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An increasing number of cross-sectional studies suggests that diet may impact memory and cognition in healthy older adults. However, randomized controlled trials investigating the effects of whole-diet interventions on memory and cognition in healthy older adults are rather rare, and conflicting results are often reported. Therefore, a systematic review was conducted to compile the current evidence regarding the potential effects of whole-diet interventions on 1) memory and 2) other cognitive outcomes in older adults. Studies that reported on randomized controlled trials with dietary interventions in healthy older adults (≥60 y) were included. Studies utilizing supplements, single food items, or trials in specific patient groups (i.e., neurodegenerative diagnoses) were excluded. For the 23 included articles, the main outcomes examined fell into 1 or more of the following categories: cognitive task-based outcomes related to memory, other cognitive task-based outcomes, and additional outcomes related to cognitive function or disease risk. Three of the studies that investigated dietary interventions alone and 2 multidomain studies showed positive effects on memory function, whereas 5 multidomain interventions and 1 intervention that focused on diet alone showed positive effects on other cognitive outcomes. The effect of randomized, controlled whole-diet interventions on memory and cognitive function in healthy older adults is modest and inconclusive, highlighting the need for more well-designed, sufficiently powered studies. Furthermore, the potential mechanisms by which diet impacts cognition in healthy aging need to be elucidated.

Prior research has established that insomnia is predictive of pain in adolescents and that psychological mechanisms have a crucial role in this relationship. Adolescent girls report more insomnia and pain than boys, yet little is known of gender differences in how insomnia influences pain. This study assessed gender differences in levels and trajectories of insomnia and pain during adolescence, and whether rumination and negative mood mediated the effect of insomnia on pain. Longitudinal survey data measured on 5 annual occasions (Nbaseline= 2,767) were analyzed in a multigroup longitudinal serial mediation model. A final model was generated with insomnia as the predictor, rumination and depressed mood as mediators, pain as the outcome, and gender as the grouping variable. The results showed that insomnia predicted pain in adolescents, with an effect 3.5 times larger in girls than boys. Depressed mood was the main mediator in boys. In girls, rumination was the only significant mediator. There were significant gender differences in the effects of insomnia on rumination and pain, and in the effects of rumination on depressed mood and pain, with stronger effects in girls. These results highlight that girls and boys should be considered separately when studying the relationship between insomnia and pain.

Near-infrared spectroscopy (NIRS) and intravascular ultrasound are promising imaging modalities to identify non-obstructive plaques likely to cause coronary-related events. We aimed to assess whether combined NIRS and intravascular ultrasound can identify high-risk plaques and patients that are at risk for future major adverse cardiac events (MACEs).

Heparin is the preferred choice of anticoagulant in percutaneous coronary intervention (PCI) for acute myocardial infarction (MI). An established dosage of heparin has not yet been determined, but treatment may be optimized through monitoring of activated clotting time (ACT). The aim of this study was to determine the relationship between heparin dose or ACT with a composite outcome of death, MI, or bleeding using data from the registry-based, randomized, controlled, and open-label VALIDATE-SWEDEHEART trial, although patients were not randomized to heparin dose in this substudy.

ObjectiveMost reports on the declining incidence of myocardial infarction (MI) during the COVID-19 have either been anecdotal, survey results or geographically limited to areas with lockdowns. We examined the incidence of MI during the COVID-19 pandemic in Sweden, which has remained an open society with a different public health approach fighting COVID-19.MethodsWe assessed the incidence rate (IR) as well as the incidence rate ratios (IRRs) of all MI referred for coronary angiography in Sweden using the nationwide Swedish Coronary Angiography and Angioplasty Registry (SCAAR), during the COVID-19 pandemic in Sweden (1 March 2020–7 May 2020) in relation to the same days 2015–2019.ResultsA total of 2443 MIs were referred for coronary angiography during the COVID-19 pandemic resulting in an IR 36 MIs/day (204 MIs/100 000 per year) compared with 15 213 MIs during the reference period with an IR of 45 MIs/day (254 MIs/100 000 per year) resulting in IRR of 0.80, 95% CI (0.74 to 0.86), p<0.001. Results were consistent in all investigated patient subgroups, indicating no change in patient category seeking cardiac care. Kaplan-Meier event rates for 7-day case fatality were 439 (2.3%) compared with 37 (2.9%) (HR: 0.81, 95% CI (0.58 to 1.13), p=0.21). Time to percutaneous coronary intervention (PCI) was shorter during the pandemic and PCI was equally performed, indicating no change in quality of care during the pandemic.ConclusionThe COVID-19 pandemic has significantly reduced the incidence of MI referred for invasive treatment strategy. No differences in overall short-term case fatality or quality of care indicators were observed.

