Where is VALDO? VAscular Lesions Detection and segmentatiOn challenge at MICCAI 2021

Imaging markers of cerebral small vessel disease provide valuable information on brain health, but their manual assessment is time-consuming and hampered by substantial intra- and interrater variability. Automated rating may benefit biomedical research, as well as clinical assessment, but diagnostic reliability of existing algorithms is unknown. Here, we present the results of the VAscular Lesions DetectiOn and Segmentation (Where is VALDO?) challenge that was run as a satellite event at the international conference on Medical Image Computing and Computer Aided Intervention (MICCAI) 2021. This challenge aimed to promote the development of methods for automated detection and segmentation of small and sparse imaging markers of cerebral small vessel disease, namely enlarged perivascular spaces (EPVS) (Task 1), cerebral microbleeds (Task 2) and lacunes of presumed vascular origin (Task 3) while leveraging weak and noisy labels. Overall, 12 teams participated in the challenge proposing solutions for one or more tasks (4 for Task 1-EPVS, 9 for Task 2-Microbleeds and 6 for Task 3-Lacunes). Multi-cohort data was used in both training and evaluation. Results showed a large variability in performance both across teams and across tasks, with promising results notably for Task 1-EPVS and Task 2-Microbleeds and not practically useful results yet for Task 3-Lacunes. It also highlighted the performance inconsistency across cases that may deter use at an individual level, while still proving useful at a population level.

Cerebrospinal fluid proteomics in patients with Alzheimer's disease reveals five molecular subtypes with distinct genetic risk profiles

Alzheimer's disease (AD) is heterogenous at the molecular level. Understanding this heterogeneity is critical for AD drug development. Here we define AD molecular subtypes using mass spectrometry proteomics in cerebrospinal fluid, based on 1,058 proteins, with different levels in individuals with AD (n = 419) compared to controls (n = 187). These AD subtypes had alterations in protein levels that were associated with distinct molecular processes: subtype 1 was characterized by proteins related to neuronal hyperplasticity; subtype 2 by innate immune activation; subtype 3 by RNA dysregulation; subtype 4 by choroid plexus dysfunction; and subtype 5 by blood-brain barrier impairment. Each subtype was related to specific AD genetic risk variants, for example, subtype 1 was enriched with TREM2 R47H. Subtypes also differed in clinical outcomes, survival times and anatomical patterns of brain atrophy. These results indicate molecular heterogeneity in AD and highlight the need for personalized medicine.

Genetic, vascular and amyloid components of cerebral blood flow in a preclinical population

Aging-related cognitive decline can be accelerated by a combination of genetic factors, cardiovascular and cerebrovascular dysfunction, and amyloid-β burden. Whereas cerebral blood flow (CBF) has been studied as a potential early biomarker of cognitive decline, its normal variability in healthy elderly is less known. In this study, we investigated the contribution of genetic, vascular, and amyloid-β components of CBF in a cognitively unimpaired (CU) population of monozygotic older twins. We included 134 participants who underwent arterial spin labeling (ASL) MRI and [18F]flutemetamol amyloid-PET imaging at baseline and after a four-year follow-up. Generalized estimating equations were used to investigate the associations of amyloid burden and white matter hyperintensities with CBF. We showed that, in CU individuals, CBF: 1) has a genetic component, as within-pair similarities in CBF values were moderate and significant (ICC > 0.40); 2) is negatively associated with cerebrovascular damage; and 3) is positively associated with the interaction between cardiovascular risk scores and early amyloid-β burden, which may reflect a vascular compensatory response of CBF to early amyloid-β accumulation. These findings encourage future studies to account for multiple interactions with CBF in disease trajectory analyses.

Genetically identical twin-pair difference models support the amyloid cascade hypothesis

The amyloid cascade hypothesis has strongly impacted the Alzheimer's disease research agenda and clinical trial designs over the past decades, but precisely how amyloid-β pathology initiates the aggregation of neocortical tau remains unclear. We cannot exclude the possibility of a shared upstream process driving both amyloid-β and tau in an independent manner instead of there being a causal relationship between amyloid-β and tau. Here, we tested the premise that if a causal relationship exists, then exposure should be associated with outcome both at the individual level as well as within identical twin-pairs, who are strongly matched on genetic, demographic and shared environmental background. Specifically, we tested associations between longitudinal amyloid-β PET and cross-sectional tau PET, neurodegeneration and cognitive decline using genetically identical twin-pair difference models, which provide the unique opportunity of ruling out genetic and shared environmental effects as potential confounders in an association. We included 78 cognitively unimpaired identical twins with [18F]flutemetamol (amyloid-β)-PET, [18F]flortaucipir (tau)-PET, MRI (hippocampal volume) and cognitive data (composite memory). Associations between each modality were tested at the individual level using generalized estimating equation models, and within identical twin-pairs using within-pair difference models. Mediation analyses were performed to test for directionality in the associations as suggested by the amyloid cascade hypothesis. At the individual level, we observed moderate-to-strong associations between amyloid-β, tau, neurodegeneration and cognition. The within-pair difference models replicated results observed at the individual level with comparably strong effect sizes. Within-pair differences in amyloid-β were strongly associated with within-pair differences in tau (β = 0.68, P < 0.001), and moderately associated with within-pair differences in hippocampal volume (β = -0.37, P = 0.03) and memory functioning (β = -0.57, P < 0.001). Within-pair differences in tau were moderately associated with within-pair differences in hippocampal volume (β = -0.53, P < 0.001) and strongly associated with within-pair differences in memory functioning (β = -0.68, P < 0.001). Mediation analyses showed that of the total twin-difference effect of amyloid-β on memory functioning, the proportion mediated through pathways including tau and hippocampal volume was 69.9%, which was largely attributable to the pathway leading from amyloid-β to tau to memory functioning (proportion mediated, 51.6%). Our results indicate that associations between amyloid-β, tau, neurodegeneration and cognition are unbiased by (genetic) confounding. Furthermore, effects of amyloid-β on neurodegeneration and cognitive decline were fully mediated by tau. These novel findings in this unique sample of identical twins are compatible with the amyloid cascade hypothesis and thereby provide important new knowledge for clinical trial designs.

