MEG source imaging method using fast L1 minimum-norm and its applications to signals with brain noise and human resting-state source amplitude images.

The present study developed a fast MEG source imaging technique based on Fast Vector-based Spatio-Temporal Analysis using a L1-minimum-norm (Fast-VESTAL) and then used the method to obtain the source amplitude images of resting-state magnetoencephalography (MEG) signals for different frequency bands. The Fast-VESTAL technique consists of two steps. First, L1-minimum-norm MEG source images were obtained for the dominant spatial modes of sensor-waveform covariance matrix. Next, accurate source time-courses with millisecond temporal resolution were obtained using an inverse operator constructed from the spatial source images of Step 1. Using simulations, Fast-VESTAL's performance was assessed for its 1) ability to localize multiple correlated sources; 2) ability to faithfully recover source time-courses; 3) robustness to different SNR conditions including SNR with negative dB levels; 4) capability to handle correlated brain noise; and 5) statistical maps of MEG source images. An objective pre-whitening method was also developed and integrated with Fast-VESTAL to remove correlated brain noise. Fast-VESTAL's performance was then examined in the analysis of human median-nerve MEG responses. The results demonstrated that this method easily distinguished sources in the entire somatosensory network. Next, Fast-VESTAL was applied to obtain the first whole-head MEG source-amplitude images from resting-state signals in 41 healthy control subjects, for all standard frequency bands. Comparisons between resting-state MEG sources images and known neurophysiology were provided. Additionally, in simulations and cases with MEG human responses, the results obtained from using conventional beamformer technique were compared with those from Fast-VESTAL, which highlighted the beamformer's problems of signal leaking and distorted source time-courses.

Stellate ganglion block improves refractory post-traumatic stress disorder and associated memory dysfunction: a case report and systematic literature review.

The prevalence of post-traumatic stress disorder (PTSD) has reached epidemic proportions among U.S. veterans, many of whom also have concurrent alcohol use disorder. This case report describes improvements in PTSD symptom severity and memory dysfunction in a combat-exposed veteran with persistent PTSD and alcohol use disorder following two treatments of stellate ganglion block (SGB). PTSD severity was measured using the PTSD Checklist, Military Version. Memory function was evaluated using the Rey Auditory Verbal Learning Test. One month after the first SGB, a 43.6% reduction in PTSD severity was observed along with increases in immediate memory (50%), recent memory (28%), and recognition memory (25%). Following a second SGB, PTSD severity decreased by 57.7% and memory function substantially improved, with pronounced changes in immediate memory (50%), recent memory (58%), and recognition memory (36%). One year after SGB treatments, the patient has stopped drinking alcohol, continues to have sustained relief from PTSD, has improved memory function, and has become gainfully employed. Future studies that employ robust epidemiologic methodologies are needed to generate confirmatory evidence that would substantiate SGB's clinical utility as an adjunctive treatment option for PTSD.

Post-Traumatic Stress Disorder Treatment Outcomes in Military Clinics.

INTRODUCTION: Despite a wide literature describing the impact of PTSD on military personnel, there is limited information concerning the results of PTSD treatment within military clinics mental health. Having such information is essential for making predictions about service members' chances of recovery, choosing best treatments, and for understanding if new interventions improve upon the standard of care. MATERIALS AND METHODS: We reviewed data from the Psychological Health Pathways (PHP) database. Psychological Health Pathways is a standardized battery of demographics and psychometric outcome measures, including measurement of PTSD symptom severity, that is collected in military mental health clinics. We examined changes in PTSD symptom severity scores over time and developed logistic regression models to predict who responded to treatment, showed clinical success, or improved to the point that they could likely stay in the military. RESULTS: After about 10 weeks in mental health clinics, severity scores for PTSD, sleep, depression, resilience, and disability all improved significantly. Of 681 patients tracked, 38% had clinically significant reductions on the PTSD Checklist (PCL) (i.e., "treatment response"), 28% no longer met criteria for PTSD on the PCL, and 23% did both (i.e., "clinical treatment success"). For the ultimate end point of "military treatment success," defined as meeting criteria for both clinical treatment success and reporting that their work-related disability was mild or better, 12.8% of patients succeeded. Depression scores were the most powerful predictor of treatment failure. CONCLUSIONS: Recovery from PTSD is possible during military service, but it is less likely in individuals with certain negative prognostic factors, most notably severe depression.

