Allogeneic hematopoietic cell transplantation for adult metachromatic leukodystrophy: a case series.

ABSTRACT: Metachromatic leukodystrophy (MLD) is a rare genetic disorder caused by pathogenic variants of the ARSA gene, leading to a deficiency of the arylsulfatase A enzyme (ARSA) and consecutive accumulation of galactosylceramide-3-0-sulfate in the nervous system. The condition leads to severe neurological deficits and subsequently results in profound intellectual and motoric disability. Especially, the adult form of MLD, which occurs in individuals aged >16 years, poses significant challenges for treating physicians because of the rarity of cases, limited therapeutic options, and different allogeneic hematopoietic cell transplantation (allo-HCT) protocols worldwide. Here, we report the results of allo-HCT treatment in 4 patients with a confirmed adult MLD diagnosis. Bone marrow or mobilized peripheral progenitor cells were infused after a reduced intensity conditioning regime consisting of fludarabine and treosulfan. In 3 patients, allo-HCT was followed by an infusion of mesenchymal cells to further consolidate ARSA production. We observed a good tolerability and an increase in ARSA levels up to normal range values in all patients. A full donor chimerism was detected in 3 patients within the first 12 months. In a 1-year follow-up, patients with complete donor chimerism showed a neurological stable condition. Only 1 patient with an increasing autologous chimerism showed neurological deterioration and a decline in ARSA levels in the first year. In summary, allo-HCT offers a therapeutic option for reconstituting ARSA enzyme levels in adult patients with MLD, with tolerable side effects.

Dimensional distress and orbitofrontal thickness in anxiety patients.

Thickness of the medial orbitofrontal cortex (mOFC) was assessed as it varied with reported symptoms of anxiety and depression in a large sample of anxiety patients. A principal component analysis identified a primary factor of transdiagnostic dimensional distress that predicted 24% of the mOFC variance. Severity of distress symptomology was associated with thinning of the mOFC in both hemispheres for both men and women, regardless of the primary DSM diagnosis. Taken together, the data indicate that mOFC thickness might be useful as an objective measure of disorder severity as well as to assess pharmacological or psychological treatment outcome.

Imagery, emotion, and bioinformational theory: From body to brain.

The bioinformational theory of emotional imagery is a model of the hypothetical mental representations activated when people imagine emotionally engaging events, and was initially proposed to guide research and practice in the use of imaginal exposure as a treatment for fear and anxiety (Lang, 1979). In this 50 year overview, we discuss the development of bioinformational theory and its impact on the study of psychophysiology and psychopathology, most importantly assessing its viability and predictions in light of more recent brain-based studies of neural functional activation. Bioinformational theory proposes that narrative imagery, typically cued by language scripts, activates an associative memory network in the brain that includes stimulus (e.g., agents, contexts), semantic (e.g., facts and beliefs) and, most critically for emotion, response information (e.g., autonomic and somatic) that represents relevant real-world coping actions and reactions. Psychophysiological studies in healthy and clinical samples reliably find measurable response output during aversive and appetitive narrative imagery. Neuroimaging studies confirm that emotional imagery is associated with significant activation in motor regions of the brain, as well as in regions implicated in episodic and semantic memory retrieval, supporting the bioinformational view that narrative imagery prompts mental simulation of events that critically includes the actions and reactions engaged in emotional contexts.

Hippocampal and amygdala volumes vary with transdiagnostic psychopathological dimensions of distress, anxious arousal, and trauma.

Reduced hippocampal and/or amygdala volumes have been reported in patients with a variety of different anxiety diagnoses, suggesting that structural alterations may vary transdiagnostically across the internalizing disorders. The current study measured hippocampal and amygdala volumes in anxiety and mood disorder patients assessing differences that vary dimensionally with transdiagnostic factors of distress, anxious arousal, and trauma, based on a principal components analysis of questionnaires relating to symptomology. High-resolution structural images were collected in a sample of 165 patients, and volumes extracted from the hippocampal formation (including CA1, CA2/3, CA4/DG, subiculum, and molecular layer) and the amygdala. Transdiagnostically, increasing distress was associated with reduced hippocampal CA1 volume, increasing anxious arousal was associated with reduced hippocampal CA4/DG volume, and increasing trauma severity was associated with reduced amygdala volume in women. Taken together, the data indicate that subcortical brain volumes decrease as the severity of transdiagnostic psychopathological symptomology increases.

