A generalizable deep voxel-guided morphometry algorithm for the detection of subtle lesion dynamics in multiple sclerosis

Introduction

Multiple sclerosis (MS) is a chronic neurological disorder characterized by the progressive loss of myelin and axonal structures in the central nervous system. Accurate detection and monitoring of MS-related changes in brain structures are crucial for disease management and treatment evaluation. We propose a deep learning algorithm for creating Voxel-Guided Morphometry (VGM) maps from longitudinal MRI brain volumes for analyzing MS disease activity. Our approach focuses on developing a generalizable model that can effectively be applied to unseen datasets.

Methods

Longitudinal MS patient high-resolution 3D T1-weighted follow-up imaging from three different MRI systems were analyzed. We employed a 3D residual U-Net architecture with attention mechanisms. The U-Net serves as the backbone, enabling spatial feature extraction from MRI volumes. Attention mechanisms are integrated to enhance the model's ability to capture relevant information and highlight salient regions. Furthermore, we incorporate image normalization by histogram matching and resampling techniques to improve the networks' ability to generalize to unseen datasets from different MRI systems across imaging centers. This ensures robust performance across diverse data sources.

Results

Numerous experiments were conducted using a dataset of 71 longitudinal MRI brain volumes of MS patients. Our approach demonstrated a significant improvement of 4.3% in mean absolute error (MAE) against the state-of-the-art (SOTA) method. Furthermore, the algorithm's generalizability was evaluated on two unseen datasets (n = 116) with an average improvement of 4.2% in MAE over the SOTA approach.

Discussion

Results confirm that the proposed approach is fast and robust and has the potential for broader clinical applicability.

Ketamine in DUID cases in the greater Cologne area

INTRODUCTION

Ketamine is primarily used as an anaesthetic or for analgesics in medical treatment, but due to its dissociative and hallucinogenic effects, abuse has increased in the past years leading to several drug impaired driving cases.

METHODS

Eight DUID (driving under the influence of drugs) cases involving ketamine from two institutes of legal medicine over a period from January 2021 to January 2023 were evaluated. The cases were compared with regard to psychomotor impairments, adverse effects on driving performance and co-consumption of drugs. Analyses of ketamine were carried out by high performance liquid chromatography with diode array detection (HPLC-DAD). Other drugs of abuse were either detected via liquid chromatography with tandem mass spectromety (LC-MS/MS) and/or gas chromatography with (tandem) mass spectrometry (GC-MS(/MS)).

RESULTS

Ketamine plasma concentrations in a range of approx. 100-1200 ng/mL (mean: 510 ng/mL, median: 370 ng/mL) were detected. Co-consumption of at least one substance was ascertained in all cases. Besides driving impairments, recorded psychomotor impairments of the drivers comprised e.g. dilated pupils, missing or delayed pupil reactions, a slurred or decelerated speech, delayed reaction, lack of concentration, vertigo or agitation.

DISCUSSION

The observed peculiarities were in-line with literature data. However, the assessment and differentiation of ketamine-induced impairments was aggravated due to co-consumption of other drugs of abuse or pharmaceuticals in the herein investigated cases. Nevertheless, in two cases impairments can be attributed mainly to ketamine consumption since the co-consumed substances were only detected in low concentrations.

CONCLUSION

The presented cases provide additional data on psychomotor impairments observed in ketamine-related DUID cases. Limiting factors are co-consumption of substances, unknown habituation to drugs and the limited case number. Nevertheless, the results of this study are comparable with existing literature data. Since the abuse of ketamine has increased in the past years, these data will support forensic casework.

Long-term dynamics of multiple sclerosis iron rim lesions

BACKGROUND

Several studies have pointed out that seemingly chronic multiple sclerosis (MS) lesions may also be in inflammatory states. In pathological studies, up to 40% of chronic MS lesions are characterized as "chronic active" or "smoldering" lesions that are characterized by a rim of iron-laden proinflammatory macrophages/microglial cells at the lesion edge with low-grade continuous myelin breakdown. In vivo, these lesions can be visualized as "iron rim lesions" (IRLs) on susceptibility-weighted imaging (SWI). The aim of this study was to investigate the long-term dynamics of IRLs in vivo for a more detailed evolution of dynamic lesion volume changes occurring over time.

METHODS

We retrospectively identified patients with MS who were followed for at least 36 months (up to 72 months) and underwent at least an annual MRI on the same 3 Tsystem. Using Voxel-Guided Morphometry (VGM) we investigated regional volume changes within lesions and correlated these findings with SWI for the presence of a characteristic hypointense lesion rim. To estimate tissue damage, apparent diffusion coefficient (ADC) values for every lesion at baseline and follow-up MRIs were determined.

RESULTS

Forty-three patients were included in the study. Overall, we identified 302 supratentorial non-confluent MS lesions (52 persistent IRLs, nine transient IRLs, 228 non-IRLs and 13 acute contrast-enhancing lesions). During follow-up, persistent IRLs significantly enlarged, whereas non-IRLs showed a tendency to shrink. At baseline MRI, ADC values were significantly higher in persistent IRLs (1.23 × 10^-3 mm/s²) compared to non-IRLs (1.01 × 10^-3 mm/s²; p < 0.001), but not compared to transient IRLs (1.06 × 10^-3 mm/s²; p = 0.15) and contrast-enhancing lesions (1.15 × 10^-3 mm/s²; p = 1.0). During follow-up, ADC values significantly increased more often in persistent IRLs compared to all other lesion types (p < 0.0001).

CONCLUSIONS

Our long-term data demonstrate that persistent IRLs enlarge during disease duration, whereas non-IRLs show a tendency to shrink. Furthermore, IRLs are associated with sustained tissue damage, supporting the notion that IRLs could represent a new imaging biomarker in MS.

Implementation study of the 2021 German guideline for diagnosis and treatment of multiple sclerosis

BACKGROUND

In May 2021, a new guideline on the diagnosis and treatment of multiple sclerosis and related disorders was released in Germany. Since the success of a guideline depends on how it integrates into everyday clinical practice, the German Society for Neurology (DGN) has launched a multimethod implementation project. Here we report on the results based on the consultation version of the guideline.

