Resting-state EEG as Biomarker of Maladaptive Motor Function and Depressive Profile in Stroke Patients

Objective: Investigate the relationship between resting-state EEG-measured brain oscillations and clinical and demographic measures in Stroke patients. Methods: We performed a cross-sectional analysis of a cohort study (DEFINE cohort), Stroke arm, with 85 patients, considering demographic, clinical, and stroke characteristics. Resting-state EEG relative power from delta, theta, alpha, and beta oscillations were measured from the central region. Multivariate regression models were used for both affected and non-affected hemispheres. Results: Motor function was negatively associated with Delta and Theta oscillations, while positively associated with Alpha oscillations (both hemispheres). Similarly, cognition levels measured were negatively associated with Delta activity. Depression levels were negatively associated with Alpha activity specifically in the affected hemisphere, while positively associated with Beta activity in both hemispheres. Regarding pain measures, no significant association was observed, while CPM measure showed a positive association with Alpha activity in the non-affected hemisphere. Finally, we found that theta/alpha ratio was negatively associated with motor function and CPM scores. Conclusion: The results lead us to propose a framework for brain oscillations in stroke, whereas Delta and Beta would represent disrupted mal-adaptive brain plasticity and Theta and Alpha would represent compensatory and functional brain oscillations for motor and sensory deficits in stroke, respectively.

Pain Science in Practice (Part 7): How Is Descending Modulation of Pain Measured?

SYNOPSIS: Understanding the descending pain modulatory system allows for a neuroscientific explanation of naturally occurring pain relief. Evidence from basic science and clinical studies on the effectiveness of drugs in certain patient groups led to pharmacological manipulation of the descending pain modulatory system for analgesia. Understanding mechanisms and theories helps clinicians make sense of chronic musculoskeletal pain. This editorial explains how test paradigms, including conditioned pain modulation, offset analgesia, and stress-induced analgesia work, provide an overview of a placebo analgesia circuitry, and discusses how evoking activity in the descending pain modulatory system using specific paradigms can give new insights into how specific treatments work to reduce pain. J Orthop Sports Phys Ther 2024;54(2):1-6. doi:10.2519/jospt.2024.12113.

Body-site effect on CPM efficiency in healthy subjects: Central vs. peripheral stimulation

Structural changes in the peripheral nerve system in neuropathic states alter sensory capacity of the affected area, thus biasing results of conditioned pain modulation (CPM) responses. The aim of this study was to evaluate CPM efficiency of central (i.e. trunk) vs. peripheral (i.e. limb) application of 'test' and 'conditioning' stimuli. Methods: Healthy volunteers (ages 18-73 yrs) underwent two CPM protocols: 'CPM Limb' and 'CPM Trunk'. Each included two types of test stimuli (Ts) (pressure pain threshold: PPT; and contact heat) conditioned either to hand immersion in cold noxious water (CPM limb), or to noxious contact heat applied on lower back (CPM trunk). Results: Both protocols generated efficient pain inhibition for each of the applied Ts; the PPT-based protocol induced more efficient CPM when the conditioned stimulus was applied on the trunk (p = 0.016). Moreover, the PPT-based CPM responses were significantly correlated (ρ = 0.349; p = 0.007). Conclusions: An efficient CPM induced by both central and peripheral stimulation, along with significant correlation between PPT-based responses, advances using the central 'CPM Trunk' protocol in patients with peripheral neuropathy.

SDFPoseGraphNet: Spatial Deep Feature Pose Graph Network for 2D Hand Pose Estimation

In the field of computer vision, hand pose estimation (HPE) has attracted significant attention from researchers, especially in the fields of human-computer interaction (HCI) and virtual reality (VR). Despite advancements in 2D HPE, challenges persist due to hand dynamics and occlusions. Accurate extraction of hand features, such as edges, textures, and unique patterns, is crucial for enhancing HPE. To address these challenges, we propose SDFPoseGraphNet, a novel framework that combines the strengths of the VGG-19 architecture with spatial attention (SA), enabling a more refined extraction of deep feature maps from hand images. By incorporating the Pose Graph Model (PGM), the network adaptively processes these feature maps to provide tailored pose estimations. First Inference Module (FIM) potentials, alongside adaptively learned parameters, contribute to the PGM's final pose estimation. The SDFPoseGraphNet, with its end-to-end trainable design, optimizes across all components, ensuring enhanced precision in hand pose estimation. Our proposed model outperforms existing state-of-the-art methods, achieving an average precision of 7.49% against the Convolution Pose Machine (CPM) and 3.84% in comparison to the Adaptive Graphical Model Network (AGMN).

A modified DRASTIC model for groundwater vulnerability assessment using connecting path and analytic hierarchy process methods

Groundwater plays a vital role in supporting water for the different needs of domestic, agricultural, and industrial sectors, and its vulnerability assessment to pollution is a valuable tool for establishing protective and preventive management. DRASTIC is a well-known GIS-based model for assessing groundwater vulnerability to pollution, which uses seven parameters including depth-to-water level, net recharge, aquifer media, soil media, topography, the impact of the vadose zone, and hydraulic conductivity. The predefined weights of DRASTIC parameters have made a barrier to its applicability for different regions with different hydroclimatic conditions. To overcome this problem, it has been suggested to apply analytic hierarchy process (AHP) method for modifying the model by adjusting the weights of the parameters. AHP is a widely used method to elicit experts' judgments about different involving parameters through constructing pairwise comparison matrixes (PCMs). Since AHP calculates the weights by performing pairwise comparisons between the parameters, achieving consistent comparisons is difficult when the number of parameters increases. The objective of this research is to modify the DRASTIC model by integrating the connecting path method (CPM) and AHP. The proposed methodology involves asking experts to perform a number of pairwise comparisons between the parameters and then construct an incomplete PCM using the obtained information. To complete the missing values in the PCM, CPM is employed. The CPM is an effective approach that not only estimates missing judgments but also ensures minimal geometric consistency. The proposed method along with DRASTIC and pesticide DRASTIC models is applied to Khoy County, which is located in the northwest part of Iran. The efficiency of the proposed method was further confirmed through the results of the Pearson coefficient test conducted on nitrate concentrations. The test revealed correlation values of 0.47, 0.27, and 0.57 for DRASTIC, pesticide DRASTIC, and modified DRASTIC, respectively. These results demonstrated that the proposed method provides a more precise evaluation of groundwater vulnerability.

Beyond biopsychosocial: The keystone mechanism theory of pain

Pain is a deeply personal experience, with interindividual differences in its chronification and treatment presenting a formidable healthcare challenge. The biopsychosocial model (BPSm) has been hugely influential within nascent attempts at precision pain medicine, steering the field away from a reductionist biomechanical viewpoint and emphasising complex interactions of biological, psychological, and social factors which shape the individuality of pain. However, despite offering a strong theoretical foundation and holistic perspective, we contend that the BPSm remains limited in its capacity to deliver truly mechanistically informed treatment of pain. We therefore propose the keystone model of pain which offers a pragmatic balance between the dimensionality expansive BPSm and overly reductive approaches, providing both theoretical and practical advantages for the transition from treating populations to individual people.

Comparison of Survival Outcomes in Young Patients With Breast Cancer Receiving Contralateral Prophylactic Mastectomy Versus Unilateral Mastectomy

BACKGROUND

Contralateral prophylactic mastectomy (CPM) has been performed for several decades in patients with unilateral breast cancer (BC). However, the survival benefits of CPM are controversial, particularly in young women.

MATERIALS AND METHOD

In this retrospective study, the clinical total of 69,000 young female patients (age ≤ 40 years) who were diagnosed to have unilateral BC and underwent unilateral mastectomy (UM) or CPM between January 1, 2000 and December 31, 2019 were retrieved from the Surveillance, Epidemiology, and End Results (SEER) database. Propensity score matching (PSM) was performed to minimize selection bias and overcome differences in tumor characteristics between the CPM and UM groups. Overall survival (OS) and BC-specific survival (BCSS) were assessed using Kaplan-Meier curves and compared across groups using log-rank test. Multivariable Cox proportional hazards regression analysis was performed to estimate hazard ratios (HRs).

RESULTS

A total of 36,528 patients (21,600 and 14,928 patients in the UM and CPM groups, respectively) were included in follow study. The CPM group showed a higher 5-year OS rate (82.1% vs. 75.8%) and a higher 5-year BCSS rate (83.5% vs. 77.7%) than the UM group. Multivariate Cox analysis after PSM (n = 13,089) showed that CPM significantly decreased 25% risk of all-cause mortality (OS, HR: 0.75, 95% confidence interval [CI]: 0.70-0.80; P < .001) and 25% risk of BC-specific mortality (BCSS, HR: 0.75, 95% CI: 0.70-0.80; P < .001) in young BC patients as compared to UM.

CONCLUSION

This study suggests that CPM improved OS and BCSS benefits in young BC patients as compared to UM. Randomized clinical trials with a larger sample size are required in the future to confirm these results.

