and extraversion compared to those of the MDD group and control group with high self-esteem. In contrast, the MDS group with low self-esteem showed no differences in social support, resilience, agreeableness and openness according to the NEO-PI scale. Sex and age had no significant impact on the results. Levels of self-esteem are strongly associated with the development of depression. Results suggest that early intervention for depression in young adults needs to focus on improving their levels of social support, resilience, and positive domains of personality. Further studies on the effects of high self-esteem in the development of depression are warranted.

Comparison of psychiatric disturbances in patients with multiple sclerosis and neuromyelitis optica

Although both multiple sclerosis (MS) and neuromyelitis optica (NMO) are demyelinating diseases, their psychiatric disturbances may differ given differences in the neurological manifestations. We used subjective and objective measurements to compare the psychiatric disturbances in patients with MS and NMO.Psychiatric disturbances were assessed in 24 MS and 35 NMO patients using the Beck Hopelessness Scale, Symptom Checklist-95 and the brief version of World Health Organization Quality of Life. Personality was assessed using the Big Five Inventory-10. Disease-related function was assessed using the Fatigue Severity Scale, Short-Form McGill Pain Questionnaire, and the Global Assessment of Function. Positivity offset (PO) and negativity bias (NB) and heart rate variability (HRV) were measured using a modified implicit affect test and photoplethysmograph, respectively. Data were analyzed using analysis of covariance with age and sex as covariates.MS patients had higher levels of depression, anxiety, panic attacks, obsessive-compulsiveness, aggression, paranoia, interpersonal sensitivity, self-regulation problems, stress vulnerability, and lower psychological quality of life (QOL) compared with NMO patients. The PO and NB and HRV values were not significantly different between groups. However, NMO patients had lower QOL, and higher levels of hopelessness, suicidality, and fatigue than the normal range. Disease duration was associated with hopelessness in NMO patients and with several psychiatric disturbances, but not hopelessness, in MS patients.Subjective psychiatric disturbances were more severe in patients with MS than in those with NMO, whereas PO and NB and HRV in patients with NMO were comparable with those of MS patients. Our findings highlight the need for different clinical approaches to assess and treat psychiatric disturbances in patients with MS and NMO.

Neural evidence for persistent attentional bias to threats in patients with social anxiety disorder

Does the biased attention toward social threats dwells on or disappears in patients with social anxiety disorder (SAD)? We investigated the neural mechanism of attentional bias in terms of attentional capture and holding in SAD. A total of 31 SAD patients and 30 healthy controls performed a continuous performance task detecting the orientation of a red letter 'T' while angry or neutral face distractors appeared or disappeared at the center of the screen. Behaviorally, typical attentional capture effects were found in response to abruptly appearing distractors in both groups. The patient group showed significant attentional dwelling effects in response to the angry face distractor only. Patients showed increased neural activity in the amygdala, insula/inferior frontal gyrus (IFG) and temporo-parietal junction (TPJ) compared with those of controls for the abruptly appearing angry distractor. Patients also maintained increased activities in brain regions related to attentional reorienting to distractor, namely the TPJ and IFG in line with their behavioral results of attentional holding effects. Our results indicate that patients with SAD showed prolonged attentional bias to task-irrelevant social threats. The underlying mechanism of prolonged attentional bias in SAD was indicated with amygdala hyperactivity and continued activity of the bottom-up attention network including the TPJ and IFG.

Sleeping, sleeping environments, and human errors in South Korean male train drivers

Objectives

Reducing human errors caused by daytime sleepiness among train drivers is important to prevent train accidents. Our purpose of the study was to investigate the association among sleep, workplace sleeping environments, and human errors.

Methods

We recruited 144 South Korean train drivers belongs to the Korean Railroad Corporation. This cross‐sectional data was analyzed to investigate the association of insomnia (insomnia severity index), sleep quality (Pittsburgh sleep quality index), obstructive sleep apnea (Berlin questionnaire), and daytime sleepiness (Epworth scale) with human error and near‐miss experiences. We examined whether human error and near‐miss events were associated with various sleeping environments at work and at home after adjusting for the sleep indices.

Results

The experience of human errors was associated with insomnia and daytime sleepiness, and near‐miss events were associated with insomnia among South Korean drivers. Sleeping environments including cold temperature and odor were related to both human errors and near‐miss events among South Korean train drivers, after adjusted for age, working years, shiftwork, obesity, smoking, binge drinking, regular exercise, caffeine consumption, sleep quality, severity of insomnia, obstructive sleep apnea, and daytime sleepiness.

Conclusions

The train drivers’ workplace sleeping environment is significantly associated with human error events and near‐miss events after adjusting for sleep quality, insomnia, obstructive sleep apnea, and daytime sleepiness. To prevent train accidents caused by human errors, more attention is necessary for improving workplace sleeping environments.

