Telemedicine in Radiation Oncology: Is It Here to Stay? Impacts on Patient Care and Resident Education.

PURPOSE: Telemedicine was rapidly and ubiquitously adopted during the COVID-19 pandemic. However, there are growing discussions as to its role postpandemic. METHODS AND MATERIALS: We surveyed patients, radiation oncology (RO) attendings, and RO residents to assess their experience with telemedicine. Surveys addressed quality of patient care and utility of telemedicine for teaching and learning core competencies. Satisfaction was rated on a 6-point Likert-type scale. The quality of teaching and learning was graded on a 5-point Likert-type scale, with overall scores calculated by the average rating of each core competency required by the Accreditation Council for Graduate Medical Education (range, 1-5). RESULTS: Responses were collected from 56 patients, 12 RO attendings, and 13 RO residents. Patient feedback was collected at 17 new-patient, 22 on-treatment, and 17 follow-up video visits. Overall, 88% of patients were satisfied with virtual visits. A lower proportion of on-treatment patients rated their virtual visit as "very satisfactory" (68.2% vs 76.5% for new patients and 82.4% for follow-ups). Only 5.9% of the new patients and none of the follow-up patients were dissatisfied, and 27% of on-treatment patients were dissatisfied. The large majority of patients (88%) indicated that they would continue to use virtual visits as long as a physical examination was not needed. Overall scores for medical training were 4.1 out of 5 (range, 2.8-5.0) by RO residents and 3.2 (range, 2.0-4.0) by RO attendings. All residents and 92% of attendings indicated they would use telemedicine again; however, most indicated that telemedicine is best for follow-up visits. CONCLUSIONS: Telemedicine is a convenient means of delivering care to patients, with some limitations demonstrated for on-treatment patients. The majority of both patients and providers are interested in using telemedicine again, and it will likely continue to supplement patient care.

A Bayesian Approach for Estimating Dynamic Functional Network Connectivity in fMRI Data.

Dynamic functional connectivity, i.e., the study of how interactions among brain regions change dynamically over the course of an fMRI experiment, has recently received wide interest in the neuroimaging literature. Current approaches for studying dynamic connectivity often rely on ad-hoc approaches for inference, with the fMRI time courses segmented by a sequence of sliding windows. We propose a principled Bayesian approach to dynamic functional connectivity, which is based on the estimation of time varying networks. Our method utilizes a hidden Markov model for classification of latent cognitive states, achieving estimation of the networks in an integrated framework that borrows strength over the entire time course of the experiment. Furthermore, we assume that the graph structures, which define the connectivity states at each time point, are related within a super-graph, to encourage the selection of the same edges among related graphs. We apply our method to simulated task-based fMRI data, where we show how our approach allows the decoupling of the task-related activations and the functional connectivity states. We also analyze data from an fMRI sensorimotor task experiment on an individual healthy subject and obtain results that support the role of particular anatomical regions in modulating interaction between executive control and attention networks.

Artifact removal in the context of group ICA: A comparison of single-subject and group approaches.

Independent component analysis (ICA) has been widely applied to identify intrinsic brain networks from fMRI data. Group ICA computes group-level components from all data and subsequently estimates individual-level components to recapture intersubject variability. However, the best approach to handle artifacts, which may vary widely among subjects, is not yet clear. In this work, we study and compare two ICA approaches for artifacts removal. One approach, recommended in recent work by the Human Connectome Project, first performs ICA on individual subject data to remove artifacts, and then applies a group ICA on the cleaned data from all subjects. We refer to this approach as Individual ICA based artifacts Removal Plus Group ICA (IRPG). A second proposed approach, called Group Information Guided ICA (GIG-ICA), performs ICA on group data, then removes the group-level artifact components, and finally performs subject-specific ICAs using the group-level non-artifact components as spatial references. We used simulations to evaluate the two approaches with respect to the effects of data quality, data quantity, variable number of sources among subjects, and spatially unique artifacts. Resting-state test-retest datasets were also employed to investigate the reliability of functional networks. Results from simulations demonstrate GIG-ICA has greater performance compared with IRPG, even in the case when single-subject artifacts removal is perfect and when individual subjects have spatially unique artifacts. Experiments using test-retest data suggest that GIG-ICA provides more reliable functional networks. Based on high estimation accuracy, ease of implementation, and high reliability of functional networks, we find GIG-ICA to be a promising approach.

