The two most common general anesthesia techniques are total intravenous anesthesia (TIVA) and venous/inhalation balanced general anesthesia (BGA). It is unclear whether any of these two techniques affect patient perception of the quality of recovery. The aim of this randomized, double-blinded clinical trial was to assess the quality of postoperative recovery of women undergoing laparoscopic cholecystectomy under general anesthesia. We compared patients who received TIVA with those who received BGA. We also evaluated the factors that may decrease patient-perceived quality of postoperative recovery.We prospectively recruited 121 women aged 18–65 years who were scheduled for elective laparoscopic cholecystectomy due to cholelithiasis. These patients were randomized to receive TIVA (target-controlled infusion of propofol and remifentanil) or BGA . To measure the quality of postanesthetic and postoperative recovery, we administered the Quality of Recovery-40 (QoR-40) questionnaire 24 hours after the patient awoke from anesthesia.All 60 patients in the TIVA group responded to QoR-40 . Sixty-one patients in the BGA group had a mean QoR-40 score of 186 points . There was no significant difference in the QoR-40 score between the two groups (p = 0.577). The patients who presented postoperative nausea and vomiting (PONV) and pain had worse perception of the quality of postoperative recovery.Both TIVA and BGA had a similar effect on the perception of the quality of postoperative recovery in women undergoing elective laparoscopic cholecystectomy. PONV and pain may negatively affect patient perception of the quality of postoperative recovery. Surgical and anesthetic procedures may initially negatively affect a patient’s quality of life, producing a sensation of discomfort, even in the absence of specific complications . In addiThe two most commonly used general anesthesia techniques are total intravenous anesthesia (TIVA) and balanced general anesthesia (BGA), with intravenous anesthesia combined with inhalation anesthesia . The useThe Quality of Recovery-40 (QoR-40) questionnaire measures the quality of recovery from anesthesia through five dimensions: physical comfort, physical independence, emotional state, psychological support, and pain , 8. The The aim of this clinical trial was to assess the quality of postoperative recovery of women undergoing elective laparoscopic cholecystectomy. We hypothesized that the perception of the quality of postoperative recovery 24 hours after waking from anesthesia would be better in women treated with total intravenous anesthesia than in women treated with balanced general anesthesia. We also evaluated the influence of pain, nausea and vomiting, and hypothermia on patient perception of the quality of postoperative recovery.http://www.ensaiosclinicos.gov.br/rg/RBR-7cwtgg/). All patients provided written informed consent to participate in the study. Data were collected at a hospital of the Brazilian public health network located in a city in the state of São Paulo, Brazil, between 10/2/2017 and 10/31/2018.This randomized, double-blinded clinical trial complied with international standards of research ethics involving human subjects, based on Resolution 466/12 of the Brazilian Ministry of Health and the Declaration of Helsinki. This study was approved by the Research Ethics Committee of the Jundiaí Medical School (2.157.459) and by the Brazilian National System of Research Records Involving Human Beings ("Plataforma Brasil") (CAAE 69609417.5.0000.5412) and was registered prior to patient enrollment at the Brazilian Clinical Trials Registry (ReBEC) ; patients who were pregnant or breastfeeding; carriers of pathologies that cause cognitive impairment .Exclusion criteria for the randomization process were as follows: patients who refused to participate in the study; patients taking any sedative, opioid, or sleep-inducing drugs; patients with a history of allergy to any drug used in the study; patients who had already undergone any surgery of the upper abdominal cavity; morbidly obese patients  surgery, as decided by the surgeon, patients who presented complications requiring a new surgical intervention or transfer to the intensive care unit during hospitalization, and patients who chose to abandon the study were also excluded.www.random.org. Next, the researcher wrote the group to which the patient belonged in an opaque envelope, sealed it, and handed it to the anesthesiologist who performed the procedure according to the allocation declared in the envelope.Patients were randomly assigned to the TIVA or BGA group by a researcher who was not responsible for performing anesthesia and did not collect the questionnaires. The randomization sequence was generated the morning of the surgery, using an internet-based random number generator available at ®)-measured anesthetic depth.Due to considerable procedural differences between the two general anesthesia techniques, the anesthesiologist and the surgeons who attended the surgery were not blinded to patient allocation. However, both the patient and the researcher were unaware of the patient’s group until the questionnaire data were collected. Patients in the study did not receive preanesthetic medication. As soon as the patients entered the operating room, the following variables were monitored: peripheral oxygen saturation, plethysmography data, electrocardioscopy data, automatic non-invasive blood pressure measured every 5 minutes, oropharyngeal temperature, and bispectral index (BIStarget-controlled infusion (TCI) with propofol and remifentanil using a commercial infusion pump and the Marsh (propofol) or Minto (remifentanil) pharmacological model. Anesthesia induction and maintenance steps aimed at a plasma concentration of the medication of 2–8 mcg·ml-1 for propofol and 2–8 ng·ml-1 for remifentanil, as guided by BIS®, which should remain between 45 and 60.Sixty patients in the TIVA group received -1 of propofol and TCI of remifentanil (Minto) targeting a plasma concentration of 2–8 ng·ml-1. Anesthesia was maintained using 1.5–3% sevoflurane with adjunctive remifentanil infusion (2–8 ng·ml-1). The infusion rate of remifentanil and the expired concentration of sevoflurane were also guided by BIS®, which should remain between 45 and 60.Sixty-one patients in the BGA group received a bolus administration of 1.5–2 mg·kg-1 rocuronium injected intravenously to facilitate intubation and pneumoperitoneum in all patients. During anesthesia, the patients were monitored with transcutaneous ulnar nerve stimulation and evaluated for the response of the adductor muscle of the thumb in the train of four stimuli (TOF). Tracheal intubation was performed in all patients after finding no muscular response, and a tracheal tube with a cuff was used, with an internal diameter ranging from 6.5 to 7.5 mm, calculated from the weight and BMI of the patient. The cuff pressure was maintained between 20 and 25 cm H2O. If the patient had a response greater than two stimuli in the assessment of neuromuscular blockade during surgery, a dose of 20% of the initial dose of rocuronium was administered.Neuromuscular blockade occurred with 0.6 mg·kg-1, ventilatory frequency of 10–16 breaths per minute, and final positive expiratory pressure (PEEP) of 5–7 cm H2O, aiming for an end-tidal carbon dioxide (ETCO2) value between 35 and 45 mmHg. The mixture of gases with oxygen and ambient air gave the patients an inspired fraction of 50% oxygen. In both groups, mean blood pressure could vary within 20% of the pre-induction values. If necessary, hypotension was corrected with 5 mg of ephedrine, and hypertension was treated with an increased infusion of remifentanil.Mechanical ventilation was maintained throughout the procedure with a tidal volume of 7 ml·kg-1 of neostigmine, with 0.01 mg·kg-1 of intravenous atropine, was administered to reverse the possible residual effects of a neuromuscular blockade. The tracheal tube was removed as soon as consciousness was recovered and sufficient spontaneous breathing was confirmed. After verifying the oropharyngeal temperature and confirming stable vital signs and adequate breathing, the patients were transferred to the postanesthesia care unit (PACU).Between 10 and 30 minutes before the end of surgery, patients in both groups received 8 mg ondansetron, 100 mg ketoprofen, 10 mg dexamethasone, and 100 mg tramadol intravenously. At the end of surgery, the surgical wound was infiltrated with 50% enantiomeric levobupivacaine hydrochloride at a concentration of 0.5% with vasoconstrictor, respecting the toxic dose of this anesthetic. After surgery was completed, all anesthetics were discontinued, and 0.05 mg·kg-1 of dimenhydrinate, 5 mg·ml-1 of pyridoxine hydrochloride, 100 mg·ml-1 of glucose, and 100 mg·ml-1 of fructose.Pain and PONV were assessed using a numerical rating scale (NRS) of 11 points on arrival at the PACU and every 10 minutes thereafter, until discharge to the hospital ward. When the pain score was equal to or greater than 4 points, the patient received 2 mg of morphine at 20-minute intervals until the pain score was less than 4 points. When the PONV score was greater than 3 points, the patient received a single 10-ml dose of the following mixture: 3 mg·mlAfter reaching a score equal to or greater than 9 in the modified Aldrete–Kroulik scale and a score of less than 4 in the evaluation of PONV and pain, the patients were discharged from the PACU and were referred to the hospital ward. During the stay in the hospital bed, the patients were medicated intravenously with 100 mg of ketoprofen every 12 hours as an analgesic medication. If they still had a pain score equal to or greater than 4, they received 100 mg of tramadol as rescue medication for pain. To prevent PONV, they received 8 mg of ondansetron every 8 hours.The quality of postoperative functional recovery was measured at 24 hours upon awakening from anesthesia by the QoR-40 questionnaire in In addition to QoR-40, patients and groups were compared on the basis of age, weight, height, occurrence of PONV and pain, hypothermia (defined as a temperature below 36° C at the end of surgery), duration of surgery, and length of stay in the PACU.