Carotid Plaque-RADS: A Novel Stroke Risk Classification System

BACKGROUND

Carotid artery atherosclerosis is highly prevalent in the general population and is a well-established risk factor for acute ischemic stroke. Although the morphological characteristics of vulnerable plaques are well recognized, there is a lack of consensus in reporting and interpreting carotid plaque features.

OBJECTIVES

The aim of this paper is to establish a consistent and comprehensive approach for imaging and reporting carotid plaque by introducing the Plaque-RADS (Reporting and Data System) score.

METHODS

A panel of experts recognized the necessity to develop a classification system for carotid plaque and its defining characteristics. Using a multimodality analysis approach, the Plaque-RADS categories were established through consensus, drawing on existing published reports.

RESULTS

The authors present a universal classification that is applicable to both researchers and clinicians. The Plaque-RADS score offers a morphological assessment in addition to the prevailing quantitative parameter of "stenosis." The Plaque-RADS score spans from grade 1 (indicating complete absence of plaque) to grade 4 (representing complicated plaque). Accompanying visual examples are included to facilitate a clear understanding of the Plaque-RADS categories.

CONCLUSIONS

Plaque-RADS is a standardized and reliable system of reporting carotid plaque composition and morphology via different imaging modalities, such as ultrasound, computed tomography, and magnetic resonance imaging. This scoring system has the potential to help in the precise identification of patients who may benefit from exclusive medical intervention and those who require alternative treatments, thereby enhancing patient care. A standardized lexicon and structured reporting promise to enhance communication between radiologists, referring clinicians, and scientists.

Carotid geometry is independently associated with complicated carotid artery plaques

Introduction

Complicated carotid artery plaques (cCAPs) are associated with an increased risk of rupture and subsequent stroke. The geometry of the carotid bifurcation determines the distribution of local hemodynamics and could thus contribute to the development and composition of these plaques. Therefore, we studied the role of carotid bifurcation geometry in the presence of cCAPs.

Methods

We investigated the association of individual vessel geometry with carotid artery plaque types in the Carotid Plaque Imaging in Acute Stroke (CAPIAS) study. After excluding arteries without plaque or with insufficient MRI quality, 354 carotid arteries from 182 patients were analyzed. Individual parameters of carotid geometry [i.e., internal carotid artery (ICA)/common carotid artery (CCA) ratio, bifurcation angle, and tortuosity) were derived from time-of-flight MR images. The lesion types of carotid artery plaques were determined according to the American Heart Association classification of lesions by multi-contrast 3T-MRI. The association between carotid geometry and a cCAP was studied using logistic regression after adjusting for age, sex, wall area, and cardiovascular risk factors.

Results

Low ICA/CCA ratios (OR per SD increase 0.60 [95%CI: 0.42-0.85]; p = 0.004) and low bifurcation angles (OR 0.61 [95%CI: 0.42-0.90]; p = 0.012) were significantly associated with the presence of cCAPs after adjusting for age, sex, cardiovascular risk factors, and wall area. Tortuosity had no significant association with cCAPs. Only ICA/CCA ratio remained significant in a model containing all three geometric parameters (OR per SD increase 0.65 [95%CI: 0.45-0.94]; p = 0.023).

Conclusions

A steep tapering of the ICA relative to the CCA and, to a lesser extent, a low angle of the carotid bifurcation were associated with the presence of cCAPs. Our findings highlight the contribution of bifurcation geometry to plaque vulnerability. Thus, assessment of carotid geometry could be helpful in identifying patients at risk of cCAPs.

Machine learning-based approach reveals essential features for simplified TSPO PET quantification in ischemic stroke patients

INTRODUCTION

Neuroinflammation evaluation after acute ischemic stroke is a promising option for selecting an appropriate post-stroke treatment strategy. To assess neuroinflammation in vivo, translocator protein PET (TSPO PET) can be used. However, the gold standard TSPO PET quantification method includes a 90 min scan and continuous arterial blood sampling, which is challenging to perform on a routine basis. In this work, we determine what information is required for a simplified quantification approach using a machine learning algorithm.

MATERIALS AND METHODS

We analyzed data from 18 patients with ischemic stroke who received 0-90 min [18F]GE-180 PET as well as T1-weigted (T1w), FLAIR, and arterial spin labeling (ASL) MRI scans. During PET scans, five manual venous blood samples at 5, 15, 30, 60, and 85 min post injection (p.i.) were drawn, and plasma activity concentration was measured. Total distribution volume (VT) was calculated using Logan plot with the full dynamic PET and an image-derived input function (IDIF) from the carotid arteries. IDIF was scaled by a calibration factor derived from all the measured plasma activity concentrations. The calculated VT values were used for training a random forest regressor. As input features for the model, we used three late PET frames (60-70, 70-80, and 80-90 min p.i.), the ASL image reflecting perfusion, the voxel coordinates, the lesion mask, and the five plasma activity concentrations. The algorithm was validated with the leave-one-out approach. To estimate the impact of the individual features on the algorithm's performance, we used Shapley Additive Explanations (SHAP). Having determined that the three late PET frames and the plasma activity concentrations were the most important features, we tested a simplified quantification approach consisting of dividing a late PET frame by a plasma activity concentration. All the combinations of frames/samples were compared by means of concordance correlation coefficient and Bland-Altman plots.

RESULTS

When using all the input features, the algorithm predicted VT values with high accuracy (87.8 ± 8.3%) for both lesion and non-lesion voxels. The SHAP values demonstrated high impact of the late PET frames (60-70, 70-80, and 80-90 min p.i.) and plasma activity concentrations on the VT prediction, while the influence of the ASL-derived perfusion, voxel coordinates, and the lesion mask was low. Among all the combinations of the late PET frames and plasma activity concentrations, the 70-80 min p.i. frame divided by the 30 min p.i. plasma sample produced the closest VT estimate in the ischemic lesion.

CONCLUSION

Reliable TSPO PET quantification is achievable by using a single late PET frame divided by a late blood sample activity concentration.

History and Science behind the Eating Assessment Tool-10 (Eat-10): Lessons Learned

INTRODUCTION

Oropharyngeal dysphagia (OD) is an underdiagnosed medical condition with a high prevalence in populations such as patients with frailty, neurological disease, or head and neck pathology. Potential barriers to its diagnosis include lack of (or low) awareness of the existence and severity of the condition, the hidden nature of the condition within the 'normal ageing' process, clinical limitations, and socioeconomic reasons. Consequently, an effective treatment is not systematically offered in a timely manner, and complications, such as dehydration and respiratory infections or aspiration pneumonia, can arise. To overcome this issue, the early use of screening questionnaires to identify people at risk of swallowing disorders represents the cornerstone of preventive medicine. Several screening tools have been created but few are widely used in clinical practice. The Eating Assessment Tool-10 (EAT-10) was developed as a quick, easy-to-understand, and self-administered screening tool for OD.

METHODS

A literature review was conducted in five databases with no restrictions on the language, date of publication, or design of the study to identify aspects of the validation, applicability, and usefulness of EAT-10.

