Reward is not reward: Differential impacts of primary and secondary rewards on expectation, outcome, and prediction error in the human brain's reward processing regions

According to their nature, rewarding stimuli are classified as primary (e.g., food, sex) and secondary (e.g., money) rewards. Neuroimaging studies have provided valuable insights in neural reward processing and its various aspects including reward expectation, outcome and prediction error encoding. However, there is only limited evidence of whether the two different types of rewards are processed in common or distinct brain areas, in particular when considering the different functions of reward processing. We analyzed a sample of 42 healthy, male participants using task-based functional magnetic resonance imaging (fMRI) during a variant of the monetary incentive delay task. We aimed to investigate the effects of three different rewarding stimuli-two primary (food and sex) and one secondary (money)-on the various functions of reward processing. To provide a thorough description, we focused on 12 brain regions of interest and utilized the Bayes factor bound (BFB) to express stimulus-related main effects and pairwise differences at different levels of evidence, ranging from weak to decisive. Our results revealed a dominance of sexually charged stimuli in engaging the brain's reward structures for all investigated aspects of reward processing. Nevertheless, the ventral tegmental area, amygdala, ventral caudate, ventromedial prefrontal cortex, subgenual anterior cingulate cortex, and lateral orbitofrontal cortex were activated by both primary and secondary reward outcomes. For other reward processing functions, i.e., reward expectation and the prediction error, effects of the different stimuli were weaker, and effects from one reward type cannot easily be generalized to the other.

Adjuvant capecitabine versus nihil in older patients with node-positive/high-risk node-negative early breast cancer receiving ibandronate - The ICE randomized clinical trial

AIM OF THE STUDY

Evaluation of the impact of a de-escaleted chemotherapy regimen consisting of capecitabine (Cap) on invasive disease-free survival (iDFS) in patients ≥65 years with node-positive/high-risk node-negative early breast cancer (BC) receiving ibandronate (Ib).

METHODS

ICE (Ib with or without Cap in Elderly patients with early breast cancer) was a multicentre phase 3 clinical trial with a 2020 update of long-term follow-up for overall survival enroling node-positive/high-risk node-negative patients ≥65 years with early BC. Patients were randomised to Cap 2000 mg/m² day 1-14 q3w for 6 cycles plus Ib (50 mg p.o. daily or alternatively 6 mg intravenous q4w) or Ib alone for 2 years. Endocrine therapy was recommended for hormone receptor (HR)-positive patients. The primary endpoint was iDFS analysed using Cox proportional hazards regression and log-rank analysis.

RESULTS

1358 (96.4%) of 1409 randomised patients started treatment. 564 (83.4%) completed 6 cycles of Cap. 513 (77.7%) and 516 (78.8%) completed Ib in the Cap+Ib and Ib alone arm, respectively. Median age was 71 (range 64-88) years, 1099 (81%) were HR-positive, 705 (51.9%) node-negative. At a median follow-up of 61.3 months, 5-year iDFS was 78.8% for Cap+Ib versus 75.0% for Ib alone (p = 0.80). Effects were independent of age, nodal, and HR status. The addition of Cap caused significantly higher skin and gastrointestinal toxicity.

CONCLUSIONS

The adjuvant combination of Cap+Ib did not show significantly better iDFS than Ib alone in node-positive/high-risk node-negative older BC patients, of whom HR-positive patients were also treated with endocrine therapy.

TRIAL REGISTRATION

Study in elderly patients with early breast cancer (ICE), NCT00196859, https://clinicaltrials.gov/ct2/show/NCT00196859?term=NCT00196859.

The potential association between psychiatric symptoms and the use of levonorgestrel intrauterine devices (LNG-IUDs): A systematic review

BACKGROUND

Levonorgestrel (LNG)-intrauterine devices (IUDs) are an effective method of contraception; however, there is growing evidence regarding potential psychiatric side effects such as depressive symptoms, anxiety, and suicidal thoughts. Therefore, we conducted this systematic review to summarise the psychiatric effects of using LNG-IUDs.

METHODS

We searched six databases (MEDLINE, Web of Science, Scopus, Science Direct, Cochrane Library, and PsycInfo), and we included all study designs. The included studies were extracted, quality assessed, and qualitatively summarised.

RESULTS

Out of the screened studies, only 22 were finally included. While ten studies showed increased depressive symptoms, two studies showed reduced symptoms. Moreover, one study showed increased anxiety, another one reported an increased risk of suicide, four studies concluded no association with depressive symptoms, and four other studies showed uncertainty about a potential association but mentioned other psychiatric symptoms.

CONCLUSION

Despite unreliable data, many studies report psychiatric symptoms associated with LNG-IUDs, predominantly depression. Gynaecologists, general practitioners, and psychiatrists should therefore be aware of these potential risks, especially depressive symptoms and suicidality. Counselling patients about these risks should be mandatory. Further studies should investigate the absolute risk of mental disorders associated with LNG-IUDs and other hormonal contraceptives.KEY MESSAGESMany researchers are reporting adverse psychiatric events associated with levonorgestrel intrauterine devices (LNG-IUDs).Despite their effectiveness, a proper psychiatric assessment should be done before inserting LNG-IUDs.Proper counselling regarding the depressive symptoms and suicidality should be done by the treating obstetrician.Further studies should investigate the absolute risk of mental disorders associated with LNG-IUDs and other hormonal contraceptives.