An automatic MEG low-frequency source imaging approach for detecting injuries in mild and moderate TBI patients with blast and non-blast causes.

Traumatic brain injury (TBI) is a leading cause of sustained impairment in military and civilian populations. However, mild (and some moderate) TBI can be difficult to diagnose because the injuries are often not detectable on conventional MRI or CT. Injured brain tissues in TBI patients generate abnormal low-frequency magnetic activity (ALFMA, peaked at 1-4 Hz) that can be measured and localized by magnetoencephalography (MEG). We developed a new automated MEG low-frequency source imaging method and applied this method in 45 mild TBI (23 from combat-related blasts, and 22 from non-blast causes) and 10 moderate TBI patients (non-blast causes). Seventeen of the patients with mild TBI from blasts had tertiary injuries resulting from the blast. The results show our method detected abnormalities at the rates of 87% for the mild TBI group (blast-induced plus non-blast causes) and 100% for the moderate group. Among the mild TBI patients, the rates of abnormalities were 96% and 77% for the blast and non-blast TBI groups, respectively. The spatial characteristics of abnormal slow-wave generation measured by Z scores in the mild blast TBI group significantly correlated with those in non-blast mild TBI group. Among 96 cortical regions, the likelihood of abnormal slow-wave generation was less in the mild TBI patients with blast than in the mild non-blast TBI patients, suggesting possible protective effects due to the military helmet and armor. Finally, the number of cortical regions that generated abnormal slow-waves correlated significantly with the total post-concussive symptom scores in TBI patients. This study provides a foundation for using MEG low-frequency source imaging to support the clinical diagnosis of TBI.

Post-traumatic stress disorder symptom severity in service members returning from Iraq and Afghanistan with different types of injuries.

INTRODUCTION: Risk for post-traumatic stress disorder (PTSD) varies in part due to the nature of the traumatic event involved. Both injury and return from combat pose high risk of PTSD symptoms. How different injuries may predispose towards PTSD is less well understood. METHODS: A retrospective record review was conducted from 1402 service members who had returned to Naval Medical Center San Diego from Iraq or Afghanistan and who had completed the PTSD Checklist as part of their post-deployment screening. Rates of PTSD were examined in relation to mechanism of injury. RESULTS: Of those without injury, 8% met Diagnostic and Statistical Manual criteria for PTSD. Thirteen percent of those with a penetrating injury, 29% with blunt trauma, and 33% with combination injuries met criteria for PTSD. PTSD severity scores varied significantly according to type of injury. DISCUSSION: The World War I concept of "shell shock" implied that blast-related injuries were more likely to result in psychological symptoms than were other injuries. These data may support that idea. Circumstance of injury, population differences, and reporting bias could also have influenced the results. CONCLUSION: These results suggest that service members with blunt or combination injuries merit particular attention when screening for PTSD.

Development and testing of virtual reality exposure therapy for post-traumatic stress disorder in active duty service members who served in Iraq and Afghanistan.

This study was an open-label, single-group, treatment-development project aimed at developing and testing a method for applying virtual reality exposure therapy (VRET) to active duty service members diagnosed with combat post-traumatic stress disorder (PTSD). Forty-two service members with PTSD were enrolled, and 20 participants completed treatment. The PTSD Checklist-Military version, Patient Health Questionnaire-9 for depression, and the Beck Anxiety Inventory were used as outcome measures. Of those who completed post-treatment assessment, 75% had experienced at least a 50% reduction in PTSD symptoms and no longer met DSM-IV criteria for PTSD at post treatment. Average PSTD scores decreased by 50.4%, depression scores by 46.6%, and anxiety scores by 36%. Intention-to-treat analyses showed that statistically significant improvements in PTSD, depression, and anxiety occurred over the course of treatment and were maintained at follow up. There were no adverse events associated with VRET treatment. This study provides preliminary support for the use of VRET in combat-related PTSD. Further study will be needed to determine the wider utility of the method and to determine if it offers advantages over other established PTSD treatment modalities.