Biological brain age prediction using machine learning on structural neuroimaging data: Multi-cohort validation against biomarkers of Alzheimer's disease and neurodegeneration stratified by sex

Brain-age can be inferred from structural neuroimaging and compared to chronological age (brain-age delta) as a marker of biological brain aging. Accelerated aging has been found in neurodegenerative disorders like Alzheimer's disease (AD), but its validation against markers of neurodegeneration and AD is lacking. Here, imaging-derived measures from the UK Biobank dataset (N=22,661) were used to predict brain-age in 2,314 cognitively unimpaired (CU) individuals at higher risk of AD and mild cognitive impaired (MCI) patients from four independent cohorts with available biomarker data: ALFA+, ADNI, EPAD, and OASIS. Brain-age delta was associated with abnormal amyloid-β, more advanced stages (AT) of AD pathology and APOE-ε4 status. Brain-age delta was positively associated with plasma neurofilament light, a marker of neurodegeneration, and sex differences in the brain effects of this marker were found. These results validate brain-age delta as a non-invasive marker of biological brain aging in non-demented individuals with abnormal levels of biomarkers of AD and axonal injury.

Eigenvector centrality dynamics are related to Alzheimer’s disease pathological changes in non-demented individuals

Amyloid-β accumulation starts in highly connected brain regions and is associated with functional connectivity alterations in the early stages of Alzheimer’s disease. This regional vulnerability is related to the high neuronal activity and strong fluctuations typical of these regions. Recently, dynamic functional connectivity was introduced to investigate changes in functional network organization over time. High dynamic functional connectivity variations indicate increased regional flexibility to participate in multiple subnetworks, promoting functional integration. Currently only a limited number of studies have explored the temporal dynamics of functional connectivity in the pre-dementia stages of Alzheimer’s disease. We study the associations between abnormal cerebrospinal fluid amyloid and both static and dynamic properties of functional hubs, using eigenvector centrality, and their relationship with cognitive performance, in 701 non-demented participants from the European Prevention of Alzheimer’s Dementia (EPAD) cohort.

Voxel-wise eigenvector centrality was computed for the whole functional magnetic resonance imaging time series (static), and within a sliding window (dynamic). Differences in static eigenvector centrality between amyloid positive (A+) and negative (A-) participants and amyloid-tau (AT) groups were found in a general linear model. Dynamic eigenvector centrality standard deviation and range were compared between groups within clusters of significant static eigenvector centrality differences, and within 10 canonical resting-state networks. The effect of the interaction between amyloid status and cognitive performance on dynamic eigenvector centrality variability was also evaluated with linear models. Models were corrected for age, sex and education level.

Lower static centrality was found in A + participants in posterior brain areas including a parietal and an occipital cluster; higher static centrality was found in a medio-frontal cluster. Lower eigenvector centrality variability (standard deviation) occurred in A + participants in the frontal cluster. The default mode network and the dorsal visual networks of A + participants had lower dynamic eigenvector centrality variability. Centrality variability in the Default Mode Network and dorsal visual networks were associated with cognitive performance in the A- and A + groups, with lower variability being observed in A + participants with good cognitive scores.

Our results support the role and timing of eigenvector centrality alterations in very early stages of Alzheimer’s disease and show that centrality variability over time adds relevant information on the dynamic patterns that cause static eigenvector centrality alterations. We propose that dynamic eigenvector centrality is an early biomarker of the interplay between early Alzheimer’s disease pathology and cognitive decline.

The amyloid imaging for the prevention of Alzheimer's disease consortium: A European collaboration with global impact

Background

Amyloid-β (Aβ) accumulation is considered the earliest pathological change in Alzheimer's disease (AD). The Amyloid Imaging to Prevent Alzheimer's Disease (AMYPAD) consortium is a collaborative European framework across European Federation of Pharmaceutical Industries Associations (EFPIA), academic, and 'Small and Medium-sized enterprises' (SME) partners aiming to provide evidence on the clinical utility and cost-effectiveness of Positron Emission Tomography (PET) imaging in diagnostic work-up of AD and to support clinical trial design by developing optimal quantitative methodology in an early AD population.

The AMYPAD studies

In the Diagnostic and Patient Management Study (DPMS), 844 participants from eight centres across three clinical subgroups (245 subjective cognitive decline, 342 mild cognitive impairment, and 258 dementia) were included. The Prognostic and Natural History Study (PNHS) recruited pre-dementia subjects across 11 European parent cohorts (PCs). Approximately 1600 unique subjects with historical and prospective data were collected within this study. PET acquisition with [¹⁸F]flutemetamol or [¹⁸F]florbetaben radiotracers was performed and quantified using the Centiloid (CL) method.

Results

AMYPAD has significantly contributed to the AD field by furthering our understanding of amyloid deposition in the brain and the optimal methodology to measure this process. Main contributions so far include the validation of the dual-time window acquisition protocol to derive the fully quantitative non-displaceable binding potential (BP _ND ), assess the value of this metric in the context of clinical trials, improve PET-sensitivity to emerging Aβ burden and utilize its available regional information, establish the quantitative accuracy of the Centiloid method across tracers and support implementation of quantitative amyloid-PET measures in the clinical routine.