METHODS

We used qualitative and quantitative data analyses to capture the nature and extent of barriers and facilitating factors to the implementation. We centered on the guideline's chapter A on diagnosis, relapse therapy, and immunotherapy of multiple sclerosis. We performed nine online focus group discussions and a web-based survey and analyzed emails and letters with comments from stakeholders and independent parties that were sent spontaneously or by invitation.

RESULTS

94 neurologists answered the survey, and ≥70% agreed with the recommendations of the guideline on each major content topic. Barriers to implementation were detected in group discussions and written input. The most controversial issues of the guideline were "early treatment", "criteria for starting or switching therapy", "stepwise escalation versus early aggressive treatment", "classification of drugs into three categories of efficacy" and the scenarios on "treatment cessation". Some appreciated the highly structured recommendations, but others felt that the guideline restricts the free choice of therapy, or they were afraid of recourse claims. Some considered the guideline as too cautious regarding treatment initiation, possibly delaying necessary therapies. Others appreciated that conflicts of interests of the guideline's authoring group were minimized and thought that the new guideline is clearer, more extensive and practical.

CONCLUSION

In contrast to the survey, feedback in the focus group discussions and from individuals was diverse and sometimes more critical. Based on the overall feedback rate of about 250 people in relation to the number of 6500 board-certified neurologists in Germany, the overall appreciation of the guideline can only be considered as an indicator and not proof of acceptance. Results of this analysis were incorporated into several adjustments to the final guideline of 2021. Since the guideline is to be updated regularly under the auspices of a "living guideline", active interaction with users will continue to matter and help to improve it.

Interaction of therapeutic12C ions with bone-like targets: physical characterization and dosimetric effect at material interfaces

Carbon therapy is a promising treatment option for cancer. The physical and biological properties of carbon ions can theoretically allow for the delivery of curative doses to the tumor, while simultaneously limiting risks of toxicity to adjacent healthy structures. The treatment effectiveness can be further improved by decreasing the uncertainties stemming from several sources, including the modeling of tissue heterogeneity. Current treatment plans employ density-based conversion methods to translate patient-specific anatomy into a water system, where dose distribution is calculated. This approach neglects differences in nuclear interactions stemming from the elemental composition of each tissue. In this work, we investigated the interaction of therapeutic carbon ions with bone-like materials. The study concentrated on nuclear interactions and included attenuation curves of 200 and 400 AMeV beams in different types of bones, as well as kinetic energy spectra of all charged fragments produced up to 29 degrees from the beam direction. The comparison between measurements and calculations of the treatment planning system TRiP98 indicated that bone tissue causes less fragmentation of carbon ions than water. Overall, hydrogen and helium particles were found to be the most abundant species, while heavier fragments were mostly detected within 5 degrees from the beam direction. We also investigated how the presence of a soft tissue-bone interface could affect the depth-dose profile. The results revealed a dose spike in the transition region, that extended from the entry channel to the target volume. The findings of this work indicated that the tissue-to-water conversion method based only on density considerations can result in dose inaccuracies. Tissue heterogeneity regions containing bones can potentially produce dose spikes, whose magnitude will depend on the patient anatomy. Dose uncertainties can be decreased by modeling nuclear interactions directly in bones, without applying the tissue-to-water conversion.

Characterization of chronic active multiple sclerosis lesions with sodium (23 Na) magnetic resonance imaging-preliminary observations

BACKGROUND AND PURPOSE

There has been an increasing interest in chronic active multiple sclerosis (MS) lesions as a new magnetic resonance imaging (MRI) marker of disease progression. Chronic active lesions are characterized by progressive tissue matrix damage, axonal loss and chronic inflammation. Sodium (²³ Na) MRI provides a biochemical marker of cell integrity and tissue viability in a quantitative manner. The aim of this study was to investigate with ²³ Na MRI tissue abnormalities in chronic active lesions as indicators of tissue destruction.

METHODS

To identify chronic active lesions, two 3D magnetization-prepared rapid acquisition gradient-echo datasets obtained 12 months apart were processed using the voxel-guided morphometry algorithm. Cross-sectional ²³ Na MRI was performed during the 12-month follow-up period. Total sodium concentration was calculated in chronic active lesions compared to shrinking, chronic stable and acute contrast-enhancing lesions.

RESULTS

Overall, 70 MS lesions (21 chronic active, 10 shrinking, 29 chronic stable lesions, 10 acute contrast-enhancing lesions) in 12 patients were included. Total sodium concentration in chronic active lesions (49.57 ± 8.47 mM) was significantly higher than in shrinking (42.16 ± 3.9 mM; p = 0.03) and chronic stable lesions (39.92 ± 4.82 mM; p < 0.001). Chronic active lesions showed similar sodium values compared to acute contrast-enhancing lesions (48.06 ± 6.65 mM; p = 0.97). No differences between shrinking and chronic stable lesions were observed (p = 0.89).

CONCLUSION

High sodium values in chronic active MS lesions may be an indicator of ongoing inflammation and tissue damage.

Quantitative MRI texture analysis in chronic active multiple sclerosis lesions

OBJECTIVE

Recently, there has been an increasing interest in "chronic enlarging" or "chronic active" multiple sclerosis (MS) lesions that are associated with clinical disability. However, investigation of dynamic lesion volume changes requires longitudinal MRI data from two or more time points. The aim of this study was to investigate the application of texture analysis (TA) on baseline T1-weighted 3D magnetization-prepared rapid acquisition gradient-echo (MPRAGE) images to differentiate chronic active from chronic stable MS lesions.

MATERIAL AND METHODS

To identify chronic active lesions as compared to non-enhancing stable lesions, two MPRAGE datasets acquired on a 3 T MRI at baseline and after 12 months follow-up were applied to the Voxel-Guided Morphometry (VGM) algorithm. TA was performed on the baseline MPRAGE images, 36 texture features were extracted for each lesion.

RESULTS

Overall, 374 chronic MS lesions (155 chronic active and 219 chronic stable lesions) from 60 MS patients were included in the final analysis. Multiple texture features including "DISCRETIZED_HISTO_Energy", "GLCM_Energy", "GLCM_Contrast" and "GLCM_Dissimilarity" were significantly higher in chronic active as compared to chronic stable lesions. Partial least squares regression yielded an area under the curve of 0.7 to differentiate both lesion types.

