Neonatal hemodynamics of recipient twins after fetoscopic selective laser coagulation for twin-to-twin transfusion syndrome: An unicist classification

To characterize the neonatal hemodynamic profiles in recipients born after twin-to-twin transfusion syndrome (TTTS) treated with fetoscopic selective laser coagulation (FSLC). Retrospective analysis during the first month of life of recipient twins. Of the 480 newborns born during an 11-year period, 138 recipient twins with prenatal FSLC were classified into four groups: no hemodynamic impairment (NoHI, n = 102, 74%), isolated high blood pressure (HighBP, n = 18, 13%), right ventricular outflow tract obstruction (RVOTO, n = 10, 7%), and cardiac failure (CF, n = 8, 6%). The time (median (IQR)) between FSLC and birth was significantly shorter in the HighBP (36 days (23-54)) and CF (44 days (18-54)) groups than in the RVOTO (91 days (68-112)) and NoHi (82 days (62-104)) groups (p < 0.001).     Conclusion: Four distinct and well-characterized groups of recipients were identified based on their hemodynamics. High blood pressure and heart failure occurred in approximately 20% of the infants and were associated with a time between laser coagulation and birth of less than 2 months. What is Known: • Twin-to-twin transfusion syndrome (TTTS) is characterized by a hemodynamic imbalance that leads to high fetal and neonatal mortality if left untreated. One-third of recipient twins born without prenatal fetoscopic laser coagulation (FSLC) develop a life-threatening cardiac failure. What is New: • Four distinct groups of recipient twins with prenatal FSLC have been identified based on their hemodynamics. High blood pressure and cardiac failure occurred in 20% of the infants and were associated with an interval between FSLC and birth of less than 2 months.

Low rCBV values in glioblastoma tumor progression under chemoradiotherapy

PURPOSE

After standard treatment for glioblastoma, perfusion MRI remains challenging for differentiating tumor progression from post-treatment changes. Our objectives were (1) to correlate rCBV values at diagnosis and at first tumor progression and (2) to analyze the relationship of rCBV values at tumor recurrence with enhancing volume, localization of tumor progression, and time elapsed since the end of radiotherapy in tumor recurrence.

METHODS

Inclusion criteria were (1) age > 18 years, (2) histologically confirmed glioblastoma treated with STUPP regimen, and (3) tumor progression according to RANO criteria > 12 weeks after radiotherapy. Co-registration of segmented enhancing tumor VOIs with dynamic susceptibility contrast perfusion MRI was performed using Olea Sphere software. For tumor recurrence, we correlated rCBV values with enhancing tumor volume, with recurrence localization, and with time elapsed from the end of radiotherapy to progression. Analyses were performed with SPSS software.

RESULTS

Sixty-four patients with glioblastoma were included in the study. Changes in rCBV values between diagnosis and first tumor progression were significant (p < 0.001), with a mean and median decreases of 32% and 46%, respectively. Mean rCBV values were also different (p < 0.01) when tumors progressed distally (radiation field rCBV values of 1.679 versus 3.409 distally). However, changes and, therefore, low rCBV values after radiotherapy in tumor recurrence were independent of time.

CONCLUSION

Chemoradiation alters tumor perfusion and rCBV values may be decreased in the setting of tumor progression. Changes in rCBV values with respect to diagnosis, with low rCBV in tumor progression, are independent of time but related to the site of recurrence.

Cerebral amyloid angiopathy-related inflammation: clinical features and treatment response in a case series

INTRODUCTION

Cerebral amyloid angiopathy-related inflammation (CAA-ri) is an entity characterised by an inflammatory response to β-amyloid deposition in the walls of cerebral microvessels.

METHODS

We conducted a retrospective review of a series of patients with a diagnosis of CAA-ri according to histopathological study findings or clinical-radiological diagnostic criteria.

RESULTS

The study included 7 patients (5 men) with a mean age of 79 years. Disease onset was acute or subacute in 6 patients. The most frequent symptoms were cognitive impairment (n = 6), behavioural alterations (n = 5), epileptic seizures (n = 5), focal neurological signs (n = 4), and headache (n = 2). Cerebrospinal fluid was abnormal in 3 patients (lymphocytic pleocytosis and high protein levels). The most frequent MRI findings were microbleeds (n = 7), subcortical white matter hyperintensities on T2-FLAIR sequences (n = 7), and leptomeningeal enhancement (n = 6). Lesions were bilateral in 3 patients and most frequently involved the parieto-occipital region (n = 5). Amyloid PET studies were performed in 2 patients, one of whom showed pathological findings. Two patients underwent brain biopsy, which confirmed diagnosis. All patients received immunosuppressive therapy. An initially favourable clinical-radiological response was observed in all cases, with 2 patients presenting radiological recurrence after treatment withdrawal, with a subsequent improvement after treatment was resumed.

CONCLUSIONS

Early diagnosis of CAA-ri is essential: early treatment has been shown to improve prognosis and reduce the risk of recurrence. Although a histopathological study is needed to confirm diagnosis, clinical-radiological criteria enable diagnosis without biopsy.