® and transferred to and analyzed in SPSS® 24. Categorical data and their frequencies were compared using Fisher’s exact test and Yates’ chi-square test. Normally distributed ordinal data (presented as the mean and SD) were compared using the Student’s t-test. Ordinal data and non-Gaussian continuous data , which were not normally distributed as per the Kolmogorov–Smirnov test, were compared between groups using the Mann–Whitney test. A test power of 90% and a type I error of 5% were considered.After collection, quantitative data were entered into a database in ExcelA total of 132 patients were initially enrolled in this study. One of those patients refused to participate and 6 others did not meet the inclusion criteria; therefore, they were not considered for the randomization process. The remaining 125 patients signed the informed consent form and were randomized to TIVA or BGA; however, four patients were excluded during follow-up . Finally, the questionnaire data of 121 patients were collected and analyzed .There were no significant differences between the two groups regarding age, BMI, duration of surgery, length of stay in the PACU, and temperature upon awakening from anesthesia There were also no significant differences between the two groups regarding history of previous surgeries or pathologies, ASA physical status, presence of intraoperative complications, presence of PONV in the PACU, and need for rescue medication for pain (morphine) due to a pain score greater than 3 in the PACU There were also no significant differences between the two groups regarding patient perception of the quality of postoperative recovery through the QoR-40 total score (p = 0.577), its individual domains , physical independence (p = 0.129), psychological support (p = 0.111), pain (p = 0.337), and PONV at 24 hours upon awakening from anesthesia (p = 0.364) We analyzed the influence of moderate or severe pain in the PACU and in the first 24 hours postoperatively, PONV in the PACU and in the first 24 hours postoperatively, and hypothermia in patient-perceived quality of postoperative recovery We found that patients who presented moderate or severe pain in the PACU (p = 0.007) or in the first 24 hours postoperatively (p = 0.009), as well as those who presented PONV in the first 24 hours postoperatively (p < 0.001) had a worse perception of the quality of postoperative recovery, as evaluated by the total QoR-40 score. Patients who presented PONV in the PACU (p = 0.281) or those who presented hypothermia upon awakening from anesthesia (p = 0.159) did not have a significantly lower QoR-40 score.This clinical trial assessed and compared patient-perceived quality of postoperative recovery in women undergoing elective laparoscopic cholecystectomy, between those who received TIVA and those who received BGA. It also investigated the factors that may negatively affect this perception.During the development and validation of the questionnaire (QoR-40), a lower average of the scores was attributed to the questionnaires answered by women compared to men . TherefoThere were no significant differences between the two groups regarding history of previous surgeries or pathologies, ASA physical status, presence of intraoperative complications, presence of PONV in the PACU, and need for rescue medication for pain, which demonstrates adequate group randomization and concealment. Factors such as age, obesity, previous surgeries, and associated pathologies are associated with complications during the postoperative period and may affect the quality of postoperative recovery , 16–19. The overall QoR-40 score was high , denoting a good evaluation of the quality of recovery by the patients. There were no significant differences between the two groups regarding patient-perceived quality of postoperative recovery, possibly because there were also no significant differences in undesirable side effects, such as PONV, pain, and hypothermia.In this study, all patients received 10 mg of parenteral dexamethasone prior to the onset of anesthesia. The perioperative use of dexamethasone reduces the incidence of pain, nausea, and fatigue and shortens the period of stay in the hospital after laparoscopic cholecystectomy, leading to better evaluation of the quality of recovery by the patients . In addiA randomized clinical trial reported better perception of the quality of postoperative recovery among women undergoing thyroidectomy who received TIVA with remifentanil and propofol compared to those who received BGA with propofol, remifentanil, and desflurane . DiffereA meta-analysis also related better perception of the quality of postoperative recovery in the TIVA group, which was attributed to lower frequency of PONV, agitation, and postoperative pain . HoweverAnother clinical trial evaluated the quality of postoperative recovery in 110 men and women undergoing otorhinolaryngologic surgery with either TIVA (remifentanil and propofol) or BGA  with a population sample from a region close to the population of this clinical trial . As in tAn important aspect that may help understand the high QoR-40 scores in both groups was the monitoring and maintenance of a deep intraoperative neuromuscular blockade. Laparoscopic surgeries under low abdominal pressure are associated with a lower incidence of postoperative pain and referred pain in the shoulder, 24 hours after surgery . In addiIn this study, we found that the presence of moderate or intense pain in the PACU or in the first 24 hours significantly decreased patient-perceived quality of postoperative recovery. The same phenomenon occurred when patients reported PONV in the first 24 hours, but not in the PACU. As for hypothermia upon awakening, no significant decrease in QoR-40 scores was observed. As in our study, postoperative pain , 16–18 aAlthough hypothermia is related to complications such as increased cardiac morbidity, infection at the surgical site, residual effects of anesthetic drugs, increased PACU stay, coagulopathies, hormonal changes, and tremors , these pDuring this clinical trial, difficulties were encountered in measuring the quality of recovery, due to the subjective aspect of the tested domains, which may be influenced by emotional fragility, presence of side effects, fasting, and residual effects of drugs that may alter patient cognition . The comDespite these limitations, the increasing concern about patient perception of the quality of health care requires anesthesiologists to constantly seek anesthesia techniques that provide better quality of recovery. In this study, even though we did not observe superiority of either one of the two general anesthesia techniques, we found that achieving better patient-perceived quality of postoperative recovery may involve minimizing the side effects, such as PONV and pain.The choice of general anesthesia technique did not influence the perception of the quality of postoperative recovery in women undergoing elective laparoscopic cholecystectomy, but PONV and pain should be given special attention in this population.S1 FileEnglish version.(DOCX)Click here for additional data file.S2 FileIncludes the QoR-40 Portuguese (BRA) version questionnaire.(DOCX)Click here for additional data file.S3 File(DOC)Click here for additional data file.S4 FilePortuguese (BRA) version.(PDF)Click here for additional data file.S5 FileEnglish version.(DOCX)Click here for additional data file.


Brain activity concordance between patients and clinicians supports therapeutic alliance and treatment relief of pain. The patient-clinician interaction can powerfully shape treatment outcomes such as pain but is often considered an intangible “art of medicine” and has largely eluded scientific inquiry. Although brain correlates of social processes such as empathy and theory of mind have been studied using single-subject designs, specific behavioral and neural mechanisms underpinning the patient-clinician interaction are unknown. Using a two-person interactive design, we simultaneously recorded functional magnetic resonance imaging (hyperscanning) in patient-clinician dyads, who interacted via live video, while clinicians treated evoked pain in patients with chronic pain. Our results show that patient analgesia is mediated by patient-clinician nonverbal behavioral mirroring and brain-to-brain concordance in circuitry implicated in theory of mind and social mirroring. Dyad-based analyses showed extensive dynamic coupling of these brain nodes with the partners’ brain activity, yet only in dyads with pre-established clinical rapport. These findings introduce a putatively key brain-behavioral mechanism for therapeutic alliance and psychosocial analgesia. The patient-clinician interaction is fundamental to clinical care. Positive clinical encounters are associated with higher patient satisfaction, mutual trust , anterior insula (aINS), and ventrolateral prefrontal cortices (vlPFCs) are implicated in social processes such as empathy and theory of mind   to record brain activity simultaneously (fMRI hyperscanning) in patients with chronic pain and clinicians (acupuncturists) during an ecologically valid yet experimentally controlled clinical encounter, in which the clinician treated the patient to reduce evoked pain .We enrolled 45 participants, including 23 female patients with chronic pain diagnosed with fibromyalgia (FM) for at least 1 year and 22 acupuncture clinicians . Each participant was matched with up to two partners, forming a total of 40 distinct, interacting dyads. Each dyad was scanned under one of two conditions : Under the “Clinical-Interaction” condition, the clinician performed a clinical consultation and intake with the patient before MRI scanning to enable the dyad to establish clinical rapport. The “No-Interaction” control condition was identical to Clinical-Interaction except that the patient and the clinician had not had an intake and were only introduced briefly before scanning . We hypoEach participant completed four sessions: (i) a behavioral session for informed consent and familiarization with protocol; (ii) a clinical intake session, in which the clinician (acupuncturist) performed an intake with the patient, encouraged to be “as similar as possible to your daily practice” to maximize ecological validity; (iii) a Clinical-Interaction MRI on a separate day after the intake, in which the same patient and clinician were scanned together during a pain treatment session; and (iv) a No-Interaction MRI to control for the social relationship established at the intake. The order of Clinical-Interaction MRI and No-Interaction MRI was counterbalanced between participants . DiffereF = 20.82, P < 0.001, ηp2 = 0.60]. Planned direct comparisons indicated significantly lower CARE scores for No-Interaction MRI (mean ± SD = 32.19 ± 8.09), compared to Intake  and Clinical-Interaction MRI  contexts (fig. S1). No significant difference in CARE scores was noted between Intake and Clinical-Interaction MRI  sessions. A similar pattern was seen for clinician-rated therapeutic alliance (see fig. S1). These results support the ability of the intake to robustly establish therapeutic alliance and clinical rapport, which was then carried over to the Clinical-Interaction MRI session.The Consultation and Relational Empathy (CARE)  throughout hyperscanning. During block-design fMRI, patients received 12 moderately painful cuff pressures to the left leg , and an equivalence test  indicated that the difference between verum and sham EA was statistically equivalent to zero , supporting combining these collectively as treatment for subsequent analyses. Therefore, these conditions were pooled together as Treatment, collectively, for further analyses, and Treatment – No-Treatment differences are referred to as “analgesia” . For patients’ pain intensity, a repeated-measures ANOVA confirmed a main effect of “Treatment condition,” in which pain intensity was rated significantly