Cue-exposure treatment influences resting-state functional connectivity-a randomized controlled fMRI study in alcohol use disorder

RATIONALE

Cue-exposure therapy (CET) consists of exposing patients to the cause of their affliction in a controlled environment and after psychological preparation. Ever since it was conceived, it has been suggested as a treatment for different types of behavioural impairments, from anxiety disorders to substance abuse. In the field of addictive behaviour, many different findings have been shown regarding the effectiveness of this therapy.

OBJECTIVES

This study aims to examine the underlying neurobiological mechanisms of the effects of CET in patients with alcohol use disorder using resting-state functional magnetic resonance imaging (rs-fMRI).

METHODS

In a randomized, controlled study, we examined patients after inpatient detoxification as well as healthy controls. Patients underwent nine sessions of CET spaced over 3 weeks. Rs-fMRI was conducted before treatment and 3 weeks after treatment onset in patients, healthy controls received only one rs-fMRI measurement. The final participant sample with complete data included 35 patients in the CET group, 17 patients in the treatment-as-usual group, and 43 HCs.

RESULTS

Our results show differences in the Salience Network when comparing the CET group to the treatment-as-usual group (TAU). Functional connectivity between the anterior cingulate Cortex (ACC) and the insula was increased after CET, whereas it was decreased from ACC to the putamen and globus pallidus. Further, increased connectivity with the precuneus was found in the dorsal attention network after cue exposure treatment.

CONCLUSIONS

These findings suggest that cue exposure therapy changes the resting-state brain connectivity with additional effects to the standard psychotherapy treatment. Hence, our study results suggest why including CET in standard therapies might improve the preparation of patients in front of daily situations.

Clinical characteristics, management, and outcomes of acute heart failure patients in Central Asia

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiovascular disease (CVD) is the leading cause of death in Central Asia. In 2019, crude mortality rate in the region was 348.13 per 100,000 population. Heart failure (HF) is important CVD subtype owing to even worse outcome. There has been a dearth of information on the epidemiology of HF in Central Asia.

Purpose

we aimed to describe aetiology, comorbidities, adherence to guideline-directed medical therapy (GDMT), and outcomes in patients hospitalised for heart failure in Central Asian population.

Methods

the retrospective analysis included 538 patients hospitalised for decompensated heart failure in a tertiary hospital from December 2011 to December 2019. Inclusion criteria were (i) age ≥18 years; (ii) hospitalisation for HF treatment. Exclusion criteria were (i) pregnancy; (ii) comorbidity with survival time considered to be <1 year on the basis of patients` medical history; (iii) acute HF caused by acute myocardial infarction, metabolic, toxic or infectious disorders. Primary outcome was one-year all-cause mortality, secondary outcome - readmission for HF at one year. Given that the data had been collected retrospectively, informed consent was not obtained, nevertheless, local ethics committee approved the study.

Results

Central Asian patients were relatively young (mean age 64.0 years), 61.2% of them were male, 77.7% had ischemic heart disease, 8.7% rheumatic heart disease, 32.2% obstructive pulmonary disease, 47.7% atrial fibrillation/flutter, 45.7% hyperlipidemia, 72.1% hypertension, and 31.6% diabetes mellitus. Use of GDMT at discharge was 76.0% for beta-blockers, 29.7% for angiotensin-converting enzyme inhibitors, 21.2% for angiotensin II receptor blockers, 71.9% for mineralocorticoid receptor antagonists. Only 3.9% of patients were implanted with a pacemaker and 0.9% with an implantable cardioverter defibrillator. All-cause mortality at one year was 19.0%, with no difference between patients with preserved and reduced ejection fraction (14.9 vs. 19.9%, p=0.243). However, patients with preserved ejection fraction were less likely to experience a readmission for heart failure at one year (13.9 vs. 29.3%, p=0.002).

Conclusions

results of the analysis showed that Central Asian patients are relatively young, mostly male, with high prevalence of ischemic heart disease, and reduced ejection fraction, and lower rate of GDMT use and device therapy.

Brain age as a surrogate marker for cognitive performance in multiple sclerosis

Background and purpose

Data from neuro‐imaging techniques allow us to estimate a brain's age. Brain age is easily interpretable as ‘how old the brain looks’ and could therefore be an attractive communication tool for brain health in clinical practice. This study aimed to investigate its clinical utility by investigating the relationship between brain age and cognitive performance in multiple sclerosis (MS).

Methods

A linear regression model was trained to predict age from brain magnetic resonance imaging volumetric features and sex in a healthy control dataset (HC_train, n = 1673). This model was used to predict brain age in two test sets: HC_test (n = 50) and MS_test (n = 201). Brain‐predicted age difference (BPAD) was calculated as BPAD = brain age minus chronological age. Cognitive performance was assessed by the Symbol Digit Modalities Test (SDMT).