CONCLUSION

Our results suggest that multiple texture features extracted from MPRAGE images indicate higher intralesional heterogeneity, however they demonstrate only a fair accuracy to differentiate chronic active from chronic stable MS lesions.

Venous Diameter Changes in Chronic Active Multiple Sclerosis Lesions

BACKGROUND AND PURPOSE

To investigate the temporal evolution of venous diameter in chronic active and nonenhancing shrinking multiple sclerosis (MS) lesions in a longitudinal magnetic resonance imaging (MRI) study including susceptibility-weighted images (SWI).

METHODS

We compared the venous diameter in chronic active and nonenhancing shrinking lesions to the venous diameter in nonenhancing stable lesions on two 3 T MRI data sets obtained 12 months apart. Chronic active and nonenhancing shrinking lesions were identified by Voxel-Guided Morphometry. Coregistered, overlaid fluid-attenuated inversion recovery/SWI were analyzed for the presence of a central vein. Quantitative calculation of the venous diameter for each time point was performed on the reconstructed veins.

RESULTS

Sixty-two relapsing-remitting MS patients (50 women; mean age: 36 ± 11 years; mean disease duration: 4 ± 7 years) were included in the study. Overall, we identified 222 chronic MS lesions (48 chronic active, 48 shrinking, 126 stable) with a corresponding intralesional central vein. On baseline MRI, the mean venous diameter did not statistically differ between all subgroups, whereas on follow-up MRI, the mean intralesional venous diameter was smaller in chronic active (0.92 ± 0.15 mm) and shrinking lesions (0.90 ± 0.19 mm) compared to stable lesions (1.10 ± 0.18 mm; P < .001).

CONCLUSION

Our findings demonstrate venous narrowing in chronic active and nonenhancing shrinking MS lesions. The smaller diameter of intralesional veins during follow up in these lesions may reflect structural, degenerative, and metabolic changes due to chronic inflammation, (perivascular) fibrosis, collagenous thickening, and increased levels of oxygenated hemoglobin.

Stroke care during the COVID-19 pandemic: experience from three large European countries

In order to cope with the exponentially increasing number of patients infected with SARS-CoV-2, European countries made enormous efforts to reorganize medical assistance and several diseases, including stroke, were particularly impacted. We report the experience of stroke neurologists from three European countries (Italy, France and Germany) that faced the pandemic at diverse time points and with different approaches, depending on their resources and healthcare system organization. Pre-hospital and in-hospital acute stroke pathways were reorganized to prioritize COVID-19 management and, in severely affected regions of Italy and France, stroke care was centralized to a limited number of centers, whereas the remaining stroke units were dedicated to patients with COVID-19. Access to acute stroke diagnostics and time-dependent therapies was limited or delayed because of reduced capacities of emergency services due to the burden of patients with COVID-19. A marked reduction in the number of patients presenting with transient ischaemic attack and stroke was noted in the emergency departments of all three countries. Although we only have preliminary data, these conditions may have affected stroke outcome. These indirect effects of the COVID-19 pandemic could negate the efforts of stroke neurologists over the last few years to improve outcome and reduce mortality of stroke patients. Although the SARS-CoV-2 infection rate is slowing down in Europe, the effects of ending lockdown in the next months are unpredictable. It is important for the European and world stroke community to share what has been learned so far to be plan strategies to ensure stroke care in the future and upcoming challenging times.

Heritable and non-heritable uncommon causes of stroke

Despite intensive investigations, about 30% of stroke cases remains of undetermined origin. After exclusion of common causes of stroke, there is a number of rare heritable and non-heritable conditions, which often remain misdiagnosed, that should be additionally considered in the diagnosis of cryptogenic stroke. The identification of these diseases requires a complex work up including detailed clinical evaluation for the detection of systemic symptoms and signs, an adequate neuroimaging assessment and a careful family history collection. The task becomes more complicated by phenotype heterogeneity since stroke could be the primary or unique manifestation of a syndrome or represent just a manifestation (sometimes minor) of a multisystem disorder. The aim of this review paper is to provide clinicians with an update on clinical and neuroradiological features and a set of practical suggestions for the diagnostic work up and management of these uncommon causes of stroke. The identification of these stroke causes is important to avoid inappropriate and expensive diagnostic tests, to establish appropriate management measures, including presymptomatic testing, genetic counseling, and, if available, therapy. Therefore, physicians should become familiar with these diseases to provide future risk assessment and family counseling.

German validation of the Conners Adult ADHD Rating Scales (CAARS) II: Reliability, validity, diagnostic sensitivity and specificity

Background

The German version of the Conners Adult ADHD Rating Scales (CAARS) has proven to show very high model fit in confirmative factor analyses with the established factors inattention/memory problems, hyperactivity/restlessness, impulsivity/emotional lability, and problems with self-concept in both large healthy control and ADHD patient samples. This study now presents data on the psychometric properties of the German CAARS-self-report (CAARS-S) and observer-report (CAARS-O) questionnaires.

Methods

CAARS-S/O and questions on sociodemographic variables were filled out by 466 patients with ADHD, 847 healthy control subjects that already participated in two prior studies, and a total of 896 observer data sets were available. Cronbach's-alpha was calculated to obtain internal reliability coefficients. Pearson correlations were performed to assess test-retest reliability, and concurrent, criterion, and discriminant validity. Receiver Operating Characteristics (ROC-analyses) were used to establish sensitivity and specificity for all subscales.

Results

Coefficient alphas ranged from .74 to .95, and test-retest reliability from .85 to .92 for the CAARS-S, and from .65 to .85 for the CAARS-O. All CAARS subscales, except problems with self-concept correlated significantly with the Barrett Impulsiveness Scale (BIS), but not with the Wender Utah Rating Scale (WURS). Criterion validity was established with ADHD subtype and diagnosis based on DSM-IV criteria. Sensitivity and specificity were high for all four subscales.

Conclusion

The reported results confirm our previous study and show that the German CAARS-S/O do indeed represent a reliable and cross-culturally valid measure of current ADHD symptoms in adults.