Background It is not clear if the European Systematic Coronary Risk Evaluation algorithm is useful for identifying prevalent subclinical atherosclerosis in a population of apparently healthy individuals. Our aim was to explore the association between the risk estimates from Systematic Coronary Risk Evaluation and prevalent subclinical atherosclerosis.Design The design of this study was as a cross-sectional analysis from a population-based study cohort.Methods From the general population, the Swedish Cardiopulmonary Bioimage Study randomly invited individuals aged 50–64 years and enrolled 13,411 participants mean age 57 (standard deviation 4.3) years; 46% males between November 2013–December 2016. Associations between Systematic Coronary Risk Evaluation risk estimates and coronary artery calcification and plaques in the carotid arteries by using imaging data from a computed tomography of the heart and ultrasonography of the carotid arteries were examined.Results Coronary calcification was present in 39.5% and carotid plaque in 56.0%. In men, coronary artery calcium score >0 ranged from 40.7–65.9% and presence of carotid plaques from 54.5% to 72.8% in the age group 50–54 and 60–65 years, respectively. In women, the corresponding difference was from 17.1–38.9% and from 41.0–58.4%. A doubling of Systematic Coronary Risk Evaluation was associated with an increased probability to have coronary artery calcium score >0 (odds ratio: 2.18 (95% confidence interval 2.07–2.30)) and to have >1 carotid plaques (1.67 (1.61–1.74)).Conclusion Systematic Coronary Risk Evaluation estimated risk is associated with prevalent subclinical atherosclerosis in two major vascular beds in a general population sample without established cardiovascular disease or diabetes mellitus. Thus, the Systematic Coronary Risk Evaluation risk chart may be of use for estimating the risk of subclinical atherosclerosis.

The key steps in cellular signaling and regulatory pathways rely on reversible noncovalent protein-ligand binding, yet the equilibrium parameters for such events remain challenging to characterize and quantify in solution. Here, we demonstrate a microfluidic platform for the detection of protein-ligand interactions with an assay time on the second timescale and without the requirement for immobilization or the presence of a highly viscous matrix. Using this approach, we obtain absolute values for the electrophoretic mobilities characterizing solvated proteins and demonstrate quantitative comparison of results obtained under different solution conditions. We apply this strategy to characterize the interaction between calmodulin and creatine kinase, which we identify as a novel calmodulin target. Moreover, we explore the differential calcium ion dependence of calmodulin ligand-binding affinities, a system at the focal point of calcium-mediated cellular signaling pathways. We further explore the effect of calmodulin on creatine kinase activity and show that it is increased by the interaction between the two proteins. These findings demonstrate the potential of quantitative microfluidic techniques to characterize binding equilibria between biomolecules under native solution conditions.

Objectives: Despite increasing use of selective, nerve-sparing surgical techniques during neck dissections, the reported rate of postoperative paralysis of the trapezius muscle is still high. The aim of the study is to measure and compare motor inflow to the trapezius muscle, in order to better understand the peripheral neuroanatomy.Methods: Intraoperative nerve monitoring (electroneurography) in patients undergoing routine neck dissection (n = 18). The innervation of the 3 functional parts of the trapezius muscle was mapped and quantified through compound muscle action potentials.Results: In 18/18 (100%) of the patients, the spinal accessory nerve (SAN) innervated all parts of the trapezius muscle. In 7/18 (39%) of the patients, an active motor branch from the cervical plexus was detected, equally distributed to all functional parts of the trapezius muscle, at levels comparable to the SAN.Conclusions: Compared to the SAN, branches from cervical plexus provide a significant amount of neural input to all parts of the trapezius muscle. Intraoperative nerve monitoring can be used in routine neck dissections to detect these branches, which may be important following surgical injury to the SAN.

