The influence of different inositol stereoisomers supplementation in pregnancy on maternal gestational diabetes mellitus and fetal outcomes in high-risk patients: a randomized controlled trial

Objective: To identify the effects of different dietary inositol stereoisomers on insulin resistance and the development of gestational diabetes mellitus (GDM) in women at high risk for this disorder.Design: A preliminary, prospective, randomized, placebo controlled clinical trial.Participants: Nonobese singleton pregnant women with an elevated fasting glucose in the first or early second trimester were studied throughout pregnancy.Intervention: Supplementation with myo-inositol, d-chiro-inositol, combined myo- and d-chiro-inositol or placebo.Main outcome measure: Development of GDM on a 75 grams oral glucose tolerance test at 24-28 weeks' gestation. Secondary outcome measures were increase in BMI, need for maternal insulin therapy, macrosomia, polyhydramnios, neonatal birthweight and hypoglycemia.Results: The group of women allocated to receive myo-inositol alone had a lower incidence of abnormal oral glucose tolerance test (OGTT). Nine women in the control group (C), one of the myo-inositol (MI), five in d-chiro-inositol (DCI), three in the myo-inositol/D-chiro-inositol group (MI/DCI) required insulin (p = .134). Basal, 1-hour, and 2 hours glycemic controls were significantly lower in exposed groups (p < .001, .011, and .037, respectively). The relative risk reduction related to primary outcome was 0.083, 0.559, and 0.621 for MI, DCI, and MI/DCI groups.Conclusions: This study compared the different inositol stereoisomers in pregnancy to prevent GDM. Noninferiority analysis demonstrated the largest benefit in the myo-inositol group. The relevance of our findings is mainly related to the possibility of an effective approach in GDM. Our study confirmed the efficacy of inositol supplementation in pregnant women at risk for GDM.

Correlations between cervical spinal cord magnetic resonance diffusion tensor and diffusion kurtosis imaging metrics and motor performance in patients with chronic ischemic brain lesions of the corticospinal tract

PURPOSE

To investigate modifications of Magnetic Resonance Diffusion Tensor Imaging (DTI) and Diffusion Kurtosis Imaging (DKI) metrics in lateral white matter (WM) bundles of the cervical spinal cord in patients with previous stroke in the vascular territory of the middle cerebral artery (MCA).

METHODS

Twenty consecutive patients with a previous ischemic stroke of the MCA territory and a varying degree of upper motor impairment were enrolled. DKI was centered at the C3C4 and C5C6 intervertebral level.

RESULTS

The fractional anisotropy (FA) values in C3C4 and C5C6 were found to be significantly lower in the lateral WM bundles contralateral to the ischemic lesion and thus, in the WM bundle including the affected corticospinal tract (CST) (p = 0.005 and p = 0.008, respectively), as well as mean kurtosis (MK) and axonal water fraction (AWF) values (p = 0.004 and p = 0.04. respectively). FA values correlated significantly with the Global Motor Index (GMI) both for C3C4 (ρ = 0.61, p = 0.004) and C5C6 (ρ = 0.69, p = 0.002). At C3C4, AWF correlated significantly with GMI (ρ = 0.54, p = 0.03). No correlations were found between lateral WM bundle volumes and GMI.

CONCLUSION

A reduction of anisotropy and microstructural complexity in the affected lateral WM bundle of the cervical spinal cord was observed in patients with previous ischemic stroke involving the CST. The correlations between these metrics and motor performance were statistically significant.

Diagnosis of Beckwith-Wiedemann syndrome in children presenting with Wilms tumor

Beckwith-Wiedemann syndrome (BWS) is a genetic syndrome associated with overgrowth and cancer predisposition, including predisposition to Wilms tumor (WT). Patients with BWS and BWS spectrum are screened from birth to age 7 years for BWS-associated cancers. However, in some cases a BWS-associated cancer may be the first recognized manifestation of the syndrome. We describe 12 patients diagnosed with BWS after presenting with a WT. We discuss the features of BWS in these patients and hypothesize that earlier detection of BWS by attention to its subtler manifestations could lead to earlier detection of children at risk for associated malignancies.

