Impact of a Best Practices Program in Patients with Relapsed/Refractory Multiple Myeloma Receiving Selinexor

Best practice (BP) in cancer care consists of a multifaceted approach comprising individualized treatment plans, evidence-based medicine, the optimal use of supportive care and patient education. We investigated the impact of a BP program in patients with relapsed/refractory multiple myeloma (RRMM) receiving selinexor. Features of the BP program that were specific to selinexor were initiating selinexor at doses ≤80 mg once weekly and the upfront use of standardized antiemetics. Study endpoints included time to treatment failure (TTF), duration of therapy, dose limiting toxicities and overall survival. Comparative analysis on TTF and duration of therapy was conducted using a log-rank test and multivariate Cox proportional hazard regression. Over the ensuing 12-month post-BP period, 41 patients received selinexor-based therapy compared to 68 patients who received selinexor-based therapy pre-BP implementation. Patients treated in the post-BP period had reductions in TTF (hazard ratio [HR] = 0.50; 95% CI: 0.27 to 0.92). Patients in the pre-BP period were four times more likely to stop therapy than those in the post-period (odds ratio [OR] = 4.0, 95% CI: 1.75 to 9.3). The findings suggest a BP program tailored to selinexor could increase the time to treatment failure, increase treatment duration and lower the incidence of drug limiting toxicities.

Systematic review and meta-analysis of the effects of menopause hormone therapy on risk of Alzheimer's disease and dementia

Introduction

Despite a large preclinical literature demonstrating neuroprotective effects of estrogen, use of menopausal hormone therapy (HT) for Alzheimer's disease (AD) risk reduction has been controversial. Herein, we conducted a systematic review and meta-analysis of HT effects on AD and dementia risk.

Methods

Our systematic search yielded 6 RCT reports (21,065 treated and 20,997 placebo participants) and 45 observational reports (768,866 patient cases and 5.5 million controls). We used fixed and random effect meta-analysis to derive pooled relative risk (RR) and 95% confidence intervals (C.I.) from these studies.

Results

Randomized controlled trials conducted in postmenopausal women ages 65 and older show an increased risk of dementia with HT use compared with placebo [RR = 1.38, 95% C.I. 1.16-1.64, p < 0.001], driven by estrogen-plus-progestogen therapy (EPT) [RR = 1.64, 95% C.I. 1.20-2.25, p = 0.002] and no significant effects of estrogen-only therapy (ET) [RR = 1.19, 95% C.I. 0.92-1.54, p = 0.18]. Conversely, observational studies indicate a reduced risk of AD [RR = 0.78, 95% C.I. 0.64-0.95, p = 0.013] and all-cause dementia [RR = .81, 95% C.I. 0.70-0.94, p = 0.007] with HT use, with protective effects noted with ET [RR = 0.86, 95% C.I. 0.77-0.95, p = 0.002] but not with EPT [RR = 0.910, 95% C.I. 0.775-1.069, p = 0.251]. Stratified analysis of pooled estimates indicates a 32% reduced risk of dementia with midlife ET [RR = 0.685, 95% C.I. 0.513-0.915, p = 0.010] and non-significant reductions with midlife EPT [RR = 0.775, 95% C.I. 0.474-1.266, p = 0.309]. Late-life HT use was associated with increased risk, albeit not significant [EPT: RR = 1.323, 95% C.I. 0.979-1.789, p = 0.069; ET: RR = 1.066, 95% C.I. 0.996-1.140, p = 0.066].

Discussion

These findings support renewed research interest in evaluating midlife estrogen therapy for AD risk reduction.

In vivo Brain Estrogen Receptor Expression By Neuroendocrine Aging And Relationships With Gray Matter Volume, Bio-Energetics, and Clinical Symptomatology

17β-estradiol,the most biologically active estrogen, exerts wide-ranging effects in brain through its action on estrogen receptors (ERs), influencing higher-order cognitive function and neurobiological aging. However, our knowledge of ER expression and regulation by neuroendocrine aging in the living human brain is limited. This in vivo multi-modality neuroimaging study of healthy midlife women reveals progressively higher ER density over the menopause transition in estrogen-regulated networks. Effects were independent of age and plasma estradiol levels, and were highly consistent, correctly classifying all women as being post-menopausal or not. Higher ER density was generally associated with lower gray matter volume and blood flow, and with higher mitochondria ATP production, possibly reflecting compensatory mechanisms. Additionally, ER density predicted changes in thermoregulation, mood, cognition, and libido. Our data provide evidence that ER density impacts brainstructure, perfusion and energy production during female endocrine aging, with clinical implications for women's health.