Results

Brain age was significantly related to SDMT scores in the MS_test dataset (r = −0.46, p < 0.001) and contributed uniquely to variance in SDMT beyond chronological age, reflected by a significant correlation between BPAD and SDMT (r = −0.24, p < 0.001) and a significant weight (−0.25, p = 0.002) in a multivariate regression equation with age.

Conclusions

Brain age is a candidate biomarker for cognitive dysfunction in MS and an easy to grasp metric for brain health.

Investigation of brain functional connectivity to assess cognitive control over cue-processing in Alcohol Use Disorder

Alcohol Use Disorder has been associated with impairments of functional connectivity between neural networks underlying reward processing and cognitive control. Evidence for aberrant functional connectivity between the striatum, insula, and frontal cortex in alcohol users exists at rest, but not during cue-exposure. In this study, we investigated functional connectivity changes during a cue-reactivity task across different subgroups of alcohol consumers. Ninety-six participants (ranging from light social to heavy social drinkers and nonabstinent dependent to abstinent dependent drinkers) were examined. A functional magnetic resonance imaging cue-reactivity paradigm was administered, during which alcohol-related and neutral stimuli were presented. Applying psychophysiological interaction analyses, we found: (a) Abstinent alcohol-dependent patients compared with non-abstinent dependent drinkers showed a greater increase of functional connectivity of the ventral striatum and anterior insula with the anterior cingulate cortex and dorsolateral prefrontal cortex during the presentation of alcohol cues compared with neutral cues. (b) Subjective craving correlated positively with functional connectivity change between the posterior insula and the medial orbitofrontal cortex and negatively with functional connectivity change between the ventral striatum and the anterior cingulate cortex, dorsolateral prefrontal cortex, and lateral orbitofrontal cortex. (c) Compulsivity of alcohol use correlated positively with functional connectivity change between the dorsolateral prefrontal cortex and the ventral striatum, anterior insula, and posterior insula. Results suggest increased cognitive control over cue-processing in abstinent alcohol-dependent patients, compensating high levels of cue-provoked craving and compulsive use. Clinical trial registration details: ClinicalTrials.gov ID: NCT00926900.

Tricuspid valve Swan-Ganz catheter entrapment before cardiac surgery

A Swan-Ganz catheter during cardiac surgery offers peri-operative haemodynamic monitoring, although insertion of these catheters is not without risk. We report a case of Swan-Ganz catheter entrapment within the tricuspid valve during elective off-pump coronary artery bypass surgery. The diagnosis was made immediately by transoesophageal echocardiography, thus preventing forced withdrawal of the catheter. Intra-operatively, the echocardiographically detected findings of complex entrapment was confirmed. The Swan-Ganz catheter was tightly wrapped around the subvalvular apparatus, requiring on-pump open surgical removal. This case illustrates the anatomical complexity of such a catheter entrapment around the tricuspid valve apparatus and the importance of rapid echocardiographic diagnosis to prevent iatrogenic damage.

Dynamic frontostriatal functional peak connectivity (in alcohol use disorder)

Alcohol use disorder (AUD) is associated with changes in frontostriatal connectivity, but functional magnetic resonance imaging (fMRI) functional connectivity (FC) approaches are usually not adapted to these circuits. We developed a circuit‐specific fMRI analysis approach to detect dynamic changes in frontostriatal FC inspired by medial‐ventral‐rostral to lateral‐dorsal‐caudal frontostriatal gradients originally identified in nonhuman primate tract‐tracing data. In our PeaCoG (“peak connectivity on a gradient”) approach we use information about the location of strongest FC on empirical frontostriatal connectivity gradients. We have recently described a basic PeaCoG version with conventional FC, and now developed a dynamic PeaCoG approach with sliding‐window FC. In resting state data of n = 66 AUD participants and n = 40 healthy controls we continue here the analyses that we began with the basic version. Our former result of an AUD‐associated ventral shift in right orbitofrontal cortex PeaCoG is consistently detected in the dynamic approach. Temporospatial variability of dynamic PeaCoG in the left dorsolateral prefrontal cortex is reduced in AUD and associated with self‐efficacy to abstain and days of abstinence. Our method has the potential to provide insight into the dynamics of frontostriatal circuits, which has so far been relatively unexplored, and into their role in mental disorders and normal cognition.

Intra-patient potassium variability after hypothermic cardiac arrest: a multicentre, prospective study

Background

To date, the decision to set up therapeutic extra-corporeal life support (ECLS) in hypothermia-related cardiac arrest is based on the potassium value only. However, no information is available about how the analysis should be performed. Our goal was to compare intra-individual variation in serum potassium values depending on the sampling site and analytical technique in hypothermia-related cardiac arrests.

Methods

Adult patients with suspected hypothermia-related refractory cardiac arrest, admitted to three hospitals with ECLS facilities were included. Blood samples were obtained from the femoral vein, a peripheral vein and the femoral artery. Serum potassium was analysed using blood gas (BGA) and clinical laboratory analysis (CL).