Neonatal Hemodynamic Characteristics of the Recipient Twin of Twin-To-Twin Transfusion Syndrome Not Treated with Fetoscopic Laser Surgery

Background: This paper’s intent is to describe the neonatal hemodynamic characteristics of recipient twins of monochorionic pregnancies complicated with twin-to-twin transfusion syndrome (TTTS), born without prenatal fetoscopic selective laser coagulation (FSLC). Methods: Retrospective analysis of hemodynamic characteristics was performed during the first five days of life of recipient twins from untreated TTTS. Results: Forty-two recipient twins were included and divided into three groups: no hemodynamic impairment (NoHI) (n = 15, 36%), isolated high blood pressure (HighBP) (n = 12, 28%), and cardiac failure group (CF) (n = 15, 36%). Patients of both CF and HighBP groups had high systolic blood pressure during the first 12 h of life and ventricular hypertrophy at early echocardiography. Cardiac failure occurred at a median age of 14 h (IQR = 6−24) and was followed by a drop in systolic and diastolic blood pressure. Acute kidney injury was more frequent (93% vs. 25%, p < 0.001) and severe (p <0.001) in the CF group than in the HighBP group. The mortality rate in the CF group was 40%. Factors associated with CF were twin anemia-polycythemia sequence (p = 0.012), very preterm birth (p = 0.040), and polycythemia (p = 0.002). Conclusion: One-third of recipient twins born without prenatal FSLC developed life-threatening cardiac failure during the first 24 h of life.

Prevalence and factors associated with food insecurity in southern Mozambique

Background

Food insecurity (FI) is one of the major causes of malnutrition in low- and middle-income countries. In Mozambique, the burden of FI and how it’s related to negative health outcomes is unknown. This study aimed to investigate the prevalence of FI as well as the factors associated with FI in southern Mozambique.

Methods

Preliminary data from 301 household heads residing in suburb and peri-urban districts of Maputo were analysed in a cross-sectional design. Accordingly, FI was assessed using the 8-items of the United States Department of Agriculture Household Food Security Survey Module, and its association with various factors was determined through multiple regression models.

Results

The prevalence of FI was 62.8% (23.6% of households had mild FI, 16.6% had moderate FI, 22.6% had severe FI). Based on multiple regression models, 10 variables (out of 11) were relevant drivers of FI and reached statistical significance (p-value&lt;0.05) with focus on food diversity, climate change, illnesses, household income, number of meals, type of work, household size.

Conclusions

These preliminary findings suggest the need for decent work and job creation. In addition, food diversity, climate change and some relevant diseases should be taken into account in the development of public health policies designed to alleviate household food insecurity in Mozambique.

Key messages

• Food insecurity in Mozambique calls for joint efforts from government, private sector, international institutions and communities.

• The basic food basket for the most vulnerable groups is encouraged as a short-term solution.

P10.01.A Reversible blood-brain barrier (BBB) disruption by Tumor Treating Fields (TTFields) in a human 3Din vitro model

Background

Drug delivery to the central nervous system (CNS) is often impeded by the restrictive nature of the blood brain barrier (BBB). Since many therapeutic molecules are not able to traverse this barrier, the development of new methods to disrupt the BBB is of paramount importance. Tumor Treating Fields (TTFields) are alternating electric fields of low intensity (1-3 V/cm) and intermediate frequency (100-300 kHz), which are approved and effective for the treatment of glioblastoma at a frequency of 200 kHz. We recently demonstrated that TTFields at lower frequencies are able to transiently induce BBB permeability in in vitro and in vivo murine models. Here, we explored whether the transient opening of the BBB by TTFields in our murine systems also translates to a human cell-based 3D model.

Material and Methods

A three-dimensional BBB model was established by co-culturing primary human brain microvascular endothelial cells (HBMVEC) on a transwell insert together with human pericytes on the bottom of a well-plate. The model was treated with TTFields at 100-300 kHz for 2496 h using the inovitro™ TTFields Lab Bench System (Novocure®). Afterwards, the cells recovered for 24-96 h. In order to analyze the effects of TTFields on barrier integrity and compromise, transendothelial electrical resistance (TEER) of the HBMVEC monolayer was measured before the start of TTFields treatment, immediately after TTFields cessation, as well as 24-96 h after TTFields treatment. Permeability of the barrier was assessed by visualizing the movement of FITC-dextran through the HBMVEC monolayer. In addition, changes in expression and localization of the tight junction protein (TJP) claudin-5 (Cl-5) after application of TTFields were analyzed by fractionated Western-blotting and immunofluorescence (IF) staining, respectively.

Results

Application of TTFields at all investigated frequencies significantly decreased TEER across the HBMVEC monolayer after as early as 24 h, with the strongest effects seen after 72 h at a TTFields frequency of 100 kHz. TTFields treatment delocalized TJP Cl5 from the cell boundaries to the cytoplasm as evidenced by Western-blots and IF stainings. Restoration of the cell barrier was already measurable as early as 24 h after TTFields cessation and a complete recovery was evident after 48 h.

