Effectiveness of Personalized Hippocampal Network-Targeted Stimulation in Alzheimer Disease: A Randomized Clinical Trial

Importance

Repetitive transcranial magnetic stimulation (rTMS) has emerged as a safe and promising intervention for Alzheimer disease (AD).

Objective

To investigate the effect of a 4-week personalized hippocampal network-targeted rTMS on cognitive and functional performance, as well as functional connectivity in AD.

Design, Setting, and Participants

This randomized clinical trial, which was sham-controlled and masked to participants and evaluators, was conducted between May 2020 and April 2022 at a single Korean memory clinic. Eligible participants were between ages 55 and 90 years and had confirmed early AD with evidence of an amyloid biomarker. Participants who met the inclusion criteria were randomly assigned to receive hippocampal network-targeted rTMS or sham stimulation. Participants received 4-week rTMS treatment, with assessment conducted at weeks 4 and 8. Data were analyzed between April 2022 and January 2024.

Interventions

Each patient received 20 sessions of personalized rTMS targeting the left parietal area, functionally connected to the hippocampus, based on fMRI connectivity analysis over 4 weeks. The sham group underwent the same procedure, excluding actual magnetic stimulation. A personalized 3-dimensional printed frame to fix the TMS coil to the optimal target site was produced.

Main Outcomes and Measures

The primary outcome was the change in the AD Assessment Scale-Cognitive Subscale test (ADAS-Cog) after 8 weeks from baseline. Secondary outcomes included changes in the Clinical Dementia Rating-Sum of Boxes (CDR-SOB) and Seoul-Instrumental Activity Daily Living (S-IADL) scales, as well as resting-state fMRI connectivity between the hippocampus and cortical areas.

Results

Among 30 participants (18 in the rTMS group; 12 in the sham group) who completed the 8-week trial, the mean (SD) age was 69.8 (9.1) years; 18 (60%) were female. As the primary outcome, the change in ADAS-Cog at the eighth week was significantly different between the rTMS and sham groups (coefficient [SE], -5.2 [1.6]; P = .002). The change in CDR-SOB (-4.5 [1.4]; P = .007) and S-IADL (1.7 [0.7]; P = .004) were significantly different between the groups favoring rTMS groups. The fMRI connectivity analysis revealed that rTMS increased the functional connectivity between the hippocampus and precuneus, with its changes associated with improvements in ADAS-Cog (r = -0.57; P = .005).

Conclusions and Relevance

This randomized clinical trial demonstrated the positive effects of rTMS on cognitive and functional performance, and the plastic changes in the hippocampal-cortical network. Our results support the consideration of rTMS as a potential treatment for AD.

Trial Registration

ClinicalTrials.gov Identifier: NCT04260724.

The result of prospective evaluation of 3-dimensional printing-aided extensive thoracoabdominal aorta repair

OBJECTIVES

Paraplegia is a distressing complication after open thoracoabdominal aortic aneurysm (TAAA) repair, and revascularization of T8-L2-level segmental arteries is considered pivotal to prevent paraplegia. We employed 3-dimensional (3D) printing to efficiently revascularize segmental/visceral arteries and prospectively evaluated its safety and efficacy.

METHODS

From January 1, 2020, to June 30, 2022, we prospectively enrolled patients of extent I, II, or III TAAA repair. Guidance models were 3D-printed based on preoperative computed tomography, and multibranched aortic grafts were manually constructed upon this model before surgery. The composite outcome of operative mortality, permanent stroke, and permanent spinal cord deficit (SCD) was compared with the historical control group (n = 77, in 2015-2020), subjected to similar TAAA repair without 3D printing.

RESULTS

A total of 38 patients (58.6 ± 13.2 years) underwent open TAAA repair with the aid of 3D printing. Extent I, II, and III repairs were performed in 14 (36.8%), 17 (44.7%), and 7 (18.4%), respectively. Concomitant arch repair and bi-iliac reconstruction were performed in 7 (18.4%) and 6 patients (15.8%), respectively. Mean pump time was 107.7 ± 55.5 minutes. Operative mortality, permanent stroke, and permanent SCD each occurred in 1 patient (2.6%), and the incidence of the composite outcome was 7.9% (3/38). In the control group, mean pump time was 166.0 ± 83.9 minutes, significantly longer than the 3D-printing group (P < .001), and operative mortality, permanent stroke, permanent SCD, and the composite outcome occurred in 7 (9.1%), 9 (11.7%), 8 (10.4%), and 19 (24.7%), respectively.

CONCLUSIONS

Open repairs of extensive TAAA with 3D printing showed favorable safety and efficacy, which need further validation by larger studies.

IntraBrain Injector (IBI): A Stereotactic-Guided Device for Repeated Delivery of Therapeutic Agents Into the Brain Parenchyma

BACKGROUND

To deliver therapeutics into the brain, it is imperative to overcome the issue of the blood-brain-barrier (BBB). One of the ways to circumvent the BBB is to administer therapeutics directly into the brain parenchyma. To enhance the treatment efficacy for chronic neurodegenerative disorders, repeated administration to the target location is required. However, this increases the number of operations that must be performed. In this study, we developed the IntraBrain Injector (IBI), a new implantable device to repeatedly deliver therapeutics into the brain parenchyma.

METHODS

We designed and fabricated IBI with medical grade materials, and evaluated the efficacy and safety of IBI in 9 beagles. The trajectory of IBI to the hippocampus was simulated prior to surgery and the device was implanted using 3D-printed adaptor and surgical guides. Ferumoxytol-labeled mesenchymal stem cells (MSCs) were injected into the hippocampus via IBI, and magnetic resonance images were taken before and after the administration to analyze the accuracy of repeated injection.

RESULTS

We compared the planned vs. insertion trajectory of IBI to the hippocampus. With a similarity of 0.990 ± 0.001 (mean ± standard deviation), precise targeting of IBI was confirmed by comparing planned vs. insertion trajectories of IBI. Multiple administrations of ferumoxytol-labeled MSCs into the hippocampus using IBI were both feasible and successful (success rate of 76.7%). Safety of initial IBI implantation, repeated administration of therapeutics, and long-term implantation have all been evaluated in this study.