Neural correlates of repeated retrieval of emotional autobiographical events.

Understanding the neural correlates of repetitive retrieval of emotional events is critical in addressing pathological emotional processing, as repeated processing is central for a number of different therapeutic interventions. In the current study, single-trial functional brain activity was assessed in key regions implicated in episodic retrieval, including the medial prefrontal cortex (mPFC), anterior hippocampus, posterior hippocampus, and the posteromedial parietal cortex (i.e., posterior cingulate cortex and the precuneus) following repeated retrieval of pleasant and unpleasant autobiographical events. Replicating previous studies, repetition prompted reduced blood-oxygen-level-dependent (BOLD) amplitude in the anterior hippocampus and the mPFC, but not in the posterior hippocampus, due to no functional activity during mental imagery, or in the posteromedial parietal cortex, due to enhanced activation that was sustained across repetitions. Neural activation during pleasant and unpleasant autobiographical retrieval did not differ as a function of repetition, indicating similar processing effects regardless of motivational relevance. Taken together, the hedonic valence of retrieved memories does not affect functional activity associated with repeated retrieval of episodic events, in which the pattern of BOLD amplitude change suggests a dissociation between the hippocampal-prefrontal circuit, which shows repetition suppression, and the posteromedial parietal cortex, which shows sustained activation.

Narrative imagery: Emotional modulation in the default mode network.

The default mode network (DMN) is activated when constructing and imagining narrative events, with functional brain activity in the medial-prefrontal cortex hypothesized to be modulated during emotional processing by adding value (or pleasure) to the episodic representation. However, since enhanced reactivity during emotional, compared to neutral, content is a more frequent finding in both the brain and body in physiological, neural, and behavioral measures, the current study directly assesses the effects of pleasure and emotion during narrative imagery in the DMN by using a within-subject design to first identify the DMN during resting state and then assess activation during pleasant, neutral, or unpleasant imagery. Replicating previous findings, enhanced functional activity in the medial prefrontal cortex was found when imagining pleasant, compared to unpleasant, events. On the other hand, emotion-related activation was found when imagining either pleasant or unpleasant, compared to neutral, events in other nodes of the DMN including the posterior cingulate cortex (PCC), angular gyrus, anterior hippocampus, lateral temporal cortex, temporal pole, dorsomedial prefrontal cortex (dmPFC), and ventrolateral prefrontal cortex (vlPFC). Pervasive emotional modulation in the DMN is consistent with the view that a primary function of event retrieval and construction is to remember, recreate, and imagine motivationally relevant events important for planning adaptive behavior.

Trauma-related dysfunction in the fronto-striatal reward circuit.

INTRODUCTION: Reduced reactivity to pleasurable stimulation is a defining symptom of post-traumatic stress disorder (PTSD), but trauma exposure also increases the severity of many anxiety and mood disorders, including depression, social anxiety, and panic disorder, suggesting that reward system dysfunction might be pervasive in the internalizing disorders. The ventromedial prefrontal cortex (vmPFC) and ventral striatum are core components of the reward circuit and the current study assesses functional activity and connectivity in this circuit during emotional picture viewing in anxiety and mood disorder patients. METHOD: Functional brain activity (fMRI) and functional connectivity in the fronto-striatal circuit were measured in a large sample of patients diagnosed with anxiety and mood disorders (n=155) during affective scene viewing as it varied with trauma exposure and temperament. RESULTS: In women, but not men, blunted fronto-striatal connectivity was associated with increased posttraumatic anhedonic symptoms, whereas the amplitude of functional activity was not related to trauma exposure. In both men and women, reduced fronto-striatal connectivity was associated with decreases in temperamental positive affect. When predicting fronto-striatal connectivity, temperament and posttraumatic symptomology accounted for independent proportions of variance. LIMITATIONS: In this civilian sample of anxiety disorder patients, men reported very little trauma-related symptomology. CONCLUSIONS: Because dysfunctional reward processing due to trauma and temperament is pervasive across the internalizing disorder spectrum, assessing the integrity of the fronto-striatal reward circuit could provide important information in diagnostic and treatment protocols.

Assessing the role of the amygdala in fear of pain: Neural activation under threat of shock.

