Is repetitive Transcranial Magnetic Stimulation really effective in the treatment of major depression? – Results of a Meta-Analysis

Introduction

Clinical studies demonstrated the efficacy of rTMS treatment in major depressive disorder. However, the results of meta-analyses are contradictory due to the heterogeneity of the included studies.

Objectives

The aim was to analyse the effectiveness of rTMS for treatment-resistant major depression.

Methods

A systematic literature review of English-language articles published in the last 10 years was performed on PubMed and Scopus databases according to PRISMA guideline principles. To assess the effects of rTMS on response and remission rates, random-effects model and inverse variance method were used.

Results

23 randomized double-blind sham-controlled studies met the inclusion criteria for quantitative analysis for response (n= 1020 patients) and 12 studies for remission (n= 846 patients). The relative risk for response and remission were 2.19 (95% CI: 1.68-2,86, p=0.000 n=912) and 2.65 (95% CI: 1.32-5,31, p=0.002, n=603), respectively using rTMS as add on treatment (in patients after two antidepressant treatment failures) compared to standard pharmacotherapy. I²analysis showed no considerable heterogeneity in the combined effect sizes neither for remission studies (I²=23.36%) nor for response studies (I²=0.00%).

Conclusions

Transcranial magnetic stimulation became an evidence-based, effective treatment for treatment-resistant major depressive disorder, either as a monotherapy or as an augmentation of pharmacotherapy. However, because of the lack of standardized protocol, a substantial methodological heterogeneity exists. According to our results, rTMS was significantly more effective than sham rTMS in both response and remission outcomes, which is consistent with previous meta-analyses, but the effect size was a bit smaller than what was reported previously.

Disclosure

No significant relationships.

Analysis of population immunity to poliovirus following cessation of trivalent oral polio vaccine

BACKGROUND

The global withdrawal of trivalent oral poliovirus vaccine (OPV) (tOPV, containing Sabin poliovirus strains serotypes 1, 2 and 3) from routine immunization, and the introduction of bivalent OPV (bOPV, containing Sabin poliovirus strains serotypes 1 and 3) and trivalent inactivated poliovirus vaccine (IPV) into routine immunization was expected to improve population serologic and mucosal immunity to types 1 and 3 poliovirus, while population mucosal immunity to type 2 poliovirus would decline. However, over the period since tOPV withdrawal, the implementation of preventive bOPV supplementary immunization activities (SIAs) has decreased, while outbreaks of type 2 circulating vaccine derived poliovirus (cVDPV2) have required targeted use of monovalent type 2 OPV (mOPV2).

METHODS

We develop a dynamic model of OPV-induced immunity to estimate serotype-specific, district-level immunity for countries in priority regions and characterize changes in immunity since 2016. We account for the changes in routine immunization schedules and varying implementation of preventive and outbreak response SIAs, assuming homogenous coverages of 50% and 80% for SIAs.

RESULTS

In areas with strong routine immunization, the switch from tOPV to bOPV has likely resulted in gains in population immunity to types 1 and 3 poliovirus. However, we estimate that improved immunogenicity of new schedules has not compensated for declines in preventive SIAs in areas with weak routine immunization. For type 2 poliovirus, without tOPV in routine immunization or SIAs, mucosal immunity has declined nearly everywhere, while use of mOPV2 has created highly heterogeneous population immunity for which it is important to take into account when responding to cVDPV2 outbreaks.

CONCLUSIONS

The withdrawal of tOPV and declining allocations of resources for preventive bOPV SIAs have resulted in reduced immunity in vulnerable areas to types 1 and 3 poliovirus and generally reduced immunity to type 2 poliovirus in the regions studied, assuming homogeneous coverages of 50% and 80% for SIAs. The very low mucosal immunity to type 2 poliovirus generates substantially greater risk for further spread of cVDPV2 outbreaks. Emerging gaps in immunity to all serotypes will require judicious targeting of limited resources to the most vulnerable populations by the Global Polio Eradication Initiative (GPEI).