High-Sensitivity Dry Rehydratable Film Method for Enumeration of Coliforms in Dairy Products: Collaborative Study

A dry-film coliform count plate that is inoculated with 5 mL sample was compared with the Violet Red Bile Agar plate method in a collaborative study by 18 laboratories. Products analyzed were 2% milk, chocolate milk, cream, vanilla ice cream, cottage cheese, and cheese. Collaborators tested blind duplicate uninoculated samples and samples inoculated at low, medium, and high level. Significantly (P&lt; 0.05) higher numbers of coliforms were recovered by the dry-film method from 2% milk samples at the 3 inoculum levels, the chocolate milk at the low- and high-inoculum levels, and the cream at the high-inoculum level. Significantly higher counts were obtained by the agar method for cottage cheese samples at the low-inoculum level. The repeatability standard deviation for the dry-film method was significantly higher for the high-inoculum level chocolate milk sample and the medium-inoculum level cottage cheese. The same statistic was significantly higher for the agar method at all 3 inoculum levels in the 2% milk and the medium-inoculum level cream. The high-sensitivity dry rehydratable film method for enumeration of coliforms in dairy products has been adopted first action by AOAC INTERNATIONAL.

Backscattered electron emission after proton impact on gold nanoparticles with and without polymer shell coating

This work aims at measuring experimentally proton induced secondary electron energy spectra after interaction with gold nano particles (GNPs) and polymer-coated GNPs. Backscattered electron energy spectra were collected over a 0 to 1000 eV energy range using a retarding field analyzer (RFA). This paper presents the spectra obtained for proton beam energies of 0.5 and 2 MeV and diameter 2.5 and 3.8 nm GNPs. The spectra were also measured for 3.8 nm GNPs after 5 and 10 MeV proton irradiations. GNPs were deposited on a 100 nm carbon film. Each experimental spectrum was compared with dedicated simulations based on existing numerical models used in the TRAX and Geant4 Monte Carlo codes. For 100 nm carbon target, good agreement between experimental, TRAX and Geant4 simulation results can be observed. For 3.8 nm GNPs, the TRAX simulations reproduce with good agreement the electron energy spectra produced after 0.5, 2, 5 and 10 MeV proton irradiations, while Geant4 spectra display a lower secondary electron yield at low energy (<600 eV) for all the studied energies. This underestimation can mostly be explained by the 790 eV threshold applied in the condensed history model used by Geant4 which impacts the secondary electron energy distribution. Results obtained for carbon and gold targets highlight the impact of the secondary electron production threshold for proton ionization process considered in condensed history models. The experimental results demonstrate that the single interaction approach used in TRAX is adapted to reproduce secondary electron emission from GNPs. On the other hand, the standard electron generation threshold implement in G4BetheBlochModel and G4BraggModel condensed-history models used in Geant4 is not adapted to reproduce low energy electron emission in gold targets. Finally, the results highlight that the GNP coating leads to a decrease of the electron yield and mostly affects low energy electrons (<500 eV) emitted from GNPs.

Experimental measurements validate the use of the binary encounter approximation model to accurately compute proton induced dose and radiolysis enhancement from gold nanoparticles

In protontherapy, it has been suggested that nanoparticles of high-Z material like gold (GNP) could be used as radiosensitizers. The origin of this enhancement phenomenon for proton radiation is not yet well understood and additional mechanistic insights are required. Previous works have highlighted the good capabilities of TRAX to reproduce secondary electron emission from gold material. Therefore, TRAX cross sections obtained with the binary encounter approximation (BEA) model for proton ionization were implemented within Geant4 for gold material. Based on the TRAX cross sections, improved Geant4 simulations have been developed to investigate the energy deposition and radical species production around a spherical gold nanoparticle (5 and 10 nm in diameter) placed in a water volume during proton irradiation. Simulations were performed for incident 2 MeV proton. The dose enhancement factor and the radiolysis enhancement factor were quantified. Results obtained with the BEA model were compared with results obtained with condensed-history models. Experimental irradiation of 200 nm gold films were performed to validate the secondary electron emission reproduction capabilities of physical models used in Monte Carlo (MC) simulations. TRAX simulations reproduced the experimental backscattered electron energy spectrum from gold film with better agreement than Geant4. Results on gold film obtained with the BEA model enabled to estimate the electron emission from GNPs. Results obtained in our study tend to support that the use of the BEA discrete model leads to a significant increase of the dose in the near vicinity of GNPs (<20 nm), while condensed history models used in Geant4 seem to overestimate the dose and the number of chemical species for increasing distances from the GNP. Based on discrete BEA model results, no enhancement effect due to secondary electron emitted from the GNP is expected if the GNP is not in close proximity to key cellular functional elements (DNA, mitochondria…).

Cerebrospinal fluid findings in reversible cerebral vasoconstriction syndrome: a way to differentiate from cerebral vasculitis?

Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by an acute onset of severe headache and multi-focal segmental vasoconstriction of cerebral arteries resolving within 12 weeks. Diagnostic criteria include normal or near-normal findings in cerebrospinal fluid (CSF) analysis, especially leucocyte levels < 10/mm³. Distinguishing RCVS from primary angiitis of the central nervous system (PACNS) is essential to avoid unnecessary and sometimes unfavourable immunosuppressive treatment. We reviewed retrospectively the clinical and diagnostic data of 10 RCVS patients who presented in our neurological department from 1 January 2013 to February 2017. The main purpose was to verify whether CSF leucocyte counts < 10/mm³ serve to discriminate RCVS from PACNS. Five of six patients who underwent lumbar puncture presented with CSF leucocyte levels ≥ 10/mm³. Two patients had a history of misinterpretation of CSF pleocytosis as cerebral vasculitis and of immunosuppressive treatment. A complete restitution of cerebral vasoconstriction was evident in all. No patient had further cerebral strokes or bleedings without immunosuppressive treatment over more than 12 weeks. Despite the established diagnostic criteria, RCVS can manifest with CSF leucocyte levels > 10/mm³. Careful anamnesis and the response of 'vasculitis-like angiography' to nimodipine given as a test during angiography and as oral medication are key to differentiate RCVS from cerebral vasculitis.