Palliative care outpatients in a German comprehensive cancer center-identifying indicators for early and late referral

PURPOSE

Despite that early integration of palliative care is recommended in advanced cancer patients, referrals to outpatient specialised palliative care (SPC) frequently occur late. Well-defined referral criteria are still missing. We analysed indicators associated with early (ER) and late referral (LR) to SPC of an high volume outpatient unit of a comprehensive cancer center.

METHODS

Characteristics, laboratory parameters and symptom burden of 281 patients at first SPC referral were analysed. Timing of referral was categorized as early, intermediate and late (> 12, 3-12 and < 3 months before death). Ordinal logistic regression analysis was used to identify factors related to referral timing. Kruskal-Wallis test was used to determine symptom severity and laboratory parameter in each referral category.

RESULTS

LRs (50.7%) had worse scores of weakness, loss of appetite, drowsiness, assistance of daily living (all p < 0.001) and organisation of care (p < 0.01) in contrast to ERs. The mean symptom sum score was significantly higher in LRs than ERs (13.03 vs. 16.08; p < 0.01). Parameters indicative of poor prognosis, such as elevated LDH, CRP and neutrophil-to-lymphocyte ratio (NLR) (p < 0.01) as well as the presence of ascites (p < 0.05), were significantly higher (all p < 0.001) in LRs. In univariable analyses, psychological distress (p < 0.05) and female gender (p < 0.05) were independently associated with an ER.

CONCLUSION

A symptom sum score and parameters of poor prognosis like NLR or LDH might be useful to integrate into palliative care screening tools.

Progressive superficial siderosis from Chronic CSF leak as a long-term complication of cervical anterior corpectomy: A case report and review of the literature

Background:

Superficial siderosis of the central nervous system (SSCNS) is a rare progressive neurological disorder resulting from chronic subarachnoid hemorrhage and subsequent subpial hemosiderin deposition. A prolonged cerebrospinal fluid (CSF) leak is a known cause of SSCNS. We present a novel case where progressive SSCNS resulted from a chronic CSF leak related to an anterior cervical corpectomy.

Case Description:

A 73-year-old man presented with gait ataxia and progressive hearing loss. Thirteen years before, he had undergone a combined anterior-posterior cervical decompression for symptomatic ossification of the posterior longitudinal ligament (OPLL). The presenting MR imaging showed extensive superficial siderosis and focal spinal cord herniation at the site of a ventral dural defect at the corpectomy site. A CT myelogram showed extensive CSF leakage into the corpectomy surgical site and a communicating pseudomeningocele in the anterior neck.

Conclusion:

This is the first reported case of progressive SSCNS as a long-term complication of an anterior cervical corpectomy for OPLL. Clinicians should be aware of SSCNS secondary to a chronic CSF leak in patients with a prior corpectomy.

Prenatal diagnosis of rhombencephalosynapsis: neuroimaging features and severity of vermian anomaly

OBJECTIVES

To describe the prenatal neuroimaging spectrum of rhombencephalosynapsis (RES) and criteria for its classification according to the severity of vermian anomaly.

METHODS

In this multicenter retrospective study of fetuses with RES between 2002 and 2020, the medical records and brain ultrasound and magnetic resonance images were evaluated comprehensively to determine the severity of the vermian anomaly and the presence of associated brain findings. RES was classified, according to the pattern of vermian agenesis and the extent of the fusion of the hemispheres, as complete RES (complete absence of the vermis) or partial RES (further classified according to the part of the vermis that was missing and, consequently, the region of hemispheric fusion, as anterior, posterior, severe or mixed RES). Findings were compared between cases with complete and those with partial RES.

RESULTS

Included in the study were 62 fetuses with a gestational age ranging between 12 and 37 weeks. Most had complete absence of the vermis (complete RES, 77.4% of cases), a 'round-shaped' cerebellum on axial views (72.6%) and a transverse cerebellar diameter (TCD) < 3^rd centile (87.1%). Among the 22.6% of cases with partial RES, 6.5% were classified as severe partial, 6.5% as partial anterior, 8.1% as partial mixed and 1.6% as partial posterior. Half of these cases presented with normal or nearly normal cerebellar morphology and 28.5% had a TCD within the normal limits. Infratentorially, the fourth ventricle was abnormal in 88.7% of cases overall, and anomalies of the midbrain and pons were frequent (93.5% and 77.4%, respectively). Ventriculomegaly was observed in 80.6% of all cases, being more severe in cases with complete RES than in those with partial RES, with high rates of parenchymal and septal disruption.