CONCLUSION

Precise and repeated delivery of therapeutics into the brain parenchyma can be done without performing additional surgeries via IBI implantation.

Differences between 3D isovoxel fat suppression VIBE MRI and CT models of proximal femur osseous anatomy: A preliminary study for bone tumor resection planning

Purpose

To evaluate the osseous anatomy of the proximal femur extracted from a 3D-MRI volumetric interpolated breath-hold (VIBE) sequence using either a Dixon or water excitation (WE) fat suppression method, and to measure the overall difference using CT as a reference standard.

Material and methods

This retrospective study reviewed imaging of adult patients with hip pain who underwent 3D hip MRI and CT. A semi-automatically segmented CT model served as the reference standard, and MRI segmentation was performed manually for each unilateral hip joint. The differences between Dixon-VIBE-3D-MRI vs. CT, and WE-VIBE-3D-MRI vs. CT, were measured. Equivalence tests between Dixon-VIBE and WE-VIBE models were performed with a threshold of 0.1 mm. Bland–Altman plots and Lin’s concordance-correlation coefficient were used to analyze the agreement between WE and Dixon sequences. Subgroup analyses were performed for the femoral head/neck, intertrochanteric, and femoral shaft areas.

Results

The mean and maximum differences between Dixon-VIBE-3D-MRI vs. CT were 0.2917 and 3.4908 mm, respectively, whereas for WE-VIBE-3D-MRI vs. CT they were 0.3162 and 3.1599 mm. The mean differences of the WE and Dixon methods were equivalent (P = 0.0292). However, the maximum difference was not equivalent between the two methods and it was higher in WE method. Lin’s concordance-correlation coefficient showed poor agreement between Dixon and WE methods. The mean differences between the CT and 3D-MRI models were significantly higher in the femoral shaft area (P = 0.0004 for WE and P = 0.0015 for Dixon) than in the other areas. The maximum difference was greatest in the intertrochanteric area for both techniques.

Conclusion

The difference between 3D-MR and CT models were acceptable with a maximal difference below 3.5mm. WE and Dixon fat suppression methods were equivalent. The mean difference was highest at the femoral shaft area, which was off-center from the magnetization field.

Case Report: A 3D-Printed Surgical Guide for Breast-Conserving Surgery After Neoadjuvant Chemotherapy

Background

A challenging problem for patients undergoing breast-conserving surgery after neoadjuvant chemotherapy (NACT) is the accuracy of preoperative tumor localization. After chemotherapy, the original tumor is likely to shrink or scatter dramatically or even show complete remission. For breast-conserving surgery, the development of a guidance device to accurately estimate the resection area is imperative.

Case Presentation

We produced a three-dimensional (3D)-printed breast surgical guide (BSG) based on prone and supine magnetic resonance imaging (MRI). This device was tested on a patient who underwent breast-conserving surgery after NACT. Both ultrasonography and MRI revealed that the tumor shrank substantially after NACT. Identifying the target tumor area using pre-NACT MRI was feasible, and the tumor was safely removed with clear resection margins.

Conclusion

The BSG has several advantages over conventional methods for tumor localization after NACT. In particular, the BSG provided precise quantitative MRI information about the tumor area.

Breast-Conserving Surgery after Neoadjuvant Chemotherapy Using a Three-Dimensional-Printed Surgical Guide Based on Supine Magnetic Resonance Imaging: A Case Report

Tumor localization in patients receiving neoadjuvant chemotherapy (NACT) is challenging because substantial therapeutic remission of the original tumor after NACT is often noted. Currently, there is no guidance device that allows for an accurate estimation of the resection range in breast-conserving surgery after NACT. To increase the accuracy of tumor resection, we used a 3-dimensional-printed breast surgical guide based on magnetic resonance imaging (MRI) in the supine position for a breast cancer patient who underwent breast-conserving surgery after NACT. Using this device, the breast tumor with apparent therapeutic changes after NACT on imaging was successfully removed with clear resection margins by identifying the original tumor site in the affected breast. Irrespective of whether the residual tumor area after NACT is well defined, it is possible to confirm and target the tumor area on pre-NACT MRI using this device.

Limits on the Existence of sub-MeV Sterile Neutrinos from the Decay of ^{7}Be in Superconducting Quantum Sensors

Sterile neutrinos are natural extensions to the standard model of particle physics and provide a possible portal to the dark sector. We report a new search for the existence of sub-MeV sterile neutrinos using the decay-momentum reconstruction technique in the decay of ^{7}Be. The experiment measures the total energy of the ^{7}Li daughter atom from the electron capture decay of ^{7}Be implanted into sensitive superconducting tunnel junction (STJ) quantum sensors. This first experiment presents data from a single STJ operated at a low count rate for a net total of 28 days, and provides exclusion limits on sterile neutrinos in the mass range from 100 to 850 keV that improve upon previous work by up to an order of magnitude.

Direct Measurement of the ^{7}Be L/K Capture Ratio in Ta-Based Superconducting Tunnel Junctions

We report a high-statistics measurement of the L/K orbital electron capture ratio in ^{7}Be embedded in cryogenic Ta. The thin Ta film formed part of a high-resolution superconducting tunnel junction radiation detector that was used to identify the signals from different decay channels. The measured L/K capture ratio of 0.070(7) is significantly larger than the only previous measurement of this quantity and the theoretical predictions that include in-medium effects. This value is a uniquely sensitive probe of the 1s and 2s orbital overlaps with the nucleus and is of relevance to nuclear and atomic physics, as well as Li production in novae and other astrophysical scenarios. This is the first experiment that uses superconducting tunnel junctions for nuclear-recoil detection, opening a new experimental avenue for low-energy precision measurements with rare isotopes.

