Research advances in geriatric depression

Technical advances have facilitated the exploration of factors related to geriatric depression and have helped generate novel biological and psychosocial treatment approaches. This review summarizes the main advancements in epidemiology, clinical presentation and course, genetics, and other areas of biological research. Treatment interventions outlined in this paper include electroconvulsive therapy, repetitive transcranial magnetic stimulation, magnetic seizure therapy, vagus nerve stimulation, deep brain stimulatn, depression prophylaxis, multidisciplinary approaches to depression treatment, and psychotherapy. Forms of psychotherapy for geriatric depression summarized include interpersonal psychotherapy, supportive psychotherapy, cognitive-behavioral therapy, problem-solving therapy, and ecosystem-focused therapy. Neuroimaging techniques based on magnetic resonance imaging are discussed briefly, including volumetric brain studies, diffusion tensor imaging, fractional anisotropy, fiber tractography, magnetization transfer imaging, and blood-oxygenation-level-dependent functional magnetic resonance imaging. Finally, treatment effectiveness is addressed in a discussion of new models to improve access to and quality of care offered in the community.     

Mortality and Suicide Risk in Treatment-Resistant Depression: An Observational Study of the Long-Term Impact of Intervention

Major depressive disorder is a common global disease that causes a significant societal burden. Most interventional studies of depression provide a limited assessment of the interventions on mortality and suicide risks. This study utilizes data from an observational registry of patients with major depressive disorder to determine the impact of intervention (vagus nerve stimulation or standard pharmacological/non-pharmacological therapy) and a latent factor, patient trajectory toward response, on mortality, suicide and suicidal ideation. A total of 636 patients were available for an intent-to-treat analysis of all-cause mortality, suicide and suicidal ideation. Patients treated with vagus nerve stimulation in addition to standard therapies experienced lower, but not statistically significant, all-cause mortality (vagus nerve stimulation 4.93 per 1,000 person-years vs. 10.02 per 1,000 patient years for treatment as usual) and suicide rates (vagus nerve stimulation 0.88 per 1,000 person-years vs. 1.61 per 1,000 patient years for treatment as usual). Treatment with vagus nerve stimulation produced a statistically lower relative risk of suicidal ideation 0.80, 95% confidence interval (0.68,0.95). Further, patients that responded to either treatment saw a 51% reduction in relative risk of suicidal behavior; relative risk and 95% confidence interval of 0.49 (0.41,0.58). In summary, we find that treatment with adjunctive vagus nerve stimulation can potentially lower the risk of all-cause mortality, suicide and suicide attempts.     

The influence of electrical stimulation of vagus nerve on elemental composition of dopamine related brain structures in rats

Recent studies of Parkinson's disease indicate that dorsal motor nucleus of nerve vagus is one of the earliest brain areas affected by alpha-synuclein and Lewy bodies pathology. The influence of electrical stimulation of vagus nerve on elemental composition of dopamine related brain structures in rats is investigated. Synchrotron radiation based X-ray fluorescence was applied to the elemental micro-imaging and quantification in thin tissue sections. It was found that elements such as P, S, Cl, K, Ca, Fe, Cu, Zn, Se, Br and Rb are present in motor cortex, corpus striatum, nucleus accumbens, substantia nigra, ventral tectal area, and dorsal motor nucleus of vagus. The topographic analysis shows that macro-elements like P, S, Cl and K are highly concentrated within the fiber bundles of corpus striatum. In contrast the levels of trace elements like Fe and Zn are the lowest in these structures. It was found that statistically significant differences between the animals with electrical stimulation of vagus nerve and the control are observed in the left side of corpus striatum for P (p = 0.04), S (p = 0.02), Cl (p = 0.05), K (p = 0.02), Fe (p = 0.04) and Zn (p = 0.02). The mass fractions of these elements are increased in the group for which the electrical stimulation of vagus nerve was performed. Moreover, the contents of Ca (p = 0.02), Zn (p = 0.07) and Rb (p = 0.04) in substantia nigra of right hemisphere are found to be significantly lower in the group with stimulation of vagus nerve than in the control rats.     