Results

Of the 15 consecutive patients included, 12 met the principal criteria, and 5 (33%) survived. The difference in average potassium values between sites or analytical method used was ≤1 mmol/L. The agreement between potassium values according to the three different sampling sites was poor. The ranges of the differences in potassium using BGA measurement were − 1.6 to + 1.7 mmol/L; − 1.18 to + 2.7 mmol/L and − 0.87 to + 2 mmol/L when comparing respectively central venous and peripheral venous, central venous and arterial, and peripheral venous and arterial potassium.

Conclusions

We found important and clinically relevant variability in potassium values between sampling sites. Clinical decisions should not rely on one biological indicator. However, according to our results, the site of lowest potassium, and therefore the preferred site for a single potassium sampling is central venous blood. The use of multivariable prediction tools may help to mitigate the risks inherent in the limits of potassium measurement.

Trial registration

ClinicalTrials.gov Identifier: NCT03096561.

Shifts in the functional topography of frontal cortex-striatum connectivity in alcohol use disorder

Frontostriatal circuits are centrally involved in the selection of behavioral programs and play a prominent role in alcohol use disorder (AUD) as well as other mental disorders. However, how frontal regions change their striatal connectivity to implement adaptive cognitive control is still not fully understood. Here, we developed an approach for functional magnetic resonance imaging (fMRI) connectivity analysis in which we change the focus from connectivity to individual voxels towards spatial information about the location of strongest functional connectivity. In resting state data of n = 66 participants with AUD and n = 40 healthy controls (HC) we used the approach to estimate frontostriatal connectivity gradients consistent with nonhuman primate tract-tracing studies, characterized for each frontal voxel the striatal peak connectivity location on this gradient (PeaCoG), and tested for group differences and associations with clinical variables. We identified a cluster in the right orbitofrontal cortex (rOFC) with a peak connectivity shift towards ventral striatal regions in AUD. Reduced variability of rOFC striatal peak connectivity in the AUD group suggests a "clamping" to the ventral striatum as the underlying effect. Within the AUD group striatal peak connectivity in the superior frontal gyrus was associated with self-efficacy to abstain from alcohol, in the medial frontal and dorsolateral prefrontal cortex with alcohol dependency, and in the right inferior frontal gyrus with the urge to consume alcohol. Our results demonstrate that the functional topography of frontostriatal circuits exhibits interindividual variability, which provides insight into frontostriatal network adaptations in AUD and potentially other mental disorders.

Complications and results of the arthrodesis after total ankle arthroplasty failure: a retrospective monocentric study of 12 cases

INTRODUCTION

Total ankle arthroplasty (TAA) has the objective to maintain the range of motion of the tibiotarsal joint and to preserve the nearby joints. However, the complication rate and failures remain quite high after TAA. The main objective of the study was to evaluate the improvement in the functional scores of the tibiotarsal arthrodesis after TAA failure. The secondary objective was to assess the specific complications.

MATERIALS AND METHODS

This monocentric retrospective series includes 12 patients (nine men, three women, average age 52.5 years) operated between 2003 and 2018. An iliac graft was used in all cases. The arthrodesis was stabilized either by screws or by retrograde nailing.

RESULTS

The reoperation was due to painful malleolar conflicts or loosening. The AOFAS score increased from 38/100 to 67/100 (51-86) post-operatively. The fusion was acquired at 3.7 months (3-6) except in two cases.

DISCUSSION AND CONCLUSION

The 83% primary fusion rate is in the low average of the literature and 92% fusion rate in the high average after reoperation. All patients were improved even in two non-unions. The results of this study confirm that the arthrodesis after TAA failure is a reliable alternative to the TAA replacement. However, they are lower than those after a first-line arthrodesis.

Association of the alcohol dehydrogenase gene polymorphism rs1789891 with gray matter brain volume, alcohol consumption, alcohol craving and relapse risk

Alcohol metabolizing enzymes, such as the alcohol dehydrogenases and the aldehyde dehydrogenases, regulate the levels of acetaldehyde in the blood and play an important role in the development and maintenance of alcohol addiction. Recent genome-wide systematic searches found associations between a single nucleotide polymorphism (rs1789891, risk allele: A, protective allele: C) in the alcohol dehydrogenase gene cluster and the risk of alcohol dependence. The current study investigated the effect of this single nucleotide polymorphism on alcohol consumption, craving for alcohol, relapse risk and brain gray matter volume. Alcohol-dependent patients (n = 74) and controls (n = 43) were screened, genotyped and underwent magnetic resonance imaging scanning, and relapse data were collected during 3 months following the experiment. Alcohol-dependent A allele carriers reported increased alcohol craving and higher alcohol consumption compared with the group of alcohol-dependent individuals homozygous for the C allele, which displayed craving values similar to the control group. Further, follow-up data indicated that A allele carriers relapsed earlier to heavy drinking compared with individuals with two C alleles. Analyses of gray matter volume indicated a significant genotype difference in the patient group: individuals with two C alleles had reduced gray matter volume in the left and right superior, middle and inferior temporal gyri. Findings of the current study further support the relevance of genetic variants in alcohol metabolizing enzymes to addictive behavior, brain tissue volume and relapse risk. Genotype-dependent differences in acetaldehyde formation, implicated by earlier studies, might be the biological substrate of the genotype differences.

