Feasibility and Reliability of Transcranial POCUS Color-Coded Duplex Sonography Performed by Physicians of Varied Ultrasound Experience in Diagnosing Vasospasm in Aneurysmal Subarachnoid Hemorrhage

PURPOSE

Aneurysmal subarachnoid hemorrhage (aSAH) is associated with high morbidity and mortality, which is largely attributable to secondary complications such as vasospasm and subsequent delayed cerebral ischemia. Transcranial Doppler (TCD) is recommended for the screening of vasospasm; however, technicians are not always available. We aimed to see how feasible and reliable bedside transcranial point-of-care ultrasound (POCUS) color-coded duplex sonography was compared with formal non-imaging TCD in measuring velocities and in diagnosing vasospasm.

METHODS

This was a prospective observational study that took place in the neuroscience intensive care unit at a single academic medical center. Patients with aSAH who were undergoing formal TCDs were scanned on days 2-10 of their admission by physicians of ranging ultrasound experience. Absolute velocities were compared as well as the diagnosis of vasospasm via POCUS and formal TCDs.

RESULTS

A total of 226 bedside ultrasound exams were performed and compared with 126 formal TCD studies. Sonographic windows were obtained in 89.4% of patients. Scans took 6.6 minutes to complete on average by the advanced group versus 14.5 minutes in the beginner. Correlation ranged from .52 in the beginner group to .65 in the advanced. When good quality of images obtained at a depth of 4-5 cm were reviewed, correlation of mean velocities increased to .96. Overall sensitivity for diagnosing vasospasm was 75%, with a specificity of 99% and negative predictive value of 99%.

CONCLUSION

Overall, POCUS TCD cannot replace a formal study performed by expert sonographers. An abbreviated POCUS scan can be performed quickly, however, particularly with more experienced operators. POCUS TCD can also feasibly detect vasospasm, and accurate velocities can be obtained by those with all levels of ultrasound experience. Care must be taken on image interpretation that velocities are obtained at an appropriate depth to ensure appropriate insonation of the MCA as well as in optimal alignment with the vessel to obtain the most accurate velocities.

Glycemic Control in Hospitalized Stroke Patients: A Review

PURPOSE OF REVIEW

The purpose of this review is to discuss clinical trials involving glycemic control in hospitalized stroke patients and to review oral medications used in glycemic control. GLP-1 agonists, which have some preliminary studies in ischemic stroke, will also be reviewed.

RECENT FINDINGS

Until recently, glycemic control targets in hospitalized stroke patients remained unclear. The SHINE (Stroke Hyperglycemia Insulin Network Effort) trial demonstrated no significant difference between aggressive versus standard of care glycemic control in the acute ischemic stroke patient. Although SHINE demonstrated a lack of statistical difference in glycemic control targets, many questions remain including glycemic control in patients with other stroke types (SAH, ICH). The role of non-insulin-based medications in glycemic control for hospitalized stroke patients remains unclear and presents an opportunity for further research. Finally, GLP-1 agonists present an interesting area of research for acute ischemic stroke.

Lung nodules are reliably detectable on ultra-low-dose CT utilising model-based iterative reconstruction with radiation equivalent to plain radiography

AIM

To determine if ultra-low-dose (ULD) computed tomography (CT) utilising model-based iterative reconstruction (MBIR) with radiation equivalent to plain radiography allows the detection of lung nodules.

MATERIALS AND METHODS

Ninety-nine individuals undergoing surveillance of solid pulmonary nodules undertook a low-dose (LD) and ULD CT during the same sitting. Image pairs were read blinded, in random order, and independently by two experienced thoracic radiologists. With LD-CT as the reference standard, the number, size, and location of nodules was compared, and inter-rater agreement was established.