Production of ERCP training model using a 3D printing technique (with video)

BACKGROUND

ERCP training models are very different in terms of anatomical differences, ethical issues, storage problems, realistic tactile sensation, durability and portability. There is no easy way to select an optimized model for ERCP training. If the ERCP training model could be made as a soft silicone model using 3D printing technique, it would have numerous advantages over the models presented so far. The purpose of this study was to develop an optimized ERCP training model using a 3D printing technique and to try to find ways for implementing various practical techniques.

METHODS

All organ parts of this model were fabricated using silicone molding techniques with 3D printing. Especially, various anatomy of the ampulla of Vater and common bile duct (CBD) were creatively designed for different diagnostic and therapeutic procedures. In order to manufacture each of the designed organ parts with silicone, a negative part had to be newly designed to produce the molder. The negative molders were 3D printed and then injection molding was applied to obtain organ parts in silicone material. The eight different types of ampulla and CBD were repeatedly utilized and replaced to the main system as a module-type.

RESULTS

ERCP training silicone model using 3D technique was semi-permanently used to repeat various ERCP procedures. All ERCP procedures using this model could be observed by real-time fluoroscopic examination as well as endoscopic examination simultaneously. Using different ampulla and CBD modules, basic biliary cannulation, difficult cannulation, stone extraction, mechanical lithotripsy, metal stent insertion, plastic stent insertion, and balloon dilation were successfully and repeatedly achieved. Endoscopic sphincterotomy was also performed on a specialized ampulla using a Vienna sausage. After repeat procedures and trainings, all parts of organs including the ampulla and CBD modules were not markedly damaged or deformed.

CONCLUSIONS

We made a specialized ERCP training silicon model with 3D printing technique. This model is durable, relatively cheap and easy to make, and thus allows the users to perform various specialized ERCP techniques, which increases its chances of being a good ERCP training model.

Stereotaxic endoscopy for the ocular imaging of awake, freely moving animal models

Stereotaxic instruments are increasingly used in research animals for the study of disease, but typically require restraints and anesthetic procedures. A stereotaxic head mount that enables imaging of the anterior chamber of the eye in alert and freely mobile mice is presented in this study. The head mount is fitted based on computed tomography scans and manufactured using 3D printing. The system is placed noninvasively using temporal mount bars and a snout mount, without breaking the skin or risking suffocation, while an instrument channel stabilizes the ocular probes. With a flexible micro-endoscopic probe and a confocal scanning laser microscopy system, <20 μm resolution is achieved in vivo with a field of view of nearly 1 mm. Discomfort is minimal, and further adaptations for minimally invasive neuroscience, optogenetics and auditory studies are possible.

Breast tumor movements analysis using MRI scans in prone and supine positions

We quantitatively evaluated breast tumor movement and volume changes between magnetic resonance imaging (MRI) scans in prone and supine positions. Twenty-seven breast tumor patients who received neoadjuvant systemic therapy (NST) for breast-conserving surgery were studied. Before and after NST, MRI scans in prone and supine positions were performed immediately. Tumor segmentation, volume, and position of tumors were evaluated in both positions. Average tumor volumes in prone and supine positions did not significantly differ (p = 0.877). Tumor movement from prone to supine positions from the origin of the bottom center of the sternum was strongly correlated with the distance from the tumor center to the chest wall (r = 0.669; p < 0.05). Tumor changes from prone to supine positions measured from the origin of the nipple depended on the location of the tumor in the breast. The prone-to-supine movement of all tumors from the origin of the bottom center of the sternum tended to move outward from the sagittal centerline of the body on the coronal plane, to the inside of the body on the sagittal plane, and outward and downward close to the body on the axial plane, which might help in planning operations using prone MRI in supine-position breast cancer surgery.

Development of a CT imaging phantom of anthromorphic lung using fused deposition modeling 3D printing

Development of patient-specific CT imaging phantoms with randomly incorporated lesions of various shapes and sizes for calibrating image intensity and validating quantitative measurement software is very challenging. In this investigation, a physical phantom that accurately represents a patient's specific anatomy and the intensity of lung CT images at the voxel level will be fabricated using fused deposition modeling (FDM) 3D printing. Segmentation and modeling of a patient's CT data were performed by an expert and the results were confirmed by a thoracic radiologist with more than 20 years of experience. This facilitated the extraction of the details of the patient's anatomy; various kinds of nodules with different shapes and sizes were randomly added to the modeled lung for evaluating the size-accuracy of the quantification software. To achieve these Hounsfield Units (HU) ranges for the corresponding voxels in acquired CT scans, the infill ratios of FDM 3D printing were controlled. Based on CT scans of the 3D printed phantoms, the measured HU for normal pulmonary parenchyma, ground glass opacity (GGO), and solid nodules were determined to be within target HU ranges. The accuracy of the mean absolute difference and the mean relative difference of nodules were less than 0.55 ± 0.30 mm and 3.72 ± 1.64% (mean difference ± 95 CI), respectively. Patient-specific CT imaging phantoms were designed and manufactured using an FDM printer, which could be applied for the precise calibration of CT intensity and the validation of image quantification software.

Comparison of Shallow and Deep Learning Methods on Classifying the Regional Pattern of Diffuse Lung Disease

This study aimed to compare shallow and deep learning of classifying the patterns of interstitial lung diseases (ILDs). Using high-resolution computed tomography images, two experienced radiologists marked 1200 regions of interest (ROIs), in which 600 ROIs were each acquired using a GE or Siemens scanner and each group of 600 ROIs consisted of 100 ROIs for subregions that included normal and five regional pulmonary disease patterns (ground-glass opacity, consolidation, reticular opacity, emphysema, and honeycombing). We employed the convolution neural network (CNN) with six learnable layers that consisted of four convolution layers and two fully connected layers. The classification results were compared with the results classified by a shallow learning of a support vector machine (SVM). The CNN classifier showed significantly better performance for accuracy compared with that of the SVM classifier by 6-9%. As the convolution layer increases, the classification accuracy of the CNN showed better performance from 81.27 to 95.12%. Especially in the cases showing pathological ambiguity such as between normal and emphysema cases or between honeycombing and reticular opacity cases, the increment of the convolution layer greatly drops the misclassification rate between each case. Conclusively, the CNN classifier showed significantly greater accuracy than the SVM classifier, and the results implied structural characteristics that are inherent to the specific ILD patterns.

