Intermittent Fasting as a Potential Therapeutic Instrument for Major Depression Disorder: A Systematic Review of Clinical and Preclinical Studies

Recent studies have reported positive effects of Intermittent Fasting (IF) on metabolic parameters, cognition, and mood. However, regarding depressive symptoms, the effect of IF is not clear. The purpose of this review was to assess the available evidence on IF interventions for depression in both clinical and preclinical studies. Of the 23 included studies, 15 were performed on humans and 8 on animal models. The studies on rodents suggested that IF acts as a circadian regulator, improving neurotransmitter availability and increasing the levels of neurotrophic factors in the brain. However, the investigations on humans mainly evaluated healthy volunteers and showed a great heterogeneity regarding both the IF regimen studied and the observed effects on mood. Most available clinical trials have specific limitations, such as small sample sizes and uncontrolled designs. A comprehensive systematic review was conducted on five databases, PubMed, Cochrane, the Central Register of Controlled Trials, Web of Science databases, BVS and Scopus, identifying 23 relevant studies up to 6 October 2022. IF has potentially relevant physiological effects for the treatment of mood disorders, but better designed studies and controlled evaluations are needed to evaluate its efficiency in the treatment of major depression.

Differentiating Hypoglycemia Awareness Status from Hypoglycemia Experience in Tools for Measuring Impaired Awareness of Hypoglycemia

Background: Developing technologies in real-time continuous glucose monitoring (CGM) are successfully reducing severe hypoglycemia (SH) in trials and clinical practice. Their impact on impaired awareness of hypoglycemia, a major risk factor for SH, is uncertain. Methods: The present study examined two scales for assessing hypoglycemia awareness status, the Gold score and the eight-item Minimally Modified Clarke Hypoglycemia Survey (MMCHS), commonly used in trials of CGM, in Portuguese-speaking adults with type 1 diabetes and conducted an exploratory factor analysis on MMCHS. Results: A bifactorial structure in MMCHS was revealed, with a clear distinction between items that measure SH experience and those that measure hypoglycemia awareness status. The latter is associated with the same risk for SH as the Gold score. Conclusions: We conclude that improvement in awareness scores by the MMCHS may reflect only a reduction in SH with no restoration of endogenous awareness, making the current literature consistent in evidence that CGM does not improve endogenous awareness and nonsensor supported protection from SH. This has implications for risk of SH when CGM is not being worn.

FRI0441 INFECTIOUS DISEASES RISK ASSESSMENT PRIOR TO IMMUNOMODULATION THERAPY - EXPERIENCE FROM AN INFECTIOUS DISEASES UNIT

Background:

The increasing use of immunomodulatory therapies has motivated the development of strategies to assess and prevent infectious diseases in these immunosuppressed patients, in whom the risk of serious infections is higher.

Objectives:

The aim of this study was to recognize the need to standardize prophylactic and therapeutic strategies in this population.

Methods:

Retrospective review of clinical files of patients evaluated in the infectious risk assessment in an outpatient clinic at the Infectious Diseases Unit at Hospital de Curry Cabral in Lisbon, between June 2016 and November 2019. We reviewed information regarding sex, age, origin, occupation, past travels as well as plans of future ones, contact with live animals, intake of unpasteurized products or unsafe drinking water, along with relevant data regarding past medical history and previous and/or ongoing treatments, including immunomodulatory ones.

Results:

During the established timeline,1305 appointments were carried out, corresponding to a total of 415 patients. The majority of patients were female (263; 63.7%), the average age was 50 years and 82% were of Portuguese nationality. The most frequent groups of diseases were autoimmune/inflammatory (84.1%) and demyelinating (10.1%). At the date of the first consultation, 70% were already under immunosuppression. Screening for latent tuberculosis infection (LTBI) was done in 99% of the patients (n = 410) and treatment was proposed to 160 patients (38.5%). At the time of screening, 56,8% of the patients were under immunossuppressive therapies, which included high doses of systemic corticosteroids (37%), anti-TNF alpha (7,7%) and combine therapy with non-biologic agents. Active disease was diagnosed and treated in two patients. Interferon gamma release assay test (IGRA) was positive in 56.8% of patients (n = 91), negative in 32.5% (n = 52) and indeterminate in 7.5% (n=12). Of the 69 patients (43%) with indeterminate/negative or not performed IGRA, Mantoux test (TST) was positive in 48 patients. In the remainder, the treatment proposal for LTBI was based on clinical, epidemiological or radiological signs suggestive of past infection.