Future steps

The AMYPAD consortium has succeeded in recruiting and following a large number of prospective subjects and setting up a collaborative framework to integrate data across European PCs. Efforts are currently ongoing in collaboration with ARIDHIA and ADDI to harmonize, integrate, and curate all available clinical data from the PNHS PCs, which will become openly accessible to the wider scientific community.

Regional associations of white matter hyperintensities and early cortical amyloid pathology

White matter hyperintensities (WMHs) have a heterogeneous aetiology, associated with both vascular risk factors and amyloidosis due to Alzheimer’s disease. While spatial distribution of both amyloid and WM lesions carry important information for the underlying pathogenic mechanisms, the regional relationship between these two pathologies and their joint contribution to early cognitive deterioration remains largely unexplored.

We included 662 non-demented participants from three Amyloid Imaging to Prevent Alzheimer’s disease (AMYPAD)-affiliated cohorts: EPAD-LCS (N = 176), ALFA+ (N = 310), and EMIF-AD PreclinAD Twin60++ (N = 176). Using PET imaging, cortical amyloid burden was assessed regionally within early accumulating regions (medial orbitofrontal, precuneus, and cuneus) and globally, using the Centiloid method. Regional WMH volume was computed using Bayesian Model Selection. Global associations between WMH, amyloid, and cardiovascular risk scores (Framingham and CAIDE) were assessed using linear models. Partial least square (PLS) regression was used to identify regional associations. Models were adjusted for age, sex, and APOE-e4 status. Individual PLS scores were then related to cognitive performance in 4 domains (attention, memory, executive functioning, and language).

While no significant global association was found, the PLS model yielded two components of interest. In the first PLS component, a fronto-parietal WMH pattern was associated with medial orbitofrontal–precuneal amyloid, vascular risk, and age. Component 2 showed a posterior WMH pattern associated with precuneus-cuneus amyloid, less related to age or vascular risk. Component 1 was associated with lower performance in all cognitive domains, while component 2 only with worse memory.

In a large pre-dementia population, we observed two distinct patterns of regional associations between WMH and amyloid burden, and demonstrated their joint influence on cognitive processes. These two components could reflect the existence of vascular-dependent and -independent manifestations of WMH-amyloid regional association that might be related to distinct primary pathophysiology.

Atypically high influence of subcortical activity on primary sensory regions in autism

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The age-dependent decrease of subcortico-cortical connectivity is attenuated in ASD.

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Primary sensory regions remain less segregated from subcortical activity in ASD.

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This could underlie an excessive amount of sensory input relayed to the cortex.

Background

Hypersensitivity, stereotyped behaviors and attentional problems in autism spectrum disorder (ASD) are compatible with inefficient filtering of undesired or irrelevant sensory information at early stages of neural processing. This could stem from the persistent overconnectivity between primary sensory regions and deep brain nuclei in both children and adults with ASD – as reported by several previous studies – which could reflect a decreased or arrested maturation of brain connectivity. However, it has not yet been investigated whether this overconnectivity can be modelled as an excessive directional influence of subcortical brain activity on primary sensory cortical regions in ASD, with respect to age-matched typically developing (TD) individuals.

Methods

To this aim, we used dynamic causal modelling to estimate (1) the directional influence of subcortical activity on cortical processing and (2) the functional segregation of primary sensory cortical regions from subcortical activity in 166 participants with ASD and 193 TD participants from the Autism Brain Imaging Data Exchange (ABIDE). We then specifically tested the hypothesis that the age-related changes of these indicators of brain connectivity would differ between the two groups.

Results

We found that in TD participants age was significantly associated with decreased influence of subcortical activity on cortical processing, paralleled by an increased functional segregation of cortical sensory processing from subcortical activity. Instead these effects were highly reduced and mostly absent in ASD participants, suggesting a delayed or arrested development of the segregation between subcortical and cortical sensory processing in ASD.

Conclusion

This atypical configuration of subcortico-cortical connectivity in ASD can result in an excessive amount of unprocessed sensory input relayed to the cortex, which is likely to impact cognitive functioning in everyday situations where it is beneficial to limit the influence of basic sensory information on cognitive processing, such as activities requiring focused attention or social interactions.

The Open-Access European Prevention of Alzheimer's Dementia (EPAD) MRI dataset and processing workflow

The European Prevention of Alzheimer Dementia (EPAD) is a multi-center study that aims to characterize the preclinical and prodromal stages of Alzheimer's Disease. The EPAD imaging dataset includes core (3D T1w, 3D FLAIR) and advanced (ASL, diffusion MRI, and resting-state fMRI) MRI sequences. Here, we give an overview of the semi-automatic multimodal and multisite pipeline that we developed to curate, preprocess, quality control (QC), and compute image-derived phenotypes (IDPs) from the EPAD MRI dataset. This pipeline harmonizes DICOM data structure across sites and performs standardized MRI preprocessing steps. A semi-automated MRI QC procedure was implemented to visualize and flag MRI images next to site-specific distributions of QC features - i.e. metrics that represent image quality. The value of each of these QC features was evaluated through comparison with visual assessment and step-wise parameter selection based on logistic regression. IDPs were computed from 5 different MRI modalities and their sanity and potential clinical relevance were ascertained by assessing their relationship with biological markers of aging and dementia. The EPAD v1500.0 data release encompassed core structural scans from 1356 participants 842 fMRI, 831 dMRI, and 858 ASL scans. From 1356 3D T1w images, we identified 17 images with poor quality and 61 with moderate quality. Five QC features - Signal to Noise Ratio (SNR), Contrast to Noise Ratio (CNR), Coefficient of Joint Variation (CJV), Foreground-Background energy Ratio (FBER), and Image Quality Rate (IQR) - were selected as the most informative on image quality by comparison with visual assessment. The multimodal IDPs showed greater impairment in associations with age and dementia biomarkers, demonstrating the potential of the dataset for future clinical analyses.