Foveal avascular zone area and parafoveal vessel density measurements in different stages of diabetic retinopathy by optical coherence tomography angiography

AIM

To investigate foveal avascular zone (FAZ) and parafoveal vessel densities (PRVD) by means of optical coherence tomography angiography (OCTA) in diabetic patients with or without diabetic retinopathy (DR) and to assess the reproducibility of FAZ and PRVD measurements.

METHODS

Sixty diabetic patients (60 eyes) with different stage of DR (graded according to the International Clinical Severity Scale for DR) and 20 healthy subjects underwent FAZ area and PRVD measurements using OCTA by two experienced examiners. FAZ area in all patients was also assessed using fluorescein angiography (FA).

RESULTS

In subject with proliferative DR and with moderate-severe non proliferative DR, FAZ area was significantly increased compared to healthy controls (P=0.025 and P=0.050 respectively measured with OCTA and P=0.025 and P=0.048 respectively measured with FA). OCTA showed significantly less inter-observer variability compared to FA. Concordance correlation coefficient (CCC) for FAZ area measurements was 0.829 (95%CI: 0.736-0.891) P<0.001 with FA and 1.000 (95%CI: 0.999-1.000) P<0.001 with OCTA. CCC was 0.834 (95%CI: 0.746-0.893) P<0.001 and 0.890 (95%CI: 0.828-0.930) P<0.001 for parafoveal superficial and deep vessel density measurements, respectively.

CONCLUSION

OCTA shows progressive increase of FAZ area and reduction of PRVD in both superficial and deep plexus at increasing DR severity. FAZ area and PRVD measurements using OCTA are highly reproducible.

Management of adrenal masses in patients with Beckwith-Wiedemann syndrome

Beckwith-Wiedemann syndrome (BWS) is a genetic overgrowth and cancer predisposition syndrome, associated with both benign and malignant adrenal findings. Literature review and an institutional case series elucidate the wide spectrum of adrenal findings in BWS patients. The altered expression of the 11p15 region is likely related to adrenal gland hyperplasia and growth dysregulation. Given the absence of guidelines for managing adrenal findings in BWS, we propose a systematic approach to adrenal findings in BWS patients, to allow for maximum detection of potentially malignant pathology without posing additional risk to patients.

Spinal cord microstructure integrating phase-sensitive inversion recovery and diffusional kurtosis imaging

PURPOSE

The aim of this prospective study was to determine the feasibility in terms of repeatability and reproducibility of diffusional kurtosis imaging (DKI) for microstructural assessment of the normal cervical spinal cord (cSC) using a phase-sensitive inversion recovery (PSIR) sequence as the anatomical reference for accurately defining white-matter (WM) and gray-matter (GM) regions of interests (ROIs).

METHODS

Thirteen young healthy subjects were enrolled to undergo DKI and PSIR sequences in the cSC. The repeatability and reproducibility of kurtosis metrics and fractional anisotropy (FA) were calculated in GM, WM, and cerebral-spinal-fluid (CSF) ROIs drawn by two independent readers on PSIR images of three different levels (C1-C4). The presence of statistically significant differences in DKI metrics for levels, ROIs (GM, WM, and CSF) repeatability, reproducibility, and inter-reader agreement was evaluated.

RESULTS

Intra-class correlation coefficients between the two readers ranged from good to excellent (0.75 to 0.90). The inferior level consistently had the highest concordance. The lower values of scan-rescan variability for all DKI parameters were found for the inferior level. Statistically significant differences in kurtosis values were not found in the lateral white-matter bundles of the spinal cord.