RESULTS AND CONCLUSIONS

Transcultural adaptation and translation studies, as well as studies involving various types of patients with dysphagia in different settings have shown the validity and reliability of EAT-10 in relation to the gold standard and other validation tools. The use of this standardised screening tool could be used as a primary screening instrument of dysphagia in routine clinical practice across a wide range of diseases and settings and thereby increase the likelihood of early diagnosis and management of a condition that lead to serious complications and impaired quality of life.

Complicated Carotid Artery Plaques and Risk of Recurrent Ischemic Stroke or TIA

BACKGROUND

Complicated nonstenosing carotid artery plaques (CAPs) are an under-recognized cause of stroke.

OBJECTIVES

The purpose of this study was to determine whether complicated CAP ipsilateral to acute ischemic anterior circulation stroke (icCAP) are associated with recurrent ischemic stroke or transient ischemic attack (TIA).

METHODS

The CAPIAS (Carotid Plaque Imaging in Acute Stroke) multicenter study prospectively recruited patients with ischemic stroke restricted to the territory of a single carotid artery. Complicated (AHA-lesion type VI) CAP were defined by multisequence, contrast-enhanced carotid magnetic resonance imaging obtained within 10 days from stroke onset. Recurrent events were assessed after 3, 12, 24, and 36 months. The primary outcome was recurrent ischemic stroke or TIA.

RESULTS

Among 196 patients enrolled, 104 patients had cryptogenic stroke and nonstenosing CAP. During a mean follow-up of 30 months, recurrent ischemic stroke or TIA occurred in 21 patients. Recurrent events were significantly more frequent in patients with icCAP than in patients without icCAP, both in the overall cohort (incidence rate [3-year interval]: 9.50 vs 3.61 per 100 patient-years; P = 0.025, log-rank test) and in patients with cryptogenic stroke (10.92 vs 1.82 per 100 patient-years; P = 0.003). The results were driven by ipsilateral events. A ruptured fibrous cap (HR: 4.91; 95% CI: 1.31-18.45; P = 0.018) and intraplaque hemorrhage (HR: 4.37; 95% CI: 1.20-15.97; P = 0.026) were associated with a significantly increased risk of recurrent events in patients with cryptogenic stroke.

CONCLUSIONS

Complicated CAP ipsilateral to acute ischemic anterior circulation stroke are associated with an increased risk of recurrent ischemic stroke or TIA. Carotid plaque imaging identifies high-risk patients who might be suited for inclusion into future secondary prevention trials. (Carotid Plaque Imaging in Acute Stroke [CAPIAS]; NCT01284933).

Repeated exposure of the oral mucosa over 12 months with cold plasma is not carcinogenic in mice

Peri-implantitis may result in the loss of dental implants. Cold atmospheric pressure plasma (CAP) was suggested to promote re-osseointegration, decrease antimicrobial burden, and support wound healing. However, the long-term risk assessment of CAP treatment in the oral cavity has not been addressed. Treatment with two different CAP devices was compared against UV radiation, carcinogen administration, and untreated conditions over 12 months. Histological analysis of 406 animals revealed that repeated CAP exposure did not foster non-invasive lesions or squamous cell carcinoma (SCCs). Carcinogen administration promoted non-invasive lesions and SCCs. Molecular analysis by a qPCR screening of 144 transcripts revealed distinct inflammatory profiles associated with each treatment regimen. Interestingly, CAP treatment of carcinogen-challenged mucosa did not promote but instead left unchanged or reduced the proportion of non-invasive lesions and SCC formation. In conclusion, repeated CAP exposure of murine oral mucosa was well tolerated, and carcinogenic effects did not occur, motivating CAP applications in patients for dental and implant treatments in the future.

Union of the European Phoniatricians' position statement on the exit strategy of phoniatric and laryngological services: staying safe and getting back to normal after the peak of coronavirus disease 2019 (issued on 25th May 2020)

BACKGROUND

The following position statement from the Union of the European Phoniatricians, updated on 25th May 2020 (superseding the previous statement issued on 21st April 2020), contains a series of recommendations for phoniatricians and ENT surgeons who provide and/or run voice, swallowing, speech and language, or paediatric audiology services.

OBJECTIVES

This material specifically aims to inform clinical practices in countries where clinics and operating theatres are reopening for elective work. It endeavours to present a current European view in relation to common procedures, many of which fall under the aegis of aerosol generating procedures.

CONCLUSION

As evidence continues to build, some of the recommended practices will undoubtedly evolve, but it is hoped that the updated position statement will offer clinicians precepts on safe clinical practice.

The role of progestogen supplementation (dydrogesterone) in the prevention of preeclampsia

Our goal was determine the effects of dydrogesterone supplementation to reduce the incidence of preeclampsia (PE) in early pregnancy (from 6 to 20 weeks of gestation). A total of 406 pregnant women were involved into the study. The Study group enrolled 169 women, supplemented with dydrogesterone at a dose of 30 mg/d 6-20 weeks of gestation compared with the control group (237 subjects) - without dydrogesterone supplementation. The women were randomized by age, race, obstetrics complications, and their somatic history. The use of dydrogesterone in early pregnancy - before 20 weeks of gestation (at a dose of 30 mg/d) with high-risk factors of PE contributed to a statistically significant reduction in the frequency of this complication (13.1% and 71.4%, p < .001). It was seen, that women who took dydrogesterone developed significantly less such disorders like hypertension (3.2% and 71.2%, p < .001), proteinuria (0.0% and 66.18%, p < .001), fetal growth retardation syndrome (2.2% and 21.58%, p < .001), destroy of uteri-placenta velocity (3.2% and 21.58%, p < .001), preterm labor (8.6% and 53.95%, p < .001). Dydrogesterone supplementation in the first and second period of pregnancy (from 6 to 20 weeks of gestation) significantly reduced the incidence of PE in women with higher risk pregnancy.

Prediction of Stroke Risk by Detection of Hemorrhage in Carotid Plaques: Meta-Analysis of Individual Patient Data

OBJECTIVES

The goal of this study was to compare the risk of stroke between patients with carotid artery disease with and without the presence of intraplaque hemorrhage (IPH) on magnetic resonance imaging.

BACKGROUND

IPH in carotid stenosis increases the risk of cerebrovascular events. Uncertainty remains whether risk of stroke alone is increased and whether stroke is predicted independently of known risk factors.

METHODS

Data were pooled from 7 cohort studies including 560 patients with symptomatic carotid stenosis and 136 patients with asymptomatic carotid stenosis. Hazards of ipsilateral ischemic stroke (primary outcome) were compared between patients with and without IPH, adjusted for clinical risk factors.

RESULTS

IPH was present in 51.6% of patients with symptomatic carotid stenosis and 29.4% of patients with asymptomatic carotid stenosis. During 1,121 observed person-years, 66 ipsilateral strokes occurred. Presence of IPH at baseline increased the risk of ipsilateral stroke both in symptomatic (hazard ratio [HR]: 10.2; 95% confidence interval [CI]: 4.6 to 22.5) and asymptomatic (HR: 7.9; 95% CI: 1.3 to 47.6) patients. Among patients with symptomatic carotid stenosis, annualized event rates of ipsilateral stroke in those with IPH versus those without IPH were 9.0% versus 0.7% (<50% stenosis), 18.1% versus 2.1% (50% to 69% stenosis), and 29.3% versus 1.5% (70% to 99% stenosis). Annualized event rates among patients with asymptomatic carotid stenosis were 5.4% in those with IPH versus 0.8% in those without IPH. Multivariate analysis identified IPH (HR: 11.0; 95% CI: 4.8 to 25.1) and severe degree of stenosis (HR: 3.3; 95% CI: 1.4 to 7.8) as independent predictors of ipsilateral stroke.