Visualization and Classification of Deeply Seated Collateral Networks in Moyamoya Angiopathy with 7T MRI

BACKGROUND AND PURPOSE

Collateral networks in Moyamoya angiopathy have a complex angioarchitecture difficult to comprehend on conventional examinations. This study aimed to evaluate morphologic patterns and the delineation of deeply seated collateral networks using ultra-high-field MRA in comparison with conventional DSA.

MATERIALS AND METHODS

Fifteen white patients with Moyamoya angiopathy were investigated in this prospective trial. Sequences acquired at 7T were TOF-MRA with 0.22 × 0.22 × 0.41 mm³ resolution and MPRAGE with 0.7 × 0.7 × 0.7 mm³ resolution. Four raters evaluated the presence of deeply seated collateral networks and image quality in a consensus reading of DSA, TOF-MRA, and MPRAGE using a 5-point scale in axial source images and maximum intensity projections. Delineation of deeply seated collateral networks by different imaging modalities was compared by means of the McNemar test, whereas image quality was compared using the Wilcoxon signed-rank test.

RESULTS

The relevant deeply seated collateral networks were classified into 2 categories and 6 pathways. A total of 100 collateral networks were detected on DSA; 106, on TOF-MRA; and 73, on MPRAGE. Delineation of deeply seated collateral networks was comparable between TOF-MRA and DSA (P = .25); however, both were better than MPRAGE (P < .001).

CONCLUSIONS

This study demonstrates excellent delineation of 6 distinct deeply seated collateral network pathways in Moyamoya angiopathy in white adults using 7T TOF-MRA, comparable to DSA.

A survey of patient and physician acceptance of skin toxicities from anti-epidermal growth factor receptor therapies

BACKGROUND

Inhibition of the epidermal growth factor receptor (EGFR) extends patient survival in multiple tumor types. Skin toxicities are the most common adverse event (AE) elicited by EGFR inhibitors. Here, we provide deeper insights into patients' and physicians' acceptance of the risk/benefit trade-offs of skin toxicities during cancer therapy, including comparison of their perceptions and experiences with dermatologic AEs.

METHODS

A multinational survey of 195 patients and 120 physicians was conducted to gauge attitudes regarding skin toxicities as an AE during cancer therapy.

RESULTS

Skin toxicities were identified by patients and physicians as the AE that is most discouraging to patients when undergoing cancer therapies. Skin toxicities were cited as causing pain, impairing quality of life, and proving difficult to manage. Despite these negative influences, the majority of patients (71%) indicated they were willing to accept skin toxicities as an AE of an effective therapy. Indeed, the majority of patients and physicians preferred a more effective therapy that induces more severe skin toxicities than a less efficacious therapy that induces less severe skin toxicities; interestingly, patients were willing to accept a higher likelihood of severe skin toxicities than physicians.

CONCLUSION

In this examination of patients' perspectives, we found that patients were willing to accept skin toxicities if they were the anticipated byproduct of a more effective therapeutic regimen. Important differences were observed between patients' and physicians' attitudes regarding risk/benefit trade-offs during cancer therapy, suggesting that patient's considerations and shared decision-making are key to cancer care.

Experimental Evaluation of a Cell Module for Hybrid Liver Support

Aim of the study was to evaluate a hybrid liver support system in a porcine model of acute liver failure, after hepatectomy. Pigs with a body weight of 70±18 kg underwent total hepatectomy and porto - cavo - caval shunting as well as ligation of the bile duct and the hepatic artery. Control animals were connected to the system (including capillary membrane plasma separation) containing a four compartment bioreactor with integral oxygenation and decentralized mass exchange but without liver cells. The treatment group received hybrid liver support with the same system including 370±42 g primary isolated porcine parenchymal liver cells in co-culture with hepatocyte nursing cells, tissue engineered to liver- like structures at high density. Treatment started after complete recovery from anesthesia and was performed continuously. A positive influence on peripheral vascular resistance and a reduced need of catecholamine dosage was observed in the treatment group. Hybrid liver support with a cell module upscaled for clinical application significantly prolonged survival time in animals after hepatectomy with the longest survival being 26 hours in the control group an 57 hours in the treatment group.

Perception of emotional prosody in adults with attention deficit hyperactivity disorder

OBJECTIVE

Attention deficit hyperactivity disorder (ADHD) is associated with social conflicts. The purpose of this study was to explore domains of social cognition in adult patients with ADHD.

METHODS

The assessment of social cognition was based on established neuropsychological tests: the Tübinger Affect Battery (TAB) for prosody and the Cambridge Behaviour Scale (CBS) for empathy. The performance of adults with ADHD (N = 28) was compared with the performance of a control group (N = 29) matched according to basic demographic variables.

RESULTS

Treatment-naïve adults with ADHD showed deficits in emotional prosody (P = 0.02) and in the ability to empathize (P < 0.02) independent of executive functioning. In particular, their ability to perceive angry feelings was found to be compromised (P = 0.04). When emotional prosody was considered in relation to facial expressions, patients and controls showed no impairments (P > 0.2). No gender differences concerning social cognitive skills were detected.

CONCLUSIONS

ADHD is associated with social cognition impairments involving both emotional prosody and empathy.

Ventricular Microaneurysms in Moyamoya Angiopathy Visualized with 7T MR Angiography

The pathophysiologic role of hemodynamic alteration to peripheral vessels in Moyamoya angiopathy and the formation of microaneurysms remains unclear. The purpose of this study was to investigate microaneurysms in collateral Moyamoya vessels by using 7T ultra-high-field MR imaging. Ten patients with Moyamoya disease were evaluated with TOF-MRA at 7T acquired with 0.22 × 0.22 × 0.41 mm(3) resolution. In 10 patients, 4 microaneuryms located in the ventricles were delineated. The mean diameters of collateral vessels and microaneurysms arising from those vessels were 0.87 mm (range, 0.79-1.07 mm) and 0.80 mm (range, 0.56-0.96 mm), respectively. In 1 case with follow-up scans 6 months after a direct extracranial-intracranial bypass operation, the microaneurysm disappeared. Ventricular microaneurysms in Moyamoya angiopathy collateral vessels, inaccessible by conventional imaging techniques, can be detected by 7T TOF-MRA.