Relationships among stress, emotional intelligence, cognitive intelligence, and cytokines

The brain has multiple functions, and its structures are very closely related to one another. Thus, the brain areas associated with stress, emotion, and intelligence are closely connected. The purpose of this study was to investigate the multiple associations between stress and emotional intelligence (EI), between EI and intelligence quotient (IQ), between cytokines and stress, and between cytokines and IQ. We measured the stress, EI, cognitive intelligence using IQ, and cytokine levels of 70 healthy subjects. We also analyzed the association of cytokines with IQ according to hemispheric dominance using the brain preference indicator (BPI). We found significant negative correlations between stress and the components of EI, such as emotional awareness and expression, emotional thinking, and emotional regulation. High levels of anger, which is a component of stress, were significantly related to poor emotional regulation. Additionally, emotional application was positively correlated with full-scale IQ scores and scores on the vocabulary, picture arrangement, and block design subtests of the IQ test. High IL-10 levels were significantly associated with low stress levels only in the right-brain-dominant group. High IL-10 and IFN-gamma levels have been associated with high scores of arithmetic intelligence. TNF-alpha and IL-6 were negatively associated with vocabulary scores and full-scale IQ, but IL-10 and IFN-gamma were positively associated with scores on the arithmetic subtest in left-brain-dominant subjects. On the other hand, IL-10 showed positive correlations with scores for vocabulary and for vocabulary and arithmetic in right-brain-dominant subjects. Furthermore, we found significant linear regression models which can show integrative associations and contribution on emotional and cognitive intelligence. Thus, we demonstrated that cytokines, stress, and emotional and cognitive intelligence are closely connected one another related to brain structure and functions. Also, the pro-inflammatory cytokines TNF-alpha and IL-6 had negative effects, whereas the anti-inflammatory cytokines (e.g., IL-10 and IFN-gamma) showed beneficial effects, on stress levels, and multiple dimensions of emotional and cognitive intelligence. Additionally, these relationships among cytokines, stress, and emotional and cognitive intelligence differed depending on right and left hemispheric dominance.

Abstract P4-14-09: A nationwide data on the cardiovascular protective effect of tamoxifen and aromatase inhibitor in postmenopausal women with breast cancer

A large proportion of breast cancer patients receive hormonal therapy as their adjuvant treatment options. For postmenopausal women, the initial choice for the hormonal therapy is aromatase inhibitor (AI), and tamoxifen (TM) is reserved for women experiencing severe side effects against AI or having low bone density. An important but unresolved clinical question regarding the use of AI in postmenopausal women is the safety of AI regarding the risk cardiovascular events. Studies have shown inconsistent results over the cardiovascular safety of AI and TM. In this study, we investigated the risk of developing cardiovascular and cerebrovascular events in women with breast cancer who receive hormonal therapy using AI, TM, or both.

To this end, we used the National Health Insurance Sharing Service in Korea which is provided by National Health Insurance Service. The database provides anonymized insurance data for research purposes after the approval of the review committee. In the database, we identified 47,569 women with the age older than 55 who were diagnosed with breast cancer. Patients were classified as no hormonal treatment group (n=18,807), AI group (n=19,584), TM group (n=7,081), or Switch group (n=2,097). The Switch group was defined as the women with history of both AI and TM prescriptions. During the studied period, a total of 2,032 cardiovascular or cerebrovascular events (CVE) were recorded.

Overall, the women prescribed with TM had significantly less hazard ratio for developing CVE when compared to the women who did not receive any hormonal treatment (HR 0.809 95% C.I. 0.706-0.928). However, this protective effect of tamoxifen was not observed in either AI or Switch group (HR 0.917 95% C.I. 0.833-1.010, and HR 0.856 95% C.I. 0.695-1.053, respectively). The protective effect of TM was also similar in women older than 60 (HR 0.808 95% C.I. 0.696-0.938). The cardiovascular and cerebrovascular protective effects of tamoxifen was also substantial in high risk women defined by their family history of cardiovascular diseases and the diagnosis of hypertension or diabetes.

Our results suggest that the use of TM is associated with a substantial protective effect against developing cardiovascular or cerebrovascular events in women with breast cancer. However, the protective effect was not observed for women receiving AI. Our data suggest the potential tailored approach in hormonal treatment in breast cancer patients who are at high risk of cardiovascular of cerebrovascular events.

Citation Format: Moon H-G, Choi SH, Park Y, Jung JG, Ju YW, Kim KE, Kim Y, Lee E, Lee H-B, Han W, Noh D-Y, Yoon H-J. A nationwide data on the cardiovascular protective effect of tamoxifen and aromatase inhibitor in postmenopausal women with breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-14-09.