CONCLUSIONS

IPH is common in patients with symptomatic and asymptomatic carotid stenosis and is a stronger predictor of stroke than any known clinical risk factors. Magnetic resonance imaging might help identify patients with carotid disease who would benefit from revascularization.

Efficacy of trans-nasal fiberendoscopic injection laryngoplasty with centrifuged autologous fat in the treatment of glottic insufficiency due to unilateral vocal fold paralysis

SUMMARY

The objective of this work is to evaluate the safety, feasibility and efficacy of trans-nasal fiberendoscopic injection laryngoplasty (IL) with centrifuged autologous fat, performed under local anaesthesia, in the treatment of glottic insufficiency due to unilateral vocal fold paralysis (UVFP). It is a within-subject study with follow-up 1 week after phonosurgery and after 6 months. A total of 22 patients with chronic dysphonia caused by glottic insufficiency due to UVFP were enrolled. Each patient underwent trans-nasal IL with centrifuged autologous fat through flexible operative endoscope under local anaesthesia and was evaluated before and twice (1 week and 6 months) after phonosurgery, using a multidimensional set of investigations. The assessment protocol included videolaryngostroboscopy, perceptual evaluation of dysphonia, maximum phonation time and patient's self-assessment on voice-related quality of life (QOL) with the Voice Handicap Index-10 and the comparative self-assessment on vocal fatigue and voice quality pre-post treatment. Trans-nasal IL with centrifuged autologous fat was performed in all 22 patients and there were no complications in any case. Significant improvements in videolaryngostroboscopic findings, perceptual evaluation of dysphonia, maximum phonation time and QoL self-assessment were reported after 1 week and were maintained at 6 months. In one patient, the result after 6 months was not satisfactory and this patient then underwent a medialization laryngoplasty (thyroplasty type I) with satisfactory long-term results. In conclusion, trans-nasal fiberendoscopic IL with centrifuged autologous fat seems to be a safe, feasible and efficacious phonosurgical procedure for treatment of glottic insufficiency due to unilateral vocal fold paralysis.

Efficacy of microsurgery in Reinke's oedema evaluated by traditional voice assessment integrated with the Vocal Extent Measure (VEM)

SUMMARY

There are few data analysing to what specific extent phonomicrosurgery improves vocal function in patients suffering from Reinke's oedema (RE). The recently introduced parameter vocal extent measure (VEM) seems to be suitable to objectively quantify vocal performance. The purpose of this clinical prospective study was to investigate the outcomes of phonomicrosurgery in 60 RE patients (6 male, 54 female; 56 ± 8 years ([mean ± SD]) by analysing its effect on subjective and objective vocal parameters with particular regard to VEM. Treatment efficacy was evaluated at three months after surgery by comparing pre- and postoperative videolaryngostroboscopy (VLS), auditory-perceptual assessment (RBH-status), voice range profile (VRP), acoustic-aerodynamic analysis and patient's self-assessment using the voice handicap index (VHI-9i). Phonomicrosurgically, all RE were carefully ablated. VLS revealed removal or substantial reduction of oedema with restored periodic vocal fold vibration. All subjective and most objective acoustic and aerodynamic parameters significantly improved. The VEM increased on average from 64 ± 37 to 88 ± 25 (p #x003C; 0.001) and the dysphonia severity index (DSI) from 0.5 ± 3.4 to 2.9 ± 1.9. Both parameters correlated significantly with each other (rs = 0.70). RBH-status revealed less roughness, breathiness and overall grade of hoarseness (2.0 ± 0.7 vs 1.3 ± 0.7). The VHI-9i-score decreased from 18 ± 8 to 12 ± 9 points. The average total vocal range enlarged by 4 ± 7 semitones, and the mean speaking pitch rose by 2 ± 4 semitones. These results confirm that: (1) the use of VEM in RE patients objectifies and quantifies their vocal capacity as documented in the VRP, and (2) phonomicrosurgery is an effective, objectively and subjectively satisfactory therapy to improve voice in RE patients.

Horizontal lateral lamella as a risk factor for iatrogenic cerebrospinal fluid leak. Clinical retrospective evaluation of 24 cases

BACKGROUND

Several authors highlighted the limitations of the Keros classification system in predicting intracranial entry risk. Recently, our group proposed a new classification system based on the angle formed between the lateral lamella of the cribriform plate (LLCP) and the continuation of an horizontal plane passing through the cribriform plate (Gera classification). The aim of this study was to analyze whether the risk of iatrogenic cerebrospinal fluid leak (CSF-L) was better predicted by Keros or Gera classification.

METHODOLOGY

The pre-operative CT scans of 24 patients (CSF-L group) who suffered from iatrogenic CSF-L during endoscopic sinus surgery (ESS) were compared to those obtained from a group of 100 patients who underwent uneventful ESS (control group). The skull base measurements as well as the distribution of Keros and Gera classes in the 2 groups were analyzed.

RESULTS

No difference in the distribution of Keros classes or in the depth of the cribriform plate between CSF-L and control group were demonstrated. On the contrary, significant differences in the distribution of Gera classes and in the degree of the angle formed by the LLCP and the continuation of the horizontal plane passing through the cribriform plate were found. In particular, according to Gera classification system, 19 out of 24 patients in the CSF-L group were considered at risk for iatrogenic CSF-L.

CONCLUSIONS

Gera classification system might be more sensitive to anatomical variations associated with CSF-L than the Keros one, further suggesting the application of the former during the preoperative CT scan evaluation.

Attachment and Substance Use Disorders-Theoretical Models, Empirical Evidence, and Implications for Treatment

Introduction: The article reviews attachment-oriented research in individuals with substance use disorders (SUDs). Based on attachment theory, substance abuse can be understood as "self-medication," as an attempt to compensate for lacking attachment strategies. Attachment theory suggests a developmental pathway from insecure attachment to SUD and, on the other hand, a negative impact of substance abuse on attachment security. Earlier reviews have indicated a general link but have been inconclusive with regard to other aspects. In the light of a growing body of research, this review is looking for evidence for the general link, for its direction, for differences due to different patterns of attachment, different substances and severities, comorbid psychiatric disorders, and age groups. Methods: Using medical and psychological databases, 34 cross-sectional studies, three longitudinal studies, and a systematic meta-analysis were identified. Methodological problems such as poor assessment of SUD and the use of different measures of attachment limit comparability. Results: All cross-sectional studies in the review confirm a link between insecure attachment and SUD. Results of longitudinal studies show insecure attachment to be a risk factor for SUD, while continued substance abuse impairs the ability to form close relationships. With regard to specific patterns of attachment, results mainly point toward very insecure patterns. They indicate different patterns of attachment in different groups of substance abusers, suggesting different developmental pathways. Fearful-avoidant attachment was frequent in heroin addicts, while alcohol abusers displayed more heterogeneous patterns. Comorbid mental disorders and severity of SUD seem to be important factors, but data are still inconclusive. The link between insecure attachment and SUD seems to be stronger in adolescence compared to adulthood. Discussion: The last decades have seen a substantial growth in studies on attachment and SUDs. Despite methodological problems, the general link between insecure attachment and SUD today is well established. Attachment theory might contribute to the understanding and treatment of SUDs in a significant way. But to do so, a lot of open questions have to be answered. We will need more carefully designed longitudinal studies, more studies connecting psychological data with brain processes, and more clinical trials.