In order to prevent hyperinfection/disseminated strongyloidiasis, 354 individuals were screened withStrongyloides stercoralisserology, of which 51 patients (14.4%) had a positive result and were treated with ivermectin. Regarding vaccination, the recommendation for annual influenza vaccination was reinforced, together with the prevention of invasive pneumococcal disease. In view of future travelling plans, vaccination against yellow fever (n = 10), meningococcal disease (n = 7), typhoid fever (n = 6), and polio (n = 2) was recommended. In cases without a previous history of measles and according to the year of birth, VASPR was prescribed to 6 patients. Vaccination to prevent herpes zoster was recommended to 20 patients. After serological evaluation, the vaccine against hepatitis A and hepatitis B was prescribed to 89 and 132 patients, respectively, the latter when serological evidence of previous vaccination or contact was absent. We identified 10 cases of positive anti-HCV antibodies, with undetectable viral load. Primary prophylaxis forPneumocystis jiroveciipneumonia was recommended to 104 patients. Prophylaxis against reactivation of Herpes simplex infection was initiated in 4 patients.

Conclusion:

The decision to start immunosuppressive therapy comes with benefits and risks. Appropriate screening prior to starting therapy is an essential tool for its safe use. Referral to a specialised Infectious Risk Assessment consultation should be done promptly in order to review and address accordingly the risk of specific infections taking in to account the patients clinical and epidemiologic history.

Disclosure of Interests:

None declared

Mapping language with resting-state functional magnetic resonance imaging: A study on the functional profile of the language network

Resting-state functional magnetic resonance imaging (rsfMRI) is a promising technique for language mapping that does not require task-execution. This can be an advantage when language mapping is limited by poor task performance, as is common in clinical settings. Previous studies have shown that language maps extracted with rsfMRI spatially match their task-based homologs, but no study has yet demonstrated the direct participation of the rsfMRI language network in language processes. This demonstration is critically important because spatial similarity can be influenced by the overlap of domain-general regions that are recruited during task-execution. Furthermore, it is unclear which processes are captured by the language network: does it map rather low-level or high-level (e.g., syntactic and lexico-semantic) language processes? We first identified the rsfMRI language network and then investigated task-based responses within its regions when processing stimuli of increasing linguistic content: symbols, pseudowords, words, pseudosentences and sentences. The language network responded only to language stimuli (not to symbols), and higher linguistic content elicited larger brain responses. The left fronto-parietal, the default mode, and the dorsal attention networks were examined and yet none showed language involvement. These findings demonstrate for the first time that the language network extracted through rsfMRI is able to map language in the brain, including regions subtending higher-level syntactic and semantic processes.

Consensus Recommendations of the Multiple Sclerosis Study Group and the Portuguese Neuroradiological Society for the Use of Magnetic Resonance Imaging in Multiple Sclerosis in Clinical Practice: Part 2

INTRODUCTION

Magnetic resonance imaging is recognized as the most important diagnostic test in the diagnosis of multiple sclerosis, differential diagnosis and evaluation of progression/therapeutic response. However, to make optimal use of magnetic resonance imaging in multiple sclerosis, the use of a standard, reproducible and comparable imaging protocol is of uttermost importance. In this context, the Portuguese Society of Neuroradiology and the Group of Studies of Multiple Sclerosis, after a joint discussion, appointed a committee of experts to create recommendations adapted to the national reality on the use of magnetic resonance imaging in multiple sclerosis. This document represents the second part of the first Portuguese consensus recommendations on the use of magnetic resonance imaging in multiple sclerosis in clinical practice.

MATERIAL AND METHODS

The Portuguese Society of Neuroradiology and the Group of Studies of Multiple Sclerosis, after discussing the topic in national meetings and after a working group meeting held in Figueira da Foz, May 2017, appointed a committee of experts that have developed several standard protocols on the use of magnetic resonance imaging on multiple sclerosis by consensus. The document obtained was based on the best scientific evidence and expert opinion. Portuguese multiple sclerosis consultants and departments of neuroradiology scrutinized and reviewed the consensus paper; comments and suggestions were considered. Standardized strategies of magnetic resonance imaging referral in clinical practice for diagnosis and follow-up of multiple sclerosis were published in the first part of this paper.

RESULTS

We provide magnetic resonance imaging acquisition protocols regarding multiple sclerosis diagnostic and monitoring and the information to be included in the report for application across Portuguese healthcare institutions.

CONCLUSION

We hope that these first Portuguese magnetic resonance imaging guidelines will contribute to optimize multiple sclerosis management and improve patient care in Portugal.