INTRODUCTION: The DSM-5 explicitly states that the neural system model of specific phobia is centered on the amygdala. However, this hypothesis is predominantly supported by human studies on animal phobia, whereas visual cuing of other specific phobias, such as dental fear, do not consistently show amygdala activation. Considering that fear of anticipated pain is one of the best predictors of dental phobia, the current study investigated neural and autonomic activity of pain anticipation in individuals varying in the degree of fear of dental pain. METHOD: Functional brain activity (fMRI) was measured in women (n = 31) selected to vary in the degree of self-reported fear of dental pain when under the threat of shock, in which one color signaled the possibility of receiving a painful electric shock and another color signaled safety. RESULTS: Enhanced functional activity during threat, compared to safety, was found in regions including anterior insula and anterior/mid cingulate cortex. Importantly, threat reactivity in the anterior insula increased as reported fear of pain increased and further predicted skin conductance changes during pain anticipation. LIMITATIONS: The sample was comprised of women. CONCLUSIONS: Individual differences in fear of pain vary with activation in the anterior insula, rather than with the amygdala, indicating that fear is not uniquely associated with amygdala activation. Whereas coping techniques such as emotion regulation have been found to vary with activation in a frontal-amygdala circuit when confronted with visual cues, precision psychiatry may need to target specific brain circuits to diagnose and treat different types of specific phobia.

Aversive perception in a threat context: Separate and independent neural activation.

Unpleasant, compared to neutral, scenes reliably prompt enhanced functional brain activity in the amygdala and inferotemporal cortex. Considering data from psychophysiological studies in which defensive reactivity is further enhanced when viewing unpleasant scenes under threat of shock (compared to safety), the current study investigates functional activation in the amygdala-inferotemporal circuit when unpleasant (or neutral) scenes are viewed under threat of shock or safety. In this paradigm, a cue signaling threat or safety was presented in conjunction with either an unpleasant or neutral picture. Replicating previous studies, unpleasant, compared to neutral, scenes reliably enhanced activation in the amygdala and inferotemporal cortex. Functional activity in these regions, however, did not differ whether scenes were presented in a context threatening shock exposure, compared to safety, which instead activated regions of the anterior insula and cingulate cortex. Taken together, the data support a view in which neural regions activated in different defensive situations act independently.

Motivated action: Pupil diameter during active coping.

Pupil diameter is dynamically modulated by a number of factors, including emotion, motor activity, and attention. Here, pupil modulation was examined as it varies with locus of control during aversive processing. Participants could control aversive exposure either by escape (terminating the event) or avoidance (blocking the event entirely), or they had no control. Highly anxious (n = 19), moderately anxious (n = 23), and less anxious (n = 23) participants saw cues that signaled whether a fast button press would terminate, prevent, or not affect subsequent presentation of an aversive picture. Pupil diameter was measured throughout the cuing interval. Pupil diameter was larger when preparing to escape or avoid compared to anticipating uncontrollable exposure. All participants, regardless of reported anxiety, showed increased pupil diameter in coping, relative to uncontrollable, contexts. Results support hypotheses that pupil diameter reflects action preparation and that differences in trait anxiety do not modulate this aspect of coping behavior in healthy subjects.

Common circuit or paradigm shift? The functional brain in emotional scene perception and emotional imagery.

Meta-analytic and experimental studies investigating the neural basis of emotion often compare functional activation in different emotional induction contexts, assessing evidence for a "core affect" or "salience" network. Meta-analyses necessarily aggregate effects across diverse paradigms and different samples, which ignore potential neural differences specific to the method of affect induction. Data from repeated measures designs are few, reporting contradictory results with a small N. In the current study, functional brain activity is assessed in a large (N = 61) group of healthy participants during two common emotion inductions-scene perception and narrative imagery-to evaluate cross-paradigm consistency. Results indicate that limbic and paralimbic regions, together with visual and parietal cortex, are reliably engaged during emotional scene perception. For emotional imagery, in contrast, enhanced functional activity is found in several cerebellar regions, hippocampus, caudate, and dorsomedial prefrontal cortex, consistent with the conception that imagery is an action disposition. Taken together, the data suggest that a common emotion network is not engaged across paradigms, but that the specific neural regions activated during emotional processing can vary significantly with the context of the emotional induction.

Transdiagnostic trauma severity in anxiety and mood disorders: Functional brain activity during emotional scene processing.