Horizontal lateral lamella as a risk factor for iatrogenic cerebrospinal fluid leak. Clinical retrospective evaluation of 24 cases

BACKGROUND

Several authors highlighted the limitations of the Keros classification system in predicting intracranial entry risk. Recently, our group proposed a new classification system based on the angle formed between the lateral lamella of the cribriform plate (LLCP) and the continuation of an horizontal plane passing through the cribriform plate (Gera classification). The aim of this study was to analyze whether the risk of iatrogenic cerebrospinal fluid leak (CSF-L) was better predicted by Keros or Gera classification.

METHODOLOGY

The pre-operative CT scans of 24 patients (CSF-L group) who suffered from iatrogenic CSF-L during endoscopic sinus surgery (ESS) were compared to those obtained from a group of 100 patients who underwent uneventful ESS (control group). The skull base measurements as well as the distribution of Keros and Gera classes in the 2 groups were analyzed.

RESULTS

No difference in the distribution of Keros classes or in the depth of the cribriform plate between CSF-L and control group were demonstrated. On the contrary, significant differences in the distribution of Gera classes and in the degree of the angle formed by the LLCP and the continuation of the horizontal plane passing through the cribriform plate were found. In particular, according to Gera classification system, 19 out of 24 patients in the CSF-L group were considered at risk for iatrogenic CSF-L.

CONCLUSIONS

Gera classification system might be more sensitive to anatomical variations associated with CSF-L than the Keros one, further suggesting the application of the former during the preoperative CT scan evaluation.

Human V6 Integrates Visual and Extra-Retinal Cues during Head-Induced Gaze Shifts

A key question in vision research concerns how the brain compensates for self-induced eye and head movements to form the world-centered, spatiotopic representations we perceive. Although human V3A and V6 integrate eye movements with vision, it is unclear which areas integrate head motion signals with visual retinotopic representations, as fMRI typically prevents head movement executions. Here we examined whether human early visual cortex V3A and V6 integrate these signals. A previously introduced paradigm allowed participant head movement during trials, but stabilized the head during data acquisition utilizing the delay between blood-oxygen-level-dependent (BOLD) and neural signals. Visual stimuli simulated either a stable environment or one with arbitrary head-coupled visual motion. Importantly, both conditions were matched in retinal and head motion. Contrasts revealed differential responses in human V6. Given the lack of vestibular responses in primate V6, these results suggest multi-modal integration of visual with neck efference copy signals or proprioception in V6.

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Setup with head-mounted goggles and head movement during fMRI

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Simulation of forward flow in stable or unstable world during head rotation

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Human V6 integrates visual self-motion with head motion signals

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Likely mediated by efference copy or proprioception as V6 lacks vestibular input

Dynamic CTA in Native Kidneys Using a Multiphase CT Protocol-Potential of Significant Reduction of Contrast Medium

RATIONALE AND OBJECTIVE

The objective of this study was to assess an optimized renal multiphase computed tomography angiography (MP-CTA) protocol regarding reduction of contrast volume.

MATERIALS AND METHODS

Thirty patients underwent MP-CTA (12 phases, every 3.5 seconds, 80 kV/120 mAs) using 30 mL of contrast medium. The quality of MP-CTA was assessed quantitatively measuring vessel attenuation, image noise, and contrast-to-noise ratio. MP-CTA was evaluated qualitatively regarding depiction of vessels, cortex differentiation, and motion artifacts (grades 1-4, 1 = best). Mean effective radiation dose was registered. Results were compared to standard renal computed tomography angiography (CTA) (80 mL). Student t test was applied, if variables followed normal distribution. For other variables, nonparametric Mann-Whitney U test was used.

RESULTS

All acquisitions were successfully performed, and no patient had to be excluded from the study. MP-CTA enabled high attenuation (aorta: 503 ± 91 HU, renal arteries: 450 ± 73 HU/456 ± 72 HU) at adequate image noise (13.7 ± 1.5) and good contrast-to-noise ratio (34.2 ± 10.2). Good attenuation of renal veins was observed (286 ± 43 HU/282 ± 42 HU). Arterial enhancement was significantly higher compared to renal CTA (aorta: 396 ± 90 HU, renal arteries: 331 ± 74 HU/333 ± 80 HU; P < .001). MP-CTA protocol enabled good image quality of renal arteries (1.5 ± 0.6) and veins (1.7 ± 0.6). Cortex differentiation and motion artifacts were ranked 1.8 ± 0.8 and 1.6 ± 0.8. The mean effective radiation dose was 9 mSv (MP-CTA).

CONCLUSIONS

Compared to standard renal CTA, the renal MP-CTA enabled the significant reduction of contrast volume and simultaneously provided a significantly higher arterial attenuation.

Real-motion signals in human early visual cortex

Eye movements induce visual motion that can complicate the stable perception of the world. The visual system compensates for such self-induced visual motion by integrating visual input with efference copies of eye movement commands. This mechanism is central as it does not only support perceptual stability but also mediates reliable perception of world-centered objective motion. In humans, it remains elusive whether visual motion responses in early retinotopic cortex are driven by objective motion or by retinal motion associated with it. To address this question, we used fMRI to examine functional responses of sixteen visual areas to combinations of planar objective motion and pursuit eye movements. Observers were exposed to objective motion that was faster, matched or slower relative to pursuit, allowing us to compare conditions that differed in objective motion velocity while retinal motion and eye movement signals were matched. Our results show that not only higher level motion regions such as V3A and V6, but also early visual areas signaled the velocity of objective motion, hence the product of integrating retinal with non-retinal signals. These results shed new light on mechanisms that mediate perceptual stability and real-motion perception, and show that extra-retinal signals related to pursuit eye movements influence processing in human early visual cortex.

Connectivity Reveals Sources of Predictive Coding Signals in Early Visual Cortex During Processing of Visual Optic Flow

Superimposed on the visual feed-forward pathway, feedback connections convey higher level information to cortical areas lower in the hierarchy. A prominent framework for these connections is the theory of predictive coding where high-level areas send stimulus interpretations to lower level areas that compare them with sensory input. Along these lines, a growing body of neuroimaging studies shows that predictable stimuli lead to reduced blood oxygen level-dependent (BOLD) responses compared with matched nonpredictable counterparts, especially in early visual cortex (EVC) including areas V1-V3. The sources of these modulatory feedback signals are largely unknown. Here, we re-examined the robust finding of relative BOLD suppression in EVC evident during processing of coherent compared with random motion. Using functional connectivity analysis, we show an optic flow-dependent increase of functional connectivity between BOLD suppressed EVC and a network of visual motion areas including MST, V3A, V6, the cingulate sulcus visual area (CSv), and precuneus (Pc). Connectivity decreased between EVC and 2 areas known to encode heading direction: entorhinal cortex (EC) and retrosplenial cortex (RSC). Our results provide first evidence that BOLD suppression in EVC for predictable stimuli is indeed mediated by specific high-level areas, in accord with the theory of predictive coding.