Safety, tolerability, and efficacy of repeated doses of dihydroartemisinin-piperaquine for prevention and treatment of malaria: a systematic review and meta-analysis

BACKGROUND

Intermittent preventive treatment (IPT) for malaria is used in infants, children, adults, and pregnant women. Dihydroartemisinin-piperaquine (DP) is an effective, well tolerated artemisinin-based combination therapy. The long half-life of piperaquine makes it attractive for IPT. We conducted a systematic review and meta-analysis to establish the efficacy and safety of repeated treatment with DP.

METHODS

Following PRISMA guidelines, we searched multiple databases on Sept 1, 2016, with the terms: "human" AND "dihydroartemisinin-piperaquine" OR "DHA-PPQ". Studies were eligible if they were randomised controlled trials (RCTs) or prospective cohort studies involving repeat exposures to standard 3-day courses of DP for either seasonal malaria chemoprevention, mass drug administration, or treatment of clinical malaria, conducted at any time and in any geographic location. Random-effects meta-analysis was used to generate pooled incidence rate ratios and relative risks, or risk differences.

FINDINGS

11 studies were included: two repeat treatment studies (one in children younger than 5 years and one in pregnant women), and nine IPT trials (five in children younger than 5 years, one in schoolchildren, one in adults, two in pregnant women). Comparator interventions included placebo, artemether-lumefantrine, sulfadoxine-pyrimethamine (SP), SP+amodiaquine, SP+piperaquine, SP+chloroquine, and co-trimoxazole. Of 14 628 participants, 3935 received multiple DP courses (2-18). Monthly IPT-DP was associated with an 84% reduction in the incidence of malaria parasitaemia measured by microscopy compared with placebo. Monthly IPT-DP was associated with fewer serious adverse events than placebo, daily co-trimoxazole, or monthly SP. Among 56 IPT-DP recipients (26 children, 30 pregnant women) with cardiac parameters, all QTc intervals were within normal limits, with no significant increase in QTc prolongation with increasing courses of DP.

INTERPRETATION

Monthly DP appears well tolerated and effective for IPT. Additional data are needed in pregnancy and to further explore the cardiac safety with monthly dosing.

FUNDING

Bill & Melinda Gates Foundation and NIH.

Wheeze as an adverse event in pediatric vaccine and drug randomized controlled trials: A systematic review

INTRODUCTION

Wheeze is an important sign indicating a potentially severe adverse event in vaccine and drug trials, particularly in children. However, there are currently no consensus definitions of wheeze or associated respiratory compromise in randomized controlled trials (RCTs).

OBJECTIVE

To identify definitions and severity grading scales of wheeze as an adverse event in vaccine and drug RCTs enrolling children <5 years and to determine their diagnostic performance based on sensitivity, specificity and inter-observer agreement.

METHODS

We performed a systematic review of electronic databases and reference lists with restrictions for trial settings, English language and publication date ≥1970. Wheeze definitions and severity grading were abstracted and ranked by a diagnostic certainty score based on sensitivity, specificity and inter-observer agreement.

RESULTS

Of 1205 articles identified using our broad search terms, we identified 58 eligible trials conducted in 38 countries, mainly in high-income settings. Vaccines made up the majority (90%) of interventions, particularly influenza vaccines (65%). Only 15 trials provided explicit definitions of wheeze. Of 24 studies that described severity, 11 described wheeze severity in the context of an explicit wheeze definition. The remaining 13 studies described wheeze severity where wheeze was defined as part of a respiratory illness or a wheeze equivalent. Wheeze descriptions were elicited from caregiver reports (14%), physical examination by a health worker (45%) or a combination (41%). There were 21/58 studies in which wheeze definitions included combined caregiver report and healthcare worker assessment. The use of these two methods appeared to have the highest combined sensitivity and specificity.

CONCLUSION

Standardized wheeze definitions and severity grading scales for use in pediatric vaccine or drug trials are lacking. Standardized definitions of wheeze are needed for assessment of possible adverse events as new vaccines and drugs are evaluated.