'Wherever you are, my son, wait for me.' study on medically assisted reproduction

Introduction

In Italy the use of Medically Assisted Procreation (MAP) is increasingly frequent also because the mean age at which Italian women have their first child has increased in recent decades (31.8 years in 2017) and it is more difficult to have a child for an older woman. The aim of this study was evaluate the maternal and neonatal outcomes of MAP and compare them with those of natural pregnancies.

Methods

The cross-sectional study was performed during the period January 2015-June 2019. All women that gave birth in the Hospital of Siena were included. The sample was divided in two groups (Natural pregnancy/MAP Pregnancy). The outcome variables were: maternal age, number of foetus, type of childbirth, timing of the birth, Apgar Index and necessity of hospitalization in neonatal intensive therapy unit (NITU) or resuscitation. The statistical analysis was performed with Stata 12.

Results

In total 5066 females were included (4.5% MAP pregnancy). The average age (±SD) of females was 32,9±5,56 (min 14-max 61). The mean age (±SD) of women with PMA was significantly higher 38.7 ± 5.7 vs. 32.6± 5.4 of those who had natural pregnancy. In PMA Pregnancy there was a higher probability of multiple pregnancy (OR = 16.13; 95% CI 10.38-25.07; p &lt; 0.001), Caesarean Section (OR:4,54; 95% CI 3.28-6.31; p &lt; 0,001) and preterm birth (OR 3.79; 95% IC 2.80-5.14; p &lt; 0.001). Apgar index at the first minute was significantly lower in children born from pregnancies from MAP (8,6 ±1,4 vs, 9 ±1,4 p &lt; 0.01), the difference was significant even in the 5th minute (9,6 ±0,7 vs. 9,8 ±0,6 p &lt; 0.01). Children born by MAP Pregnancy had higher probability of hospitalization in Neonatal Intensive Care (OR = 3.12; 95% CI 2.12-4.59; p &lt; 0.001).

Conclusions

In our sample we found that MAP is used by women with older average age and it is associated with less favourable maternal and neonatal outcomes than those from natural conception.

Key messages

In Italy the use of Medically Assisted Procreation (MAP) is increasingly frequent because it is more difficult to have a child for an older woman. In our sample we found that MAP is used by women with older average age and it is associated with less favourable maternal and neonatal outcomes than those from natural conception.

Application of the ATN classification scheme in a population without dementia: Findings from the EPAD cohort

BACKGROUND

We classified non-demented European Prevention of Alzheimer's Dementia (EPAD) participants through the amyloid/tau/neurodegeneration (ATN) scheme and assessed their neuropsychological and imaging profiles.

MATERIALS AND METHODS

From 1500 EPAD participants, 312 were excluded. Cerebrospinal fluid cut-offs of 1000 pg/mL for amyloid beta (Aß)1-42 and 27 pg/mL for p-tau181 were validated using Gaussian mixture models. Given strong correlation of p-tau and t-tau (R2  = 0.98, P < 0.001), neurodegeneration was defined by age-adjusted hippocampal volume. Multinomial regressions were used to test whether neuropsychological tests and regional brain volumes could distinguish ATN stages.

RESULTS

Age was 65 ± 7 years, with 58% females and 38% apolipoprotein E (APOE) ε4 carriers; 57.1% were A-T-N-, 32.5% were in the Alzheimer's disease (AD) continuum, and 10.4% suspected non-Alzheimer's pathology. Age and cerebrovascular burden progressed with biomarker positivity (P < 0.001). Cognitive dysfunction appeared with T+. Paradoxically higher regional gray matter volumes were observed in A+T-N- compared to A-T-N- (P < 0.001).

DISCUSSION

In non-demented individuals along the AD continuum, p-tau drives cognitive dysfunction. Memory and language domains are affected in the earliest stages.

Effects of Topical Application of CHF6467, a Mutated Form of Human Nerve Growth Factor, on Skin Wound Healing in Diabetic Mice

Nerve growth factor (NGF) is the protein responsible for the development and maintenance of sensory skin innervation. Given the role of appropriate innervation in skin healing, NGF has been indicated as a possible prohealing treatment in pathologic conditions characterized by nerve-ending loss, such as chronic ulcers in diabetes; however, its use as a therapeutic agent is limited by its hyperalgesic effect. We tested the effect of topical application of the nonalgogenic NGF derivative hNGFP61S/R100E in two models of skin ulcer induced in dbdb diabetic mice, investigating healing time, skin histology, reinnervation, and angiogenesis using morphologic and molecular approaches. We showed that the topical administration of CHF6467, a recombinant human NGF in which an amino acid substitution (R100E) abolished the hyperalgesic effect usually associated with NGF, accelerated skin repair in experimental wounds (full-excision and pressure-ulcer) induced in diabetic mice (dbdb). CHF6467-induced acceleration of wound healing was accompanied by increased re-epithelization, reinnervation, and revascularization as assessed by histology, immunohistochemistry, and image analysis. Bioinformatic analysis of differentially expressed genes and signaling pathways in the wound tissues showed that protein kinase B-mammalian target of rapamycin was the most regulated pathway. In spite of the transdermal absorption leading to measurable, dose-dependent increases in CHF6467 plasma levels, no systemic thermal or local mechanical hyperalgesia was observed in treated mice. When tested in vitro in human cell lines, CHF6467 stimulated keratinocyte and fibroblast proliferation and tube formation by endothelial cells. Collectively, these results support a possible use of CHF6467 as a prohealing agent in skin lesions in diabetes. SIGNIFICANCE STATEMENT: Topical application of CHF6467 accelerates reinnervation, neoangiogenesis, and wound healing in diabetic mice in both full-thickness skin-excision and pressure-ulcer models through the protein kinase B/mammalian target of rapamycin pathway and does not induce hyperalgesia.