Electrical stimulation of afferent vagus nerve induces IL-1beta expression in the brain and activates HPA axis

Possible roles of the afferent vagus nerve in regulation of interleukin (IL)-1beta expression in the brain and hypothalamic-pituitary-adrenal (HPA) axis were examined in anesthetized rats. Levels of IL-1beta mRNA and protein in the brain were measured by comparative RT-PCR and ELISA. Direct electrical stimulation of the central end of the vagus nerve was performed continuously for 2 h. The afferent stimulation of the vagus nerve induced increases in the expression of mRNA and protein levels of IL-1beta in the hypothalamus and the hippocampus. Furthermore, expression of corticotropin-releasing factor mRNA was increased in the hypothalamus 2 h after vagal stimulation. Plasma levels of ACTH and corticosterone were also increased by this stimulation. The present results indicate that activation of the afferent vagus nerves itself can induce production of IL-1beta in the brain and activate the HPA axis. Therefore, the afferent vagus nerve may play an important role in transmitting peripheral signals to the brain in the infection and inflammation.     

"肠道微生物-肠道-脑轴"机制--肠道微生物干预神经退行性病变研究进展

肠道微生物是人体中最为庞大和复杂的微生物群落,其对机体的健康,尤其是中枢神经退行性病变具有重要调节作用。其中,"肠道微生物-肠道-脑轴"机制是肠道微生物干预中枢神经退行性病变的重要途径。该机制主要通过以下三种方式来调节大脑功能:一是肠道微生物直接产生神经递质通过肠神经细胞上行至中枢神经系统;二是肠道微生物代谢产物刺激肠内分泌细胞产生神经肽类和胃肠激素类物质,影响大脑功能;三是肠道微生物或其代谢产物直接刺激肠道免疫系统,产生干扰素类物质干扰大脑免疫反应。本文对"肠道微生物-肠道-脑轴"机制的概念及研究进展进行了详细的介绍,同时总结了有关肠道微生物与阿尔兹海默症、帕金森症和多发性硬化症等神经退行性疾病相互作用的相关文献。依据"肠道微生物-肠道-脑轴"机制,利用肠道微生物预防和治疗神经退行性病变,或将成为解决中枢神经系统疾病的新措施。     

Improved mood and remission of symptoms in long-term major depression using vagus nerve stimulation

This is a case study of a 68-year-old woman with previously unremitting depression. The patient came to our care in 1994 following a series of treatment interventions that did not alter the course of chronic depression. We report our treatment approach and results seen with this patient, including her tepid response to traditional antidepressants and the positive results seen in the past year using vagus nerve stimulation (VNS) therapy. The patient experienced broad gains in measures of depression severity and well-being under her current treatment regimen. She has had no serious adverse events associated with the regimen, which includes VNS therapy and decreased doses of common antidepressant medications.     

大鼠蓝斑核对迷走-迷走抑胃反射的加强作用

本文研究了蓝斑核对迷走-迷走抑胃反射的影响。实验结果表明,单独刺激迷走神经中枢端抑制胃电和胃运动,胃电慢波的振幅和胃内压分别下降到对照值的60.9％和45.7％,与对照值相比有明显的统计学意义(P<0.05)。刺激迷走神经中枢端的同时,以弱刺激刺激蓝斑核时,胃电慢渡的振幅和胃内压分别下降到对照值的42.1％和34.1％,与单独刺激迷走神经的效果相比较有非常显著的差异(P<0.01)。本文结果提示:蓝斑核的兴奋加强迷走-迷走抑胃反射。     

A novel transcutaneous vagus nerve stimulation leads to brainstem and cerebral activations measured by functional MRI]

BACKGROUND: Left cervical vagus nerve stimulation (VNS) using the implanted NeuroCybernetic Prosthesis (NCP) can reduce epileptic seizures and has recently been shown to give promising results for treating therapy-resistant depression. To address a disadvantage of this state-of-the-art VNS device, the use of an alternative transcutaneous electrical nerve stimulation technique, designed for muscular stimulation, was studied. Functional magnetic resonance imaging (MRI) has been used to test non-invasively access nerve structures associated with the vagus nerve system. The results and their impact are unsatisfying due to missing brainstem activations. These activations, however, are mandatory for reasoning, higher subcortical and cortical activations of vagus nerve structures. The objective of this study was to test a new parameter setting and a novel device for performing specific (well-controlled) transcutaneous VNS (tVNS) at the inner side of the tragus. This paper shows the feasibility of these and their potential for brainstem and cerebral activations as measured by blood oxygenation level dependent functional MRI (BOLD fMRI). MATERIALS AND METHODS: In total, four healthy male adults were scanned inside a 1.5-Tesla MR scanner while undergoing tVNS at the left tragus. We ensured that our newly developed tVNS stimulator was adapted to be an MR-safe stimulation device. In the experiment, cortical and brainstem representations during tVNS were compared to a baseline. RESULTS: A positive BOLD response was detected during stimulation in brain areas associated with higher order relay nuclei of vagal afferent pathways, respectively the left locus coeruleus, the thalamus (left > right), the left prefrontal cortex, the right and the left postcentral gyrus, the left posterior cingulated gyrus and the left insula. Deactivations were found in the right nucleus accumbens and the right cerebellar hemisphere. CONCLUSION: The method and device are feasible and appropriate for accessing cerebral vagus nerve structures, respectively. As functional patterns share features with fMRI BOLD, the effects previously studied with the NCP are discussed and new possibilities of tVNS are hypothesised.     