Conclusion

These results in a human 3D in vitro model confirm our previous observations from mouse models that TTFields could transiently open the BBB. These fundamental pre-clinical data demonstrate the feasibility of facilitating drug delivery to the CNS via concomitant application of TTFields. This method opens up the prospect of improved drug-based treatment of devastating CNS diseases such as GBM if these results could be translated to the clinical setting in the future.

What are the clues for an inherited metabolic disorder in Reye syndrome? A single Centre study of 58 children

OBJECTIVES

Reye Syndrome is an acute encephalopathy with increased liver enzymes and blood ammonia, without jaundice. The prevalence of an underlying inherited metabolic disorder (IMD) is unclear, nor the clinical or biological factors directing toward this diagnosis. Our aims were to define these clues in a large series of patients.

PATIENTS AND METHODS

We retrospectively studied all patients with Reye admitted in our institution from 1995. We defined 3 groups: Group 1 with a confirmed IMD, Group 2 considered as free of IMD, Group 3 unclassified. Statistical analysis compared patients in Groups 1 and 2, to find criteria for a diagnosis of IMD.

RESULTS

Fifty-eight children were included; 41 (71%) had a confirmed IMD, 12 (20%) were free of IMD, and 5 remained unclassified. IMDs included Urea Cycle Disorders (51%), Fatty-Acid Oxidation Disorders (24%), ketogenesis defects (5%), other mitochondrial energy metabolism defects (10%), NBAS mutation (7%), Glycosylation Disorders (2%). In Group 2, the trigger was a viral infection, or a drug, deferasirox in three children. Univariate analysis showed that onset before 2 years-old, recurrent Reye and the association with rhabdomyolysis were significantly associated with IMD. Blood ammonia was a poor discriminating marker. All children were admitted into the intensive care unit, 23% needed continuous venovenous hemodialysis and one died from brain oedema.

CONCLUSION

Metabolic tests should be performed early in all cases of Reye, regardless of triggers. As they can be inconclusive, we suggest to systematically go to Next-Generation Sequencing study. These children should be transferred early to a specialized unit.

Reports from the 1st Young Investigator’s Day of the French Intensive Care Society

The Translational Research Committee of the French Intensive Care Society organized the first Young Investigator’s Day on October 18th 2019.  This seminar gave young Intensive Care students the opportunity to present their Master’s or PhD research work to a college of expert researchers.  For this first event, Professors Jean-Marc Cavaillon (Paris), Laurent Papazian (Marseille), Peter Radermacher (Ulm) et Hafid Ait-Oufella (Paris) kindly accepted to give young candidates their critical support.  The subjects of presentations, covering the fields of neuroscience, immunology, hemodynamics and pharmacology illustrated the richness and diversity of translational research in Intensive Care Medicine.

Cerebral amyloid angiopathy-related inflammation: clinical features and treatment response in a case series

INTRODUCTION

Cerebral amyloid angiopathy-related inflammation (CAA-ri) is an entity characterised by an inflammatory response to β-amyloid deposition in the walls of cerebral microvessels.

METHODS

We conducted a retrospective review of a series of patients with a diagnosis of CAA-ri according to histopathological study findings or clinical-radiological diagnostic criteria.

RESULTS

The study included 7 patients (5 men) with a mean age of 79 years. Disease onset was acute or subacute in 6 patients. The most frequent symptoms were cognitive impairment (n = 6), behavioural alterations (n = 5), epileptic seizures (n = 5), focal neurological signs (n = 4), and headache (n = 2). Cerebrospinal fluid was abnormal in 3 patients (lymphocytic pleocytosis and high protein levels). The most frequent MRI findings were microbleeds (n = 7), subcortical white matter hyperintensities on T2-FLAIR sequences (n = 7), and leptomeningeal enhancement (n = 6). Lesions were bilateral in 3 patients and most frequently involved the parieto-occipital region (n = 5). Amyloid PET studies were performed in 2 patients, one of whom showed pathological findings. Two patients underwent brain biopsy, which confirmed diagnosis. All patients received immunosuppressive therapy. An initially favourable clinical-radiological response was observed in all cases, with 2 patients presenting radiological recurrence after treatment withdrawal, with a subsequent improvement after treatment was resumed.

CONCLUSIONS

Early diagnosis of CAA-ri is essential: early treatment has been shown to improve prognosis and reduce the risk of recurrence. Although a histopathological study is needed to confirm diagnosis, clinical-radiological criteria enable diagnosis without biopsy.

Brain and Lung Imaging Correlation in Patients with COVID-19: Could the Severity of Lung Disease Reflect the Prevalence of Acute Abnormalities on Neuroimaging? A Global Multicenter Observational Study

PURPOSE

Our aim was to study the association between abnormal findings on chest and brain imaging in patients with coronavirus disease 2019 (COVID-19) and neurologic symptoms.

MATERIALS AND METHODS

In this retrospective, international multicenter study, we reviewed the electronic medical records and imaging of hospitalized patients with COVID-19 from March 3, 2020, to June 25, 2020. Our inclusion criteria were patients diagnosed with Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) infection with acute neurologic manifestations and available chest CT and brain imaging. The 5 lobes of the lungs were individually scored on a scale of 0-5 (0 corresponded to no involvement and 5 corresponded to >75% involvement). A CT lung severity score was determined as the sum of lung involvement, ranging from 0 (no involvement) to 25 (maximum involvement).