Neural Signatures of Error Processing in Depressed Adolescents with Comorbid Non-Suicidal Self-Injury (NSSI)

Non-suicidal self-injury (NSSI), as a highly prevalent psychiatric symptom in adolescents and young adults, is defined as the deliberate destruction of body tissue without suicidal intent. Impulsivity and dysfunctional response inhibition have been suggested to play a central role in adolescents' vulnerability to self-harm. To investigate the potentially distinct neurobiology of NSSI, we used a well-established Go/No Go task in which activation of the inferior frontal gyrus (IFG) and dorsal anterior cingulate cortex (dACC) is interpreted as a neural correlate of processing failed response inhibition. Task-based functional magnetic resonance imaging data were obtained from 14 adolescents with a diagnosis of major depression and a history of NSSI (MD-NSSI), 13 depressed adolescents without NSSI (MD-only), and 14 healthy controls (HC). In line with hypotheses of dysfunctional response inhibition, we observed increased rates of commission errors in MD-NSSI along with significantly reduced error-related activations of the dACC and IFG. Intact response inhibition, as reflected by low commission error rates not different from HC, was observed in MD-only, along with increased activation of the error-processing network. Our findings support the hypothesis of a distinct neurobiological signature of NSSI. Further research on biomarkers of NSSI could focus on behavioral and neural correlates of failed response inhibition.

Glutamate receptor 4 as a fluid biomarker for the diagnosis of psychiatric disorders

Psychiatric disorders are widely underreported diseases, especially in their early stages. So far, there is no fluid biomarker to confirm the diagnosis of these disorders. Proteomics data suggest the synaptic protein glutamate receptor 4 (GluR4), part of the AMPA receptor, as a potential diagnostic biomarker of major depressive disorder (MDD). A novel sandwich ELISA was established and analytically validated to detect GluR4 in cerebrospinal fluid (CSF) samples. A total of 85 subjects diagnosed with MDD (n = 36), bipolar disorder (BD, n = 12), schizophrenia (SCZ, n = 12) and neurological controls (CON, n = 25) were analysed. The data exhibited a significant correlation (r = 0.74; CI:0.62 to 0.82; p < 0.0001) with the antibody-free multiple reaction monitoring (MRM) mass spectrometry (MS) data. CSF GluR4 levels were lower in MDD (p < 0.002) and BD (p = 0.012) than in CON. Moreover, subjects with SCZ described a trend towards lower levels than CON (p = 0.13). The novel GluR4 ELISA may favour the clinical application of this protein as a potential diagnostic biomarker of psychiatric disorders and may facilitate the understanding of the pathophysiological mechanisms behind these disorders.

Impact of serotonin transporter (SERT) binding affinity on the risk of libido disorders related to antidepressants

Introduction

Sexual dysfunction is a frequent adverse drug reaction (ADR) of antidepressants that considerably affects quality of life and adherence to therapy. We previously investigated the potential underlying neurofunctional mechanisms by neuroimaging methods and revealed a dampening of the dopaminergic mesolimbic-mesocortical reward system along with decreased sexual functioning under serotonergic antidepressants compared to placebo.

Objectives

Within a combined pharmacoepidemiologic and pharmacodynamic approach, we examined the association between serotonin transporter (SERT) affinity of various antidepressants and corresponding alterations in sexual desire as ADR.

Methods

Using disproportionality analyses, reporting odds ratios (RORs) were calculated for reports indicating decreased sexual desire as ADR under the antidepressants. The data were extracted from the WHO global database of individual case safety reports VigiBase and several MedDRA terms were grouped for “Sexual Desire Disorders”. For the pharmacodynamic assessment, we calculated Pearson correlation coefficients between SERT affinity and corresponding RORs

Results

16 signals were detected for “Sexual Desire Disorders”. We observed a statistically significant (r (20) =. 65, p = 0.001) association between SERT affinity and decreased sexual desire. Higher SERT affinity was associated with higher risk of sexual desire.

Conclusions

While sexual dysfunctions under serotonergic medication were previously described, we now elaborated that in particular attenuated sexual desire as ADR is associated with SERT affinity of the antidepressant. These results strengthen our previously described neurofunctional model regarding sexual dysfunction under antidepressant medication and indicate that the specific SERT affinity of the antidepressant drug should be considered in clinical practice to minimize the risk of this ADR.

Disclosure

No significant relationships.

Glial fibrillary acidic protein as blood biomarker for differential diagnosis and severity of major depressive disorder

Neuroinflammation has been connected to the pathophysiology of major depressive disorder (MDD) and neurochemical biomarkers of glial pathology could aid the diagnosis and might support patient stratification and monitoring in clinical trials. Our study aimed to determine the utility of glial fibrillary acidic protein (GFAP), a marker of astrocyte activation, for the differential diagnosis and monitoring of MDD. Employing Simoa technology we measured levels of GFAP in prospectively collected serum samples from 81 age-matched patients with MDD, schizophrenia (SZ), bipolar disorder (BP), and healthy controls (HC). Highest GFAP levels were determined for MDD. At a cut-off of 130 pg/ml, MDD could be discriminated with 87% sensitivity from SZ and BP (specificity 70%) and from HC (specificity 56%). GFAP levels increased with age (r = 0.5236, p = 0.0002) and with MDD severity quantified based on the Montgomery-Åsberg Depression Rating Scale (r = 0.4308, p = 0.0221). Neurofilament light chain serum levels were not different in the diagnostic groups and not associated with GFAP levels (r = 0.0911, p = 0.576) pointing to an independence of astrocyte activation on neurodegeneration. Our study provides first evidence that serum GFAP levels could improve the differential diagnosis of MDD and that depression severity could be objectively quantified using serum GFAP levels. Furthermore, serum GFAP might represent a marker to monitor astroglial pathology in the course of MDD.

Diagnostic criteria for enduring sexual dysfunction after treatment with antidepressants, finasteride and isotretinoin

BACKGROUND:

A set of enduring conditions have been reported in the literature involving persistent sexual dysfunction after discontinuation of serotonin reuptake inhibiting antidepressants, 5 alpha-reductase inhibitors and isotretinoin.

OBJECTIVE:

To develop diagnostic criteria for post-SSRI sexual dysfunction (PSSD), persistent genital arousal disorder (PGAD) following serotonin reuptake inhibitors, post-finasteride syndrome (PFS) and post-retinoid sexual dysfunction (PRSD).

METHODS:

The original draft was designed using data from two published case series (Hogan et al., 2014 and Healy et al., 2018), which represent the largest public collections of data on these enduring conditions. It was further developed with the involvement of a multidisciplinary panel of experts.