Criterion validity of the Strengths and Difficulties Questionnaire (SDQ) with inpatient adolescents

Increasing rates of adolescent admissions to inpatient psychiatric settings and acute length of stay necessitates valid psychiatric screening tools. The Strengths and Difficulties Questionnaire (SDQ) appears to have valuable clinical application due to its brevity and strong psychometric properties. In this study we aimed to evaluate the criterion validity of the SDQ in 159 psychiatric inpatients between the ages of 12-17 against the Computerized Diagnostic Interview Schedule for Children (CDISC). In determining the criterion validity of the SDQ against the CDISC-IV, we further sought to compare its classification accuracy with the DSM-oriented scales of two widely-used clinical screeners for children and adolescents, the Child Behavior Checklist (CBCL) and Youth Self Report (YSR). Results demonstrated comparable diagnostic accuracy for the three measures in detecting common emotional and behavioral disorders. Tentative clinical cutoffs were proposed specific to American adolescents for parent and youth reports. Sensitivity and specificity values are also reported and discussed.

Technologies for detecting falsified and substandard drugs in low and middle-income countries

Falsified and substandard drugs are a global health problem, particularly in low- and middle-income countries (LMIC) that have weak pharmacovigilance and drug regulatory systems. Poor quality medicines have important health consequences, including the potential for treatment failure, development of antimicrobial resistance, and serious adverse drug reactions, increasing healthcare costs and undermining the public's confidence in healthcare systems. This article presents a review of the methods employed for the analysis of pharmaceutical formulations. Technologies for detecting substandard and falsified drugs were identified primarily through literature reviews. Key-informant interviews with experts augmented our methods when warranted. In order to aid comparisons, technologies were assigned a suitability score for use in LMIC ranging from 0-8. Scores measured the need for electricity, need for sample preparation, need for reagents, portability, level of training required, and speed of analysis. Technologies with higher scores were deemed the most feasible in LMICs. We categorized technologies that cost $10,000 USD or less as low cost, $10,000-100,000 USD as medium cost and those greater than $100,000 USD as high cost technologies (all prices are 2013 USD). This search strategy yielded information on 42 unique technologies. Five technologies were deemed both low cost and had feasibility scores between 6-8, and an additional four technologies had medium cost and high feasibility. Twelve technologies were deemed portable and therefore could be used in the field. Many technologies can aid in the detection of substandard and falsified drugs that vary from the simplest of checklists for packaging to the most complex mass spectrometry analyses. Although there is no single technology that can serve all the requirements of detecting falsified and substandard drugs, there is an opportunity to bifurcate the technologies into specific niches to address specific sections within the workflow process of detecting products.

Patterns and predictors of multiple sexual partnerships among newly arrived Latino migrant men

Multiple sexual partnerships (MSP), both concurrent and serial short gap, are thought to increase the risk of HIV and sexually transmitted infection (STI) acquisition and transmission. In this study we evaluate potential individual and environmental risk factors for engaging in MSP in a cohort of newly arrived Latino migrant men (LMM) in New Orleans, LA, USA. Participants were surveyed at three time points over a nine-month period to examine factors associated with MSP. Of the 113 men, 32.5 % reported ever MSP. In 290 observations, 19.5 % of men had concurrent, and 15.0 % had serial short gap partnerships in at least one interviews. Substance was associated with MSP, OR (95 % CI) 2.00 (1.16, 3.45) whereas belonging to a community organization was found to be protective, OR 0.32 (0.17, 0.59). Interventions to reduce substance use and promote social connection are needed to prevent a potential HIV/STI epidemic in this population.

Percutaneous Drainage of Aortic Aneurysm Sac Abscesses Following Endovascular Aneurysm Repair

Purpose: To report preliminary experiences with the treatment of aortic aneurysm sac abscesses following prior endovascular aortic aneurysm repair (EVAR) using computerized tomography (CT)-guided percutaneous drainage. Case Reports: Three patients aged 73 to 78 years with aortic aneurysm sac infections following prior EVAR, 2 of which were associated with aortoduodenal fistula, underwent CT-guided percutaneous drainage and catheter placement. One patient had complete resolution of the aortic aneurysm sac abscess following percutaneous drainage; 1 patient was stabilized to eventual extraanatomic bypass, graft explantation, and fistula repair; and 1 patient was temporized to debridement and fistula repair with endograft preservation. Conclusion: CT-guided percutaneous drainage may be a helpful therapy in selected patients for the treatment of aortic aneurysm sac infections following EVAR.

Under-reporting of infectious gastrointestinal illness in British Columbia, Canada: who is counted in provincial communicable disease statistics?