RESULTS

A total of 135 patients met the inclusion criteria with 132 brain CT, 36 brain MR imaging, 7 MRA of the head and neck, and 135 chest CT studies. Compared with 86 (64%) patients without acute abnormal findings on neuroimaging, 49 (36%) patients with these findings had a significantly higher mean CT lung severity score (9.9 versus 5.8, P < .001). These patients were more likely to present with ischemic stroke (40 [82%] versus 11 [13%], P < .0001) and were more likely to have either ground-glass opacities or consolidation (46 [94%] versus 73 [84%], P = .01) in the lungs. A threshold of the CT lung severity score of >8 was found to be 74% sensitive and 65% specific for acute abnormal findings on neuroimaging. The neuroimaging hallmarks of these patients were acute ischemic infarct (28%), intracranial hemorrhage (10%) including microhemorrhages (19%), and leukoencephalopathy with and/or without restricted diffusion (11%). The predominant CT chest findings were peripheral ground-glass opacities with or without consolidation.

CONCLUSIONS

The CT lung disease severity score may be predictive of acute abnormalities on neuroimaging in patients with COVID-19 with neurologic manifestations. This can be used as a predictive tool in patient management to improve clinical outcome.

Severe and fatal forms of COVID-19 in children

Objectives

The aim of this study was to describe severe forms of novel coronavirus disease 2019 in children, including patient characteristics, clinical, laboratory, and imaging findings, as well as the disease management and outcomes.

Methods

This was a retrospective, single-center, observational study conducted in a pediatric intensive and high-dependency care unit (PICU, HDU) in an urban hospital in Paris. All patients, aged from 1 month to 18 years, admitted for confirmed or highly suspected SARS-CoV-2 were included.

Results

We analyzed the data of 27 children. Comorbidities (n = 19, 70%) were mainly neurological (n = 7), respiratory, (n = 4), or sickle cell disease (n = 4). SARS-CoV-2 PCR results were positive in 24 children (nasopharyngeal swabs). The three remaining children had a chest CT scan consistent with COVID-19. Respiratory involvement was observed in 24 patients (89%). Supportive treatments were invasive mechanical ventilation (n = 9), catecholamine (n = 4), erythropheresis (n = 4), renal replacement therapy (n = 1), and extracorporeal membrane oxygenation (n = 1). Five children died, of whom three were without past medical history.

Conclusion

This study highlighted the large spectrum of clinical presentation and time course of disease progression as well as the non-negligible occurrence of pediatric life-threatening and fatal cases of COVID-19 mostly in patients with comorbidities. Additional laboratory investigations are needed to further analyze the mechanism underlying the variability of SARS-Cov-2 pathogenicity in children.

Kawasaki-like multisystem inflammatory syndrome in children during the covid-19 pandemic in Paris, France: prospective observational study

OBJECTIVES

To describe the characteristics of children and adolescents affected by an outbreak of Kawasaki-like multisystem inflammatory syndrome and to evaluate a potential temporal association with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

DESIGN

Prospective observational study.

SETTING

General paediatric department of a university hospital in Paris, France.

PARTICIPANTS

21 children and adolescents (aged ≤18 years) with features of Kawasaki disease who were admitted to hospital between 27 April and 11 May 2020 and followed up until discharge by 15 May 2020.

MAIN OUTCOME MEASURES

The primary outcomes were clinical and biological data, imaging and echocardiographic findings, treatment, and outcomes. Nasopharyngeal swabs were prospectively tested for SARS-CoV-2 using reverse transcription-polymerase chain reaction (RT-PCR) and blood samples were tested for IgG antibodies to the virus.

RESULTS

21 children and adolescents (median age 7.9 (range 3.7-16.6) years) were admitted with features of Kawasaki disease over a 15 day period, with 12 (57%) of African ancestry. 12 (57%) presented with Kawasaki disease shock syndrome and 16 (76%) with myocarditis. 17 (81%) required intensive care support. All 21 patients had noticeable gastrointestinal symptoms during the early stage of illness and high levels of inflammatory markers. 19 (90%) had evidence of recent SARS-CoV-2 infection (positive RT-PCR result in 8/21, positive IgG antibody detection in 19/21). All 21 patients received intravenous immunoglobulin and 10 (48%) also received corticosteroids. The clinical outcome was favourable in all patients. Moderate coronary artery dilations were detected in 5 (24%) of the patients during hospital stay. By 15 May 2020, after 8 (5-17) days of hospital stay, all patients were discharged home.

CONCLUSIONS

The ongoing outbreak of Kawasaki-like multisystem inflammatory syndrome among children and adolescents in the Paris area might be related to SARS-CoV-2. In this study an unusually high proportion of the affected children and adolescents had gastrointestinal symptoms, Kawasaki disease shock syndrome, and were of African ancestry.

Kawasaki-like multisystem inflammatory syndrome in children during the covid-19 pandemic in Paris, France: prospective observational study

OBJECTIVES

To describe the characteristics of children and adolescents affected by an outbreak of Kawasaki-like multisystem inflammatory syndrome and to evaluate a potential temporal association with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

DESIGN

Prospective observational study.

