Testing the Food Experience in Healthy Human Volunteers: a Proof-of-Concept Study

BACKGROUND AND AIMS

For a healthy food to be introduced to the consumer's diet, it has to be attractive, yet testing for food acceptance and the sensory postprandial responses is still not standardized. The main objective of this study was to demonstrate that healthier foods can be obtained without impact on the responses to ingestion.

METHODS

A randomized, cross-over, double-blind, pilot study in non-obese, healthy men (n=8) comparing the responses to a standard sausage rich in animal fat (mortadella) versus a modified product based on a plant-derived fat analogue and an aroma. Palatability and postprandial sensations were measured on 10 cm scales and brain activity was evaluated by functional magnetic resonance imaging before and after each meal on separate days.

RESULTS

Both meals were rated equally palatable and induced the same degree of homeostatic sensations (satiety, fullness) with a similar hedonic dimension (improved mood and digestive well-being). Both meals induced similar changes in brain connectivity: decreased activity in the frontal-parietal, basal ganglia and thalamus, visual occipital, sensory-motor, temporal superior and in the "default-mode" networks, while increased activity was detected in the network associated with white matter.

CONCLUSION

A substantial improvement in the nutritional profile of food can be achieved without affecting the responses to ingestion.

Early experience with a novel net temporary bridging device (Cascade) to assist endovascular coil embolization of intracranial aneurysms

OBJECTIVE

The goal of this study was to evaluate the effectiveness and safety of a new noncompletely occlusive net-assisted remodeling technique in which the Cascade net device is used for temporary bridging of intracranial aneurysms.

METHODS

Between July 2018 and May 2019, patients underwent coil embolization with the Cascade net device within 4 centers in Europe. Analysis of angiographic (modified Raymond-Roy classification [MRRC]) and clinical outcomes data was conducted immediately following treatment and at the 6-month follow-up.

RESULTS

Fifteen patients were included in the study (mean age 58 ± 13 years, 11/15 [73.3%] female). Ten patients had unruptured aneurysms, and 5 presented with ruptured aneurysms with acute subarachnoid hemorrhage. The mean aneurysm dome length was 6.27 ± 2.33 mm and the mean neck width was 3.64 ± 1.19 mm. Immediately postprocedure, MRRC type I (complete obliteration) was achieved in 11 patients (73.3%), whereas a type II (residual neck) was achieved in 4 patients (26.7%). Follow-up examination was performed in 7/15 patients and showed stabilization of aneurysm closure with no thromboembolic complications and only 1 patient with an increased MRRC score (from I to II) due to coil compression.

CONCLUSIONS

Initial experience shows that the use of a new noncompletely occlusive net-assisted remodeling technique with the Cascade net device may be safe and effective for endovascular coil embolization of intracranial aneurysms.

SVM recursive feature elimination analyses of structural brain MRI predicts near-term relapses in patients with clinically isolated syndromes suggestive of multiple sclerosis

•

RFE-SVMs predict future outcome of CIS patients with conservative accuracy estimates between 64.9% and 88.1%.

•

Recursive feature selection improves classification performance compared to using all information.

•

Relevant features include regional WM lesion load and GM density, as well as the type of CIS onset.

•

Cross-validation introduces positive bias on accuracy estimate.

Machine learning classification is an attractive approach to automatically differentiate patients from healthy subjects, and to predict future disease outcomes. A clinically isolated syndrome (CIS) is often the first presentation of multiple sclerosis (MS), but it is difficult at onset to predict who will have a second relapse and hence convert to clinically definite MS. In this study, we thus aimed to distinguish CIS converters from non-converters at onset of a CIS, using recursive feature elimination and weight averaging with support vector machines. We also sought to assess the influence of cohort size and cross-validation methods on the accuracy estimate of the classification.

We retrospectively collected 400 patients with CIS from six European MAGNIMS MS centres. Patients underwent brain MRI at onset of a CIS according to local standard-of-care protocols. The diagnosis of clinically definite MS at one-year follow-up was the standard against which the accuracy of the model was tested. For each patient, we derived MRI-based features, such as grey matter probability, white matter lesion load, cortical thickness, and volume of specific cortical and white matter regions. Features with little contribution to the classification model were removed iteratively through an interleaved sample bootstrapping and feature averaging approach. Classification of CIS outcome at one-year follow-up was performed with 2-fold, 5-fold, 10-fold and leave-one-out cross-validation for each centre cohort independently and in all patients together.

