Interictal EEG source connectivity to localize the epileptogenic zone in patients with drug-resistant epilepsy: A machine learning approach

OBJECTIVE

To deconstruct the epileptogenic networks of patients with drug-resistant epilepsy (DRE) using source functional connectivity (FC) analysis; unveil the FC biomarkers of the epileptogenic zone (EZ); and develop machine learning (ML) models to estimate the EZ using brief interictal electroencephalography (EEG) data.

METHODS

We analyzed scalp EEG from 50 patients with DRE who had surgery. We reconstructed the activity (electrical source imaging [ESI]) of virtual sensors (VSs) across the whole cortex and computed FC separately for epileptiform and non-epileptiform EEG epochs (with or without spikes). In patients with good outcome (Engel 1a), four cortical regions were defined: EZ (resection) and three non-epileptogenic zones (NEZs) in the same and opposite hemispheres. Region-specific FC features in six frequency bands and three spatial ranges (long, short, inner) were compared between regions (Wilcoxon sign-rank). We developed ML classifiers to identify the VSs in the EZ using VS-specific FC features. Cross-validation was performed using good outcome data. Performance was compared with poor outcomes and interictal spike localization.

RESULTS

FC differed between EZ and NEZs (p < .05) during non-epileptiform and epileptiform epochs, showing higher FC in the EZ than its homotopic contralateral NEZ. During epileptiform epochs, the NEZ in the epileptogenic hemisphere showed higher FC than its contralateral NEZ. In good outcome patients, the ML classifiers reached 75% accuracy to the resection (91% sensitivity; 74% specificity; distance from EZ: 38 mm) using epileptiform epochs (gamma and beta frequency bands) and 62% accuracy using broadband non-epileptiform epochs, both outperforming spike localization (accuracy = 47%; p < .05; distance from EZ: 57 mm). Lower performance was seen in poor outcomes.

SIGNIFICANCE

We present an FC approach to extract EZ biomarkers from brief EEG data. Increased FC in various frequencies characterized the EZ during epileptiform and non-epileptiform epochs. FC-based ML models identified the resection better in good than poor outcome patients, demonstrating their potential for presurgical use in pediatric DRE.

Altered mechanical interaction between rat plantar flexors due to changes in intermuscular connectivity

Connective tissue formation following muscle injury and remedial surgery may involve changes in the stiffness and configuration of the connective tissues linking adjacent muscles. We investigated changes in mechanical interaction of muscles by implanting either a tissue-integrating mesh (n = 8) or an adhesion barrier (n = 8) to respectively increase or decrease the intermuscular connectivity between soleus muscle (SO) and the lateral gastrocnemius and plantaris complex (LG+PL) of the rat. As a measure of mechanical interaction, changes in SO tendon forces and proximal-distal LG+PL force differences in response to lengthening LG+PL proximally were assessed 1 and 2 weeks post-surgery. The extent of mechanical interaction was doubled 1 week post-implantation of the tissue-integrating mesh compared to an unaffected compartment (n = 8), and was more than four times higher 2 weeks post-surgery. This was found only for maximally activated muscles, but not when passive. Implanting the adhesion barrier did not result in a reduction of the mechanical interaction between these muscles. Our findings indicate that the ratio of force transmitted via myofascial, rather than myotendinous pathways, can increase substantially when the connectivity between muscles is enhanced. This improves our understanding of the consequences of connective tissue formation at the muscle boundary on skeletal muscle function.

Percolation and three-dimensional structure of supercritical water

It is well established that at ambient and supercooled conditions water can be described as a percolating network of H bonds. This work is aimed at identifying, by neutron diffraction experiments combined with computer simulations, a percolation line in supercritical water, where the extension of the H-bond network is in question. It is found that in real supercritical water liquidlike states are observed at or above the percolation threshold, while below this threshold gaslike water forms small, sheetlike configurations. Inspection of the three-dimensional arrangement of water molecules suggests that crossing of this percolation line is accompanied by a change of symmetry in the first neighboring shell of molecules from trigonal below the line to tetrahedral above.

Determination of total and polycyclic aromatic hydrocarbons in aviation jet fuel

The aviation jet fuel widely used in turbine engine aircraft is manufactured from straight-run kerosene. The combustion quality of jet fuel is largely related to the hydrocarbon composition of the fuel itself; paraffins have better burning properties than aromatic compounds, especially naphthalenes and light polycyclic aromatic hydrocarbons (PAHs), which are characterised as soot and smoke producers. For this reason the burning quality of fuel is generally measured as smoke fermation. This evaluation is carried out with UV spectrophotometric determination of total naphthalene hydrocarbons and a chromatographic analysis to determine the total aromatic compounds. These methods can be considered insufficient to evaluate the human health impact of these compounds due to their inability to measure trace (ppm) amounts of each aromatic hyrcarbon and each PAH in accordance with limitations imposed because of their toxicological properties. In this paper two analytical methods are presented. Both are based on a gas chromatographic technique with a mass detector operating in be selected ion monitoring mode. The first method was able to determine more than 60 aromatic hydrocarbons in a fuel sample in a 35-min chromatographic run, while the second was able to carry out the analysis of more than 30 PAHs in a 40-min chromatographic run. The linearity and sensitivity of the methods in measuring these analytes at trace levels are described.

