RESUMO
Introduction: Repetitive transcranial magnetic stimulation (rTMS) is a promising intervention for late-life depression (LLD) but may have lower rates of response and remission owing to age-related brain changes. In particular, rTMS induced electric field strength may be attenuated by cortical atrophy in the prefrontal cortex. To identify clinical characteristics and treatment parameters associated with response, we undertook a pilot study of accelerated fMRI-guided intermittent theta burst stimulation (iTBS) to the right dorsolateral prefrontal cortex in 25 adults aged 50 or greater diagnosed with LLD and qualifying to receive clinical rTMS. Methods: Participants underwent baseline behavioral assessment, cognitive testing, and structural and functional MRI to generate individualized targets and perform electric field modeling. Forty-five sessions of iTBS were delivered over 9 days (1800 pulses per session, 50-min inter-session interval). Assessments and testing were repeated after 15 sessions (Visit 2) and 45 sessions (Visit 3). Primary outcome measure was the change in depressive symptoms on the Inventory of Depressive Symptomatology-30-Clinician (IDS-C-30) from Visit 1 to Visit 3. Results: Overall there was a significant improvement in IDS score with the treatment (Visit 1: 38.6; Visit 2: 31.0; Visit 3: 21.3; mean improvement 45.5%) with 13/25 (52%) achieving response and 5/25 (20%) achieving remission (IDS-C-30 < 12). Electric field strength and antidepressant effect were positively correlated in a subregion of the ventrolateral prefrontal cortex (VLPFC) (Brodmann area 47) and negatively correlated in the posterior dorsolateral prefrontal cortex (DLPFC). Conclusion: Response and remission rates were lower than in recently published trials of accelerated fMRI-guided iTBS to the left DLPFC. These results suggest that sufficient electric field strength in VLPFC may be a contributor to effective rTMS, and that modeling to optimize electric field strength in this area may improve response and remission rates. Further studies are needed to clarify the relationship of induced electric field strength with antidepressant effects of rTMS for LLD.
RESUMO
Psoriasis and PsA are associated with comorbidities including cardiovascular disease, obesity, metabolic syndrome and depression. The purpose of this study was to examine if patients recognize that they are being monitored for comorbidities associated with their condition, and to determine which physicians are managing these comorbidities. Patients with psoriasis without arthritis (PsC) and patients with PsA were recruited from the University of Toronto Psoriasis Cohort and Psoriatic Arthritis Clinic, respectively. A comorbidity questionnaire was developed through a literature review and patients completed the questionnaire at clinic visits or over the telephone. PsA patient responses were compared with information recorded by physicians at clinic visits. A total of 268 patients (103 PsC and 164 PsA) were included. Patients indicated having their blood pressure (96.3%), weight (94.4%), blood sugar (75%) and cholesterol (79.5%) levels checked, with PsA patients indicating being checked more frequently than PsC patients. PsA patients were most uncertain about whether their blood sugar and cholesterol levels were checked by physicians. The highest correlation between patient responses and physician records occurred for medications for diabetes, depression and hypercholesterolemia. Patients indicated their family physician were most responsible in monitoring the comorbidities. Overall, patients documented being moderately well screened for most comorbidities and were most unsure about having their blood sugar and cholesterol levels monitored. Patient education and records should be improved at clinic visits, as there are discrepancies between patient responses and physician records regarding the presence and treatment of comorbidities.