Individual Assessment of Brain Tissue Changes in MS and the Effect of Focal Lesions on Short-Term Focal Atrophy Development in MS: A Voxel-Guided Morphometry Study

We performed voxel-guided morphometry (VGM) investigating the mechanisms of brain atrophy in multiple sclerosis (MS) related to focal lesions. VGM maps detect regional brain changes when comparing 2 time points on high resolution T1-weighted (T1w) magnetic resonace imaging (MRI). Two T1w MR datasets from 92 relapsing-remitting MS patients obtained 12 months apart were analysed with VGM. New lesions and volume changes of focal MS lesions as well as in the surrounding tissue were identified by visual inspection on colour coded VGM maps. Lesions were dichotomized in active and inactive lesions. Active lesions, defined by either new lesions (NL) (volume increase > 5% in VGM), chronic enlarging lesions (CEL) (pre-existent T1w lesions with volume increase > 5%), or chronic shrinking lesions (CSL) (pre-existent T1w lesions with volume reduction > 5%) in VGM, were accompanied by tissue shrinkage in surrounding and/or functionally related regions. Volume loss within the corpus callosum was highly correlated with the number of lesions in its close proximity. Volume loss in the lateral geniculate nucleus was correlated with lesions along the optic radiation. VGM analysis provides strong evidence that all active lesion types (NL, CEL, and CSL) contribute to brain volume reduction in the vicinity of lesions and/or in anatomically and functionally related areas of the brain.

UTLS water vapour from SCIAMACHY limb measurementsV3.01 (2002-2012)

The SCanning Imaging Absorption spectroMeter for Atmospheric CHartographY (SCIAMACHY) aboard the Envisat satellite provided measurements from August 2002 until April 2012. SCIAMACHY measured the scattered or direct sunlight using different observation geometries. The limb viewing geometry allows the retrieval of water vapour at about 10-25 km height from the near-infrared spectral range (1353-1410 nm). These data cover the upper troposphere and lower stratosphere (UTLS), a region in the atmosphere which is of special interest for a variety of dynamical and chemical processes as well as for the radiative forcing. Here, the latest data version of water vapour (V3.01) from SCIAMACHY limb measurements is presented and validated by comparisons with data sets from other satellite and in situ measurements. Considering retrieval tests and the results of these comparisons, the V3.01 data are reliable from about 11 to 23 km and the best results are found in the middle of the profiles between about 14 and 20 km. Above 20 km in the extra tropics V3.01 is drier than all other data sets. Additionally, for altitudes above about 19 km, the vertical resolution of the retrieved profile is not sufficient to resolve signals with a short vertical structure like the tape recorder. Below 14 km, SCIAMACHY water vapour V3.01 is wetter than most collocated data sets, but the high variability of water vapour in the troposphere complicates the comparison. For 14-20 km height, the expected errors from the retrieval and simulations and the mean differences to collocated data sets are usually smaller than 10 % when the resolution of the SCIAMACHY data is taken into account. In general, the temporal changes agree well with collocated data sets except for the Northern Hemisphere extratropical stratosphere, where larger differences are observed. This indicates a possible drift in V3.01 most probably caused by the incomplete treatment of volcanic aerosols in the retrieval. In all other regions a good temporal stability is shown. In the tropical stratosphere an increase in water vapour is found between 2002 and 2012, which is in agreement with other satellite data sets for overlapping time periods.

Laparoscopic surgery of benign entero-vesical or entero-vaginal fistulae

PURPOSE

Entero-vesical or entero-vaginal fistulae (EVF) are an uncommon septic complication mainly of diverticular disease. The fistulae are usually situated within extensive and dense inflammatory masses occluding the entrance of the pelvis. There are still some controversies regarding laparoscopic feasibility and treatment modalities of this disorder.

METHODS

A retrospective chart review of all patients with EVF operated at our department since 2008. Patients were identified by use of the computerized hospital information system.

RESULTS

In nineteen patients (ten males), median age 68 years, 13 patients had entero-vesical fistulae, and 6 patients had entero-vaginal fistulae. The fistulae were caused by complicated diverticular disease in 16 patients (84 %), Crohn's disease (two patients), and ulcerative colitis (one patient). All cases were attempted laparoscopically. Operative treatment involved separation of the inflammatory mass and resection of the affected colorectal segment. There were three conversions (16 %), all three requiring bladder repair considered too extensive for laparoscopic means. In two further patients small bladder defects were sutured laparoscopically, the remaining patients required no bladder repair. The inferior mesentric artery (IMA) was preserved in all cases. Median operative time was 180 min. Two patients received a protective ileostomy: one converted patient and one cachectic patient with Crohn's disease under immune-modulating therapy. Both ileostomies were closed. Altogether, there were five complications in five patients (26 %), four of them were minor (Clavien grade I and II). The cachectic patient with Crohn's disease suffered a major (grade IIIb) complication (stoma prolapse, treated by early closure of the ileostomy). There was no anastomotic leakage and no mortality. Median hospital stay was 12 days.

CONCLUSIONS

The laparoscopic approach is a safe option for the treatment of EVF of benign inflammatory origin. In most cases it offers all the advantages pertaining to minimally invasive surgery. For a definite and causal approach, the disorder belongs primarily within the therapeutic domain of the visceral surgeon. Following the separation of the inflammatory colon, most of the bladder lesions caused by EVF will heal without further surgical measures.

The PACT trial: PAtient Centered Telerehabilitation: effectiveness of software-supported and traditional mirror therapy in patients with phantom limb pain following lower limb amputation: protocol of a multicentre randomised controlled trial

INTRODUCTION

Non-pharmacological interventions such as mirror therapy are gaining increased recognition in the treatment of phantom limb pain; however, the evidence in people with phantom limb pain is still weak. In addition, compliance to self-delivered exercises is generally low. The aim of this randomised controlled study is to investigate the effectiveness of mirror therapy supported by telerehabilitation on the intensity, duration and frequency of phantom limb pain and limitations in daily activities compared to traditional mirror therapy and care as usual in people following lower limb amputation.