Alginate microparticles for enzyme peroral administration

In order to protect protein and peptide drugs against inactivation by different barriers in the gastro-intestinal tract and to improve their absorption, alginate microparticles as a carrier of L-lactate dehydrogenase, were developed by spray-drying technique. However, alginate complexation and spray-drying conditions led to enzyme activity loss. Such a drawback was overcome by using protectant additives (carboxymethylcellulose sodium salt, polyacrylic acid sodium salt, lactose) preventing the enzyme inactivation by both interaction with alginate and experimental conditions, lactose having the most protective effect. Nevertheless, only polyacrylic acid sodium salt provided a microparticulate structure required for the target of the Peyer's patches.

Determination of phenolic antioxidants in aviation jet fuel

The world-wide aviation jet fuel used for civil and military aircraft is of a kerosene type. To avoid peroxide production after the refinery process a specific antioxidant additive should be added on fuel. The antioxidants generally used are based on hindered phenols in a range of concentration 10-20 microg/ml. In the present work a specific method to measure the concentration of phenolic antioxidants is shown. The method is based on a liquid chromatographic technique with electrochemical detection. The technique, because of its selectivity, does not require sample pre-treatments. The analysis of a 5-10 ml fuel sample can be performed in less than 10 min with a sensitivity of 0.1 microg/ml and a RSD=2.5%. A comparison with another highly selective gas chromatographic technique with mass spectrometric detection with selected ion monitoring (GC-MS-SIM) is reported. The sensitivity of GC-MS-SIM method was 2 microg/ml with a RSD=3.1%.

Surgical closure of muscular ventricular septal defects using double umbrella devices (intraoperative VSD device closure)

OBJECTIVES

Surgical closure of some muscular ventricular septal defects has been proven to be difficult. In order to simplify the surgical technique we have used intraoperatively Rashkind double umbrella devices to occlude muscular ventricular septal defects.

METHODS

On the basis of haemodynamic and echocardiographic study five children aged 4, 6, 7, 14 and 41 months were considered suitable candidates for intraoperative closure of muscular ventricular septal defects (midmuscular in three cases, apical in two) by Rashkind devices. Three of them had previously undergone pulmonary artery banding at 10, 11 and 41 days, respectively. During hypothermic cardiopulmonary by pass a delivery system was introduced across the tricuspid valve into the right ventricle and then passed through the ventricular septal defect; the distal umbrella of a 17 mm device was opened in the left ventricular cavity; a traction was applied to the introducer and the proximal umbrella was opened on the right side straddling the interventricular septum; the device was then secured on the right side by few stitches. In one case because of the wide diameter of the ventricular septal defect two umbrellas were used. The surgical procedure was completed with debanding and/or closure of other defects close to the aortic or tricuspid valve.

RESULTS

Immediate results, tested by epicardial or transesofageal echo, showed a minimal residual shunt in 4 patients and a moderate shunt in one. No early deaths occurred. A complete atrioventricular block developed in 1 patient who had an additional perimembranous defect closed with a prosthetic patch: a permanent pace maker was inserted 3 months after the operation. There was a late death for untractable right ventricular failure in 1 patient who had a large residual shunt erroneously considered moderate. In this patient, the size of the defect was underestimated both preoperatively then intraoperatively. The four survivors are doing well with no signs of hemodynamically significant residual shunts.

CONCLUSIONS

The use of Rashkind umbrella devices for closing intraoperatively muscular defects can be helpful to standard surgical techniques when technical problems make patch closure difficult. Its use avoid the need of left ventriculotomy. Careful definition of the size of the defect is mandatory to select suitable candidates.

[Classification of congenital heart diseases and surgical interventions in pediatric cardiology for the standardization of hospitalization records]

The utilization of DRGs for the evaluation of hospital activity requires the availability, on a current basis, of coded in-patient records (Hospital Discharge Form, SDO) with information concerning nosology of the patient and procedures performed. Consequently, the promotion of a standardized use of ICD.9 and ICD.9.CM code systems (International Classification of Diseases, 9th Revision, and International Classification of Diseases, 9th Revision, Clinical Modification) among clinicians is necessary. The National Research Council, Council Research Hospital for Cardiology and Cardiac Surgery (CREAS-IFC-CNR) has promoted the establishment of a permanent work group for the evaluation of the activity in the field of pediatric cardiology and cardiosurgery at a national level. In co-operation with two leading institution (AO "Bambino Gesù", Rome; AO "G. Gaslini", Genoa) an in-patient survey has been promoted including an overall revision of the ICD.9.CM code systems both for diagnosis and procedures in order to improve the standardization of data. Besides, the fitness of DRGs allocation by different codes has been judged. Some general and specific suggestions upon codes adequacy and DRGs identification have emerged from this study. The aim of this paper is to spread this preliminary standardization activity of the group as a contribution to the improvement of in-patient coded records quality.