From bench to bedside: in vitro and in vivo evaluation of a neonate-focused nebulized surfactant delivery strategy

Background

Non-invasive delivery of nebulized surfactant has been a neonatology long-pursued goal. Nevertheless, the clinical efficacy of nebulized surfactant remains inconclusive, in part, due to the great technical challenges of depositing nebulized drugs in the lungs of preterm infants. The aim of this study was to investigate the feasibility of delivering nebulized surfactant (poractant alfa) in vitro and in vivo with an adapted, neonate-tailored aerosol delivery strategy.

Methods

Particle size distribution of undiluted poractant alfa aerosols generated by a customized eFlow-Neos nebulizer system was determined by laser diffraction. The theoretical nebulized surfactant lung dose was estimated in vitro in a clinical setting replica including a neonatal continuous positive airway pressure (CPAP) circuit, a cast of the upper airways of a preterm neonate, and a breath simulator programmed with the tidal breathing pattern of an infant with mild respiratory distress syndrome (RDS). A dose-response study with nebulized surfactant covering the 100–600 mg/kg nominal dose-range was conducted in RDS-modelling, lung-lavaged spontaneously-breathing rabbits managed with nasal CPAP. The effects of nebulized poractant alfa on arterial gas exchange and lung mechanics were assessed. Exogenous alveolar disaturated-phosphatidylcholine (DSPC) in the lungs was measured as a proxy of surfactant deposition efficacy.

Results

Laser diffraction studies demonstrated suitable aerosol characteristics for inhalation (mass median diameter, MMD = 3 μm). The mean surfactant lung dose determined in vitro was 13.7% ± 4.0 of the 200 mg/kg nominal dose. Nebulized surfactant delivered to spontaneously-breathing rabbits during nasal CPAP significantly improved arterial oxygenation compared to animals receiving CPAP only. Particularly, the groups of animals treated with 200 mg/kg and 400 mg/kg of nebulized poractant alfa achieved an equivalent pulmonary response in terms of oxygenation and lung mechanics as the group of animals treated with instilled surfactant (200 mg/kg).

Conclusions

The customized eFlow-Neos vibrating-membrane nebulizer system efficiently generated respirable aerosols of undiluted poractant alfa. Nebulized surfactant delivered at doses of 200 mg/kg and 400 mg/kg elicited a pulmonary response equivalent to that observed after treatment with an intratracheal surfactant bolus of 200 mg/kg. This bench-characterized nebulized surfactant delivery strategy is now under evaluation in Phase II clinical trial (EUDRACT No.:2016–004547-36).

Electronic supplementary material

The online version of this article (10.1186/s12931-019-1096-9) contains supplementary material, which is available to authorized users.

Cognitive load and emotional processing in psoriasis: a thermal imaging study

Psoriasis is a chronic dermatologic disease which is frequently associated with psychological distress. Although studies suggest a relationship between this condition and difficulties in emotion regulation, behavioral and physiological evidence about this link is scarce. We measured implicit emotion regulation abilities of psoriasis patients and a healthy control group by examining the impact of distracting emotional (positive, negative or neutral) images on a working memory task ("Emotional N-Back") which could present high (2-back) or low (1-back) cognitive workload. Moreover, we used Functional Infrared Thermal Imaging to record participants' facial temperature and obtain a measure of the activation of the autonomic system. Rising of temperature over the peri-orbital areas and the nose tip are believed to reflect the activation and the de-activation of the sympathetic system, respectively. Patients scored higher than controls on the "Lack of emotional clarity" sub-scale of the Difficulties in Emotion Regulation Scale. Compared to controls, who performed much better in the low vs. high cognitive load condition, patients showed a smaller accuracy difference between the two conditions. Moreover, patients showed less sympathetic (lower peri-orbital and higher nasal tip temperature) activity (especially in the negative and neutral blocks) during the high vs. low cognitive load condition, suggesting that the former condition might be less emotionally demanding for them. Patients benefit more than controls from the load-dependent interference effect when dealing with emotional information; thus, therapeutic techniques aiming at teaching how to use cognitive strategies to downregulate emotions might be particularly appropriated for them.

Autotransfusion with Predeposit-Haemodilution and Perioperative Blood Salvage: 20 Years of Experience

Background

Through a prospective study, we evaluated the efficacy of an integrated autotransfusion regimen comprised of predeposit-hemodiluition and intra and post-operative blood salvage in major orthopaedic surgery.

Methods

We examined the records of 2303 consecutive patients (1524 females and 779 males, mean age 62.7, standard deviation 11 years (range 16–90 yrs), pre-operative haemoglobin (Hb) concentration 13.5 (SD 1.4) (range 6.7–19.3) g/dl undergong total hip arthroplasty (THA 1582 patients), THA after the removal of internal fixation devices (RFD+THA, 25 patients), total knee arthroplasty (TKA, 347 patients), revision surgery of the hip (HR, cup+stem revision, 248 patients; cup revision 64 patients; stem revision 23 patients) and total knee revision (TKR 14 patients). We estimated that the number of predonations (MSBOS - maximum surgery blood order schedule) was 2 units for THA, TKA and TKR, and 3 units for partial or total hip revision and for total hip arthroplasty with fixation removal.

Results

It was possible to obtain the MSBOS in 2070 patients (89.8%). Homologous red blood cell (HRBC) transfusion were carried out in 184 patients (8%). We found that the need to use HRBC was significantly associated with failure to meet the number of MSBOS, female sex, lower pre-operative Hb concentration, use of calcium heparin for antithrombosis prophylaxis, more extensive surgery, a higher ASA rating and co-existing diseases such as coronary artery disease.