CONCLUSIONS

This study provides prenatal neuroimaging criteria for the diagnosis and classification of RES, and identification of related features, using ultrasound and magnetic resonance imaging. According to our findings, a diagnosis of RES should be considered in fetuses with a small TCD (severe cerebellar hypoplasia) and/or a round-shaped cerebellum on axial views, during the second or third trimester, especially when associated with ventriculomegaly. Partial RES is more common than previously thought, but presents an extreme diagnostic challenge, especially in cases with normal or nearly-normal cerebellar morphobiometric features. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Sarcoid-Associated Bilateral Multifocal Choroiditis Secondary to Adalimumab

Purpose:

To report a rare paradoxical development of systemic sarcoidosis in a patient taking adalimumab manifesting as multifocal choroidal infiltrates and seventh nerve palsy.

Methods:

This was a single patient case report.

Results:

A 30-year-old man with a history of psoriatic arthritis on adalimumab presented with intermittent fevers and headaches. Initial infectious serology and initial ophthalmic examination were within normal limits. Over the next month, he developed a seventh nerve palsy, unilateral decreased visual acuity, and bilateral multifocal choroidal infiltrates. The patient was diagnosed with systemic sarcoidosis secondary to tumor necrosis factor alpha (TNFα) inhibitor use after a hilar lymph node biopsy. Upon treatment with high-dose oral corticosteroids, the patient's symptoms and choroidal lesions significantly improved.

Conclusion:

This case report illustrates a rare presentation of ocular, neurologic, and systemic sarcoidosis presenting as a bilateral multifocal choroiditis and seventh nerve paresis in a patient treated with adalimumab. We highlight the importance of obtaining an ophthalmic evaluation in the management of this rare adverse effect of TNFα inhibitors.

[Evaluation of outpatient medical pain management in Germany : Results of an internet-based cross-sectional survey among pain specialists in outpatient departments]

Hintergrund

Nach den Kriterien der Qualitätssicherungsvereinbarung Schmerztherapie (QSV) nahmen zum Stichtag 31.12.2016 1206 Ärztinnen und Ärzte an der ambulanten Versorgung chronischer Schmerzpatienten teil. Bei in weiten Teilen bestehender Unterversorgung chronischer Schmerzpatienten fehlen Daten zur Einschätzung der ambulanten Schmerztherapie durch die Schmerztherapeuten selbst.

Methoden

In einem Hybrid-Delphi-Verfahren wurde ein Fragebogen zur inhaltlichen, strukturellen und persönlichen Bewertung der ambulanten Schmerztherapie in Deutschland entwickelt.

Mit diesem Instrument wurde eine internetbasierte Querschnittsbefragung von 281 QSV-Schmerzmedizinern aus vier Bundesländern (Berlin, Niedersachsen, Sachsen, Baden-Württemberg) und aller universitären Schmerzambulanzleiter (n = 36) in Deutschland durchgeführt.

Ergebnisse

Die Befragung erzielte eine bereinigte Rücklaufquote von insgesamt 35,9 %. Bei den Schmerzambulanzleitern antworteten 66,7 %. Bei 91 % der Befragten lag der Anteil an chronisch Schmerzkranken in der Praxis bei über 70 %. 67,3 % geben an, mit ihrer Praxissituation zufrieden zu sein, auf der anderen Seite äußern 63,4 % ihre Unzufriedenheit mit der aktuellen Organisation der Schmerzmedizin in Deutschland insgesamt. Diese Unzufriedenheit zeigt sich vor allem in Bezug auf die Budgetregelungen (69,3 %), die Kooperation mit Psychotherapeuten (69,3 %) und die interdisziplinäre Vernetzung (50,5 %). Als gute Vorbereitung für den späteren Beruf werden die einjährige Weiterbildung bei einem Weiterbildungsbefugten (87,1 %) und die Teilnahme an dem Kurs „Psychosomatische Grundversorgung“ (90,1 %) bewertet. Vielfältige Freitextkommentare weisen darauf hin, dass die Ausbildung zu kurz und nicht ausreichend sei. Die Mehrheit der Befragten hält es sowohl aus Arztsicht (61,4 %) wie auch aus Patientensicht (54,5 %) für sinnvoll, einen Facharzt für Schmerzmedizin als Versorgungsmodell zu etablieren. 70,8 % der Schmerzambulanzleiter sprechen sich für eigenständige Strukturen mit eigenem Budget aus, 75,0 % geben an, dass ihre Ambulanz unter den aktuellen Bedingungen nicht kostendeckend arbeitet. In Bezug auf die aktuelle Ausbildungssituation berichten nur 39,7 % der QSV-Schmerztherapeuten in der Niederlassung, dass sie auch Ärzte ausbilden, 57,6 % von ihnen planen zudem, ihre Tätigkeit innerhalb der nächsten 10 Jahre aufzugeben.