AbstractKnowing when, where, and why food quality limits herbivore growth and reproduction is the core question in nutritional ecology. We investigated dietary threshold concentrations of polyunsaturated fatty acids (PUFAs) for the herbivorous zooplankter Daphnia pulexwhen fed the cyanobacterium Microcystis aeruginosaor the green algae Scenedesmus obliquus. Phosphatidylcholine liposomes were used to supplement diets with arachidonic acid (ARA, 20:4ω6), stearidonic acid (SDA, 18:4ω3), or eicosapentaenoic acid (EPA, 20:5ω3) at concentrations (per mg carbon) ranging from 0.04 to 10 μg (mg C)−1. ARA supplementation had no effect on Daphniasomatic growth or reproduction. SDA supplementation did not affect Daphniagrowth, however egg production dropped below a 50% saturation threshold when dietary SDA concentrations were <0.34–0.39 μg SDA (mg C)−1. Daphniaegg production dropped below a 50% saturation threshold when EPA concentrations for the Microcystisand Scenedesmustreatments were <0.25 and 0.17 μg EPA (mg C)−1, respectively. Growth declined below the 50% threshold when EPA concentrations for the 2 diets were <0.14 and 0.04 μg EPA (mg C)−1, respectively. These results show the demands for EPA are more intense for reproduction than for somatic growth. We used the EPA results to develop an overall model between Daphniaproduction and dietary EPA: normalized production = (EPA/C)/(0.15 + EPA/C), R2 = 0.72, n= 40. The bootstrapped 50% saturation threshold for this model was 0.15 ± 0.03 (± SE) μg EPA (mg C)−1. Our results suggest Daphnia pulexdietary EPA limitation may be common in eutrophic lakes

Body armor is used by military personnel, police officers, and security guards to protect them from fatal gunshot injuries to the thorax. The protection against high-velocity weapons may, however, be insufficient. Complementary trauma attenuating backings (TAB) have been suggested to prevent morbidity and mortality in high-velocity weapon trauma.

Objectives:Following perioperative injury to a macroscopically intact recurrent laryngeal nerve (RLN), there are two possible intraneural injury types: 1) axonal injury, including disruption of axons, and 2) conduction block, only affecting the Schwann cells and the nodes of Ranvier. In this study, it was hypothesized that the functional outcome after RLN injury may depend on the type of nerve injury.Methods:Fifteen patients with acute postoperative unilateral RLN paralysis were prospectively studied. Electrophysiological examination (laryngeal electromyography) was used to differentiate between the two types of nerve injury. Vocal fold motions were monitored by repeated laryngoscopy during the study period (up to 6 months). Three of the patients with axonal injury were treated with the regeneration-promoting agent nimodipine.Results:The patients with conduction block all recovered normal vocal fold motion, whereas patients with axonal injury within the nerve had a significantly worse outcome. The 3 patients who were treated with nimodipine all recovered normal or near-normal vocal fold mobility despite the more severe axonal injury.Conclusions:In contrast to previous reports, our results show that laryngeal electromyography is a reliable tool for diagnosing the type of injury within the injured RLN, making it possible to predict the functional outcome in these patients. On the basis of the results, a future randomized study on nimodipine treatment for RLN axonal injury is suggested.

Behind armor blunt trauma (BABT) is defined as the nonpenetrating injury resulting from a ballistic impact on body armor. Some of the kinetic energy is transferred to the body, causing internal injuries and, occasionally, death. The aim of this study was to investigate if apnea and other pathophysiological effects after BABT is a vagally mediated reflex.

A new highly hydrophilic stationary phase based on graft polymerization of sorbitol methacrylate from the surface of Kromasil silica particles is described. Polymerization was initiated by thermal cleavage of tert‐butyl hydroperoxide covalently attached to the silica particle surface. Due to the highly amphiphilic properties of the monomer, an extensive search was needed to find solvent conditions that enabled surface‐initiated polymerization. This was finally solved by using a mixture of solvents that only partially dissolved the monomer. The graft polymerization was confirmed by Fourier transform infrared spectroscopy and elemental analysis. The resulting stationary phase was evaluated by HPLC and exhibited a selectivity markedly different from that of commercially available columns and of neat silica.

The most-used safety recommendation for protective vests is that the impact should not cause more than a 44-mm impression in plasticine. The aim of this study was to investigate whether this criterion was sufficient if the vest was exposed to a high-velocity projectile. We tested the hypothesis with pigs divided into a 40-mm group (n = 10) and a 34-mm group (n = 8) protected by a vest allowing a 40-mm or 34-mm impression in plasticine, respectively. Five (50%) of 10 animals in the 40-mm group and 2 (25%) of 8 in the 34-mm group died due to the trauma. We observed severe lung hematoma, impaired circulation, desaturation, and electroencephalogram changes. These effects were more aggravated in the 40-mm group compared to the 34-mm group. Based on our results, the overall judgment is that the safety criterion of 44-mm impression is insufficient when a vest is exposed to a high-velocity projectile.

