Royal Australian and New Zealand College of Psychiatrists professional practice guidelines for the administration of repetitive transcranial magnetic stimulation

OBJECTIVES

To provide guidance for the optimal administration of repetitive transcranial magnetic stimulation, based on scientific evidence and supplemented by expert clinical consensus.

METHODS

Articles and information were sourced from existing guidelines and published literature. The findings were then formulated into consensus-based recommendations and guidance by the authors. The guidelines were subjected to rigorous successive consultation within the RANZCP, involving the Section of ECT and Neurostimulation (SEN) Committee, its broader membership and expert committees.

RESULTS

The RANZCP professional practice guidelines (PPG) for the administration of rTMS provide up-to-date advice regarding the use of rTMS in clinical practice. The guidelines are intended for use by psychiatrists and non-psychiatrists engaged in the administration of rTMS to facilitate best practice to optimise outcomes for patients. The guidelines strive to find the appropriate balance between promoting best evidence-based practice and acknowledging that evidence for rTMS use is a continually evolving.

CONCLUSION

The guidelines provide up-to-date advice for psychiatrists and non-psychiatrists to promote optimal standards of rTMS practice.

Condition Monitoring of Railway Bridges Using Vehicle Pitch to Detect Scour

This study proposes the new condition monitoring concept of using features in the measured rotation, or 'pitch' signal, of a crossing vehicle as an indicator of the presence of foundation scour in a bridge. The concept is explored through two-dimensional vehicle-bridge interaction modelling, with a reduction in stiffness under a pier used to represent the effects of scour. A train consisting of three 10-degree-of-freedom carriages cross the model on a profiled train track, each train varying slightly in terms of mass and velocity. An analysis of the pitch of the train carriages can clearly identify when scour is present. The concept is further tested in a scaled laboratory experiment consisting of a tractor-trailer crossing a four-span simply supported bridge on piers. The foundation support is represented by four springs under each pier, which can be replaced with springs of a reduced stiffness to mimic the effect of scour. The laboratory model also consistently shows a divergence in vehicle pitch between healthy and scoured bridge states.

Efficacy and safety of a 4-week course of repeated subcutaneous ketamine injections for treatment-resistant depression (KADS study): randomised double-blind active-controlled trial

BACKGROUND

Prior trials suggest that intravenous racemic ketamine is a highly effective for treatment-resistant depression (TRD), but phase 3 trials of racemic ketamine are needed.

AIMS

To assess the acute efficacy and safety of a 4-week course of subcutaneous racemic ketamine in participants with TRD. Trial registration: ACTRN12616001096448 at www.anzctr.org.au.

METHOD

This phase 3, double-blind, randomised, active-controlled multicentre trial was conducted at seven mood disorders centres in Australia and New Zealand. Participants received twice-weekly subcutaneous racemic ketamine or midazolam for 4 weeks. Initially, the trial tested fixed-dose ketamine 0.5 mg/kg versus midazolam 0.025 mg/kg (cohort 1). Dosing was revised, after a Data Safety Monitoring Board recommendation, to flexible-dose ketamine 0.5-0.9 mg/kg or midazolam 0.025-0.045 mg/kg, with response-guided dosing increments (cohort 2). The primary outcome was remission (Montgomery-Åsberg Rating Scale for Depression score ≤10) at the end of week 4.

RESULTS

The final analysis (those who received at least one treatment) comprised 68 in cohort 1 (fixed-dose), 106 in cohort 2 (flexible-dose). Ketamine was more efficacious than midazolam in cohort 2 (remission rate 19.6% v. 2.0%; OR = 12.1, 95% CI 2.1-69.2, P = 0.005), but not different in cohort 1 (remission rate 6.3% v. 8.8%; OR = 1.3, 95% CI 0.2-8.2, P = 0.76). Ketamine was well tolerated. Acute adverse effects (psychotomimetic, blood pressure increases) resolved within 2 h.

CONCLUSIONS

Adequately dosed subcutaneous racemic ketamine was efficacious and safe in treating TRD over a 4-week treatment period. The subcutaneous route is practical and feasible.

Correction: A Prospective Cohort Study of Antipsychotic Medications in Pregnancy: The First 147 Pregnancies and 100 One Year Old Babies

[This corrects the article DOI: 10.1371/journal.pone.0094788.].