Connectome-based fingerprint of motor impairment is stable along the course of Parkinson's disease

Functional alterations in brain connectivity have previously been described in Parkinson's disease, but it is not clear whether individual differences in connectivity profiles might be also linked to severity of motor-symptom manifestation. Here we investigated the relevance of individual functional connectivity patterns measured with resting-state fMRI with respect to motor-symptom severity in Parkinson's disease, through a whole-brain, data-driven approach (connectome-based predictive modeling). Neuroimaging and clinical data of Parkinson's disease patients from the Parkinson's Progression Markers Initiative were derived at baseline (session 1, n = 81) and at follow-up (session 2, n = 53). Connectome-based predictive modeling protocol was implemented to predict levels of motor impairment from individual connectivity profiles. The resulting predictive model comprised a network mainly involving functional connections between regions located in the cerebellum, and in the motor and frontoparietal networks. The predictive power of the model was stable along disease progression, as the connectivity within the same network could predict levels of motor impairment, even at a later stage of the disease. Finally, connectivity profiles within this network could be identified at the individual level, suggesting the presence of individual fingerprints within resting-state fMRI connectivity associated with motor manifestations in Parkinson's disease.

The effect of air pollution control devices in coal-fired power plants on the removal of condensable and filterable particulate matter

Total particulate matter (TPM), including condensable and filterable particulate matter (CPM and FPM), is one of the pollutants that need to be controlled in the coal combustion process. In this study, CPM and FPM were sampled from sixteen coal-fired power units and two coal-fired industrial units. The removal effects of air pollution control devices equipped in the units on the migration and emission of particles were investigated by analyzing samples from inlets and outlets of apparatus. The average removal efficiency of TPM by dry-type dust removal equipment, wet flue gas desulfurization devices, and wet-type precipitators reached 98.57 ± 0.90%, 44.89 ± 15.01%, and 28.45 ± 7.78%, respectively. The removal efficiency of dry-type dust removal equipment and wet-type precipitators to TPM is mainly determined by the purification effect of FPM and CPM, respectively, and both types of particles contribute to the removal efficiency of desulfurization systems to total TPM. The concentrations of CPM (12.01 ± 5.64 mg/Nm³) and FPM (1.95 ± 0.86 mg/Nm³) emitted from ultra-low emission units were the lowest, and CPM is the dominant particle, especially the higher proportion of organic components in CPM.

Predicting depressed and elevated mood symptomatology in bipolar disorder using brain functional connectomes

BACKGROUND

The study is aimed to identify brain functional connectomes predictive of depressed and elevated mood symptomatology in individuals with bipolar disorder (BD) using the machine learning approach Connectome-based Predictive Modeling (CPM).

METHODS

Functional magnetic resonance imaging data were obtained from 81 adults with BD while they performed an emotion processing task. CPM with 5000 permutations of leave-one-out cross-validation was applied to identify functional connectomes predictive of depressed and elevated mood symptom scores on the Hamilton Depression and Young Mania rating scales. The predictive ability of the identified connectomes was tested in an independent sample of 43 adults with BD.

RESULTS

CPM predicted the severity of depressed [concordance between actual and predicted values (r = 0.23, pperm (permutation test) = 0.031) and elevated (r = 0.27, pperm = 0.01) mood. Functional connectivity of left dorsolateral prefrontal cortex and supplementary motor area nodes, with inter- and intra-hemispheric connections to other anterior and posterior cortical, limbic, motor, and cerebellar regions, predicted depressed mood severity. Connectivity of left fusiform and right visual association area nodes with inter- and intra-hemispheric connections to the motor, insular, limbic, and posterior cortices predicted elevated mood severity. These networks were predictive of mood symptomatology in the independent sample (r ⩾ 0.45, p = 0.002).

CONCLUSIONS

This study identified distributed functional connectomes predictive of depressed and elevated mood severity in BD. Connectomes subserving emotional, cognitive, and psychomotor control predicted depressed mood severity, while those subserving emotional and social perceptual functions predicted elevated mood severity. Identification of these connectome networks may help inform the development of targeted treatments for mood symptoms.

Age-related intrinsic functional connectivity underlying emotion utilization

Previous studies investigated the age-related positivity effect in terms of emotion perception and management, whereas little is known about whether the positivity effect is shown in emotion utilization (EU). If yes, the EU-related intrinsic functional connectivity and its age-associated alterations remain to be elucidated. In this study, we collected resting-state functional magnetic resonance imaging data from 62 healthy older adults and 72 undergraduates as well as their self-ratings of EU. By using the connectome-based predictive modeling (CPM) method, we constructed a predictive model of the positive relationship between EU self-ratings and resting-state functional connectivity. Lesion simulation analyses revealed that the medial-frontal network, default mode network, frontoparietal network, and subcortical regions played key roles in the EU-related CPM. Older subjects showed significantly higher EU self-ratings than undergraduates, which was associated with strengthened connectivity between the left dorsolateral prefrontal cortex and bilateral frontal poles, and between the left frontal pole and thalamus. A mediation analysis indicated that the age-related EU network mediated the age effect on EU self-ratings. Our findings extend previous research on the age-related "positivity effect" to the EU domain, suggesting that the positivity effect on the self-evaluation of EU is probably associated with emotion knowledge which accumulates with age.

Effects of Different Orthoses on Neuromuscular Activity of Superficial and Deep Shoulder Muscles during Activities of Daily Living and Physiotherapeutic Exercises in Healthy Participants

BACKGROUND

This study aimed to investigate the effects of different shoulder orthoses on the neuromuscular activity of superficial and deep shoulder muscles during activities of daily living (ADL) and physiotherapeutic exercises.

METHODS

Ten participants with healthy shoulders (31 ± 3 years, 23.1 ± 3.8 kg/m²) were randomized to receive a "shoulder sling", an "abduction pillow" and a "variably adjustable orthosis" on the dominant side. With each orthosis, they completed seven ADL with and four physiotherapeutic exercises without wearing the orthoses. An electromyographic system was used to record the neuromuscular activity of three superficial (trapezius, deltoid, pectoralis major) and two deep shoulder muscles (infraspinatus, supraspinatus) using surface and intramuscular fine-wire electrodes.

RESULTS

The neuromuscular activity differs between the orthoses during ADL (p ≤ 0.045), whereby the "variably adjustable orthosis" mostly showed the highest activation levels associated with the worst subjective wearing comfort rated on a visual analog scale. In addition, differences exist between the physiotherapeutic exercises (p ≤ 0.006) demonstrating the highest activations of the infra- and supraspinatus muscles for assistive elevation and wipe across a table, middle for pendulum and lowest for continuous passive motion exercises.

CONCLUSIONS

The neuromuscular activity of superficial and deep shoulder muscles differs between the orthoses during ADL and also between the physiotherapeutic exercises.

Iodine Intake and Related Cognitive Function Impairments in Elementary Schoolchildren

Iodine deficiency, the most common cause of preventable mental impairment worldwide, has been linked to poorer intellectual function in several studies. However, to our knowledge, no studies have been performed in moderate iodine-deficient schoolchildren using the complete form of Wechsler Intelligence Scale for Children (WISC-III; Portuguese version). The main purpose of this study was to ascertain whether moderate iodine deficiency would affect the cognitive function of schoolchildren (7-11 years old; 3rd and 4th grades). Raven's Colored Progressive Matrices (CPM; Portuguese version) were used for measuring the intelligence quotient (IQ) of the total population (n = 256; median UIC = 66.2 μg/L), and the WISC-III was used to study two selected subgroups: one moderately iodine-deficient (n = 30) and the other with adequate iodine intake (n = 30). WISC-III was shown to be the prime instrument for cognitive function assessment among moderate iodine-deficient schoolchildren; this subgroup had a Full-Scale IQ 15.13 points lower than the adequate iodine intake subgroup, with a magnitude effect of d = 0.7 (p = 0.013). Significant differences were also registered in 6 of the 13 Verbal-Performance IQ subtests. Moderate iodine deficiency has a substantial impact on mental development and cognitive functioning of schoolchildren, with significant impairment in both Performance IQ and Verbal IQ spectrum, adversely impacting their educational performance.

AMAZONE: prevention of persistent pain after breast cancer treatment by online cognitive behavioral therapy-study protocol of a randomized controlled multicenter trial

Background

Surviving breast cancer does not necessarily mean complete recovery to a premorbid state of health. Among the multiple psychological and somatic symptoms that reduce the quality of life of breast cancer survivors, persistent pain after breast cancer treatment (PPBCT) with a prevalence of 15–65% is probably the most invalidating. Once chronic, PPBCT is difficult to treat and requires an individualized multidisciplinary approach. In the past decades, several somatic and psychological risk factors for PPBCT have been identified. Studies aiming to prevent PPBCT by reducing perioperative pain intensity have not yet shown a significant reduction of PPBCT prevalence. Only few studies have been performed to modify psychological distress around breast cancer surgery. The AMAZONE study aims to investigate the effect of online cognitive behavioral therapy (e-CBT) on the prevalence of PPBCT.

Methods

The AMAZONE study is a multicenter randomized controlled trial, with an additional control arm. Patients (n=138) scheduled for unilateral breast cancer surgery scoring high for surgical or cancer-related fears, general anxiety or pain catastrophizing are randomized to receive either five sessions of e-CBT or online education consisting of information about surgery and a healthy lifestyle (EDU). The first session is scheduled before surgery. In addition to the online sessions, patients have three online appointments with a psychotherapist. Patients with low anxiety or catastrophizing scores (n=322) receive treatment as usual (TAU, additional control arm).

Primary endpoint is PPBCT prevalence 6 months after surgery.

Secondary endpoints are PPBCT intensity, the intensity of acute postoperative pain during the first week after surgery, cessation of postoperative opioid use, PPBCT prevalence at 12 months, pain interference, the sensitivity of the nociceptive and non-nociceptive somatosensory system as measured by quantitative sensory testing (QST), the efficiency of endogenous pain modulation assessed by conditioned pain modulation (CPM) and quality of life, anxiety, depression, catastrophizing, and fear of recurrence until 12 months post-surgery.