CONCLUSION

The integration of DKI and PSIR sequences in a clinical MR acquisition to explore the regional microstructure of the cSC in healthy subjects is feasible, and the results obtainable are reproducible. Further investigation will be required to verify the possibility to translate this method to a clinical setting to study patients with SC involvement especially in the absence of MRI abnormalities on standard sequences.

Microvascular changes after vitrectomy with internal limiting membrane peeling: an optical coherence tomography angiography study

PURPOSE

To evaluate superficial capillary plexus (SCP) changes occurring after internal limiting membrane (ILM) peeling for the treatment of idiopathic epiretinal membrane (ERM).

METHODS

A total of 15 eyes of 15 patients affected by idiopathic ERM (eight males and seven females; mean age 59.8 ± 9.6 years) were enrolled in the study. Patients were treated with pars plana vitrectomy followed by ERM and ILM peeling. Subjects were evaluated at baseline and at the week-1 and month-1 follow-up visits. At each visit, patients were evaluated with a complete ophthalmologic evaluation, which included imaging with optical coherence tomography angiography.

RESULTS

Overall, the SCP vessel density was 43.0 ± 3.0% at baseline and was stable throughout the follow-up (40.0 ± 4.0% at week-1 and 41.0 ± 4.0% at month-1 follow-up visits; p = 0.087 and p = 0.426, respectively). Nevertheless, the SCP vessel density was reduced at week-1 visit in both the superior and inferior sectors. In these sectors, the superficial vessel density was still reduced at the month-1 follow-up visit.

CONCLUSIONS

We observed a reduction in the SCP vessel density occurring after pars plana vitrectomy with ILM peeling. The reduction is referred to those areas where other changes (e.g., swelling of the arcuate nerve fiber layer) have been already described. In theory, superficial vessel density modifications may be due to the direct surgical trauma to the inner retina, where the superficial plexus is contained, during the ILM grasping.

Optical Coherence Tomography Angiography in the Multimodal Imaging Evaluation of Interferon-Associated Retinopathy: A Case Report

The authors present the case of a 59-year-old woman in treatment with interferon alfa-2b for stage IV melanoma and widespread metastases who presented with interferon-associated retinopathy. An ocular examination revealed multiple retinal cotton-wool spots and hard exudates. Interferon treatment was suspended. The patient was followed up for 5 months following the baseline visit by means of en face optical coherence tomography (OCT), spectral-domain OCT, and OCT angiography. Multimodal imaging was useful in the follow-up of this condition, permitting the characterization of all the lesions hallmarking the interferon-retinopathy and showing that this illness was related to a reduction of the retinal vascular perfusion. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:498-504.].

Optical Coherence Tomography Angiography Findings in Stargardt Disease

Background

to assess vessel density of superficial capillary plexus (SCP), deep capillary plexus (DCP) and choriocapillaris (CC) in advanced Stargardt disease (STGD) using optical coherence tomography angiography (OCTA) and correlate these findings with macular function using pattern electroretinogram (PERG) and multifocal electroretinogram (mfERG).

Methods

Twelve patients (24 eyes) with advanced STGD underwent vessel densities and macular thickness measurements using OCTA. A control group of 24 healthy controls (24 eyes) was chosen for comparison. In the STGD group correlation between vessel density and macular thickness and between macular function and morphologic parameters were evaluated.

Results

Whole parafoveal vessel density (VD) of SCP was significantly lower in STGD group compared to the control group (p<0.05). Foveal VD and whole parafoveal VD of the DCP were significantly lower in STGD group compared to the controls (p<0.05). CC was significantly decreased in STGD compared to controls (p<0.05). Foveal macular thickness (MT), full parafoveal MT, and inner limiting membrane (ILM)-inner plexiform layer (IPL) parafoveal MT thickness were decreased in STGD eyes compared to controls (p<0.001). PERG and mfERG were both significantly reduced in STGD compared to controls (p<0.001). A direct correlation was found between full parafoveal MT and vessel density in the STGD group.