RESULTS:

A set of criteria were agreed upon for each of the above conditions. Features of PSSD, PFS and PRSD commonly include decreased genital and orgasmic sensation, decreased sexual desire and erectile dysfunction. Ancillary non-sexual symptoms vary depending on the specific condition but can include emotional blunting and cognitive impairment. PGAD presents with an almost mirror image of unwanted sensations of genital arousal or irritability in the absence of sexual desire. A new term, post-SSRI asexuality, is introduced to describe a dampening of sexual interest and pleasure resulting from a pre-natal or pre-teen exposure to a serotonin reuptake inhibitor.

CONCLUSIONS:

These criteria will help in both clinical and research settings. As with all criteria, they will likely need modification in the light of developments.

Quality of Life in SMA Patients Under Treatment With Nusinersen

Background: Spinal Muscular Atrophy (SMA) is a severe neurodegenerative disease, characterized by progressive muscle weakness and atrophy. The approval of the antisense oligonucleotide (ASO) nusinersen now provides an effective pharmacological approach with the potential to slow down or stop disease progression with a potentially major impact on patients' well-being.

Objective: This study evaluates quality of life (QoL) in pediatric and adult patients over the course of therapy with nusinersen.

Methods: Twenty-six SMA patients treated with nusinersen were evaluated regarding global QoL (gQoL), health-related QoL (HRQoL) and depressiveness. Assessments were conducted three times over the first 6 months of treatment. Applied were different questionnaires: the Anamnestic Comparative Self-Assessment (ACSA) for gQoL, the Short Form-36 Health Survey (SF-36) for HRQoL in adult patients and the ALS Depression Inventory 12 Items (ADI-12) for depressiveness. The sample was matched with 22 healthy controls.

Results: Despite severe physical restrictions, patients reported high levels of QoL and low levels of depressiveness at study entry. Early disease onset and low levels of physical functioning were associated with better gQoL and lower levels of depressiveness. A significant decrease of gQoL in patients was evident over the course of the study. Still, adult patients reported a significant increase in perceived health.

Conclusions: Our study provides first insight that SMA patients experience a gQoL superior to healthy controls at start of therapy. This might indicate patients' high hopes and expectations toward treatment. gQoL returns to a level similar to that of healthy controls over the course of therapy.

Neural signature of error processing in major depression

The clinical presentation of major depression (MD) is heterogenous and comprises various affective and cognitive symptoms including an increased sensitivity to errors. Various electrophysiological but only few functional magnetic resonance imaging (fMRI) studies investigated neural error processing in MD with inconsistent findings. Thus, reliable evidence regarding neural signatures of error processing in patients with current MD is limited despite its potential relevance as viable neurobiological marker of psychopathology. We therefore investigated a sample of 16 young adult female patients with current MD and 17 healthy controls (HC). During fMRI, we used an established Erikson-flanker Go/NoGo-paradigm and focused on neural alterations during errors of commission. In the absence of significant differences in rates of errors of commission in MD compared to HC, we observed significantly (p < 0.05, FWE-corrected on cluster level) enhanced neural activations of the dorsal anterior cingulate cortex (dACC) and the pre-supplementary motor area (pre-SMA) in MD relative to HC and thus, in brain regions consistently associated to neural error processing and corresponding behavioral adjustments. Considering comparable task performance, in particular similar commission error rates in MD and HC, our results support the evidence regarding an enhanced responsivity of neural error detection mechanisms in MD as a potential neural signature of increased negative feedback sensitivity as one of the core psychopathological features of this disorder.

Emotional Components of Pain Perception in Borderline Personality Disorder and Major Depression-A Repetitive Peripheral Magnetic Stimulation (rPMS) Study

Various studies suggested alterations in pain perception in psychiatric disorders, such as borderline personality disorder (BPD) and major depression (MD). We previously investigated affective components of pain perception in BPD compared to healthy controls (HC) by increasing aversive stimulus intensities using repetitive peripheral magnetic stimulation (rPMS) and observed alterations in emotional rather than somatosensory components in BPD. However, conclusions on disorder specific alterations in these components of pain perception are often limited due to comorbid depression and medication in BPD. Here, we compared 10 patients with BPD and comorbid MD, 12 patients with MD without BPD, and 12 HC. We applied unpleasant somatosensory stimuli with increasing intensities by rPMS and assessed pain threshold (PT), cutaneous sensation, emotional valence, and arousal by a Self-Assessments Manikins scale. PTs in BPD were significantly higher compared to HC. The somatosensory discrimination of stimulus intensities did not differ between groups. Though elevated rPMS intensities led to increased subjective aversion and arousal in MD and HC, these emotional responses among intensity levels remained unchanged in BPD. Our data give further evidence for disorder-specific alterations in emotional components of pain perception in BPD with an absent emotional modulation among varying aversive intensity levels.

Depressive Disorder With Panic Attacks After Replacement of an Intrauterine Device Containing Levonorgestrel: A Case Report

The levonorgestrel-releasing intrauterine system (LNG-IUS) is used as hormonal contraception by millions of women worldwide. It is considered as a safe device with low rates of systemic adverse drug reactions (ADRs). However, an emerging evidence suggest mood changes as ADRs. Whereas most of these studies report psychiatric ADRs after the first implantation of the LNG-IUS, it has to be considered that these may also occur after replacement, even when psychiatric symptoms were not evident at the time of the initial insertion. A potential explanation for the development of psychiatric ADRs in subsequent LNG-IUS may rely on fluctuations of sex hormones throughout the female life cycle with changing windows of vulnerabilities for developing mood disorders. Thus, the reliable contraception for women remains a continual challenge. We present the case of a 41-year-old woman that used the LNG-IUS (Mirena®) for contraception over 5 years without any complaints. Within the first weeks after insertion of the second LNG-IUS, she developed a depressive syndrome and anxieties. An extensive somatic, including gynecological examination revealed no pathological findings and a mental disorder was suggested. Due to the patient´s request and the recommendation of her psychiatrist, the device was removed and led to a remission of her mental complaints up to a 6- and 12-months follow-up. Beyond the mood changes considerably affecting her quality of life, the patient raised the concerns that she has never been informed about potential ADRs on mental health and her remarks regarding the potential association between psychiatric symptoms and the LNG-IUS were considered as groundless. With this case, we strengthen previous observations regarding mood changes under LNG-IUS. Moreover, we illustrate that psychiatric symptoms may also occur as ADRs during the subsequent insertion. Thus, we emphasize that psychiatric symptoms have to be clearly communicated as ADRs to patients with LNG-IUS within a written informed consent and should be routinely examined by gynecologists.