SETTING

General paediatric department of a university hospital in Paris, France.

PARTICIPANTS

21 children and adolescents (aged ≤18 years) with features of Kawasaki disease who were admitted to hospital between 27 April and 11 May 2020 and followed up until discharge by 15 May 2020.

MAIN OUTCOME MEASURES

The primary outcomes were clinical and biological data, imaging and echocardiographic findings, treatment, and outcomes. Nasopharyngeal swabs were prospectively tested for SARS-CoV-2 using reverse transcription-polymerase chain reaction (RT-PCR) and blood samples were tested for IgG antibodies to the virus.

RESULTS

21 children and adolescents (median age 7.9 (range 3.7-16.6) years) were admitted with features of Kawasaki disease over a 15 day period, with 12 (57%) of African ancestry. 12 (57%) presented with Kawasaki disease shock syndrome and 16 (76%) with myocarditis. 17 (81%) required intensive care support. All 21 patients had noticeable gastrointestinal symptoms during the early stage of illness and high levels of inflammatory markers. 19 (90%) had evidence of recent SARS-CoV-2 infection (positive RT-PCR result in 8/21, positive IgG antibody detection in 19/21). All 21 patients received intravenous immunoglobulin and 10 (48%) also received corticosteroids. The clinical outcome was favourable in all patients. Moderate coronary artery dilations were detected in 5 (24%) of the patients during hospital stay. By 15 May 2020, after 8 (5-17) days of hospital stay, all patients were discharged home.

CONCLUSIONS

The ongoing outbreak of Kawasaki-like multisystem inflammatory syndrome among children and adolescents in the Paris area might be related to SARS-CoV-2. In this study an unusually high proportion of the affected children and adolescents had gastrointestinal symptoms, Kawasaki disease shock syndrome, and were of African ancestry.

Population pharmacokinetics of cefazolin in critically ill children infected with methicillin-sensitive Staphylococcus aureus

OBJECTIVES

Cefazolin is one of curative treatments for infections due to methicillin-sensitive Staphylococcus aureus (MSSA). Both growth and critical illness may impact the pharmacokinetic (PK) parameters. We aimed to build a population PK model for cefazolin in critically ill children in order to optimize individual dosing regimens.

METHODS

We included all children (age < 18 years, body weight (BW) > 2.5 kg) receiving cefazolin for MSSA infection. Cefazolin total plasma concentrations were quantified by high-performance liquid chromatography. A data modelling process was performed with the software MONOLIX. Monte Carlo simulations were used in order to attain the PK target of 100% fT _> 4 ×MIC.

RESULTS

Thirty-nine patients with a median (range) age of 7 (0.1-17) years and a BW of 21 (2.8-79) kg were included. The PK was ascribed to a one-compartment model, where typical clearance and volume of distribution estimations were 1.4 L/h and 3.3 L respectively. BW, according to the allometric rules, and estimated glomerular filtration rate (eGFR) on clearance were the two influential covariates. Continuous infusion with a dosing of 100 mg/kg/day to increase to 150 mg/kg/day for children with a BW < 10 kg or eGFR >200 mL/min/1.73m² were the best schemes to reach the PK target of 100% fT_> 4 ×MIC.

CONCLUSIONS

In critically ill children infected with MSSA, continuous infusion seems to be the most appropriate scheme to reach the PK target of 100 % fT _> 4 ×MIC in children with normal and augmented renal function.

P11.28 Alteration of blood brain barrier (BBB) permeability by Tumor Treating Fields (TTFields) in vivo

BACKGROUND

Alternating electric fields with intermediate frequency (100 - 300 kHz) and low intensity (1 - 3 V/cm), known as Tumor Treating Fields (TTFields), have been established as a novel adjuvant therapy for glioblastoma (GBM) patients. The blood brain barrier (BBB) tightly controls the influx of the majority of compounds from blood to brain. Due to this regulation, the BBB may block delivery of drugs for treatment of brain tumors, in particular GBM. In this study, we investigated the influence of TTFields on BBB permeability in vivo.

MATERIAL AND METHODS

For determination of BBB permeability, rats were treated with 100 kHz TTFields for 72 h. At the end of treatment, rats were i.v. injected with Evan′s Blue (EB), which binds Albumin (~70 kDa) upon injection to the blood. EB was extracted after brain homogenization and quantified at 610 nm. In addition, cryosections of rat brains were prepared following TTFields application at 100 kHz for 72 h, and sections were stained for Claudin 5, Occludin and immunoglobulin G (IgG) to assess vessel structure. Moreover, serial dynamic contrast-enhanced DCE-MRI with Gadolinium contrast agent (Gd) was performed before and after TTFields application.

RESULTS

In vivo, the EB accumulation in the brain was significantly increased by application of TTFields to the rat head. Claudin 5 and Occludin staining was visible in vessel endothelial cells and localized at the cells’ edges in control cryosections of rat brains. In TTFields-treated rats, the vessel structure became diffuse; Claudin 5 and Occludin were delocalized and IgG was found throughout the brain tissue and not solely inside the vessels, as it is normally the case. Serial DCE-MRI demonstrated significantly increased accumulation of Gd in the brain, detected directly after 72 h of TTFields application. 96 h after end of TTFields treatment the effect on the BBB disappeared and no difference in contrast enhancement between controls and TTFields treated animals was observable.