Reduced error signalling in medication-naive children with ADHD: associations with behavioural variability and post-error adaptations.

BACKGROUND: We examined the blood-oxygen level-dependent (BOLD) activation in brain regions that signal errors and their association with intraindividual behavioural variability and adaptation to errors in children with attention-deficit/hyperactivity disorder (ADHD). METHODS: We acquired functional MRI data during a Flanker task in medication-naive children with ADHD and healthy controls aged 8-12 years and analyzed the data using independent component analysis. For components corresponding to performance monitoring networks, we compared activations across groups and conditions and correlated them with reaction times (RT). Additionally, we analyzed post-error adaptations in behaviour and motor component activations. RESULTS: We included 25 children with ADHD and 29 controls in our analysis. Children with ADHD displayed reduced activation to errors in cingulo-opercular regions and higher RT variability, but no differences of interference control. Larger BOLD amplitude to error trials significantly predicted reduced RT variability across all participants. Neither group showed evidence of post-error response slowing; however, post-error adaptation in motor networks was significantly reduced in children with ADHD. This adaptation was inversely related to activation of the right-lateralized ventral attention network (VAN) on error trials and to task-driven connectivity between the cingulo-opercular system and the VAN. LIMITATIONS: Our study was limited by the modest sample size and imperfect matching across groups. CONCLUSION: Our findings show a deficit in cingulo-opercular activation in children with ADHD that could relate to reduced signalling for errors. Moreover, the reduced orienting of the VAN signal may mediate deficient post-error motor adaptions. Pinpointing general performance monitoring problems to specific brain regions and operations in error processing may help to guide the targets of future treatments for ADHD.

Presupplementary Motor Area Contributes to Altered Error Monitoring in Obsessive-Compulsive Disorder.

BACKGROUND: Hyperactive performance monitoring, as measured by the error-related negativity (ERN) in the event-related potential, is a reliable finding in obsessive-compulsive disorder (OCD) research and may be an endophenotype of the disorder. Imaging studies revealed inconsistent results as to which brain regions are involved in altered performance monitoring in OCD. We investigated performance monitoring in OCD with simultaneous recording of electroencephalography (EEG) and functional magnetic resonance imaging (fMRI) signals to determine the neural source of the enhanced ERN. METHODS: Concurrent EEG and fMRI data were collected from 20 patients with OCD and 22 healthy control subjects during a flanker task. Independent component analysis was used separately on EEG and fMRI to segment the data functionally and focus on processes of interest. The ERN, hemodynamic responses following errors, and intraindividual correlation of the ERN and blood oxygen level-dependent activity were compared between groups. RESULTS: Patients with OCD showed significantly increased ERN amplitudes. Blood oxygen level-dependent activity in midcingulate cortex was not significantly different between groups. Increased activation of the right amygdala and the subgenual anterior cingulate cortex following errors was observed in patients with OCD. Increased intraindividual correlation of the ERN and activity of the presupplementary motor area was found in patients with OCD compared with healthy controls. CONCLUSIONS: Higher error-related activity was found in the amygdala and subgenual anterior cingulate cortex, suggesting a stronger affective response toward errors in patients with OCD. Additionally, increased correlation of the ERN and presupplementary motor area may indicate stronger recruitment of proactive control in OCD.

Multidimensional frequency domain analysis of full-volume fMRI reveals significant effects of age, gender, and mental illness on the spatiotemporal organization of resting-state brain activity.