Complementary and alternative medicine and musculoskeletal pain in the first year of adjuvant aromatase inhibitor treatment in early breast cancer patients

Background

Patients with breast cancer (BC) show strong interest in complementary and alternative medicine (CAM), particularly for adverse effects of adjuvant endocrine treatment — e.g., with letrozole. Letrozole often induces myalgia/limb pain and arthralgia, with potential noncompliance and treatment termination. This analysis investigated whether CAM before aromatase inhibitor (AI) therapy is associated with pain development and the intensity of AI-induced musculoskeletal syndrome (AIMSS) during the first year of treatment.

Patients and methods

The multicenter phase IV PreFace study evaluated letrozole therapy in postmenopausal, hormone receptor–positive patients with early BC. Patients were asked about CAM use before, 6 months after, and 12 months after treatment started. They recorded pain every month for 1 year in a diary including questions about pain and numeric pain rating scales. Data were analyzed for patients who provided pain information for all time points.

Results

Of 1396 patients included, 901 (64.5%) had used CAM before AI treatment. Throughout the observation period, patients with CAM before AI treatment had higher pain values, for both myalgia/limb pain and arthralgia, than non-users. Pain increased significantly in both groups over time, with the largest increase during the first 6 months. No significant difference of pain increase was noted regarding CAM use.

Conclusions

CAM use does not prevent or improve the development of AIMSS. Pain intensity was generally greater in the CAM group. Therefore, because of the risk of non-compliance and treatment discontinuation due to the development of higher pain levels, special attention must be paid to patient education and aftercare in these patients.

•

Pain levels of myalgia/limb pain and arthralgia increase under letrozole intake.

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Within one year pain levels increase in both, CAM users as well as non-CAM users.

•

In CAM users pain levels were higher at all time points than in non-CAM users.

•

The greatest increase of pain levels was noted in the first six treatment months.

•

CAM does not prevent or improve the development of myalgia/limb pain and arthralgia.

Preexisting musculoskeletal burden and its development under letrozole treatment in early breast cancer patients

One of the most common adverse events (AEs) occurring during treatment with aromatase inhibitors (AIs) is musculoskeletal pain. The aim of our study was to analyze the influence of preexisting muscle/limb pain and joint pain on the development of AI-induced musculoskeletal AEs. Women eligible for upfront adjuvant endocrine therapy with letrozole were included in the PreFace study, a multicenter phase IV trial. During the first treatment year, they were asked to record musculoskeletal AEs monthly by answering questions regarding pain symptoms and rating the pain intensity on a numeric rating scale from 0 (no pain) to 10 (very strong pain). Pain values were compared using nonparametric statistical tests. Overall, 1,416 patients were evaluable. The average pain value over all time points in women with preexisting muscle/limb pain was 4.3 (median 4.3); in those without preexisting pain, it was 2.0 (median 1.7). In patients without preexisting muscle/limb pain, pain levels increased relatively strongly within the first 6 months (mean increase +0.9, p < 0.00001) in comparison with those with preexisting pain (mean increase +0.3, p < 0.001), resulting in a statistically significant difference (p < 0.00001) between the two groups. The development of joint pain was similar in the two groups. Women without preexisting muscle/limb pain or joint pain have the greatest increase in pain after the start of adjuvant AI therapy. Women with preexisting pain have significantly higher pain values. The main increase in pain values takes place during the first 6 months of treatment.

Somatosensory Stimulus Intensity Encoding in Borderline Personality Disorder

Borderline Personality Disorder (BPD) is clinically characterized by emotional instability, interpersonal disturbances and dysfunctional behavior such as non-suicidal self-injury (NSSI). During NSSI, patients with BPD typically report analgesic or hypoalgesic phenomena, and pain perception and pain processing in BPD have been repeatedly investigated. Most of the studies so far focused on affective-motivational and cognitive-evaluative neural components of pain within categorial study designs. By contrast, rather basic somatosensory aspects such as neural intensity-encoding of somatosensory stimuli were not examined in further details. Thus, we investigated patients with BPD and healthy controls (HC) by functional magnetic resonance imaging (fMRI) during an unpleasant sensory stimulation task with parametrically increasing stimulus intensities. 15 females diagnosed with BPD and 15 HCs were investigated with fMRI during four individually adjusted levels of electrical stimulus intensities. Ratings of stimulus intensity were assessed by button presses during fMRI. fMRI-data were analyzed by analyses of variances (ANOVA) at a statistical threshold of p < 0.05 FWE-corrected on cluster level. Subjective ratings of stimulus intensities were alike between BPD and HC, and intensity levels identified with equal accuracy. Significant intensity-encoding neural activations were observed within the primary and secondary somtasensory cortex, the posterior insula, the posterior midcingulate cortex (pMCC) and the supplementary motor area (SMA) in both, HC and BPD. Notably, there were no significant between-groups differences in intensity-encoding neural activations, even at lowered significance thresholds. Present results suggest a similar neural somatosensory stimulus intensity encoding in BPD as previously observed on a behavioral level. The alterations in neural affective-motivational or cognitive-evaluative components reported so far may be restricted to pain rather than unpleasant stimulus processing and were absent in our study.