RESULTS

There was very good inter-rater agreement with regards nodules ≥4mm for both the LD- (k=0.931) and ULD-CT (k=0.869). One hundred and ninety-nine nodules were reported on the LD-CT by both radiologists and 196 reported on the ULD-CT, with no nodules reported only on the ULD-CT. This gives a sensitivity of 98.5% and specificity of 100% for ULD-CT with MBIR. The effective dose of radiation was significantly different between the two scans (p<0.0001), 1.67 mSv for the LD-CT and 0.13 mSv for the ULD-CT.

CONCLUSION

ULD-CT utilising MBIR and delivering radiation equivalent to plain radiography, allows detection of lung nodules with high sensitivity. The attendant 10-fold reduction in radiation may allow for dramatic reductions in cumulative radiation exposure.

Cerebrospinal Fluid in Posterior Reversible Encephalopathy Syndrome: Implications of Elevated Protein and Pleocytosis

Background and Purpose

Patients with posterior reversible encephalopathy syndrome (PRES) sometimes undergo analysis of cerebrospinal fluid (CSF) to exclude alternative diagnoses. This study's objectives were to describe the CSF characteristics in patients with PRES and to identify clinical and radiologic findings associated with distinct CSF abnormalities.

Methods

We identified a retrospective cohort of patients with PRES. We compared clinical and radiographic characteristics of those who did versus did not undergo lumbar puncture, described the observed range of CSF findings, and analyzed clinical and radiographic features associated with specific CSF abnormalities.

Results

A total of 188 patients were included. Patients with (n = 77) and without (n = 111) CSF analysis had similar clinical and radiographic characteristics. Cerebrospinal fluid protein was elevated in 46 (60%) of 77, with median CSF protein 53 mg/dL (upper limit of normal 45 mg/dL). Protein elevation was significantly associated with radiographic severity (P = .0058) but not with seizure, time from symptom onset, radiographic evidence of diffusion restriction, or contrast enhancement. Five (7%) patients had elevated CSF white blood cells, all of whom had infarction and/or hemorrhage on neuroimaging, and 4 of whom had eclampsia.

Conclusion

The CSF of most patients with PRES shows a mild protein elevation commensurate with radiographic severity. Cerebrospinal fluid pleocytosis may mark a distinct subtype of PRES with predisposition toward infarction and/or hemorrhage. These findings help clinicians interpret CSF findings in these patients and generate new hypotheses about the pathophysiology of this syndrome.

Predicting rhesus monkey eye movements during natural-image search

There are three prominent factors that can predict human visual-search behavior in natural scenes: the distinctiveness of a location (salience), similarity to the target (relevance), and features of the environment that predict where the object might be (context). We do not currently know how well these factors are able to predict macaque visual search, which matters because it is arguably the most popular model for asking how the brain controls eye movements. Here we trained monkeys to perform the pedestrian search task previously used for human subjects. Salience, relevance, and context models were all predictive of monkey eye fixations and jointly about as precise as for humans. We attempted to disrupt the influence of scene context on search by testing the monkeys with an inverted set of the same images. Surprisingly, the monkeys were able to locate the pedestrian at a rate similar to that for upright images. The best predictions of monkey fixations in searching inverted images were obtained by rotating the results of the model predictions for the original image. The fact that the same models can predict human and monkey search behavior suggests that the monkey can be used as a good model for understanding how the human brain enables natural-scene search.

Advanced biomaterial strategies to transplant preformed micro-tissue engineered neural networks into the brain

OBJECTIVE

Connectome disruption is a hallmark of many neurological diseases and trauma with no current strategies to restore lost long-distance axonal pathways in the brain. We are creating transplantable micro-tissue engineered neural networks (micro-TENNs), which are preformed constructs consisting of embedded neurons and long axonal tracts to integrate with the nervous system to physically reconstitute lost axonal pathways.

APPROACH

We advanced micro-tissue engineering techniques to generate micro-TENNs consisting of discrete populations of mature primary cerebral cortical neurons spanned by long axonal fascicles encased in miniature hydrogel micro-columns. Further, we improved the biomaterial encasement scheme by adding a thin layer of low viscosity carboxymethylcellulose (CMC) to enable needle-less insertion and rapid softening for mechanical similarity with brain tissue.