The estimated classification accuracy across centres ranged from 64.9% to 88.1% using 2-fold cross-validation and from 73% to 92.9% using leave-one-out cross-validation. The classification accuracy estimate was higher in single-centre, smaller data sets than in combinations of data sets, being the lowest when all patients were merged together.

Regional MRI features such as WM lesions, grey matter probability in the thalamus and the precuneus or cortical thickness in the cuneus and inferior temporal gyrus predicted the occurrence of a second relapse in patients at onset of a CIS using support vector machines. The increased accuracy estimate of the classification achieved with smaller and single-centre samples may indicate a model bias (overfitting) when data points were limited, but also more homogeneous. We provide an overview of classifier performance from a range of cross-validation schemes to give insight into the variability across schemes. The proposed recursive feature elimination approach with weight averaging can be used both in single- and multi-centre data sets in order to bridge the gap between group-level comparisons and making predictions for individual patients.

The long-term outcomes of CIS patients in the Barcelona inception cohort: Looking back to recognize aggressive MS

Objective:

To explore the long-term outcomes of patients with clinically isolated syndromes from the Barcelona cohort.

Methods:

We selected patients with a follow-up longer than 10 years to (1) estimate the risks of multiple sclerosis (MS) and disability accumulation according to the baseline number of T2 lesions and to compare treated versus untreated patients and early versus delayed treatment, and (2) to study baseline features of patients with aggressive MS (Expanded Disability Status Scale (EDSS) ⩾6.0 at 10 years).

Results:

In all, 401 patients were included (mean follow-up of 14.4 (standard deviation of 2.9) years). A higher number of T2 lesions was associated with an earlier MS diagnosis and an earlier risk of irreversible disability. Early treatment was associated with a decreased risk of EDSS of 3.0: adjusted hazard ratio = 0.4, 95% confidence interval = (0.2, 0.7). Patients with aggressive MS differed in their baseline brain magnetic resonance images: The median (interquartile range) number of T2 lesions and contrast-enhancing lesions (CEL) was 71 (28–95) versus 7 (1–19) and 3 (1–24) versus 0 (0–1), respectively. The cut-offs that better classified patients with aggressive MS were 20 for T2 lesions and 2 for CEL.

Conclusion:

Although MS natural history is changing, a high lesion load at onset is helpful to identify patients at risk of presenting an aggressive MS.

CLIPPERS and its mimics: evaluation of new criteria for the diagnosis of CLIPPERS

OBJECTIVE

To evaluate the accuracy of the recently proposed diagnostic criteria for chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS).

METHODS

We enrolled 42 patients with hindbrain punctate and/or linear enhancements (<3 mm in diameter) and tested the CLIPPERS criteria.

RESULTS

After a median follow-up of 50 months (IQR 25-82), 13 out of 42 patients were CLIPPERS-mimics: systemic and central nervous system lymphomas (n=7), primary central nervous system angiitis (n=4) and autoimmune gliopathies (n=2). The sensitivity and specificity of the CLIPPERS criteria were 93% and 69%, respectively. Nodular enhancement ( ≥ 3 mm in diameter), considered as a red flag in CLIPPERS criteria, was present in 4 out of 13 CLIPPERS-mimics but also in 2 out of 29 patients with CLIPPERS, explaining the lack of sensitivity. Four out of 13 CLIPPERS-mimics who initially met the CLIPPERS criteria displayed red flags at the second attack with a median time of 5.5 months (min 3, max 18), explaining the lack of specificity. One of these four patients had antimyelin oligodendrocyte glycoprotein antibodies, and the three remaining patients relapsed despite a daily dose of prednisone/prednisolone ≥ 30 mg and a biopsy targeting atypical enhancing lesions revealed a lymphoma.

CONCLUSIONS

Our study highlights that (1) nodular enhancement should be considered more as an unusual finding than a red flag excluding the diagnosis of CLIPPERS; (2) red flags may occur up to 18 months after disease onset; (3) as opposed to CLIPPERS-mimics, no relapse occurs when the daily dose of prednisone/prednisolone is ≥ 30 mg; and (4) brain biopsy should target an atypical enhancing lesion when non-invasive investigations remain inconclusive.

Peri-ictal magnetic resonance imaging in status epilepticus: Temporal relationship and prognostic value in 60 patients

PURPOSE

Magnetic resonance imaging (MRI) changes associated with status epilepticus (SE) have been described in recent studies. Our aim was to evaluate the diagnosis and prognosis of the peri-ictal MRI changes detected in SE patients.