Biocompatibility of High-Flux Membranes

Standard dialysis with cuprophane membranes is known to stimulate the immune system. As a result of activation of macrophages various interleukins and tumor necrosis factor (TNF) are secreted, presenting further evidence of the poor biocompatibility of cuprophane. We investigated the immunogenic properties of three modern high-flux membranes. Seven patients were studied during hemodiafiltration sessions using either a polysulfone (F60, Fresenius), a polymethylmetacrylate (BK 2.1, Toray) or a cellulose triacetate (FB-210 U, Nipro) dialyzer in a hemodiafiltration procedure. Serial measurements were made during each treatment of interleukin-1β (II-1β), TNF, soluble IL-2 receptor (sII-2r), soluble CD4 (sCD4), soluble CD8 (sCD8), interferon gamma (IFNg) and neopterin. In contrast to the known increase of IL-1β, IL-2r and TNF with cuprophane membranes, none of the modern high-flux dialyzers stimulated the production of these factors. Significant decreases of neopterin and sCD4 were observed. IFNg and sCD8 did not change significantly. Our results suggest that the modern high-flux dialyzers are non-immunogenic, and thus provide further evidence of the superior biocompatibility of synthetic or semisynthetic membranes over the conventional cuprophane.

Effects of Unilateral Ligamentoplasty on Spinal Development in the Growing Rabbit

Numerous models of scoliosis have been proposed, but few were characterized geometrically, easily reproductible and avalaible for testing orthopaedic procedures. Sixteen growing rabbits underwent unilateral ligamentoplasty of three lumbar vertebrae using screws in the vertebral body. Spinal modifications were evaluated at six and 12 weeks post-operatively by radiography, scannography and histology. The mean lateral deviation was found to be 21°± 3.1 at six weeks and 41.6 ± 6.6 at 12 weeks. Significant lordosis, cyphosis or vertebral rotation were not observed. Vertebral torsion was significative (p <0.005). Histological assessments of the modifications of paraspinal muscles, intervertebral discs and articular facets were performed for evaluation of consequences of surgery, spinal immobilization and deviation. We concluded that unilateral ligamentoplasty produce a reproductible model of lateral deviation of the spine in the growing rabbit.

This article analyses the spinal deformities obtained after unilateral ligamentoplasty of three lumbar vertebrae. A time-dependent lateral deviation and a vertebral torsion were found but significant lordosis, cyphosis or vertebral rotation were not observed. Paraspinal muscles, intervertebral discs and articular facets modifications are reported. Clinical relevance of these data are discussed.

Neural Correlates of Social Inclusion in Borderline Personality Disorder

Humans engage in social interactions and have a fundamental need and motivation to establish and maintain social connections. Neuroimaging studies particularly focused on the neural substrates of social exclusion in healthy subjects (HC), borderline personality disorder (BPD), and major depression (MD). However, there is evidence regarding neural alterations also during social inclusion in BPD that we intended to elucidate in our study. Considering that patients with BPD often have comorbid MD, we investigated patients with BPD, and comorbid MD, patients with MD without BPD, and a sample of HC. By investigating these two clinical samples within one study design, we attempted to disentangle potential confounds arising by psychiatric disorder or medication and to relate neural alterations under social inclusion specifically to BPD. We investigated 48 females (15 BPD and MD, 16 MD, and 17 HC) aged between 18 and 40 years by fMRI (3T), using the established cyberball paradigm with social exclusion, inclusion, and passive watching conditions. Significant group-by-condition interaction effects (p < 0.05, FWE-corrected on cluster level) were observed within the dorsolateral (dlPFC) and dorsomedial prefrontal cortex (dmPFC), the temporo-parietal junction (TPJ), the posterior cingulate cortex (PCC), and the precuneus. Comparisons of estimated neural activations revealed that significant interaction effects were related to a relative increase in neural activations during social inclusion in BPD. In detail, we observed a significant increase in differential (social inclusion vs. passive watching) neural activation within the dmPFC and the PCC in BPD compared to both, MD and HC. However, significant interaction effects within the dlPFC and the TPJ could not specifically be linked to BPD considering that they did not differ significantly between the two clinical groups in post-hoc comparisons. Our study supports previous results on effects of social and inclusion in BPD, and provides further evidence regarding disorder specific neural alterations in BPD for brain regions associated with self-referential and mentalizing processes during social inclusion.

Differential Noradrenergic Modulation of Monetary Reward and Visual Erotic Stimulus Processing

We recently investigated the effects of the noradrenergic antidepressant reboxetine and the antipsychotic amisulpride compared to placebo on neural correlates of primary reinforcers by visual erotic stimulation in healthy subjects. Whereas, amisulpride left subjective sexual functions and corresponding neural activations unimpaired, attenuated neural activations were observed under reboxetine within the nucleus accumbens (Nacc) along with diminished behavioral sexual functioning. However, a global dampening of the reward system under reboxetine seemed not intuitive considering the complementary role of the noradrenergic to the dopamine system in reward-related learning mediated by prediction error processing. We therefore investigated the sample of 17 healthy males in a mean age of 23.8 years again by functional magnetic resonance imaging (fMRI), to explore the noradrenergic effects on neural reward prediction error signaling. Participants took reboxetine (4 mg/d), amisulpride (200 mg/d), and placebo each for 7 days within a randomized, double-blind, within-subject cross-over design. During fMRI, we used an established monetary incentive task to assess neural reward expectation and prediction error signals within the bilateral Nacc using an independent anatomical mask for a region of interest (ROI) analysis. Activations within the same ROI were also assessed for the erotic picture paradigm. We confirmed our previous results from the whole brain analysis for the selected ROI by significant (p < 0.05 FWE-corrected) attenuated activations within the Nacc during visual sexual stimulation under reboxetine compared to placebo. However, activations in the Nacc concerning prediction error processing and monetary reward expectation were unimpaired under reboxetine compared to placebo, along with unimpaired reaction times in the reward task. For both tasks, neural activations and behavioral processing were not altered by amisulpride compared to placebo. The observed attenuated neural activations within the Nacc during visual erotic stimulation along with unimpaired neural prediction error and monetary reward expectation processing provide evidence for a differential modulation of the neural reward system by the noradrenergic agent reboxetine depending on the presence of primary reinforcers such as erotic stimuli in contrast to secondary such as monetary rewards.