TOCP对鸡迷走神经不同纤维成份传导速度和兴奋性的影响

对磷酸三邻甲苯醋(TOCP)染毒母鸡进行迷走神经不同纤维成份传导速度和兴奋性测定,发现实验组动物在染毒后14天迷走神经第5波(类似于C纤维)传导速度减慢30%,染毒后21天时减慢52%,并出现迷走神经各波兴奋性显著降低.实验结果说明,TOCP所致迟发性神经病可损害与内脏活动有关的迷走神经.     

Stimulation of vagal C-fibers alters timing and distribution of respiratory motor output in cats

Pulmonary vascular congestion or pulmonary embolism in humans produces shallow tachypnea, and indirect experimental evidence suggests that this characteristic breathing pattern may result from activation of vagal unmyelinated afferents from the lung. We have investigated, in decerebrate cats, reflex changes in breathing pattern and in the activation of the diaphragm, posterior cricoarytenoid, and thyroarytenoid muscles caused by activating C-fiber afferents in the vagus nerve. The right vagus nerve was sectioned distal to the origin of the recurrent laryngeal nerve, eliminating vagal afferent traffic although preserving motor innervation of the larynx on that side. The left cervical vagus was stimulated electrically, and efferent activation of the laryngeal muscles was avoided by cutting the left recurrent laryngeal nerve. Transmission to the brain of vagal afferent traffic resulting from this stimulation was controlled by graded cold block of the nerve cranial to the site of application of the stimulus. Activation of C-fibers, when A-fibers were blocked, significantly decreased respiratory period and amplitude of diaphragm inspiratory burst. In addition, this selective activation of vagal C-fibers augmented postinspiratory activity of the diaphragm and recruited phasic expiratory bursts in the thyroarytenoid. We conclude that, in unanesthetized decerebrate cats, afferent traffic of vagal C-fibers initiates a pontomedullary reflex that increases respiratory frequency, decreases tidal volume, and augments braking of expiratory airflow.     

Inhibition of norepinephrine re-uptake by angiotensin in brain

—A method for perfusion of rat brain ventricles accompanied by electrical stimulation of right vagus nerve was used in the study of the re-uptake mechanism of norepinephrine in rat brain. Tritiated norepinephrine was injected into the left lateral brain ventricle. After a 1-hr equilibration period, the brain was perfused, and effluent was collected and assayed for norepinephrine, normetanephrine and acid metabolites by means of column chromatography and liquid scintillation counting. Electrical stimulation of central end of right vagus nerve produced a significant release of norepinephrine and decrease of acid metabolites; this indicates a shift of catecholamines to extracellular sites. Angiotensin (200 ng/min) added to the perfusion fluid potentiated the effect of nerve stimulation. Cocaine, desmethylimipramine and phenoxybenzamine greatly reduced the release of norepinephrine from brain tissue. None on these drugs potentiated the effect of angiotensin. It is concluded that angiotensin prevents re-uptake of norepinephrine released by nerve stimulation. As a naturally occurring, physiologically active peptide, angiotensin seems to be highly specific in modulation of adrenergie neurotransmission, allowing increased extraneuronal accumulation of neurotransmitter.     

The cholinergic anti-inflammatory pathway: a missing link in neuroimmunomodulation

This review outlines the mechanisms underlying the interaction between the nervous and immune systems of the host in response to an immune challenge. The main focus is the cholinergic anti-inflammatory pathway, which we recently described as a novel function of the efferent vagus nerve. This pathway plays a critical role in controlling the inflammatory response through interaction with peripheral a7 subunit-containing nicotinic acetylcholine receptors expressed on macrophages. We describe the modulation of systemic and local inflammation by the cholinergic anti-inflammatory pathway and its function as an interface between the brain and the immune system. The clinical implications of this novel mechanism also are discussed.     