Exposure to traumatic events is not unique to post-traumatic stress disorder (PTSD) and is a significant factor in the development of physical and mental disease across the diagnostic spectrum. Using fMRI, this study assesses functional activation in the amygdala and visual cortex during emotional scene processing in a sample of anxiety and mood disorder patients (N = 162). Replicating previous studies with healthy young participants, a strong covariation was found between functional activity in the amygdala and ventral visual cortex, with blood-oxygen-level dependent (BOLD) activity overall significantly enhanced in both regions when viewing emotionally arousing, compared to neutral, scenes. BOLD changes during emotional processing predicted questionnaire reports of experienced trauma and PTSD-like symptoms (e.g., intrusive thoughts, bad dreams, re-experiencing) and associated functional impairment. Patients showing the smallest BOLD changes when viewing emotional (compared to neutral) scenes in the amygdala and ventral visual cortex reported the highest trauma scores, whereas those patients with the largest amygdala emotional reactivity differences reported the lowest trauma scores. Experiencing a life-threatening event (to self or other) that prompts high fear, distress, and functional impairment was associated with reduced functional limbic-visual activity, independent of a PTSD diagnosis. The findings suggest that experienced trauma may be a transdiagnostic vulnerability factor contributing significantly to psychopathology in many patients with anxiety and mood disorders.

Correction: Hematopoietic stem cell transplantation for children with acute myeloid leukemia-results of the AML SCT-BFM 2007 trial.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Hematopoietic stem cell transplantation for children with acute myeloid leukemia-results of the AML SCT-BFM 2007 trial.

AML SCT-BFM 2007 was the first hematopoietic stem cell transplantation (HCT) trial in Germany to comply with the European Clinical Trials Directive, and aimed to standardize pediatric HCT for acute myeloid leukemia (AML) across centers in Germany, Austria, and the Czech Republic. Children with high-risk features and a good early response achieving a complete first remission (CR-1) and those in CR-2 after a first relapse were stratified to receive HCT from a matched donor after myeloablative conditioning consisting of busulfan, cyclophosphamide, and melphalan. Four-year EFS and OS were 61 and 70%. Cumulative incidence of relapse (CIR) was 22%. TRM was 15% and correlated with age reaching 9% (SE 3%) in children younger than 12 years and 31% (SE 9%) in older children and adolescents. Children with poorly responding primary disease or relapse were allocated to receive early HCT after a cytoreductive regimen with fludarabine, amsacrine, and cytarabine, followed by reduced intensity conditioning and prophylactic donor lymphocyte infusions. Four-year EFS and OS were 49 and 53%. CIR was 38% and TRM 11%. For patients with primary poor response disease, early use of RIC HCT followed by prophylactic DLI can induce long-term remissions in more than 50% (EFS 46% (SE 9%)).

The Startle-Evoked Potential: Negative Affect and Severity of Pathology in Anxiety/Mood Disorders.

BACKGROUND: The National Institute of Mental Health Research Domain Criteria initiative encourages a search for dimensional biological measures of psychopathology unconstrained by current diagnostic categories. Consistent with this aim, the presented research studies a large sample of anxiety and mood disorder patients, assessing differences in principal diagnoses and comorbidity patterns, clinicians' ratings, and questionnaire measures of negative affect and life dysfunction as they relate to a potential brain marker of pathology: the amplitude of the event-related potential (ERP) elicited by a startle-evoking stimulus. METHODS: Patients seeking evaluation or treatment for anxiety and mood disorders (N = 208) participated in two tasks at the University of Florida (Gainesville, FL): 1) imagining emotional and neutral events and 2) viewing emotional and neutral pictures while acoustic startle probes were presented and the ERP was recorded. For a comparison patient group (N = 120), startle probes were administered and ERPs recorded at the University of Greifswald (Greifswald, Germany) while performing the same imagery task. RESULTS: Reduced positive amplitude of a centroparietal startle-evoked ERP (156-352 ms after onset) significantly predicted higher questionnaire scores of anxiety/depression, reports of increased life dysfunction, greater comorbidity, and clinician ratings of heightened severity and poorer prognosis. The effect was general across principal diagnoses, found for both the Florida and German samples, and consistent in pattern despite differences in the tasks administered. CONCLUSIONS: The startle-evoked ERP reliably predicts severity and breadth of psychopathology, independent of task context. It is a potential significant contributor to a needed array of biological measures that might improve classification of anxiety and mood disorders.