Discussion

With perioperative e-CBT targeting preoperative anxiety and pain catastrophizing, we expect to reduce the prevalence and intensity of PPBCT. By means of QST and CPM, we aim to unravel underlying pathophysiological mechanisms. The online application facilitates accessibility and feasibility in a for breast cancer patients emotionally and physically burdened time period.

Trial registration

NTR NL9132, registered December 16 2020.

Conditioned Pain Modulation in Children: The Effects of Painful and Nonpainful Conditioning Stimuli

Conditioned pain modulation (CPM), a psychophysical measure in which 1 pain stimulus (conditioning stimulus) is used to inhibit another pain stimulus (test stimulus), is an important indicator of endogenous pain inhibition in adults, but is understudied in children. Preliminary evidence suggests that CPM effects are present in healthy children and are more robust in adolescents. However, developmental differences in younger children are not well documented and few studies control for potential distraction effects of the conditioning stimulus (CS). Participants were 54 healthy children aged 6 to 12 years. After a baseline pressure pain threshold (PPT) test, participants underwent 2 conditioning trials in which PPT was assessed while they placed their left hand in a water bath maintained at either 12 °C (painful CS) or 22 °C (nonpainful sham CS) in counterbalanced order. Results revealed a significant CPM effect. PPT values were significantly higher relative to baseline during the painful CS trial; PPT during the nonpainful CS trial did not differ from baseline. There were no significant age differences in magnitude of CPM effect. The results indicate that children as young as 6 years of age demonstrate CPM, suggesting that descending inhibitory pathways may be better developed in young children than previously thought. PERSPECTIVE: This study was successful in producing inhibitory CPM effects in physically healthy children while controlling for sensory distraction. The findings provide strong evidence that the obtained CPM responses cannot be attributed to sensory distraction or other nonspecific effects. Future studies could utilize CPM paradigms to study various aspects of pediatric endogenous pain inhibition, in order to better predict pain responses and improve interventions.

Estimation of Tibiofemoral Joint Contact Forces Using Foot Loads during Continuous Passive Motions

Continuous passive motion (CPM) machines are commonly used after various knee surgeries, but information on tibiofemoral forces (TFFs) during CPM cycles is limited. This study aimed to explore the changing trend of TFFs during CPM cycles under various ranges of motion (ROM) and body weights (BW) by establishing a two-dimensional mathematical model. TFFs were estimated by using joint angles, foot load, and leg−foot weight. Eleven healthy male participants were tested with ROM ranging from 0° to 120°. The values of the peak TFFs during knee flexion were higher than those during knee extension, varying nonlinearly with ROM. BW had a significant main effect on the peak TFFs and tibiofemoral shear forces, while ROM had a limited effect on the peak TFFs. No significant interaction effects were observed between BW and ROM for each peak TFF, whereas a strong linear correlation existed between the peak tibiofemoral compressive forces (TFCFs) and the peak resultant TFFs (R2 = 0.971, p < 0.01). The proposed method showed promise in serving as an input for optimizing rehabilitation devices.

A Randomized, Sham-Controlled Trial of Repetitive Transcranial Magnetic Stimulation Targeting M1 and S2 in Central Poststroke Pain: A Pilot Trial

OBJECTIVES

Central poststroke pain (CPSP), a neuropathic pain condition, is difficult to treat. Repetitive transcranial magnetic stimulation (rTMS) targeted to the primary motor cortex (M1) can alleviate the condition, but not all patients respond. We aimed to assess a promising alternative rTMS target, the secondary somatosensory cortex (S2), for CPSP treatment.

MATERIALS AND METHODS

This prospective, randomized, double-blind, sham-controlled three-arm crossover trial assessed navigated rTMS (nrTMS) targeted to M1 and S2 (10 sessions, 5050 pulses per session at 10 Hz). Participants were evaluated for pain, depression, anxiety, health-related quality of life, upper limb function, and three plasticity-related gene polymorphisms including Dopamine D2 Receptor (DRD2). We monitored pain intensity and interference before and during stimulations and at one month. A conditioned pain modulation test was performed using the cold pressor test. This assessed the efficacy of the descending inhibitory system, which may transmit TMS effects in pain control.

RESULTS

We prescreened 73 patients, screened 29, and included 21, of whom 17 completed the trial. NrTMS targeted to S2 resulted in long-term (from baseline to one-month follow-up) pain intensity reduction of ≥30% in 18% (3/17) of participants. All stimulations showed a short-term effect on pain (17-20% pain relief), with no difference between M1, S2, or sham stimulations, indicating a strong placebo effect. Only nrTMS targeted to S2 resulted in a significant long-term pain intensity reduction (15% pain relief). The cold pressor test reduced CPSP pain intensity significantly (p = 0.001), indicating functioning descending inhibitory controls. The homozygous DRD2 T/T genotype is associated with the M1 stimulation response.

CONCLUSIONS

S2 is a promising nrTMS target in the treatment of CPSP. The DRD2 T/T genotype might be a biomarker for M1 nrTMS response, but this needs confirmation from a larger study.

Use of hydrous ABE-glycerin-diesel microemulsions in a nonroad diesel engine - Performance and unignorable emissions

Oversupply, extra energy consumption, and CO₂ emissions from the refinery of biodiesel-derived glycerin (G) led to the consideration of its use as an alternative fuel. In this study, a nonroad diesel engine generator was employed to represent potential emissions under stringent regulated standards. G-diesel has been reported to reduce nitrogen oxides (NOx) and soot levels but increase CO and hydrocarbon emissions. A bio-producible acetone-butanol-ethanol (ABE) solution with multiple polarities was added to stabilize the glycerin and water in diesel examined in this study. A series of ABE-G-diesel blends were prepared to form the thermostable microemulsions. Four blends with small and well-dispersed bubbles were tested in the engine generator. The specific thermal efficiencies of the engine were slightly improved by using ABE-G from regular diesel due to better spray quality, longer ignition delay, and fuel-oxygen content that would enhance combustion. Meanwhile, the PM-NOx-CO emission trade-off in the previous study has been overcome by using ABE-G-diesel since the better fuel atomization and more premixed combustion were approached, as well as the lower and homogeneous in-cylinder temperature caused by water content and micro-explosion. However, the condensable particulate matter and nitro-PAHs were also observed and realized their unignorable contribution, which has not been regulated and even researched for the generators. Fortunately, the new fuels could inhibit both of them to a certain degree. Consequently, this study proposes using recyclable glycerin with a simple pretreatment mixed with ABE and diesel for greener nonroad diesel engine especially those equipped with low-grade aftertreatment.

Abnormal Brain Network Interaction Associated With Positive Symptoms in Drug-Naive Patients With First-Episode Schizophrenia

Positive symptoms are marked features of schizophrenia, and emerging evidence has suggested that abnormalities of the brain network underlying these symptoms may play a crucial role in the pathophysiology of the disease. We constructed two brain functional networks based on the positive and negative correlations between positive symptom scores and brain connectivity in drug-naive patients with first-episode schizophrenia (FES, n = 45) by using a machine-learning approach (connectome-based predictive modeling, CPM). The accuracy of the model was r = 0.47 (p = 0.002). The positively and negatively associated network strengths were then compared among FES subjects, individuals at genetic high risk (GHR, n = 41) for schizophrenia, and healthy controls (HCs, n = 48). The results indicated that the positively associated network contained more cross-subnetwork connections (96.02% of 176 edges), with a focus on the default-mode network (DMN)-salience network (SN) and the DMN-frontoparietal task control (FPT) network. The negatively associated network had fewer cross-subnetwork connections (71.79% of 117 edges) and focused on the sensory/somatomotor hand (SMH)-Cingulo opercular task control (COTC) network, the DMN, and the visual network with significantly decreased connectivity in the COTC-SMH network in FES (FES < GHR, p = 0.01; FES < HC, p = 0.01). Additionally, the connectivity strengths of the right supplementary motor area (SMA) (p < 0.001) and the right precentral gyrus (p < 0.0001) were reduced in FES. To the best of our knowledge, this is the first study to generate two brain networks associated with positive symptoms by utilizing CPM in FES. Abnormal segregation, interactions of brain subnetworks, and impaired SMA might lead to salience attribution abnormalities and, thus, as a result, induce positive symptoms in schizophrenia.

Trends of Contralateral prophylactic mastectomy at the time of ipsilateral breast tumor recurrence

BACKGROUND

Contralateral prophylactic mastectomy rates have substantially increased. The study aimed to examine contralateral prophylactic mastectomy (CPM) at the time of ipsilateral breast tumor recurrence (IBTR) and evaluate factors contributing to CPM decision making process.

METHOD

Patients who developed IBTR after BCS from 2011 to 2019 were reviewed. Patient and tumor characteristics, genetic testing and reconstruction details were analyzed.

RESULTS

Ninety-six patients had IBTR after BCS and were treated with mastectomy, with 30% electing for a CPM. Patients who underwent CPM were younger, had higher BMI and less comorbidities. A genetic mutation was identified in 19% of patients who underwent testing at the time of IBTR. Tumor characteristics and performing surgeon were not predictors for CPM, however, patients were more likely to undergo CPM if they received reconstruction of the ipsilateral breast with IBTR.