The SyBil-AA real-time fMRI neurofeedback study: protocol of a single-blind randomized controlled trial in alcohol use disorder

BACKGROUND

Alcohol Use Disorder is a highly prevalent mental disorder which puts a severe burden on individuals, families, and society. The treatment of Alcohol Use Disorder is challenging and novel and innovative treatment approaches are needed to expand treatment options. A promising neuroscience-based intervention method that allows targeting cortical as well as subcortical brain processes is real-time functional magnetic resonance imaging neurofeedback. However, the efficacy of this technique as an add-on treatment of Alcohol Use Disorder in a clinical setting is hitherto unclear and will be assessed in the Systems Biology of Alcohol Addiction (SyBil-AA) neurofeedback study.

METHODS

N = 100 patients with Alcohol Use Disorder will be randomized to 5 parallel groups in a single-blind fashion and receive real-time functional magnetic resonance imaging neurofeedback while they are presented pictures of alcoholic beverages. The groups will either downregulate the ventral striatum, upregulate the right inferior frontal gyrus, negatively modulate the connectivity between these regions, upregulate, or downregulate the auditory cortex as a control region. After receiving 3 sessions of neurofeedback training within a maximum of 2 weeks, participants will be followed up monthly for a period of 3 months and relapse rates will be assessed as the primary outcome measure.

DISCUSSION

The results of this study will provide insights into the efficacy of real-time functional magnetic resonance imaging neurofeedback training in the treatment of Alcohol Use Disorder as well as in the involved brain systems. This might help to identify predictors of successful neurofeedback treatment which could potentially be useful in developing personalized treatment approaches.

TRIAL REGISTRATION

The study was retrospectively registered in the German Clinical Trials Register (trial identifier: DRKS00010253 ; WHO Universal Trial Number (UTN): U1111-1181-4218) on May 10th, 2016.

Orbitofrontal structural markers of negative affect in alcohol dependence and their associations with heavy relapse-risk at 6 months post-treatment

BACKGROUND

Alcohol relapse is often occurring to regulate negative affect during withdrawal. On the neurobiological level, alcoholism is associated with gray matter (GM) abnormalities in regions that regulate emotional experience such as the orbitofrontal cortex (OFC). However, no study to our knowledge has investigated the neurobiological unpinning of affect in alcoholism at early withdrawal and the associations of OFC volume with long-term relapse risk.

METHODS

One hundred and eighty-two participants were included, 95 recently detoxified alcohol dependent patients (ADP) and 87 healthy controls (HC). We measured affective states using the positive and negative affect schedule (PANAS). We collected T1-weighted brain structural images and performed Voxel-based morphometry (VBM).

RESULTS

Findings revealed GM volume decrease in alcoholics in the prefrontal cortex (including medial OFC), anterior cingulate gyrus, and insula. GM volume in the medial OFC was positively associated with NA in the ADP group. Cox regression analysis predicted that risk to heavy relapse at 6 months increases with decreased GM volume in the medial OFC.

CONCLUSIONS

Negative affect during alcohol withdrawal was positively associated with OFC volume. What is more, increased GM volume in the OFC also moderated risk to heavy relapse at 6 months. Reduced GM in the OFC poses as risk to recovery from alcohol dependence and provides valuable insights into transient negative affect states during withdrawal that can trigger relapse. Implications exist for therapeutic interventions signifying the OFC as a neurobiological marker to relapse and could explain the inability of ADP to regulate internal negative affective states.

Frontostriatal Connectivity During Reward Anticipation

Abstract. Neurobiological research indicates that altered reward processing is among the most promising risk mechanisms in alcohol use disorder and depression. To elucidate differences and similarities between both disorders, we investigated clinical patients and at-risk individuals in two studies using a functional magnetic resonance imaging (fMRI) monetary reward paradigm. In the first study, alcohol use disorder patients compared to depressed and healthy individuals showed increased activation of the ventral striatum during reward anticipation. In contrast, both patient groups showed reduced frontostriatal connectivity compared to controls. In the second study, at-risk comorbid individuals showed decreased activation in the dorsal striatum along with decreased frontostriatal connectivity. While the connectivity results replicate the common pattern found for the patient groups, the activation results indicate a more depression-related pattern in individuals prone to developing both disorders. In conclusion, frontostriatal connectivity might be a promising transdiagnostic marker for depression, alcohol use disorder, and their comorbidity.