Noradrenergic modulation of neural erotic stimulus perception

We recently investigated neuromodulatory effects of the noradrenergic agent reboxetine and the dopamine receptor affine amisulpride in healthy subjects on dynamic erotic stimulus processing. Whereas amisulpride left sexual functions and neural activations unimpaired, we observed detrimental activations under reboxetine within the caudate nucleus corresponding to motivational components of sexual behavior. However, broadly impaired subjective sexual functioning under reboxetine suggested effects on further neural components. We now investigated the same sample under these two agents with static erotic picture stimulation as alternative stimulus presentation mode to potentially observe further neural treatment effects of reboxetine. 19 healthy males were investigated under reboxetine, amisulpride and placebo for 7 days each within a double-blind cross-over design. During fMRI static erotic picture were presented with preceding anticipation periods. Subjective sexual functions were assessed by a self-reported questionnaire. Neural activations were attenuated within the caudate nucleus, putamen, ventral striatum, the pregenual and anterior midcingulate cortex and in the orbitofrontal cortex under reboxetine. Subjective diminished sexual arousal under reboxetine was correlated with attenuated neural reactivity within the posterior insula. Again, amisulpride left neural activations along with subjective sexual functioning unimpaired. Neither reboxetine nor amisulpride altered differential neural activations during anticipation of erotic stimuli. Our results verified detrimental effects of noradrenergic agents on neural motivational but also emotional and autonomic components of sexual behavior. Considering the overlap of neural network alterations with those evoked by serotonergic agents, our results suggest similar neuromodulatory effects of serotonergic and noradrenergic agents on common neural pathways relevant for sexual behavior.

Absent substance use disorder and survival of extraordinarily high blood alcohol concentration

Introduction

Intoxications with alcohol are very frequent in clinical psychiatry and may lead to death depending on (maximum) blood alcohol concentration (BAC) and accompanying factors as liver function, tolerance, comedication, etc. Death may occur due to ethanol-induced respiratory depression and/or aspiration of gastric content (due to an impaired gag reflex); thus, securing of the airway and ventilation are occasionally necessary.

Objectives/aims

To illustrate the broad range of clinical outcomes of alcohol intoxications and their adequate therapy.

Methods

We present the case of a 58-year female patient with depression who demonstrated a very high BAC of 8.68 g/L (representing the highest survived BAC in literature) due to ingestion of large amounts of alcohol with suicidal intent.

Results

Intubation and ventilation were lifesaving and the patient did not develop any physical or mental consequential damage. As the patient had not regularly used alcohol or any other psychotropic agent tolerance could be ruled out.

Conclusions

This case emphasizes the necessity of rapid securing of the airway in patients with alcohol intoxication and respiratory depression and, furthermore, illustrates the large inter-individual differences regarding ethanol susceptibility.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Survival of Very High Blood Alcohol Concentration Without Consequential Damage in a Patient Without a Previous Substance Use Disorder

Intoxications with alcohol may lead to death depending on (maximum) blood alcohol concentration (BAC) and accompanying factors such as liver function, tolerance, and comedication. Death may occur due to ethanol-induced respiratory depression and/or aspiration of gastric content (due to an impaired gag reflex); thus, securing of the airway and ventilation is occasionally necessary. A case of a 58-year-old female patient with depression who demonstrated a very high BAC of 8.68 gm/L (0.868%) following ingestion of large amounts of alcohol with suicidal intent is presented. Intubation and ventilation were life-saving, and the patient did not develop any physical or consequential damage. As the patient had not regularly used alcohol or any other psychotropic agent, tolerance could be ruled out. This case emphasizes the necessity of rapid securing of the airway in patients with alcohol intoxication and respiratory depression and, furthermore, illustrates the large interindividual differences regarding ethanol susceptibility.

Local and Global Resting State Activity in the Noradrenergic and Dopaminergic Pathway Modulated by Reboxetine and Amisulpride in Healthy Subjects

BACKGROUND

Various psychiatric populations are currently investigated with resting state fMRI, with the aim of individualizing diagnostics and treatment options and improving treatment outcomes. Many of these studies are conducted in large naturalistic samples, providing rich insights regarding disease-related neural alterations, but with the common psychopharmacological medication limiting interpretations of the results. We therefore investigated the effects of common noradrenergic and anti-dopaminergic medications on local and global resting state activity (rs-activity) in healthy volunteers to further the understanding of the respective effects independent from disease-related alterations.

METHODS

Within a randomized, double-blind, placebo-controlled crossover design, we investigated 19 healthy male subjects by resting state fMRI after the intake of reboxetine (4 mg/d), amisulpride (200mg/d), and placebo for 7 days each. Treatment-related differences in local and global rs-activity were measured by the fractional amplitude of low frequency fluctuations (fALFF) and resting state functional connectivity (rs-FC).

RESULTS

fALFF revealed alterations of local rs-activity within regions of the core noradrenergic pathway, including the locus coeruleus under reboxetine, correlated with its plasma levels. Moreover, reboxetine led to increased rs-FC between regions within this pathway, i.e. the locus coeruleus, tectum, thalamus, and amygdala. Amisulpride modulated local rs-activity of regions within the dopaminergic pathway, with the altered signal in the putamen correlating with amisulpride plasma levels. Correspondingly, amisulpride increased rs-FC between regions of the dopaminergic pathway comprising the substantia nigra and putamen.

CONCLUSION

Our data provide evidence of how psychopharmacological agents alter local and global rs-activity within the respective neuroanatomical pathways in healthy subjects, which may help with interpreting data in psychiatric populations.