Conclusions

Patients with advanced STGD showed a reduction of SCP, DCP and CC compared to healthy eyes related to a reduction of total and ILM-IPL macular thickness. These results suggest that both retinal capillaris plexuses and choriocapillaris reduction occur in STDG along with inner and outer retinal thinning.

All laser cataract surgery compared to femtosecond laser phacoemulsification surgery: corneal trauma

The aim of this study was to evaluate corneal tissue trauma after femtosecond laser-assisted cataract surgery (FLACS) and phacoemulsification (femtophaco surgery) compared to FLACS and nanolaser emulsification (all laser surgery). This is a prospective nonrandomized clinical study conducted at the Ophthalmology Clinic, University "G. d'Annunzio" of Chieti-Pescara, Italy, involving forty-two eyes of 42 patients candidates to cataract surgery. Patients were enrolled in two groups: femtophaco surgery (group 1 with 21 eyes) and all laser surgery (group 2 with 21 eyes). Main outcome measures included uncorrected visual acuity and distance corrected visual acuity, corneal endothelial cell count, and corneal thickness at the tunnel site and at the center of the cornea. Best correct visual acuity was not significantly different between the two groups. Postoperatively, a significant decrement of endothelial cell count at the center of the cornea was observed in group 1 compared with preoperative values at 90 days (p < 0.001) while t remained stable in group 2. The central corneal thickness showed a statistically significant increase for both groups that reached a maximum thickness at 7 days and then returned to presurgery levels after 90 days for group 1 and after 60 days for group 2. The tunnel corneal thickness showed a statistically significant increase for both groups that reached a maximum thickness at 7 days, which did not return to presurgery level for group 1 but did return to presurgery levels after 60 days for group 2. All laser surgery induced lower central endothelial cell loss and lower increase of corneal thickness compared to femtophaco surgery.

Myo-Inositol Supplementation to Prevent Gestational Diabetes Mellitus

Gestational diabetes mellitus (GDM) is a common complication characterized by increased insulin resistance, and by increased risk for adverse pregnancy outcomes affecting both the mother and the fetus. International guidelines describe optimal ways to recognize it, and the recommended treatment of patients affected to reduce adverse outcomes. Improving insulin resistance could reduce incidence of GDM and its complications. Recently, a few trials have been published on the possible prevention of GDM. Inositol has been proposed as a food supplement that might reduce gestational diabetes incidence in high-risk pregnant women.

Perinatal MRI diffusivity is related to early assessment of motor performance in preterm neonates

Preterm neonates represent a high-risk population for abnormal neuropsychological development. But presently, an accurate method for identifying those at risk is not available. This study evaluated the association between the microstructural organization measured with Diffusion Tensor Imaging (DTI) in term-corrected preterm neonates and subsequent motor performance. Fractional anisotropy (FA), axial diffusion (AD), mean diffusivity (MD) and radial diffusivity (RD) were determined in two regions of interest (ROIs) corresponding to the posterior limb of the internal capsule (PLIC) and cortico-spinal tract (CST). The Griffiths Mental Developmental Scales (GMDS) were longitudinally administered at 3, 6 and 15 months; and correlations between the metrics of diffusivity and the motor subscale of the GMDS were assessed using the Spearman correlation. A statistically significant negative correlation was observed between the AD of PLIC of the left hemisphere and the 3-month GMDS Locomotor Subscale. These results suggested that AD is a valid indicator of the stage of maturation of the motor pathway in preterm neonates, but not of later motor outcome.

Postoperative IOL Axial Movements and Refractive Changes After Femtosecond Laser-assisted Cataract Surgery Versus Conventional Phacoemulsification

PURPOSE

To evaluate intraocular lens (IOL) axial movements and refractive changes during a 6-month follow-up period after femtosecond laser-assisted cataract surgery and conventional cataract surgery, investigate the influence of capsulorhexis features on postoperative IOL axial changes, and assess the prediction error for both techniques.