Neural activation and memory for natural scenes: Explicit and spontaneous retrieval.

Stimulus repetition elicits either enhancement or suppression in neural activity, and a recent fMRI meta-analysis of repetition effects for visual stimuli (Kim, 2017) reported cross-stimulus repetition enhancement in medial and lateral parietal cortex, as well as regions of prefrontal, temporal, and posterior cingulate cortex. Repetition enhancement was assessed here for repeated and novel scenes presented in the context of either an explicit episodic recognition task or an implicit judgment task, in order to study the role of spontaneous retrieval of episodic memories. Regardless of whether episodic memory was explicitly probed or not, repetition enhancement was found in medial posterior parietal (precuneus/cuneus), lateral parietal cortex (angular gyrus), as well as in medial prefrontal cortex (frontopolar), which did not differ by task. Enhancement effects in the posterior cingulate cortex were significantly larger during explicit compared to implicit task, primarily due to a lack of functional activity for new scenes. Taken together, the data are consistent with an interpretation that medial and (ventral) lateral parietal cortex are associated with spontaneous episodic retrieval, whereas posterior cingulate cortical regions may reflect task or decision processes.

Avoidance and escape: Defensive reactivity and trait anxiety.

Although avoidance and escape behaviors each contribute to maintaining anxiety disorders, only avoidance completely eliminates exposure to the aversive context. Current research compared anticipatory defensive engagement when aversion could either be completely avoided or escaped after initial exposure; in addition, this research examined the impact of trait anxiety on coping-related defensive engagement. Cues signaled that upcoming rapid action would avoid (block), escape (terminate), or not affect subsequent aversive exposure; the acoustic startle reflex was measured during each anticipatory interval to index defensive engagement, and blink magnitudes were compared across low-, moderate-, and high-anxious individuals. For all participants, startle was potentiated when aversive exposure was uncontrollable and attenuated when aversion was avoidable. On escape trials, on the other hand, startle potentiation increased with rising participant anxiety. Results suggest 1) defensive engagement is generally reduced in avoidance contexts relative to contexts in which exposure is certain, and; 2) trait anxiety increases defensive engagement specifically when aversive exposure can be controlled but remains certain.

Startle reflex modulation during threat of shock and "threat" of reward.

During threat of shock, the startle reflex is potentiated, suggesting modulation by defensive mobilization. To determine whether startle potentiation is specific to aversive anticipation, startle reflexes were measured in the context of either aversive or appetitive anticipation in a between-subject study. Participants wore a device on the wrist that could deliver electrical shock (n = 49), or vibrotactile stimulation indicating monetary reward (n = 48). Cues signaling "threat" or "safe" periods were presented alone, or accompanied by presentation of affective and neutral pictures on half of the trials. Results indicated that the startle reflex was significantly potentiated when anticipating either shock or reward, compared to safe periods, both when no picture was presented, as well as during picture viewing. The difference between threat and safety in both reflex magnitude and skin conductance changes was larger for those anticipating shock, suggesting that the aversive context was more motivationally engaging. The pattern of reflex modulation as a function of picture valence varied under threat and safety, but was identical in the shock and reward groups, consistent with a hypothesis that anticipation of either aversive or appetitive events prompts heightened perceptual vigilance, potentiating the acoustic startle reflex.

Emotional imagery and pupil diameter.

Pupil diameter is enhanced in a variety of emotional contexts, including viewing pictures, listening to sounds, and during threat of shock. In this study, we investigated pupil diameter changes during emotional imagery. Participants imagined scenes describing pleasant, unpleasant, or neutral events while pupil diameter was continuously recorded. Second by second changes in pupil diameter were analyzed to determine whether, and when, modulation of the pupil as a function of hedonic content is found. Results indicated a significant effect of hedonic content beginning shortly after script onset, with enhanced pupil diameter when imagining emotional (pleasant or unpleasant), compared to neutral, scenes. Pupil diameter during imagery covaried with rated emotional arousal, consistent with an interpretation that changes in pupil diameter during emotional imagery reflect sympathetic nervous system activity. Because emotional imagery is a key element in clinical assessment and treatment, pupil diameter could prove a useful index of emotional engagement in a variety of clinically pertinent contexts.