Pain, Analgesic Use, and Patient Satisfaction With Spinal Versus General Anesthesia for Hip Fracture Surgery : A Randomized Clinical Trial

BACKGROUND

The REGAIN (Regional versus General Anesthesia for Promoting Independence after Hip Fracture) trial found similar ambulation and survival at 60 days with spinal versus general anesthesia for hip fracture surgery. Trial outcomes evaluating pain, prescription analgesic use, and patient satisfaction have not yet been reported.

OBJECTIVE

To compare pain, analgesic use, and satisfaction after hip fracture surgery with spinal versus general anesthesia.

DESIGN

Preplanned secondary analysis of a pragmatic randomized trial. (ClinicalTrials.gov: NCT02507505).

SETTING

46 U.S. and Canadian hospitals.

PARTICIPANTS

Patients aged 50 years or older undergoing hip fracture surgery.

INTERVENTION

Spinal or general anesthesia.

MEASUREMENTS

Pain on postoperative days 1 through 3; 60-, 180-, and 365-day pain and prescription analgesic use; and satisfaction with care.

RESULTS

A total of 1600 patients were enrolled. The average age was 78 years, and 77% were women. A total of 73.5% (1050 of 1428) of patients reported severe pain during the first 24 hours after surgery. Worst pain over the first 24 hours after surgery was greater with spinal anesthesia (rated from 0 [no pain] to 10 [worst pain imaginable]; mean difference, 0.40 [95% CI, 0.12 to 0.68]). Pain did not differ across groups at other time points. Prescription analgesic use at 60 days occurred in 25% (141 of 563) and 18.8% (108 of 574) of patients assigned to spinal and general anesthesia, respectively (relative risk, 1.33 [CI, 1.06 to 1.65]). Satisfaction was similar across groups.

LIMITATION

Missing outcome data and multiple outcomes assessed.

CONCLUSION

Severe pain is common after hip fracture. Spinal anesthesia was associated with more pain in the first 24 hours after surgery and more prescription analgesic use at 60 days compared with general anesthesia.

PRIMARY FUNDING SOURCE

Patient-Centered Outcomes Research Institute.

Interlaboratory collaboration to determine the performance of the Randox food diagnostics biochip array technology for the simultaneous quantitative detection of seven mycotoxins in feed

An inter-laboratory collaborative study was performed to evaluate the performance of the Biochip Array Technology (BAT) Myco 7 method. The Myco 7 Array is a method which simultaneously and quantitatively detects 20 mycotoxins including aflatoxins B1, B2, G1 and G2, ochratoxin A, deoxynivalenol, zearalenone, fumonisin B1, B2 and B3 and T-2 and HT-2 toxin. The BAT Myco 7 method was collaboratively evaluated by nine government and private Association of American Feed Control Officials (AAFCO) laboratories. Samples were analysed in a proficiency testing round format. Seventeen blind samples were analysed on the same equipment using Myco 7 kits. 99% of the results fell within an acceptable Z-score range of -2|<Z<|+2. Deoxynivalenol had a 100% Z-score pass rate, while a 99% pass was recorded for aflatoxins, zearalenone, ochratoxin A and fumonisins. T-2 toxin had a 97% Z-score pass rate. HorRat analysis for reproducibility used a range of 0.3<|HorRat|≤2. The target was met for deoxynivalenol, zearalenone, T-2 and HT-2 toxin, and aflatoxins B1, B2, G1 and G2 assays. Fumonisins and ochratoxin A assays had a 93% and 94% pass, respectively. The reproducibility co-efficiency of variation was between 16 and 20% meeting set criterion of <40% and is, therefore, fit-for-purpose for use in the AAFCO control programs for mycotoxins.