MAIN RESULTS

The engineered architecture of cortical micro-TENNs facilitated robust neuronal viability and axonal cytoarchitecture to at least 22 days in vitro. Micro-TENNs displayed discrete neuronal populations spanned by long axonal fasciculation throughout the core, thus mimicking the general systems-level anatomy of gray matter-white matter in the brain. Additionally, micro-columns with thin CMC-coating upon mild dehydration were able to withstand a force of 893 ± 457 mN before buckling, whereas a solid agarose cylinder of similar dimensions was predicted to withstand less than 150 μN of force. This thin CMC coating increased the stiffness by three orders of magnitude, enabling needle-less insertion into brain while significantly reducing the footprint of previous needle-based delivery methods to minimize insertion trauma.

SIGNIFICANCE

Our novel micro-TENNs are the first strategy designed for minimally invasive implantation to facilitate nervous system repair by simultaneously providing neuronal replacement and physical reconstruction of long-distance axon pathways in the brain. The micro-TENN approach may offer the ability to treat several disorders that disrupt the connectome, including Parkinson's disease, traumatic brain injury, stroke, and brain tumor excision.

Tyrosine phosphatases Shp1 and Shp2 have unique and opposing roles in oligodendrocyte development

Oligodendrocyte progenitor cells first proliferate to generate sufficient cell numbers and then differentiate into myelin-producing oligodendrocytes. The signal transduction mediators that underlie these events, however, remain poorly understood. The tyrosine phosphatase Shp1 has been linked to oligodendrocyte differentiation as Shp1-deficient mice show hypomyelination. The Shp1 homolog, Shp2, has recently been shown to regulate astrogliogenesis, but its role in oligodendrocyte development remains unknown. Here, we report that Shp2 protein levels were developmentally regulated in oligodendrocytes, with Shp2 phosphorylation being promoted by oligodendroglial mitogens but suppressed by laminin, an extracellular matrix protein that promotes oligodendroglial differentiation. In contrast, oligodendrocyte progenitors were found to be unresponsive to mitogens following Shp2, but not Shp1, depletion. In agreement with previous studies, Shp1 depletion led to decreased levels of myelin basic protein in differentiating oligodendrocytes, as well as reduced outgrowth of myelin membrane sheets. Shp2 depletion in contrast did not prevent oligodendrocyte differentiation but promoted expanded myelin membrane outgrowth. Taken together these data suggest that Shp1 and Shp2 have distinct functions in oligodendrocyte development: Shp2 regulates oligodendrocyte progenitor proliferation and Shp1 regulates oligodendrocyte differentiation. Adhesion to laminin may additionally provide extrinsic regulation of Shp2 activity and thus promote the transition from progenitor to differentiating oligodendrocyte.

Zfra is an inhibitor of Bcl-2 expression and cytochrome c release from the mitochondria

Zfra is a small size 31-amino-acid C2H2 zinc finger-like protein, which is known to interact with c-Jun N-terminal kinase 1 (JNK1), WW domain-containing oxidoreductase (WWOX, FOR or WOX1), TNF receptor-associated death domain protein (TRADD) and nuclear factor kappaB (NF-kappaB) during stress response. Here, we show that Zfra became phosphorylated at Ser8 (as determined by specific antibody) and translocated to the mitochondria in response to inducers of mitochondrial permeability transition (MPT) (e.g. staurosporine and betulinic acid). Overexpressed Zfra induced cell death. This event is associated, in part, with increased dissipation of mitochondrial membrane potential (MMP) and increased chromosomal DNA fragmentation. Intriguingly, Zfra significantly downregulated Bcl-2 and yet blocked cytochrome c release from the mitochondria. Overexpression of an S8G-Zfra mutant (Ser8 to Gly8 alteration) could not induce cell death, probably due to its failure of translocating to the mitochondria and causing MMP dissipation. Over-expressed proapoptotic WOX1 induced cytochrome c release from the mitochondria. Zfra bound and blocked the effect of WOX1. Taken together, Ser8 is essential for overexpressed Zfra to exert cell death via the mitochondrial pathway. Zfra downregulates Bcl-2 and induces MMP dissipation but causes no cytochrome c release, indicating a novel death pathway from the mitochondria.