lower for Treatment (mean ± SD = 26.32 ± 15.92), relative to No-Treatment  and no statistical interaction between Clinical context and Treatment condition , suggesting that pain intensity and analgesia were comparable across different clinical interaction contexts. Furthermore, there were no interactions involving “Order” (Ps > 0.12). However, an analysis of covariance (ANCOVA) confirmed that patient analgesia was significantly associated with subjective evaluations of the relationship, indicating that in dyads where relationship quality was rated more highly, patients reported stronger analgesia . There were no significant main effects or interactions involving clinical interaction context (P > 0.06) and “HRS item” (P > 0.72), suggesting that the association between analgesia and relationship evaluation was comparable across HRS items and clinical interaction contexts.There was no significant difference in pain between sham and verum EA  = 17.27, P < 0.001, ηp2 = 0.55, 95% CI = 7.27 to 21.82; F = 0.51, P = 0.49, ηp2 = 0.04, CI = −7.19 to 14.70], no statistical interaction with treatment condition  and no interactions involving Order (P > 0.61). Furthermore, patients’ analgesia  correlated with clinicians’ perceived treatment efficacy , such that for patients who reported greater pain relief, their clinician also perceived higher treatment efficacy , supporting patients’ ability to communicate their subjective pain to their clinician  relative to No-Treatment  and clinicians  felt more positively about Treatment trials than No-Treatment trials  = 0.02, P = 0.90, ηp2 = 0.001, 95% CI = −5.25 to 2.11; clinicians: F = 0.01, P = 0.92, ηp2 < 0.01, 95% CI = −6.48 to 5.99]. There were no Clinical Context * Treatment statistical interactions , indicating that affect was comparable across scans. There were no significant statistical interactions involving order .Correspondingly, repeated-measures ANOVAs on ratings of affect indicated that both patients . Patients with chronic pain diagnosed with FM for at least 1 year, meeting updated Wolfe and Häuser  or Clinical-Interaction . Each clinician came in for three visits—depending on interaction order, with their initial behavioral session completed on the same visit as the No-Interaction MRI  or immediately before the clinical intake session with the patient . See below for further detail on each session.After informed consent, participants were seated with a pressure cuff wrapped around their left lower leg, level with the gastrocnemius muscle. Participants went through a cuff pain calibration procedure to determine an individual stimulus intensity (pressure) level corresponding to moderate pain (40/100 pain rating). This pressure level was then used for all experimental cuff stimuli for this individual. Patients then had two acupuncture needles inserted on the anterior/distal aspect of the lower thigh, proximal to the cuff, with electrodes attached to each needle. Patients were then familiarized with the anticipation cue and pain stimuli and received six cuff stimuli, three of which were preceded by a visual cue indicating that upcoming evoked pain would be treated with subsensory threshold EA (see below). For these treatment trials, cuff pressure was surreptitiously reduced by 5, 10, and 20% of the target pressure (randomized order) to enhance expectations of treatment benefit, similar to boosting approaches previously used in investigations of the placebo effect .Once the patient had been positioned in the MRI scanner , the clinician entered the scanner room and led the patient through the process of acupuncture needling. MRI-compatible titanium needles  were inserted proximal to the cuff , with MR-compatible electrodes attached to each needle. These acupoints were chosen for their local/segmental effects on a pain source delivered at the calf. Because of hospital policy, the actual needle penetration was performed by a staff acupuncturist with hospital credentials, but under direct supervision of the subject clinician, and evident to the patient. The clinician then attached MRI-compatible electrodes to the needles, and electrodes were connected to an electronic needle stimulation device , controlled by the computer running the experimental protocol. The acupuncturist was then positioned in the other MRI scanner , a 1-min walk within the same building. To allow for unimpeded facial coverage for video transfer, both participants were positioned with an adapted coil configuration, using the 64-channel head coil bottom, and a small (4-channel) flex coil wrapped over the participants’ forehead to cover the frontal lobes of the brain. Before the scan, participants were instructed that they would be free to communicate their feelings to the other person nonverbally using facial expressions, as long as they kept their head as still as possible. Before fMRI scanning for the Clinical-Interaction session, the clinician was given the option to “check in” with the patient via the between-scanner audio/video connection to reinforce the clinical relationship.To assess the therapeutic empathy attributed to clinicians, patients filled out the validated CARE  and clinicians  after each MRI visit .The patient scale included the following items: (i) I had frequent eye contact with the acupuncturist. (ii) I felt as if the acupuncturist was in the same room as me. (iii) I felt like I could communicate with the acupuncturist. (iv) I felt comforted by seeing the acupuncturist. (v) I felt discomforted by seeing the acupuncturist. (vi) I felt as if the acupuncturist was really trying to treat my leg pain with electroacupuncture. (vii) The acupuncturist was genuinely concerned for me when I was in pain. (viii) I expressed my feelings to the acupuncturist. (ix) The acupuncturist was emotionally distant.The clinician scale included the following items: (i) I had frequent eye contact with the patient. (ii) I felt as if the patient was in the same room as me. (iii) I felt like I could communicate with the patient. (iv) I felt comforted by seeing the patient. (v) I felt discomforted by seeing the patient. (vi) I thought my treatment was helping the patients’ pain. (vii) I felt genuine concern for the patient when she was in pain. (viii) I expressed my feelings to the patient. (ix) I felt emotionally distant from the patient. (x) I cared whether I was providing electroacupuncture or not.At the end of each trial, participants used an MRI-compatible button-box to deliver two consecutive ratings (8 s each) on a VAS. Patients rated pain intensity (“how painful was the cuff?” with anchors “no pain” and “most pain imaginable”) and affect related to either receiving treatment (“how did you feel about getting treated with electroacupuncture?” with anchors “extremely negative” and “extremely positive”) or not receiving treatment (“how did you feel about not getting the electroacupuncture?” with anchors “extremely negative” and “extremely positive”). Clinicians rated vicarious pain (“how painful was it for the patient?”) and affect related to either providing treatment (“how did you feel about doing the electroacupuncture?”) or not providing treatment (“how did you feel about not doing the electroacupuncture?”) with anchors “extremely negative” and “extremely positive.”Before the scan at each MRI visit, participants indicated their expectancy of EA treatment efficacy using a 0 to 10 VAS .For both participants, visual stimuli were projected onto a screen behind the MRI scanner bore, and participants viewed projected video through a mirror. To enable visual communication between the scanners, MRI-compatible cameras  were attached to the table-mounted mirror with each MRI scanner and manually adjusted to capture the full face. The two-way video stream (20 Hz) was sent over a local network (measured to have consistent <40-ms delay) and recorded for human facial expression artificial intelligence analyses (see below).MRI-compatible optical microphones  were also set up in each MRI scanner to enable verbal communication between scans. To avoid speech-related motion during fMRI, we decided to disallow verbal communication during fMRI scanning.A custom in-house software (C++) was created for synchronizing fMRI scans between MRI scanners, transferring video and audio signals, and tracking the network delay between scanners. One laptop in each MRI scanner controlled the initiation of the fMRI scan acquisition sequence via remote trigger, the video stream, the experimental design visual stimuli, onset/offset of the cuff stimuli via remote trigger, and recording of in-scanner ratings. Both laptops were connected through a local area network. The MRI teams in each control room communicated with one another via phone, and when ready to start, the master computer (patient MRI control room) sent a signal to the slave computer (clinician MRI control room) to initiate the fMRI pulse sequence. Thus, after a lag corresponding to the current network delay , each computer initiated the fMRI pulse sequence locally. This procedure ensured synchronized timing of the two fMRI time series, video streams, and experimental protocols.All nonimaging statistical analyses were completed using R (RStudio 1.1.456) and JASP . Threshold for statistical significance was set at α = 0.05.To evaluate whether therapeutic alliance (CARE score) was different between sessions, we performed separate one-way repeated-measures ANOVAs for the patient group and the clinician group, each with three levels . We then performed follow-up contrasts comparing the different sessions.Intake) was used as a continuous predictor, and HRS Item was used as a categorical predictor to investigate potential differences between items of the HRS scale.To evaluate whether the relationship established during the intake carried over to the Clinical-Interaction MRI, we performed two ANCOVAs (separately for patient-rated and clinician-rated scores), with HRS values at MRI  as the dependent variable, as an indicator of social interaction quality. Therapeutic alliance at intake , Clinical context , and Order as a between-subjects factor .Treat-NoTreat) as the dependent variable, HRS values (Patient-rated) as a continuous predictor and Clinical context  and HRS Item  as categorical predictors.To evaluate whether differences in the social interaction between dyads were associated with analgesia, we performed an ANCOVA with analgesia (PainTreat-NoTreat) during scanning.To evaluate whether prior expectancy of therapeutic efficacy predicted treatment-related pain relief, we calculated Pearson’s correlation coefficients between expectancy as rated by the patient and the clinician before scanning versus analgesia  and include participants comparable in patient age , clinician age , and patients’ clinical pain levels , which supports the contention that this subsample is likely to be representative of the total sample from which other outcomes are reported. For the Affectiva algorithm, 33 facial landmarks are initially identified, which were used to estimate 21 facial action units. These