CONCLUSION

Application of TTFields at 100 kHz could have the potential to deliver drugs to the brain, which normally are unable to cross the BBB by altering BBB integrity and permeability. Utilizing TTFields to open the BBB and its subsequent recovery, as demonstrated by the data presented herein, could lead to a clinical approach of drug delivery for treatment of malignant brain tumors and other diseases of the central nervous system. These results will be further validated in clinical trials.

Leakage decrease detected by dynamic susceptibility-weighted contrast-enhanced perfusion MRI predicts survival in recurrent glioblastoma treated with bevacizumab

BACKGROUND AND PURPOSE

In glioblastoma, tumor progression appears to be triggered by expression of VEGF, a regulator of blood vessel permeability. Bevacizumab is a monoclonal antibody that inhibits angiogenesis by clearing circulating VEGF, resulting in a decline in the contrast-enhancing tumor, which does not always correlate with treatment response. Our objectives were: (1) to evaluate whether changes in DSC perfusion MRI-derived leakage could predict survival in recurrent glioblastoma, and (2) to estimate whether leakage at baseline was related to treatment outcome.

MATERIALS AND METHODS

We retrospectively analyzed DSC perfusion MRI in 24 recurrent glioblastomas treated with bevacizumab as second line chemotherapy. Leakage at baseline and changes in maximum leakage between baseline and the first follow-up after treatment were selected for quantitative analysis. Survival univariate analysis was made constructing survival curves using Kaplan-Meier method and comparing subgroups by log rank probability test.

RESULTS

Leakage reduction at 8 weeks after initiation of bevacizumab treatment had a significant influence on overall survival (OS) and progression-free survival (PFS). Median OS and PFS were 2.4 and 2.8 months longer for patients with leakage reduction at the first follow-up. Higher leakage at baseline was associated with leakage reduction after treatment. Odds ratio of treatment response was 9 for patients with maximum leakage at baseline >5.

CONCLUSIONS

Leakage decrease may predict OS and PFS in recurrent glioblastomas treated with bevacizumab. Leakage reduction postulates as a potential biomarker for treatment response evaluation. Leakage at baseline seems to predict response to treatment, but was not independently associated with survival.

A prognostic model based on preoperative MRI predicts overall survival in patients with diffuse gliomas

BACKGROUND AND PURPOSE

Diffuse gliomas are classified as grades II-IV on the basis of histologic features, with prognosis determined mainly by clinical factors and histologic grade supported by molecular markers. Our aim was to evaluate, in patients with diffuse gliomas, the relationship of relative CBV and ADC values to overall survival. In addition, we also propose a prognostic model based on preoperative MR imaging findings that predicts survival independent of histopathology.

MATERIALS AND METHODS

We conducted a retrospective analysis of the preoperative diffusion and perfusion MR imaging in 126 histologically confirmed diffuse gliomas. Median relative CBV and ADC values were selected for quantitative analysis. Survival univariate analysis was made by constructing survival curves by using the Kaplan-Meier method and comparing subgroups by log-rank probability tests. A Cox regression model was made for multivariate analysis.

RESULTS

The study included 126 diffuse gliomas (median follow-up of 14.5 months). ADC and relative CBV values had a significant influence on overall survival. Median overall survival for patients with ADC < 0.799 × 10(-3) mm(2)/s was <1 year. Multivariate analysis revealed that patient age, relative CBV, and ADC values were associated with survival independent of pathology. The preoperative model provides greater ability to predict survival than that obtained by histologic grade alone.

CONCLUSIONS

ADC values had a better correlation with overall survival than relative CBV values. A preoperative prognostic model based on patient age, relative CBV, and ADC values predicted overall survival of patients with diffuse gliomas independent of pathology. This preoperative model provides a more accurate predictor of survival than histologic grade alone.

Severe traumatic head injury: prognostic value of brain stem injuries detected at MRI

BACKGROUND AND PURPOSE

Traumatic brain injuries represent an important cause of death for young people. The main objectives of this work are to correlate brain stem injuries detected at MR imaging with outcome at 6 months in patients with severe TBI, and to determine which MR imaging findings could be related to a worse prognosis.

MATERIALS AND METHODS

One hundred and eight patients with severe TBI were studied by MR imaging in the first 30 days after trauma. Brain stem injury was categorized as anterior or posterior, hemorrhagic or nonhemorrhagic, and unilateral or bilateral. Outcome measures were GOSE and Barthel Index 6 months postinjury. The relationship between MR imaging findings of brain stem injuries, outcome, and disability was explored by univariate analysis. Prognostic capability of MR imaging findings was also explored by calculation of sensitivity, specificity, and area under the ROC curve for poor and good outcome.

