Modelling subject variability in the spatial and temporal characteristics of functional modes.

Recent work has highlighted the scale and ubiquity of subject variability in observations from functional MRI data (fMRI). Furthermore, it is highly likely that errors in the estimation of either the spatial presentation of, or the coupling between, functional regions can confound cross-subject analyses, making accurate and unbiased representations of functional data essential for interpreting any downstream analyses. Here, we extend the framework of probabilistic functional modes (PFMs) (Harrison et al., 2015) to capture cross-subject variability not only in the mode spatial maps, but also in the functional coupling between modes and in mode amplitudes. A new implementation of the inference now also allows for the analysis of modern, large-scale data sets, and the combined inference and analysis package, PROFUMO, is available from git.fmrib.ox.ac.uk/samh/profumo. A new implementation of the inference now also allows for the analysis of modern, large-scale data sets. Using simulated data, resting-state data from 1000 subjects collected as part of the Human Connectome Project (Van Essen et al., 2013), and an analysis of 14 subjects in a variety of continuous task-states (Kieliba et al., 2019), we demonstrate how PFMs are able to capture, within a single model, a rich description of how the spatio-temporal structure of resting-state fMRI activity varies across subjects. We also compare the new PFM model to the well established independent component analysis with dual regression (ICA-DR) pipeline. This reveals that, under PFM assumptions, much more of the (behaviorally relevant) cross-subject variability in fMRI activity should be attributed to the variability in spatial maps, and that, after accounting for this, functional coupling between modes primarily reflects current cognitive state. This has fundamental implications for the interpretation of cross-sectional studies of functional connectivity that do not capture cross-subject variability to the same extent as PFMs.

Hospitalization in fibromyalgia: a cohort-level observational study of in-patient procedures, costs and geographical variation in England.

OBJECTIVES: Fibromyalgia is a complex, debilitating, multifactorial condition that can be difficult to manage. Recommended treatments are usually delivered in outpatient settings; evidence suggests that significant inpatient care occurs. We describe the scale and cost of inpatient care with a primary diagnostic code of fibromyalgia within the English National Health Service. METHODS: We conducted a cohort-level observational study of all patients admitted to hospital due to a diagnosis of fibromyalgia, between 1 April 2014 and 31 March 2018 inclusive, in the National Health Service in England. We used data from Hospital Episode Statistics Admitted Patient Care to study: the age and sex of patients admitted, number and costs of admissions, length of stay, procedures undertaken, class and type of admission, and distribution of admissions across clinical commissioning groups. RESULTS: A total of 24 295 inpatient admissions, costing £20 220 576, occurred during the 4-year study period. Most patients were women (89%) with peak age of admission of between 45 and 55 years. Most admissions were elective (92%). A number of invasive therapeutic procedures took place, including a continuous i.v. infusion (35%). There was marked geographical variation in the prevalence and cost of inpatient fibromyalgia care delivered across the country, even after accounting for clinical commissioning group size. CONCLUSIONS: Many patients are admitted for treatment of their fibromyalgia and given invasive procedures for which there is weak evidence, with significant variation in practice and cost across the country. This highlights the need to identify areas of resource use that can be rationalized and diverted to provide more effective, evidence-based treatment.

Calibration of arterial spin labeling data-potential pitfalls in post-processing.

PURPOSE: To assess the impact of the different post-processing options in the calibration of arterial spin labeling (ASL) data on perfusion quantification and its reproducibility. THEORY AND METHODS: Absolute quantification of perfusion measurements is one of the promises of ASL techniques. However, it is highly dependent on a calibration procedure that involves a complex processing pipeline for which no standardized procedure has been fully established. In this work, we systematically compare the main ASL calibration methods as well as various post-processing calibration options, using 2 data sets acquired with the most common sequences, pulsed ASL and pseudo-continuous ASL. RESULTS: Significant and sometimes large discrepancies in ASL perfusion quantification were obtained when using different post-processing calibration options. Nevertheless, when using a set of theoretically based and carefully chosen options, only small differences were observed for both reference tissue and voxelwise methods. The voxelwise and white matter reference tissue methods were less sensitive to post-processing options than the cerebrospinal fluid reference tissue method. However, white matter reference tissue calibration also produced poorer reproducibility results. Moreover, it may also not be an appropriate reference in case of white matter pathology. CONCLUSION: Poor post-processing calibration options can lead to large errors in perfusion quantification, and a complete description of the calibration procedure should therefore be reported in ASL studies. Overall, our results further support the voxelwise calibration method proposed by the ASL white paper, particularly given the advantage of being relatively simple to implement and intrinsically correcting for the coil sensitivity profile.