units were then mapped onto seven basic emotional expressions  and two core expressions . We calculated these nine expressions frame by frame and averaged across each trial duration (separately for anticipation and pain/treatment phases).Facial expressions during fMRI scanning were analyzed using automated facial feature extraction . The Affectiva Facial Expression Analysis algorithm is based on the Emotional Facial Action Coding System  and analgesia.Behavioral mimicry such as the mirroring of facial expressions is thought to be fundamental for social development   for each patient. The resulting contrast parameter estimate maps were then passed up to a group analysis where a whole-brain group mean was calculated for all patients.Details on MRI acquisition and preprocessing are described in Supplementary Materials and Methods. For all whole-brain group fMRI analyses, significance testing was performed using FSL FLAME 1+2 with cluster correction for multiple comparisons (Treat – PainNoTreat) ratings as a regressor of interest.To investigate brain regions where treatment-related change in BOLD contrast correlated with analgesia, we performed a whole-brain regression GLM using each patient’s mean analgesia  and the patient-clinician trial-by-trial correspondence in pain/vicarious pain ratings for each dyad (see above for a detailed description of this metric) as a regressor of interest.Patient-clinician concordance related to therapeutic alliance and pain outcomes could be driven by social interaction during the anticipation of both treated and nontreated pain. Therefore, we first calculated overall brain response to anticipation of pain irrespective of Treat/NoTreat conditions, followed by a group conjunction between patients and clinicians, to identify ROIs for concordance analyses.Specifically, single-subject GLM analyses were performed using FILM with local autocorrelation correction. Similar to above, for each of the two runs, we modeled periods corresponding to anticipation of pain and pain stimulation as regressors. We also modeled ratings periods and the six motion parameter time series as regressors of no interest. We computed bidirectional contrasts for Anticipation-Rest and Pain-Rest. The Rest control period comprised the periods outside anticipation, pain stimulation, and ratings. In second-level fixed-effects analyses, we averaged these contrast parameter estimates across both runs and both visits  for each individual. We then passed the resulting contrast parameter estimate maps up to group analyses (separately for patients and clinicians), indicating overall response to (i) anticipation of pain (patients) and preparing to treat/not treat (clinicians) and (ii) pain (patients) and observing pain and treating/not treating (clinicians). To identify shared activation between patients and clinicians during the anticipation phase, for ROI identification for concordance analyses, we first performed a conjunction of the minimum statistic between these two maps. This group conjunction map was corrected for multiple comparisons using false discovery rate (α = 0.05). We then intersected this whole-brain map with a priori structural ROIs involved in social mirroring, empathy, and theory of mind  to yield more specific functional ROIs for use in concordance analyses.Given the structured experimental design with designated periods with visual cues for anticipation, pain stimulation/treatment and ratings, it was pertinent to properly model this structure in a multilevel approach to minimizing “pseudo-concordance” driven more by the shared experimental structure across individuals than social interaction itself , with each trial (anticipation period) as a separate regressor (fig. S7). We also modeled each pain period as a separate regressor of no interest. This produced a total of 12 pain anticipation parameter estimate maps (across both runs) for each individual. We then extracted the mean Zstat value from each individual’s rTPJ for each of the 12 anticipation trials, as defined by the group conjunction map intersected with the anatomical ROI. This same ROI was used for all dyads, after individual data were registered to MNI152 standard space. For each dyad, we performed a second-level whole-brain regression analysis of the clinician’s brain, using the trial-by-trial rTPJ Zstat values from the patient as a regressor and vice versa. Thus, we obtained a whole-brain map for each individual showing regions dynamically concordant  with the dynamics of the partner’s rTPJ response throughout the interaction. Next, we performed a whole-brain group contrast between Clinical-Interaction and No-Interaction to investigate regions where dynamic concordance was increased by Clinical-Interaction.Treat-NoTreat regression map and an anatomical mask . We extracted the mean Zstat value from the vlPFCTreat-NoTreat Zstat ROI from each patient, which we then used as a mediator variable in further analyses. In addition, since the PainTreat-NoTreat contrast was also increased for patients in brain regions beyond vlPFC , we also explored whether these regions mediated the association between concordance and analgesia. Each patient’s (PainTreat-NoTreat) rating difference was used as the dependent variable. We used the R package “Mediation” for mediation analyses (a * b) was statistically significant, while the previously significant direct effect (path c) became nonsignificant after controlling for the mediator (c′)  mediated the influence of brain concordance on analgesia ratings. We decided to focus on rTPJ-to-rTPJ concordance, as this metric was correlated with analgesia. We first extracted the mean Zstat value from the rTPJ region of each clinician’s whole-brain concordance map with the patient’s rTPJ, as a metric of each dyad’s rTPJ-rTPJ concordance, which was then used as the independent variable. For the mediator variable, we focused on the vlPFC, as this region is a key region for social mirroring (


Musculoskeletal disorders are debilitating conditions that significantly impair the state of health, especially in elderly subjects. A pathological triad of inter-related disorders that are highly prevalent in the elderly consists of the following main “components”: sarcopenia, tendinopathies, and arthritis. The aim of this review is to critically appraise the literature relative to the different disorders of this triad, in order to highlight the pathophysiological common denominator and propose strategies for personalized clinical management of patients presenting with this combination of musculoskeletal disorders. Their pathophysiological common denominator is represented by progressive loss of  neuromuscular performance with a risk of adverse outcomes such as pain, mobility disorders, increased risk of falls and fractures, and impaired ability or disability to perform activities of daily living. The precise management of these disorders requires not only the use of available tools and recently proposed operational definitions, but also the development of new tools and approaches for prediction, diagnosis, monitoring, and prognosis of the three disorders and their combination. Musculoskeletal disorders are debilitating conditions that significantly impair the state of health, especially in elderly subjects, since they are associated with pain, mobility disorders, increased risk of falls and fractures, and impaired ability or disability to perform activities of daily living. A pathological triad of inter-related disorders that are highly prevalent in elderly subjects consists of the following main “components”: sarcopenia, tendinopathies, and arthritis (the acronym “STAR” will be henceforth adopted).Interdependency within the different components of the triad fuels an accelerating disease progression that culminates in motor impairment, reduced quality of life, and increased risks of disability, morbidity, and mortality. Clinical and experimental findings show the interdependency within the three disorders. In fact, quadriceps weakness increases the risk of knee and hip osteoarthritis and also increases disease- and treatment-related complications ,2. SimilAn example of a clinical case that is commonly seen in daily practice, highlighting the possible interdependency of the STAR triad’s musculoskeletal disorders is as follows. A 70-year-old female presents to her general practitioner with complaints of difficulty in moving and pain. She reports that it is becoming difficult to rise from a chair and she sometimes loses her balance when walking on uneven surfaces. Reaching cups on the high kitchen shelves causes shoulder pain, and her knees, which used to ache only in the morning, now hurt all the time. Though she had multiple minor musculoskeletal injuries in her youth and worked in a factory for twenty years, she had only a few medical concerns during adulthood. After she retired, however, her activity level declined, and controlling her weight gain and diabetes has been difficult. Her doctor is concerned that multiple musculoskeletal disorders are affecting her independence and quality of life.The aim of this narrative review is to critically appraise the literature relative to the different disorders of this “STAR” triad, in order to highlight the pathophysiological common denominators and propose strategies for personalized clinical management of patients presenting with this combination of musculoskeletal disorders. Literature research was performed, including all relevant studies up to January 2020 by searching the Medline/PubMed database and Web of Science using the following search terms: arthritis, muscle weakness, musculoskeletal pain, osteoarthritis, physical frailty, sarcopenia, tendinopathy, tendon injury, and healing.Sarcopenia is the loss of skeletal muscle mass and function that occurs during the aging process (primary sarcopenia) or due to the presence of an underlying disease or medication (secondary sarcopenia). While secondary sarcopenia relies on the diagnosis and treatment for the underlying causation, primary sarcopenia has been more challenging to characterize. The European Working Group on Sarcopenia in Older People described sarcopenia as “a syndrome characterized by progressive and generalized loss of skeletal muscle mass and strength with a risk of adverse outcomes such as physical disability, poor quality of life, and death” .Epidemiological studies showed that from the second to the eighth decade of life, whole body and appendicular lean mass decline by about 20% in men and 30% in women ,9. SarcoFrom a pathophysiologic perspective, sarcopenia can be considered as an organ failure: Correa-de-Araujo and Hadley  proposedThis organ failure can develop chronically (more often) or acutely  and results from a combination of neural and muscular adaptations ,14. The The European Working Group on Sarcopenia in Older People proposed in 2010 an operational definition of sarcopenia based on the co-occurrence of low muscle mass and low muscle function (strength or performance) . This opOther consensus groups , Society of