CONCLUSION

This study shows that age, BMI, genetic testing and breast reconstruction are factors contributing to CPM decision at the time of IBTR.

Nerivio® remote electrical neuromodulation for acute treatment of chronic migraine

Nerivio^® (by Theranica Bio-Electronics Ltd, Tel Aviv, Israel) is a wireless, wearable, noninvasive, battery-operated, remote electrical neuromodulation device controlled by a smartphone application. It is US FDA authorized for the acute treatment of migraine with or without aura in people 12 years and older in the US, and European Conformity (CE) marked for the same indication in the EU. The American Headache Society Consensus Statement recommends Nerivio as a tier 2 treatment for migraines. This review summarizes a series of five independent clinical trials and two real-world evidence studies that established safety, tolerability and efficacy of Nerivio in treating migraine attacks. It further provides up-to-date practical information on device usability. Based on findings of this review, Nerivio offers a safe and effective nonpharmacological alternative for acute treatment in patients with chronic (and nonchronic) migraine.

Contralateral prophylactic mastectomy in the setting of breast cancer diagnosis and their insurance coverage in the United States

BACKGROUND

Contralateral prophylactic mastectomy (CPM) is more common in the United States than the rest of the world. However, the benefit of this procedure is still under question in many breast cancer scenarios. CPM utilization in the United States is in part dependent on a patient's health insurance coverage of breast oncology surgery and any desired reconstruction. However, there are great discrepancies in the coverage provided by insurers.

METHODS

The authors conducted a cross-sectional analysis of insurance policies for a CPM in the setting of diagnosed breast cancer. One hundred companies were selected based on their state enrollment and market share. Their policies were identified through a Web-based search and telephone interviews, and their medical necessity criteria were extracted.

RESULTS

Of the 100 companies assessed, 36 (36%) had a policy for CPM. Within those, significantly more provided coverage than denied the procedure (72% vs. 25%, p < 0.0001), with the remainder providing case-by-case coverage. Eleven criteria were identified from preauthorized policies, the most common prerequisite was breast cancer diagnosis under 45 years old (n = 9, 35%). Most policies did not differentiate between gender in their policies (n = 25, 69%), but of those that did, 100% (n = 11) provided coverage for men and women, with 82% (n = 9) requiring further criteria from the female patients.

CONCLUSION

The coverage of CPM in the United States varies from complete denial to unrestricted approval. This may be due to conflicting reports in the literature as to the utility of the procedure. The decision to undergo this procedure must be taken with thoughtful consideration and the support of a multidisciplinary approach.

Physiological noise modeling in fMRI based on the pulsatile component of photoplethysmograph

The blood oxygenation level-dependent (BOLD) contrast mechanism allows the noninvasive monitoring of changes in deoxyhemoglobin content. As such, it is commonly used in functional magnetic resonance imaging (fMRI) to study brain activity since levels of deoxyhemoglobin are indirectly related to local neuronal activity through neurovascular coupling mechanisms. However, the BOLD signal is severely affected by physiological processes as well as motion. Due to this, several noise correction techniques have been developed to correct for the associated confounds. The present study focuses on cardiac pulsatility fMRI confounds, aiming to refine model-based techniques that utilize the photoplethysmograph (PPG) signal. Specifically, we propose a new technique based on convolution filtering, termed cardiac pulsatility model (CPM) and compare its performance with the cardiac-related RETROICOR (Card-RETROICOR), which is a technique commonly used to model fMRI fluctuations due to cardiac pulsatility. Further, we investigate whether variations in the amplitude of the PPG pulses (PPG-Amp) covary with variations in amplitude of pulse-related fMRI fluctuations, as well as with the systemic low frequency oscillations (SLFOs) component of the fMRI global signal (GS - defined as the mean signal across all gray matter voxels). Capitalizing on 3T fMRI data from the Human Connectome Project, CPM was found to explain a significantly larger fraction of the fMRI signal variance compared to Card-RETROICOR, particularly for subjects with larger heart rate variability during the scan. The amplitude of the fMRI pulse-related fluctuations did not covary with PPG-Amp; however, PPG-Amp explained significant variance in the GS that was not attributed to variations in heart rate or breathing patterns. Our results suggest that the proposed approach can model high-frequency fluctuations due to pulsation as well as low-frequency physiological fluctuations more accurately compared to model-based techniques commonly employed in fMRI studies.

The Utility of Continuous Passive Motion After Anterior Cruciate Ligament Reconstruction: A Systematic Review of Comparative Studies

Background

The application of continuous passive motion (CPM) after anterior cruciate ligament reconstruction (ACLR) was popularized in the 1990s, but advancements in the understanding of ACLR rehabilitation have made the application of CPM controversial. Many sports medicine fellowship-trained surgeons report using CPM machines postoperatively.

Purpose

To determine the efficacy of CPM use for recovery after ACLR with respect to knee range of motion (ROM), knee swelling, postoperative pain, and postoperative complications.

Study Design

Systematic review; Level of evidence, 3.

Methods

The PubMed (MEDLINE), EMBASE, Cochrane, Cumulative Index of Nursing, and Allied Health Literature databases were searched from inception to January 1, 2020, for studies with evidence levels 1 to 3 on the use of CPM for ACLR rehabilitation. Included studies were those that comparatively evaluated postoperative outcomes after ACLR between at least 2 groups of patients, with 1 having received CPM rehabilitation and the other not having received CPM.

Results

A total of 12 studies from 1989 to 2019 met the inclusion criteria. These studies included 808 patients who underwent ACLR. There was no evidence of CPM improving knee stability, final postoperative ROM, or subjective pain scores. Additionally, CPM did not lead to decreased muscle atrophy or improved International Knee Documentation Committee scores. Regarding pain medication intake during postoperative hospitalization, 2 studies found that the CPM group used less pain medication, 1 study found the CPM group used more pain medication, and 1 study found that there was no difference between the 2 groups. Complications varied widely, with 2 of 12 studies reporting complications that required a return to the operating room.

Conclusion

A clinical benefit of postoperative CPM use after ACLR was not identified in this review. While our systematic review identified a number of studies that suggest CPM use may be associated with lower usage of pain medication in hospitalized patients, this cannot be confirmed without further investigation with standardized CPM protocols and larger sample sizes. Routine CPM use after ACLR was not supported by this systematic review.

Conditioned Pain Modulation (CPM) Effects Captured in Facial Expressions

Purpose

Conditioned pain modulation (CPM) is most often assessed using self-report of pain. However, self-report of pain is not always available (eg in individuals with cognitive impairment) and is susceptible to report bias. In comparison, the facial expression of pain is more reflex-like and represents one of the most sensitive and specific non-verbal signals of pain. The aim of the present study was to investigate whether the facial expression of pain is sensitive enough to capture endogenous pain inhibition as elicited during CPM paradigms.

Patients and Methods

In total, 26 female participants took part in this study. Facial and verbal responses to phasic heat pain were assessed once while participants immersed their hand in a hot water bath and once without additional stimulation. Facial responses were analyzed using the Facial Action Coding System (FACS). Verbal responses were assessed using a Numerical Rating Scale (NRS).

Results

Pain-relevant facial responses as well as pain ratings to phasic heat pain were significantly reduced when participants simultaneously immersed their hand in a hot water bath compared to baseline. Thus, CPM effects could be demonstrated both on subjective as well as on facial responses. Moreover, CPM-induced changes in pain-relevant facial responses and in NRS ratings were significantly correlated.

Conclusion

The present study shows that facial expressions of pain are sensitive enough to capture CPM effects. Given the proven clinical usefulness of assessing CPM, the parallel assessment of verbal and facial CPM effects might be a promising approach with wider scope of applications. Further research in other demographic healthy participant and clinical cohorts is warranted.

Differences in Psychosocial Factors and Experimental Pain Sensitivity between Hispanics and non-Hispanic Whites from the U.S.-Mexico Border

PURPOSE

Research suggests that ethnicity is a predictor of pain-related outcomes; however, studies comparing the differences in experimental pain sensitivity between Hispanics and non-Hispanic Whites (NHW) are scarce. This study investigated these differences between Hispanics and NHW from the U.S- Mexico border.

METHODS

Fifty-eight healthy subjects completed the survey packet, which included a demographic and a psychosocial factors questionnaire. Participants underwent quantitative sensory testing which included heat pain threshold, heat pain tolerance, Suprathreshold Heat Pain Response (SHPR), and Conditioned Pain Modulation (CPM). SHPR was induced by repeated thermal stimuli in both thenar eminences. CPM was assessed using SHPR as the experimental stimulus, and cold pressor task as the conditioning stimulus.

RESULTS

Analyses showed significant differences in experimental pain measures believed to be representative of facilitatory pain processing including SHPR, and heat pain threshold, where Hispanics reported significantly higher pain ratings than NHW. Hispanics also reported higher levels of ethnic identity and acculturation. However, these factors were not significantly associated with experimental pain sensitivity.

CONCLUSION

The experimental pain sensitivity and psychosocial factors included in this study differed by ethnic group, where Hispanics reported significantly higher pain ratings, when compared to NHW. However, ethnic identity and acculturation were not associated with these pain-related outcomes. Overall, enhanced understanding by clinicians of pain sensitivity and disparities in the pain experience between ethnic groups allows for increased cultural sensitivity and can be used to optimize pain treatment on an individual-by-individual basis.