Configurational diffusion transport of water and oil in dual continuum shales

Understanding fluid flow in shale rocks is critical for the recovery of unconventional energy resources. Despite the extensive research conducted on water and oil flow in shales, significant uncertainties and discrepancies remain in reported experimental data. The most noted being that while oil spreads more than water on shale surfaces in an inviscid medium, its uptake by shale pores is much less than water during capillary flow. This leads to misjudgement of wettability and the underlying physical phenomena. In this study, therefore, we performed a combined experimental and digital rock investigation on an organic-rich shale including contact angle and spontaneous imbibition, X-ray and neutron computed tomography, and small angle X-ray scattering tests to study the potential physical processes. We also used non-equilibrium thermodynamics to theoretically derive constitutive equations to support our experimental observations. The results of this study indicate that the pre-existing fractures (first continuum) imbibe more oil than water consistent with contact angle measurements. The overall imbibition is, however, higher for water than oil due to greater water diffusion into the shale matrix (second continuum). It is shown that more water uptake into shale is controlled by pore size and accessibility in addition to capillary or osmotic forces i.e. configurational diffusion of water versus oil molecules. While the inorganic pores seem more oil-wet in an inviscid medium, they easily allow passage of water molecules compared to oil due to the incredibly small size of water molecules that can pass through such micro-pores. Contrarily, these strongly oil-wet pores possessing strong capillarity are restricted to imbibe oil simply due to its large molecular size and physical inaccessibility to the micro-pores. These results provide new insights into the previously unexplained discrepancy regarding water and oil uptake capacity of shales.

Repeated Transcranial Magnetic Stimulation for Improving Cognition in Patients With Alzheimer Disease: Protocol for a Randomized, Double-Blind, Placebo-Controlled Trial

Background

Alzheimer disease has no known cure. As existing pharmacologic interventions only modestly slow cognitive decline, there is a need for new treatments. Recent trials of repetitive transcranial magnetic stimulation (rTMS) have reported encouraging results for improving or stabilizing cognition in patients diagnosed with Alzheimer dementia. However, owing to small samples and lack of a well-controlled double-blind design, the results to date are inconclusive. This paper presents the protocol for a large placebo-controlled double-blind study designed with sufficient statistical rigor to measure the efficacy of rTMS treatment in patients with Alzheimer dementia.

Objective

The objectives are to (1) recruit and enroll up to 200 eligible participants, (2) estimate the difference in treatment effects between active treatment and sham treatment, (3) estimate the difference in treatment effects between two doses of rTMS applications, (4) estimate the duration of treatment effects among responders to active rTMS treatment, and (5) estimate the effect of dementia severity on treatment outcomes among patients receiving active rTMS treatment.

Methods

We have designed our study to be a double-blind, randomized, placebo-controlled clinical trial investigating the short- and long-term (up to 6 months) benefits of active rTMS treatment at two doses (10 sessions over 2 weeks and 20 sessions over 4 weeks) compared with sham rTMS treatment. The study will include patients aged ≥55 years who are diagnosed with Alzheimer disease at an early to moderate stage and have no history of seizures and no major depression. The primary outcome measure is the change in the Alzheimer Disease Assessment Scale-Cognitive Subscale score from pretreatment to posttreatment. Secondary outcomes are changes in performance on tests of frontal lobe functioning (Stroop test and verbal fluency), changes in neuropsychiatric symptoms (Neuropsychiatric Inventory Questionnaire), and changes in activities of daily living (Alzheimer Disease Co-operative Study-Activities of Daily Living Inventory). Tolerability of the intervention will be assessed using a modification of the Treatment Satisfaction Questionnaire for Medication. We assess participants at baseline and 3, 5, 8, 16, and 24 weeks after the intervention.

Results

As of November 1, 2020, we have screened 523 individuals, out of which 133 were eligible and have been enrolled. Out of the 133 individuals, 104 have completed the study. Moreover, as of November 1, 2020, there has been no serious adverse event. We anticipate that rTMS will considerably improve cognitive function, with effects lasting up to 3 months. Moreover, we expect rTMS to be a well-tolerated treatment with no serious side effect.

Conclusions

This protocol design will allow to address both the rTMS active treatment dose and its short- and long-term effects compared with sham treatment in large samples.

Trial Registration

ClinicalTrials.gov NCT02908815; https://clinicaltrials.gov/ct2/show/NCT02908815

International Registered Report Identifier (IRRID)

DERR1-10.2196/25144

Virtual Monoenergetic CT Imaging via Deep Learning

Conventional single-spectrum computed tomography (CT) reconstructs a spectrally integrated attenuation image and reveals tissues morphology without any information about the elemental composition of the tissues. Dual-energy CT (DECT) acquires two spectrally distinct datasets and reconstructs energy-selective (virtual monoenergetic [VM]) and material-selective (material decomposition) images. However, DECT increases system complexity and radiation dose compared with single-spectrum CT. In this paper, a deep learning approach is presented to produce VM images from single-spectrum CT images. Specifically, a modified residual neural network (ResNet) model is developed to map single-spectrum CT images to VM images at pre-specified energy levels. This network is trained on clinical DECT data and shows excellent convergence behavior and image accuracy compared with VM images produced by DECT. The trained model produces high-quality approximations of VM images with a relative error of less than 2%. This method enables multi-material decomposition into three tissue classes, with accuracy comparable with DECT.