Erotic stimulus processing under amisulpride and reboxetine: a placebo-controlled fMRI study in healthy subjects

BACKGROUND

Impaired sexual function is increasingly recognized as a side effect of psychopharmacological treatment. However, underlying mechanisms of action of the different drugs on sexual processing are still to be explored. Using functional magnetic resonance imaging, we previously investigated effects of serotonergic (paroxetine) and dopaminergic (bupropion) antidepressants on sexual functioning (Abler et al., 2011). Here, we studied the impact of noradrenergic and antidopaminergic medication on neural correlates of visual sexual stimulation in a new sample of subjects.

METHODS

Nineteen healthy heterosexual males (mean age 24 years, SD 3.1) under subchronic intake (7 days) of the noradrenergic agent reboxetine (4 mg/d), the antidopaminergic agent amisulpride (200mg/d), and placebo were included and studied with functional magnetic resonance imaging within a randomized, double-blind, placebo-controlled, within-subjects design during an established erotic video-clip task. Subjective sexual functioning was assessed using the Massachusetts General Hospital-Sexual Functioning Questionnaire.

RESULTS

Relative to placebo, subjective sexual functioning was attenuated under reboxetine along with diminished neural activations within the caudate nucleus. Altered neural activations correlated with decreased sexual interest. Under amisulpride, neural activations and subjective sexual functioning remained unchanged.

CONCLUSIONS

In line with previous interpretations of the role of the caudate nucleus in the context of primary reward processing, attenuated caudate activation may reflect detrimental effects on motivational aspects of erotic stimulus processing under noradrenergic agents.

Patients' preferences for subcutaneous trastuzumab versus conventional intravenous infusion for the adjuvant treatment of HER2-positive early breast cancer: final analysis of 488 patients in the international, randomized, two-cohort PrefHer study

BACKGROUND

Patients with HER2-positive early breast cancer (EBC) preferred subcutaneous (s.c.) trastuzumab, delivered via single-use injection device (SID), over the intravenous (i.v.) formulation (Cohort 1 of the PrefHer study: NCT01401166). Here, we report patient preference, healthcare professional satisfaction, and safety data pooled from Cohort 1 and also Cohort 2, where s.c. trastuzumab was delivered via hand-held syringe.

PATIENTS AND METHODS

Patients were randomized to receive four adjuvant cycles of 600 mg fixed-dose s.c. trastuzumab followed by four cycles of standard i.v. trastuzumab, or vice versa. The primary endpoint was overall preference proportions for s.c. or i.v., assessed by patient interviews in the evaluable ITT population.

RESULTS

A total of 245 patients were randomized to receive s.c. followed by i.v. and 243 received i.v. followed by s.c. (evaluable ITT populations: 235 and 232 patients, respectively). s.c. was preferred by 415/467 [88.9%; 95% confidence interval (CI) 85.7-91.6; P < 0.0001; two-sided test against null hypothesis of 65% s.c. preference]; 45/467 preferred i.v. (9.6%; 95% CI 7-13); 7/467 indicated no preference (1.5%; 95% CI 1-3). Clinician-reported adverse events occurred in 292/479 (61.0%) and 245/478 (51.3%) patients during the pooled s.c. and i.v. periods, respectively (P < 0.05; 2 × 2 χ(2)); 16 patients (3.3%) in each period experienced grade 3 events; none were grade 4/5.

CONCLUSIONS

PrefHer revealed compelling and consistent patient preferences for s.c. over i.v. trastuzumab, regardless of SID or hand-held syringe delivery. s.c. was well tolerated and safety was consistent with previous reports, including the HannaH study (NCT00950300). No new safety signals were identified compared with the known i.v. profile in EBC. PrefHer and HannaH confirm that s.c. trastuzumab is a validated and preferred option over i.v. for improving patients' care in HER2-positive breast cancer.

CLINICALTRIALSGOV REGISTRATION NUMBER

NCT01401166.

Development, implementation, and evaluation of a movie-based curriculum to teach psychopathology

BACKGROUND

Because medical students' attitudes toward psychiatry are often fostered by media, we provided an elective movie-based seminar to teach psychopathology.

DESCRIPTION

We assessed attitudes toward psychiatry by using the Attitudes towards Psychiatry (ATP 35) scale in a pre-post design. Furthermore we evaluated the knowledge of diagnostic criteria in a pre-post design within one sample.

EVALUATION

Of the 75 students who attended the seminar during 3 consecutive semesters, 54 (60.8% female) participated in the pre-post assessment. We observed a significant positive change in attitudes toward psychiatry and a significant gain of knowledge.

CONCLUSIONS

Using movies is a feasible and effective method to teach psychiatry.

SSRI-related modulation of sexual functioning is predicted by pre-treatment resting state functional connectivity in healthy men

Sexual dysfunction related to treatment with selective serotonin reuptake inhibitors (SSRIs) is a common reason for discontinuation of otherwise effective antidepressant treatment regimens. Thus, identification of subjects at risk for this side effect remains a crucial challenge. After demonstrating task-related neural correlates of impaired sexual functioning under treatment with the SSRI paroxetine (Abler et al., 2011), we studied (1) if resting state brain function before treatment predicts subsequent development of treatment-related modulation of sexual function, and (2) which neural circuits relate to different aspects of the impairment. Effects of paroxetine and bupropion administration over 1 week on subjective sexual functioning were investigated in 17 healthy male volunteers in a placebo-controlled, randomized cross-over design using the Massachusetts General Hospital Sexual Function Questionnaire. Data from a 10 min eyes-closed resting state scan were used to analyze functional connectivity under placebo in previously identified brain regions, focussing on the sublenticular extended amygdala (SLEA), dopaminergic midbrain, and anterior cingulate cortex. Resting state functional connectivities of the pregenual anterior cingulate cortex (pgACC), midbrain, and insula to the SLEA sufficiently predicted the development of subjective SSRI-related decreased sexual functioning and distinguished vulnerable from resilient subjects. Furthermore, connectivity with the midbrain particularly predicted orgasm-related deficits, while connectivity with pgACC predicted sexual satisfaction. Linking SSRI-related subjective sexual functioning to pre-treatment resting state connectivities in cortico-subcortical network of sexual processing, we demonstrated the potential of novel, non-invasive and passive brain imaging techniques to guide therapeutic decisions and adjust treatment protocols in psychiatric disorders and sexual medicine.