Comparison of complex regional pain syndrome and fibromyalgia: Differences in beta and gamma bands on quantitative electroencephalography

Complex regional pain syndrome (CRPS) and fibromyalgia (FM) share many features. Both can cause severe pain and are considered to have a mechanism of action, including dysfunction of the sympathetic nervous system. However, they have clinical differences in pain range and degree. The present study aimed to find neurophysiologic differences between CRPS and FM using quantitative electroencephalography (QEEG). Thirty-eight patients with CRPS and 33 patients with FM were included in the analysis. Resting-state QEEG data were grouped into frontal, central, and posterior regions to analyze for regional differences. General linear models were utilized to test for group differences in absolute and relative powers. As a result, the CRPS group relative to FM group showed lower total absolute powers in the beta band (F = 5.159, P < .05), high beta (F = 14.120, P < .05), and gamma band (F = 15.034, P < .05). There were no significant differences between 2 groups in the delta, theta, and alpha bands. The present findings show that the CRPS and FM groups differ mainly in the high frequency, which may reflect their distinct pathophysiology and symptomatology. Our study suggests that the QEEG differences can be clinically useful in assessing brain function in patients with CRPS and FM.

Disruption of Homeostasis Based on the Right and Left Hemisphere in Patients with Complex Regional Pain Syndrome

OBJECTIVE

Although the clinical features and pathophysiology of complex regional pain syndrome (CRPS) have been studied in the peripheral and central nervous systems, few plausible pathological interactions are known among the metabolites in these systems. Thus, the purpose of this study was to investigate abnormal relationships and interactions between peripheral metabolites and central neurometabolites in patients with CRPS.

METHODS

Various metabolites and molecules were measured in the peripheral blood, and central neurometabolites in the right and left thalamus using proton magnetic resonance spectroscopy in 12 patients with CRPS and 11 healthy controls. Interactions between peripheral metabolites in blood and central neurometabolites in the right and left thalamus were also investigated.

RESULTS

The interactions between peripheral and central metabolites were different in the right and left hemispheres of healthy subjects, suggesting the presence of right hemisphere-dependent energy homeostasis and left hemisphere-dependent acid-base homeostasis that enables effective functioning. The interactions between central and peripheral metabolites in CRPS patients were distinct from those in healthy individuals, supporting the possibility of abnormal interactions and disrupted homeostasis between peripheral and central metabolites, which may result from neuroinflammation and immune system dysfunction.

CONCLUSION

To the authors' knowledge, this is the first report describing abnormal metabolic dysfunction and disrupted homeostasis in interactions between metabolites of the peripheral and central nervous systems in CRPS. The approach used to uncover hidden pathophysiologies will improve understanding of how chronic pain can disrupt homeostasis in interactions between two systems and how alternative metabolites can be activated to recover and compensate for pathological dysfunctions in patients with CRPS.

Three Weeks of rTMS Treatment Maintains Clinical Improvement But Not Electrophysiological Changes in Patients With Depression: A 6-Week Follow-Up Pilot Study

Our previous study demonstrated that 3 weeks of repetitive transcranial magnetic stimulation (rTMS) increases P200 amplitudes and improves the symptoms of depression and anxiety in depression patients. In the present study, we investigated whether 3 weeks of rTMS treatment maintained the P200 amplitude in patients with depression at 6 weeks of follow-up. We measured the 6-week maintenance effects of rTMS using clinical questionnaires and an auditory oddball paradigm. Twenty-one patients with medication-resistant major depression participated in this pilot study. All patients underwent rTMS treatment for 3 weeks; they completed clinical ratings and performed the auditory oddball task at the pre-treatment, post-treatment, and 6-week follow-up visit (3 weeks after finishing rTMS treatment). The results revealed an increase in P200 amplitudes as well as improvements in the symptoms of depression and anxiety by 3 weeks of rTMS treatment. Furthermore, the results demonstrated maintenance effects on clinical ratings at 6-week follow-up. Depression and anxiety scales showed improvements in post-treatment and maintenance effects at the 6-week follow-up. Although P200 amplitude showed a significant main effect for 3 time points (baseline, post-treatment, and 6-week follow-up visit), at 2 time point comparisons, P200 amplitudes significantly increased in post-treatment compared to those of the baseline condition but did not show the maintenance effects of long-term rTMS at the 6-week follow-up compared to those of the baseline condition (  p = .173, Bonferroni correction). Standardized low-resolution brain electromagnetic tomography (sLORETA) for P200 showed significant activation in the left middle frontal gyrus in post-treatment but no significant activation at the 6-week follow-up. Moreover, the amplitudes of overall topographic distribution were reduced at 6 weeks of follow-up. The 3 weeks of rTMS treatment induced the maintenance of the improvements in the symptoms of depression and anxiety. However, considering the results of the event-related potential (ERP) and sLORETA, 3 weeks of rTMS treatment may not be sufficient to maintain this improvement, implying that a treatment period of more than 3 weeks may be required to reveal the electrophysiological maintenance effect of rTMS.