Imaging Clinically Relevant Pain States Using Arterial Spin Labeling.

Arterial Spin Labeling (ASL) is a perfusion-based functional magnetic resonance imaging technique that uses water in arterial blood as a freely diffusible tracer to measure regional cerebral blood flow (rCBF) noninvasively. To date its application to the study of pain has been relatively limited. Yet, ASL possesses key features that make it uniquely positioned to study pain in certain paradigms. For instance, ASL is sensitive to very slowly fluctuating brain signals (in the order of minutes or longer). This characteristic makes ASL particularly suitable to the evaluation of brain mechanisms of tonic experimental, post-surgical and ongoing/or continuously varying pain in chronic or acute pain conditions (whereas BOLD fMRI is better suited to detect brain responses to short-lasting or phasic/evoked pain). Unlike positron emission tomography or other perfusion techniques, ASL allows the estimation of rCBF without requiring the administration of radioligands or contrast agents. Thus, ASL is well suited for within-subject longitudinal designs (e.g., to study evolution of pain states over time, or of treatment effects in clinical trials). ASL is also highly versatile, allowing for novel paradigms exploring a flexible array of pain states, plus it can be used to simultaneously estimate not only pain-related alterations in perfusion but also functional connectivity. In conclusion, ASL can be successfully applied in pain paradigms that would be either challenging or impossible to implement using other techniques. Particularly when used in concert with other neuroimaging techniques, ASL can be a powerful tool in the pain imager's toolbox.

Defining the Functional Role of NaV1.7 in Human Nociception.

Loss-of-function mutations in NaV1.7 cause congenital insensitivity to pain (CIP); this voltage-gated sodium channel is therefore a key target for analgesic drug development. Utilizing a multi-modal approach, we investigated how NaV1.7 mutations lead to human pain insensitivity. Skin biopsy and microneurography revealed an absence of C-fiber nociceptors in CIP patients, reflected in a reduced cortical response to capsaicin on fMRI. Epitope tagging of endogenous NaV1.7 revealed the channel to be localized at the soma membrane, axon, axon terminals, and the nodes of Ranvier of induced pluripotent stem cell (iPSC) nociceptors. CIP patient-derived iPSC nociceptors exhibited an inability to properly respond to depolarizing stimuli, demonstrating that NaV1.7 is a key regulator of excitability. Using this iPSC nociceptor platform, we found that some NaV1.7 blockers undergoing clinical trials lack specificity. CIP, therefore, arises due to a profound loss of functional nociceptors, which is more pronounced than that reported in rodent models, or likely achievable following acute pharmacological blockade. VIDEO ABSTRACT.

A brain-based pain facilitation mechanism contributes to painful diabetic polyneuropathy.

The descending pain modulatory system represents one of the oldest and most fundamentally important neurophysiological mechanisms relevant to pain. Extensive work in animals and humans has shown how a functional imbalance between the facilitatory and inhibitory components is linked to exacerbation and maintenance of persistent pain states. Forward translation of these findings into clinical populations is needed to verify the relevance of this imbalance. Diabetic polyneuropathy is one of the most common causes of chronic neuropathic pain; however, the reason why ∼25-30% of patients with diabetes develop pain is not known. The current study used a multimodal clinical neuroimaging approach to interrogate whether the sensory phenotype of painful diabetic polyneuropathy involves altered function of the ventrolateral periaqueductal grey-a key node of the descending pain modulatory system. We found that ventrolateral periaqueductal grey functional connectivity is altered in patients suffering from painful diabetic polyneuropathy; the magnitude of which is correlated to their spontaneous and allodynic pain as well as the magnitude of the cortical response elicited by an experimental tonic heat paradigm. We posit that ventrolateral periaqueductal grey-mediated descending pain modulatory system dysfunction may reflect a brain-based pain facilitation mechanism contributing to painful diabetic polyneuropathy.