METHODS

Eighty eyes of 80 candidates for cataract extraction were randomized into two groups: femtosecond laser (40 eyes) and manual (40 eyes).

RESULTS

The overall anterior chamber depth variation was significantly lower in the femtosecond laser group compared to the manual group during follow-up (P<.001). At 30 and 180 days postoperatively, the mean spherical equivalent showed a hyperopic shift (0.09±0.28 diopters [D]) in the femtosecond laser group and a myopic shift in the manual group (-0.25±0.18 D). Median absolute error was not significantly different between the two groups with standard formulas ranging between 0.29 and 0.64 (Hoffer Q) in the femtosecond laser group and between 0.24 (SRK-T) and 0.55 D (Hoffer Q) in the manual group. There was a significant lower deviation from intended versus achieved capsulotomy/capsulorhexis area in the femtosecond laser group (P<.001) compared to the manual group. The femtosecond laser group showed better IOL centration compared to the manual group at all time periods (P<.001).

CONCLUSIONS

Femtosecond laser-assisted cataract surgery was related to a lower overall variability of anterior chamber depth compared to conventional cataract surgery with more stable postoperative refraction. The two techniques did not show significant differences of prediction error.

Circadian intraocular pressure patterns in healthy subjects, primary open angle and normal tension glaucoma patients with a contact lens sensor

PURPOSE

To examine the circadian intraocular pressure (IOP) patterns in healthy subjects, in primary open angle and normal tension glaucoma (POAG; NTG) using a contact lens sensor (CLS; Sensimed Triggerfish, Lausanne, Switzerland).

METHODS

This was an observational, nonrandomized study. Ten healthy subjects (Group 1, 10 eyes) and 20 glaucomatous patients [20 eyes, 10 with POAG (Group 2) and 10 with NTG (Group 3)] were enrolled. All patients were controlled with prostaglandin analogues. The 24-hr IOP pattern was the main outcome. The morning (6AM-11AM), afternoon/evening (noon-11PM) and night (midnight-5AM) subperiod patterns, peaks and prolonged peaks (>1 hr) were secondary outcomes.

RESULTS

Mean 24-hr IOP pattern showed a nocturnal acrophase in all groups. Patterns were significantly different among groups (p = 0.02), with highest nocturnal IOP values in POAG. Prolonged peaks were more common in patients with glaucoma (70%) than in healthy subjects (33.3%) (p < 0.001). Significant differences were found for Groups 2 and 3 in the morning versus afternoon/evening (p = 0.019 and p = 0.035, Bonferroni correction), morning versus night (p = 0.005 and p < 0.0001) and afternoon/evening versus night periods comparisons (p < 0.0001 for both groups). In Group 1, patterns significantly differed in the morning versus night and afternoon/evening versus night period comparisons (p < 0.0001).

CONCLUSIONS

Continuous 24-hr IOP monitoring with the CLS revealed a nocturnal acrophase in healthy subjects and, more markedly, in glaucoma. Because the diurnal IOP profile seems not to predict the nocturnal rhythm, the circadian IOP pattern should be evaluated in clinical practice. These findings may be worthwhile for the management of glaucoma.

Comparing 3T T1-weighted sequences in identifying hyperintense punctate lesions in preterm neonates

BACKGROUND AND PURPOSE

The loss of contrast on T1-weighted MR images at 3T may affect the detection of hyperintense punctate lesions indicative of periventricular leukomalacia in preterm neonates. The aim of the present study was to determine which 3T T1-weighted sequence identified the highest number of hyperintense punctate lesions and to explore the relationship between the number of hyperintense punctate lesions and clinical outcome.