METHOD

All adults diagnosed with SE and examined by MRI within 240 h after SE onset were enrolled (2011-2017). Demographic, clinical and electroencephalography data, and functional status at admission and discharge were collected. MRI findings were recorded and relationships between clinical and MRI data, and between these data and functional outcome were analyzed.

RESULTS

Sixty patients included, 50% women, mean age 57.5 years. Median duration of SE was 51.46 h and median time from SE onset to MRI was 86.5 h. Of the total, 41.7% had a restricted diffusion pattern on diffusion-weighted imaging (DWI) and 63.3% had hyperintensities suggestive of edema on T2-weighted (T2WI)/FLAIR sequences. The factors independently associated with T2WI hyperintensities were the presence of acute cerebral lesions (p = 0.023), baseline STESS (p = 0.007), and MRI performed within 84 h (p = 0.007). Variables independently associated with diffusion restriction were a potentially fatal cause (p = 0.020), SE duration >24 h (p = 0.022), and MRI performed within the first 84 h (p = 0.045). In patients undergoing MRI within 84 h, the DWI and T2WI abnormalities were both highly associated with an unfavorable outcome.

CONCLUSIONS

Characteristic signal changes on DWI and T2WI sequences were seen in approximately half our SE patients undergoing early (<84 h) brain MRI studies, and were independently related to the patients' functional status at discharge.

A66 Tracing the evolutionary history of an emerging Salmonella 4,[5],12:i:- clone in the United States

Salmonellosis is one of the leading causes of foodborne disease worldwide, with an estimated one million cases a year in the United States. Salmonella 4,[5],12: i:-, a monophasic variant of Salmonella typhimurium, is an emerging serovar that has been associated with multiple foodborne outbreaks throughout the world, mostly attributed to pig and pig products. Recently, we have demonstrated that two distinct groups of Salmonella 4,[5],12:i:- circulate in the USA and Europe, with the majority of isolates recovered during recent years belonging to an emerging multidrug-resistant clade (Elnekave et al. 2018). We applied Bayesian phylodynamic reconstruction to uncover the evolutionary history of this clade. We used a dataset of whole-genome sequences of 1446 4,[5],12:i:- isolates from different sources (livestock, human, food products, and others) from the USA (n = 752) and Europe (n = 694), collected between 2008 and 2017 and belonging to the Multilocus Subtype 34, which was predominant in the emerging clade (Elnekave et al. 2018). A subset (n = 110) of Salmonella 4,[5],12:i: isolates was then randomly selected after stratifying by location and year of isolation in order to achieve balanced sampling. Evidence of temporal signal was confirmed by looking at root-to-tip divergences using TempEst. Evolutionary hypotheses using strict and relaxed-clock models were tested using BEAST for a variety of demographic models and assuming a general time reversible substitution model. Model selection was performed by estimating Bayes Factors using path sampling and stepping-stone sampling. The selected model was then used for applying discrete trait models comparing different scenarios of transmission between locations (i.e. bidirectional symmetric/asymmetric or unidirectional). Our preliminary phylodynamic inference results indicate that the origin of this subtype was in Europe and dates back to 1990 (HPD 95%: 1984–2001). We report an exponential growth rate of 0.362 per year, which corresponds to a doubling time of 1.43 years. Our results suggest that this subtype was introduced to the US in the year 2000 (HPD 95%: 1994–2006). Phylodynamic analysis suggests that the recent increase in isolation of Salmonella 4,[5],12:i:- from different sources in the USA may be due to the exponential expansion of an emerging clone which originated in Europe and then expanded to the USA. The emergence and expansion of this serovar is of great public health importance due to the high prevalence of multidrug resistance traits found in USA isolates from this group and especially due to the presence of plasmid-mediated resistance genes for quinolones and extended spectrum cephalosporins, key antimicrobials used for the treatment of invasive Salmonella infections.

Progression of regional grey matter atrophy in multiple sclerosis

See Stankoff and Louapre (doi:10.1093/brain/awy114) for a scientific commentary on this article.