Sarcopenia, Cachexia and Wasting Disorders (SSCWD), Foundation for the National Institutes of Health Sarcopenia Project, and Asian Working Group on Sarcopenia) agree that the diagnosis of sarcopenia should incorporate a muscle mass evaluation with the assessment of strength and/or physical performance ,18,19,20Therefore, the reduction in muscle size and strength and neuromuscular performance impairment must be considered as core clinical presentations of sarcopenia: a critical mass of these phenotypic components identifies and evaluates the severity of the syndrome. This operationalization of the sarcopenic syndrome resembles the definition of the frailty phenotype previously proposed by Fried et al.  that is In addition to the formal clinical presentation framework, a recent stated-preference study performed in community dwelling, elderly, sarcopenic patients provided insights on the clinical features of sarcopenia that are relevant from the patients’ perspective, including mobility impairment, inability to manage domestic activities, increased risk of falls, fatigue, and reduced quality of life .Therefore, treatment interventions for sarcopenic patients should be performed to address not only the core phenotypic components of the syndrome (the impairments of muscle mass and function), but also the associated negative health outcomes.Understanding the pathophysiology and core clinical characteristics of sarcopenia is key to developing effective interventions, and translational research in this area is rapidly increasing . CurrentThe effects of exercise may be enhanced by a wide variety of other treatments, including patient education (patients must be instructed to progressively increase training load and to train at a high intensity)  and nutrFurthermore, evidence for the benefits of different physical therapies in improving muscle strength and mass individually is compelling, and evidence for their benefit in sarcopenia is growing. For example, neuromuscular electrical stimulation  , whole bRegarding pharmacological approaches, it is worth highlighting that no drugs have been approved yet for the treatment of sarcopenia. A recent umbrella review of systematic reviews and meta-analyses reported that only vitamin D, especially in older women, and testosterone in older men with low testosterone levels and muscle weakness can be justified in daily clinical practice to improve muscle mass and function in sarcopenic patients .Tendinopathy is a musculoskeletal disorder characterized by tendon pain during an activity, tendon swelling and localized tenderness upon palpation, and loss of function . DiffereThe most common tendinopathies in the elderly involve two tendons  of the rotator cuff of the shoulder ,46 and tDespite the progress achieved over the last decades, there is still great uncertainty over the factors causing this pathology and controlling its progression. A widely accepted concept for explaining the origin and development of tendinopathy is the generation of excessive tensile loads within the tendon over time. If a rapid increase in the magnitude, duration, or frequency of loading occurs, tensile strength might be exceeded locally causing a micro-injury. The mechanisms underlying the progression of this micro-injury are currently not established, but it has been hypothesized that repetitive overloading of the tendon may overwhelm the tissue’s healing capacity causing a more severe injury ,44. ThisCore clinical characteristics of rotator cuff degenerative tendinopathy include old age, focal night pain, weakness of shoulder muscles, and movement restriction ,62. ShouCalcific tendinopathy is another important, self-limiting differential diagnosis for patients presenting with shoulder pain, especially in middle-aged patients. It is a condition in which calcium deposits develop in the supraspinatus (80% of cases), infraspinatus (15% of cases), and subscapularis (5% of cases) tendons ,56. CalcLike shoulder tendinopathy, low-grade pain (with or without movement restriction) is characteristic of gluteal tendinopathy. This pain presents in the lateral hip and is aggravated with activities  and side-lying on the affected side . FurtherThe best approaches for clinical management of rotator cuff and gluteal tendinopathies have yet to be elucidated. Careful analysis of the medical history and symptoms must guide clinical decision making. Studied interventions include exercise, interventional approaches , physical therapy modalities , and topical glyceryl nitrate application.Positioning and exercise therapy seem to be effective in both rotator cuff tendinopathy and greater trochanteric pain syndrome; however, it is unclear what protocol is the best. Overuse may be managed by reducing loads and improving biomechanics. Reducing compression must be evaluated carefully in static and dynamic positioning. In greater trochanteric pain syndrome, it is probably useful to advise patients to avoid hip-adducted positions, such as standing with “hanging on one hip” or standing with crossed legs. In the same way, patients with rotator cuff tendinopathy should avoid sustained work positions where the shoulder is unsupported in abduction. Exercises commonly start with isometric contractions because they are easy to perform, well-tolerated, and may have analgesic benefits . Once paFor both gluteal tendinopathy and degenerative rotator cuff tendinopathy, peritendinous corticosteroid injection provides moderate pain relief, but only for a short time (less than 4 weeks) ,70. ReceHowever, a physiotherapy-led education and exercise program performs better than corticosteroid injection in the long-term follow-up of gluteal tendinopathy patients and should be considered as first-line treatment . SimilarRegarding rotator cuff tendinopathy, there is consistent evidence that both focused shock wave therapy and radial pressure wave treatment reduce pain and improve shoulder function when degenerative tendinopathy is present ,77. ConvExperiments suggest that nitric oxide, a free radical produced by different enzymes, enhances new tissue synthesis through several processes. A randomized control trial showed significant improvement in tendinopathy-induced shoulder pain and function at 12 and 24 weeks with glyceryl trinitrate (1.25 mg/24 h) compared to placebo . No studArthritis is a disease of articular joints that alters the joints biochemically, structurally, and physiologically. There are many classifications for arthritis since it is a heterogeneous, degenerative disorder with multiple etiologies and presentations . PrimaryOsteoarthritis is a leading cause of pain and disability around the world . UtiliziThe main reason cited for the increasing prevalence and disability of osteoarthritis is our aging population. Biochemical and mechanical changes associated with aging are the greatest non-modifiable risk factors for osteoarthritis development and progression . Women hOsteoarthritis starts as a biochemical process affecting the synovium, cartilage, or subchondral bone and progresses to biochemical and anatomical abnormalities of the entire joint complex, culminating in illness ,89,92. TThe synovium can be the source of multiple pro-inflammatory mediators that lead to pain and changes to the synovial fluid. The synovial fluid nourishes the avascular, aneural cartilage as well as produces hyaluronic acid (HA) and lubricin to reduce friction during movement. An increase in pro-inflammatory and catabolic products decrease the concentrations of cartilage-protecting factors and increase the production of cartilage degradation factors. There are also changes to the molecular weight of HA and a decrease in the concentration of lubricin .The cartilage is also protected from mechanical stress and nourished by the subchondral bone. Early osteoarthritis bone remodeling could occur through different mechanisms: cellular signaling leading to bone remodeling and resorption and vascular invasion leading to cartilage degeneration and diminished mechanical integrity. As osteoarthritis progresses, there is a net increase in remodeled bone formation, leading to the characteristic osteophytes, sclerosis, and joint deformity seen in advanced disease ,92.When an imbalance exists in the structure or functioning of the extracellular matrix of the cartilage, additional inflammatory mediators and mechanical stress create a “vicious cycle” of cartilage degeneration. Over time this “low-grade” inflammation and mechanical stress limit chondrocyte production of functional collagen (collagen type I), reduce space-occupying proteoglycans, and increase inflammatory mediators. While mechanical stress can occur over time and increase with age, there is likely an inherent age-associated change in the chondrocyte phenotype that also impairs cartilage homeostasis ,92. ThisPatients with osteoarthritis can be identified through a range of common phenotypes, the presence of risk factors, clinical signs, and symptoms .Patients presenting with osteoarthritis complain of short-lived (<30 min) pain and joint stiffness at the beginning of movement, especially in the morning. As osteoarthritis worsens, pain can be present after a period of activity or become continuous. Pain and stiffness create a functional limitation in movement, affecting the ability to perform activities of daily living. Primary physical exam findings can include crepitus, restricted movement, and bony enlargement . There is no or only minimal palpable warmth, redness, or effusion in joints affected by osteoarthritis. Through the progressive increase in pain and loss of mobility, reduction in fitness and social isolation can be common ,92. ConsRadiography is considered as the “gold standard” for osteoarthritis diagnosis and is commonly used to identify the severity and to monitor the progression of joint disease in symptomatic patients ,92. KellMultiple protocols for therapeutic management of osteoarthritis exist, including those from the European League Against Rheumatism (EULAR) , EuropeaFirst, all osteoarthritis organizations support patient information and education about their condition to promote mechanical and metabolic improvements. These include self-management, weight loss, and an exercise program to strengthen the joint and supporting structures. Additionally, a psychosocial assessment is likely beneficial for patients with chronic pain. Weight loss and obesity treatment is a universal recommendation, though many recognize the difficulty of achieving success . ESCEO’sPharmacologic treatment recommendations vary depending on the joints affected and patient comorbidities. The most common initial treatment recommendation is acetaminophen (paracetamol) due to its favorable side-effect profile . ESCEO dInterventions for osteoarthritis typically begin with intraarticular injections and can escalate to total joint replacement. Corticosteroid injections can temporarily help with pain (<3 weeks) and are generally recommended when there are additional signs of inflammation like breakthrough pain or a mild effusion, but not on a continuous basis ,109,110.The progressive loss of  neuromuscular performance is the pathophysiological denominator common to the three disorders ,13,22,24The three disorders increase the risk of adverse outcomes such as pain, motor impairment, increased risk of falls and fractures, impaired ability or disability to perform activities of daily living, and reduced quality of life ,59,89,92The three disorders have a heterogeneous clinical presentation: patient stratification based on clinical and imaging variables may be the key to developing disease-modifying interventions for different subsets of patients ,104.The precise management of the three disorders requires not only the use of available tools and recently proposed operational definitions, but also the development of new tools and approaches for prediction, diagnosis, monitoring, and prognosis of the three disorders and their combination.Physical exercise, alone or in combination with nutritional interventions, is the approach currently recommended as the primary treatment of the three disorders ,67,107.We reviewed the literature relative to three inter-related musculoskeletal disorders  that are highly prevalent in elderly subjects, in order to highlight the pathophysiological common denominator and propose strategies for personalized clinical management of patients presenting with this combination of disorders. Even though their clinical presentation can be different  ,36,89,92