RESULTS

Brain stem lesions were detected in 51 patients, of whom 66% showed a poor outcome, as expressed by the GOSE scale. Bilateral involvement was strongly associated with poor outcome (P < .05). Posterior location showed the best discriminatory capability in terms of outcome (OR 6.8, P < .05) and disability (OR 4.8, P < .01). The addition of nonhemorrhagic and anterior lesions or unilateral injuries showed the highest odds and best discriminatory capacity for good outcome.

CONCLUSIONS

The prognosis worsens in direct relationship to the extent of traumatic injury. Posterior and bilateral brain stem injuries detected at MR imaging are poor prognostic signs. Nonhemorrhagic injuries showed the highest positive predictive value for good outcome.

The added value of apparent diffusion coefficient to cerebral blood volume in the preoperative grading of diffuse gliomas

BACKGROUND AND PURPOSE

In cerebral gliomas, rCBV correlates with tumor grade and histologic findings of vascular proliferation. Moreover, ADC assesses water diffusivity and is inversely correlated with tumor grade. In the present work, we have studied whether combined rCBV and ADC values improve the diagnostic accuracy of MR imaging in the preoperative grading of gliomas.

MATERIALS AND METHODS

One hundred sixty-two patients with histopathologically confirmed diffuse gliomas underwent DWI and DSC. Mean rCBV and ADC values were compared among the tumor groups with the Student t test or ANOVA. ROC analysis was used to determine rCBV and ADC threshold values for glioma grading.

RESULTS

rCBV had significantly different values between grade II and IV gliomas and between grade III and IV tumors, but there were no significant differences between grade II and III gliomas (P > .05). Grade II and III tumors also did not differ when astrocytomas, oligodendrogliomas, and oligoastrocytomas were considered separately. ADC values were significantly different for all 3 grades. The ADC threshold value of 1.185 × 10(-3) mm(2)/s and the rCBV cutoff value of 1.74 could be used with high sensitivity in the characterization of high-grade gliomas. The area under the ROC curve for the maximum rCBV and minimum ADC was 0.72 and 0.75, respectively. The combination of rCBV and ADC values increased the area under the ROC curve to 0.83.

CONCLUSIONS

ADC measurements are better than rCBV values for distinguishing the grades of gliomas. The combination of minimum ADC and maximum rCBV improves the diagnostic accuracy of glioma grading.

[Standardization of the quantification of iron concentration in the liver by magnetic resonance imaging]

OBJECTIVE

To calibrate 1.5 tesla magnetic resonance scanners for the quantification of the concentration of iron in the liver.

MATERIAL AND METHODS

We analyzed twenty-eight 1.5 tesla magnetic resonance scanners using a phantom with four tubes containing different concentrations of iron (III) chloride and one tube without iron. The phantom represented two typical patients: one with moderate iron overload and one with high iron overload. We measured the signal intensity ratio between each iron-containing tube and the tube without iron; then we calculated the theoretical levels of iron concentration in each scanner according to the model for the two levels of overload. We compared the results of each scanner with those of the reference scanner in which the model and the phantom had been designed, and we calculated the percentage of difference between the two scanners.

RESULTS

The mean difference in the ratios compared to the reference center was 11% (0.3-39). The mean concentration of iron was 71 μmol Fe/g for moderate overload and 193 μmol Fe/g for high overload. The mean difference was 6% (1.2- 7%) and 3.4% (0-16%). respectively. In two scanners, we applied a correction factor so that the difference was below 25% in all cases.

CONCLUSION

We calibrated twenty-eight 1.5 tesla scanners for the concentration of iron in the liver and achieved variability less than 25%.

[Gender differences in the treatment of the opiate dependence with naltrexone]

INTRODUCTION

We want to know the influence of gender factor in the consumption characteristics, social support and evolution in treatment with naltrexone in an opiate addict group.

MATERIAL AND METHODS

1,432 patients (83.1% males and 16.9% females) recruited over a 12 year period who successively initiated treatment period years with naltrexone. Retrospective observance study, with design of treatment group without control group. We evaluated the role of gender in retention with the Mantel-Cox test. The differences were analyzed according to the gender with contingency tables.

RESULTS

One year retention for all of them was 29.75%, this being 30.92% for men and 23.97% for women. This difference is significant at one year according to the Mantel-Cox test (statistics: 8.38%; gl: 1; signification: 0.0038). Women show less frequency of cocaine use (p=0 . 0 1 1 ) and less use of intravenous cocaine (p=0.048), lower frequency of consumption of alcohol (p=0.000) and cannabis (p=0.002), a shorter period of heroine abuse (p =0.016) and a higher proportion of them only use heroine (p= 0.015). They have less economic independence (p = 0.001), their partner is more frequently an addict (p=0.000), they have less help for the treatment from a non-consuming partner (p=0.000).

CONCLUSIONS

There are outstanding differences with regard to consume characteristics, social support and evolution of the treatment according to the gender (either male or female). Men have better prognosis than women in the population studied. These differences seem to be due to the sociocultural contents of the gender concept.