MATERIALS AND METHODS

The presence of hyperintense punctate lesions was retrospectively evaluated in 200 consecutive preterm neonates on 4 axial T1-weighted sequences: 3-mm inversion recovery and spin-echo and 1- and 3-mm reformatted 3D-fast-field echo. Statistically significant differences in the number of hyperintense punctate lesions were evaluated by using a linear mixed-model analysis. Logistic regression analysis was used to assess the relation between the number of hyperintense punctate lesions and neuromotor outcome at 3 months.

RESULTS

Thirty-one neonates had at least 1 hyperintense punctate lesion indicative of periventricular leukomalacia in at least 1 of the 4 sequences. The 1-mm axial reformatted 3D-fast-field echo sequence identified the greatest number of hyperintense punctate lesions (P < .001). No statistically significant differences were found among the 3-mm T1-weighted sequences. The greater number of hyperintense punctate lesions detected by the 1-mm reformatted T1 3D-fast-field echo sequence in the central region of the brain was associated with a worse clinical outcome.

CONCLUSIONS

At 3T, the 1-mm axial reformatted T1 3D-fast-field echo sequence identified the greatest number of hyperintense punctate lesions in the central region of preterm neonate brains, and this number was associated with neuromotor outcome.

Optical coherence tomography and 3-dimensional confocal structured imaging system-guided femtosecond laser capsulotomy versus manual continuous curvilinear capsulorhexis

PURPOSE

To compare the features of capsulotomy obtained during femtosecond laser-assisted cataract surgery with those of continuous curvilinear capsulorhexis (CCC) obtained using a standard manual technique.

SETTING

Ophthalmology Clinic, Department of Medicine and Science of Ageing, University G. D'Annunzio Chieti-Pescara, Chieti, Italy.

DESIGN

Prospective randomized clinical study.

METHODS

Candidates for cataract extraction were randomized into 1 of 3 groups as follows: Lensx femtosecond laser-assisted cataract surgery capsulotomy (laser group 1), Lensar femtosecond laser-assisted cataract surgery capsulotomy (laser group 2), and manual CCC (manual group).

RESULTS

Each group comprised 30 eyes (30 patients). The capsulotomies in laser group 1 and laser group 2 showed significantly better circularity than the manual CCCs at 7 days (P<.001). There was a significant correlation between the intended versus achieved capsulotomy size in the 2 laser groups. Both laser groups had better intraocular lens (IOL) centration than the manual group at all timepoints (P<.001). Between-group differences in uncorrected and corrected distance visual acuities were not statistically significant. The residual spherical equivalent and mean absolute error were statistically significantly smaller in the 2 laser groups than in the manual group (P=.038) and increased significantly over time in all the groups (P<.001).

CONCLUSIONS

Femtosecond laser capsulotomies showed better circularity with more predictable size than manual CCCs. In addition, IOL centration was better immediately after surgery and over time with better refractive results in the 2 laser groups.

Evaluation of corneal biomechanical properties modification after small incision lenticule extraction using Scheimpflug-based noncontact tonometer

PURPOSE

To quantify the effect of small incision lenticule extraction (SMILE) on the corneal biomechanics using Scheimpflug noncontact tonometer (Corvis ST).

METHODS

Twenty eyes of twenty patients, evaluated as eligible for surgery, with high myopia and/or moderate myopic astigmatism, underwent small incision lenticule extraction (SMILE). All patients underwent Corvis ST preoperatively and postoperatively after 1 week, and 1 and 3 months to observe alterations of corneal biomechanical properties. The main outcome measures were Deformation Amplitude, 1st-AT, and 2nd-AT. The relationship between the amount of stroma removed and the percentage variation of the measured parameters from baseline was evaluated with generalized linear model from each time point. For completeness also intraocular pressure (IOP), central corneal thickness (CCT), and their variations after surgery were evaluated.

RESULTS

The ratio between the amount of removed refractive error and, respectively, changes of Deformation Amplitude, 1st-AT, and 2nd-AT were significantly modified at the 1st week after surgery (P = 0.005; P = 0.001; P = 0.024). At 1 and 3 months these values did not show statistically significant alterations. Intraocular pressure and central corneal thickness showed statistically significant changes during follow-up.