Clinical research employing functional magnetic resonance imaging (fMRI) is often conducted within the connectionist paradigm, focusing on patterns of connectivity between voxels, regions of interest (ROIs) or spatially distributed functional networks. Connectivity-based analyses are concerned with pairwise correlations of the temporal activation associated with restrictions of the whole-brain hemodynamic signal to locations of a priori interest. There is a more abstract question however that such spatially granular correlation-based approaches do not elucidate: Are the broad spatiotemporal organizing principles of brains in certain populations distinguishable from those of others? Global patterns (in space and time) of hemodynamic activation are rarely scrutinized for features that might characterize complex psychiatric conditions, aging effects or gender-among other variables of potential interest to researchers. We introduce a canonical, transparent technique for characterizing the role in overall brain activation of spatially scaled periodic patterns with given temporal recurrence rates. A core feature of our technique is the spatiotemporal spectral profile (STSP), a readily interpretable 2D reduction of the native four-dimensional brain × time frequency domain that is still "big enough" to capture important group differences in globally patterned brain activation. Its power to distinguish populations of interest is demonstrated on a large balanced multi-site resting fMRI dataset with nearly equal numbers of schizophrenia patients and healthy controls. Our analysis reveals striking differences in the spatiotemporal organization of brain activity that correlate with the presence of diagnosed schizophrenia, as well as with gender and age. To the best of our knowledge, this is the first demonstration that a 4D frequency domain analysis of full volume fMRI data exposes clinically or demographically relevant differences in resting-state brain function.

Dynamic coherence analysis of resting fMRI data to jointly capture state-based phase, frequency, and time-domain information.

Many approaches for estimating functional connectivity among brain regions or networks in fMRI have been considered in the literature. More recently, studies have shown that connectivity which is usually estimated by calculating correlation between time series or by estimating coherence as a function of frequency has a dynamic nature, during both task and resting conditions. Sliding-window methods have been commonly used to study these dynamic properties although other approaches such as instantaneous phase synchronization have also been used for similar purposes. Some studies have also suggested that spectral analysis can be used to separate the distinct contributions of motion, respiration and neurophysiological activity from the observed correlation. Several recent studies have merged analysis of coherence with study of temporal dynamics of functional connectivity though these have mostly been limited to a few selected brain regions and frequency bands. Here we propose a novel data-driven framework to estimate time-varying patterns of whole-brain functional network connectivity of resting state fMRI combined with the different frequencies and phase lags at which these patterns are observed. We show that this analysis identifies both broad-band cluster centroids that summarize connectivity patterns observed in many frequency bands, as well as clusters consisting only of functional network connectivity (FNC) from a narrow range of frequencies along with associated phase profiles. The value of this approach is demonstrated by its ability to reveal significant group differences in males versus females regarding occupancy rates of cluster that would not be separable without considering the frequencies and phase lags. The method we introduce provides a novel and informative framework for analyzing time-varying and frequency specific connectivity which can be broadly applied to the study of the healthy and diseased human brain.

Acetylcholine mediates behavioral and neural post-error control.

Humans often commit errors when they are distracted by irrelevant information and no longer focus on what is relevant to the task at hand. Adjustments following errors are essential for optimizing goal achievement. The posterior medial frontal cortex (pMFC), a key area for monitoring errors, has been shown to trigger such post-error adjustments by modulating activity in visual cortical areas. However, the mechanisms by which pMFC controls sensory cortices are unknown. We provide evidence for a mechanism based on pMFC-induced recruitment of cholinergic projections to task-relevant sensory areas. Using fMRI in healthy volunteers, we found that error-related pMFC activity predicted subsequent adjustments in task-relevant visual brain areas. In particular, following an error, activity increased in those visual cortical areas involved in processing task-relevant stimulus features, whereas activity decreased in areas representing irrelevant, distracting features. Following treatment with the muscarinic acetylcholine receptor antagonist biperiden, activity in visual areas was no longer under control of error-related pMFC activity. This was paralleled by abolished post-error behavioral adjustments under biperiden. Our results reveal a prominent role of acetylcholine in cognitive control that has not been recognized thus far. Regaining optimal performance after errors critically depends on top-down control of perception driven by the pMFC and mediated by acetylcholine. This may explain the lack of adaptivity in conditions with reduced availability of cortical acetylcholine, such as Alzheimer's disease.

Transcranial Magnetic Stimulation Changes Response Selectivity of Neurons in the Visual Cortex.