Schlussfolgerungen

Die mangelnde Eigenständigkeit der Schmerzmedizin und die unzureichend ausgebauten ambulanten Versorgungsnetzwerke tragen dazu bei, dass Schmerztherapeuten mit vielen Aspekten ihrer Tätigkeit unzufrieden sind. Die Etablierung eines Facharztes für Schmerztherapie wird als eine gute Lösung für eine bessere schmerzmedizinische Versorgung und für die Nachwuchsproblematik gesehen.

Individualized clinical management of patients at risk for Alzheimer's dementia

INTRODUCTION

Multidomain intervention for Alzheimer's disease (AD) risk reduction is an emerging therapeutic paradigm.

METHODS

Patients were prescribed individually tailored interventions (education/pharmacologic/nonpharmacologic) and rated on compliance. Normal cognition/subjective cognitive decline/preclinical AD was classified as Prevention. Mild cognitive impairment due to AD/mild-AD was classified as Early Treatment. Change from baseline to 18 months on the modified Alzheimer's Prevention Cognitive Composite (primary outcome) was compared against matched historical control cohorts. Cognitive aging composite (CogAging), AD/cardiovascular risk scales, and serum biomarkers were secondary outcomes.

RESULTS

One hundred seventy-four were assigned interventions (age 25-86). Higher-compliance Prevention improved more than both historical cohorts (P = .0012, P < .0001). Lower-compliance Prevention also improved more than both historical cohorts (P = .0088, P < .0055). Higher-compliance Early Treatment improved more than lower compliance (P = .0007). Higher-compliance Early Treatment improved more than historical cohorts (P < .0001, P = .0428). Lower-compliance Early Treatment did not differ (P = .9820, P = .1115). Similar effects occurred for CogAging. AD/cardiovascular risk scales and serum biomarkers improved.

DISCUSSION

Individualized multidomain interventions may improve cognition and reduce AD/cardiovascular risk scores in patients at-risk for AD dementia.

Active Control of the Spoof Plasmon Propagation in Time Varying and Non-reciprocal Metamaterial

We present an efficient concept based on time varying and non reciprocal metamaterials to achieve an active control of the spoof plasmon (SP) propagation at sub-wavelength scale. An experimental demonstration of non-reciprocal guiding device based on split ring resonator is proposed as an application of this concept in the microwave regime. We show that this device is able to blue-shift the propagated SP waves and to achieve an active steering of these SPs at sub-wavelength scale by controlling the modulation frequency of the time varying metamaterial. This approach could be extended plainly to infrared and optical regimes by considering suitable technologies.

Abstract TP507: Sex-Related Differences in Neonatal Stroke: International Maternal Newborn Stroke Registry

Background: There is evidence that male neonates have higher incidences of ischemic stroke and associated limitations in brain repair compared to female neonates. We used data from the International Maternal Newborn Stroke Registry (IMNSR) to further explore neonatal sex differences in demographics, birth characteristics, stroke onset, and maternal factors.

Methods: Eleven international sites participated; 8 entered data for this analysis. Eligible participants with newborn (28 weeks gestation to 28 postnatal days) ischemic or hemorrhagic stroke or cerebral venous thrombosis were identified prospectively and retrospectively and enrolled. Preterm infants born before 28 weeks and neonates with germinal matrix intraventricular hemorrhage were excluded. We collected APGAR scores at 1 and 5 minutes, resuscitation status, demographics, stroke type, maternal and gestational age at birth, and mother’s health conditions at birth. Descriptive statistics were performed to identify differences in female versus male neonate cases related to demographics, pregnancy-related factors, and birth-related factors.