CONCLUSIONS

No significant modifications in biomechanical properties were observed after SMILE so this procedure could induce only minimal transient alterations of corneal biomechanics.

Data-driven grading of brain gliomas: a multiparametric MR imaging study

PURPOSE

To grade brain gliomas by using a data-driven analysis of multiparametric magnetic resonance (MR) imaging, taking into account the heterogeneity of the lesions at MR imaging, and to compare these results with the most widespread current radiologic reporting methods.

MATERIALS AND METHODS

One hundred eighteen patients with histologically confirmed brain gliomas were evaluated retrospectively. Conventional and advanced MR sequences (perfusion-weighted imaging, MR spectroscopy, and diffusion-tensor imaging) were performed. Three evaluations were conducted: semiquantitative (based on conventional and advanced sequences with reported cutoffs), qualitative (exclusively based on conventional MR imaging), and quantitative. For quantitative analysis, four volumes of interest were placed: regions with contrast material enhancement, regions with highest and lowest signal intensity on T2-weighted images, and regions of most restricted diffusivity. Statistical analysis included t test, receiver operating characteristic (ROC) analysis, discriminant function analysis (DFA), leave-one-out cross-validation, and Kendall coefficient of concordance.

RESULTS

Significant differences were noted in age, relative cerebral blood volume (rCBV) in contrast-enhanced regions (cutoff > 2.59; sensitivity, 80%; specificity, 91%; area under the ROC curve [AUC] = 0.937; P = .0001), areas of lowest signal intensity on T2-weighted images (>2.45, 57%, 97%, 0.852, and P = .0001, respectively), restricted diffusivity regions (>2.61, 54%, 97%, 0.808, and P = .0001, respectively), and choline/creatine ratio in regions with the lowest signal intensity on T2-weighted images (>2.07, 49%, 88%, 0.685, and P = .0007, respectively). DFA that included age; rCBV in contrast-enhanced regions, areas of lowest signal intensity on T2-weighted images, and areas of restricted diffusivity; and choline/creatine ratio in areas with lowest signal intensity on T2-weighted images was used to classify 95% of patients correctly. Quantitative analysis showed a higher concordance with histologic findings than qualitative and semiquantitative methods (P < .0001).

CONCLUSION

A quantitative multiparametric MR imaging evaluation that incorporated heterogeneity at MR imaging significantly improved discrimination between low- and high-grade brain gliomas with a very high AUC (ie, 0.95), thus reducing the risk of inappropriate or delayed surgery, respectively.

Effect of dietary myo-inositol supplementation in pregnancy on the incidence of maternal gestational diabetes mellitus and fetal outcomes: a randomized controlled trial

OBJECTIVE

To test the hypothesis that dietary myo-inositol may improve insulin resistance and the development of gestational diabetes mellitus (GDM) in women at high risk of this disorder.

DESIGN

A prospective, randomized, double-blind, placebo controlled clinical trial, pilot study.

PARTICIPANTS

Non-obese singleton pregnant women with an elevated fasting glucose in the first or early second trimester were studied throughout pregnancy.

INTERVENTION

Supplementation with myo-inositol or placebo during pregnancy.

MAIN OUTCOME MEASURE

Development of GDM on a 75 g oral glucose tolerance test at 24-28 weeks' gestation. Secondary outcome measures were increased in BMI, need for maternal insulin therapy, macrosomia, polyhydramnios, neonatal birthweight and hypoglycemia.

RESULTS

Thirty-six women were allocated to receive myo-inositol and 39 placebo. The incidence of GDM in mid-pregnancy was significantly reduced (p = 0.001) in women randomized to receive myo-inositol compared to placebo (relative risk 0.127). Women randomized to receive myo-inositol also required less insulin therapy, delivered at a later gestational age, had significantly smaller babies with fewer episodes of neonatal hypoglycemia.