Striatal activation and frontostriatal connectivity during non-drug reward anticipation in alcohol dependence

According to prevailing neurobiological theories of addiction, altered function in neural reward circuitry is a central mechanism of alcohol dependence. Growing evidence postulates that the ventral striatum (VS), as well as areas of the prefrontal cortex, contribute to the increased incentive salience of alcohol-associated cues, diminished motivation to pursue non-drug rewards and weakened strength of inhibitory cognitive control, which are central to addiction. The present study aims to investigate the neural response and functional connectivity underlying monetary, non-drug reward processing in alcohol dependence. We utilized a reward paradigm to investigate the anticipation of monetary reward in 32 alcohol-dependent inpatients and 35 healthy controls. Functional magnetic resonance imaging was used to measure task-related brain activation and connectivity. Alcohol-dependent patients showed increased activation of the VS during anticipation of monetary gain compared with healthy controls. Generalized psychophysiological interaction analyses revealed decreased functional connectivity between the VS and the dorsolateral prefrontal cortex in alcohol dependent patients relative to controls. Increased activation of the VS and reduced frontostriatal connectivity were associated with increased craving. These findings provide evidence that alcohol dependence is rather associated with disrupted integration of striatal and prefrontal processes than with a global reward anticipation deficit.

GATA4 variant interaction with brain limbic structure and relapse risk: A voxel-based morphometry study

Atrial natriuretic peptide (ANP) receptors are highly expressed in the amygdala, caudate and hypothalamus. GATA4 gene encodes a transcription factor of ANP associated with the pathophysiology of alcohol dependence. We have previously demonstrated that the GATA4 single nucleotide polymorphism (SNP) rs13273672 revealed stronger alcohol-specific amygdala activation associated with lowered relapse risk to heavy drinking at 90 days in the AA-homozygotes. Our understanding however with respect to GATA4 variation on gray matter (GM) regional amygdala, caudate and hypothalamus volume is limited. We investigated GM differences specific to GATA4 and hypothesized that GM alterations will be predictive of heavy relapse. Eighty-three recently detoxified alcohol dependent patients were included. Neuroimaging data was analyzed using Voxel Based Morphometry (VBM). The main effects of GM volume and genotype as well as their interaction effect on time to heavy relapse (60 and 90 days) were analyzed using cox regression. Significant higher GM volume was found for the AA-genotype group compared with AG/GG-genotype in the hypothalamus and caudate. A significant interaction was revealed between caudate and amygdala GM volume and GATA4 genotype on time to heavy relapse. The interaction was expressed by means of higher GM in the AA genotype group to be associated with reduced risk to relapse whereas in the AG/GG group higher GM was associated with increased risk to relapse. This is the first report on GM regional volume alterations specific to GATA4 genotype [(SNP) rs13273672] and its association with relapse in alcohol dependence. Current findings further support the role of GATA4 in alcoholism.

Real-time functional magnetic resonance imaging neurofeedback can reduce striatal cue-reactivity to alcohol stimuli

It has been shown that in alcoholic patients, alcohol-related cues produce increased activation of reward-related brain regions like the ventral striatum (VS), which has been proposed as neurobiological basis of craving. Modulating this activation might be a promising option in the treatment of alcohol addiction. One approach might be real-time functional magnetic resonance imaging neurofeedback (rtfMRI NF). This study was set up to implement and evaluate a rtfMRI approach in a group of non-addicted heavy social drinkers. Thirty-eight heavy drinking students were assigned to a real feedback group (rFB, n = 13), a yoke feedback group (yFB, n = 13) and a passive control group (noFB, n = 12). After conducting a reward task as functional localizer to identify ventral striatal regions, the participants viewed alcohol cues during three NF training blocks in a 3 T MRI scanner. The rFB group received feedback from their own and the yFB from another participants' VS. The noFB group received no feedback. The rFB and the yFB groups were instructed to downregulate the displayed activation. Activation of the VS and prefrontal control regions was compared between the groups. We found significant downregulation of striatal regions specifically in the rFB group. While the rFB and the yFB groups showed significant activation of prefrontal regions during feedback, this activation was only correlated to the reduction of striatal activation in the rFB group. We conclude that rtfMRI NF is a suitable method to reduce striatal activation to alcohol cues. It might be a promising supplement to the treatment of alcoholic patients.

[Importance of preoperative and intraoperative imaging for operative strategies]

Recent advances in preoperative and postoperative imaging have an increasing influence on surgical decision-making and make more complex surgical interventions possible. This improves the possibilities for frequently occurring challenges and promoting improved functional and oncological outcome. This manuscript reviews the role of preoperative and intraoperative imaging in surgery. Various techniques are explained based on examples from hepatobiliary surgery and neurosurgery, in particular real-time procedures, such as the online use of augmented reality and in vivo fluorescence, as well as new and promising optical techniques including imaging of intrinsic signals and vibrational spectroscopy.

Inter-rater Agreement in Three Perfusion-Computed Tomography Evaluation Methods before Endovascular Therapy for Acute Ischemic Stroke

PURPOSE

There is ongoing debate on which method of perfusion computed tomography (PCT) evaluation in ischemic stroke is the most appropriate for improved selection of patients for endovascular treatment. We sought to test different assessment methods for inter-rater reliability.

