Maximal Analgesic Effect Attained by the Use of Objective Neurophysiological Measurements With Closed-Loop Spinal Cord Stimulation.

OBJECTIVES: Spinal cord stimulation (SCS) has been challenged by the lack of neurophysiologic data to guide therapy optimization. Current SCS programming by trial-and-error results in suboptimal and variable therapeutic effects. A novel system with a physiologic closed-loop feedback mechanism using evoked-compound action potentials enables the optimization of physiologic neural dose by consistently and accurately activating spinal cord fibers. We aimed to identify neurophysiologic dose metrics and their ranges that resulted in clinically meaningful treatment responses. MATERIALS AND METHODS: Subjects from 3 clinical studies (n = 180) with baseline back and leg pain ≥60 mm visual analog scale and physical function in the severe to crippled category were included. Maximal analgesic effect (MAE) was operationally defined as the greatest percent reduction in pain intensity or as the greatest cumulative responder score (minimal clinically important differences [MCIDs]) obtained within the first 3 months of SCS implant. The physiologic metrics that produced the MAE were analyzed. RESULTS: We showed that a neural dose regimen with a high neural dose accuracy of 2.8µV and dose ratio of 1.4 resulted in a profound clinical benefit to chronic pain patients (MAE of 79 ± 1% for pain reduction and 12.5 ± 0.4 MCIDs). No differences were observed for MAE or neurophysiological dose metrics between the trial phase and post-implant MAE visit. CONCLUSION: For the first time, an evidence-based neural dose regimen is available for a neurostimulation intervention as a starting point to enable optimization of clinical benefit, monitoring of adherence, and management of the therapy.

Upgrade of the Lyman-alpha diagnostic system on DIII-D for main chamber edge neutral studies.

The LLAMA (Lyman Alpha Measurement Apparatus) pinhole camera diagnostic had previously been deployed on DIII-D to measure radial profiles of the Lyman-α (Ly-α) deuterium neutral line brightness across the plasma boundary in the lower chamber to infer neutral deuterium density and ionization rate profiles. This system has recently been upgraded with a new diagnostic head, named ALPACA, that also encloses two pinhole cameras and duplicates the LLAMA views in the upper chamber. Similar to LLAMA, ALPACA provides two times 20 lines of sight, viewing the plasma edge on the inboard and outboard sides with a radial resolution of ∼2.5 cm (FWHM) and an effective time resolution of ∼1 ms that allows for the investigation of inter-ELM dynamics. The extended Ly-α system provides better coverage to study neutrals in experiments with various plasma shapes utilizing both the upper and lower divertors. Furthermore, post-campaign calibration of the LLAMA diagnostic has successfully been demonstrated for the first time. This was facilitated by various upgrades to the calibration set-up and detailed measurements of the emissivity distribution of the Ly-α calibration source using a pinhole collimator. It was found that the sensitivity of the inboard LLAMA pinhole camera was reduced by a factor of 2.0 ± 0.2 over the course of six months of plasma operation in 2021. The upgraded Ly-α system, equipped with improved absolute calibration, will provide key input for neutral fueling and pedestal particle transport studies and for 2D edge transport code validation on the DIII-D tokamak.

Density functional theory from spherically symmetric densities: Ground and excited states of Coulomb systems.

Recently, Theophilou [J. Chem. Phys. 149, 074104 (2018)] proposed a peculiar version of the density functional theory by showing that the set of spherical averages of the density around the nuclei determines uniquely the external potential in atoms, molecules, and solids. Here, this novel theory is extended to individual excited states. The generalization is based on the method developed in the series of papers by Ayers, Levy, and Nagy [Phys. Rev. A 85, 042518 (2012)]. Generalized Hohenberg-Kohn theorems are proved to the set of spherically symmetric densities using constrained search. A universal variational functional for the sum of the kinetic and electron-electron repulsion energies is constructed. The functional is appropriate for the ground state and all bound excited states. Euler equations and Kohn-Sham equations for the set are derived. The Euler equations can be rewritten as Schrödinger-like equations for the square root of the radial densities, and the effective potentials in them can be expressed in terms of wave function expectation values. The Hartree plus exchange-correlation potentials can be given by the difference of the interacting and the non-interacting effective potentials.

Network Meta-analysis and Economic Evaluation of Neurostimulation Interventions for Chronic Nonsurgical Refractory Back Pain.