Conclusions

Cooperation among anaesthesis, transfusionists and surgeons in the application of an integrated autotransfusion regimen enabled us to treat 92% of our patients with only autotransfusion.

Functional and molecular evidence of myelin- and neuroprotection by thyroid hormone administration in experimental allergic encephalomyelitis

AIMS

Recent data in mouse and rat demyelination models indicate that administration of thyroid hormone (TH) has a positive effect on the demyelination/remyelination balance. As axonal pathology has been recognized as an early neuropathological event in multiple sclerosis, and remyelination is considered a pre-eminent neuroprotective strategy, in this study we investigated whether TH administration improves nerve impulse propagation and protects axons.

METHODS

We followed up the somatosensory evoked potentials (SEPs) in triiodothyronine (T3)-treated and untreated experimental allergic encephalomyelitis (EAE) Dark-Agouti female rats during the electrical stimulation of the tail nerve. T3 treatment started on the 10th day post immunization (DPI) and a pulse administration was continued until the end of the study (33 DPI). SEPs were recorded at baseline (8 DPI) and the day after each hormone/ vehicle administration.

RESULTS

T3 treatment was associated with better outcome of clinical and neurophysiological parameters. SEPs latencies of the two groups behaved differently, being briefer and closer to control values (=faster impulse propagation) in T3-treated animals. The effect was evident on 24 DPI. In the same groups of animals, we also investigated axonal proteins, showing that T3 administration normalizes neurofilament immunoreactivity in the fasciculus gracilis and tau hyperphosphorylation in the lumbar spinal cord of EAE animals. No sign of plasma hyperthyroidism was found; moreover, the dysregulation of TH nuclear receptor expression observed in the spinal cord of EAE animals was corrected by T3 treatment.

CONCLUSIONS

T3 supplementation results in myelin sheath protection, nerve conduction preservation and axon protection in this animal model of multiple sclerosis.

Triiodothyronine administration ameliorates the demyelination/remyelination ratio in a non-human primate model of multiple sclerosis by correcting tissue hypothyroidism

Remyelination failure is a key landmark in chronic progression of multiple sclerosis (MS), the most diffuse demyelinating disease in human, but the reasons for this are still unknown. It has been shown that thyroid hormone administration in the rodent models of acute and chronic demyelinating diseases improved their clinical course, pathology and remyelination. In the present study, we translated this therapeutic attempt to experimental allergic encephalomyelitis (EAE) in the non-human primate Callithrix Jacchus (marmoset). We report that short protocols of triiodothyronine treatment shifts the demyelination/remyelination balance toward remyelination, as assessed by morphology, immunohistochemistry and molecular biology, and improves the clinical course of the disease. We also found that severely ill animals display hypothyroidism and severe alteration of deiodinase and thyroid hormone receptor mRNAs expression in the spinal cord, which was completely corrected by thyroid hormone treatment. We therefore suggest that thyroid hormone treatment improves myelin sheath morphology in marmoset EAE, by correcting the dysfunction of thyroid hormone cellular effectors.

Skin homeostasis during inflammation: a role for nerve growth factor

The skin is a neuroendocrine immune organ in which many different molecules operate in autocrine-paracrine manner to guarantee tissue homeostatsis in physiological and pathophysiological conditions. In this paper we examined NGF and p75 receptor expression in the skin, during CFA induced inflammation, in a time-course study. We also examined cutaneus innervation and proliferation, by means of immunohistochemistry and quantitative image analysis, RT-PCR and Western blot. Spontaneous and evoked pain-behavior was also measured in experimental rats. The main results can be summarized as follows: 1). a peripheral sensory neuropathy develops in this condition, as indicated by thermal hyperalgesia, thus leading to a sensory denervation of the hind-paw skin as indicated by disappearance of CGRP and PGP9.5-IR fibers; 2). NGF and p75 expression (mRNA and protein) increases in the skin (keratinocytes) in the acute phase of CFA inflammation; 3). at this stage, a higher proliferative activity is observed in the skin, as defined by the expression of cell cycle-associated protein Ki67; 4). in the long-lasting chronic phase there is a further up-regulation of NFG and p75 expression in the skin; 5). trkA mRNA expression inversely correlates with p75 and NGF mRNA expression. These results suggest that CFA chronic inflammation evolves from inflammation to a small fibers sensory neuropathy and NGF seems to play a role in both events.

Clawed toes deformity due to spasticity of the extensor digitorum muscle. A case report

Spasticity is a characteristic and early component of the lesions of the pyramidal tract of demyelinising diseases such as multiple sclerosis, and is included in the chief neurological scales to evaluate this disease. We report the case of a woman with a clawed toes deformity caused by spasticity of the extensor digitorum (longus and brevis) muscles.

Pulsed venous flow pattern with hemodilution

Venous flow pattern changes and venous flow were assessed in relation to the degree of hemodilution. Femoral vein flow was measured with a duplex scanner in two groups of 11 patients 20 days and 5 days preoperatively, and 1 day postoperatively. In group I, hemodilution was used and patients gave three autologous blood predonations between day 20 and day 5. Perioperative blood loss was reintegrated by electrolyte solution. In group II, hemodilution was not used and autologous blood predonations were not carried out. These patients received a perioperative homologous blood transfusion of 800 mL. Hemoglobin was lower on day 5 (11.3 +/-1.4 vs 13.1 +/-1 g/dL, p<0.05) and on postoperative day 1 (8.9 +/-1.6 vs 10.6 +/-1, p<0.05) in group I. The decrease in hemoglobin was associated with an increase in blood flow and a pulsed venous flow pattern in 14 of 22 veins after autologous blood predonation and in 21 of 22 veins on postoperative day 1 (p<0.05). Increased venous flow in hemodilution is associated with a pulsed venous flow pattern.