Cognitive impairment and magnetic resonance imaging correlates in primary progressive multiple sclerosis

OBJECTIVES

To characterize cognitive impairment in primary progressive multiple sclerosis (PPMS) and to correlate the pattern of cognitive deficits with brain magnetic resonance imaging (MRI) volumetric data.

MATERIALS AND METHODS

In a multicenter cross-sectional study, we recruited consecutive patients with PPMS as well as age, sex, and education level-matched healthy controls (HC). All participants underwent neuropsychological (NP) assessment, and brain MRI was performed in patients with PPMS for analysis of lesion load, subcortical GM volumes, and regional cortical volumes.

RESULTS

We recruited 55 patients with PPMS and 36 HC. Thirty-six patients were included in the MRI analysis. Patients with PPMS performed significantly worse than HC in all NP tests. Subcortical GM volume was significantly correlated with all NP tests, except for Stroop Test, with the largest effect for the thalamus (r=-.516 [BVMT-R DR, P=.016 FDR-corrected] to r=.664 [SDMT, P<.001 FDR-corrected]). In the stepwise linear regression model, thalamic volume was the only predictor of performance in all NP tests.

CONCLUSION

Cognitive impairment is common in PPMS and affects all evaluated cognitive domains. Subcortical GM volume, particularly of the thalamus, is a strong predictor of cognitive performance, suggesting it has a central role in the pathophysiology of PPMS-related cognitive dysfunction.

Chronic pain disrupts the reward circuitry in multiple sclerosis

Pain commonly affects multiple sclerosis (MS) patients, and has the potential to become chronic and burden an already damaged central nervous system. Imaging studies are providing insights into brain restructuring associated with chronic pain and different chronic pain conditions seem to evoke distinct plasticity patterns. Our objective was to study the structural and functional brain changes of chronic neuropathic pain of MS. Employing structural and resting functional magnetic resonance imaging we compared MS patients with chronic central pain with MS patients without pain matched with respect to age, gender, subtype and duration of MS and disability. Mean duration of pain was 7.6 years. Comparing the pain and no-pain groups, brain functional default-mode network differences were found. There was decreased coactivation in the caudate nucleus and nucleus accumbens bilaterally. Also, for the relapsing-remitting subgroup of patients, grey matter thickness changes predominated in the pain group in the mesial region of the temporal lobes, caudate, putamen, thalami and the fronto-parietal cortex; in the group without pain, changes predominated in the frontopolar and orbitofrontal cortices and in the occipital areas. A dysfunction in the reward system in chronic pain of MS was found, particularly in the brain areas involved in its motivational aspects, as such probably reflecting the maladaptive physiology of chronic pain, and possibly the signature of pain in MS, in a disease where reward impairment seems to be already one of its features.

Resting-State Functional Magnetic Resonance Imaging for Language Preoperative Planning

Functional magnetic resonance imaging (fMRI) is a well-known non-invasive technique for the study of brain function. One of its most common clinical applications is preoperative language mapping, essential for the preservation of function in neurosurgical patients. Typically, fMRI is used to track task-related activity, but poor task performance and movement artifacts can be critical limitations in clinical settings. Recent advances in resting-state protocols open new possibilities for pre-surgical mapping of language potentially overcoming these limitations. To test the feasibility of using resting-state fMRI instead of conventional active task-based protocols, we compared results from fifteen patients with brain lesions while performing a verb-to-noun generation task and while at rest. Task-activity was measured using a general linear model analysis and independent component analysis (ICA). Resting-state networks were extracted using ICA and further classified in two ways: manually by an expert and by using an automated template matching procedure. The results revealed that the automated classification procedure correctly identified language networks as compared to the expert manual classification. We found a good overlay between task-related activity and resting-state language maps, particularly within the language regions of interest. Furthermore, resting-state language maps were as sensitive as task-related maps, and had higher specificity. Our findings suggest that resting-state protocols may be suitable to map language networks in a quick and clinically efficient way.

Pain in multiple sclerosis: a systematic review of neuroimaging studies

Introduction

While pain in multiple sclerosis (MS) is common, in many cases the precise mechanisms are unclear. Neuroimaging studies could have a valuable role in investigating the aetiology of pain syndromes. The aim of this review was to synthesise and appraise the current literature on neuroimaging studies of pain syndromes in MS.

Methods

We systematically searched PubMed and Scopus from their inception dates to the 2nd of April 2013. Studies were selected by predefined inclusion and exclusion criteria. Methodological quality was appraised. Descriptive statistical analysis was conducted.