Results: We analyzed 68 cases, 38 males and 30 females. Median maternal age for all cases was 31 y (IQR 29-34). Compared to females, males were more likely to have a lower APGAR 1 score and receive resuscitation, and more likely to have a stroke onset within the first week of life. This data set did not show significant gender-related differences in stroke type, or maternal health concerns during pregnancy (Table).

Conclusions: We found that males with newborn strokes had more complications at birth and were more likely to have strokes present in the first week of life than females. Further research on the reasons for these sex differences is needed.

In vivo laser Doppler holography of the human retina

The eye offers a unique opportunity for the non-invasive exploration of cardiovascular diseases. Optical angiography in the retina requires sensitive measurements, which hinders conventional full-field laser Doppler imaging schemes. To overcome this limitation, we used digital holography to perform laser Doppler perfusion imaging of human retina with near-infrared light. Two imaging channels with a slow and a fast CMOS camera were used simultaneously for real-time narrowband measurements, and offline wideband measurements, respectively. The beat frequency spectrum of optical interferograms recorded with the fast (up to 75 kHz) CMOS camera was analyzed by short-time Fourier transformation. Power Doppler images drawn from the Doppler power spectrum density qualitatively revealed blood flow in retinal vessels over 512 × 512 pixels covering 2.4 × 2.4 mm² on the retina with a temporal resolution down to 1.6 ms. The sensitivity to lateral motion as well as the requirements in terms of sampling frequency are discussed.

Abstract TP36: Medical Specialty and Training of Physicians Performing Mechanical Thrombectomy for Acute Ischemic Stroke in the U.S

Introduction: We sought to determine the medical specialty and training of U.S. physicians who perform mechanical thrombectomy for stroke.

Methods: We analyzed claims between 2009-2015 from a 5% nationally representative sample of Medicare beneficiaries ≥65 years of age. Validated ICD-9-CM diagnosis codes were used to identify hospitalizations for acute ischemic stroke. Mechanical thrombectomy was defined as a physician claim with CPT code 37184 and an accompanying diagnosis of cerebrovascular disease. Medical specialty was identified using the claim’s Medicare provider specialty code. We reviewed public online profiles to ascertain providers’ residency and fellowship training. Statistical analysis involved chi-square tests and kappa statistics.

Results: During 77,774 stroke hospitalizations, we identified 555 thrombectomies, of which 341 (61.4%; 95% CI, 57.2-65.5%) were performed by radiologists, 110 (19.8%; 95% CI, 16.6-23.4%) by neurologists, 91 (16.4%; 95% CI, 13.4-19.7%) by neurosurgeons, and 13 (2.3%; 95% CI, 1.3-4.0%) by others such as cardiologists and vascular surgeons. Of the 555 procedures, 367 (66.1%; 95% CI, 62.0-70.1%) were performed by a physician who had completed a dedicated neurointerventional fellowship. There was excellent agreement (91.4%; kappa, 0.86) between Medicare specialty designations and the online profiles of the 350 physicians who performed these 555 procedures. The rate of mechanical thrombectomy rose from 0.62% (95% CI, 0.56-0.68%) before publication of the MR CLEAN trial to 1.45% (95% CI, 1.21-1.72%) after, but there was no significant change after its publication in the distribution of providers’ specialties or the proportion of procedures performed by those with neurointerventional fellowship training (Figure).

Conclusions: Most mechanical thrombectomies for stroke in the U.S. are performed by radiologists, neurologists, and neurosurgeons with dedicated neurointerventional fellowship training.

Does persisting fear sustain catatonia?

OBJECTIVE

To examine the psychological substrate of catatonia.

METHOD

Reviewing the historical descriptions and explanations of catatonic behaviours by clinicians from its delineation in the 19th century to the present.

RESULTS

Patients with catatonia are often haunted by fears and terrors; this has not been widely appreciated, and certainly was lost from view in the days when catatonia was considered a subtype of schizophrenia. The report contributes to resolving a major question in catatonia: is the mind in stupor inactive, as the blank state that we picture in anesthetized patients, or is the mind active, so preoccupied as to exclude all other influences.

THE MAIN FINDING

Persistent fear occupies the mind of catatonic patients.

CONCLUSION

The signs of catatonia are adaptations to persistent fear, akin to tonic immobilization. The relief afforded by sedation supports this interpretation.