Conformationally altered hyaluronan restricts complement classical pathway activation by binding to C1q, C1r, C1s, C2, C5 and C9, and suppresses WOX1 expression in prostate DU145 cells

Linear non-sulfated hyaluronan (HA) does not bind complement proteins yet inhibits their hemolytic function. We have previously induced the complement inhibitory function of HA by heat treatment. However, heated HA readily loses its anti-complementary activity probably due to instantaneous interchain re-association. Here, HA solutions were heated and then freeze-dried. Compared to native HA, heated/freeze-dried HA stably restricted serum complement-mediated hemolysis via the classical pathway, in which serum C1 hemolytic function and C3 activation were blocked. Also, treated HA had a significantly increased binding of component C1q, C1r, C1s, C2, C5, C9, P, D and H. Further, when HA was gel-fractionated by electrophoresis and then freeze-dried, its anti-complementary activity was stably induced. Both native and heated/freeze-dried HA stimulated ERK phosphorylation in prostate DU145 cells. However, treated HA suppressed the expression of tumor suppressors WOX1 and WOX2. Together, HA with an altered conformation stabilizes its inhibition and binding of complement proteins. It may recognize cell surface receptors differently from native HA, thereby differentially regulating the expression of cellular proteins.

Validation of Align Technology's Treat IIITM digital model superimposition tool and its case application

OBJECTIVE

An assessment of the efficacy and accuracy of three-dimensional computer-based predictive orthodontic systems requires that new methods of treatment analysis be developed and validated.

DESIGN

Invisalign is a digitally fabricated, removable orthodontic appliance that has been commercially available since 1999. It is made up of two main components: 1) computerized graphical images of a patient's teeth moving through a series of stages from initial to final position; 2) pressure formed clear plastic appliances made from stereolithography models of the images in the first component.

SETTING AND SAMPLE POPULATION

The manufacturer of Invisalign (Align Technology, Inc.) has created a software tool that can be used to superimpose digital models to evaluate treatment outcomes in three dimensions. Using this software, research was conducted to determine if a single operator could repeatedly superimpose two identical digital models using 12 selected points from the palatal rugae over 10 trials. The tool was then applied to one subject's orthodontic treatment. EXPERIMENT VARIABLES: The output from this tool includes rotations, translations and morphological changes. For this study, translations and rotations were chosen.

RESULTS

The results showed that the digital superimposition was reproducible, and that after multiple trials, the superimposition error decreased. The average error in x, y, z, Rx, Ry and Rz after 10 trials was determined to approach approximately 0.2 mm in translation and less than 1 degree in rotation, with a standard deviation of 0.15 mm and 0.7 mm, respectively. The treatment outcome from a single Invisalign-treated bicuspid extraction case was also evaluated tooth-by-tooth in x, y, z, Rx, Ry and Rz dimensions.

CONCLUSION

Using the palate, as a stable reference seemed to work well and the evaluation of the single case showed that many, but not all, of the planned movements occurred.

Comprehensive mutation screening in a cystic fibrosis center

OBJECTIVES AND BACKGROUND

The identities of a cystic fibrosis (CF) patient's CFTR mutations can influence therapeutic strategies, but because >800 CFTR mutations exist, cost-effective, comprehensive screening requires a multistage approach. Single-strand conformation polymorphism and heteroduplex analysis (SSCP/HA) can be an important part of mutation detection, but must be calibrated within each laboratory. The sensitivity of a combined commercial-SSCP/HA approach to genotyping in a large, ethnically diverse US center CF population has not been established.