Integration of visual and non-visual self-motion cues during voluntary head movements in the human brain

Our phenomenological experience of the stable world is maintained by continuous integration of visual self-motion with extra-retinal signals. However, due to conventional constraints of fMRI acquisition in humans, neural responses to visuo-vestibular integration have only been studied using artificial stimuli, in the absence of voluntary head-motion. We here circumvented these limitations and let participants to move their heads during scanning. The slow dynamics of the BOLD signal allowed us to acquire neural signal related to head motion after the observer's head was stabilized by inflatable aircushions. Visual stimuli were presented on head-fixed display goggles and updated in real time as a function of head-motion that was tracked using an external camera. Two conditions simulated forward translation of the participant. During physical head rotation, the congruent condition simulated a stable world, whereas the incongruent condition added arbitrary lateral motion. Importantly, both conditions were precisely matched in visual properties and head-rotation. By comparing congruent with incongruent conditions we found evidence consistent with the multi-modal integration of visual cues with head motion into a coherent "stable world" percept in the parietal operculum and in an anterior part of parieto-insular cortex (aPIC). In the visual motion network, human regions MST, a dorsal part of VIP, the cingulate sulcus visual area (CSv) and a region in precuneus (Pc) showed differential responses to the same contrast. The results demonstrate for the first time neural multimodal interactions between precisely matched congruent versus incongruent visual and non-visual cues during physical head-movement in the human brain. The methodological approach opens the path to a new class of fMRI studies with unprecedented temporal and spatial control over visuo-vestibular stimulation.

Lack of association of MRI determined subclinical cardiovascular disease with dizziness and vertigo in a cross-sectional population-based study

Objective

We investigated the association between subclinical cardiovascular diseases assessed by MRI examination and symptoms of dizziness and vertigo in participants of a population-based sample.

Methods

Data from 400 participants (169 women) aged from 39 to 73 of a cross-sectional MRI sub-study of the “Kooperative Gesundheitsforschung in der Region Augsburg” (KORA) FF4 study from the south of Germany was used. MRI determined subclinical cardiovascular diseases include left and right ventricular structure and function as well as the presence of carotid plaque and carotid wall thickness. Cerebrum diseases include white matter lesions (WML) and cerebral microbleeds (CMB). The main outcomes of dizziness and vertigo were assessed by standardized interview. Logistic regression models were applied and adjusted odds ratios (OR) with 95% confidence intervals (CI) were provided.

Results

Lifetime and 12-month prevalence of dizziness and vertigo were 30% (95%CI 26% to 35%) and 21% (95%CI 17% to 26%) respectively in this sample. On multivariable analysis, cardiac and carotid measurements were not associated with dizziness and vertigo excluding orthostatic vertigo (20%, 95CI 16% to 24%). Only in male participants, there was a significant association between WML and the presence of dizziness and vertigo (OR = 2.95, 95%CI 1.08 to 8.07). There was no significant association of CMB with dizziness and vertigo.

However, CMB and WML were tending to associate with a higher risk of dizziness and vertigo in the whole sample (CMB: OR = 1.48, 95%CI 0.70; 3.15; WML: OR = 1.71, 95%CI 0.80 to 3.67;), in persons with prediabetes and diabetes (WML: OR = 2.71, 95%CI 0.89 to 8.23) and in men with normal glucose metabolism (CMB: OR = 2.60, 95%CI 0.56 to 12.0; WML: OR = 3.08, 95%CI 0.58 to 16.5).

Conclusions

In this sample of participants without manifest cardiovascular diseases, subclinical left and right ventricular function and carotid structure were consistently not associated with dizziness and vertigo. Subclinical cerebrum measurements, however, tend to increase the risk for dizziness and vertigo, especially in men and in persons with prediabetes or diabetes.

Dysphagia screening in subacute care settings using the Italian version of the Royal Brisbane and Women's Hospital (I-RBWH) dysphagia screening tool

The large majority of the available dysphagia screening tools has been developed for the stroke population. Only few screening tools are suitable for heterogeneous groups of patients admitted to a subacute care unit. The Royal Brisbane and Women's Hospital (RBWH) dysphagia screening tool is a nurse-administered, evidence-based swallow screening tool for generic acute hospital use that demonstrates excellent sensitivity and specificity. No Italian version of this tool is available to date. The aim of this study was to determine the reliability and screening accuracy of the Italian version of the RBWH (I-RBWH) dysphagia screening tool. A total of 105 patients consecutively admitted to a subacute care unit were enrolled. Using the I-RBWH tool, each patient was evaluated twice by trained nurses and once by a speech and language pathologist (SLP) blind to nurses' scores. The SLP also performed standardised clinical assessment of swallowing using the Mann assessment of swallowing ability (MASA). During the first and the second administration of the I-RBWH by nurses, 28 and 27 patients, respectively, were considered at risk of dysphagia, and 27 were considered at risk after SLP assessment. Intra- and inter-rater reliability was satisfactory. Comparison between nurse I-RBWH scores and MASA examination demonstrated a sensitivity and specificity of the I-RBWH dysphagia screening tool up to 93% and 96%, respectively; the positive and negative predictive values were 90% and 97%, respectively. Thus, the current findings support the reliability and accuracy of the I-RBWH tool for dysphagia screening of patients in subacute settings. Its application in clinical practice is recommended.

Prevalence and distribution of calcified nodules in carotid arteries in correlation with clinical symptoms

PURPOSE

Calcified nodules ("CN") are responsible for up to 5% of coronary-infarcts and, therefore, classified as minor criteria of "vulnerable" atherosclerotic plaque. We sought to evaluate prevalence and distribution of CN in carotid arteries in correlation with clinical symptoms.

METHODS

178 consecutive patients with unilateral ischemic stroke and carotid plaques ≥2 mm by duplex ultrasound underwent a carotid-black-blood-3T-MRI with fat-saturated pre- and post-contrast T1w-, PDw-, T2w- and TOF images using dedicated surface-coils. CN were defined as distinct calcification with an irregular, protruding, and convex luminal surface. Prevalence of CN was determined in common carotid artery ("CCA") and internal carotid artery ("ICA") in consensus by two reviewers blinded to clinical information.

RESULTS

Thirty seven CN in 28 arteries of 26 patients were identified. Prevalence of CN in CCA compared to ICA was slightly higher (59 vs. 41%), but nearly similar in 66 arteries with ≥30% compared to 290 arteries with <30% stenosis (9.1 vs. 7.6%) and in the artery ipsilateral versus contralateral to stroke (7.9 vs. 7.9%; P values n.s.). Prevalence of CN was significantly higher in 40 symptomatic arteries with ≥30% stenosis compared to asymptomatic 26 arteries (15.6 vs. 0%; P = 0.04). There was a significantly higher prevalence of hypercholesterolemia and hypertension in patients with CN (57.7 vs. 36.0 and 88.5 vs. 66.7%; P values <0.05).