METHOD

A three-arm multi-centre randomised controlled trial will be performed. Participants will be randomly assigned to care as usual, traditional mirror therapy or mirror therapy supported by telerehabilitation. During the first 4 weeks, at least 10 individual sessions will take place in every group. After the first 4 weeks, participants will be encouraged to perform self-delivered exercises over a period of 6 weeks. Outcomes will be assessed at 4 and 10 weeks after baseline and at 6 months follow-up. The primary outcome measure is the average intensity of phantom limb pain during the last week. Secondary outcome measures include the different dimensions of phantom limb pain, pain-related limitations in daily activities, global perceived effect, pain-specific self-efficacy, and quality of life.

DISCUSSION

Several questions concerning the study design that emerged during the preparation of this trial will be discussed. This will include how these questions were addressed and arguments for the choices that were made.

A simple tool to evaluate common disorders: validation of a "proctological symptom scale"

PURPOSE

Proctological symptomatology is of little complexity and therefore appears particularly suitable for comparative evaluation by visual scales. We devised a "proctological symptom scale" (PSS) with separate scales for four cardinal proctological symptoms: pain, itching/irritation, discharge/moisture, and bleeding. The objective of this study was to evaluate the PSS among proctological patients and non-proctological controls.

METHODS

This was a single center non-interventional observational study on 229 proctological patients and 133 controls. The main outcome measures investigated were age- and sex-stratified comparison of the non-proctological cohort and the controls, effect of therapeutic intervention on scale values in a subset of patients with haemorrhoidal disease, and sensitivity of the PSS to detect therapeutic failure in this subset of patients.

RESULTS

The PSS was found to significantly differentiate between proctological patients and controls. Gender and age had no significant influence on PSS values in the proctological cohort. The intervention (one session of rubber band ligation in patients with haemorrhoidal disease) was reflected by a significantly improved overall PSS. In 16 cases within this group, the PSS got worse. A case-by-case follow-up of these patients showed that 14 of the 16 patients ended up with surgery (or with the advice to have surgery).

CONCLUSIONS

The PSS reliably differentiates proctological patients from non-proctological controls. Following intervention, the PSS reliably differentiated therapeutic success from failure. We find the PSS to be a simple and useful tool in our clinical routine since it provides an easily obtainable and reproducible basis for the visit-by-visit assessment of proctological patients. The PSS may also be suitable for studies to measure and compare symptomatic improvement and success of different therapies in proctology.

Cerebral vasculitis in adults: what are the steps in order to establish the diagnosis? Red flags and pitfalls

Cerebral vasculitis is a rare cause of juvenile stroke. It may occur as primary angiitis of the central nervous system (PACNS) or as CNS manifestation in the setting of systemic vasculitis. Clinical hints for vasculitis are headache, stroke, seizures, encephalopathy and signs of a systemic inflammatory disorder. Diagnostic work-up includes anamnesis, whole body examination, laboratory and cerebral spinal fluid (CSF) studies, magnetic resonance imaging (MRI), angiography and brain biopsy. Due to the rarity of the disease, exclusion of more frequent differential diagnoses is a key element of diagnostic work -up. This review summarizes the steps that lead to the diagnosis of cerebral vasculitis and describes the red flags and pitfalls. Despite considering the dilemma of angiography-negative vasculitis and false-negative brain biopsy in some cases, it is important to protect patients from 'blind' immunosuppressive therapy in unrecognized non-inflammatory differential diagnosis.

Physiological monitoring and control in hemodialysis: state of the art and outlook

Medical devices for monitoring and feedback control of physiological parameters of the dialysis patient were introduced in the early 1990s. They have a wide range of applications, aiming at increasing the safety and ensuring the efficiency of the treatment, and at an improved restoration of physiological conditions, leading to an overall reduction in morbidity and mortality. Such devices include sensors for the measurement of temperature, optical parameters and sound speed in blood, and electrical characteristics of the human body, and other parameters. Essential for the development of these devices is a detailed understanding of the pathophysiological background of a therapeutical problem. There is still a large potential to introduce new devices for further therapy improvement and automation. Also, the size of the hemodialysis market appears attractive; however, a new product has to meet several specific requirements in order to also become commercially successful. This review describes the therapeutic and technical principles of several available devices, reports on concepts for possible future devices, and presents a short overview on the market environment.

Comparative efficacy of long-acting bronchodilators for COPD: a network meta-analysis

BACKGROUND

Clinicians are faced with an increasingly difficult choice regarding the optimal bronchodilator for patients with chronic obstructive pulmonary disease (COPD) given the number of new treatments. The objective of this study is to evaluate the comparative efficacy of indacaterol 75/150/300 μg once daily (OD), glycopyrronium bromide 50 μg OD, tiotropium bromide 18 μg/5 μg OD, salmeterol 50 μg twice daily (BID), formoterol 12 μg BID, and placebo for moderate to severe COPD.

METHODS

Forty randomized controlled trials were combined in a Bayesian network meta-analysis. Outcomes of interest were trough and post-dose forced expiratory volume in 1 second (FEV1), St. George's Respiratory Questionnaire (SGRQ) score and responders (≥4 points), and Transition Dyspnea Index (TDI) score and responders (≥1 point) at 6 months.

RESULTS

Indacaterol was associated with a higher trough FEV1 than other active treatments (difference for indacaterol 150 μg and 300 μg versus placebo: 152 mL (95% credible interval (CrI): 126, 179); 160 mL (95% CrI: 133, 187)) and the greatest improvement in SGRQ score (difference for indacaterol 150 μg and 300 μg versus placebo: -3.9 (95% CrI -5.2, -2.6); -3.6 (95% CrI -4.8, -2.3)). Glycopyrronium and tiotropium 18 μg resulted in the next best estimates for both outcomes with minor differences (difference for glycopyrronium versus tiotropium for trough FEV1 and SGRQ: 18 mL (95% CrI: -16, 51); -0.55 (95% CrI: -2.04, 0.92).

CONCLUSION

In terms of trough FEV1 and SGRQ score indacaterol, glycopyrronium, and tiotropium are expected to be the most effective bronchodilators.