STUDY DESIGN

We screened all 27 CFTR exons in 10 human participants who had an unequivocal CF diagnosis including a positive sweat chloride test and at least 1 unknown allele after commercial testing for the 70 most common mutations by SSCP/HA. These participants were compared with 7 participants who had negative sweat tests but at least 1 other CF-like symptom meriting complete genotyping.

RESULTS

For the 10 CF participants, we detected 11 of 16 unknown alleles (69%) and all 4 of the known alleles (100%), for an overall rate of 75% inpatients not fully genotyped by conventional 70 mutation screen. For 7 participants with negative sweat tests, we confirmed 1 identified mutation in 14 alleles and detected 3 additional mutations. Mutations detected in both groups included 7 missense mutations (S13F, P67L, G98R, S492F, G970D, L1093P, N1303K) and 9 deletion, frameshift, nonsense or splicing mutations (R75X, G542X, DeltaF508, 451-458Delta8 bp, 5T, 663DeltaT, exon 13 frameshift, 1261+1G-->A and 3272-26A-->G). Three of these mutations were novel (G970D, L1093P, and 451-458Delta8 bp(1)). Thirteen other changes were detected, including the novel changes 1812-3 ins T, 4096-278 ins T, 4096-265 ins TG, and 4096-180 T-->G.

CONCLUSION

When combined with the 70 mutation Genzyme test, SSCP/HA analysis allows for detection of >95% of the mutations in an ethnically heterogeneous CF center population. We discuss 5 possible explanations that could account for the few remaining undetected mutations.

A retrospective comparative study of in-hospital management of acute severe asthma: 1984 vs 1989

Recent controversies examining the management of acute asthma prompted us to investigate whether there had been any significant changes in our management practices. We therefore audited the charts of all patients admitted to a large tertiary-care university-affiliated hospital with a primary diagnosis of acute asthma during the years of 1984 and 1989. A total of 67 patients' charts were reviewed (39 in 1984 and 28 in 1989). The mean age and initial flow rates (FEV1 or peak expiratory flow rate [PEFR]) were similar. In the emergency room, chest radiographs and arterial blood gas analyses were done more frequently than objective measures of flow. Fifty-one percent (20/39) of the patients had no measurement of flow in the emergency room in 1984 and 39 percent (11/28) in 1989 (p > 0.05). In both years, approximately 20 percent of the patients had no record of flow rates during their hospitalization (21 percent [8/39] in 1984 and 18 percent [5/28] in 1989). More studies of the blood were ordered in 1989, including hepatic enzyme and electrolyte measurements for no clear reasons. The clinical utility of chest radiographs was negligible. While the vast majority of patients received systemic corticosteroids in both years (85 percent [33/39] in 1984 and 96 percent [27/28] in 1989), 23 percent (9/39) and 18 percent (5/28) were discharged without oral steroid therapy in 1984 and 1989, respectively (p > 0.05). There was a significant decline in the use of aminophylline (95 percent [37/39] to 54 percent [15/28]; p < 0.05) and an increase in the use of ipratropium bromide (15 percent [6/39] to 75 percent [21/28]; p < 0.05) in 1989. Theophylline levels were less likely to be measured in 1989, and the majority of levels in both years were either subtherapeutic or toxic. No patients were discharged with peak flow meters or recorded action plans, although follow-up arrangements were recorded in 87 percent (34/39) and 96 percent (27/28) of the patients in 1984 and 1989. We conclude that while improvements in in-hospital management of asthma were noted in 1989, suboptimal management practices are still common.

Circadian pattern of prolactin and growth hormone levels in female rats of two strains

Plasma growth hormone and prolactin levels were determined by radioimmunoassay at intervals of 2 hr during the light phase of a controlled light-dark cycle in virgin female (COBS F/Crl BR) and [Sch:SPD(SD)BR] rats. Peak prolactin concentrations were observed in the afternoon during proestrus and estrus in both rat stocks. Growth hormone exhibited wide fluctuations in the Sch:SPD rat, attaining peak levels at 1300 hr, but no apparent periodicity was observed in the COBS rats.