OBJECTIVES: Different types of spinal cord stimulation (SCS) have been evaluated for the management of chronic nonsurgical refractory back pain (NSRBP). A direct comparison between the different types of SCS or between closed-loop SCS with conventional medical management (CMM) for patients with NSRBP has not been previously conducted, and therefore, their relative effectiveness and cost-effectiveness remain unknown. The aim of this study was to perform a systematic review, network meta-analysis (NMA) and economic evaluation of closed-loop SCS compared with fixed-output SCS and CMM for patients with NSRBP. METHODS: Databases were searched to September 8, 2023. Randomized controlled trials of SCS for NSRBP were included. The results of the studies were combined using fixed-effect NMA models. A cost-utility analysis was performed from the perspective of the UK National Health Service with results reported as incremental cost per quality-adjusted life-year (QALY). RESULTS: Closed-loop SCS resulted in statistically and clinically significant reductions in pain intensity (mean difference [MD] 32.72 [95% CrI 15.69-49.78]) and improvements in secondary outcomes (Oswestry Disability Index [ODI] and health-related quality of life [HRQoL]) compared with fixed-output SCS at 6-month follow-up. Compared with CMM, both closed-loop and fixed-output SCS resulted in statistically and clinically significant reductions in pain intensity (closed-loop SCS vs. CMM MD 101.58 [95% CrI 83.73-119.48]; fixed-output SCS versus CMM MD 68.86 [95% CrI 63.43-74.31]) and improvements in secondary outcomes (ODI and HRQoL). Cost-utility analysis showed that closed-loop SCS dominates fixed-output SCS and CMM, and fixed-output SCS also dominates CMM. DISCUSSION: Current evidence showed that closed-loop and fixed-output SCS provide more benefits and cost-savings compared with CMM for patients with NSRBP.

Controversies of COVID-19 vaccine promotion: lessons of three randomised survey experiments from Hungary.

OBJECTIVES: This study aimed to investigate vaccine promotion messages, examine the heterogeneous effects of these messages and provide experimental evidence to help evaluate the efficiency of COVID-19 vaccine promotion campaigns in Hungary. STUDY DESIGN: This study presents the results of three randomised survey experiments that were embedded in cross-sectional, representative, public opinion studies of Hungarian adults based on in-person interviews. Simple randomisation and blinding were applied to assign participants into the control group (no message) or treatment groups (vaccine promotion messages). METHODS: The first experiment (March 2021) aimed to test vaccination promotion messages from politicians (N = 331) and medical experts (N = 342) by comparing experimental groups' trust in vaccines and conspiratorial beliefs with the control group (N = 327). The second experiment (September 2022) tested the impact of two communication strategies ([1] highlighting the safety and effectiveness of vaccines, N = 104; and [2] highlighting the wide variety of vaccines available, N = 110) on increasing vaccine uptake among those who were still unvaccinated (control group, N = 89). The third experiment (September 2022) tested one message aiming to increase COVID-19 booster uptake among those who received only the first round of vaccination (N = 172; control group, N = 169). The outcome variable in the second and third experiments was intent to get vaccinated. Robust regressions, logit models, Mann-Whitney U-tests and model-based recursive partitioning were run. The inference criteria (p < 0.05) was set in pre-registration of the experiments. RESULTS: All treatment effects were insignificant, but exploratory research found significant conditional treatment effects. Exposure to vaccine promotion by medical professionals was associated with a higher level of trust in Russian and Chinese COVID-19 vaccines in older age cohorts (weighted robust regressions, 50-59 years old, Russian vaccine: +0.769, interaction term [i.t.] p = 0.010; Chinese vaccine: +0.326, i.t. p = 0.044; and ≥60 years old, Russian vaccine +0.183, i.t. p = 0.040; Chinese vaccine +0.559, i.t. p = 0.010) and with a lower level of trust in these vaccines among younger adults (<30 years old, Russian vaccine: -1.236, i.t. p = 0.023; Chinese vaccine: -1.281, i.t. p = 0.022). Receiving a vaccine promotion message from politicians led to a higher level of trust in Chinese vaccines among the oldest respondents (≥60 years: +0.634, i.t. p = 0.035). CONCLUSIONS: Short-term persuasion attempts that aimed to convince respondents about COVID-19 vaccination were ineffective. Booster hesitancy, similar to primary vaccine hesitancy, was resistant to vaccine promotion messages. Significant conditional effects suggest that COVID-19 vaccine promotion by medical experts and politicians may have had adverse effects for some demographic groups in Hungary.

Neurophysiological outcomes that sustained clinically significant improvements over 3 years of physiologic ECAP-controlled closed-loop spinal cord stimulation for the treatment of chronic pain.

INTRODUCTION: A novel, spinal cord stimulation (SCS) system with a physiologic closed-loop (CL) feedback mechanism controlled by evoked compound action potentials (ECAPs) enables the optimization of physiologic neural dose and the accuracy of the stimulation, not possible with any other commercially available SCS systems. The report of objective spinal cord measurements is essential to increase the transparency and reproducibility of SCS therapy. Here, we report a cohort of the EVOKE double-blind randomized controlled trial treated with CL-SCS for 36 months to evaluate the ECAP dose and accuracy that sustained the durability of clinical improvements. METHODS: 41 patients randomized to CL-SCS remained in their treatment allocation and were followed up through 36 months. Objective neurophysiological data, including measures of spinal cord activation, were analyzed. Pain relief was assessed by determining the proportion of patients with ≥50% and ≥80% reduction in overall back and leg pain. RESULTS: The performance of the feedback loop resulted in high-dose accuracy by keeping the elicited ECAP within 4µV of the target ECAP set on the system across all timepoints. Percent time stimulating above the ECAP threshold was >98%, and the ECAP dose was ≥19.3µV. Most patients obtained ≥50% reduction (83%) and ≥80% reduction (59%) in overall back and leg pain with a sustained response observed in the rates between 3-month and 36-month follow-up (p=0.083 and p=0.405, respectively). CONCLUSION: The results suggest that a physiological adherence to supra-ECAP threshold therapy that generates pain inhibition provided by ECAP-controlled CL-SCS leads to durable improvements in pain intensity with no evidence of loss of therapeutic effect through 36-month follow-up.