BACKGROUND: Transcranial magnetic stimulation (TMS) is used to selectively alter neuronal activity of specific regions in the cerebral cortex. TMS is reported to induce either transient disruption or enhancement of different neural functions. However, its effects on tuning properties of sensory neurons have not been studied quantitatively. OBJECTIVE/HYPOTHESIS: Here, we use specific TMS application parameters to determine how they may alter tuning characteristics (orientation, spatial frequency, and contrast sensitivity) of single neurons in the cat's visual cortex. METHODS: Single unit spikes were recorded with tungsten microelectrodes from the visual cortex of anesthetized and paralyzed cats (12 males). Repetitive TMS (4 Hz, 4 s) was delivered with a 70 mm figure-8 coil. We quantified basic tuning parameters of individual neurons for each pre- and post-TMS condition. The statistical significance of changes for each tuning parameter between the two conditions was evaluated with a Wilcoxon signed-rank test. RESULTS: We generally find long-lasting suppression which persists well beyond the stimulation period. Pre- and post-TMS orientation tuning curves show constant peak values. However, strong suppression at non-preferred orientations tends to narrow the widths of tuning curves. Spatial frequency tuning exhibits an asymmetric change in overall shape, which results in an emphasis on higher frequencies. Contrast tuning curves show nonlinear changes consistent with a gain control mechanism. CONCLUSIONS: These findings suggest that TMS causes extended interruption of the balance between sub-cortical and intra-cortical inputs.

EEG Spectral Features Discriminate between Alzheimer's and Vascular Dementia.

Alzheimer's disease (AD) and vascular dementia (VaD) present with similar clinical symptoms of cognitive decline, but the underlying pathophysiological mechanisms differ. To determine whether clinical electroencephalography (EEG) can provide information relevant to discriminate between these diagnoses, we used quantitative EEG analysis to compare the spectra between non-medicated patients with AD (n = 77) and VaD (n = 77) and healthy elderly normal controls (NC) (n = 77). We use curve-fitting with a combination of a power loss and Gaussian function to model the averaged resting-state spectra of each EEG channel extracting six parameters. We assessed the performance of our model and tested the extracted parameters for group differentiation. We performed regression analysis in a multivariate analysis of covariance with group, age, gender, and number of epochs as predictors and further explored the topographical group differences with pair-wise contrasts. Significant topographical differences between the groups were found in several of the extracted features. Both AD and VaD groups showed increased delta power when compared to NC, whereas the AD patients showed a decrease in alpha power for occipital and temporal regions when compared with NC. The VaD patients had higher alpha power than NC and AD. The AD and VaD groups showed slowing of the alpha rhythm. Variability of the alpha frequency was wider for both AD and VaD groups. There was a general decrease in beta power for both AD and VaD. The proposed model is useful to parameterize spectra, which allowed extracting relevant clinical EEG key features that move toward simple and interpretable diagnostic criteria.

Static and Dynamic Intrinsic Connectivity following Mild Traumatic Brain Injury.

Mild traumatic brain injury (mTBI) is the most common neurological disorder and is typically characterized by temporally limited cognitive impairment and emotional symptoms. Previous examinations of intrinsic resting state networks in mTBI have primarily focused on abnormalities in static functional connectivity, and deficits in dynamic functional connectivity have yet to be explored in this population. Resting-state data was collected on 48 semi-acute (mean = 14 days post-injury) mTBI patients and 48 matched healthy controls. A high-dimensional independent component analysis (N = 100) was utilized to parcellate intrinsic connectivity networks (ICN), with a priori hypotheses focusing on the default-mode network (DMN) and sub-cortical structures. Dynamic connectivity was characterized using a sliding window approach over 126 temporal epochs, with standard deviation serving as the primary outcome measure. Finally, distribution-corrected z-scores (DisCo-Z) were calculated to investigate changes in connectivity in a spatially invariant manner on a per-subject basis. Following appropriate correction for multiple comparisons, no significant group differences were evident on measures of static or dynamic connectivity within a priori ICN. Reduced (HC > mTBI patients) static connectivity was observed in the DMN at uncorrected (p < 0.005) thresholds. Finally, a trend (p = 0.07) for decreased dynamic connectivity in patients across all ICN was observed during spatially invariant analyses (DisCo-Z). In the semi-acute phase of recovery, mTBI was not reliably associated with abnormalities in static or dynamic functional connectivity within the DMN or sub-cortical structures.