Functional anatomy of the vagal innervation of the cervical trachea of the dog.

The canine cervical trachea has been used for numerous studies regarding the neural control of tracheal smooth muscle. The purpose of the present study was to determine whether there is lateral dominance by either the left or right vagal innervation of the canine cervical trachea. In anesthetized dogs, pressure in the cuff of the endotracheal tube was used as an index of smooth muscle tone in the trachea. After establishment of tracheal tone, as indicated by increased cuff pressure, either the right or left vagus nerve was sectioned followed by section of the contralateral vagus. Sectioning the right vagus first resulted in total loss of tone in the cervical trachea, whereas sectioning the left vagus first produced either a partial or no decrease in tracheal tone. After bilateral section of the vagi, cuff pressure was recorded during electrical stimulation of the rostral end of the right or left vagus. At the maximum current strength used, stimulation of the left vagus produced tracheal constriction that averaged 28.5% of the response to stimulation of the right vagus (9.0 +/- 1.8 and 31.6 +/- 2.5 mmHg, respectively). In conclusion, the musculature of cervical trachea in the dog appears to be predominantly controlled by vagal efferents in the right vagus nerve.     

The sphincter of the efferent filament artery in teleost gills: I. Structure and parasympathetic innervation

Previous studies have shown the existence of a sphincter in the efferent filament artery of the teleost gill and its constrictory response to acetylcholine (ACH) and vagal stimulation. This study deals with the muscular organization of this sphincter and the distribution of its innervation as elucidated by degeneration methods and cytochemistry. The sphincter innervation is supplied by the protrematic vagus nerves. Nerve endings filled with cholinergic-type vesicles are located in close association with the adventitial smooth muscle cells and display a strong acetylcholinesterase (ACHE) activity. Section of the protrematic vagus nerve induces a nearly complete degeneration of the sphincter innervation. ACHE-positive nerve cell bodies are present both in the sphincter area and in the protrematic vagus nerve. These results suggest that innervation of the sphincter in the efferent filament artery is cholinergic through the activity of postganglionic axons of the parasympathetic system.     

迷走神经切除对大鼠胃内UCP2 mRNA表达及胃酸分泌的影响

目的:观察整体大鼠胃酸分泌与ATP水平之间的关系及迷走神经对解偶联蛋白2(UCP2)mRNA表达的调节.方法:制备大鼠高选择性迷走神经切断模型.采用滴定法检测大鼠胃酸酸度,荧光测定法检测胃体组织内ATP含量,应用Northern blot法检测分析UCP2mRNA表达.结果:迷走神经切断后24 h,大鼠胃酸酸度显著降低,胃体组织内ATP含量下降.与假手术组相比,胃体组织UCP2 mRNA表达显著增加.结论:迷走神经切断后24 h大鼠胃体组织ATP含量下降;迷走神经下调胃体组织UCP2 mRNA表达.结果提示大鼠迷走神经可能通过抑制UCP2 mRNA表达,提高ATP含量,为质子泵泌酸提供能量来源.     

创伤性脑损伤与肠道菌群关系研究进展

创伤性脑损伤是一种高致死率的疾病，严重危害人类生命健康。肠脑轴是大脑和胃肠道系统之间主要的双向通讯途径。近年来，创伤性脑损伤与肠道菌群的相互作用关系逐渐被揭示。肠道菌群通过肠脑轴参与了创伤性脑损伤后急性病理损伤的调节过程并发挥重要作用。本文综述了创伤性脑损伤的发生、对人类健康的巨大影响，肠脑轴的含义及其在颅脑损伤中的病理调节机制，并在此基础上提出可能的治疗手段，包括粪便微生物菌群移植、使用益生菌、刺激迷走神经、摄入多酚类物质以及靶向免疫调节策略，以期为临床治疗创伤性脑损伤提供新的思路。     

Intrastriatal injection of Parkinson’s disease intestine and vagus lysates initiates α-synucleinopathy in rat brain