Efficacy of indacaterol 75 μg versus fixed-dose combinations of formoterol-budesonide or salmeterol-fluticasone for COPD: a network meta-analysis

Background

The purpose of this study was to update our network meta-analysis in order to compare the efficacy of indacaterol 75 μg with that of a fixed-dose combination of formoterol and budesonide (FOR/BUD) and a fixed-dose combination salmeterol and fluticasone (SAL/FP) for the treatment of chronic obstructive pulmonary disease (COPD) based on evidence identified previously in addition to two new randomized clinical trials.

Methods

Fifteen randomized, placebo-controlled clinical trials including COPD patients were evaluated: indacaterol 75 μg once daily (n = 2 studies), indacaterol 150 μg once daily (n = 5), indacaterol 300 μg once daily (n = 4), FOR/BUD 9/160 μg twice daily (n = 2), FOR/BUD 9/320 μg twice daily (n = 2), SAL/FP 50/500 μg twice daily (n = 4), and SAL/FP 50/250 μg twice daily (n = 1). All trials were analyzed simultaneously using a Bayesian network meta-analysis and relative treatment effects between all regimens were obtained. Treatment-by-covariate interactions were included where possible to improve the similarity of the trials. Outcomes of interest were trough forced expiratory volume in 1 second (FEV₁) and transitional dyspnea index at 12 weeks.

Results

Based on the results without adjustment for covariates, indacaterol 75 μg resulted in a greater improvement in FEV₁ at 12 weeks compared with FOR/BUD 9/160 μg (difference in change from baseline 0.09 L [95% credible interval 0.04–0.13]) and FOR/BUD 9/320 μg (0.07 L [0.03–0.11]) and was comparable with SAL/FP 50/250 μg (0.00 L [−0.07–0.07]) and SAL/FP 50/500 μg (0.01 L [−0.04–0.05]). For transitional dyspnea index, data was available only for indacaterol 75 μg versus SAL/FP 50/500 μg (−0.49 points [−1.87–0.89]).

Conclusion

Based on results of a network meta-analysis with and without covariates, indacaterol 75 μg is expected to be at least as efficacious as FOR/BUD (9/320 μg and 9/160 μg) and comparable with SAL/FP (50/250 μg and 50/500 μg) in terms of lung function. In terms of breathlessness (transitional dyspnea index) at 12 weeks, the results are inconclusive given the limited data.

Postoperative changes in the superficial temporal artery and the external carotid artery duplex sonography after extra-intracranial bypass surgery in European Moyamoya disease

INTRODUCTION

Despite Duplex ultrasonography being a noninvasive, easily repeatable, readily available and economical tool, this examination and its normal ranges are rarely described in Moyamoya disease (MMD).

METHODS

Duplex ultrasonography examinations of the superficial temporal artery (STA) and external carotid artery (ECA) were performed preoperatively, postoperatively (within 30 days) and as follow-up exams (6 months postoperatively) after 32 cerebral revascularization procedures in 20 European patients with MMD.

RESULTS

A significant higher mean diastolic flow of STA compared to preoperative values was found in postoperative (p<.000) and follow-up exams (p<.001) in Duplex ultrasonography. Postoperative and follow-up Duplex sonography of STA also showed a significantly higher mean systolic flow compared to preoperative values (p<.05 and p<.05). Also ECA showed significantly changes after bypass surgery (p<.05).

CONCLUSION

Duplex ultrasonography of STA is a reliable and non-invasive tool to investigate hemodynamic changes after bypass surgery and to detect bypass patency in European patients with MMD.

A diminished serotonin level influences the performance in a modified AX-continuous performance task in adult ADHD

Introduction

Attention deficit disorder (ADHD) is a psychiatric disorder, which is characterized by deficits of executive functions (EF) and impulsivity. Whereas a variety of studies on the involvement of the dopaminergic system in ADHD exists, the impact of the serotonergic system to EF in ADHD in adults is underinvestigated.

Aims

To ascertain the effects of rapid tryptophan depletion (RTD) and the resultant reduction of the central nervous levels of serotonin on the EF of male adult patients with ADHD.

Methods

20 ADHD patients and 20 healthy controls completed the RTD test on one day and a placebo on another day in a double-blind within subject crossover design.- In addition, the subtest alertness of the TAP and a modified Version of the Continuous performance test (AX-CPT) with three stimulus conditions (AX, AY, BX) were administered.

Results

Statistical analysis revealed significant shorter reaction times, more errors and more omission errors in the ADHD group in the AX-CPT. The omissions error rate increased in both groups in the RTD condition but not in the placebo condition. Statistical analyses did not yield any significant differences between groups in the subtest alertness and no significant interaction of group and effect of the RTD condition could be observed.

Conclusions

In addition to higher impulsivity of patients with ADHD as reflected by shorter reaction times and higher error rates, the results of the present study imply an involvement of the serotonergic system as reflected by RTD in sustained and selective attention.

Ophthalmological findings in children and adolescents with Silver-Russell syndrome

AIM

To evaluate ophthalmological findings in children with Silver-Russell syndrome (SRS).

METHODS

An ophthalmological evaluation including visual acuity (VA), refraction, strabismus, near point of convergence (NPC), slit-lamp examination, ophthalmoscopy, axial length measurements and full-field electroretinogram was performed on 18 children with SRS (8 girls, 10 boys; mean age 11.6 years). Fundus photographs were taken for digital image analysis. Data were compared with data on an age- and gender-matched reference group (ref) of school children (n=99).

RESULTS

Seventeen out of 18 children with SRS had ophthalmological abnormalities. Best corrected VA of the best eye was <0.1 log of the minimal angle of resolution in 11 children (ref n=98) (p<0.0001), and 11 children had refractive errors (ref n=33) (p=0.05). Anisometropia (≥1 dioptre) was noted in three of the children (ref n=3) (p=0.046). Subnormal stereo acuity and NPC were found in 2/16 (ref=0) (p=0.02). The total axial length in both eyes was shorter compared with that in controls (p<0.006 and p<0.001). Small optic discs were found in 3/16, large cup in 3/16 and increased tortuosity of retinal vessels in 4/13 children with SRS.

CONCLUSION

Children with SRS, who are severely intrauterine growth retarded, show significant ophthalmological abnormalities. Based on the present findings, ophthalmological examination is recommended in children with SRS.