Deep learning for neuroimaging: a validation study.

Deep learning methods have recently made notable advances in the tasks of classification and representation learning. These tasks are important for brain imaging and neuroscience discovery, making the methods attractive for porting to a neuroimager's toolbox. Success of these methods is, in part, explained by the flexibility of deep learning models. However, this flexibility makes the process of porting to new areas a difficult parameter optimization problem. In this work we demonstrate our results (and feasible parameter ranges) in application of deep learning methods to structural and functional brain imaging data. These methods include deep belief networks and their building block the restricted Boltzmann machine. We also describe a novel constraint-based approach to visualizing high dimensional data. We use it to analyze the effect of parameter choices on data transformations. Our results show that deep learning methods are able to learn physiologically important representations and detect latent relations in neuroimaging data.

Impact of autocorrelation on functional connectivity.

Although the impact of serial correlation (autocorrelation) in residuals of general linear models for fMRI time-series has been studied extensively, the effect of autocorrelation on functional connectivity studies has been largely neglected until recently. Some recent studies based on results from economics have questioned the conventional estimation of functional connectivity and argue that not correcting for autocorrelation in fMRI time-series results in "spurious" correlation coefficients. In this paper, first we assess the effect of autocorrelation on Pearson correlation coefficient through theoretical approximation and simulation. Then we present this effect on real fMRI data. To our knowledge this is the first work comprehensively investigating the effect of autocorrelation on functional connectivity estimates. Our results show that although FC values are altered, even following correction for autocorrelation, results of hypothesis testing on FC values remain very similar to those before correction. In real data we show this is true for main effects and also for group difference testing between healthy controls and schizophrenia patients. We further discuss model order selection in the context of autoregressive processes, effects of frequency filtering and propose a preprocessing pipeline for connectivity studies.

Restricted Boltzmann machines for neuroimaging: an application in identifying intrinsic networks.

Matrix factorization models are the current dominant approach for resolving meaningful data-driven features in neuroimaging data. Among them, independent component analysis (ICA) is arguably the most widely used for identifying functional networks, and its success has led to a number of versatile extensions to group and multimodal data. However there are indications that ICA may have reached a limit in flexibility and representational capacity, as the majority of such extensions are case-driven, custom-made solutions that are still contained within the class of mixture models. In this work, we seek out a principled and naturally extensible approach and consider a probabilistic model known as a restricted Boltzmann machine (RBM). An RBM separates linear factors from functional brain imaging data by fitting a probability distribution model to the data. Importantly, the solution can be used as a building block for more complex (deep) models, making it naturally suitable for hierarchical and multimodal extensions that are not easily captured when using linear factorizations alone. We investigate the capability of RBMs to identify intrinsic networks and compare its performance to that of well-known linear mixture models, in particular ICA. Using synthetic and real task fMRI data, we show that RBMs can be used to identify networks and their temporal activations with accuracy that is equal or greater than that of factorization models. The demonstrated effectiveness of RBMs supports its use as a building block for deeper models, a significant prospect for future neuroimaging research.

Tracking whole-brain connectivity dynamics in the resting state.

Spontaneous fluctuations are a hallmark of recordings of neural signals, emergent over time scales spanning milliseconds and tens of minutes. However, investigations of intrinsic brain organization based on resting-state functional magnetic resonance imaging have largely not taken into account the presence and potential of temporal variability, as most current approaches to examine functional connectivity (FC) implicitly assume that relationships are constant throughout the length of the recording. In this work, we describe an approach to assess whole-brain FC dynamics based on spatial independent component analysis, sliding time window correlation, and k-means clustering of windowed correlation matrices. The method is applied to resting-state data from a large sample (n = 405) of young adults. Our analysis of FC variability highlights particularly flexible connections between regions in lateral parietal and cingulate cortex, and argues against a labeling scheme where such regions are treated as separate and antagonistic entities. Additionally, clustering analysis reveals unanticipated FC states that in part diverge strongly from stationary connectivity patterns and challenge current descriptions of interactions between large-scale networks. Temporal trends in the occurrence of different FC states motivate theories regarding their functional roles and relationships with vigilance/arousal. Overall, we suggest that the study of time-varying aspects of FC can unveil flexibility in the functional coordination between different neural systems, and that the exploitation of these dynamics in further investigations may improve our understanding of behavioral shifts and adaptive processes.