CONCLUSION

CN were found in 7.9% of arteries with carotid-plaques ≥2 mm by duplex-ultrasound; prevalence was significantly higher in symptomatic arteries with ≥30% stenosis compared to asymptomatic with <30% stenosis, suggesting that CN play a role in pathogenesis of ischemic stroke in a small subset of patients.

Subclinical Disease Burden as Assessed by Whole-Body MRI in Subjects With Prediabetes, Subjects With Diabetes, and Normal Control Subjects From the General Population: The KORA-MRI Study

Detailed pathophysiological manifestations of early disease in the context of prediabetes are poorly understood. This study aimed to evaluate the extent of early signs of metabolic and cardio-cerebrovascular complications affecting multiple organs in individuals with prediabetes. Subjects without a history of stroke, coronary artery disease, or peripheral artery disease were enrolled in a case-control study nested within the Cooperative Health Research in the Region of Augsburg (KORA) FF4 cohort and underwent comprehensive MRI assessment to characterize cerebral parameters (white matter lesions, microbleeds), cardiovascular parameters (carotid plaque, left ventricular function, and myocardial late gadolinium enhancement [LGE]), and metabolic parameters (hepatic proton-density fat fraction [PDFF] and subcutaneous and visceral abdominal fat). Among 400 subjects who underwent MRI, 103 subjects had prediabetes and 54 had established diabetes. Subjects with prediabetes had an increased risk for carotid plaque and adverse functional cardiac parameters, including reduced early diastolic filling rates as well as a higher prevalence of LGE compared with healthy control subjects. In addition, people with prediabetes had significantly elevated levels of PDFF and total and visceral fat. Thus, subjects with prediabetes show early signs of subclinical disease that include vascular, cardiac, and metabolic changes, as measured by whole-body MRI after adjusting for cardiometabolic risk factors.

Evaluating the Psychometric Properties of the Eating Assessment Tool (EAT-10) Using Rasch Analysis

Early and reliable screening for oropharyngeal dysphagia (OD) symptoms in at-risk populations is important and a crucial first stage in effective OD management. The Eating Assessment Tool (EAT-10) is a commonly utilized screening and outcome measure. To date, studies using classic test theory methodologies report good psychometric properties, but the EAT-10 has not been evaluated using item response theory (e.g., Rasch analysis). The aim of this multisite study was to evaluate the internal consistency and structural validity and conduct a preliminary investigation of the cross-cultural validity of the EAT-10; floor and ceiling effects were also checked. Participants involved 636 patients deemed at risk of OD, from outpatient clinics in Spain, Turkey, Sweden, and Italy. The EAT-10 and videofluoroscopic and/or fiberoptic endoscopic evaluation of swallowing were used to confirm OD diagnosis. Patients with esophageal dysphagia were excluded to ensure a homogenous sample. Rasch analysis was used to investigate person and item fit statistics, response scale, dimensionality of the scale, differential item functioning (DIF), and floor and ceiling effect. The results indicate that the EAT-10 has significant weaknesses in structural validity and internal consistency. There are both item redundancy and lack of easy and difficult items. The thresholds of the rating scale categories were disordered and gender, confirmed OD, and language, and comorbid diagnosis showed DIF on a number of items. DIF analysis of language showed preliminary evidence of problems with cross-cultural validation, and the measure showed a clear floor effect. The authors recommend redevelopment of the EAT-10 using Rasch analysis.

Reliability, validity and normative data of the Italian version of the Bus Story test

OBJECTIVES

Evaluation of the reliability and the validity of the Italian version of the Bus Story Test (I-BST), providing normative data in Italian children.

METHODS

A total of 552 normally developing children (278 males and 274 females) aged 3; 6 to 9; 0 years, were enrolled. Test-retest, intra- and inter-rater reliability were analysed on a sample of respectively 145, 178 and 178 children. Normative data were gathered from all the enrolled children and estimate centiles according to the CG-LMS method provided. The children were divided into 11 age classes of six months each; percentile scores and standard error measurement were analysed in children from age class 4; 0-4; 5 years to age class 8; 6-811 years. Age effects on I-BST were analysed.

RESULTS

Results showed high test-retest, intra- and inter-rater reliability scores. A significant age effect on I-BST scores emerged from the ANOVA test analysis; in particular, as age increases, so do I-BST scores.

CONCLUSION

The I-BST is a reliable and valid tool. The availability of normative data for Italian speaking children may help clinicians during clinical assessment.

Visual high-level regions respond to high-level stimulus content in the absence of low-level confounds

High-level regions of the ventral stream exhibit strong category selectivity to stimuli such as faces, houses, or objects. However, recent studies suggest that at least part of this selectivity stems from low-level differences inherent to images of the different categories. For example, visual outdoor and indoor scenes as well as houses differ in spatial frequency, rectilinearity and obliqueness when compared to face or object images. Correspondingly, scene responsive para-hippocampal place area (PPA) showed strong preference to low-level properties of visual scenes also in the absence of high-level scene content. This raises the question whether all high-level responses in PPA, the fusiform face area (FFA), or the object-responsive lateral occipital compex (LOC) may actually be explained by systematic differences in low-level features. In the present study we contrasted two classes of simple stimuli consisting of ten rectangles each. While both were matched in visual low-level features only one class of rectangle arrangements gave rise to a percept compatible with a high-level 3D layout such as a scene or an object. We found that areas PPA, transverse occipital sulcus (TOS, also referred to as occipital place area, OPA), as well as FFA and LOC showed robust responses to the visual scene class compared to the low-level matched control. Our results suggest that visual category responsive regions are not purely driven by low-level visual features but also by the high-level perceptual stimulus interpretation.

Expansive arterial remodeling of the carotid arteries and its effect on atherosclerotic plaque composition and vulnerability: an in-vivo black-blood 3T CMR study in symptomatic stroke patients

BACKGROUND

Based on intravascular ultrasound of the coronary arteries expansive arterial remodeling is supposed to be a feature of the vulnerable atheroslerotic plaque. However, till now little is known regarding the clinical impact of expansive remodeling of carotid lesions. Therefore, we sought to evaluate the correlation of expansive arterial remodeling of the carotid arteries with atherosclerotic plaque composition and vulnerability using in-vivo Cardiovascular Magnetic Resonance (CMR).

METHODS

One hundred eleven symptomatic patients (74 male/71.8 ± 10.3y) with acute unilateral ischemic stroke and carotid plaques of at least 2 mm thickness were included. All patients received a dedicated multi-sequence black-blood carotid CMR (3Tesla) of the proximal internal carotid arteries (ICA). Measurements of lumen, wall, outer wall, hemorrhage, calcification and necrotic core were determined. Each vessel-segment was classified according to American Heart Association (AHA) criteria for vulnerable plaque. A modified remodeling index (mRI) was established by dividing the average outer vessel area of the ICA segments by the lumen area measured on TOF images in a not affected reference segment at the distal ipsilateral ICA. Correlations of mRI and clinical symptoms as well as plaque morphology/vessel dimensions were evaluated.