Reality graded exposure therapy with physiological monitoring for the treatment of combat related post traumatic stress disorder: a pilot study.

A high percentage of Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) combat veterans have been diagnosed with Posttraumatic Stress Disorder (PTSD) during and following their respective combat tours. Virtual Reality (VR) treatment has been documented as an exceptional treatment for anxiety disorders and specifically for PTSD. An Office of Naval Research (ONR) funded pilot study, completed by the Virtual Reality Medical Center and Naval Medical Center San Diego (NMCSD), investigated the use of Virtual Reality Graded Exposure Therapy (VR-GET) study with participants who had been diagnosed with PTSD following their combat deployments. A significant reduction in PTSD symptoms severity was noted. Implications for treatment with VR-GET and future research areas of investigation, including the use of VR-GET with smart phones and the internet, are suggested.

Use of computerized neuropsychological testing to help determine fitness to return to combat operations when taking medication that can influence cognitive function.

Nowhere is it more important to maintain peek mental functioning than in a combat zone. Conditions ranging from pain to head injury to post-traumatic stress disorder can cause impairments in neuropsychological function and place service members at risk. Medications can sometimes help alleviate these problems, but also have the risk of further slowing cognitive function or impairing reaction time. Standard methods of neuropsychological testing are often not available in a combat environment. New technologies are being advanced that can allow portable, computerized neuropsychological testing to be performed at almost any location. We present a case that demonstrates how the use of such handheld technology can assist a military physician in assessing the influence of medication on reaction time and in determining if and when a service member is ready to return to combat.

Insomnia is the most commonly reported symptom and predicts other symptoms of post-traumatic stress disorder in U.S. service members returning from military deployments.

This study retrospectively reviewed records from current members of the U.S. military who had completed the PTSD Checklist (PCL) at 0 and 3-months after returning from deployments. Insomnia was the most commonly reported symptom of PTSD on the PCL and had the highest average severity scores. At initial screen, 41% of those who had been to Iraq or Afghanistan reported sleep problems. Those who had initially reported any insomnia had significantly higher overall scores for PTSD severity at follow-up than did service members without such a complaint. These results show that insomnia is a particularly frequent, severe, and persistent complaint in service members returning from deployment. Such complaints merit particular attention in relation to the possibility of PTSD.

Use of a portable biofeedback device to improve insomnia in a combat zone, a case report.

Insomnia is a common problem in situations of stress. Some forms of stress, however, may contraindicate the use of traditional, pharmacological interventions. Working in a combat zone is such a situation. Alternative means of improving sleep are clearly needed for Service Members. We report a case involving a medical provider who was serving in a military, emergency-services facility in Iraq, and who presented with anxiety, depressed mood, and insomnia. Symptoms were sub-threshold for major depressive disorder or acute stress disorder. Mood and anxiety symptoms responded to traditional therapy techniques, but problems with insomnia remained. The patient was given a portable biofeedback device that employs an infrared sensor photoplethysmograph to measure heart rate variability (HRV) from peripheral finger pulse. One week later, sleep was significantly improved. Symptom improvement lasted to at least 6 weeks while in theater. One year later, a check-in with the patient revealed that after returning home, he had been diagnosed with post traumatic stress disorder (PTSD). PTSD symptoms had resolved after 6 months of psychopharmacology and cognitive behavioral therapy. These results indicate that biofeedback may be a useful means of improving sleep in a combat zone, but that such improvements may not necessarily prevent the development of more serious symptoms later. No clear causality can be inferred from a single case, and further study is needed to determine if this finding have wider applicability.

Intoxication with mouthwash presenting as psychosis and delirium in a combat theater.

Alcohol is prohibited in combat zones, but it still can be obtained via covert sources. This can cause complex issues for the military physician. We present a case of a U.S. Marine in Iraq who was noted to have intermittent and unexplained behavioral changes. The patient had repeatedly denied alcohol use, but during a second medical evacuation from theater, a blood alcohol level was drawn. Results did not come back fast enough to prevent the evacuation, but did eventually confirm that he was intoxicated. Mouthwash was the source. This case illustrates the importance of screening for alcohol abuse and intoxication even in situations in which conventional use of alcohol is not anticipated.