Under-reporting of infectious gastrointestinal illness (IGI) in British Columbia, Canada was calculated using simulation modelling, accounting for the uncertainty and variability of input parameters. Factors affecting under-reporting were assessed during a cross-sectional randomized telephone survey. For every case of IGI reported to the province, a mean of 347 community cases occurred (5th and 95th percentile estimates ranged from 181 to 611 community cases, respectively). Vomiting [odds ratio (OR) 2.15, 95% confidence interval (CI) 1.03-4.49] and antibiotic use in the previous 28 days (OR 3.59, 95% CI 1.17-10.97) significantly predicted health-care visits in a logistic regression model. In bivariate analyses, physicians were significantly less likely to request stool samples from patients with vomiting (RR 0.09, 95% CI 0.01-0.65) and patients of North American as opposed to non-North American cultural groups (RR 0.38, 95% CI 0.15-0.96). Physicians were more likely to request stool samples from older patients (P=0.003), patients with fewer household members (P=0.002) and those who reported anti-diarrhoeal use following illness (RR 3.33, 95% CI 1.32-8.45). People with symptoms of vomiting were under-represented in provincial communicable disease statistics. Differential degrees of under-reporting must be understood before biased surveillance data can be adjusted.

Auditory cortex stimulation for tinnitus

Functional imaging techniques have demonstrated a relationship between the intensity of tinnitus and the degree of reorganization of the primary auditory cortex. Studies in experimental animals and humans have revealed that tinnitus is associated with a synchronized hyperactivity in the auditory cortex and proposed that the underlying pathophysiological mechanism is thalamocortical dysrhythmia; hence, decreased auditory stimulation results in decreased firing rate, and decreased lateral inhibition. Consequently, the surrounding brain area becomes hyperactive, firing at gamma band rates; this is considered a necessary precondition of auditory consciousness, and also tinnitus. Synchronization of the gamma band activity could possibly induce a topographical reorganization based on Hebbian mechanisms. Therefore, it seems logical to try to suppress tinnitus by modifying the tinnitus-related auditory cortex reorganization and hyperactivity. This can be achieved using neuronavigation-guided transcranial magnetic stimulation (TMS), which is capable of modulating cortical activity. If TMS is capable of suppressing tinnitus, the effect should be maintained by implanting electrodes over the area of electrophysiological signal abnormality on the auditory cortex. The results in the first patients treated by auditory cortex stimulation demonstrate a statistically significant tinnitus suppression in cases of unilateral pure tone tinnitus without suppression of white or narrow band noise. Hence, auditory cortex stimulation could become a physiologically guided treatment for a selected category of patients with severe tinnitus.

Corticosterone release in response to repeated, short episodes of neonatal isolation: evidence of sensitization

Repeated isolation of neonatal rats produces persistent changes in physiology and behavior. In Experiment 1, we examined changes in plasma corticosterone (CORT) levels as a possible mechanism for the effects of isolation. Pups that were isolated from their mother and the nest for 1 h per day on postnatal days (PND) 2-9 were compared to control litters of pups that were either nonhandled or handled but not isolated. On PND 2, compared to nonhandled pups, handled pups had elevated CORT levels that returned to baseline levels within 30 to 60 min of return to the home cage. No significant elevation of CORT levels were found in handled pups on PND 9. The CORT levels of isolated pups were over twice those of nonhandled pups on PND 2 and four times those of nonhandled pups on PND 9. In Experiment 2, we investigated whether the increased CORT release in response to isolation on PND 9 was the result of the pups' treatment on the previous six days as against an effect of maturation. Plasma CORT levels were measured in rat pups that were either isolated, handled or nonhandled on PNDs 2-8 during the conditions of isolation, handling and nonhandling on PND 9. There were no differences among the groups in basal plasma levels of CORT. Handling on PND 9 did not result in elevated CORT levels in any of the groups. All three groups showed a significant increase in plasma CORT levels after isolation on PND 9. However, the CORT response to isolation of pups previously isolated on PND 2-8 were significantly higher than pups that were either handled or nonhandled on PNDs 2-8. Thus, daily episodes of isolation potentiate the hypothalamic-pituitary-adrenal response to stress.