Unsuspected strongyloidiasis in hospitalised elderly patients with and without eosinophilia

The prevalence and associated factors of chronic uncomplicated strongyloidiasis were estimated among 200 consecutive elderly patients (aged >or= 60 years) admitted to a general hospital in northern Italy. One-hundred patients had a peripheral eosinophil concentration >or= 500 cells/microL (group A), and 100 were age- and gender-matched controls (group B). Measurements included serum IgG anti-Strongyloides antibody titre by an indirect immunofluorescence assay, combined with faecal culture for Strongyloides stercoralis. Anti-Strongyloides antibodies were detected in 28 patients (at high titre in 11 patients). Seropositivity was significantly more common among group A than among group B patients (OR 4.85). Strong seropositivity for anti-Strongyloides antibodies was associated with farm work (p < 0.001), but not with other patient characteristics or with signs and symptoms of strongyloidiasis. In conclusion, strongyloidiasis was relatively common among elderly in-patients; eosinophilia and a history of farm work were the most useful indications for this diagnosis.

Elementos no frecuentes en cálculos renales

A group of 54 renal calculi were spontaneously passed renal stone after a nephritic colic. Two groups of calculi were found: papillary and non-papillary calculi. All calculi were analyzed by infrared spectroscopy and electronic microscopy scan (EMS) and EDAX. When the stones were analyzed with EDAX, elements such as C, N, O, Na, S, Mg, Al, Si, Cl, K, Ca, Mn, Fe, Ni, Zn were detected. The possible origin of these elements is discussed in this work.

Post-operative lumbar spine: comparative study of TSE T2 and turbo-FLAIR sequences vs contrast-enhanced SE T1

AIM

To compare turbo T2 weighted spin echo (TSE T2) and turbo-FLAIR (fluid attenuated inversion recovery) vs gadolinium enhanced T1 weighted spin echo (SE T1) sequence in the differential diagnosis between disc herniation and post-surgical fibrosis.

MATERIALS AND METHODS

Sixty-four patients who underwent surgical treatment for lumbar disc herniation with persistent or recurrent post-surgical symptoms were studied with a 0.5 Tesla MR system. The sequences used were TSE T2, turbo-FLAIR and T1 SE with and without intravenous gadolinium DTPA. The enhanced T1 SE sequence was considered the gold standard. Sensitivity and specificity were calculated.

RESULTS

The sensitivity was 100% for both TSE T2 and turbo-FLAIR sequences. The specificity was 94% for TSE T2 and 92% for turbo-FLAIR. Negative predictive value was 100% for both sequences and positive predictive value 84% and 80% for TSE T2 and turbo-FLAIR, respectively.

CONCLUSION

Although both sequences show high sensitivity, TSE-T2 presents greater specificity than turbo-FLAIR as compared to enhanced T1 SE. TSE T2 also offers the advantage of myelographic effect. We consider that the use of rapid sequences may avoid the need for intravenous contrast medium in most cases, reserving gadolinium DTPA only to those where all the criteria for hernia or fibrosis are not fulfilled.

Lateral stabilizing structures of the knee: functional anatomy and injuries assessed with MR imaging

The lateral aspect of the knee is stabilized by a complex arrangement of ligaments, tendons, and muscles. These structures can be demonstrated with routine spin-echo magnetic resonance (MR) imaging sequences performed in the sagittal, coronal, and axial planes. Anterolateral stabilization is provided by the capsule and iliotibial tract. Posterolateral stabilization is provided by the arcuate ligament complex, which comprises the lateral collateral ligament; biceps femoris tendon; popliteus muscle and tendon; popliteal meniscal and popliteal fibular ligaments; oblique popliteal, arcuate, and fabellofibular ligaments; and lateral gastrocnemius muscle. Injuries to lateral knee structures are less common than injuries to medial knee structures but may be more disabling. Most lateral compartment injuries are associated with damage to the cruciate ligaments and medial knee structures. Moreover, such injuries are frequently overlooked at clinical examination. Structures of the anterolateral quadrant are the most frequently injured; posterolateral instability is considerably less common. Practically all tears of the lateral collateral ligament are associated with damage to posterolateral knee structures. Most injuries of the popliteus muscle and tendon are associated with damage to other knee structures. MR imaging can demonstrate these injuries. Familiarity with the musculotendinous anatomy of the knee will facilitate accurate diagnosis with MR imaging.

[Silica, aluminum, iron, sulfur, and barium in a urinary calculus]

Presentation of the analytical results by Sweep Microscopy of a small papillary calculus spontaneously eliminated after a nephritic colic. The main component is monohydrate calcium oxalate. When the stone core was analyzed with EDAX, silica, aluminium, iron, sulphur and barium were detected. The origin of these elements is discussed and the presence of barium emphasized as exceptional.

Crush injury of the carpus

Severe crush injuries affecting the bones of the carpus are rare. We review the nine cases that have previously been described and report four additional cases which we have treated and followed up. All 13 present remarkable similarities, with disruption of the carpal arch through the capitate-hamate articulation distally and the piso-triquetral joint proximally. Three slightly different variations of this pattern of fracture-dislocation are identified. The flexor retinaculum must be involved to allow the displacement which is seen, and there is usually an extensive laceration of the thenar eminence. Treatment by closed reduction is usually successful. Long-term follow-up shows that, in the absence of nerve or vascular damage, the results are surprisingly good.