Combat-related post-traumatic stress disorder: a case report using virtual reality graded exposure therapy with physiological monitoring with a female Seabee.

In this report we describe virtual reality graded exposure therapy (VRGET) for the treatment of combat-related post-traumatic stress disorder (PTSD). In addition, we summarize the outcomes of a case study, from an Office Of Naval Research (ONR)-funded project of VRGET with an active duty female Seabee who completed three combat tours to Iraq. Details of the collaborative program involving this ONR-funded project at Naval Medical Center San Diego (NMCSD) and Naval Hospital Camp Pendleton (NHCP) are also discussed.

Cost effectiveness of virtual reality graded exposure therapy with physiological monitoring for the treatment of combat related post traumatic stress disorder.

Virtual Reality Graded Exposure Therapy (VRGET) is an effective treatment for combat-related PTSD. We summarize the outcomes of a VRGET pilot study with 12 participants who completed one to multiple combat tours in support of the War on Terrorism and who were subsequently diagnosed with combat-related PTSD. Details of the collaborative program amongst the Virtual Reality Medical Center (VRMC), Office of Naval Research, the Naval Medical Center San Diego (NMCSD) and the Navy Hospital Camp Pendleton are discussed as is the VRGET outcomes of significant reductions in PTSD symptoms severity. We also described the estimated cost-effectiveness of VRGET for the treatment of combat-related PTSD, as contrasted to Treatment as Usual (TAU) for combat-related PTSD.

VR PTSD exposure therapy results with active duty OIF/OEF combatants.

Post Traumatic Stress Disorder (PTSD) is reported to be caused by traumatic events that are outside the range of usual human experience including military combat, violent personal assault, being kidnapped or taken hostage and terrorist attacks. Reports indicate that at least 1 out of 6 Iraq War veterans are exhibiting symptoms of depression, anxiety and PTSD. Virtual Reality exposure therapy has been previously used for PTSD with reports of positive outcomes. This paper will present a brief description of the USC/ICT Virtual Iraq/Afghanistan PTSD therapy application and present clinical outcome data from active duty patients treated at the Naval Medical Center-San Diego (NMCSD) as of October 2009. Initial outcomes from the first twenty patients to complete treatment indicate that 16 no longer meet diagnostic criteria for PTSD at post treatment. Research and clinical tests using the Virtual Iraq/Afghanistan software are also currently underway at Weill Cornell Medical College, Emory University, Fort Lewis and WRAMC along with 20 other test sites.

Spousal military deployment as a risk factor for postpartum depression.

OBJECTIVE: To compare the Edinburgh Postnatal Depression Scale (EPDS) results in women whose spouses had deployed during or after pregnancy vs. those whose spouses had not. STUDY DESIGN: A chart review of 6-week postpartum visits of women with active-duty spouses was conducted over 10 months. Associations between military deployments and EPDS score were examined by Student's t test, and rates of positive screens (with a cutoff of 12) between groups were compared by odds ratio (OR). Linear regression was used to calculate predictors of EPDS score. RESULTS: A total of 415 charts were analyzed. The average EPDS score of women whose partner did deploy during the pregnancy was 7.36 compared to 4.81 for those whose partners did not (p < 0.001). The percentage of positive screens for women whose partner deployed during the pregnancy was 25.27% compared with 10.94% for an OR of 2.75 (p < 0.001). Linear regression showed partner's deployment during pregnancy to be an independent predictor of EPDS score (p < 0.005). CONCLUSION: Deployment of a spouse during pregnancy may be a risk factor for depression. Aggressive screening of this at-risk population is recommended.

Changes in prescription habits with the introduction of generic fluoxetine.