Behind armor blunt trauma (BABT) is defined as the nonpenetrating injury resulting from a ballistic impact on personal body armor. The protective vest may impede the projectile, but some of the kinetic energy is transferred to the body, causing internal injuries and occasionally death. The aim in this study was to investigate changes in electroencephalogram (EEG) and physiologic parameters after high-velocity BABT.

Apolipoprotein E-4 is the main known genetic risk factor for Alzheimer's disease. Functional abnormalities in the parietal cortex have been reported for Alzheimer's disease patients and also for those at risk. Hence, a critical question is whether measurements of parietal cortex integrity may predict negative outcome among at-risk persons. We studied nondemented apolipoprotein E-4 carriers and found a significant relationship between parietal blood-oxygen-level-dependent functional magnetic resonance imaging response during a word categorization task and subsequent episodic memory performance. Thus, the results show that parietal cortex alterations predict memory decline in nondemented apolipoprotein E-4 carriers, and hence likely progression to Alzheimer's disease.

The apolipoprotein E ɛ4 (APOE ɛ4) is the main known genetic risk factor for Alzheimer's disease. Genetic assessments in combination with other diagnostic tools, such as neuroimaging, have the potential to facilitate early diagnosis. In this large-scale functional MRI (fMRI) study, we have contrasted 30 APOE ɛ4 carriers (age range: 49–74 years; 19 females), of which 10 were homozygous for the ɛ4 allele, and 30 non-carriers with regard to brain activity during a semantic categorization task. Test groups were closely matched for sex, age and education. Critically, both groups were cognitively intact and thus symptom-free of Alzheimer's disease. APOE ɛ4 carriers showed reduced task-related responses in the left inferior parietal cortex, and bilaterally in the anterior cingulate region. A dose-related response was observed in the parietal area such that diminution was most pronounced in homozygous compared with heterozygous carriers. In addition, contrasts of processing novel versus familiar items revealed an abnormal response in the right hippocampus in the APOE ɛ4 group, mainly expressed as diminished sensitivity to the relative novelty of stimuli. Collectively, these findings indicate that genetic risk translates into reduced functional brain activity, in regions pertinent to Alzheimer's disease, well before alterations can be detected at the behavioural level.

Studies of non-human primates have shown that activity in inferotemporal (IT) brain regions decrease over repeated stimulus exposure, a phenomenon known as repetition suppression. In the present study, repetition suppression was examined during recognition of personally experienced events (explicit memory). Brain activity was measured while subjects encoded and subsequently recognized scenic pictures. First, two recognition conditions were compared; one that mainly included familiar pictures and one that mainly included novel pictures. Responses derived from this contrast may reflect recognition memory, perceptual priming, or novelty detection. To test specifically for responses associated with recognition memory, subjects encoded a new set of pictures followed by two recognition tests. All test pictures had been presented during the course of the experiment, and the subjects identified pictures that appeared in the second encoding list. Since all pictures were familiar, repetition suppression was specifically associated with recognition memory. In the first contrast, relative change in brain activity was observed in inferotemporal, extra-striate, and hippocampal regions during recognition of familiar versus novel pictures. In the second contrast, decreased activity in IT cortex was found. The location of this region overlapped with that for the region identified in the first contrast, and a conjunction analysis showed that reduced activity in left IT cortex was common to both contrasts. These results suggest that repetition suppression in IT cortex reflects recognition memory, and that such a response is not a simple function of stimulus repetition but can be modulated by top-down processing.

Abstract  Lesion of presumably ischemic origin of the rat sciatic nerve was induced photochemically by laser irradiation combined with systemic administration of a photosensitizing organic dye, erythrosin B. We have studied the pathologic features of the nerve after the photochemical insult with light‐ and electronmicroscopy and related them to behavioral signs of neuropathic pain. At the irradiated nerve site, occlusion of blood vessels was seen and the vessels were packed with aggregated thrombocytes, fibrins and deformed erythrocytes, supporting the notion that photochemical reaction caused intraneural ischemia. The degree of the nerve injury at the center of irradiation was related to the duration of the laser exposure. Brief irradiation (30 seconds) only caused identifiable injury to myelinated fibers, whereas longer irradiation (2 minutes) caused greater injury to myelinated and unmyelinated fibers, characterized by extensive axonal degeneration and demyelination. The rats irradiated for 2 minutes, but not 30 seconds, exhibited neuropathic pain‐like behaviors, expressed as mechanical and cold allodynia. The nerve injury was most severe 7 days after ischemia and regeneration of both myelinated and unmyelinated fibers was observed 3 months later. The nerve caudal to the irradiation exhibited Wallerian degeneration 7 days after the insult, whereas at 10 mm proximal to the irradiation the nerve was largely normal. It is thus concluded that photochemically induced intraneural ischemia caused injury to both myelinated and unmyelinated fibers, with myelinated fibers being more susceptible. However, the development of neuropathic pain‐like behaviors may require injury to the unmyelinated fibers.