Grey matter atrophy is present from the earliest stages of multiple sclerosis, but its temporal ordering is poorly understood. We aimed to determine the sequence in which grey matter regions become atrophic in multiple sclerosis and its association with disability accumulation. In this longitudinal study, we included 1417 subjects: 253 with clinically isolated syndrome, 708 with relapsing-remitting multiple sclerosis, 128 with secondary-progressive multiple sclerosis, 125 with primary-progressive multiple sclerosis, and 203 healthy control subjects from seven European centres. Subjects underwent repeated MRI (total number of scans 3604); the mean follow-up for patients was 2.41 years (standard deviation = 1.97). Disability was scored using the Expanded Disability Status Scale. We calculated the volume of brain grey matter regions and brainstem using an unbiased within-subject template and used an established data-driven event-based model to determine the sequence of occurrence of atrophy and its uncertainty. We assigned each subject to a specific event-based model stage, based on the number of their atrophic regions. Linear mixed-effects models were used to explore associations between the rate of increase in event-based model stages, and T₂ lesion load, disease-modifying treatments, comorbidity, disease duration and disability accumulation. The first regions to become atrophic in patients with clinically isolated syndrome and relapse-onset multiple sclerosis were the posterior cingulate cortex and precuneus, followed by the middle cingulate cortex, brainstem and thalamus. A similar sequence of atrophy was detected in primary-progressive multiple sclerosis with the involvement of the thalamus, cuneus, precuneus, and pallidum, followed by the brainstem and posterior cingulate cortex. The cerebellum, caudate and putamen showed early atrophy in relapse-onset multiple sclerosis and late atrophy in primary-progressive multiple sclerosis. Patients with secondary-progressive multiple sclerosis showed the highest event-based model stage (the highest number of atrophic regions, P < 0.001) at the study entry. All multiple sclerosis phenotypes, but clinically isolated syndrome, showed a faster rate of increase in the event-based model stage than healthy controls. T₂ lesion load and disease duration in all patients were associated with increased event-based model stage, but no effects of disease-modifying treatments and comorbidity on event-based model stage were observed. The annualized rate of event-based model stage was associated with the disability accumulation in relapsing-remitting multiple sclerosis, independent of disease duration (P < 0.0001). The data-driven staging of atrophy progression in a large multiple sclerosis sample demonstrates that grey matter atrophy spreads to involve more regions over time. The sequence in which regions become atrophic is reasonably consistent across multiple sclerosis phenotypes. The spread of atrophy was associated with disease duration and with disability accumulation over time in relapsing-remitting multiple sclerosis.

Abstract 4258: Preliminarily results of the Oncohabitats Study: A multicentre validation of overall survival (OS) estimation of patients with glioblastoma (GBM) using vascular biomarkers

We report preliminarily results of an international retrospective study (NCT03439332) analyzing the prognostic value of the early assessment of vascular architecture of glioblastoma (GBM).

The initial cohort included 300 pts treated at 7 European hospitals. Multiparametric images were processed by Oncohabitats (www.oncohabitats.upv.es) to obtain the cerebral blood volume (CBV) and cerebral blood flow (CBF) from 4 automatically delimited regions of interest (ROIs): high angiogenic tumor (HAT), low angiogenic tumor (LAT), infiltrating peripherial edema (IPE), and vasogenic peripherial edema (VPE). Uniparametric Cox regression models and Kaplan-Meier analysis were developed to test prognostic and stratification capabilities of each biomarker.

115 pre-surgical MRIs passed quality controls and were included in the analysis. Median follow up was 12.9 months (m) (IQR: 9.2-17.6). 73 pts (63.5%) were male. 54 pts (47%) underwent total resection; 84 pts (73%) received adjuvant temozolomide. Median OS was 13.6 m (95%CI:12.1-15.2). Cox regression analysis yielded a significant correlation between OS and maximum rCBV and rCBF in HAT and LAT (Table), independent of the extent of resection. Median OS by Kaplan-Meier analysis in patients with high and low vascularity is shown in the Table.

Our preliminarily results shows that patients with lower vascularity (rCBV or rCBF) in vascular habitats inside enhancing tumor region (HAT and LAT) is associated with higher OS, and could improve patient stratification. Our results are consistent with our pilot study [1], Validation in large multicentric studies is underway.