MRI-based 3D-printed surgical guides for breast cancer patients who received neoadjuvant chemotherapy

Magnetic resonance imaging (MRI) is the most accurate technique for evaluating residual tumor after neoadjuvant chemotherapy. However, precise determination of the extent of dispersed residual tumor in the breast following treatment remains a difficult task. We hereby introduce three-dimensional (3D)-printed surgical guides for use in breast cancer patients undergoing breast-conserving surgery after receiving neoadjuvant chemotherapy. We prospectively applied the 3D-printed surgical guides on breast cancer patients who underwent partial breast resection after receiving neoadjuvant chemotherapy. Breasts and tumors were modeled in 3D by using pretreatment magnetic resonance images, and surgical guides were created by using a 3D printer to mark the primary tumor. Out of the five patients who participated in the study, all patients had clear resection margins, and two patients experienced complete pathological remission. There were no recurrences during the median follow-up period of 21.9 months. Thus, our newly-developed 3D-printed surgical guides were useful for accurately marking the extent of breast tumor based on pretreatment magnetic resonance images, which is important for designating the extent of surgery needed in patients who have received neoadjuvant chemotherapy.

Effects of acute lipopolysaccharide-induced toxemia model on some neglected blood parameters

The presence of lipopolysaccharide (LPS) in blood induces an inflammatory response which leads to multiple organ dysfunction and numerous metabolic disorders. Uncontrolled, improper or late intervention may lead to tissue hypoxia, anaerobic glycolysis and a disturbance in the acid -base balance. The effects of LPS-induced toxemia on biological and immunological markers were well studied. However, parameters such as base excess, ions, and acid-base balance were not fully investigated. Therefore, the objective of this study was to examine these blood parameters collectively in LPS-induced inflammatory toxemia in rat's model. After induction of toxemia by injecting LPS at a rate of 5 mg/kg body weight intravenously, blood was collected from the tail vein of twenty rats and immediately analyzed. After 24 hours, the animals were sacrificed and the blood was collected from the caudal vena cava. The results revealed that the levels of pH, bicar- bonate, partial pressure of oxygen, oxygen saturation, Alveolar oxygen, hemoglobin, hematocrit, magnesium (Mg2+), and calcium (Ca2+) were significantly decreased. On the other side, the levels of Base excess blood, Base excess extracellular fluid, partial pressure of carbon dioxide, lactate, Ca2+/Mg2+, potassium, and chloride were significantly increased compared to those found pre toxemia induction. However, sodium level showed no significant change. In conclusion, Acute LPS-toxemia model disturbs acid-base balance, blood gases, and ions. These parameters can be used to monitor human and animal toxemic inflammatory response induced by bacterial LPS conditions to assist in the management of the diagnosed cases.

Effect of pannus formation on the prosthetic heart valve: In vitro demonstration using particle image velocimetry

Although hemodynamic influence of the subprosthetic tissue, termed as pannus, may contribute to prosthetic aortic valve dysfunction, the relationship between pannus extent and hemodynamics in the prosthetic valve has rarely been reported. We investigated the fluid dynamics of pannus formation using in vitro experiments with particle image velocimetry. Subvalvular pannus formation caused substantial changes in prosthetic valve transvalvular peak velocity, transvalvular pressure gradient (TPG) and opening angle. Maximum flow velocity and corresponding TPG were mostly affected by pannus width. When the pannus width was 25% of the valve diameter, pannus formation elevated TPG to >2.5 times higher than that without pannus formation. Opening dysfunction was observed only for a pannus involvement angle of 360°. Although circumferential pannus with an involvement angle of 360° decreased the opening angle of the valve from approximately 82° to 58°, eccentric pannus with an involvement angle of 180° did not induce valve opening dysfunction. The pannus involvement angle largely influenced the velocity flow field at the aortic sinus and corresponding hemodynamic indices, including wall shear stress, principal shear stress and viscous energy loss distributions. Substantial discrepancy between the velocity-based TPG estimation and direct pressure measurements was observed for prosthetic valve flow with pannus formation.

Validation of a CT-guided intervention robot for biopsy and radiofrequency ablation: experimental study with an abdominal phantom

PURPOSE

We aimed to evaluate the accuracy of a needle-placement robot for biopsy and radiofrequency ablation on an abdominal phantom.

METHODS

A master-slave robotic system has been developed that includes a needle-path planning system and a needle-inserting robot arm with computed tomography (CT) and CT fluoroscopy guidance. For evaluation of its accuracy in needle placement, a commercially available abdominal phantom (Model 057A; CIRS Inc.) was used. The liver part of the phantom contains multiple spherical simulated tumors of three different size spheres. Various needle insertion trials were performed in the transverse plane and caudocranial plane two nodule sizes (10 mm and 20 mm in diameter) to test the reliability of this robot. To assess accuracy, a CT scan was performed after each trial with the needle in situ.

RESULTS

The overall error was 2 mm (0-2.6 mm), which was calculated as the distance from the planned trajectory before insertion to the actual needle trajectory after insertion. The standard deviations of the insertions on two nodules (10 mm and 20 mm in diameter) were 0.5 mm and 0.2 mm, respectively.

CONCLUSION

The CT-compatible needle placement robot for biopsy and radiofrequency ablation shows relatively acceptable accuracy and could be used for radiofrequency ablation of nodules ≥10 mm under CT fluoroscopy guidance.

3D-printed phantom study for investigating stent abutment during gastroduodenal stent placement for gastric outlet obstruction

Background

Placing a self-expandable metallic stent (SEMS) is safe and effective for the palliative treatment of malignant gastroduodenal (GD) strictures. SEMS abutment in the duodenal wall is associated with increased food impaction, resulting in higher stent malfunction and shorter stent patency. The desire to evaluate the mechanism and significance of stent abutment led us to design an in vitro experiment using a flexible anthropomorphic three-dimensional (3D)-printed GD phantom model.