RESULTS

Seventy-eight percent (157/202) of all internal carotid arteries showed atherosclerotic disease with AHA Lesion-Type (LT) III or higher. The mRI of the ICA was significantly different in normal artery segments (AHA LT I; mRI 1.9) compared to atherosclerotic segments (AHA LT III-VII; mRI 2.5; p < 0.0001). Between AHA LT III-VII there was no significant difference of mRI. Significant correlations (p < 0.05) of the mRI with lumen-area (LA), wall-area (WA), vessel-area (VA) and wall-thickness (WT), necrotic-core area (NC), and ulcer-area were observed. With respect to clinical presentation (symptomatic/asymptomatic side) and luminal narrowing (stenotic/non-stenotic) no relevant correlations or significant differences regarding the mRI were found.

CONCLUSION

Expansive arterial remodeling exists in the ICA. However, no significant association between expansive arterial remodeling, stroke symptoms, complicated AHA VI plaque, and luminal stenosis could be established. Hence, results of our study suggest that expansive arterial remodeling is not a very practical marker for plaque vulnerability in the carotid arteries.

Motion parallax links visual motion areas and scene regions

When we move, the retinal velocities of objects in our surrounding differ according to their relative distances and give rise to a powerful three-dimensional visual cue referred to as motion parallax. Motion parallax allows us to infer our surrounding's 3D structure as well as self-motion based on 2D retinal information. However, the neural substrates mediating the link between visual motion and scene processing are largely unexplored. We used fMRI in human observers to study motion parallax by means of an ecologically relevant yet highly controlled stimulus that mimicked the observer's lateral motion past a depth-layered scene. We found parallax selective responses in parietal regions IPS3 and IPS4, and in a region lateral to scene selective occipital place area (OPA). The traditionally defined scene responsive regions OPA, the para-hippocampal place area (PPA) and the retrosplenial cortex (RSC) did not respond to parallax. During parallax processing, the occipital parallax selective region entertained highly specific functional connectivity with IPS3 and with scene selective PPA. These results establish a network linking dorsal motion and ventral scene processing regions specifically during parallax processing, which may underlie the brain's ability to derive 3D scene information from motion parallax.

High-risk plaque features can be detected in non-stenotic carotid plaques of patients with ischaemic stroke classified as cryptogenic using combined (18)F-FDG PET/MR imaging

PURPOSE

The aim of this study was to investigate in 18 patients with ischaemic stroke classified as cryptogenic and presenting non-stenotic carotid atherosclerotic plaques the morphological and biological aspects of these plaques with magnetic resonance imaging (MRI) and (18)F-fluoro-deoxyglucose positron emission tomography ((18)F-FDG PET) imaging.

METHODS

Carotid arteries were imaged 150 min after injection of (18)F-FDG with a combined PET/MRI system. American Heart Association (AHA) lesion type and plaque composition were determined on consecutive MRI axial sections (n = 460) in both carotid arteries. (18)F-FDG uptake in carotid arteries was quantified using tissue to background ratio (TBR) on corresponding PET sections.

RESULTS

The prevalence of complicated atherosclerotic plaques (AHA lesion type VI) detected with high-resolution MRI was significantly higher in the carotid artery ipsilateral to the ischaemic stroke as compared to the contralateral side (39 vs 0 %; p = 0.001). For all other AHA lesion types, no significant differences were found between ipsilateral and contralateral sides. In addition, atherosclerotic plaques classified as high-risk lesions with MRI (AHA lesion type VI) were associated with higher (18)F-FDG uptake in comparison with other AHA lesions (TBR = 3.43 ± 1.13 vs 2.41 ± 0.84, respectively; p < 0.001). Furthermore, patients presenting at least one complicated lesion (AHA lesion type VI) with MRI showed significantly higher (18)F-FDG uptake in both carotid arteries (ipsilateral and contralateral to the stroke) in comparison with carotid arteries of patients showing no complicated lesion with MRI (mean TBR = 3.18 ± 1.26 and 2.80 ± 0.94 vs 2.19 ± 0.57, respectively; p < 0.05) in favour of a diffuse inflammatory process along both carotid arteries associated with complicated plaques.

CONCLUSION

Morphological and biological features of high-risk plaques can be detected with (18)F-FDG PET/MRI in non-stenotic atherosclerotic plaques ipsilateral to the stroke, suggesting a causal role for these plaques in stroke. Combined (18)F-FDG PET/MRI systems might help in the evaluation of patients with ischaemic stroke classified as cryptogenic.

Cross-cultural adaptation and validation of the Nijmegen Cochlear Implant Questionnaire into Italian

The NCIQ is a quantifiable self-assessment health-related quality of life instrument specific for cochlear implant users. The aim of this study was to culturally adapt the NCIQ into Italian (I-NCIQ). A prospective instrument validation study was conducted. Cross-cultural adaptation and validation were accomplished. Cronbach α was used to test internal consistency in 51 CI users and in a control group composed by 38 post-lingual deaf adult on a waiting list for a CI. ICC test was used for test-retest reliability analysis. Kruskal-Wallis test with Mann-Whitney post hoc were used to compare the I-NCIQ scores in CI users before and after the cochlear implantation and in control patients. I-NCIQ scores obtained in CI users were compared with the results of Italian version of disyllabic testing without lip-reading and without masking. Good internal consistency and good test-retest reliability were found. I-NCIQ scores obtained in the 51 CI users after implantation were consistently higher than those obtained before implantation and in the control group. Moreover, no differences were found in the results of I-NCIQ obtained in the group of 51 CI users before implantation and in the group of control patients on post hoc Mann-Whitney analysis. Positive correlations between I-NCIQ scores and the results of disyllabic testing without lip-reading and without masking were found. The I-NCIQ is a reliable, valid, self-administered questionnaire for the measurement of QOL in CI users; its application is recommended.

[The role of colloids in intensive care medicine. Evidence instead of emotions]

BACKGROUND

Besides albumin, which is gained from human donors, synthetic colloids have been playing a dominant role in treating patients in shock and are standard therapy in intensive care units (ICU). Since the publication of large randomized controlled trials indicating negative effects on renal function, their use has been questioned, especially for hydroxyethyl starch products. The preliminary assumption that these side effects are only existent in first or secondary generation starch fluids was proven incorrect. In fact, the use of hydroxyethyl starch products in critically ill patients is prohibited by the European Medicines Agency.

CURRENT DISCUSSION AND INDICATIONS

Several methodological limitations exist in each of these trials that limit the evidence value of these investigations, although they served as the basis for the negative judgment of the European Medicines Agency. In addition, a large randomized controlled trial on the efficacy of gelatin is lacking. The use of colloids in ICU patients is indicated in cases where crystalloid volume therapy is inadequate.

CONCLUSION

Especially during the first 6 h of sepsis, when aggressive volume therapy is decisive for patient outcome, colloids may be relevant to increase patient survival. The latest guideline on treatment with colloids has been published in the German S3 guideline "Intravascular volume therapy in adults."

Computed tomography angiography vs 3 T black-blood cardiovascular magnetic resonance for identification of symptomatic carotid plaques

BACKGROUND

The purpose of this prospective study was to perform a head-to-head comparison of the two methods most frequently used for evaluation of carotid plaque characteristics: Multi-detector Computed Tomography Angiography (MDCTA) and black-blood 3 T-cardiovascular magnetic resonance (bb-CMR) with respect to their ability to identify symptomatic carotid plaques.