Background: Chronic pain and fatigue are two cardinal features of ankylosing spondylitis (AS) and how to effectively treat these conditions continues to be a challenge. The underlying mechanisms and the relationship between AS-related pain and fatigue remain poorly understood. The present study was conducted, therefore, to explore the brain functional and structural changes associated with pain and fatigue in AS.Methods: A total of 65 AS patients  and 53 age- and sex-matched controls were enrolled in the study. The patients underwent clinical assessment based on Total Back Pain scores, Fatigue Severity Scale, Bath Ankylosing Spondylitis Disease Activity Index, (BASDAI), high-sensitivity C-reactive Protein (hsCRP), erythrocyte sedimentation rate (ESR), and Beck Depression Inventory (BDI). Using 3T magnetic resonance imaging (3T-MRI), we analyzed the brain functional  and structural (covariance and gray matter volumes) differences between AS patients and controls. Furthermore, we extracted the values of the significantly changed regions in the AS cohort and explored their association with pain and fatigue.Results: In AS patients, there were functional and structural abnormalities distributed in the default mode network (DMN), salience network (SN), sensory/somatomotor network (SMN), dorsal attention network (DAN), task control network (TCN), and visual network, and some regions showed both types of changes. Among these, the functional connectivity (FC) between the left insula and medial prefrontal cortex, the betweenness centrality of the left medial prefrontal cortex and the gray matter volume of the right putamen tracked both pain and fatigue. In addition, pain was related to within-DMN FC disruption and nodal function / gray matter volumes changes in DMN, SN, and the visual network, while fatigue mainly involved the SMN, DAN, and TCN. Moreover, certain changes were also related to BASDAI and inflammation level.Conclusion: This study offers new insights into understanding the neural mechanism of AS-related pain and fatigue, and could help to stratify patients based on the correlation features and ultimately move towards a personalized therapy. Ankylosing spondylitis (AS) is an immune-mediated systemic inflammatory disease that mainly affects the spine and sacroiliac joint and is characterized as inflammatory low back pain . InflammOn the other hand, AS patients always suffer another major and frequent symptom—fatigue, which is reported in 50–70% patients  and closThere have been a number of studies that have explored the relationship between AS-related pain and fatigue, but the results are inconsistent. Some researchers found AS-related fatigue to be strongly correlated with pain , but othIn recent years, on the basis of functional MRI (fMRI) technique, there have been considerable evidence on the fatigue or pain-associated brain functional or structural alterations in chronic pain diseases , 10, 11.There have been only a few neuroimaging studies on AS , 11, 16,With these scientific problems in mind, the current study used a relatively large sample to: (i) identify the whole-brain network functional connectivity (FC) abnormalities associated with pain and fatigue in AS based on a validated, well-recognized human brain atlas (264 ROI) ; (ii) chA total of 65 AS patients  and 53 age- and gender-matched healthy controls  participated in the study. Our recruitment goal was to obtain a sample size of more than 50, as this would possess enough power to determine a moderately sized correlation at relatively conservative thresholds and is believed to be a sample size that performs well in receiver operating characteristic (ROI)-based unbiased functional connectivity analyses . WrittenTo be included in the study, AS patients had to meet the following criteria: (i) AS diagnosis that fulfilled the 1984 Modified New York Criteria , (ii) anThe exclusion criteria for both patients and healthy controls were: (i) any contraindication for having an MRI; (ii) a history of psychiatric, neurologic, or metabolic conditions; (iii) major surgery within the past 2 years; or (iv) serious infection  within 2 months of testing. Except for 1 control subject and 1 patient with AS, all participants were right-handed. The study was conducted strictly in accordance with the World Medical Association's Declaration of Helsinki and in line with relevant institutional and national guidelines.All consenting subjects completed a set of clinical evaluation, which included total back pain (TBP) scores based on a scale of 0-10  to evaluate the average degree of back pain experienced in the previous week. Fatigue was assessed using a modified 9-item, 10-point Fatigue Severity Scale (FSS), which is a unidimensional scale for assessing the influence of fatigue on daily living . Disease3) and fluid-attenuated inversion recovery . Next, we obtained (i) a T1-weighted high resolution anatomical scan  for structural analysis, and (ii) an 8-minute T2-weighted resting-state fMRI scan  for functional analysis. During the fMRI scan, the patients and healthy controls were instructed to “open your eyes naturally, do not think about anything in particular and do not fall asleep.” All images underwent strict quality inspection by a neurologist and radiologist.Brain magnetic resonance image data were obtained with a 3T MRI scanner equipped with an 8-channel phased-array head coil . All subjects were instructed to lie quietly in the supine position, and head motion was minimized with foam padding surrounding (outside) the head. Earplugs were used to attenuate the scanner noise. To exclude any structural abnormalities of the brain, we firstly obtained the conventional T1-weighted images  and GRETNA 2.0 (http://www.nitrc.org/projects/gretna/) loaded on MATLAB R2014a , as previously described , was also regressed. The temporal filter was in the range of 0.01–0.1 Hz. Finally, we performed scrubbing .To explore the whole-brain inter-regional functional relationship, we constructed the brain network according to a set of 264-region-of-interest (ROI) atlas  derived from resting-state functional connectivity meta-analyses , 27. TheGraph theoretical measures can reflect not only brain network functional integration, but functional separation based on nodal indices . On the t-test with FDR correction (p < 0.05). These analyses were conducted in GRETNA. Connectome figures were presented by BrainNet Viewer 1.7 (www.nitrc.org/projects/bnv/).Briefly, nodal degree centrality (DC) represents the number of connections to a given node and reflects a node's accessibility, and nodal betweenness centrality (BC) embodies the important roles of nodal communication across a given node as the bridge . On the http://dbm.neuro.uni-jena.de/cat12/) toolbox segment data pipeline and integrated into SPM12. Firstly, we spatially registered the 3DT1 images to the tissue probability maps (TPM) and segmented them into gray matter, white matter, and cerebrospinal fluid. We then performed the affine registration to the stereotactic MNI space using the ICBM152 space. Secondly, on the basis of the Jacobian determinants calculated from the normalization process, we completed high-dimensional DARTEL normalization and nonlinear modulation. Thirdly, we removed the noise and bias and normalized the intensities to avoid MRI inhomogeneities and noise. Finally, to reduce potential inaccuracies during the normalization process, we smoothed the GM image (8 × 8 × 8 mm3 Gaussian kernel). Moreover, we assessed the quality of the resulting images by visual check and analyzed the image quality index  framework in CAT 12, http://www.neuro.uni-jena.de/cat/), only including the participants with QA no less than B- in our final analyses. Two subjects did not pass the image quality control and were excluded in our final analysis.In this part, we aimed to determine whether functional changes (if any) are derived from underlying structural abnormalities. It is well known that functional changes represent a state of transition over a relatively short period while structural changes need time to develop. Data were analyzed with the Computational Anatomy Toolbox  structural covariance (SC) . We thent-tests. Significance for these tests was set at p < 0.05 (two-sided).Demographic data (age and gender), TBP, FSS, questionnaire scores (BDI), clinical index (hsCRP and ESR), and levels of mean relative motion recorded during the fMRI scan were compared between groups using independent sample t-test, significance p < 0.05, FDR corrected). To explore the group differences in SC and GMV, we used two-sample t-test based on the significant FCs and nodes found in functional analyses controlling for age, gender, and total intracranial volume (TIV) with FDR multiple correction .To examine the group differences in FC and nodal properties (BC/DC), we applied general linear models (GLMs) on the composite graph theoretical measures controlling for age and gender (two-sample p < 0.05 corrected with multiple comparisons of Bonferroni correction (p < 0.05). The age, gender, and education level of each subject were imported as covariates in the statistical analysis. All statistical analyses were conducted in SPSS version 17.0, and correlation graphs were generated using GraphPad Prism 8.Partial correlations between fMRI measures  of the brain regions which showed group difference and clinical features (pain and fatigue) were analyzed in AS patients by means of Spearman's correlation or multiple linear regression models with stepwise elimination. Additionally, we examined the relationship between the above findings and other indexes . The significance was set at t = 0.04, p = 0.96, two-sample t test) or gender. All the AS patients reported a TBP score of at least 1, and 51 out of 65 AS patients reported experiencing fatigue (FSS) to some extent during the previous week. The group average TBP and FSS scores were 5.15 and 5.02 in AS patients, respectively. The AS group reported suffering from pain or fatigue for 7.8 (6.8) and 3.5 (4.3) years, respectively. At the time of enrolment, 38 AS patients were taking nonsteroidal anti-inflammatory drugs, which included Celebrex, Meloxicam, Diclofenac, and Ibuprofen. No patients had received other central analgesics or biologic agents in the past 2 months. To exclude possible determinants of AS-related pain, we conducted multiple regression analyses controlling for age and gender, where FSS, BASDAI, hsCRP, ESR, and BDI were selected as the dependent variables. Only BASDAI score was shown to be weakly associated with TBP score  and explained an approximate 30% variance in TBP scores. There was no significant correlation between TBP scores and age, sex, FSS scores, hsCRP, ESR, or BDI scores (p > 0.05)  were excluded because of head motion > 2 mm, and 5 (3 + 2) had MRI scans deemed unacceptable or acquired with different parameters, resulting in 54 AS patients and 50 HC being included in the final analysis.  > 0.05) . Moreovep < 0.05, FDR corrected) : the FC between nodes 208 and 115 was correlated with both TBP and FSS; and the FC between nodes 115 and 262 with FSS, and the FC between nodes 107 and 92 were correlated with TBP  : (i) enhwith TBP .p < 0.05, Bonferroni corrected, adjusted for age and sex)  is the fraction of all the shortest paths in the network that go through a given node and evaluates the contribution of a node based on the communication with other nodes. Nodes with higher BC possess higher efficiency in transferring information. Degree centrality (DC) refers to the number of ties a node has with other nodes and is another measure of node importance in the network. In our topological analyses, a dozen nodes were found to have altered BC or DC which was distributed in the DMN, SMN, DAN, TCN, SN, and visual and subcortical cortex . Furtherand sex) .p < 0.05, FDR corrected): one was the increased SC between node 115  and 208 , and the other was also an increased SC between node 107  and node 92   also see . We only cortex) . Interesp < 0.05, FDR corrected)   . Of thesrrected) .r = 0.41, p = 0.02, Bonferroni corrected); (ii) the GMV of putamen was weakly associated with BASDAI, which did not pass the multiple correction ; and (iii) the GMV decrease of node 115  was weakly associated with ESR, and also did not pass multiple correction  . Our results were as follows: (i) the FC between nodes 208 and 115 was moderately correlated to BASDAI (rrected) .p = 0.35, two-sample t-test). Moreover, our main findings remained largely unchanged after entering mean relative head motion as a covariate of no interest in our analyses.We conducted additional tests to exclude the bias caused by head motion in our analyses. The mean relative framewise displacement in the AS patients was comparable to that in the HCs  are known to cause specific lesions in the brain. Although all the recruited patients were not clinically diagnosed as depressed or as suffering from other psychiatric conditions, the BDI of the AS patients was significantly higher than that of the HCs. However, there was no significant relationship observed between any of the above-mentioned FC, nodal properties, and GMV results with BDI scores. Therefore, it is unlikely that our main findings were confounded by depression.n = 38) and treatment-naïve (n = 16) patients. There were no major between-group differences in any significant FC or nodes identified in our primary analysis  and for the first time demonstrates a prominent aberration in both function and structure associated with pain and fatigue in AS. Our key findings were: (i) there were multiple pain and fatigue-related FC changes in several key regions belonging to the DMN, SN, SSN, and DAN; (ii) AS-related pain mainly involved the DMN, SN, and visual networks, while fatigue was associated with the DMN, SMN, and DAN; (iii) some of the above changes could, at least in part, be explained by underlying structural alterations; and (iv) there were both distinct and overlapping functional and structural abnormalities correlated with pain and fatigue, reflecting the multifactorial nature of the two symptoms of AS at a neurobiological level.Under normal conditions, the DMN and SN are anticorrelated . HoweverA region of DAN  also had increased connectivity to mPFC and interestingly, this FC tracked fatigue in AS. A key role of DAN is the top-down control of attention in response to predictable stimuli, which complements the ventral attention network's bottom-up control of attention to unexpected stimuli. An fMRI study on rheumatoid arthritis (RA) indicated that fatigue was related to mPFC-DAN FC . PsycholRecent fMRI studies observed within-DMN disruptions in migraines , fibromyBrain topological analysis can identify nodes that might have a significant or contributing role in disease. Schrepf et al. demonstrated that RA patients with higher level inflammation exhibited changed properties in mPFC and inferior parietal lobule . ConsidePrevious studies have suggested that fatigue and pain exert different influence on the CNS: fatigue impacts more on the SMN and DAN than regions classically involved in pain perception . For insOur structural analyses suggested there were also underlying structural abnormalities in AS. The higher insula-mPFC SC might result from the increased insula-mPFC FC—a synchronous discharge of neurons induced the synapse formation between neurons. The increased SC between left ACC and right PCC might be a compensatory response resulting from disrupted within-DMN activity—the brain needs to enhance its structural synergy within the DMN to maintain stability in resting states.GMV analyses further confirmed the roll of DMN and visual network in AS-related pain and the importance of DAN, SMN, and TCN in the pathogenesis of fatigue. First, GMV decrease of the primary somatosensory cortex might result from activity-dependent plasticity due to sensory loss, as evidenced by the mechanical and thermal hyposensitivity in the feet of the AS patients. Second, the GMV decrease of left ACC might be because of the preferential loss of inhibitory inter-neurons in this region, which could explain the increased pain effect mediated by the subgenual part of the ACC . Third, Our study has the following limitations: Firstly, the study design is cross-sectional; therefore, we cannot clarify the causality of the detected brain abnormalities. Alternatively, these changes might be the downstream signals. Regardless, our results could still be meaningful in that no recognized objective measure of pain and fatigue exists for AS at present. It is important to validate our results using the same cohorts based on a longitudinal design. Secondly, whether the correlates we found are AS-specific or generic in pain or fatigue is still unknown, as similarly designed studies in this field are scarce. Additional validation on distinct pain and fatigue disorders are therefore warranted. Thirdly, our observations might be confined to resting state. Attention networks (e.g. SN and TCN) are known to show enhanced activity when performing tasks or in an attention condition, so future attempts are necessary to replicate our findings using take-based paradigms.In conclusion, the present study is the first to clearly examine the brain in the pathophysiology of AS-related pain and fatigue. The level of pain and fatigue was correlated significantly to a series of functional and structural abnormalities in the brain, a few of which overlapped. Certain regions were also associated with other clinical characteristics, reflecting the multi-factor nature of these symptoms in AS.Our study not only identified some initial targets for urgently-needed fatigue or pain-directed therapies, but also created an objective measure for neurobiologically stratifying AS patients. Additionally, applying machine-learning technology to an even larger sample can contribute to stratifying patients based on the correlation signature and subsequently move toward a personalized therapy. Meanwhile, neuromodulating the neural correlates may facilitate the verification of the causation of the selected brain structures and offers a potential therapy for specific symptoms. Pain and fatigue are the most predominant symptoms and the most heterogeneous of constructs; thus, clinicians need a more effective means of achieving mechanistically individualized treatments to help patients reach a better outcome.The datasets generated for this study are available on request to the corresponding author.The studies involving human participants were reviewed and approved by the ethics committee of the third affiliated hospital of Sun Yat-sen University. The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.All authors were involved in drafting the manuscript, revising it critically for important intellectual content, and in the final approval of the publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Cardiac amyloidosis is common in elderly patients with aortic stenosis (AS) referred for transcatheter aortic valve implantation (TAVI). We hypothesized that patients with dual aortic stenosis and cardiac amyloid pathology (AS-amyloid) would have different baseline characteristics, periprocedural and mortality outcomes.P = 0.001), with reduced quality of life . Left ventricular wall thickness was higher , ECG voltages lower  with lower voltage/mass ratio . High-sensitivity troponin T and N-terminal pro-brain natriuretic peptide were higher . Gender, comorbidities, 6-min walk distance, AS severity, prevalence of disproportionate hypertrophy, and post-TAVI complication rates  were the same. At a median follow-up of 19 (10–27) months, there was no mortality difference (P = 0.71). Transcatheter aortic valve implantation significantly improved outcome in the overall population (P < 0.001) and in those with AS-amyloid (P = 0.03).Patients aged ≥75 with severe AS referred for TAVI at two sites underwent blinded bone scintigraphy prior to intervention . Baseline assessment included echocardiography, electrocardiogram (ECG), blood tests, 6-min walk test, and health questionnaire, with periprocedural complications and mortality follow-up. Two hundred patients were recruited . AS-amyloid was found in 26 (13%): 8 Grade 1, 18 Grade 2. AS-amyloid patients were older (88 ± 5 vs. 85 ± 5 years, AS-amyloid is common and differs from lone AS. Transcatheter aortic valve implantation significantly improved outcome in AS-amyloid, while periprocedural complications and mortality were similar to lone AS, suggesting that TAVI should not be denied to patients with AS-amyloid. This study complies with the Declaration of Helsinki, relevant local ethics and site approvals were