Inhibitory efficiency of potential drugs against SARS-CoV-2 by blocking human angiotensin converting enzyme-2: Virtual screening and molecular dynamics study

Till date millions of people are infected by SARS-CoV-2 throughout the world, while no potential therapeutics or vaccines are available to combat this deadly virus. Blocking of human angiotensin-converting enzyme 2 (ACE-2) receptor, the binding site of SARS-CoV-2 spike protein, an effective strategy to discover a drug for COVID-19. Herein we have selected 24 anti-bacterial and anti-viral drugs and made a comprehensive analysis by screened them virtually against ACE-2 receptor to find the best blocker by molecular docking and molecular dynamics studies. Analysis of results revealed that, Cefpiramide (CPM) showed the highest binding affinity of −9.1 kcal/mol. Furthermore, MD study for 10 ns and evaluation of parameters like RMSD, RMSF, radius of gyration, solvent accessible surface area analysis confirmed that CPM effectively binds and blocks ACE-2 receptor efficiently.

Retrospective details of false-positive and false-negative results in non-invasive prenatal testing for fetal trisomies 21, 18 and 13

OBJECTIVE

Maternal characteristics and neonatal outcomes associated with cell-free DNA (cfDNA) results were analysed retrospectively to assess the details of false-positive and false-negative results after initial blood sampling in non-invasive prenatal testing (NIPT).

STUDY DESIGN

A multicentre retrospective study was performed for women undergoing NIPT who received discordant cfDNA results between April 2013 and March 2018. The NIPT data obtained using massive parallel sequencing were studied in terms of maternal background, fetal fraction, z-scores, invasive procedure results and neonatal outcomes after birth.

RESULTS

Of the 56,545 women who participated in this study, 54 false-positive (0.095 %) and three false-negative (0.006 %) cases were found. Seven of the 54 false-positive cases (13.0 %) had vanishing twin on ultrasonography. Among the 18 false-positive cases of trisomy 18, confined placental mosaicism (CPM) was confirmed in three cases (16.7 %), while CPM was present in one of the three false-negative cases of trisomy 21.

CONCLUSION

These data suggest that the incidence of women with false-positive or false-negative results is relatively low, that such false results can often be explained, and that vanishing twin and CPM are potential causes of NIPT failure. Genetic counselling with regard to false results is important for clients prior to undergoing NIPT.

Electrophysiological investigation of the contribution of attention to altered pain inhibition processes in patients with irritable bowel syndrome

Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder associated with chronic abdominal pain and altered pain processing. The aim of this study was to examine whether attentional processes contribute to altered pain inhibition processes in patients with IBS. Nine female patients with IBS and nine age-/sex-matched controls were included in a pain inhibition paradigm using counter-stimulation and distraction with electroencephalography. Patients with IBS showed no inhibition of pain-related brain activity by heterotopic noxious counter-stimulation (HNCS) or selective attention. In the control group, HNCS and selective attention decreased the N100, P260 and high-gamma oscillation power. In addition, pain-related high-gamma power in sensorimotor, anterior cingulate and left dorsolateral prefrontal cortex was decreased by HNCS and selective attention in the control group, but not in patients with IBS. These results indicate that the central pain inhibition deficit in IBS reflects interactions between several brain processes related to pain and attention.

Second primary breast cancer after unilateral mastectomy alone or with contralateral prophylactic mastectomy

Background

An increasing number of patients undergo contralateral prophylactic mastectomy (CPM) for unilateral breast cancer. However, the benefit of CPM has not been quantified in the setting of contemporary breast cancer therapy.

Methods

We performed an analysis of 180 068 patients in the Surveillance, Epidemiology, and End Results (SEER) database, diagnosed with unilateral ductal breast carcinoma between 1998 and 2013 and treated with unilateral mastectomy (UM) or CPM. UM was performed in 146 213 patients (81.2%); CPM was performed in 33 855 patients (19.8%). Primary outcome of interest was cumulative incidence of a second primary breast cancer in the ipsilateral or contralateral breast greater than 3 months after initial diagnosis. Cumulative incidence analysis was based on a Cox proportional model to generate curves of second primary breast cancer in any breast, ipsilateral breast only, or contralateral breast only.

Results

Patients who underwent CPM had a significantly reduced incidence of second primary breast cancer 10 and 15 years after surgery (CPM 0.93% [0.73%, 1.12%] vs UM 4.44% [4.28%, 4.60%]). Patients who underwent CPM had significantly lower adjusted hazard of second primary breast cancer when compared with UM (HR 0.38 vs 1.0, P < .0001).

Conclusions

CPM offers some protection from a second primary breast cancer, attributable to a reduced incidence in the contralateral breast. These findings provide additional information to providers and patients as they make decisions regarding surgical management. They should also be interpreted in the context of the absolute incidence of second primary breast cancer after UM and previous literature demonstrating no survival benefit.

Identification of genetic effects and potential causal polymorphisms of CPM gene impacting milk fatty acid traits in Chinese Holstein

Our previous GWAS revealed 83 significant SNPs and 20 promising candidate genes associated with milk fatty acid traits in dairy cattle. Out of them, the carboxypeptidase M (CPM) gene contains a genome-wide significant SNP, Hapmap49848-BTA-106779, which is strongly associated with myristic acid (C14:0; P = 0.0064). Herein, we aimed to confirm the genetic effects of CPM on milk fatty acids in Chinese Holstein. Seven SNPs were detected by re-sequencing the sequences of entire exons and 3000 bp of up-/downstream flanking regions of the CPM gene, of which three were in 5' flanking region, one in the 3' UTR and three were in the 3' flanking region. Using the Haploview 4.1, we estimated the LD among the identified SNPs and found two haplotype blocks. With the animal model, we performed the SNP- and haplotype-based association analyses, and observed that these SNPs and haplotype blocks mainly had strong genetic associations with medium-chain saturated fatty acids (caproic acid, C6:0; caprylic acid, C8:0; capric acid, C10:0; and lauric acid, C12:0) (P < 0.0001-0.0257). In addition, using the Genomatix software, we predicted that three SNPs in the 5' flanking region of CPM (g.45079507A>G, g.45080228C>A and g.45080335C>G) changed the transcription factor binding sites for PREF (progesterone receptor biding site), ZBRK1 (transcription factor with eight central zinc fingers and an N-terminal KRAB domain), SOX9 (sex-determining region Y-box 9, dimeric binding sites), SOX6 (sex-determining region Y-box 6) and FOXP1-ES (alternative splicing variant of FOXP1, activated in ESCs). Further, the dual-luciferase reporter assay showed these three SNPs altered the transcriptional activity of CPM gene (P ≤ 0.0006). In summary, using the post-GWAS strategy, we first confirmed the significant genetic effects of CPM with milk fatty acids in dairy cattle, and identified three potential causal mutations.

Pain Modulation Mechanisms in ASD Adults

We tested endogenous pain modulation mechanisms in adults with autism spectrum disorders (ASD). Nineteen ASD adults without intellectual disabilities were included, matched with 19 healthy volunteers on the basis of sex and chronological age. An experimental pain model was used to measure excitatory and inhibitory pain mechanisms in a single session. Statistical analyses indicated that endogenous pain modulation mechanisms in ASD group did not differ significantly from those of healthy adults. The pain scores were very disparate in ASD group with a greater range of extreme scores than in control group. Unlike schizophrenic patients, there was no systematic dysfunction of endogenous excitatory pain modulation mechanisms, but the high variability requires to be wise to interpret the results and formulate conclusion.

Cardiopharyngeal mesoderm origins of musculoskeletal and connective tissues in the mammalian pharynx

Cardiopharyngeal mesoderm (CPM) gives rise to muscles of the head and heart. Using genetic lineage analysis in mice, we show that CPM develops into a broad range of pharyngeal structures and cell types encompassing musculoskeletal and connective tissues. We demonstrate that CPM contributes to medial pharyngeal skeletal and connective tissues associated with both branchiomeric and somite-derived neck muscles. CPM and neural crest cells (NCC) make complementary mediolateral contributions to pharyngeal structures, in a distribution established in the early embryo. We further show that biallelic expression of the CPM regulatory gene Tbx1, haploinsufficient in 22q11.2 deletion syndrome patients, is required for the correct patterning of muscles with CPM-derived connective tissue. Our results suggest that CPM plays a patterning role during muscle development, similar to that of NCC during craniofacial myogenesis. The broad lineage contributions of CPM to pharyngeal structures provide new insights into congenital disorders and evolution of the mammalian pharynx.

Conditioned pain modulation in drug-naïve patients with de novo Parkinson's disease

Background

Pain is highly prevalent in patients with Parkinson’s disease (PD), but underlying pathophysiological mechanisms are largely unclear. In many chronic pain syndromes deficits in endogenous pain inhibition have been detected that can be assessed using conditioned pain modulation paradigms. Previous studies employing this approach in medicated PD patients did not find abnormal pain inhibition. However, these results might have been confounded by residual dopaminergic medication.

Methods

An established conditioned pain modulation paradigm was used in 17 drug-naïve de novo PD patients and 17 healthy age and gender-matched controls. We tested i) whether conditioned pain modulation responses differed between the patient and control group and ii) whether pain inhibition differed between PD subtypes.

Results

PD patients and healthy controls did not differ in their conditioned pain modulation responses. Furthermore, there were no significant differences in CPM responses depending on the PD subtype. However, at a descriptive level, tremor-dominant patients showed a tendency for better descending pain inhibition compared to akinetic-rigid and mixed type patients.