A systematic study of the sensitivity of partial volume correction methods for the quantification of perfusion from pseudo-continuous arterial spin labeling MRI.

Arterial spin labeling (ASL) MRI is a non-invasive technique for the quantification of cerebral perfusion, and pseudo-continuous arterial spin labeling (PCASL) has been recommended as the standard implementation by a recent consensus of the community. Due to the low spatial resolution of ASL images, perfusion quantification is biased by partial volume effects. Consequently, several partial volume correction (PVEc) methods have been developed to reduce the bias in gray matter (GM) perfusion quantification. The efficacy of these methods relies on both the quality of the ASL data and the accuracy of partial volume estimates. Here we systematically investigate the sensitivity of different PVEc methods to variability in both the ASL data and partial volume estimates using simulated PCASL data and in vivo PCASL data from a reproducibility study. We examined the PVEc methods in two ways: the ability to preserve spatial details and the accuracy of GM perfusion estimation. Judging by the root-mean-square error (RMSE) between simulated and estimated GM CBF, the spatially regularized method was superior in preserving spatial details compared to the linear regression method (RMSE of 1.2 vs 5.1 in simulation of GM CBF with short scale spatial variations). The linear regression method was generally less sensitive than the spatially regularized method to noise in data and errors in the partial volume estimates (RMSE 6.3 vs 23.4 for SNR = 5 simulated data), but this could be attributed to the greater smoothing introduced by the method. Analysis of a healthy cohort dataset indicates that PVEc, using either method, improves the repeatability of perfusion quantification (within-subject coefficient of variation reduced by 5% after PVEc).

The dorsal posterior insula subserves a fundamental role in human pain.

Several brain regions have been implicated in human painful experiences, but none have been proven to be specific to pain. We exploited arterial spin-labeling quantitative perfusion imaging and a newly developed procedure to identify a specific role for the dorsal posterior insula (dpIns) in pain. Tract tracing studies in animals identify a similar region as fundamental to nociception, which suggests the dpIns is its human homolog and, as such, a potential therapeutic target.

The dorsal posterior insula is not an island in pain but subserves a fundamental role - Response to: "Evidence against pain specificity in the dorsal posterior insula" by Davis et al.

An interesting and valuable discussion has arisen from our recent article (Segerdahl, Mezue et al., 2015) and we are pleased here to have the opportunity to expand on the various points we made. Equally important, we wish to correct several important misunderstandings that were made by Davis and colleagues that possibly contributed to their concerns about power when assessing our paper (e.g. actual subject numbers used in control experiment and the reality of the signal-to-noise and sampling of the multi-TI technique we employed). Here, we clarify the methods and analysis plus discuss how we interpret the data in the Brief Communication noting that the extrapolation and inferences made by Davis and colleagues are not consistent with our report or necessarily, in our opinion, what the data supports. We trust this reassures the F1000Research readership regarding the robustness of our results and what we actually concluded in the paper regarding their possible meaning. We are pleased, though, that Davis and colleagues have used our article to raise an important discussion around pain perception, and here offer some further insights towards that broader discussion.

Optimization and reliability of multiple postlabeling delay pseudo-continuous arterial spin labeling during rest and stimulus-induced functional task activation.