On uniform stability and numerical simulations of complex valued neural networks involving generalized Caputo fractional order.

The dynamics and existence results of generalized Caputo fractional derivatives have been studied by several authors. Uniform stability and equilibrium in fractional-order neural networks with generalized Caputo derivatives in real-valued settings, however, have not been extensively studied. In contrast to earlier studies, we first investigate the uniform stability and equilibrium results for complex-valued neural networks within the framework of a generalized Caputo fractional derivative. We investigate the intermittent behavior of complex-valued neural networks in generalized Caputo fractional-order contexts. Numerical results are supplied to demonstrate the viability and accuracy of the presented results. At the end of the article, a few open questions are posed.

PLM-GAN: A Large-Scale Protein Loop Modeling Using pix2pix GAN.

Revealing the tertiary structure of proteins holds huge significance as it unveils their vital properties and functions. These intricate three-dimensional configurations comprise diverse interactions including ionic, hydrophobic, and disulfide forces. In certain instances, these structures exhibit missing regions, necessitating the reconstruction of specific segments, thereby resulting in challenges in protein design, which encompasses loop modeling, circular permutation, and interface prediction. To address this problem, we present two pioneering models: pix2pix generative adversarial network (GAN) and PLM-GAN. The pix2pix GAN model is adept at generating and inpainting distance matrices of protein structures, whereas the PLM-GAN model incorporates residual blocks into the U-Net network of the GAN, building upon the foundation of the pix2pix GAN model. To bolster the models' performance, we introduce a novel loss function named the "missing to real regions loss" (LMTR) within the GAN framework. Additionally, we introduce a distinctive approach of pairing two different distance matrices: one representing the native protein structure and the other representing the same structure with a missing region that undergoes changes in each successive epoch. Moreover, we extend the reconstruction of missing regions, encompassing up to 30 amino acids and increase the protein length by 128 amino acids. The evaluation of our pix2pix GAN and PLM-GAN models on a random selection of natural proteins (4ZCB, 3FJB, and 2REZ) demonstrated promising experimental results. Our models constitute significant contributions to addressing intricate challenges in protein structure design. These contributions hold immense potential to propel advancements in protein-protein interactions, drug design, and further innovations in protein engineering. Data, code, trained models, examples, and measurements are available on https://github.com/mena01/PLM-GAN-A-Large-Scale-Protein-Loop-Modeling-Using-pix2pix-GAN_.

Durable multimodal and holistic response for physiologic closed-loop spinal cord stimulation supported by objective evidence from the EVOKE double-blind randomized controlled trial.

INTRODUCTION: Chronic pain patients may experience impairments in multiple health-related domains. The design and interpretation of clinical trials of chronic pain interventions, however, remains primarily focused on treatment effects on pain intensity. This study investigates a novel, multidimensional holistic treatment response to evoked compound action potential-controlled closed-loop versus open-loop spinal cord stimulation as well as the degree of neural activation that produced that treatment response. METHODS: Outcome data for pain intensity, physical function, health-related quality of life, sleep quality and emotional function were derived from individual patient level data from the EVOKE multicenter, participant, investigator, and outcome assessor-blinded, parallel-arm randomized controlled trial with 24 month follow-up. Evaluation of holistic treatment response considered whether the baseline score was worse than normative values and whether minimal clinical important differences were reached in each of the domains that were impaired at baseline. A cumulative responder score was calculated to reflect the total minimal clinical important differences accumulated across all domains. Objective neurophysiological data, including spinal cord activation were measured. RESULTS: Patients were randomized to closed-loop (n=67) or open-loop (n=67). A greater proportion of patients with closed-loop spinal cord stimulation (49.3% vs 26.9%) were holistic responders at 24-month follow-up, with at least one minimal clinical important difference in all impaired domains (absolute risk difference: 22.4%, 95% CI 6.4% to 38.4%, p=0.012). The cumulative responder score was significantly greater for closed-loop patients at all time points and resulted in the achievement of more than three additional minimal clinical important differences at 24-month follow-up (mean difference 3.4, 95% CI 1.3 to 5.5, p=0.002). Neural activation was three times more accurate in closed-loop spinal cord stimulation (p<0.001 at all time points). CONCLUSION: The results of this study suggest that closed-loop spinal cord stimulation can provide sustained clinically meaningful improvements in multiple domains and provide holistic improvement in the long-term for patients with chronic refractory pain. TRIAL REGISTRATION NUMBER: NCT02924129.