Results

A GD phantom was fabricated using 3D printer data after performing computed tomography gastrography. A partially covered (PC) or fully covered (FC) stent was placed so that its distal end abutted onto the duodenal wall in groups PC-1 and FC-1 or its distal end was sufficiently directed caudally in groups PC-2 and FC-2. The elapsed times of the inflowing of three diets (liquid, soft, and solid) were measured in the GD phantom under fluoroscopic guidance. There was no significant difference in the mean elapsed times for the liquid diet among the four groups. For the soft diet, the mean elapsed times in groups PC-1 and FC-1 were longer than those in groups PC-2 and FC-2 (P = 0.018 and P < 0.001, respectively). For the solid diet, the mean elapsed time in group PC-1 was longer than that in group PC-2 (P < 0.001). The solid diet could not pass in group FC-1 due to food impaction. The mean elapsed times were significantly longer in groups FC-1 and FC-2 than in groups PC-1 and PC-2 for soft and solid diets (all P < 0.001).

Conclusions

This flexible anthropomorphic 3D-printed GD phantom study revealed that stent abutment can cause prolonged passage of soft and solid diets through the stent as well as impaction of solid diets into the stent.

Deep Learning in Medical Imaging: General Overview

The artificial neural network (ANN)-a machine learning technique inspired by the human neuronal synapse system-was introduced in the 1950s. However, the ANN was previously limited in its ability to solve actual problems, due to the vanishing gradient and overfitting problems with training of deep architecture, lack of computing power, and primarily the absence of sufficient data to train the computer system. Interest in this concept has lately resurfaced, due to the availability of big data, enhanced computing power with the current graphics processing units, and novel algorithms to train the deep neural network. Recent studies on this technology suggest its potentially to perform better than humans in some visual and auditory recognition tasks, which may portend its applications in medicine and healthcare, especially in medical imaging, in the foreseeable future. This review article offers perspectives on the history, development, and applications of deep learning technology, particularly regarding its applications in medical imaging.

Overlapping self-expandable metallic stent for palliation of a long (>10 cm) malignant gastroduodenal obstruction

Background Self-expandable metallic stent (SEMS) placement is a well-established palliative treatment approach for malignant gastroduodenal obstruction. In patients with a long (>10 cm) stricture, multiple stents placed in an overlapping fashion are often required. Purpose To investigate the outcomes of overlapping SEMS placement for the palliative treatment of malignant gastroduodenal obstruction in patients with a long (>10 cm) stricture. Material and Methods The medical records of 40 patients who underwent fluoroscopic overlapping SEMS placement for malignant gastroduodenal obstruction due to a long (>10 cm) stricture were reviewed. Results The technical and clinical success rates were 100% and 65.0%, respectively. The mean length of the stricture was 17.0 ± 4.7 cm and the mean number of stents placed in each patient was 2.2 ± 0.5. Metastatic cancer (odds ratio [OR], 0.315; P = 0.018), Eastern Cooperative Oncology Group (ECOG) score ≥3 (OR, 0.018; P = 0.006), and carcinomatosis with ascites (OR, 0.025; P = 0.017) were independent predictors of poor clinical success. The rates of minor and major complications were 27.5% and 2.5%, respectively. The median stent patency and survival were 33 days (interquartile range [IQR], 19-60 days) and 35 days (IQR, 19-73 days), respectively. An ECOG score ≥3 was an independent predictor of a poor survival outcome (hazard ratio, 4.681; P < 0.001). Conclusion Overlapping SEMS placement may be safe and effective for the palliative treatment of malignant gastroduodenal obstruction in patients with a long (>10 cm) stricture.

Fluoroscopic removal of retrievable self-expandable metal stents in patients with malignant oesophageal strictures: Experience with a non-endoscopic removal system

OBJECTIVES

To evaluate clinical outcomes of fluoroscopic removal of retrievable self-expandable metal stents (SEMSs) for malignant oesophageal strictures, to compare clinical outcomes of three different removal techniques, and to identify predictive factors of successful removal by the standard technique (primary technical success).

METHODS

A total of 137 stents were removed from 128 patients with malignant oesophageal strictures. Primary overall technical success and removal-related complications were evaluated. Logistic regression models were constructed to identify predictive factors of primary technical success.

RESULTS

Primary technical success rate was 78.8 % (108/137). Complications occurred in six (4.4 %) cases. Stent location in the upper oesophagus (P=0.004), stricture length over 8 cm (P=0.030), and proximal granulation tissue (P<0.001) were negative predictive factors of primary technical success. If granulation tissue was present at the proximal end, eversion technique was more frequently required (P=0.002).

CONCLUSIONS

Fluoroscopic removal of retrievable SEMSs for malignant oesophageal strictures using three different removal techniques appeared to be safe and easy. The standard technique is safe and effective in the majority of patients. The presence of proximal granulation tissue, stent location in the upper oesophagus, and stricture length over 8 cm were negative predictive factors for primary technical success by standard extraction and may require a modified removal technique.

KEY POINTS

• Fluoroscopic retrievable SEMS removal is safe and effective. • Standard removal technique by traction is effective in the majority of patients. • Three negative predictive factors of primary technical success were identified. • Caution should be exercised during the removal in those situations. • Eversion technique is effective in cases of proximal granulation tissue.

The influence of the aortic valve angle on the hemodynamic features of the thoracic aorta

Since the first observation of a helical flow pattern in aortic blood flow, the existence of helical blood flow has been found to be associated with various pathological conditions such as bicuspid aortic valve, aortic stenosis, and aortic dilatation. However, an understanding of the development of helical blood flow and its clinical implications are still lacking. In our present study, we hypothesized that the direction and angle of aortic inflow can influence helical flow patterns and related hemodynamic features in the thoracic aorta. Therefore, we investigated the hemodynamic features in the thoracic aorta and various aortic inflow angles using patient-specific vascular phantoms that were generated using a 3D printer and time-resolved, 3D, phase-contrast magnetic resonance imaging (PC-MRI). The results show that the rotational direction and strength of helical blood flow in the thoracic aorta largely vary according to the inflow direction of the aorta, and a higher helical velocity results in higher wall shear stress distributions. In addition, right-handed rotational flow conditions with higher rotational velocities imply a larger total kinetic energy than left-handed rotational flow conditions with lower rotational velocities.