Arterial spin labeling (ASL) sequences that incorporate multiple postlabeling delay (PLD) times allow estimation of when arterial blood signal arrives within a region of interest. Sequences that account for such variability may improve the reliability of ASL and therefore make the technique well suited for future clinical and experimental investigations of cerebral perfusion. This study assessed the within- and between-session reproducibility of an optimized pseudo-continuous ASL (pCASL) functional magnetic resonance imaging (FMRI) sequence that incorporates multiple postlabeling delays (multi-PLD pCASL). Healthy subjects underwent four identical scans separated by 30 minutes, 1 week, and 1 month using multi-PLD pCASL to image absolute perfusion (cerebral blood flow (CBF) and arterial arrival time (AAT)) during both rest and a visual-cued motor task. We show good test-retest reliability, with strong consistency across subjects and sessions during rest (inter-session within-subject coefficient of variation: gray matter (GM) CBF=6.44%; GM AAT=2.20%). We also report high sensitivity and reproducibility during the functional task, where we show robust task-related decreases in AAT corresponding with regions of increased CBF. Importantly, these results give insight into optimal PLD selection for future investigations using single-PLD ASL to image different brain regions, and highlight the necessity of multi-PLD ASL when imaging perfusion in the whole brain.

Widespread modulation of cerebral perfusion induced during and after transcranial direct current stimulation applied to the left dorsolateral prefrontal cortex.

Noninvasive neuromodulatory techniques such as transcranial direct current stimulation (tDCS) are attracting increasing interest as potential therapies for a wide range of neurological and psychiatric conditions. When targeted to the dorsolateral prefrontal cortex (DLPFC), anodal, facilitatory tDCS has been shown to improve symptoms in a range of domains including working memory, mood, and pain perception (Boggio et al., 2008a; Dockery et al., 2009; Kalu et al., 2012). However, the mechanisms underlying these promising behavioral effects are not well understood. Here, we investigated brain perfusion changes, as assessed using whole-brain arterial spin labeling (ASL), during tDCS applied to the left DLPFC in healthy humans. We demonstrated increased perfusion in regions closely anatomically connected to the DLPFC during anodal tDCS in conjunction with a decreased functional coupling between the left DLPFC and the thalami bilaterally. Despite highly similar effects on cortical excitability during and after stimulation (Nitsche and Paulus, 2000, 2001), cortical perfusion changes were markedly different during these two time periods, with widespread decreases in cortical perfusion being demonstrated after both anodal and cathodal tDCS compared to the period during stimulation. These findings may at least partially explain the different effects on behavior in these time periods described previously in the motor system (Stagg et al., 2011). In addition, the data presented here provide mechanistic explanations for the behavioral effects of anodal tDCS applied to the left DLPFC in terms of modulating functional connectivity between the DLPFC and thalami, as has been hypothesized previously (Lorenz et al., 2003).

Imaging the neural correlates of neuropathic pain and pleasurable relief associated with inherited erythromelalgia in a single subject with quantitative arterial spin labelling.

We identified a patient with severe inherited erythromelalgia secondary to an L858F mutation in the voltage-gated sodium channel Na(v)1.7. The patient reported severe ongoing foot pain, which was exquisitely sensitive to limb cooling. We confirmed this heat hypersensitivity using quantitative sensory testing. Additionally, we employed a novel perfusion imaging technique in a simple block design to assess her baseline erythromelalgia pain vs cooling relief. Robust activations of key pain, pain-affect, and reward-related centres were observed. This combined approach allowed us to confirm the presence of a temperature-sensitive channelopathy of peripheral neurons and to investigate the neural correlates of tonic neuropathic pain and relief in a single subject.

Anxiety-like behaviour is attenuated by gabapentin, morphine and diazepam in a rodent model of HIV anti-retroviral-associated neuropathic pain.

Neuropathic pain is commonly associated with affective disorders such as anxiety and depression. We have previously characterised a rodent model of HIV, anti-retroviral-associated neuropathy in which rats develop hypersensitivity to a punctate mechanical stimulus and display anxiety-like behaviour in the open field paradigm. To assess the potential of this behavioural paradigm for the assessment of pain related co-morbidities in rodent models of pain, here we test the sensitivity of this anxiety-like behaviour to the analgesic agents gabapentin and morphine in comparison to the known anxiolytic drug diazepam. We found that gabapentin (30 mg/kg, i.p.) and morphine (2.5 mg/kg, i.p.), which reduce mechanical hypersensitivity in these rats, significantly reduces measures of thigmotaxis in the open field. The effect of gabapentin and morphine did not differ significantly from diazepam (1 mg/kg, i.p.). This study highlights the potential use of this rodent model and behavioural paradigm in the validation of the affective component of novel analgesic pharmacological targets and elucidation of underlying pathophysiological mechanisms.