Anticholinesterase activity measurement by a choline biosensor: application in water analysis

A choline amperometric biosensor was assembled and used to measure the anticholinesterase activity due to compounds (which have the property to inhibit cholinesterase enzymes) present in water samples. This parameter can be used as a 'toxicological index', defined as the amount of compound which causes a certain percentage of cholinesterase inhibition equivalent to a known amount of a reference compound causing the same percentage inhibition. The organophosphorus insecticide Paraoxon, which has proved to be a strong inhibitor of cholinesterase enzymes, was chosen as the reference compound. The analysis was carried out by monitoring the decrease of cholinesterase activity in the presence of a pesticide and a substrate specific for the enzyme whose reaction produces choline. The decrease in choline production was measured by the choline sensor and correlated to the concentration of anticholinesterase compound present in the solution. Parameters such as buffer, pH, temperature and incubation time were optimized. The rate constant Ki was calculated experimentally for Paraoxon and used in the anticholinesterase activity measurements at different fixed incubation times. The probe was calibrated with different standard solutions of Paraoxon. The effect of Paraoxon and heavy metals on the choline probe was evaluated. This probe was then used for the determination of anticholinesterase activity of some organophosphorus pesticides, and heavy metals in spiked waters. Samples were also analysed by liquid/liquid extraction and GC determination. Results seem to correlate with acute toxicity expressed as LD50 (oral, rat). Analysis of water samples from different sources in central Italy were analysed for total anticholinesterase activity (TAA) and compared with a reference procedure.

Secretion of neurotensin from isolated perfused porcine ileum

The secretion and molecular nature of immunoreactive neurotensin (NT) was studied following stimulation of an isolated perfused porcine ileal segment with glucose, triglyceride and intra-arterial infusion of gastrin-releasing peptide (GRP). Secreted peptides were separated using gel chromatography and analyzed with 3 sequence-specific radioimmunoassays towards NT. Glucose (5%) and GRP both stimulated NT secretion from the ileal segment whereas pure triglyceride did not. Maximal secretion of NT during glucose perfusion was 0.448 nmol/min and 6.9 nmol/min during GRP infusion (medians, n = 5). GRP infused in doses from 10(-10) to 10(-8) M stimulated NT release in a dose-related manner. Following gel chromatography only the intact peptide and no smaller or larger molecular size immunoreactive components were observed. The study showed that both luminal and humoral stimuli release NT from the isolated pig ileum. Apparently no fragments or other NT-related immunoreactive components were cosecreted with the peptide.

Posterior enlargement of the small annulus during aortic valve replacement versus implantation of a small prosthesis

Twenty-two patients with a small aortic annulus were identified among 196 consecutive patients undergoing aortic valve replacement (AVR). The 11 patients in Group 1 underwent posterior enlargement aortic annuloplasty, and the 11 in Group 2 received a small aortic prosthesis (less than or equal to 21 mm). The two groups were unselected. Core hypothermia, cardioplegia, and local cooling were employed for all operations. Isolated AVR was performed in 3 patients in each group. In Group 1, the mean increase in diameter of the annulus was 4.82 mm, which resulted in a mean area increase of 169.91 mm2 (51.7%). Mean aortic cross-clamp times were 140.4 minutes and 93.5 minutes in Groups 1 and 2, respectively. There were 2 operative deaths in Group 1, and 1 operative and 1 late death in Group 2. Mean follow-up was 26.5 months for Group 1 and 43.4 months for Group 2. No thomboembolic or bleeding episodes have been recorded. Considerations and conclusions are offered from the study of this small series of patients.

Correction versus palliation of congenital heart diseases in the first year of life

In the period 1971-1981 220 children below 1 year of age have been operated upon in our Hospital for Congenital Heart Diseases (CHD). Among them, 125 children were selected, in whom, because of the type of CHD present, either a palliation or a correction could have been chosen as the surgical approach. The first three common malformation treated are presented.

Total pericardiectomy for chronic constrictive pericarditis using femoro-femoral bypass

A technique of total pericardiectomy for chronic constrictive pericarditis is presented. The authors have used a femoro-femoral cardiopulmonary bypass in nine cases of constrictive pericarditis to prevent the complications of the traditional approach. The advantages of this technique in comparison to the performance of pericardiectomy without the use of extracorporeal circulation (ECC) or with standard ECC are discussed.

Successful repair of delayed rupture of the left ventricular wall after mitral valve replacement. Report of two cases

Rupture of left ventricular wall (LVWR) following mitral replacement (MVR) is rare (0.5 to 7.3% of all MVR). Two "types" of LVWR have been recognized and attributed to technical errors during MVR and/or to co-existing unfavourable conditions. The two types are precisely located, and appear "early" during operation, at discontinuation of cardiopulmonary bypass (CPB). Miller et al. have described a "third type" LVWR which depends primarily on local conditions, is located between the other two and occurs "late". Successful repair is rare. The outcome is favourably influenced by intraoperative recognition. This paper reports two LVWRs "type III" which occurred among 282 MVR (0.7%) done in our Department since 1977. Both were successfully repaired respectively 12 (and again 48) and 15 hours after MVRs. To the best of our knowledge these are the only cases of successful repair of a "type III" LVWR reported in the literature. On the basis of this experience some considerations are presented.