Conclusions

In this first study investigating conditioned pain modulation in de novo PD patients, we found no additional impairment in descending pain modulation besides the known age-related decline. Our findings indicate that mechanisms other than an impaired descending inhibition contribute to high pain prevalence rates in PD and suggest that mechanisms underlying pain may differ between PD subtypes.

Electronic supplementary material

The online version of this article (10.1186/s42466-019-0029-x) contains supplementary material, which is available to authorized users.

Differential Neuroplastic Changes in Fibromyalgia and Depression Indexed by Up-Regulation of Motor Cortex Inhibition and Disinhibition of the Descending Pain System: An Exploratory Study

Background: Major depressive disorder (MDD) and fibromyalgia (FM) present overlapped symptoms. Although the connection between these two disorders has not been elucidated yet, the disruption of neuroplastic processes that mediate the equilibrium in the inhibitory systems stands out as a possible mechanism. Thus, the purpose of this cross-sectional exploratory study was: (i) to compare the motor cortex inhibition indexed by transcranial magnetic stimulation (TMS) measures [short intracortical inhibition (SICI) and intracortical facilitation (ICF)], as well as the function of descending pain modulatory systems (DPMS) among FM, MDD, and healthy subjects (HS); (ii) to compare SICI, ICF, and the role of DPMS evaluated by the change on Numerical Pain Scale (NPS) during the conditioned pain modulation test (CPM-test) between FM and MDD considering the BDNF-adjusted index; (iii) to assess the relationship between the role of DPMS and the BDNF-adjusted index, despite clinical diagnosis. Patients and Methods: A cohort of 63 women, aged 18 to 75 years [FM (n = 18), MDD (n = 19), and HC (n = 29)]. Results: The MANCOVA analysis revealed that the mean of SICI was 53.40% larger in FM compared to MDD [1.03 (0.50) vs. 0.55 (0.43)] and 66.99% larger compared to HC [1.03 (0.50) vs. 0.34 (0.19)], respectively. The inhibitory potency of the DPMS assessed by the change on the NPS during CPM-test was 112.29 % lower in the FM compared to MDD [0.22 (1.37) vs. -0.87 (1.49)]. The mean of BDNF from FM compared to MDD was 35.70% higher [49.82 (16.31) vs. 14.12 (8.86)]. In FM, the Spearman's coefficient between the change in the NPS during CPM-test with the SICI was Rho = -0.49, [confidence interval (CI) 95%; -0.78 to -0.03]. The BDNF-adjusted index was positively correlated with the disinhibition of the DPMS. Conclusion: These findings support the hypothesis that in FM a deteriorated function of cortical inhibition, indexed by a higher SICI parameter, a lower function of the DPMS, together with a higher level of BDNF indicate that FM has different pathological substrates from depression. They suggest that an up-regulation phenomenon of intracortical inhibitory networks associated with a disruption of the DPMS function occurs in FM.

Intramuscular electrical stimulus potentiates motor cortex modulation effects on pain and descending inhibitory systems in knee osteoarthritis: a randomized, factorial, sham-controlled study

Background

Neuroplastic changes in nociceptive pathways contribute to severity of symptoms in knee osteoarthritis (KOA). A new look at neuroplastic changes management includes modulation of the primary motor cortex by transcranial direct current stimulation (tDCS).

Objectives

We investigated whether tDCS combined with intramuscular electrical stimulation (EIMS) would be more efficacious than a sham (s) intervention (s-tDCS/s-EIMS) or a single active(a)-tDCS/s-EIMS intervention and/or s-tDCS/a-EIMS in the following domains: pain measures (visual analog scale [VAS] score and descending pain modulatory system [DPMS], and outcomes, and analgesic use, disability, and pain pressure threshold (PPT) for secondary outcomes.

Registration

The trial is registered in Clinicaltrials.gov: NCT01747070.

Methods

Sixty women with KOA, aged 50–75 years old, randomly received five sessions of one of the four interventions (a-tDCS/a-EIMS, s-tDCS/s-EIMS, a-tDCS/s-EIMS, and s-tDCS/a-EIMS). tDCS was applied over the primary motor cortex (M1), for 30 minutes at 2 mA and the EIMS paraspinal of L1–S2.

Results

A generalized estimating equation model revealed the main effect of the a-tDCS/a-EIMS in the VAS pain scores at end treatment compared with the other three groups (P<0.0001). There existed a significant effect of time and a significant interaction between group and time (P<0.01 for both). The delta-(Δ) pain score on VAS in the a-tDCS/a-EIMS group was −3.59, 95% CI: −4.10 to −2.63. The (Δ) pain scores on VAS in the other three groups were: a-tDCS/s-EIMS=−2.13, 95% CI: −2.48 to −1.64; s-tDCS/a-EIMS=−2.25, 95% CI: −2.59 to −1.68; s-tDCS/s-EIMS MR =–1.77, 95% CI: −2.08 to −1.38. The a-tDCS/a-EIMS led to better effect in DPMS, PPT, analgesic use, and disability related to pain.

Conclusion

This study provides additional evidence regarding additive clinical effects to improve pain measures and descending pain inhibitory controls when the neuromodulation of the primary motor cortex with tDCS is combined with a bottom-up modulation with EIMS in KOA. Also, it improved the ability to walk due to reduced pain and reduced analgesic use.

Reframing the conversation about contralateral prophylactic mastectomy: Preparing women for postsurgical realities

OBJECTIVE

Women with unilateral, early-stage breast cancer and low genetic risk are increasingly opting for contralateral prophylactic mastectomy (CPM), a concerning trend because CPM offers few clinical benefits while increasing risks of surgical complications. Few qualitative studies have analyzed factors motivating this irreversible decision. Using qualitative methods, this study sought to understand women's decision making and the impact of CPM on self-confidence, sense of femininity, sexual intimacy, and peace of mind.

METHODS

Women who had CPM within the last 10 years were recruited to participate in the study. We conducted a thematic analysis of the data.

RESULTS

Forty-five women were interviewed. When making the decision for CPM, most had incomplete knowledge of potential negative outcomes. However, all believed CPM had more benefits than harms and would confer the most peace of mind and the fewest regrets should cancer return. They knew their contralateral breast cancer risk was low but were not persuaded by statistics. They wanted to do everything possible to reduce their risk of another breast cancer, even by a minimal amount, but most reported paying an unexpectedly high price for this small reduction in risk. Nevertheless, 41 of 45 reported that they would make the same decision again.

CONCLUSIONS

These findings highlight an opportunity for physicians to reframe the conversation to focus on the patient experience of the tradeoffs of CPM rather than statistical odds of future cancers. Our findings suggest that more data may not dissuade women from CPM but may better prepare them for its outcomes.

Real-world Experience with Volume Augmentation using Cohesive Polydensified Matrix Hyaluronic Acid Gel: A Retrospective Single-center Analysis of 110 Consecutive Patients with Medium- to Long-term Follow-up

Objective: Hyaluronic acid (HA) volumizer injection into subcutaneous and deep tissue layers is increasingly used for nonsurgical volume loss correction. Information on optimal techniques, safety, and medium- to long-term satisfaction is limited. This study evaluated cohesive polydensified matrix^® HA volumizer CPM-26 (Modélis^® Shape or Belotero^® Volume) across different indications. Design: This study was a retrospective chart review and included a patient questionnaire given at six months posttreatment and during long-term assessment (mean: 3.2 years). Setting: This study was conducted in a Belgian single-site plastic surgery practice. Participants: Consecutive patients (n=110, aged 19-74 years, 81% female) receiving single/ multiple injections with CPM-26 between 2010 and 2016 were included. Measurements: Procedural details and safety outcomes, patient estimates of satisfaction and adverse events, and Global Aesthetic Improvement Scale (GAIS) score were considered. Results: Participants received 601 injections over 189 sessions. The most common sites for volumizing injection were the lateral midface, deep prejowl sulcus, and anterior midface. In six participants, the injection site was the penis (8, 1.3%). Questionnaire data were provided by 81 patients. At six months, 94.9 percent (74/78) were satisfied with outcomes, while, at long-term assessment (mean: 3.2 years), 74.9 percent (54/73) were satisfied. Conclusion: Deep CPM-26 injection improved appearance and was reported as beneficial by two-thirds of patients at long-term assessment. Local adverse events were minor, transient, and infrequently required treatment.

Milnacipran poorly modulates pain in patients suffering from fibromyalgia: a randomized double-blind controlled study

Introduction

Fibromyalgia is characterized by widespread and chronic pain, and its prevalence is increasing worldwide. Milnacipran, an antidepressant, is often prescribed for fibromyalgia with a possible beneficial effect on central pain modulation. The aim of this study was to evaluate if milnacipran could modify the status of conditioned pain modulation (CPM) in patients suffering from fibromyalgia.

Design and setting

Randomized, double-blind controlled trial.

Subjects and methods

Women with fibromyalgia received milnacipran 100 mg or placebo. The primary end point was the evolution of CPM with treatments after a 30-second painful stimulus. Secondary outcomes included the predictability of milnacipran efficacy from CPM performance, evolution of global pain, mechanical sensitivity, thermal pain threshold, mechanical allodynia, cognitive function, and tolerance.