Characterization of rodent models of HIV-gp120 and anti-retroviral-associated neuropathic pain.

A distal symmetrical sensory peripheral neuropathy is frequently observed in people living with Human Immunodeficiency Virus Type 1 (HIV-1). This neuropathy can be associated with viral infection alone, probably involving a role for the envelope glycoprotein gp120; or a drug-induced toxic neuropathy associated with the use of nucleoside analogue reverse transcriptase inhibitors as a component of highly active anti-retroviral therapy. In order to elucidate the mechanisms underlying drug-induced neuropathy in the context of HIV infection, we have characterized pathological events in the peripheral and central nervous system following systemic treatment with the anti-retroviral agent, ddC (Zalcitabine) with or without the concomitant delivery of HIV-gp120 to the rat sciatic nerve (gp120+ddC). Systemic ddC treatment alone is associated with a persistent mechanical hypersensitivity (33% decrease in limb withdrawal threshold) that when combined with perineural HIV-gp120 is exacerbated (48% decrease in threshold) and both treatments result in thigmotactic (anxiety-like) behaviour. Immunohistochemical studies revealed little ddC-associated alteration in DRG phenotype, as compared with known changes following perineural HIV-gp120. However, the chemokine CCL2 is significantly expressed in the DRG of rats treated with perineural HIV-gp120 and/or ddC and there is a reduction in intraepidermal nerve fibre density, comparable to that seen in herpes zoster infection. Moreover, a spinal gliosis is apparent at times of peak behavioural sensitivity that is exacerbated in gp120+ddC as compared to either treatment alone. Treatment with the microglial inhibitor, minocycline, is associated with delayed onset of hypersensitivity to mechanical stimuli in the gp120+ddC model and reversal of some measures of thigmotaxis. Finally, the hypersensitivity to mechanical stimuli was sensitive to systemic treatment with gabapentin, morphine and the cannabinoid WIN 55,212-2, but not with amitriptyline. These data suggests that both neuropathic pain models display many features of HIV- and anti-retroviral-related peripheral neuropathy. They therefore merit further investigation for the elucidation of underlying mechanisms and may prove useful for preclinical assessment of drugs for the treatment of HIV-related peripheral neuropathic pain.

Pharmacological, behavioural and mechanistic analysis of HIV-1 gp120 induced painful neuropathy.

A painful neuropathy is frequently observed in people living with human immunodeficiency virus type 1 (HIV-1). The HIV coat protein, glycoprotein 120 (gp120), implicated in the pathogenesis of neurological disorders associated with HIV, is capable of initiating neurotoxic cascades via an interaction with the CXCR4 and/or CCR5 chemokine receptors, which may underlie the pathogenesis of HIV-associated peripheral neuropathic pain. In order to elucidate the mechanisms underlying HIV-induced painful peripheral neuropathy, we have characterised pathological events in the peripheral and central nervous system following application of HIV-1 gp120 to the rat sciatic nerve. Perineural HIV-1 gp120 treatment induced a persistent mechanical hypersensitivity (44% decrease from baseline), but no alterations in sensitivity to thermal or cold stimuli, and thigmotactic (anxiety-like) behaviour in the open field. The mechanical hypersensitivity was sensitive to systemic treatment with gabapentin, morphine and the cannabinoid WIN 55,212-2, but not with amitriptyline. Immunohistochemical studies reveal: decreased intraepidermal nerve fibre density, macrophage infiltration into the peripheral nerve at the site of perineural HIV-1 gp120; changes in sensory neuron phenotype including expression of activating transcription factor 3 (ATF3) in 27% of cells, caspase-3 in 25% of cells, neuropeptide Y (NPY) in 12% of cells and galanin in 13% of cells and a spinal gliosis. These novel findings suggest that this model is not only useful for the elucidation of mechanisms underlying HIV-1-related peripheral neuropathy but may prove useful for preclinical assessment of drugs for the treatment of HIV-1 related peripheral neuropathic pain.