Age-associated changes in basal c-fos transcription factor binding activity in rat hearts

The early response proto-oncogene c-fos is expressed at very low levels in the mammalian heart at baseline. To further investigate the mechanism of altered c-fos expression with age, we studied in the basal state the binding of five transcription proteins to their cognate sites in the c-fos promoter/enhancer region, in adult and old F344 rats. Our results show a reduced binding of E2F and AP1 proteins to the c-fos promoter in aging hearts. The major calcium/cyclic AMP response element (CRE) and SP1 binding was unchanged. The only increase seen with age was in the serum response element (SRE) binding proteins. SRE is the point of convergence of different signal transduction pathways (via MAP kinases and the Rho family of GTPases) at the c-fos promoter. Increased SRE binding may reflect a compensation for a decreased binding of other transcription proteins to the c-fos promoter, alteration in the phosphorylation status of SRF, or a change in the ternary complex factors Elk 1 or SAP 1. Other possibilities include defects in the signal transduction pathways with aging, which combine to produce an overall negative balance in the function of the c-fos promoter despite the increased SRE binding activity. Both in vitro and in vivo experiments have shown decreased c-fos expression with age. This may be due partly to alterations in the basal levels of transcription factor binding.

[Is dopaminergic therapy immunologically rejuvinating? Increased interferon-gamma production with the dopaminergic agent lisuride]

Eighteen patients with advanced Parkinson's disease (n = 13) or dopamine-sensitive dystonia (n = 5) were treated with the dopaminergic agent, lisuride, applied as a long-term subcutaneous infusion. The results were compared with those obtained in a group of younger, and a group of older, healthy volunteers. The liberation of gamma-interferon (gamma-IFN) following mitogenic stimulation of whole blood with phytohemagglutinin (PHA) was highly significantly elevated in comparison with the group of older healthy volunteers, and clearly, but not significantly, elevated in comparison with the younger group. There was no difference between patients with dystonia and those with Parkinson's disease. The effect observed is thus probably due to lisuride. This effect might explain the longer life expectancy and reduced proclivity for infection shown by patients with Parkinson's disease. It needs to be determined whether, on the basis of these initial data, a therapeutic principle for the treatment of diseases that can be directly influenced by gamma-IFN can be derived.

Lonidamine in high-risk breast cancer patients

Lonidamine revealed synergistic effects with anthracyclines and alkylating agents in experimental investigations. It differs from conventional cytostatics by acting on the cell energy metabolism and also lacks their typical side effects; therefore it may be valuable to be combined with established chemotherapeutic regimens. Because in unselected patients the results of randomized studies may be influenced by differences in type and combination of prognostic factors, we defined strict entry criteria: no previous systemic palliative treatment, disease-free interval less than or equal to 2 years, measurable visceral metastases, number of tumor sites less than or equal to 2, no brain or bone metastases, World Health Organization performance status less than or equal to 2, age less than or equal to 55. In an ongoing rate, remission duration, time to treatment failure, and survival time in patients treated with vindesin 3 mg/m2 plus epirubicin 100 mg/m2 plus cyclophosphamide 600 mg/m2 (day 1, intravenous, repeated every 3 weeks) +/- lonidamine 600 mg/day orally. Eight of 12 patients achieved an objective remission (complete response 4, partial response 4), 1 patients had a stable disease, 2 patients experienced tumor progression; 1 patient is not yet evaluable for response. In spite of the intensity of the therapy no treatment interval prolongation was necessary. Main toxicities were myelosuppression, nausea, emesis, alopecia, and in patients treated with lonidamine, mild myalgia. The addition of lonidamine to polychemotherapy did not affect myelosuppression. Differences in remission rates or remission duration due to lonidamine could not yet be demonstrated.

Regeneration of an enchondroma defect under the influence of an implant of human bone morphogenetic protein

A 29-year-old woman with an enchondroma that was expanding and eroding the palmar cortex of the middle phalanx was successfully treated by curettage and implantation of bone morphogenetic protein. The metaphysis and cortex were repaired by lamellar bone within 2 months. The medulla was completely filled with trabecular bone by 9 months. The full range of motion and normal functions of finger and hand joints were restored, and there was no recurrence or abnormalities at follow-up visits 2 1/2 years after the operation.