Hemodynamic Measurement Using Four-Dimensional Phase-Contrast MRI: Quantification of Hemodynamic Parameters and Clinical Applications

Recent improvements have been made to the use of time-resolved, three-dimensional phase-contrast (PC) magnetic resonance imaging (MRI), which is also named four-dimensional (4D) PC-MRI or 4D flow MRI, in the investigation of spatial and temporal variations in hemodynamic features in cardiovascular blood flow. The present article reviews the principle and analytical procedures of 4D PC-MRI. Various fluid dynamic biomarkers for possible clinical usage are also described, including wall shear stress, turbulent kinetic energy, and relative pressure. Lastly, this article provides an overview of the clinical applications of 4D PC-MRI in various cardiovascular regions.

Three-Dimensional Printing: Basic Principles and Applications in Medicine and Radiology

The advent of three-dimensional printing (3DP) technology has enabled the creation of a tangible and complex 3D object that goes beyond a simple 3D-shaded visualization on a flat monitor. Since the early 2000s, 3DP machines have been used only in hard tissue applications. Recently developed multi-materials for 3DP have been used extensively for a variety of medical applications, such as personalized surgical planning and guidance, customized implants, biomedical research, and preclinical education. In this review article, we discuss the 3D reconstruction process, touching on medical imaging, and various 3DP systems applicable to medicine. In addition, the 3DP medical applications using multi-materials are introduced, as well as our recent results.

Post-stenotic Recirculating Flow May Cause Hemodynamic Perforator Infarction

BACKGROUND AND PURPOSE

The primary mechanism underlying paramedian pontine infarction (PPI) is atheroma obliterating the perforators. Here, we encountered a patient with PPI in the post-stenotic area of basilar artery (BA) without a plaque, shown by high-resolution magnetic resonance imaging (HR-MRI). We performed an experiment using a 3D-printed BA model and a particle image velocimetry (PIV) to explore the hemodynamic property of the post-stenotic area and the mechanism of PPI.

METHODS

3D-model of a BA stenosis was reconstructed with silicone compound using a 3D-printer based on the source image of HR-MRI. Working fluid seeded with fluorescence particles was used and the velocity of those particles was measured horizontally and vertically. Furthermore, microtubules were inserted into the posterior aspect of the model to measure the flow rates of perforators (pre-and post-stenotic areas). The flow rates were compared between the microtubules.

RESULTS

A recirculating flow was observed from the post-stenotic area in both directions forming a spiral shape. The velocity of the flow in these regions of recirculation was about one-tenth that of the flow in other regions. The location of recirculating flow well corresponded with the area with low-signal intensity at the time-of-flight magnetic resonance angiography and the location of PPI. Finally, the flow rate through the microtubule inserted into the post-stenotic area was significantly decreased comparing to others (P<0.001).

CONCLUSIONS

Perforator infarction may be caused by a hemodynamic mechanism altered by stenosis that induces a recirculation flow. 3D-printed modeling and PIV are helpful understanding the hemodynamics of intracranial stenosis.

Multi-VENC acquisition of four-dimensional phase-contrast MRI to improve precision of velocity field measurement

PURPOSE

The present study aims to improve precision of four-dimensional (4D) phase-contrast (PC) MRI technique by using multiple velocity encoding (VENC) parameters.

THEORY AND METHODS

The 3D flow fields in an in vitro stenosis phantom and an in vivo ascending aorta were determined using a 4D PC-MRI sequence with multiple VENC values. The velocity field obtained for large VENC was combined with that from small VENC, unless velocity data were lost by phase aliasing and phase dispersion. Noise levels of the combined velocity fields were compared with the increasing overlapping number of VENC parameters.

RESULTS

The phantom measurement showed that the multi-VENC acquisition reduced the noise levels in radial and axial velocities (> 24 cm/s at VENC = 300 cm/s) down to 0.80 ± 0.45 cm/s and 5.60 ± 2.63 cm/s, respectively. This increased the velocity-to-noise ratio (VNR) by approximately two-fold to six-fold depending on the locations. As a result, the multi-VENC measurement could visualize the low-velocity recirculating flows more clearly.

CONCLUSION

The multi-VENC measurement of 4D PC-MRI sequence increased the VNR distribution by reducing velocity noise. The improved VNR can be beneficial for investigating blood flow structures in a flow field with a high velocity dynamic range.

Spatial heterogeneity and stability of bacterial community in the gastrointestinal tracts of broiler chickens

Bacterial communities in the different regions of gastrointestinal tract (GIT) of broiler chickens were analyzed by pyrosequencing approach to understand microbial composition and diversity. The DNA samples extracted from 7 different regions along the GIT were subjected to bacterial-community analysis by pyrosequencing of the V1-V3 region of 16S rRNA gene. Major bacterial phyla in the chicken-gut microbiota included Firmicutes, Proteobacteria, Bacteroidetes, Actinobacteria, and Acidobacteria, but Firmicutes were mostly dominant (67.3 ± 16.1% of the total sequence reads identified). Among Firmicutes, Lactobacillales, including the genera Lactobacillus and Enterococcus, were the most dominant (51.8 ± 34.5% of the total sequence reads identified) from the crop to ileum. In contrast, in the cecum and large intestine, those genera were rarely detected, and Clostridiales were dominant (55.9 ± 31.4%). Fast UniFrac analysis showed that microbial communities from the crop to jejunum of the same individual chicken were grouped together, and those from ileum, cecum, and large intestine were clustered in a more GIT-specific manner. The numbers of shared operational taxonomic units between the neighboring segments of GIT were low, ranging from 2.9 to 20.3%. However, the abundance of shared operational taxonomic units in each segment was relatively high, ranging from 61.7 to 85.0%, suggesting that substantial proportions of microbial communities were shared between each segment and its neighboring segments, comprising a core microbiota. Our results suggested that the microbial communities of 7 main segments in the chicken GIT were distinctive according to both individuals and the different segments of GIT, but their stability was maintained along the GIT.