METHODS

22 stroke unit patients with unilateral symptomatic carotid disease and >50% stenosis by duplex ultrasound underwent MDCTA and bb-CMR (TOF, pre- and post-contrast fsT1w-, and fsT2w- sequences) within 15 days of symptom onset. Both symptomatic and contralateral asymptomatic sides were evaluated. By bb-CMR, plaque morphology, composition and prevalence of complicated AHA type VI lesions (AHA-LT6) were evaluated. By MDCTA, plaque type (non-calcified, mixed, calcified), plaque density in HU and presence of ulceration and/or thrombus were evaluated. Sensitivity (SE), specificity (SP), positive and negative predictive value (PPV, NPV) were calculated using a 2-by-2-table.

RESULTS

To distinguish between symptomatic and asymptomatic plaques AHA-LT6 was the best CMR variable and presence / absence of plaque ulceration was the best CT variable, resulting in a SE, SP, PPV and NPV of 80%, 80%, 80% and 80% for AHA-LT6 as assessed by bb-CMR and 40%, 95%, 89% and 61% for plaque ulceration as assessed by MDCTA. The combined SE, SP, PPV and NPV of bb-CMR and MDCTA was 85%, 75%, 77% and 83%, respectively.

CONCLUSIONS

Bb-CMR is superior to MDCTA at identifying symptomatic carotid plaques, while MDCTA offers high specificity at the cost of low sensitivity. Results were only slightly improved over bb-CMR alone when combining both techniques.

Factors in rehospitalisation for severe pressure ulcer care in spinal cord injury/disorders

OBJECTIVE

Repeated hospital admissions (RHA) for ongoing pressure ulcer (PU) care remains a significant challenge in the clinical management of the spinal cord injury/disorders (SCI/D) population. The current study investigated the significance of risk factors for PU treatment and RHA.

METHOD

A retrospective chart review of veterans admitted to the Louis Stokes Cleveland Department of Veterans Affairs Medical Center (LSCDVAMC) Spinal Cord Injury (SCI) unit for Category III or IV PUs was carried out. A random sample of 105 individuals with SCI/D, evaluated by the Wound Care Team (WCT) from 2006 to 2009 was assessed. Multiple PU development risk factors were extracted from the electronic health record system using standardised data collection forms and entered into the Spinal Cord Injury Pressure Ulcer Database (SCIPUD). Potential associations with RHA were analysed.

RESULTS

Twenty variables were initially identified as potentially related to PU development. Descriptive statistics and statistically significant associations between risk factors and RHA were determined. Demographic factors showed no significant association with RHA. Duration of injury, power wheelchair use and sub-optimally managed spasticity (SMS) were significantly associated with higher RHA. Sub-optimally managed neurogenic bowel (SMNB) at admission was significantly associated with reduced RHA.

CONCLUSION

Factors previously found to be predictive of initial PU development may not, in fact, be predictive of RHA. Some protective trends were observed, such as polypharmacy and marital status, but these did not reach statistical significance in this preliminary study of admission characteristics, warranting further research.

DECLARATION OF INTEREST

There were no external sources of funding for this study. The authors have no conflicts of interests to declare.

Comparison of epicardial fat volume by computed tomography in black versus white patients with acute chest pain

Disparities in the risk of coronary artery disease (CAD) between races may be influenced by differences in the thoracic adipose tissue. We compared computed tomography (CT)-derived volumes of epicardial adipose tissue (EAT), mediastinal adipose tissue (MAT), and pericoronary fat thickness (PFT) and correlations with CAD between black and white patients. This institutional review board-approved Health Insurance Portability and Accountability Act-compliant study included 372 age- and gender-matched black versus white patients (186 black, 54 ± 11 years, 50% men; 186 white, 54 ± 11 years, 50% men) who underwent CT for chest pain evaluation. EAT, MAT, and PFT were measured. The amount of coronary calcium was quantified as calcium score. CAD was defined as ≥50% coronary artery narrowing. EAT and MAT volumes were significantly lower in black than white patients (59 [twenty-fifth to seventy-fifth percentile 39 to 84] vs 97 [67 to 132] cm(3) and 44 [27 to 77] vs 87 [52 to 157] cm(3), for both p <0.001). Mean PFT in black patients was slightly lower than white patients (17.2 ± 3.2 vs 18.1 ± 3.4 mm, p <0.01). The relation between race and extent of adipose tissue remained significant after adjustment for cardiovascular risk factors. Significant correlations were observed between EAT and MAT volumes and calcium score in black and white patients (r = 0.19 to 0.26, p <0.01). For both races, the level of thoracic fat measurements was higher in present versus absent coronary calcification. A greater amount of thoracic fat was found with obstructive CAD only in white patients. In conclusion, CT-derived measurements of thoracic fat differ between symptomatic black and white patients, suggesting a differential relation between thoracic adipose tissue and CAD pathophysiology by race.

Vomer aplasia in a patient carrying a de novo mutation of the TP63 gene (3q27)

The congenital vomer defect (CVD) is a rare and still partially unknown condition. Only few cases have been reported in the international literature and the large majority of them appeared to be isolated. We report a case of CVD detected in a 7-year-old girl affected by ectodermal dysplasia clefting syndrome caused by a mutation of the TP63 gene.

CTA for screening of complicated atherosclerotic carotid plaque--American Heart Association type VI lesions as defined by MRI

BACKGROUND AND PURPOSE

High-resolution carotid MR imaging can accurately identify complicated American Heart Association lesion type VI plaques, which are characterized by thrombus, hemorrhage, or a ruptured fibrous cap. The purpose of this study is to evaluate whether CTA can be used as screening tool to predict the presence or absence of American Heart Association lesion type VI plaques as defined by high-resolution MR imaging.

METHODS

Fifty-one patients with suspected ischemic stroke or TIA with carotid CTA and carotid MR imaging performed within 14 days of the event/admission from April 2008 to December 2010 were reviewed. Vessels with stents or occlusion were excluded (n = 2). Each carotid artery was assigned an American Heart Association lesion type classification by MR imaging. The maximum wall thickness, maximum soft plaque component thickness, maximum calcified component thickness, and its attenuation (if the soft plaque component thickness was >2 mm) were obtained from the CTA.

RESULTS

The maximum soft plaque component thickness proved the best discriminating factor to predict a complicated plaque by MR imaging, with a receiver operating characteristic area under the curve of 0.89. The optimal sensitivity and specificity for detection of complicated plaque by MR imaging was achieved with a soft plaque component thickness threshold of 4.4 mm (sensitivity, 0.65; specificity, 0.94; positive predictive value, 0.75; and negative predictive value, 0.9). No complicated plaque had a soft tissue plaque thickness <2.2 mm (negative predictive value, 1) and no simple (noncomplicated) plaque had a thickness >5.6 mm (positive predictive value, 1).

CONCLUSIONS

Maximum soft plaque component thickness as measured by carotid CTA is a reliable indicator of a complicated plaque, with a threshold of 2.2 mm representing little to no probability of a complicated American Heart Association lesion type VI plaque.