How good is the levothyroxine replacement in primary hypothyroidism patients in Brazil? Data of a multicentre study

BACKGROUND

Studies from every continent have shown that only around 50% of the patients subjected to thyroid hormone replacement have TSH in the normal range. However, to date, there are no consistent data about Brazil.

OBJECTIVES

To evaluate levothyroxine (LT4) replacement treatment in patients with primary hypothyroidism followed in referral centers in Brazil.

METHODS

Patients with primary hypothyroidism followed in referral centers (University Hospitals from Universidade Federal do Rio de Janeiro - UFRJ, Unicamp, Universidade Federal do Paraná - UFPR and Universidade Federal do Ceará-UFC) answered a questionnaire that inquired about clinical and biochemical conditions, social- economic status, life quality and clinicians' orientations as well as their understanding about the information given. Serum TSH was checked close to the interview.

RESULTS

2292 consecutive patients met the inclusion criteria. Mean age 51.2 yr and TSH values between 0.4 and 4.0 mUI/l were considered to be within the reference range. Among all patients taking thyroid medication, 42.7% had an abnormal serum TSH (28.3% were undertreated and 14.4% were overtreated). Approximately all patients (99%) took LT4 in the morning but less than 30 min before breakfast (85.4%). Regarding the clinicians' orientations: 97.5% of the patients were instructed to take the medication daily, and 92.6% to take 30 min before breakfast (92.6%). However, only 52.1% were told not to take LT4 along with other medication.

CONCLUSIONS

Our study found that a significant number of patients taking thyroid hormones were not in the therapeutic range. Clinicians should, therefore, consider monitoring patients on thyroid replacement more frequently and being more precise on giving recommendations about the correct use of LT4.

Mechanical endurance and in vivo radiographic analysis of a flexible, mono-unit cervical disc implant in intermediate follow-up period

AIM

The flexible artificial disc may create a system with a biomimetic structure that has the potential to tolerate dynamic motion in a way similar to a normal intervertebral disc over a long period. The objective was to evaluate the mechanical feasibility and clinical and radiological findings with a mono-unit and flexible artificial disc at intermediate-term follow-up.

METHODS

Fifty-six patients with degenerative disc disease were selected to participate in the study. They underwent discectomy with a flexible artificial disc with a mean follow-up period of 24.8 months. Outcomes were evaluated with the visual analogue scale (VAS) and Oswestry Disability Index (ODI). Mechanical endurance was evaluated by a dynamic testing.

RESULTS

Fifty one-levels and six bi-levels were included in the study (average age 41.8 years). VAS improved from 6.8 ± 2.2 to 1.5 ± 1.7 (P<0.05) and ODI improved from 43.1 ± 10.4 to 18.2 ± 10.2 (P<0.05). Disc height before mechanical testing was 8.9 mm, and decreased to 8.4 mm after six million cycles with no mechanical failure.

CONCLUSION

Our results indicate that flexible and mono-unit cervical disc provides favorable mechanical performance and clinical outcomes for at least a relatively intermediate-term follow up period. It is indicated that the flexible cervical disc maintains mobility at the level of the prosthesis that is comparable with preoperative ranges of motion. Further evaluation will be completed once long-term results have been obtained.

Modified-release recombinant human TSH (MRrhTSH) augments the effect of (131)I therapy in benign multinodular goiter: results from a multicenter international, randomized, placebo-controlled study

BACKGROUND

Recombinant human TSH (rhTSH) can be used to enhance (131)I therapy for shrinkage of multinodular goiter (MG).

OBJECTIVE, DESIGN, AND SETTING

The objective of the study was to compare the efficacy and safety of 0.01 and 0.03 mg modified-release (MR) rhTSH as an adjuvant to (131)I therapy, vs. (131)I alone, in a randomized, placebo-controlled, international, multicenter study.

PATIENTS AND INTERVENTION

Ninety-five patients (57.2 ± 9.6 yr old, 85% females, 83% Caucasians) with MG (median size 96.0, range 31.9-242.2 ml) were randomized to receive placebo (group A, n = 32), MRrhTSH 0.01 mg (group B, n = 30), or MRrhTSH 0.03 mg (group C, n = 33) 24 h before a calculated activity of (131)I.

MAIN OUTCOME MEASURES

The primary end point was a change in thyroid volume (by computerized tomography scan, at 6 months). Secondary end points were the smallest cross-sectional area of the trachea; thyroid function tests; Thyroid Quality of Life Questionnaire; electrocardiogram; and hyperthyroid symptom scale.

RESULTS

Thyroid volume decreased significantly in all groups. The reduction was comparable in groups A and B (23.1 ± 8.8 and 23.3 ± 16.5%, respectively; P = 0.95). In group C, the reduction (32.9 ± 20.7%) was more pronounced than in groups A (P = 0.03) and B. The smallest cross-sectional area of the trachea increased in all groups: 3.8 ± 2.9% in A, 4.8 ± 3.3% in B, and 10.2 ± 33.2% in C, with no significant difference among the groups. Goiter-related symptoms were effectively reduced and there were no major safety concerns.

CONCLUSION

In this dose-selection study, 0.03 mg MRrhTSH was the most efficacious dose as an adjuvant to (131)I therapy of MG. It was well tolerated and significantly augmented the effect of (131)I therapy in the short term. Larger studies with long-term follow-up are warranted.

[Painful swollen leg 52 years after bimalleolar fracture]

Calcific myonecrosis is a late complication of a previous trauma which presents as a calcified fusiforme mass on an x-ray film. It is affecting mostly the anterior compartment of the lower leg. 43 cases have been reported in the literature and are reviewed. The current authors report a case of calcific myonecrosis with calcific tenosynovitis of the tibialis anterior muscle. Precipitated hydroxyapatite crystals were found by ultrasound-guided aspiration, the lesion was then treated by injection of corticosteroids and an anesthetic.