Guidelines for TMS/tES clinical services and research through the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic has broadly disrupted biomedical treatment and research including non-invasive brain stimulation (NIBS). Moreover, the rapid onset of societal disruption and evolving regulatory restrictions may not have allowed for systematic planning of how clinical and research work may continue throughout the pandemic or be restarted as restrictions are abated. The urgency to provide and develop NIBS as an intervention for diverse neurological and mental health indications, and as a catalyst of fundamental brain research, is not dampened by the parallel efforts to address the most life-threatening aspects of COVID-19; rather in many cases the need for NIBS is heightened including the potential to mitigate mental health consequences related to COVID-19.

OBJECTIVE

To facilitate the re-establishment of access to NIBS clinical services and research operations during the current COVID-19 pandemic and possible future outbreaks, we develop and discuss a framework for balancing the importance of NIBS operations with safety considerations, while addressing the needs of all stakeholders. We focus on Transcranial Magnetic Stimulation (TMS) and low intensity transcranial Electrical Stimulation (tES) - including transcranial Direct Current Stimulation (tDCS) and transcranial Alternating Current Stimulation (tACS).

METHODS

The present consensus paper provides guidelines and good practices for managing and reopening NIBS clinics and laboratories through the immediate and ongoing stages of COVID-19. The document reflects the analysis of experts with domain-relevant expertise spanning NIBS technology, clinical services, and basic and clinical research - with an international perspective. We outline regulatory aspects, human resources, NIBS optimization, as well as accommodations for specific demographics.

RESULTS

A model based on three phases (early COVID-19 impact, current practices, and future preparation) with an 11-step checklist (spanning removing or streamlining in-person protocols, incorporating telemedicine, and addressing COVID-19-associated adverse events) is proposed. Recommendations on implementing social distancing and sterilization of NIBS related equipment, specific considerations of COVID-19 positive populations including mental health comorbidities, as well as considerations regarding regulatory and human resource in the era of COVID-19 are outlined. We discuss COVID-19 considerations specifically for clinical (sub-)populations including pediatric, stroke, addiction, and the elderly. Numerous case-examples across the world are described.

CONCLUSION

There is an evident, and in cases urgent, need to maintain NIBS operations through the COVID-19 pandemic, including anticipating future pandemic waves and addressing effects of COVID-19 on brain and mind. The proposed robust and structured strategy aims to address the current and anticipated future challenges while maintaining scientific rigor and managing risk.

Exploring Theta Burst Stimulation for Post-traumatic Stress Disorder in Australian Veterans—A Pilot Study

Introduction

Post-traumatic stress disorder (PTSD) is a severe and debilitating condition affecting a significant proportion of the veteran community. A substantial number of veterans with PTSD fail to benefit from trauma-focused psychological therapies or pharmacotherapy or are left with residual symptoms, and therefore, investigation of new and innovative treatment is required. Theta Burst Stimulation (TBS) is a novel form of Repetitive Transcranial Magnetic Stimulation, which has been shown to improve depression symptoms and associated cognitive deficits. The current pilot study aimed to explore the acceptability, safety, and tolerability of intermittent TBS (iTBS) as a treatment for PTSD in Australian veterans.

Materials and Methods

This study employed a case series, repeated-measures design. Eight Australian Defence Force veterans with PTSD received 20 bilateral iTBS treatments (1 session per day, 5 days per week over a 4-week period) and were assessed on a range of mental health and neuropsychological measures, including the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) and Hamilton Depression Rating Scale (HAM-D), at pretreatment, post-treatment, and a 3-month follow-up.

Results

Treatment was generally welltolerated, with reported side-effects including mild to moderate site-specific cranial pain and headaches during stimulation, which were relieved with the use of low dose analgesics. No serious side effects or adverse events were reported. Participants exhibited reductions in both PTSD and depression symptom severity (the repeated-measures effect size [dRM] for the CAPS-5 was −1.78, and the HAM-D was −1.16 post-treatment), as well as improvements in working memory and processing speed. Although significance cannot be inferred, these preliminary estimates of effect size indicate change over time.