METHODS

Twenty-six patients were enrolled prospectively before endovascular therapy for acute anterior circulation ischemic stroke. Three raters experienced in stroke imaging and blinded to other imaging and clinical information independently analyzed 22 technically successful PCT scans according to 3 prespecified assessment methods applied to cerebral blood flow (CBF)/cerebral blood volume (CBV) and time-to-peak (TTP) maps: (1) visual mismatch estimate (VME), (2) Alberta Stroke Program Early CT Score perfusion method (ASPECTS-PCT), and (3) quantitative perfusion ratios (qPRs): RCBF, RCBV, RTTP. Inter-rater agreement was assessed with Cohen's kappa, intraclass correlation coefficients (ICC), Bland-Altman plots, and global and descriptive statistics.

RESULTS

Significant differences between raters were found with VME and ASPECTS-PCT (P < .001) but with qPRs only for CBV (P = .03). Inter-rater agreement for VME was at best moderate by kappa statistics (.51); moderate by ICC for all parametric maps of ASPECTS-PCT (.56-.62), strong for RTTP (.76), and excellent for RCBF (.92) and RCBV (.86). Pairwise comparisons revealed less scattering of individual values with qPRs and less deviation of mean differences from 0, suggesting minor systematic deviation by any 1 rater as compared with VME or ASPECTS-PCT.

CONCLUSION

PCT evaluation methods used before endovascular therapy for acute anterior circulation stroke are subject to substantial inter-rater disagreement. QPRs in PCT evaluation had better inter-rater reliability than the often used VME and ASPECTS-PCT assessment.

The effects of single nucleotide polymorphisms in glutamatergic neurotransmission genes on neural response to alcohol cues and craving

The aim of the current study was to determine genotype effects of four single nucleotide polymorphisms (SNPs) in the genes of the N-Methyl-d-aspartate receptor (GRIN1, GRIN2A, GRIN2C) and kainate receptor (GRIK1), which have been previously associated with alcoholism, on behavior, neural cue-reactivity and drinking outcome. Eighty-six abstinent alcohol dependent patients were recruited from an in-patient setting. Neuropsychological tests, genotyping and functional magnetic resonance imaging (fMRI) were used to study genotype effects. GRIN2C risk allele carriers displayed increased alcohol cue-induced activation in the anterior cingulate cortex (ACC) and dorsolateral prefrontal cortex (dlPFC). Neural activation in the ACC positively correlated with craving for alcohol (r = 0.201, P = 0.032), whereas activation in the dlPFC showed a negative association (r = -0.215, P = 0.023). In addition, dlPFC activation predicted time to first relapse (HR = 2.701, 95%CI 1.244-5.864, P = 0.012). GRIK1 risk allele carriers showed increased cue-induced activation in the medial prefrontal (PFC) and orbitofrontal cortex (OFC) and in the lateral PFC and OFC. Activation in both clusters positively correlated with alcohol craving (rmedOFC, medPFC  = 0.403, P = 0.001, rlatOFC, latPFC  = 0.282, P = 0.008), and activation in the cluster that encompassed the medial OFC predicted time to first relapse (HR = 1.911, 95%CI 1.030-3.545, P = 0.040). Findings indicate that SNPs in the GRIN2C and GRIK1 genes are associated with altered cue-induced brain activation that is related to craving for alcohol and relapse risk.

Intraoperative identification of somato-sensory brain areas using optical imaging and standard RGB camera equipment – a feasibility study

Intraoperative Optical Imaging (IOI) is a neuro-imaging technique that allows the visualization of changes in optical properties of the brain cortex. Recent developments enhanced the method regarding the robustness under intraoperative conditions. However, the necessity of additional hardware still limits the use in the operating room (OR). Since modern surgical microscopes are potentially equipped with all required hardware for imaging, we investigated the possible use of such standard RGB camera for IOI. Measurements were performed on eight patients. Changes in optical properties of the cortical surface were acquired with a monochrome CCD camera (AxioCam MRm) and simultaneously with a standard RGB camera (Trio 610). Maps of cortical activity were calculated from the image data and the quality of these maps was assessed with a spatial signal-to-noise ratio. Activity maps calculated from AxioCam MRm data showed highest SNR in six out of eight patients. In two patients the activity map calculated from Trio 610 red channel performed best overall. The Trio 610 maps calculated from red channel data performed best in three out of eight cases like the activity maps calculated from green channel data, whereas the activity map calculated from blue channel data performed best in only two cases. If the color channel with the highest SNR is chosen in each patient for comparison to AxioCam MRm, the median of the SNR (SNR AxioCam /SNRBestColorChannel ) is 84 % (Quartile 1 (Q1): 78 %, Quartile 3 (Q3): 99%). Results reveal that the integration of the Intraoperative Optical Imaging method into the OR and surgical workflow can be further improved by using RGB camera equipment. A robust identification of somato-sensory areas seems possible. Due to the gain of information from different wavelength bands the need for intelligent evaluation algorithms is increased and should therefore be topic of future research.