Carbon-nanotube-modified electrodes for highly efficient acute neural recording

Microelectrodes are widely used for monitoring neural activities in various neurobiological studies. The size of the neural electrode is an important factor in determining the signal-to-noise ratio (SNR) of recorded neural signals and, thereby, the recording sensitivity. Here, it is demonstrated that commercial tungsten microelectrodes can be modified with carbon nanotubes (CNTs), resulting in a highly sensitive recording ability. The impedance with the respect to surface area of the CNT-modified electrodes (CNEs) is much less than that of tungsten microelectrodes because of their large electrochemical surface area (ESA). In addition, the noise level of neural signals recorded by CNEs is significantly less. Thus, the SNR is greater than that obtained using tungsten microelectrodes. Importantly, when applied in a mouse brain in vivo, the CNEs can detect action potentials five times more efficiently than tungsten microelectrodes. This technique provides a significant advance in the recording of neural signals, especially in brain regions with sparse neuronal densities.

A case of isolated bilateral pulmonary arterial calcification diagnosed in utero

We report a very rare case of isolated multiple pulmonary arterial calcification with severe bilateral peripheral pulmonary arterial stenosis diagnosed in utero. Despite treatment with bisphosphonate for 6 months, systolic right ventricular pressure increased persistently and surpassed left ventricular pressure. After successful bilateral pulmonary arterioplasty at 13 months of age, the patient showed decreased systolic right ventricular pressure with normal interventricular septal configuration. This is the first case report for an isolated pulmonary artery calcification without other arterial calcification proven by non-contrast computed tomography of a living patient.

Development of decay energy spectroscopy using low temperature detectors

We have developed a high-resolution detection technique for measuring the energy and activity of alpha decay events using low-temperature detectors. A small amount of source material containing alpha-emitting radionuclides was enclosed in a 4π metal absorber. The energy of the alpha particles as well as that of the recoiled nuclides, low-energy electrons, and low-energy x-rays and γ-rays was converted into thermal energy of the gold absorber. A metallic magnetic calorimeter serving as a fast and sensitive thermometer was thermally attached to the metal absorber. In the present report, experimental demonstrations of Q spectroscopy were made with a new meander-type magnetic calorimeter. The thermal connection between the temperature sensor and the absorber was established with annealed gold wires. Each alpha decay event in the absorber resulted in a temperature increase of the absorber and the temperature sensor. Using the spectrum measured for a drop of (226)Ra solution in a 4π gold absorber, all of the alpha emitters in the sample were identified with a demonstration of good detector linearity. The resolution of the (226)Ra spectrum showed a 3.3 keV FWHM at its Q value together with an expected gamma escape peak at the energy shifted by its γ-ray energy.

Cortical mapping of the optically evoked responses in channelrhodopsin-2 mouse model

Little is known about the information transfer properties of large-scale neural circuit in brain system. We applied optical deep brain stimulation to define the properties of information flow within a living brain assisted by channel rhodopsin-2 (ChR2) transgenic mice, of which neurons express the light-activated ion channel. We first characterized the responses of neuronal ensemble to the impinged light with respect to stimulation parameters by co-registering local field potentials with optical stimulation. Secondly, we applied recently developed polyimide based microarray for mouse electroencephalogram (EEG) to obtain the cortical responses with respect to deep brain stimulation. Particularly, the spatiotemporal cortical mapping with respect to deep brain stimulation of primary somatosensory cortex and hippocampus CA1 were presented in this article.

Development of a compact x-ray particle image velocimetry for measuring opaque flows

A compact x-ray particle image velocimetry (PIV) system employing a medical x-ray tube as a light source was developed to measure quantitative velocity field information of opaque flows. The x-ray PIV system consists of a medical x-ray tube, an x-ray charge coupled device camera, a programmable shutter for a pulse-type x ray, and a synchronization device. Through performance tests, the feasibility of the developed x-ray PIV system as a flow measuring device was verified. To check the feasibility of the developed system, we tested a tube flow at two different mean velocities of 1 and 2 mm/s. The x-ray absorption of tracer particles must be quite different from that of working fluid to have a good contrast in x-ray images. All experiments were performed under atmospheric pressure condition. This system is unique and useful for investigating various opaque flows or flows inside opaque conduits.

Development of Gerontological Nursing Curriculum Model

PURPOSE

This study was conducted to develop gerontological curriculum model which reflects the need of Korean society.

METHOD

Three round Delphi survey method was applied to find consensus of gerontological nursing competencies (knowledge, attitudes and skills) for graduates of nursing schools from the panel of gerontological nursing practice experts. Important concepts in gerontological nursing were delineated from literature review and discussions of gerontological nursing educators. Based on these results the gerontological nursing curriculum model was developed and course structure outlined by the researchers as a group.

RESULT

As the result of delphi survey, 32 items of knowledge, 29 items of attitude, and 21 items of skill were identified. The curriculum model constructed around a cube with three plane- functional capacity levels, settings, and nursing practice. Specific knowledge, attitudes and skills for gerontological theory and practicum course were suggested. Competency items were assigned to theory and/or practice.

CONCLUSION

A curriculum model for gerontological nursing has been developed by a group of gerontological nursing educators. The curriculum model should be further tested and developed with detailed theory and practicum course outline and textbooks.