Results

We identified 38 studies of variable methodology and quality. All studies but one used conventional structural magnetic resonance imaging, and the majority reported a positive association between location of demyelinating lesions and specific neuropathic pain syndromes. Most investigated headache and facial pain, with more common pain syndromes such as limb pain being relatively understudied. We identified a number of methodological concerns, which along with variable study design and reporting limit our ability to synthesise data. Higher quality studies were however less likely to report positive associations of lesion distribution to pain syndromes.

Conclusions

Further high quality hypothesis-driven neuroimaging studies of pain syndromes in MS are required to clarify pain mechanisms, particularly for the commonest pain syndromes.

•

We reviewed neuroimaging studies of pain syndromes in multiple sclerosis (MS).

•

All studies investigated neuropathic pain or headache, mainly using structural MRI.

•

Most reported associations between location of demyelinating lesions and pain.

•

Culprit lesions were most commonly reported in the brainstem.

•

High quality hypothesis-driven neuroimaging studies of pain in MS are still needed.

Brain magnetic resonance imaging: perception and expectations of neurologists, neurosurgeons and psychiatrists

Magnetic resonance imaging (MRI) has rapidly become an essential diagnostic tool in modern medicine. Understanding the objectives, perception and expectations of the different medical specialties towards MRI is therefore important to improve the quality of the examinations. Our aim was to better comprehend the reasons and expectations of neurologists, neurosurgeons and psychiatrists when requesting brain MRI scans for their patients, and also to perceive the degree of confidence of these specialists in the images and respective reports. Sixty-three specialists were recruited from two tertiary hospitals and answered a tailored questionnaire. Neurosurgeons were more concerned with the images themselves; neurologists lacked confidence in both MRI images and reports, and one third of the psychiatrists only read the report and were the most confident of the specialties in MRI findings. These results possibly reflect the idiosyncrasies of each of these medical specialties. This knowledge, driven by efficient communication between neuroradiologists and neurosurgeons, neurologists and psychiatrists, may contribute to improve the quality of MRI examinations and consequently patient care and management of health resources.

Giant left middle fossa VII nerve schwannoma associated with amnesia

The facial nerve is the third most frequent location of intracranial schwannomas, with facial paresis the most common sign.(1,2) A 77-year-old woman presented with amnesia; the Mini-Mental State Examination score was 26, with normal cranial nerve function. A giant multicystic VII nerve schwannoma was identified in the left middle fossa, with components of the tumor in the temporal bone facial canal, geniculate ganglion, and internal auditory canal (figure). Compression of the hippocampus may have accounted for the clinical presentation. The middle fossa component of the tumor was resected for mass effect relief, with iatrogenic facial palsy.

Investigating the role of the ventromedial prefrontal cortex in the assessment of brands

The ventromedial prefrontal cortex (vmPFC) is believed to be important in everyday preference judgments, processing emotions during decision-making. However, there is still controversy in the literature regarding the participation of the vmPFC. To further elucidate the contribution of the vmPFC in brand preference, we designed a functional magnetic resonance imaging (fMRI) study where 18 subjects assessed positive, indifferent, and fictitious brands. Also, both the period during and after the decision process were analyzed, hoping to unravel temporally the role of the vmPFC, using modeled and model-free fMRI analysis. Considering together the period before and after decision-making, there was activation of the vmPFC when comparing positive with indifferent or fictitious brands. However, when the decision-making period was separated from the moment after the response, and especially for positive brands, the vmPFC was more active after the choice than during the decision process itself, challenging some of the existing literature. The results of the present study support the notion that the vmPFC may be unimportant in the decision stage of brand preference, questioning theories that postulate that the vmPFC is in the origin of such a choice. Further studies are needed to investigate in detail why the vmPFC seems to be involved in brand preference only after the decision process.