Increased mesolimbic cue-reactivity in carriers of the mu-opioid-receptor gene OPRM1 A118G polymorphism predicts drinking outcome: a functional imaging study in alcohol dependent subjects

The endogenous opioid system is involved in the pathophysiology of alcohol-use disorders. Genetic variants of the opioid system alter neural and behavioral responses to alcohol. In particular, a single nucleotide polymorphism rs1799971 (A118G) in the mu-opioid receptor gene (OPRM1) is suggested to modulate alcohol-related phenotypes and neural response in the mesocorticolimbic dopaminergic system. Little is known about the clinical implications of these changes. The current study investigated the relationship of genotype effects on subjective and neural responses to alcohol cues and relapse in a sample of abstinent alcohol-dependent patients. Functional magnetic resonance imaging (fMRI) was used to investigate alcohol cue-reactivity and drinking outcome of 81 abstinent alcohol-dependent patients. G-allele carriers displayed increased fMRI cue-reactivity in the left dorsal striatum and bilateral insulae. Neural responses to alcohol cues in these brain regions correlated positively with subjective craving for alcohol and positive expectations of alcohol׳s effects. Moreover, alcohol cue-reactivity in the left dorsal striatum predicted time to first severe relapse. Current results show that alcohol-dependent G-allele carriers׳ increased cue-reactivity is associated with an increased relapse risk. This suggests that genotype effects on cue-reactivity might link the OPRM1 A118G risk allele with an increased relapse risk that was reported in earlier studies. From a clinical perspective, risk-allele carriers might benefit from treatments, such as neuro-feedback or extinction-based therapy that are suggested to reduce mesolimbic reactivity.

Bridge to transplantation using paracorporeal biventricular assist devices or the syncardia temporary total artificial heart: is there a difference?

AIM

Biventricular support can be achieved using paracorporeal ventricular assist devices (p-BiVAD) or the Syncardia temporary total artificial heart (t-TAH). The purpose of the present study was to compare survival and morbidity between these devices.

METHODS

Data from 2 French neighboring hospitals were reviewed. Between 1996 and 2009, 148 patients (67 p-BiVADs and 81 t-TAH) underwent primary, planned biventricular support. There were 128 (86%) males aged 44±13 years.

RESULTS

Preoperatively, p-BiVAD recipients had significantly lower systolic and diastolic blood pressures, more severe hepatic cytolysis and higher white blood cell counts than t-TAH recipients. In contrast, t-TAH patients had significantly higher rates of pre-implant ECLS and hemofiltration. Mean support duration was 79±100 days for the p-BiVAD group and 71±92 for t-TAH group (P=0.6). Forty two (63%) p-BiVAD recipients were bridged to transplantation (39, 58%) or recovery (3, 5%), whereas 51 (63%) patients underwent transplantation in the t-TAH group. Death on support was similar between groups (p-BiVAD, 26 (39%); t-TAH, 30 (37%); P=0.87). Survival while on device was not significantly different between patient groups and multivariate analysis showed that only preimplant diastolic blood pressure and alanine amino-transferase levels were significant predictors of death. Post-transplant survival in the p-BiVAD group was 76±7%, 70±8%, and 58±9% at 1, 3, and 5 years after transplantation, respectively, and was similar to that of the t-TAH group (77±6%, 72±6%, and 70±7%, P=0.60).

CONCLUSION

Survival while on support and up to 5 years after heart transplantation was not significantly different in patients supported by p-BiVADs or t-TAH. Multivariate analysis revealed that survival while on transplantation was not affected by the type of device implanted.

[Interdisciplinary emergency room - key to success?]

In Germany, which is also faced with a scarcity of resources, the concept of central, interdisciplinary emergency rooms ("Zentrale Notfallaufnahme", ZNA) is being developed as an answer to the complex demands of modern emergency medicine with increasing numbers of patients and complexity of the medical conditions. This autonomous institution is the first point of contact for all emergency patients. The central tasks of the ZNA are triage and the interdisciplinary primary treatment of patients. The establishment of the ZNA includes specific facilities (treatment rooms, short stay units, resuscitation rooms, triage and management areas, integration of the premises on site) as well as specific processes (triage systems, specific standard operating procedures) and training for the staff (European Curriculum for Emergency Medicine). It could be shown that by establishing a ZNA along with all its structures the satisfaction of the patients (including shorter waiting times), resource management (intensive care capacity), and patient outcome could be significantly improved.