Brain functional networks extraction based on fMRI artifact removal: Single subject and group approaches.

Independent component analysis (ICA) has been widely applied to identify brain functional networks from multiple-subject fMRI. However, the best approach to handle artifacts is not yet clear. In this work, we study and compare two ICA approaches for artifact removal using simulations and real fMRI data. The first approach, recommended by the human connectome project, performs ICA on individual data to remove artifacts, and then applies group ICA on the cleaned data from all subjects. We refer to this approach as Individual ICA artifact Removal Plus Group ICA (TRPG). A second approach, Group Information Guided ICA (GIG-ICA), performs ICA on group data, and then removes the artifact group independent components (ICs), followed by individual subject ICA using the remaining group ICs as spatial references. Experiments demonstrate that GIG-ICA is more accurate in estimation of sources and time courses, more robust to data quality and quantity, and more reliable for identifying networks than IRPG.

Dynamic functional connectivity: promise, issues, and interpretations.

The brain must dynamically integrate, coordinate, and respond to internal and external stimuli across multiple time scales. Non-invasive measurements of brain activity with fMRI have greatly advanced our understanding of the large-scale functional organization supporting these fundamental features of brain function. Conclusions from previous resting-state fMRI investigations were based upon static descriptions of functional connectivity (FC), and only recently studies have begun to capitalize on the wealth of information contained within the temporal features of spontaneous BOLD FC. Emerging evidence suggests that dynamic FC metrics may index changes in macroscopic neural activity patterns underlying critical aspects of cognition and behavior, though limitations with regard to analysis and interpretation remain. Here, we review recent findings, methodological considerations, neural and behavioral correlates, and future directions in the emerging field of dynamic FC investigations.

Extracting intrinsic functional networks with feature-based group independent component analysis.

There is increasing use of functional imaging data to understand the macro-connectome of the human brain. Of particular interest is the structure and function of intrinsic networks (regions exhibiting temporally coherent activity both at rest and while a task is being performed), which account for a significant portion of the variance in functional MRI data. While networks are typically estimated based on the temporal similarity between regions (based on temporal correlation, clustering methods, or independent component analysis [ICA]), some recent work has suggested that these intrinsic networks can be extracted from the inter-subject covariation among highly distilled features, such as amplitude maps reflecting regions modulated by a task or even coordinates extracted from large meta analytic studies. In this paper our goal was to explicitly compare the networks obtained from a first-level ICA (ICA on the spatio-temporal functional magnetic resonance imaging (fMRI) data) to those from a second-level ICA (i.e., ICA on computed features rather than on the first-level fMRI data). Convergent results from simulations, task-fMRI data, and rest-fMRI data show that the second-level analysis is slightly noisier than the first-level analysis but yields strikingly similar patterns of intrinsic networks (spatial correlations as high as 0.85 for task data and 0.65 for rest data, well above the empirical null) and also preserves the relationship of these networks with other variables such as age (for example, default mode network regions tended to show decreased low frequency power for first-level analyses and decreased loading parameters for second-level analyses). In addition, the best-estimated second-level results are those which are the most strongly reflected in the input feature. In summary, the use of feature-based ICA appears to be a valid tool for extracting intrinsic networks. We believe it will become a useful and important approach in the study of the macro-connectome, particularly in the context of data fusion.

Data visualization in the neurosciences: overcoming the curse of dimensionality.

In publications, presentations, and popular media, scientific results are predominantly communicated through graphs. But are these figures clear and honest or misleading? We examine current practices in data visualization and discuss improvements, advocating design choices which reveal data rather than hide it.

Reliability of the amplitude of low-frequency fluctuations in resting state fMRI in chronic schizophrenia.

The resting state amplitude of low frequency fluctuations (ALFF) in functional magnetic resonance imaging has been shown to be reliable in healthy subjects, and to correlate with antipsychotic treatment response in antipsychotic-naïve schizophrenia patients. We found moderate to high test-retest stability of ALFF in chronically treated schizophrenia patients assessed twice over a median interval of 2.5 months.