Results

Fifty-four women with fibromyalgia (46.7±10.6 years) were included and randomized, and 24 patients were analyzed in each group. At inclusion, CPM was dysfunctional (CPM₃₀=-0.5±1.9), and global pain was 6.5±1.8. After treatment, there was a nonsignificant CPM difference between milnacipran and placebo (CPM₃₀=-0.46±1.22 vs -0.69±1.43, respectively, p=0.55) and 18.8% vs 6.3% (p=0.085) patients did reactivate CPM after milnacipran vs placebo. Initial CPM was not a predictor of milnacipran efficacy. Global pain, mechanical and thermal thresholds, allodynia, cognition, and tolerance were not significantly different between both groups.

Conclusion

Milnacipran did not display a significant analgesic effect after 1-month treatment, but the tendency of milnacipran to reactivate CPM in a number of patients must be explored with longer treatment duration in future studies and pleads for possible subtypes of fibromyalgia patients.

Development and pilot testing of a Decision Aid (DA) for women with early-stage breast cancer considering contralateral prophylactic mastectomy

OBJECTIVE

Describe the development, acceptability and feasibility of a Decision Aid (DA) for women with early-stage breast cancer (BC) at average contralateral breast cancer (CBC) risk considering contralateral prophylactic mastectomy (CPM).

METHODS

The DA was developed using the International Patient Decision Aid Standards (IPDAS) and the Ottawa Decision Support Framework. It provides evidence-based information about CPM in a booklet format combining text, graphs and images of surgical options. Twenty-three women with a history of early-stage breast cancer were interviewed in person or over the phone using a 'think aloud approach'. Framework analysis was used to code and analyse data.

RESULTS

Twenty-three women participated in the study. Mean age of participants was 58.6 years and time since diagnosis ranged from 14 months to 21 years. Five women had CPM and eighteen had not. Women strongly endorsed the DA. Many felt validated by a section on appearance and found information on average risk of recurrence and metastases helpful, however, noted the importance of discussing personal risk with their surgeon. Many requested more information on surgery details (time taken, recovery) and costs of the different options.

CONCLUSION

The DA was acceptable to women, including the format, content and proposed implementation strategies. Practical and financial issues are important to women in considering treatment options.

PRACTICE IMPLICATIONS

Women appreciate information about CPM at diagnosis and emphasised the importance of discussing potential downsides of the procedure in addition to benefits. The DA was considered acceptable to facilitate such discussions.

Contralateral prophylactic mastectomy rate and predictive factors among patients with breast cancer who underwent multigene panel testing for hereditary cancer

Although multigene panel testing is increasingly common in patients with cancer, the relationship between its use among breast cancer patients with non-BRCA mutations or variants of uncertain significance (VUS) and disease management decisions has not been well described. This study evaluated the rate and predictive factors of CPM patients who underwent multigene panel testing. Three hundred and fourteen patients with breast cancer who underwent multigene panel testing between 2014 and 2017 were included in the analysis. Of the 314 patients, 70 elected CPM. Election of CPM by gene status was as follows: BRCA carriers (42.3%), non-BRCA carriers (30.1%), and VUS (10.6%). CPM election rates did not differ between non-BRCA carriers and BRCA carriers (P = 0.6205). Among non-BRCA carriers, negative hormone receptor status was associated with CPM (P = 0.0115). For those with a VUS, hormone receptor status was not associated with CPM (P = 0.1879). Although the rate of CPM between BRCA carriers and non-BRCA carriers was not significantly different, the predictors of CPM were different in each group. Our analyses shed the light on the increasing use of CPM among patients who are non-BRCA carriers as well those with a VUS. Our study elucidates the differing predictive factors of CPM election among BRCA carriers, non-BRCA carries, and those with a VUS. Our findings reveal the need for providers to be cognizant that non-BRCA genes and VUS drive women to elect CPM despite the lack of data for contralateral breast cancer risk associated with these genes.

Effects of Transcranial Direct Current Stimulation Block Remifentanil-Induced Hyperalgesia: A Randomized, Double-Blind Clinical Trial

Background: Remifentanil-induced hyperalgesia (r-IH) involves an imbalance in the inhibitory and excitatory systems. As the transcranial Direct Current Stimulation (tDCS) modulates the thalamocortical synapses in a top-down manner, we hypothesized that the active (a)-t-DCS would be more effective than sham(s)-tDCS to prevent r-IH. We used an experimental paradigm to induce temporal summation of pain utilizing a repetitive cold test (rCOLDT) assessed by the Numerical Pain Score (NPS 0-10) and we evaluated the function of the descending pain modulatory system (DPMS) by the change on the NPS (0–10) during the conditioned pain modulation (CPM)-task (primary outcomes). We tested whether a-tDCS would be more effective than s-tDCS to improve pain perception assessed by the heat pain threshold (HPT) and the reaction time during the ice-water pain test (IPT) (secondary outcomes).

Methods: This double-blinded, factorial randomized trial included 48 healthy males, ages ranging 19–40 years. They were randomized into four equal groups: a-tDCS/saline, s-tDCS/saline, a-tDCS/remifentanil and s-tDCS/remifentanil. tDCS was applied over the primary motor cortex, during 20 min at 2 mA, which was introduced 10 min after starting remifentanil infusion at 0.06 μg⋅kg^-1⋅min^-1 or saline.

Results: An ANCOVA mixed model revealed that during the rCOLDT, there was a significant main effect on the NPS scores (F = 3.81; P = 0.01). The s-tDCS/remifentanil group presented larger pain scores during rCOLDT, [mean (SD) 5.49 (1.04)] and a-tDCS/remifentanil group had relative lower pain scores [4.15 (1.62)]; showing its blocking effect on r-IH. a-tDCS/saline and s-tDCS/saline groups showed lowest pain scores during rCOLDT, [3.11 (1.2)] and [3.15 (1.62)], respectively. The effect of sedation induced by remifentanil during the rCOLDT was not significant (F = 0.76; P = 0.38). Remifentanil groups showed positive scores in the NPS (0–10) during the CPM-task, that is, it produced a disengagement of the DPMS. Also, s-tDCS/Remifentanil compared to a-tDCS showed lower HPT and larger reaction-time during the IPT.

Conclusion: These findings suggest that effects of a-tDCS prevent the summation response induced by r-IH during rCOLDT and the a-tDCS blocked the disengagement of DPMS. Thereby, tDCS could be considered as a new approach to contra-regulate paradoxical mechanisms involved in the r-IH. Clinical trials identification: NCT02432677. URL:https://clinicaltrials.gov/.

Using communication privacy management theory to examine HIV disclosure to sexual partners/spouses among PLHIV in Guangxi

The current study employed Communication Privacy Management (CPM) theory to examine the factors associated with disclosure of HIV infection to sexual partners or spouses as well as gender differences in these associations among a sample of people living with HIV (PLHIV) in China. A total of 1254 PLHIV who had 5–16 years old children were invited to answer the questions related to disclosure of HIV infection to sexual partners/spouses. Prevalence of HIV disclosure was reported. Key variables related to CPM theory (such as motivations for disclosure and nondisclosure, HIV-related stigma, and relational factors) were compared between females and males. Logistic regression was employed to determine the factors of influencing whether or not the participants disclosed their HIV status to spouses/partners for the male, the female and the combined samples. Fear of rejection was a significant predictor of HIV nondisclosure for the male, the female and the combined samples. Concern about privacy was a significant factor in not disclosing to sexual partners/spouses only in the male sample. The endorsement of duty to inform/educate was the only motivation factor that was significantly related to HIV disclosure for the three samples. The motivation to establish a close/supportive relationship with intimate partners/spouses was found to be associated with HIV disclosure for the combined and male samples. The current study confirmed the utilities of CPM in studying HIV disclosure to sexual partners/spouse. The findings have theoretical and practical implications for HIV disclosure interventions among PLHIV in Guangxi.

Does self-perception of sensitivity to pain correlate with actual sensitivity to experimental pain?

Background

People often state that they are “sensitive” or “insensitive” to pain. However, the accuracy and clinical relevance of such statements is unclear.

Objective

The aim of this study was to search for associations between self-perception of sensitivity to pain and experimental pain measures, including known psychophysical inhibitory or excitatory pain paradigms.

Subjects and methods

Subjective sensitivity to pain was reported by 75 healthy participants and included three self-perceived variables: pain threshold, pain sensitivity and pain intensity in response to a hypothetical painful event (hypothetical pain intensity [HPI]). Experimental pain measures consisted of thermal pain threshold (°C), suprathreshold thermal pain intensity (Visual Analog Scale, 0–100) and the psychophysical paradigms of conditioned pain modulation (CPM) and temporal summation (TS), representing inhibitory and excitatory pain processes, respectively.

Results

No significant correlations were found between self-perceived pain threshold or pain sensitivity and any of the experimental pain measures. In contrast, the reported HPI correlated with thermal pain threshold (r = −0.282; p = 0.014), suprathreshold thermal pain intensity (r = 0.367; p = 0.001) and CPM (r = 0.233; p = 0.044), but not with TS.

Conclusion

Self-perception of pain sensitivity articulated by intangible expressions such as pain threshold or pain sensitivity is unrelated to actual sensitivity to experimental pain. In contrast, when measured by intensity of a hypothetical painful event (HPI), sensitivity to pain is associated with some, but not all, experimental pain reports. Further studies are needed for better understanding of these associations and their potential clinical significance.

Evoked potentials after painful cutaneous electrical stimulation depict pain relief during a conditioned pain modulation

BACKGROUND

Conditioned pain modulation (CPM) evaluates the pain modulating effect of a noxious conditioning stimulus (CS) on another noxious test stimulus (TS), mostly based solely on subjective pain ratings. We used painful cutaneous electrical stimulation (PCES) to induce TS in a novel CPM-model. Additionally, to evaluate a more objective parameter, we recorded the corresponding changes of cortical evoked potentials (PCES-EP).