Pain in portuguese patients with multiple sclerosis

Early reports often ignored pain as an important symptom in multiple sclerosis (MS). Pain prevalence figures in MS from European countries other than Portugal range between 40 and 65%. To our knowledge there is no published data in English on pain in MS in Portugal. We describe the demographic and clinical characteristics, with an emphasis on pain, of 85 MS patients followed-up in a Portuguese hospital, contributing to pain epidemiology in MS. Patients were interviewed sequentially after their regular appointments at the MS clinic; patients with pain completed The Brief Pain Inventory and The McGill Pain Questionnaire (MPQ). The prevalence of pain found was 34%. Headache and back pain were the most common anatomical sites described, followed by upper and lower limbs. Intensity of pain in an 11-point scale was, for the maximum pain intensity 6.7 ± 1.8, for the minimum pain intensity 2.2 ± 2.0, for the mean pain intensity 4.5 ± 1.5, and for the actual pain intensity 2.4 ± 2.9. Pain interfered significantly with general activity, mood, work, social relations, and enjoyment of life. All MS patients with pain employed words from both the sensory and affective categories of the MPQ to describe it. Patient pain descriptions’ included the word “hot-burning” in 59% of the cases, common in the report of central pain, but neuropathic pain medications were only used by 10% of them. Pain is an important symptom in Portuguese patients with MS, not only because of the high prevalence found, concordant with other European countries, but also because of its interference with quality-of-life.

[Pain in multiple sclerosis: characterization of a Portuguese population of 85 patients]

Multiple sclerosis (MS) is a frequent neurological disease, with an estimated prevalence in Portugal of 60/100.000. It is a disease of the young adult, whose first symptoms are commonly of sensory type. The pathological process is of inflammatory nature, involving the central nervous system. The typical histopathological lesion is an area of demyelination. Initial descriptive studies affirmed that pain was an uncommon symptom in MS. However, it soon became evident that the majority of MS patients experience pain in the course of their disease. In MS it is possible to find any kind of pain syndrome, being the most common central neuropathic pain. A sample of 85 MS patients of the Outpatient Clinic of Demyelinating Diseases of the Neurology Department of São João Hospital, Oporto, Portugal, was studied. The presence of pain, demographic characteristics, disease duration, year of diagnosis, MS subtype, treatments and Expanded Disability Status Scale (EDSS) score were investigated. The group of MS patients with pain completed the short versions of the pain questionnaires The Brief Pain Inventory (BPI) and The McGill Pain Questionnaire (MPQ), for more detailed pain characterization. The prevalence of pain found was 34%. We have not established an association between the existence of pain and disease duration or functional impairment. However, pain interfered significantly with the patients' general activity, mood, work, social relations with others and enjoyment of life. All the pain and MS patients that completed the MPQ employed more than one word to describe their pain, using always words from both the sensory and affective categories. Patient pain descriptions included the word hot-burning in 58,8% of the cases; this word is used commonly in the description of central neuropathic pain. Pain is an important symptom in 85 Portuguese patients with MS, not only because of the high pain prevalence found, but also because of its interference with their quality of life. Pain recognition in MS patients is fundamental to adequately treating MS patients with pain.

Identification of drought-responsive genes in roots of upland rice (Oryza sativa L)

Background

Rice (Oryza sativa L.) germplasm represents an extraordinary source of genes that control traits of agronomic importance such as drought tolerance. This diversity is the basis for the development of new cultivars better adapted to water restriction conditions, in particular for upland rice, which is grown under rainfall. The analyses of subtractive cDNA libraries and differential protein expression of drought tolerant and susceptible genotypes can contribute to the understanding of the genetic control of water use efficiency in rice.

Results

Two subtractive libraries were constructed using cDNA of drought susceptible and tolerant genotypes submitted to stress against cDNA of well-watered plants. In silico analysis revealed 463 reads, which were grouped into 282 clusters. Several genes expressed exclusively in the tolerant or susceptible genotypes were identified. Additionally, proteome analysis of roots from stressed plants was performed and 22 proteins putatively associated to drought tolerance were identified by mass spectrometry.

Conclusion

Several genes and proteins involved in drought-response, as well as genes with no described homologs were identified. Genes exclusively expressed in the tolerant genotype were, in general, related to maintenance of turgor and cell integrity. In contrast, in the susceptible genotype, expression of genes involved in protection against cell damage was not detected. Several protein families identified in the proteomic analysis were not detected in the cDNA analysis. There is an indication that the mechanisms of susceptibility to drought in upland rice are similar to those of lowland varieties.

Agenesis of the internal carotid artery and hypogenesis of the pituitary gland: cause, consequence or coincidence?

The CT and MR imaging findings in a case of unilateral agenesis of the internal carotid artery and hypogenesis of the pituitary gland are described in a child with congenital hypopituitarism. The embryological pathogenesis is discussed.

[Orbital vascular pathology: clinical and imagiological differential diagnosis]

Orbital vascular lesions represent an important group of orbital pathology, because of their high prevalence, particularly in the pediatric population. They are also the most controversial group of lesions, due to the polemics in regard to their nature. Based on cases of their experience, the authors analyze the orbital vascular pathology, especially its clinical and imagiological characteristics, important to the diagnosis.