COX REGRESSION ANALYSISKAPLAN-MEIER STRATIFICATION ANALYSISCOX REGRESSION ANALYSISKAPLAN-MEIER STRATIFICATION ANALYSISHAZARD RATIO95% CONFIDENCE INTERVALP-VALUE*NUMBER OF PATIENTSMEDIAN SURVIVAL (months)P-VALUErCBV máximumHigh Angiogenic Tumor10.339[1.09- 1.14]0.0202*[29 86][16.66 12.78]0.004***Low Angiogenic Tumor10.485[1.17- 1.31]0.0262*[29 86][17.10 12.78]0.002***Infiltrating Peripheral Edema0.9835[1.30- 1.71]0.1208[29 86][14.60 12.91]0.119Vasogenic Peripheral Edema0.7942[1.14- 1.63]0.6046[29 86][15.23 12.91]0.220rCBF máximumHigh Angiogenic Tumor0.9997[1.02- 1.03]0.1077[47 68][14.93 11.65]0.009**Low Angiogenic Tumor10.411[1.21- 1.40]0.0384*[29 86][15.56 12.75]0.016*InfiltratingPeripheral Edema0.8923[1.35- 2.04]0.2589[29 86][15.23 12.83]0.394Vasogenic Peripheral Edema0.6846[1.11- 1.81]0.7447[29 86][14.60 12.96]0.508Table: Results of Cox-regression and Kaplan-Meier analysis. (P VALUE*: False discovery rate corrected.)[1]: https://doi.org/10.1148/radiol.2017170845

Citation Format: María del Mar Álvarez-Torres, Fuensanta Bellvís–Bataller, Javier Juan–Albarracín, Elies Fuster–Garcia, David Lorente Estellés, Gaspar Reynes, Fernando Aparici-Robles, Carlos Botella, Jose Muñoz-Langa, Raquel Faubel, Sabina Asensio-Cuesta, Germán Adrían García–Ferrando, Cristina Auger, Alex Rovira, Jose Pineda, Jaime Font de Mora, Enrique Mollà-Olmos, Antonio José Revert-Ventura, Luaba Tshibanda, Didier Martin, Girolamo Crisi, Kyrre Eeg Emblem, Paulina Due-Tonnessen, Torstein R Meling, Juan M García-Gómez. Preliminarily results of the Oncohabitats Study: A multicentre validation of overall survival (OS) estimation of patients with glioblastoma (GBM) using vascular biomarkers [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 4258.

Menarche, pregnancies, and breastfeeding do not modify long-term prognosis in multiple sclerosis

OBJECTIVE

To investigate the effect of menarche, pregnancies, and breastfeeding on the risk of developing multiple sclerosis (MS) and disability accrual using a multivariate approach based on a large prospective cohort of patients with clinically isolated syndrome (CIS).

METHODS

A cross-sectional survey of the reproductive information of female participants in a CIS cohort was performed. We examined the relationship of age at menarche with the risk of clinically definite MS (CDMS), McDonald 2010 MS, and Expanded Disability Status Scale (EDSS) 3.0 and 6.0. The effect of pregnancy (before and after CIS) and breastfeeding in the risk of CDMS, McDonald 2010 MS, and EDSS 3.0 was also examined. Univariate and multivariate analyses were performed and findings were confirmed using sensitivity analyses and a propensity score model.

RESULTS

The data of 501 female participants were collected. Age at menarche did not correlate with age at CIS and was not associated with the risk of CDMS or EDSS 3.0 or 6.0. Pregnancy before CIS was protective for CDMS in the univariate analysis, but the effect was lost in the multivariate model and did not modify the risk of EDSS 3.0. Pregnancy after CIS was protective for both outcomes in univariate and multivariate analyses when pregnancy was considered a baseline variable, but the protective effect disappeared when analyzed as a time-dependent event. Breastfeeding did not modify the risk for the 3 outcomes.

CONCLUSIONS

These results demonstrate that menarche, pregnancies, and breastfeeding did not substantially modify the risk of CDMS or disability accrual using a multivariable and time-dependent approach.

Unraveling treatment response in multiple sclerosis: A clinical and MRI challenge

Over the last few decades, the improved diagnostic criteria, the wide use of MRI, and the growing availability of effective pharmacologic treatments have led to substantial advances in the management of multiple sclerosis (MS). The importance of early diagnosis and treatment is now well-established, but there is still no consensus on how to define and monitor response to MS treatments. In particular, the clinical relevance of the detection of minimal MRI activity is controversial and recommendations on how to define and monitor treatment response are warranted. An expert panel of the Magnetic Resonance Imaging in MS Study Group analyzed and discussed published studies on treatment response in MS. The evolving concept of no evidence of disease activity and its effect on predicting long-term prognosis was examined, including the option of defining a more realistic target for daily clinical practice: minimal evidence of disease activity. Advantages and disadvantages associated with the use of MRI activity alone and quantitative scoring systems combining on-treatment clinical relapses and MRI active lesions to detect treatment response in the real-world setting were also discussed. While most published studies on this topic involved patients treated with interferon-β, special attention was given to more recent studies providing evidence based on treatment with other and more efficacious oral and injectable drugs. Finally, the panel identified future directions to pursue in this research field.