METHODS

We examined the CPM-effect in 17 healthy subjects in a randomized controlled cross-over design during immersion of the non-dominant hand into 10 °C or 24 °C cold water (CS). Using three custom-built concentric surface electrodes, electrical stimuli were applied on the dominant hand, inducing pain of 40-60 on NRS 0-100 (TS). At baseline, during and after CS we assessed the electrically induced pain intensity and electrically evoked potentials recorded over the central electrode (Cz).

RESULTS

Only in the 10 °C-condition, both pain (52.6 ± 4.4 (baseline) vs. 30.3 ± 12.5 (during CS)) and amplitudes of PCES-EP (42.1 ± 13.4 μV (baseline) vs. 28.7 ± 10.5 μV (during CS)) attenuated during CS and recovered there after (all p < 0.001). In the 10 °C-condition changes of subjective pain ratings during electrical stimulation and amplitudes of PCES-EP correlated significantly with each other (r = 0.5) and with CS pain intensity (r = 0.5).

CONCLUSIONS

PCES-EPs are a quantitative measure of pain relief, as changes in the electrophysiological response are paralleled by a consistent decrease in subjective pain ratings. This novel CPM paradigm is a feasible method, which could help to evaluate the function of the endogenous pain modulation processes.

TRIAL REGISTRATION

German Clinical Trials Register DRKS-ID: DRKS00012779 , retrospectively registered on 24 July 2017.

Manual acupuncture plus usual care versus usual care alone in the treatment of endometriosis-related chronic pelvic pain: study protocol for a randomised controlled feasibility study

Background

Endometriosis is the most common cause of chronic pelvic pain worldwide. Non-surgical treatments are effective for only 30–50% of women and have a significant side effect burden that leads to high discontinuation rates. Surgery can be effective but is expensive and invasive, and symptoms tend to recur within 5 years. There is early evidence that acupuncture may be effective in treating endometriosis-related chronic pelvic pain, showing clinically significant analgesia. Both levels of inflammation and pain processing have been shown to be altered in women with chronic pelvic pain. Acupuncture has been shown to reduce inflammation and change central pain processing in other conditions, but research on women with endometriosis is currently lacking. The aim of this feasibility study is to provide data on recruitment rates, retention, appropriateness of outcome measures, minimal clinically important difference in numeric rated scales for pain and the potential effect of acupuncture on pain processing and markers of inflammation in endometriosis-related CPP.

Methods

We will include women aged 18–45 years with a diagnosis of endometriosis via laparoscopy in the past 5 years. A total of 30 participants will be recruited and randomly allocated in a 1:1 ratio to receive acupuncture or usual care. Women in the acupuncture group will receive two 45-min treatment sessions per week for 8 weeks (total of 16 sessions). Women in the usual care group will continue with their current treatment regimen. The primary feasibility outcomes are recruitment rates, retention rates and the safety and acceptability of the intervention; secondary patient-centred outcomes include a change in 0–10 daily pelvic pain ratings, the Endometriosis Health Profile 30 (EHP-30) and changes in conditioned pain modulation, resting and task-related EEG activity and inflammatory markers. Analyses will be performed blind to group allocation.

Discussion

This is a two-armed, assessor blind, randomised controlled feasibility trial. Data will be compared at baseline and trial completion 8 weeks later. Outcomes from this feasibility study will inform a larger, fully powered clinical trial should the treatment show trends for potential effectiveness.

Trial registration

Australian New Zealand Clinical Trials Registry, ACTRN12617000053325 (http://www.ANZCTR.org.au/ACTRN12617000053325.aspx).

Electronic supplementary material

The online version of this article (doi:10.1186/s40814-017-0152-9) contains supplementary material, which is available to authorized users.

The plasticity of descending controls in pain: translational probing

Descending controls, comprising pathways that originate in midbrain and brainstem regions and project onto the spinal cord, have long been recognised as key links in the multiple neural networks that interact to produce the overall pain experience. There is clear evidence from preclinical and clinical studies that both peripheral and central sensitisation play important roles in determining the level of pain perceived. Much emphasis has been put on spinal cord mechanisms in central excitability, but it is now becoming clear that spinal hyperexcitability can be regulated by descending pathways from the brain that originate from predominantly noradrenergic and serotonergic systems. One pain can inhibit another. In this respect diffuse noxious inhibitory controls (DNIC) are a unique form of endogenous descending inhibitory pathway since they can be easily evoked and quantified in animals and man. The spinal pharmacology of pathways that subserve DNIC are complicated; in the normal situation these descending controls produce a final inhibitory effect through the actions of noradrenaline at spinal α₂ -adrenoceptors, although serotonin, acting on facilitatory spinal 5-HT₃ receptors, influences the final expression of DNIC also. These descending pathways are altered in neuropathy and the effects of excess serotonin may now become inhibitory through activation of spinal 5-HT₇ receptors. Conditioned pain modulation (CPM) is the human counterpart of DNIC and requires a descending control also. Back and forward translational studies between DNIC and CPM, gauged between bench and bedside, are key for the development of analgesic therapies that exploit descending noradrenergic and serotonergic control pathways.

Examining the relationship between endogenous pain modulation capacity and endurance exercise performance

The aim of the current study was to examine the relationship between pain modulatory capacity and endurance exercise performance. Twenty-seven recreationally active males between 18 and 35 years of age participated in the study. Pain modulation was assessed by examining the inhibitory effect of a noxious conditioning stimulus (cuff occlusion) on the perceived intensity of a second noxious stimulus (pressure pain threshold). Participants completed two, maximal voluntary contractions followed by a submaximal endurance time task. Both performance tasks involved an isometric contraction of the non-dominant leg. The main analysis uncovered a correlation between pain modulatory capacity and performance on the endurance time task (r = -.425, p = .027), such that those with elevated pain modulation produced longer endurance times. These findings are the first to demonstrate the relationship between pain modulation responses and endurance exercise performance.

The effects of elevated pain inhibition on endurance exercise performance

BACKGROUND

The ergogenic effects of analgesic substances suggest that pain perception is an important regulator of work-rate during fatiguing exercise. Recent research has shown that endogenous inhibitory responses, which act to attenuate nociceptive input and reduce perceived pain, can be increased following transcranial direct current stimulation of the hand motor cortex. Using high-definition transcranial direct current stimulation (HD-tDCS; 2 mA, 20 min), the current study aimed to examine the effects of elevated pain inhibitory capacity on endurance exercise performance. It was hypothesised that HD-tDCS would enhance the efficiency of the endogenous pain inhibitory response and improve endurance exercise performance.

METHODS

Twelve healthy males between 18 and 40 years of age (M = 24.42 ± 3.85) were recruited for participation. Endogenous pain inhibitory capacity and exercise performance were assessed before and after both active and sham (placebo) stimulation. The conditioned pain modulation protocol was used for the measurement of pain inhibition. Exercise performance assessment consisted of both maximal voluntary contraction (MVC) and submaximal muscular endurance performance trials using isometric contractions of the non-dominant leg extensors.

RESULTS

Active HD-tDCS (pre-tDCS, -.32 ± 1.33 kg; post-tDCS, -1.23 ± 1.21 kg) significantly increased pain inhibitory responses relative to the effects of sham HD-tDCS (pre-tDCS, -.91 ± .92 kg; post-tDCS, -.26 ± .92 kg; p = .046). Irrespective of condition, peak MVC force and muscular endurance was reduced from pre- to post-stimulation. HD-tDCS did not significantly influence this reduction in maximal force (active: pre-tDCS, 264.89 ± 66.87 Nm; post-tDCS, 236.33 ± 66.51 Nm; sham: pre-tDCS, 249.25 ± 88.56 Nm; post-tDCS, 239.63 ± 67.53 Nm) or muscular endurance (active: pre-tDCS, 104.65 ± 42.36 s; post-tDCS, 93.07 ± 33.73 s; sham: pre-tDCS, 123.42 ± 72.48 s; post-tDCS, 100.27 ± 44.25 s).

DISCUSSION

Despite increasing pain inhibitory capacity relative to sham stimulation, active HD-tDCS did not significantly elevate maximal force production or muscular endurance. These findings question the role of endogenous pain inhibitory networks in the regulation of exercise performance.

Covalent Guanosine Mimetic Inhibitors of G12C KRAS

Ras proteins are members of a large family of GTPase enzymes that are commonly mutated in cancer where they act as dominant oncogenes. We previously developed an irreversible guanosine-derived inhibitor, SML-8-73-1, of mutant G12C RAS that forms a covalent bond with cysteine 12. Here we report exploration of the structure-activity relationships (SAR) of hydrolytically stable analogues of SML-8-73-1 as covalent G12C KRAS inhibitors. We report the discovery of difluoromethylene bisphosphonate analogues such as compound 11, which, despite exhibiting reduced efficiency as covalent G12C KRAS inhibitors, remove the liability of the hydrolytic instability of the diphosphate moiety present in SML-8-73-1 and provide the foundation for development of prodrugs to facilitate cellular uptake. The SAR and crystallographic results reaffirm the exquisite molecular recognition that exists in the diphosphate region of RAS for guanosine nucleotides which must be considered in the design of nucleotide-competitive inhibitors.