Impact of viral hepatitis aetiology on survival outcomes in hepatocellular carcinoma: A large multicentre cohort study

While HBV and HCV are risk factors for HCC, uncertainty exists as to whether these viral infections have prognostic significance in HCC. Thus, we compared the overall survival of patients with HBV, HCV and nonviral HCC, and evaluated whether the presence of HBV and HCV predicts patient outcomes. We conducted a multicentre study of HCC cases diagnosed at six Melbourne tertiary hospitals between Jan 2000-Dec 2014. Patient demographics, liver disease and tumour characteristics and patient outcomes were obtained from hospital databases, computer records and the Victorian Death Registry. Survival outcomes were compared between HBV, HCV and nonviral hepatitis cases and predictors of survival determined using Cox proportional hazards regression. There were 1436 new HCC cases identified including 776 due to viral hepatitis (HBV 235, HCV 511, HBV-HCV 30) and 660 from nonviral causes. The median survival of HBV, HCV and nonviral HCC patients was 59.1, 28.4 and 20.9 months, respectively (P<.0001). On multivariate analysis, independent risk factors for survival included HCC aetiology, gender, BCLC stage, serum AFP, total number and size of lesions, and serum creatinine and albumin. After adjusting for these and method of detection, HBV remained an independent predictor of improved overall survival when compared to both nonviral (HR 0.60%, 95% CI 0.35-0.98; P=.03) and HCV-related HCC (HR 0.51%, 95% CI 0.30-0.85; P=.01). In this large multicentre study, HBV is independently associated with improved overall survival compared with HCV and nonviral-related HCC. Further studies are needed to determine the underlying factor(s) responsible.

New Mobile Stroke Unit Programs Aim to Improve Outcomes

Now well-established throughout Europe, mobile stroke unit (MSU) programs are in the early stages of development in the United States. The concept aims to improve outcomes by bringing diagnostic capabilities and clot-busting care to the patients experiencing stroke, thereby reducing the time to treatment. In October, New York Presbyterian/Weill Cornell Medical Center in New York became the first medical center on the East Coast to deploy an MSU, and in July, the University of Tennessee College of Medicine in Memphis deployed a first-of-its-kind MSU that is larger and more robust than other MSUs currently in use. In the first month of operation, the MSU in New York responded to 29 calls and brought 12 patients to the hospital with suspected strokes. Two of these patients received tissue plasminogen activator in the field and both made full recoveries by the next day. The MSU deployed in Memphis is larger and carries more sophisticated diagnostic equipment than other MSUs. The program also replies on doctorally prepared, vascular neurology fellowship-trained nurse practitioners, instead of relying on telemedicine connections to external experts. Now operating with the assistance of grant funding, leaders of both programs hope that strong outcomes will prove convincing to hospitals and prayers, although the U.S. healthcare model complicates the establishment of a reimbursement structure for MSUs.

High speed optical holography of retinal blood flow

We performed noninvasive video imaging of retinal blood flow in a pigmented rat by holographic interferometry of near-infrared laser light backscattered by retinal tissue, beating against an off-axis reference beam sampled at a frame rate of 39 kHz with a high throughput camera. Local Doppler contrasts emerged from the envelopes of short-time Fourier transforms and the phase of autocorrelation functions of holograms rendered by Fresnel transformation. This approach permitted imaging of blood flow in large retinal vessels (∼30 microns diameter) over 400×400  pixels with a spatial resolution of ∼8 microns and a temporal resolution of ∼6.5  ms.

Assessing particle kinematics via template matching algorithms

Template matching algorithms represent a viable tool to locate particles in optical images. A crucial factor of the performance of these methods is the choice of the similarity measure. Recently, it was shown in [Gao and Helgeson, Opt. Express 22 (2014)] that the correlation coefficient (CC) leads to good results. Here, we introduce the mutual information (MI) as a nonlinear similarity measure and compare the performance of the MI and the CC for different noise scenarios. It turns out that the mutual information leads to superior results in the case of signal dependent noise. We propose a novel approach to estimate the velocity of particles which is applicable in imaging scenarios where the particles appear elongated due to their movement. By designing a bank of anisotropic templates supposed to fit the elongation of the particles we are able to reliably estimate their velocity and direction of motion out of a single image.