When the patent on fluoxetine expired in 2001, prices for it fell sharply and marketing decreased. We investigated how market share for fluoxetine changed with the introduction of the generic. Prescribing information was tracked at a military hospital where providers knew the cost of medication, but were not compelled to use the cheaper form. Market share for fluoxetine among selective serotonin reuptake inhibitors was observed for the 64 months surrounding the introduction, and changes were examined by linear regression analysis. Results showed that in the 32 months before the introduction of the generic, fluoxetine maintained a relatively steady share of prescriptions. After the introduction of the generic, fluoxetine steadily lost market share over time. No significant relationship could be seen between drug company visits and gains for their individual products. Examination of all Department of Defense prescriptions for the 16 months surrounding the introduction of generic fluoxetine showed a similar drop in its market share.

Virtual Iraq: initial results from a VR exposure therapy application for combat-related PTSD.

Post Traumatic Stress Disorder (PTSD) is reported to be caused by traumatic events that are outside the range of usual human experience including (but not limited to) military combat, violent personal assault, being kidnapped or taken hostage and terrorist attacks. Initial data suggests that at least 1 out of 6 Iraq War veterans are exhibiting symptoms of depression, anxiety and PTSD. Virtual Reality (VR) delivered exposure therapy for PTSD has been used with reports of positive outcomes. The aim of the current paper is to present the rationale and brief description of a Virtual Iraq PTSD VR therapy application and present initial findings from its use with PTSD patients. Thus far, Virtual Iraq consists of a series of customizable virtual scenarios designed to represent relevant Middle Eastern VR contexts for exposure therapy, including a city and desert road convoy environment. User-centered design feedback needed to iteratively evolve the system was gathered from returning Iraq War veterans in the USA and from a system deployed in Iraq and tested by an Army Combat Stress Control Team. Clinical trials are currently underway at Ft. Lewis, Camp Pendleton, Emory University, Weill Cornell Medical College, Walter Reed Army Medical Center, San Diego Naval Medical Center and 12 other sites.

Combat related post traumatic stress disorder: a multiple case report using virtual reality graded exposure therapy with physiological monitoring.

The current report summarizes case studies from an Office of Naval Research (ONR) funded project to compare the effects of Virtual Reality Graded Exposure Therapy (VRGET) with a treatment as usual control condition in active-duty Navy Corpsmen, Navy SeaBees and Navy and Marine Corps Support Personnel. Details of the collaborative program between the Virtual Reality Medical Center (VRMC) and Naval Medical Center San Diego (NMCSD) will be discussed.

Combat-related post-traumatic stress disorder: a case report using virtual reality exposure therapy with physiological monitoring.

The current report summarizes a case study from an Office of Naval Research (ONR) funded project to compare the effects of virtual reality graded exposure therapy (VRGET) with cognitive behavioral group therapy in active-duty corpsmen. Details of the collaborative program between the Virtual Reality Medical Center (VRMC) and Naval Medical Center San Diego (NMCSD) will be discussed.

A Randomized, Head-to-Head Study of Virtual Reality Exposure Therapy for Posttraumatic Stress Disorder.

Virtual reality exposure therapy (VRET) is one of the few interventions supported by randomized controlled trials for the treatment of combat-related posttraumatic stress disorder (PTSD) in active duty service members. A comparative effectiveness study was conducted to determine if virtual reality technology itself improved outcomes, or if similar results could be achieved with a control exposure therapy (CET) condition. Service members with combat-related PTSD were randomly selected to receive nine weeks of VRET or CET. Assessors, but not therapists, were blinded. PTSD symptom improvement was assessed one week and 3 months after the conclusion of treatment using the clinician-administered PTSD scale (CAPS). A small crossover component was included. Results demonstrated that PTSD symptoms improved with both treatments, but there were no statistically significant differences between groups. Dropout rates were higher in VRET. Of those who received VRET, 13/42 (31%) showed >30% improvement on the CAPS, versus 16/43 (37%) who received CET. Three months after treatment, >30% improvement was seen in 10/33 (30%) of VRET participants and 12/33 (36%) in CET. Participants who crossed over (n = 11) showed no statistically significant improvements in a second round of treatment, regardless of condition. This study supported the utility of exposure therapy for PTSD, but did not support additional benefit by the inclusion of virtual reality.