Parkinson’s disease (PD) is characterized by the selective loss of dopaminergic neurons in the midbrain and the pathological accumulation of misfolded α-synuclein (α-syn) in the brain. A growing body of evidence suggests that the formation of misfolded α-syn and aggregation may begin in the peripheral nervous system, specifically the enteric nervous system, and then propagate to the central nervous system via the vagus nerve. However, the PD-like neuropathology induced by the intestine and vagus nerve extracts is rarely investigated. In this work, we injected lysates of the intestine and vagus obtained from a diagnosed PD patient, which contained abnormal α-syn aggregates, into the rat striatum unilaterally. Strikingly, such an injection induced dopaminergic neurodegeneration and α-syn depositions in the striatum, substantia nigra, and other brain regions, including the frontal cortex, somatosensory cortex, hypothalamus, brain stem, and cerebellum. Moreover, significant activation of microglia and the development of astrogliosis were observed in the substantia nigra pars compacta of the injected rats. These findings provide essential information for our understanding of PD pathogenesis, as we established for the first time that the α-syn aggregates in the intestine and vagus of a PD patient were sufficient to induce prion-like propagation of endogenous α-syn pathology in wild-type rats.Subject terms: Inflammation, Peripheral nervous system     

Human Vagus Nerve Branching in the Cervical Region

BackgroundVagus nerve stimulation is increasingly applied to treat epilepsy, psychiatric conditions and potentially chronic heart failure. After implanting vagus nerve electrodes to the cervical vagus nerve, side effects such as voice alterations and dyspnea or missing therapeutic effects are observed at different frequencies. Cervical vagus nerve branching might partly be responsible for these effects. However, vagus nerve branching has not yet been described in the context of vagus nerve stimulation.ResultsCervical vagus nerve branching was observed in 29% of all cases (26% unilaterally, 3% bilaterally) and proven histologically in all cases. Right-sided branching (22%) was more common than left-sided branching (12%) and occurred on the level of the fourth and fifth vertebra on the left and on the level of the second to fifth vertebra on the right side. Vagus nerves without branching were significantly larger than vagus nerves with branches, concerning their diameters (4.79 mm vs. 3.78 mm) and cross-sections (7.24 mm² vs. 5.28 mm²).DiscussionCervical vagus nerve branching is considerably more frequent than described previously. The side-dependent differences of vagus nerve branching may be linked to the asymmetric effects of the vagus nerve. Cervical vagus nerve branching should be taken into account when identifying main trunk of the vagus nerve for implanting electrodes to minimize potential side effects or lacking therapeutic benefits of vagus nerve stimulation.     

Calmodulin-Binding Proteins Within the Slow Phase of Axonal Transport in the Rabbit Vagus Nerve Per Ekstrom and Martin Kanje

Calmodulin-binding proteins (CBPs) in the rabbit vagus nerve were studied by means of calmodulin-Sepharose affinity chromatography and polyacrylamide gel electrophoresis. The soluble fraction (10(5) g supernatant) of a nerve homogenate contained four CBPs with molecular weights of 44, 55, 91, and 93 kD, respectively. Slowly transported proteins were recovered in the vagus 3 days after injection of [35S]methionine into the nodose ganglion. Four labelled CBPs with molecular weights of 44, 55, 69, and 83 kD, respectively were found. The nodose ganglion contained two labelled CBPs, 44 and 55 kD. The 55-kD CBP was identified as tubulin after immunoblotting. In separate experiments it was also shown that bovine brain tubulin bound to the calmodulin column.     

On the anatomical organization of the vagal nuclei

The neurons of origin of the right vagus and its components in both the monkey (Macaca fascicularis) and albino rats were localized by the retrograde transport of horseradish peroxidase (HRP) applied to the stomach wall, the vagal trunk and its recurrent laryngeal branch. An attempt was also made to localize the neurons forming the superior laryngeal nerve and those supplying the thoracic organs by a combination of operative procedures. The results showed that the stomach was innervated by neurons distributed throughout the entire rostrocaudal extent of the dorsal motor nucleus (DMN) on both sides of the brain stem. Neurons scattered throughout the entire extent of the DMN and nucleus ambiguus (NA) supplied the thoracic viscera. There did not appear to be any topographic arrangement in the DMN neurons supplying the abdominal and thoracic viscera as reported by other workers, and there was no clear evidence of crossing of vagal fibers in the monkey brain stem, though such crossing was seen in the rat brain stem. Both the superior and inferior ganglia of the vagus nerve were labeled following application of HRP to the vagal trunk. Neurons in the caudal part of the NA gave rise to fibers in the ipsilateral recurrent laryngeal nerve, at least on the right side. The neurons giving rise to the superior laryngeal nerve could not be delineated in this study. In all the experimental procedures described, the hypoglossal nucleus was labeled only after applying HRP to the hypoglossal nerve.