Mathematical modeling and simulation in animal health. Part I: Moving beyond pharmacokinetics

The application of mathematical modeling to problems in animal health has a rich history in the form of pharmacokinetic modeling applied to problems in veterinary medicine. Advances in modeling and simulation beyond pharmacokinetics have the potential to streamline and speed-up drug research and development programs. To foster these goals, a series of manuscripts will be published with the following goals: (i) expand the application of modeling and simulation to issues in veterinary pharmacology; (ii) bridge the gap between the level of modeling and simulation practiced in human and veterinary pharmacology; (iii) explore how modeling and simulation concepts can be used to improve our understanding of common issues not readily addressed in human pharmacology (e.g. breed differences, tissue residue depletion, vast weight ranges among adults within a single species, interspecies differences, small animal species research where data collection is limited to sparse sampling, availability of different sampling matrices); and (iv) describe how quantitative pharmacology approaches could help understanding key pharmacokinetic and pharmacodynamic characteristics of a drug candidate, with the goal of providing explicit, reproducible, and predictive evidence for optimizing drug development plans, enabling critical decision making, and eventually bringing safe and effective medicines to patients. This study introduces these concepts and introduces new approaches to modeling and simulation as well as clearly articulate basic assumptions and good practices. The driving force behind these activities is to create predictive models that are based on solid physiological and pharmacological principles as well as adhering to the limitations that are fundamental to applying mathematical and statistical models to biological systems.

The Region of Difference Four is a Robust Genetic Marker for Subtyping Mycobacterium caprae Isolates and is Linked to Spatial Distribution of Three Subtypes

Alpine Mycobacterium caprae isolates found in cattle and red deer display at least three genetic variations in the region of difference four (RD4) that can be used for further differentiation of the isolates into the subtypes 'Allgäu', 'Karwendel' and 'Lechtal'. Each genomic subtype is thereby characterized by a specific nucleotide deletion pattern in the 12.7-kb RD4 region. Even though M. caprae infections are frequently documented in cattle and red deer, little is known about the transmission routes. Hence, robust markers for M. caprae subtyping are needed to gain insight into the molecular epidemiology. For this reason, a rapid and robust multiplex PCR was developed for the simultaneous detection of three M. caprae RD4 subtypes and was used to subtype a total number of 241 M. caprae isolates from animals (145 cattle, 95 red deer and one fox) from Bavaria and Austria. All three subtypes occur spatially distributed and are found in cattle and in red deer suggesting transmission between the two species. As subtypes are genetically stable in both species it is hypothesized that the described genetic variations developed within the host due to 'within-host replication'. The results of this study recommend the genomic RD4 region as a reliable diagnostic marker for M. caprae subtype differentiation.

Abstract 188: Safety of Stroke Thrombolysis During Pregnancy: A Population-Based Analysis

Background: Use of tissue plasminogen activator (TPA) during pregnancy is controversial given potential risks of placental and fetal complications. Since knowledge on this topic is limited, we assessed rates of TPA use during pregnancy and the associated patient characteristics and outcomes in a population-based sample of patients.

Methods: We used administrative claims data on all discharges from nonfederal emergency departments and acute care hospitals in California, Florida, and New York between 2005 and 2012. Pregnancy was defined as the 40 weeks prior to delivery or abortive outcome. Using a validated ICD-9-CM diagnosis code algorithm, we identified cases of ischemic stroke, as well as cases of intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH) since these may represent hemorrhagic transformation of an infarct. We included only the first recorded stroke to focus on incident cases. TPA use was identified by ICD-9-CM procedure code 99.10, which has been validated as 98% specific in this population. Comparisons between groups were made using Fisher’s exact test and t-test or rank-sum test as appropriate.

Results: Among 428,564 women with stroke, 599 cases occurred during pregnancy. The rate of TPA use for stroke was significantly lower during pregnancy (1.2%; 95% CI, 0.4-2.4%) than otherwise (3.5%; 95% CI, 3.4-3.6%; P = 0.001). Among pregnant stroke patients, we found few notable differences in the baseline characteristics of the 7 who received TPA versus the 592 who did not: those receiving TPA had higher rates of heart failure (28.6% versus 2.2%; P = 0.01) and pneumonia (14.3% versus 1.2%; P = 0.09) and lower rates of of pre-eclampsia (0.0% versus 29.1%; P = 0.09). There were no notable differences between pregnant stroke patients who did or did not receive TPA in terms of length of hospital stay, discharge disposition, and in-hospital mortality rate. However, we noted a significantly higher rate of abortive pregnancy outcomes during stroke hospitalization in those who received TPA than those who did not (28.6% versus 4.6%; P = 0.04).

Conclusion: We found a significantly higher rate of abortive pregnancy outcomes in patients who received TPA. This suggests the need for caution and further research regarding TPA use for stroke in pregnancy.