obtained and all patients provided informed consent. Recruitment took place across two sites: Barts Heart Centre, London (October 2016 to January 2019) and John Radcliffe Hospital, Oxford (January 2018 to June 2019). To reduce bias, recruitment took place when referred for TAVI, but typically before the multidisciplinary team meeting. We therefore anticipated some cross-over to medical therapy and rarely to surgical valve replacement, which occurred. Baseline assessment included blood tests for high-sensitivity troponin T (hsTnT) and N-terminal pro-brain natriuretic peptide (NT-proBNP), a 6-min walk test and EQ-5D-5L health questionnaire in addition to routine clinical care—including electrocardiogram (ECG) and echocardiogram.This work forms part of ATTRact-AS .et al. All patients underwent clinical transthoracic echocardiogram, primarily for assessment of AS severity , any concomitant valve pathology, left and right ventricular systolic and left ventricular diastolic, according to the local protocol, which is based on the American Society of Echocardiography, the British Society of Echocardiography, as well as the European Association of Cardiovascular Imaging guidelines.Where IVSd is the interventricular septal diameter, LVIDd is the left ventricular internal dimension in diastole, and PWd is the posterior wall diameter, all measured in 2D. Longitudinal strain analysis was performed offline by an accredited echocardiographer using Tomtec software.2, with an LVEF <50%, an indexed SV <35 mL/m2, a peak aortic valve velocity <4 m/s, and a mean gradient <40 mmHg, conversely ‘paradoxical’ low-flow, low-gradient was defined as an LVEF ≥50%, but an indexed SV <35 mL/m2, peak velocity <4 m/s, and mean gradient <40 mmHg., , , Myocardial contraction fraction (MCF), which indexed the SV to the myocardial volume, was calculated as previously described.Figure 1). DPD scan findings were also independently reviewed by the National Amyloidosis Centre (NAC). The managing clinicians were blinded to the results of the DPD scan until after the patient’s TAVI procedure  unless the scan had been requested clinically  or there was evidence of a plasma cell dyscrasia on serum free light chains, serum and urine immunofixation (sent when the DPD scan was confirmed positive). All patients with a positive DPD scan were discussed with NAC and, where appropriate, referred for further review. Detailed clinical review for those patients seen at the NAC with a plasma cell dyscrasia included: clinical history and examination, cardiovascular magnetic resonance (where appropriate), serum amyloid P scintigraphy, fat biopsy, genotyping, 6-min walk test, and serum biomarkers.All DPD scans were performed using a hybrid Phillips Brightview single-photon emission computed tomography (SPECT)–CT gamma camera, a Siemens Symbia gamma camera or Pulse CDC gamma camera (IS2) following the injection of 700 MBq DPD. The imaging protocol consisted of an optional early  and a late (3 h) planar whole-body image, with a SPECT/CT (or SPECT only) of the chest at 3 h. DPD scans were reported by two experienced clinicians using the Perugini grading system,prior to discharge, except one occurring within 2 months of the procedure.Periprocedural complications were defined using the Valve Academic Research Consortium-2 (VARC-2) criteria and occurred Follow-up was for mortality using national data via the National Health Service and was 100% complete.t-test or Mann–Whitney U test was used to compare continuous variables and either χ2 or Fisher’s exact testing for categorical data. Univariate and multivariable analysis was performed using binary logistic regression with the presence of AS-amyloid as the dependent variable. A two-sided P-value <0.05 was considered significant.Statistical analysis used IBM SPSS Statistics (Version 25) and Stata/SE (Version 15) software. Where appropriate, results are described as mean ± standard deviation or median ± interquartile range. Normality was initially assessed using the Kolmogorov–Smirnov test and then (when indicated) plotted on a histogram. Kruskal–Wallis one-way analysis of variance was used when comparing more than two groups as the omnibus test, with the Dunn–Bonferroni test for pairwise comparison. The Student’s Table 1). Baseline LVEF was 54 ± 11%, aortic valve measurements were: peak velocity 4.13 ± 0.65 m/s, mean gradient 41 ± 14 mmHg, area 0.73 ± 0.22 cm2. One hundred and forty-nine (75%) patients had undergone TAVI, 2 (1%) surgical aortic valve replacement, and 49 (24%) were being managed medically .Two hundred patients  were recruited. Comorbidities  were common (n = 12) were wild-type ATTR.AS-amyloid was found in 26 patients, a prevalence of 13% . The amyloid burden was skewed with no patients with a DPD Perugini Grade 3, but more with Grade 2 than Grade 1 . A plasma cell dyscrasia was detected in 6 (23%), necessitating unblinding and a referral to the National Amyloidosis Centre, but following detailed review (as described in the methods), AL amyloid was felt unlikely in all cases. All genotyped patients to date (P = 0.001) and slightly more male, but this did not reach clinical significance . They had a reduced quality of life at baseline , but the same 6-min walk distance . There was no difference in comorbidities (Table 1). Both had the same aortic valve severity  and the same degree of valve calcification by CT.AS-amyloid patients were 3 years older  and more right bundle branch block (RBBB) (36% vs. 13%), but low limb lead voltages hardly occurred .AS-amyloid had lower Sokolow–Lyon criteria . There was no difference in the prevalence of either ‘classical’ (impaired LVEF) low-flow, low-gradient AS  or ‘paradoxical’  low-flow, low-gradient AS . Mitral annular S′ was slightly lower, but LVEF, SVs, global longitudinal strain, MCF, left atrial size, right ventricular function, and all other diastolic measures were the same. Combining ECG and echocardiography, the V/M ratio was lower . N-terminal pro-brain natriuretic peptide and hsTnT were approximately double: hsTnT 41 (25–84) ng/L vs. 21 (14–34) ng/L, P < 0.001 and NT-proBNP 3702 (1286–5626) ng/L vs. 1254 (598–2769) ng/L, P = 0.001, differences that were not related to renal function. Both hsTnT and NT-proBNP had a dose–response curve with amyloid burden by DPD Perugini grade .When clinically identified, cardiac amyloidosis typically has marked echocardiographic changes. Here, with discovery by DPD scan and in the presence of severe AS and confounding comorbidities, differences were modest: wall thickness was 1–2 mm thicker with higher mass, but no difference in disproportionate hypertrophy (Table 2). Voltage/mass (V/M) ratio was also associated (P = 0.045); however, the analysis was performed separately (with age and gender) to avoid underpowering the main model, as the voltage component of the V/M ratio cannot be assessed in bundle branch block or ventricular paced rhythm, present in 30%  patients who underwent TAVI , complication rates were equivalent to published international trials.P = 0.77 Table S4.P = 0.71 , with no difference by DPD Perugini grade, P = 0.93 (P < 0.001) and in AS-amyloid alone (P = 0.03) compared to medical management .At a median follow-up post-DPD of 19 (10–27) months, 42 (21%) patients had died. AS-amyloid vs. lone AS mortality overall was 6 (23%) and 36 (21%), respectively, P = 0.93 Figure S4These data show that AS-amyloid is common and affects around one in eight elderly patients with severe AS being considered for TAVI. It is different to lone AS with the patients being slightly older, with reduced quality of life  is more prevalent than the lower burden (DPD Grade 2 69% vs. Grade 1 31%) does not fit a conventional model of amyloid accumulation and discovery by chance . We hypothesize that there is an interaction: the ‘AS-primed’ myocardium being pro the deposition of amyloid. The absence of DPD Grade 3 AS-amyloid in our cohort may suggest censoring by mortality, but this is beyond the scope of this study. Two other observations support interaction: firstly, the discovered prevalence is higher than it is thought to be in healthy ageing and secondly, the lack of survival disadvantage (even though AS-amyloid patients are older) hints that TAVI could be treating the amyloid by reversing pro-amyloidogenic substrate changes. This work highlights our incomplete knowledge about amyloid prevalence in healthy ageing and raises other questions about whether, if AS primes the myocardium for amyloid deposition what other common cardiac conditions do the same? The similar male: female burden could be because AS primes the myocardial interstitium for amyloid regardless of gender, but it could also be that other studies have underestimated female involvement through referral bias and gender dimorphism in the male myocyte hypertrophic response . Furthermore, given that AS-amyloid patients were older, with a worse baseline quality of life and markedly elevated biomarkers, this lack of increased mortality is striking, particularly given the increased mortality seen in patients with such dual pathology following surgical aortic valve replacement.We have alluded to some unanswered questions about AS-amyloid biology, but there are many more. The elevated biomarkers clearly suggest this is disease, but whether some  can sometimes be considered bystander is unknown. We do not know if patients receive the same functional benefit to intervention and how biomarkers respond, and we do not know if the amyloid burden changes. There are hints that AS-amyloid is not like ‘typical’ cardiac amyloid so we should not assume that the impact of amyloid-specific therapies such as tafamidis,n = 16)—we estimate that we would have recruited around half these patients anyway. Not all patients underwent TAVI, particularly in the AS-amyloid group. Follow-up was only mortality, and there was no short-term functional assessment. The study is underpowered to compare DPD Grade 1 to Grade 2.Blinding pre-procedure was broken for two reasons: seven patients had a plasma cell dyscrasia necessitating unblinding as per protocol and some DPD scans were performed clinically .Conflict of interest: P.R.S. is supported by a British Heart Foundation Clinical Research Training Fellowship (FS/16/31/32185). K.P.P. is supported by an unrestricted educational grant from Edwards Lifesciences. T.A.T. is supported by a clinical lecturer grant from the National Institute of Health Research . F.P. has received research support from Siemens Healthineers and this work forms part of the translational research portfolio of the NIHR Cardiovascular Biomedical Research Centre at Barts Heart Centre, which is supported and funded by the NIHR. M.M. has received grants and personal fees from Edwards Lifesciences and personal fees from Abbott Vascular. J.C.M. is directly and indirectly supported by the UCLH NIHR Biomedical Research Centre and Biomedical Research Unit at UCLH and Barts, respectively. The remaining authors have no relevant conflict of interest.ehaa170_Supplementary_DataClick here for additional data file.