The notion of overlap between encoding and retrieval processes is central in cognitive theories of episodic memory, but to date most functional neuroimaging studies have emphasized differences between these processes. In the present study, overlap between encoding and retrieval processes was investigated by analyzing data from a positron emission tomography (PET) study of encoding and retrieval of different kinds of event information. Using a conjunction analysis, we specifically aimed at identifying overlap in activation patterns for encoding and retrieval of three classes of event information: item, temporal, and spatial. It was found that both encoding and retrieval of spatial information activated posterior parietal areas bilaterally. In addition, item encoding and retrieval were associated with increased activity in the right temporal pole, and temporal encoding and retrieval with left inferior frontal and left inferior temporal regions. These findings suggest that when specific episodic information is retrieved from memory, regions involved in encoding of the same information are engaged. Microsc. Res. Tech. 51:39–44, 2000. © 2000 Wiley‐Liss, Inc.

The notion of overlap between encoding and retrieval processes is central in cognitive theories of episodic memory, but to date most functional neuroimaging studies have emphasized differences between these processes. In the present study, overlap between encoding and retrieval processes was investigated by analyzing data from a positron emission tomography (PET) study of encoding and retrieval of different kinds of event information. Using a conjunction analysis, we specifically aimed at identifying overlap in activation patterns for encoding and retrieval of three classes of event information: item, temporal, and spatial. It was found that both encoding and retrieval of spatial information activated posterior parietal areas bilaterally. In addition, item encoding and retrieval were associated with increased activity in the right temporal pole, and temporal encoding and retrieval with left inferior frontal and left inferior temporal regions. These findings suggest that when specific episodic information is retrieved from memory, regions involved in encoding of the same information are engaged. Microsc. Res. Tech. 51:39–44, 2000. © 2000 Wiley-Liss, Inc.

The number of c-fos protein-like immunoreactive (Fos-LI) cells in the gracile nucleus was determined after electrical stimulation at Aα/Aβ-fiber strength of the normal and of the previously injured sciatic nerve in adult rats. No Fos-LI cells were seen after electrical stimulation of the noninjured sciatic nerve, or after sciatic nerve injury without electrical stimulation. However, stimulation 21 days after sciatic nerve transection resulted in numerous Fos-LI cells in the ipsilateral gracile nucleus. Combined Fos immunocytochemistry and retrograde labeling from the thalamus showed that the majority (76%; range = 70-80%) of the cells in the gracile nucleus that expressed Fos-LI after nerve injury projected to the thalamus. The results indicate that morphological, biochemical, and physiological alterations in primary sensory central endings and second-order neurons, which have earlier been demonstrated in the dorsal column nuclei after peripheral nerve injury, are accompanied by changes in the c-fos gene activation pattern after stimulation of the injured sciatic nerve. A substantial number of the c-fos-expressing neurons project to the thalamus.

Ultrastructural changes in the gracile nucleus of the rat have been examined after peripheral nerve injury. The sciatic nerve of adult rats was transected at mid-thigh level, and after survival times ranging from 1 day to 32 weeks sections from the gracile nucleus were prepared for electron microscopic examination. Unoperated animals served as controls. Atypical profiles were regularly observed in the experimental cases at post-operative survival times from 3 days up to 32 weeks. It was sometimes not possible to classify these as pre-terminal axons or terminals, because synaptic contacts could not be identified. The two most common changes throughout the entire post-operative period were greatly expanded myelinated axons, or unmyelinated profiles containing numerous mitochondria, osmiophilic dense bodies and vacuoles. Atypical profiles were occasionally observed in unoperated control animals. The results clearly show that various types of degenerative changes occur in the gracile nucleus after peripheral nerve injury. These changes differ markedly from previously described transganglionic changes in other systems. It cannot be excluded that some of the changes reflect growth-related reactions, although the typical features of axon regeneration could not be found.