Comet assays to assess DNA damage and repair in grass shrimp embryos exposed to phototoxicants

Exposure of grass shrimp (Palaemonetes pugio) embryos to four compounds (anthracene, pyrene, alpha-terthienyl, methylene blue) along with solar exposure resulted in extensive DNA strand damage using the comet assay. DNA tail moments of embryos exposed to these chemicals in the dark ranged from 1.8 to 4.3, while exposure to chemicals and solar resulted in tail moments of 14.3-15.3. Reduction of DNA tail moments when solar exposed embryos were transferred to the dark, suggested DNA repair systems were active. The comet assay can be used to follow both DNA damage and repair following exposure to phototoxic chemicals.

Induction of the P450 reporter gene system bioassay by polycyclic aromatic hydrocarbons in Ulsan Bay (South Korea) sediments

Polycyclic aromatic hydrocarbons (PAHs) and induction of the P450 reporter gene system (RGS) for 6- and 16-h exposure periods were determined in organic extracts of Ulsan Bay (South Korea) sediments to assess the utility of this bioassay as a screening tool for PAH contamination. The sum of the concentrations of 23 individual PAHs in 30 sediment samples (sigma PAH) based on GC-MS analysis ranged from 0.05 to 6.1 micrograms/g dry wt. P450 RGS fold induction ranged from 4.0 to 320 micrograms/g based on benzo[a]pyrene toxic equivalents (BaPEq). P450 RGS BaPEq and the 'chemical BaPEq', defined as the sum of the products of individual PAH concentrations and pre-determined toxic equivalency factors, exhibited very strong positive correlations with sigma PAH (r2 > 0.90; P < 0.001). Fold induction did not increase (and in some cases decreased) after the optimal incubation period (6 h) for PAHs, indicating that other compounds known to induce the P450 RGS (e.g. chlorinated organics) were not present at levels effecting significant induction. This was supported by GC-ECD analysis where non-ortho and mono-ortho polychlorinated biphenyls (PCBs) known to be strong P450 RGS inducers were found to be at very low or non-detectable levels in samples with the highest P450 RGS responses. The profound difference in PAH profiles for the two most contaminated sites suggested that this assay is especially sensitive for selected PAHs with greater than four rings. Combined with previous results, the P450 RGS shows promise as a useful screening tool for predicting deleterious biological effects resulting from CYP1A1-inducing, sediment-associated chemicals, particularly high molecular weight PAHs.

DNA strand breaks (comet assay) and embryo development effects in grass shrimp (Palaemonetes pugio) embryos after exposure to genotoxicants

Grass shrimp embryos develop in egg sacs (stages 1-10) attached to the female for 14-20 days after which they 'hatch' from the egg sacs into a swimming zoea stage (stage 11). Until they emerge from the egg sacs, embryos depend on lipids and lipovitellin stored within the egg. The percent of embryos which hatch after exposure to toxicants relative to controls was the basis of an embryo development assay. Exposure of embryos to chromium(III) chloride, sodium chromate, mercuric chloride, and 2-methyl-1,2-naphthoquinone (MNQ) resulted in a reduced hatching rate. In addition to effects on embryo development, DNA strand damage tests were carried out on contaminant-exposed embryos, using the single-cell electrophoresis method often referred to as comet assay. Development of stage 4 embryos was more affected by MNQ exposure than stage 7 embryos. The hatching rates of stages 4 and 7 embryos exposed to MNQ (172 micrograms/l) were 0 and 90%, respectively. DNA strand damage, measured as DNA tail moments, were 3.4 and 4.4, respectively. Thus, exposure of an early embryo stage to MNQ prevented full embryo development while development of later embryo stages was not affected. It may be that the DNA repair systems are more efficient in later embryo stages than in early stages and thus DNA damaged in the early stages affects development.

Pharmacokinetics, skin absorption, stability, blood partition, and protein binding of AS 2-006A, a new wound healing agent

After intravenous administration of AS 2-006A, 20, 50, and 90 mg/kg, to rats, the pharmacokinetic parameters, terminal half-life (69.8-86. 6 min), mean residence time (56.2-75.2 min), apparent volume of distribution at steady state (809-1040 mL/kg), and total body clearance (11.4-11.9 mL/min/kg), were dose-independent. After topical application of 0.5 or 1% AS 2-006A ointment, 300 mg, to abraded rat skin, the absorbed amounts were dose (0.5 and 1%) and time (30, 60, 120, 240, 360 and 480 min)-independent; the value was approximately 20%. The tissue-to-plasma ratios of AS 2-006A were greater than unity in all rat tissues studied, except in the muscle and large intestine. AS 2-006A was stable for up to 24 h incubation in rat plasma, and human plasma and urine; however, it seemed not to be stable in rat urine; the disappearance rate constant was 0.0218/h. AS 2-006A reached equilibrium fast between plasma and blood cells, and the equilibrium plasma/blood cells partition ratios were independent of the initial rabbit blood concentrations of AS 2-006A, 10, 20, and 50 microg/mL; the mean values were in the range of 2.38-2.75 for three rabbit blood. The protein binding of AS 2-006A to rat plasma was high, as the drug was under detection limit in the filtrate at the plasma concentrations of the drug, ranging from 7.21 to 228 microg/mL.

Determination of a new asiatic acid derivative, AS 2-006A in rat plasma and urine, and human plasma by high-performance liquid chromatography

A high-performance liquid chromatographic method was developed for the determination of a new wound healing agent, AS 2-006A (ethoxymethyl 2-oxo-3, 23-O-isopropylideneasiatate), in rat plasma and urine, and human plasma. The sample preparation was simple: 2 volumes of acetonitrile were added to the biological samples to deproteinize it. A 50-microl aliquot of the supernatant was injected onto the reversed-phase column. The mobile phase employed was acetonitrile : H2O (9:1, v/v) and run at a flow rate of 1.1 ml/min. The column effluent was monitored by a UV detector set at 205 nm. The retention time for AS 2-006A was approximately 29.5 min. The detection limits for AS 2-006A in rat and human plasma were both 1 microg/ml, and in rat urine was 2 microg/ml. The coefficients of variation of the assay (within-day and between-day) were generally low (below 10.8%) for rat plasma and urine, and human plasma. No interferences from endogenous substances were found.