Perfluorodecalin-soluble fluorescent dyes for the monitoring of circulating nanocapsules with intravital fluorescence microscopy

Perfluorodecalin (PFD) is an established artificial oxygen carrier due to its physical capability to solve the respiratory gases oxygen and carbon dioxide. PFD-filled poly(n-butyl-cyanoacrylate) (PACA) nanocapsules are already discussed as effective artificial oxygen carriers, and their principal suitability for intravenous administration had been shown. To further elucidate their action in vivo, it is imperative to characterise their preclinical safety and particularly their biodistribution. For these purposes, intravital fluorescence microscopy would display an attractive technique in order to monitor the PACA nanocapsules in vivo, but unfortunately, it is impossible to stain the PACA nanocapsules with a fluorescent dye fulfilling special criteria required for in vivo microscopy. In order to develop such a dye, a long-chained fluorinated thiol was used to modify a BODIPY derivative that is a highly fluorescent organic compound belonging to the difluoro-boraindacene family, as well as to functionalise mesoscopic systems, such as CdSe/ZnS-quantum dots and gold nanoparticles. Furthermore, a functionalisation of porphyrin derivatives was investigated by placing divalent ions in the centre of these systems. Due to the high solubility of all synthesised dyes in PFD, it should be possible to stain PFD-filled particles in general. However, only the functionalised BODIPY derivative was suitable for in vivo monitoring of the PFD-filled PACA nanocapsules.

[Endovascular treatment of acute ischemic stroke under conscious sedation compared to general anesthesia - safety, feasibility and clinical and radiological outcome]

PURPOSE

Vessel recanalization is an important predictor of clinical outcome in the treatment of acute ischemic stroke. Endovascular therapies are used with increasing frequency. There is no general agreement on the policy of anesthesia during endovascular therapy, ranging from general anesthesia (GA) to local anesthesia at the puncture site with conscious sedation (CS) as needed. The aim of the study was to evaluate the safety and feasibility and radiological and clinical outcome of endovascular stroke therapy under CS.

MATERIALS AND METHODS

We retrospectively included all patients with acute ischemic stroke who were treated with endovascular therapy over a five-year period. Data was evaluated with respect to type of sedation, conversion from CS to GA, recanalization rate, infarct volume and peri- and post-procedural complications.

RESULTS

There was a technical failure in 7 patients. Of the remaining 124 patients (mean age 68.8 ± 14.6 years), 65 were female (52 %). The site of occlusion was located in the anterior circulation in 94 patients (76 %) and in the posterior circulation in 30 cases (24 %). 105 patients (85 %) were treated under CS and 16 cases (13 %) primarily under GA. In 3 cases (2 %) peri-procedural conversion to GA was necessary. Primary intra-arterial thrombolysis, mechanical recanalization only, and combination therapy were performed in 60 (48 %), 27 (22 %) and 37 (30 %) patients, respectively. There were no significant differences for recanalization rate and complications between GA and CS. The mean procedure time was significantly shorter in patients treated under CS (p < 0.01).

CONCLUSION

Endovascular stroke therapy with CS is feasible, can be performed safely and is faster than with GA.

Rocket fuel for the quantification of S-nitrosothiols. Highly specific reduction of S-nitrosothiols to thiols by methylhydrazine

Reduction of S-nitrosothiols to the corresponding thiol function is the key step in analyzing S-nitrosocysteinyl residues in proteins. Though it has been shown to give low yields, ascorbate-dependent reduction is commonly performed in the frequently used biotin-switch technique. We demonstrate that the compound methylhydrazine can act as a specific and efficient reducing agent for S-nitrosothiols. The corresponding thiol function is exclusively generated from low molecular weight and proteinaceous S-nitrosothiols while methylhydrazine failed to reduce disulfides. It was possible to optimize the experimental conditions so that thiol autoxidation is excluded, and high reaction yields (>90%) are obtained for the thiol function. The biotin-switch technique performed with methylhydrazine-dependent reduction shows remarkably improved sensitivity compared to the ascorbate-dependent procedure.

The prognostic value of IDH mutations and MGMT promoter status in secondary high-grade gliomas

Reports about the prognostic value of IDH mutations and the promoter region of the O6-Methyl-guanyl-methyl-transferase gene in secondary high-grade gliomas (sHGG) are few in number. We investigated the prognostic value of IDH mutations and methylation of the promoter region of the MGMT gene in 99 patients with sHGG and analyzed the clinical course of those tumors. Patients with sHGG were screened for IDH mutations by direct sequencing, and, for promoter status of MGMT gene, by the methylation-specific polymerase chain reaction. A total of 48 of 99 patients (48.5 %) had secondary anaplastic gliomas (Group 1), while 51 patients had secondary glioblastomas (Group 2). The median survival time after malignant progression of all patients with sHGG and with an IDH mutation was 4 years, which is significantly longer than in patients with wild-type IDH (1.2 years, p = 0.009). Patients' survival was not significantly influenced by the tumors' MGMT promoter status, both in Group 1- 9.7 years vs. 6.1 years, methylated vs. unmethylated promoter (p = 0.330)-as well as in Group 2-1.5 years vs. 1.6 years, methylated versus unmethylated promoter (p = 0.829). In our population, the IDH mutation status was not associated with increased PFS or median survival time in sGBM patients. However, patients with secondary anaplastic glioma and IDH mutation had a significantly improved outcome. In addition, IDH mutations are a more powerful prognostic marker concerning both PFS and MS than the MGMT promoter status in those patients.