[Gasless laparoscopic cholecystectomy. Our experience with 130 cases compared with 450 cases treated with the CO2 technique]

Alongside the technique based on the creation of an abdominal cavity for surgery following the introduction of gas (usually CO2) into the peritoneal cavity, a new method has been developed. This involves the use of an atraumatic mechanical lifting device connected to the same abdominal wall (gasless laparoscopy). The authors report a technique that uses an inflatable cushion inserted into the abdomen through a periumbilical incision. The cushion is connected to an external motorized hydraulic jack fixed to the operating table, fitted with an electric motor and friction gear. Between May 1991 and June 1998, 580 patients underwent laparoscopic cholecystectomy. Since December 1995 a total of 130 patients have undergone surgery using gasless laparoscopy. Shoulder pain and pain in the upper abdominal quadrant were no longer reported; pain was present in 70% of the patients operated using the CO2 technique. There was also a marked reduction in the anesthesiological risks, above all in elderly patients with cardiopulmonary insufficiency. Surgical manoeuvres are made easier owing to the possibility of using traditional surgical instruments. Washing and continuous aspiration allow a good control of intraoperative hemostasis, and reduce the phenomenon of lens misting without the risk of losing pneumoperitoneum. Less visibility of the surgical field was reported, particularly in obese patients, above all because of the reduced diaphragmatic distension and the lack of displacement of the intestinal loops. In the authors' opinion the gasless technique is suitable above all in patients affected by cardiopulmonary disorders in whom hypercapnia might represent a significant operating risk.

[Arterial supply in the left colonic flexure]

The authors study the behaviour of the middle colic, left colic superior, middle and inferior and the first sigmoidal arteries in the territory of the terminal portion of the transverse colon, the left colonic flexure and the descending colon. The study was carried out on 1200 angiographies of the superior and inferior mesenteric aa. and on 150 anatomical specimens, surgically extirpated in the course of left emicolectomy operations. Contrary to what is believed by most authors, the left flexure is a colonic tract very well supplied by blood while the descending colon results to be poorly supplied, being served only by one artery (the left sup. colic a.) often of limited caliber and with branches (the middle and the inf. left colic aa.) sometimes totally or partially lacking. In this last colonic tract the vascular continuity, represented by the arterial arcades, is often interrupted. The Riolan's arcade, variously shaped, is to be considered a constant vascular structure (only once it was lacking in this study). Sometimes it is doubled by a second more internal arcade which must not be confused with the intermesenteric arcade. In four of the observed cases, the Riolan's arcade resulted strengthened by a second retroperitoneal arcade, derived from a branching of the middle colic a., whose branches of division went to the two colonic flexures and descended along the postero-lateral walls of the ascending and descending colon, often parallel to the regular abdominal branches. Exceptionally the colonic flexure is supplied by the only left colic a., which behaves as a specific artery, by us called "dominant artery". The central branches of the artery go to the flexure while the lateral ones join the branches of the middle colic and the first sigmoidal aa., effecting tenuous connections, surgically unreliable. In this case the arterial continuity of the Riolan's arcade can be considered interrupted, at least for the surgical practice. The intermesenteric arcade, in its three forms (direct, mixed and indirect), was observed in 20% of the cases. The colic marginal a. is considered by the authors a tier of arches formed by the colic aa. The left colonic flexure is also supplied by particular vessels originated from the middle colic and the left colic aa. (angular branches and arcades and bridge-branches) or from the superior mesenteric a. (angular artery of Donati) and from other sources, particularly from the splenic a. These vessels then join the colic "vasa recta" through the phrenocolic ligament and the marginal omental vessels. This research shows that the vascular continuity of the left colon is not a constant element, able to reassure the surgeon, for possible interruptions that may occur in its composition.

[Antibiotic prophylaxis with ++vancomycin in corrective surgery with alloplastic material]

The authors report a controlled series of 40 patients treated for recidivating inguinal hernia and laparocele with the implant of alloplastic material. Short-term prophylaxis with vancomycin was performed in all cases. The antibiotic was found to be well tolerated at the doses used and this was associated with a good clinical success rate. The use of vancomycin in prophylaxis for this type of surgery is considered a rational choice and the use of short-term prophylaxis reduces the risks linked to possible collateral effects.

Different mass spectrometric approaches in the identification of endogenous methylated purine bases in urine extracts

A preliminary identification of endogenous and exogenous methylated purine bases in urinary extracts of healthy and tumor-bearing subjects has been performed using high performance liquid chromatography, and tandem mass spectrometry (MS/MS). MS/MS gave particularly fast and sensitive analyses, allowing the simultaneous and rapid determination of 26 different urinary methylated purines. Both sets of data confirm that tumor-bearing patients show changed levels of methylated purine bases.

Folinic acid and 5-fluorouracil as adjuvant chemotherapy in colon cancer

BACKGROUND/AIMS

Colon cancer is one of the major health problems in industrialized countries, and its incidence appears to be increasing. Surgical resectability is the most important prognostic determinant, although despite apparently curative surgery, recurrent tumors are common. Metastatic disease cannot be cured, and thus, there is a need for better adjuvant therapies.

METHODS

Two hundred and thirty-nine patients with surgically resected colon cancer in Dukes' stage B2 or C were randomly assigned to chemotherapy or observation alone to determine whether adjuvant chemotherapy could effectively reduce the rate of cancer recurrence. One hundred and twenty-one patients in stage B2 and 118 patients in stage C were enrolled in the study. Adjuvant treatment consisted of folinic acid 200 mg/m2, intravenously, plus 5-fluorouracil 400 mg/m2, intravenously, on days 1-5 every 4 weeks for 12 cycles.