What was learned: studies by the consortium for research in ECT (CORE) 1997-2011

OBJECTIVE

To review the findings of the four-hospital collaborative studies of electroconvulsive therapy (ECT) in unipolar depressed patients known as CORE between 1997 and 2011. Unipolar depressed patients were treated with bilateral ECT, and on remission were randomly assigned to a fixed schedule continuation ECT or to combined lithium and nortriptyline for 6 months. A second study compared three electrode placements in unipolar and bipolar depressed patients.

METHOD

Nineteen published reports were reviewed. The findings are compared with those of a parallel multi-hospital study of ECT led by a Columbia University Collaboration (CUC) team that studied right unilateral ECT in a similar population with similar inclusion/exclusion and remission criteria. Successful ECT was followed by placebo, nortriptyline alone, or combined lithium, and nortriptyline.

RESULTS

Relapse rates after remission were similar with fixed schedule ECT as with medications. Predictors of outcome (psychosis, suicide risk, polarity, melancholia, atypical depression, age) and technical aspects (electrode placement, seizure threshold, speed of response) are discussed,

CONCLUSION

The findings offer criteria to optimize the selection of patients, the technique, and outcome of ECT for unipolar and bipolar depressed patients. Continuation ECT is an effective alternative to continuation treatment with lithium and nortriptyline. Bilateral electrode placement is more efficient than alternative placements. ECT relieves both bipolar and unipolar depression.

Metric precision via soft-tissue landmarks in three-dimensional structured-light scans of human faces

OBJECTIVES

The goal of the current work was to investigate the suitability of ten facial soft-tissue landmarks (trichion, glabella, nasion, left and right orbital, subnasal, left and right porion, pogonion, gnathion) as reference points for metric facial analysis by analyzing their intra- and interserial precision in all three dimensions.

METHODS

The faces of 32 volunteers were scanned using a standardized protocol with a structured-light scanner (FaceSCAN(3D) Scientific Photolab 60 Hz; 3D Shape, Erlangen, Germany). Three examiners placed the landmarks twice within a 2-week interval. Image processing (Onyx Ceph(3); Image Instruments; Chemnitz, Germany) and statistical (SAS 9.2; SAS Institute, Cary, NC, USA) software was used for analysis. All measurements were corrected for mean values per patient and analyzed for intraserial and interserial error by model II ANOVA for a simple classification with random effects.

RESULTS

Median intraserial precision was 0.40 mm (range 0.05-1.01 mm) overall, including 0.40 mm (0.33-0.85 mm) on the x-axis, 0.64 mm (0.36-0.87 mm) on the y-axis, and 0.27 mm (0.05-1.01 mm) on the z-axis. Interserial precision was substantially lower at a median of 0.05 mm (0-0.22 mm), often not statistically assessable with intraserial precision. We observed no landmark-associated differences; in particular, the medians of the bilateral landmarks orbital (intraserial: 0.40 mm; interserial: 0.02 mm) and porion (intraserial: 0.36 mm; interserial: small and not assessable) were in the middle of the range of our results. Trichion (intraserial: 0.73 mm; interserial: 0.05 mm) and gnathion (intraserial: 0.87 mm; interserial: 0.20 mm) revealed the highest degrees of intraserial measurement imprecision. Outliers were identified in 1.2% (64 of 5400) of measurements.

CONCLUSION

All selected landmarks offer suitably high levels of intra- and interserial precision for the three-dimensional (3D) metric assessment of facial soft-tissue parameters. No difference between (bi)lateral and facial midline landmarks was noted.

Efficient HEX-Program Evaluation Based on Unfounded Sets

HEX-programs extend logic programs under the answer set semantics with external computations through external atoms. As reasoning from ground Horn programs with nonmonotonic external atoms of polynomial complexity is already on the second level of the polynomial hierarchy, minimality checking of answer set candidates needs special attention. To this end, we present an approach based on unfounded sets as a generalization of related techniques for ASP programs. The unfounded set detection is expressed as a propositional SAT problem, for which we provide two different encodings and optimizations to them. We then integrate our approach into a previously developed evaluation framework for HEX-programs, which is enriched by additional learning techniques that aim at avoiding the reconstruction of the same or related unfounded sets. Furthermore, we provide a syntactic criterion that allows one to skip the minimality check in many cases. An experimental evaluation shows that the new approach significantly decreases runtime.