Conclusions

Bilateral iTBS appears to be welltolerated by Australian veterans. Within this repeated-measures case series, iTBS treatment shows promise in reducing both PTSD and mood symptoms, as well as improving cognitive difficulties associated with these disorders. Large-scale randomized controlled trials of this promising treatment are warranted.

Warfarin therapy in atrial fibrillation: assessment of patient knowledge of risks and benefits

Patients with atrial fibrillation are at an increased risk for stroke, and many benefits from anticoagulation. Despite the emergence of direct oral anticoagulants, many patients continue to rely on warfarin for their anticoagulation due to logistical, pharmacokinetic, clinical, or patient preference issues. Previous work has suggested that outcomes of warfarin therapy are related to patient education/knowledge. We assessed knowledge of indications, benefits, and complications of warfarin therapy in 99 randomly selected patients enrolled in the Warfarin Anticoagulation Clinic at the Mayo Clinic in Florida who were taking warfarin for non-valvular atrial fibrillation. Patients were labeled as 'knowledgeable' or 'not knowledgeable' regarding warfarin therapy according to the results of a cross-sectional questionnaire. The majority of patients in both the knowledgeable and not knowledgeable groups displayed understanding that they were taking warfarin for atrial fibrillation (valvular vs non-valvular atrial fibrillation was not an included answer choice). However, there was a clear lack of knowledge amongst patients with atrial fibrillation in both groups about their stroke risk while on and off warfarin, and their risk of major bleeding or adverse events related to their warfarin therapy. There was only a significant difference between the two groups regarding their knowledge of what increases or decreases the risk of bleeding while on warfarin. There was no major difference between the groups with regards to demographic and medical characteristics, except that 'not knowledgeable' patients tended to have more peripheral vascular disease, ulcer disease, and moderate-severe renal disease compared to 'knowledgeable' patients.

A two-dimensional feasibility study of deep learning-based feature detection and characterization directly from CT sinograms

Machine Learning, especially deep learning, has been used in typical x-ray computed tomography (CT) applications, including image reconstruction, image enhancement, image domain feature detection and image domain feature characterization. To our knowledge, this is the first study on machine learning for feature detection and analysis directly based on CT projection data. Specifically, we present neural network methods for blood vessel detection and characterization in the sinogram domain avoiding any partial volume, beam hardening, or motion artifacts introduced during reconstruction. First, we estimate sinogram domain vessel maps using a residual encoder-decoder convolutional neural network (REDCNN). Next, we estimate the vessel centerline and we extract the vessel-only sinogram from the original sinogram, eliminating any background information. Finally, we use a fully connected neural network to estimate the vessel lumen cross-sectional area from the vessel-only sinogram. We trained and tested the proposed methods using CatSim simulations, real CT measurements of vessel phantoms, and clinical data from the NIH CT image database. We achieved encouraging initial results showing the feasibility of CT analysis in the sinogram domain. In principle, sinogram domain analysis should be possible for many other and more complicated clinical CT analysis tasks. Further studies are needed for this sinogram domain analysis approach to become practical for clinical applications.

Transcranial electrical and magnetic stimulation (tES and TMS) for addiction medicine: A consensus paper on the present state of the science and the road ahead

There is growing interest in non-invasive brain stimulation (NIBS) as a novel treatment option for substance-use disorders (SUDs). Recent momentum stems from a foundation of preclinical neuroscience demonstrating links between neural circuits and drug consuming behavior, as well as recent FDA-approval of NIBS treatments for mental health disorders that share overlapping pathology with SUDs. As with any emerging field, enthusiasm must be tempered by reason; lessons learned from the past should be prudently applied to future therapies. Here, an international ensemble of experts provides an overview of the state of transcranial-electrical (tES) and transcranial-magnetic (TMS) stimulation applied in SUDs. This consensus paper provides a systematic literature review on published data - emphasizing the heterogeneity of methods and outcome measures while suggesting strategies to help bridge knowledge gaps. The goal of this effort is to provide the community with guidelines for best practices in tES/TMS SUD research. We hope this will accelerate the speed at which the community translates basic neuroscience into advanced neuromodulation tools for clinical practice in addiction medicine.