RESULTS

In stage B2, no significant difference between the adjuvant arm and the observation arm was noted. In stage C, adjuvant chemotherapy produced an advantage over observation in terms of a reduction in cancer recurrence rate with prolongation of a disease-free interval (P = 0.0016) and an improvement in overall survival (P = 0.0025).

CONCLUSIONS

This study shows that folinic acid plus 5-fluorouracil adjuvant chemotherapy is effective in patients with surgically resected Dukes' stage C colon carcinoma.

Toxic injury to rat gut musculature following intraperitoneal administration of 2-t-butyl-4-methoxyphenol

The 100-fold increase in toxicity of intraperitoneal (i.p.) rather than orally administered 2-t-butyl-4-methoxyphenol (BHA) is adduced to the depressive effect which this compound exerts on the contractility of the gut musculature. A structure/activity relation study shows the t-butyl group on the benzene ring as being the major determinant of i.p. BHA toxicity. Contractile activity, elicited by field electrical stimulation, acetylcholine or Ba2+, of the ileum longitudinal muscle preparation from BHA-treated rats was greatly reduced 30 min after i.p. injection, and almost absent during the subsequent 48 h. Electron-microscope examination of ileum longitudinal muscle also showed partial destruction of cell membranes 4 h after BHA administration with subsequent mitochondrial swelling and destruction of cristae, myofibrillar fragmentation and cell necrosis. Comparable suppression of contractile activity and morphological damage were observed in BHA or t-butylbenzene incubated ileum segments where longitudinal smooth muscle contractility was irreversibly depressed in a time- and dose-dependent manner. These convergent findings point to the toxic effect of i.p. BHA on gut musculature with consequent impairment of intestinal transit.

[Fryns syndrome. Description of a case]

We report on a female infant who presents a pattern of malformations including dysmorphic facies, Dandy-Walker anomaly, hypoplasia of the upper lobe of the right lung, associated with diaphragmatic elevation and slight digital anomalies. This whole clinical picture allows us to formulate the diagnosis of Fryns syndrome; this is one of the very few not lethal cases that are reported in literature.

Phenotypic overlaps between pleomorphic malignant T-cell lymphomas and mixed-cellularity Hodgkin's disease

Histologically diagnosed, or in part questionable, malignant pleomorphic peripheral T-cell lymphomas (pPTCLs, n = 16) and mixed-cellularity Hodgkin's disease (MCHD, n = 12) were objectively compared by the use of combined immunohistochemistry on paraffin sections, test-point analysis of tissue components, and semi-automated nuclear morphometry on semi-thin resin sections. Classical, qualitative histomorphological distinction of these sub-types of lymphomas proved to be valid and is probably still the best method. Quantitative discriminant features, in order of decreasing significance, were: (i) expression by large atypical cells (LACs) of CD45R0, CD43 and CD45 in pPTCLs, and of CD30 and CD15 in MCHD; (ii) means and standard deviations (SDs) of LAC nuclear-profile areas (greater in MCHD than in pPTCLs); (iii) expression of CD3 by LACs in pPTCLs; (iv) prominence of small lymphoid cells in MCHD; (v) higher percentage of medium-sized lymphoid cells in pPTCLs; and (vi) higher SDs of nuclear-profile circularity factor of small lymphoid cells in MCHD. The medians of the largest nucleolar profile areas in LACs per field did not differ in pPTCLs and MCHD, but dispersion of individual values towards higher levels was significantly greater in the latter. Stepwise discriminant analysis of test point and nucleometric variables that best distinguished pPTCLs from MCHD revealed considerable overlaps, and questionable cases tended to be intermediate between the two. In conclusion, our results confirm and expand the notion of intra-group heterogeneity, with indistinct borders and the existence of intermediate phenotypes between these two taxonomic categories of malignant lymphomas.

[The origin of the arteria sigmoidea ima]

The authors report the results of their observations on the lowest sigmoid artery, carried out on 92 anatomical specimens coming from surgical operations on the sigmoid and rectum. The specimens were injected and radiographed immediately after their removal . The observations were often preceded by pre-operative angiographies performed for diagnostic reasons. The AA. document all the variational patterns of this artery. They confirm the poor functional value of this artery more known by the old surgeons than by the anatomists.

A case-control study of gastric cancer and diet in Italy. III. Risk patterns by histologic type

In a case-control study of gastric cancer (GC) in high-risk and low-risk areas of Italy, 923 GCs were systematically categorized by one pathologist according to the Lauren classification distinguishing 2 main histologic types, intestinal (55%) and diffuse (23%). Intestinal types outnumbered diffuse types by a 3 to 1 margin in high-risk regions in the north-central part of the country, while both types occurred at nearly equal rates in low-risk areas. Intestinal types also occurred relatively more frequently at older ages and among males. Relative risks of each type of GC were evaluated in relation to dietary and other data obtained from interviews with the cancer patients and controls. The risk patterns for intestinal and diffuse types were remarkably similar. Increased risks of both types were associated with high intake of meat, salted/dried fish, seasoned cheeses and traditional soups, while decreased risks of both types were found among heavy consumers of fresh vegetables and fruits. Correspondingly similar patterns were seen with indices of nutrients, with risks of both intestinal and diffuse GC rising with animal protein intake and declining with consumption of vitamins C and E. Both types were inversely related to socio-economic status, and neither was associated with cigarette smoking. A familial history of GC was reported more frequently by patients with each type than by controls, although the highest risk was for unclassified GC, a group of poorly differentiated and medullary carcinomas accounting for 15% of all GCs in this study. The findings suggest that, despite differences in geographic and demographic patterns, the intestinal and diffuse types of GC have etiologic factors in common.