One motivation for the need of maps to be organized hierarchically in different resolutions is the fact that in most applications low-resolution maps require less heavy computations than maps represented at higher resolutions. Spatial data structures that permit generation of lower levels or resolution in a hierarchical fashion already exist, e.g., quad-trees and resolution pyramids. Many other spatial data structures that are non-hierarchical, and therefore do not permit the generation of resolution hierarchies, also exist. One such structure is the run-length-code (RLC), which has many powerful advantages that make the structure feasible in geographical information systems. In this article an approach to the problem of generating a resolution hierarchy from RLC is described and discussed.

Abstract:  The time course of the astroglial cell reaction in the nucleus gracilis and the spinal cord dorsal horn was examined following sciatic nerve transection in the adult rat with qualitative and quantitative analysis of glial fibrillary acidic protein immunoreactivity and in situ hybridization for its mRNA. In addition, the potential effect of exogenous nerve growth factor (NGF) was examined on the astroglial and microglial cells in the spinal cord dorsal horn at certain time points following sciatic nerve transection. An increase in glial fibrillary acidic protein immunoreactivity as well as mRNA labelling was observed from 1 day after lesioning, with a peak at about 1 week and 2 days after lesioning, respectively, followed by a decline. However, NGF application during 1, 2 and 4 weeks following nerve transection did not result in any significantly reduced astroglial or microglial activity. Our results show that the astroglial cell response in the nucleus gracilis and the spinal cord dorsal horn is rapid in comparison with previously described central degenerative changes following peripheral nerve lesions (transganglionic degeneration), that the astroglial cell reaction develops concomitantly with the microglial cell reaction previously described and that the „signal” from the axotomized neurons which induces these reactions can not be prevented by exogenous NGF applied to the peripheral nerve.

The article reviews several sequencers including Apple Logic Studio from Apple Inc. and Digidesign Pro Tools from Digidesign Inc.

Episodic memory for simple commands is better following enacted than verbal encoding. This has been proposed to be due to the possibility to base retrieval on motor information. Here we used PET to test the hypothesis that motor brain areas show increased retrieval-related activity following enacted compared to verbal encoding. Brain activity was also monitored during retrieval after imaginary enactment during encoding. It was found that activity in the right motor cortex was maximal following encoding enactment, intermediate following imaginary encoding enactment, and lowest following verbal encoding. These findings provide support that one basis for the facilitating effect on memory performance of overt, and to a lesser degree covert, encoding enactment is the possibility to base retrieval on motor information.

Electroconvulsive treatment (ECT) is often considered more effective than repetitive transcranial magnetic stimulation (rTMS). This case report concerns a patient with treatment resistant depression (TRD) on maintenance ECT since four years with only partial effect and debilitating side effects, who achieved full remission after a course of rTMS. This is a 30-year old woman, with recurrent depressive episodes (non-psychotic, non-melancholic) since five years, full-time working, mother of several children, without any co-morbidities. She had undergone treatment trials with seven different antidepressants from four different classes and four different augmenting medications including lithium, without reaching remission but experiencing troublesome side effects. She achieved remission after an initial trial of ECT four years ago, but after relapsing, subsequent ECT had only partial effect. Nevertheless, maintenance ECT at least offered some symptom alleviation, most importantly decreased suicidal ideation. She was experiencing subjective memory impairment affecting work performance and post-ECT somnolence often requiring over-night hospitalization. The past six months before rTMS she had no antidepressant medication, only maintenance ECT and weekly psychotherapy. One week after last ECT she was started on a 1Hz rTMS protocol [1]over F4. In the first two weeks she experienced severe fatigue, but decreased memory complaints. However, since MADRS score deteriorated her treatment was changed to a conventional 10Hz protocol over F3 [2]. She experienced a warm sensation during treatment sessions, fatigue persisted initially, and headache followed a few hours after each session. MADRS score gradually decreased though, and after three weeks she reached 50% reduction and remission after four weeks (Figure 1). Memory complaints had vanished by then and over-all subjective health rating had increased by 40%. Remission status was maintained without other treatment for about four months and after five months another rTMS course was applied with equally good effect. Currently still in remission after seven months.

While repetitive transcranial magnetic stimulation (rTMS) is a promising alternative in treatment resistant depression (TRD) the optimal coil placement and stimulation protocol, as well as its mechanism of action, are still largely unknown.

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