CONCLUSIONS

Myo-inositol supplementation in pregnancy reduced the incidence of GDM in women at high risk of this disorder. The reduction in incidence of GDM in the treatment arm was accompanied by improved outcomes.

Combination training in aging individuals modifies functional connectivity and cognition, and is potentially affected by dopamine-related genes

Background

Aging is a major co-risk factor in many neurodegenerative diseases. Cognitive enrichment positively affects the structural plasticity of the aging brain. In this study, we evaluated effects of a set of structured multimodal activities (Combination Training; CT) on cognitive performances, functional connectivity, and cortical thickness of a group of healthy elderly individuals. CT lasted six months.

Methodology

Neuropsychological and occupational performances were evaluated before and at the end of the training period. fMRI was used to assess effects of training on resting state network (RSN) functional connectivity using Independent Component Analysis (ICA). Effects on cortical thickness were also studied. Finally, we evaluated whether specific dopamine-related genes can affect the response to training.

Principal Findings

Results of the study indicate that CT improves cognitive/occupational performances and reorganizes functional connectivity. Intriguingly, individuals responding to CT showed specific dopamine-related genotypes. Indeed, analysis of dopamine-related genes revealed that carriers of DRD3 ser9gly and COMT Val158Met polymorphisms had the greatest benefits from exposure to CT.

Conclusions and Significance

Overall, our findings support the idea that exposure to a set of structured multimodal activities can be an effective strategy to counteract aging-related cognitive decline and also indicate that significant capability of functional and structural changes are maintained in the elderly.

Modifications of default-mode network connectivity in patients with cerebral glioma

Purpose

The aim of the study was to evaluate connectivity modifications in the Default Mode Network (DMN) in patients with cerebral glioma, and to correlate these modifications to tumor characteristics.

Methods

Twenty-four patients with a left-hemisphere cerebral tumor (14 grade II and 10 grade IV gliomas) and 14 healthy age-matched right-hand volunteers were enrolled in the study. Subjects underwent fMRI while performing language tasks for presurgical mapping. Data was analyzed with independent component analysis in order to identify the DMN. DMN group maps were produced by random-effect analysis (p<0.001, FDR-corrected). An analysis of variance across the three groups (p<0.05) and post-hoc t-test contrasts between pairs of groups were calculated (p<0.05, FDR-corrected).

Results

All three groups showed typical DMN areas. However, reduced DMN connectivity was detected in tumor patients with respect to controls. A significantly increased and reduced integration of DMN areas was observed in the hippocampal and prefrontal regions, respectively. Modifications were closely related to tumor grading. Moreover, the DMN lateralized to the hemisphere contralateral to tumor in the low-grade, but not in the high-grade tumor patients.

Conclusion

Modifications of DMN connectivity were induced by gliomas and differed for high and low grade tumors.

Reorganization of functional connectivity of the language network in patients with brain gliomas

BACKGROUND AND PURPOSE

fcMRI measures spontaneous and synchronous fluctuations of BOLD signal between spatially remote brain regions. The present study investigated potential LN fcMRI modifications induced by left hemisphere brain gliomas.

MATERIALS AND METHODS

We retrospectively evaluated fcMRI in 39 right-handed patients with a left hemisphere brain glioma and 13 healthy controls. Patients and controls performed a verb-generation task to identify individual BOLD activity in the left IFG (Broca area); the active region was used as seed to create whole-brain background connectivity maps and to identify the LN (including bilateral regions of the IFG, STS, and TPJ) following regression of task-evoked activity. We assessed differences between patients and controls in the pattern of functional connectivity of the LN, as well as potential effects of tumor position, histopathology, and volume.

RESULTS

Global fcMRI of the LN was significantly reduced in patients with tumor compared with controls. Specifically, fcMRI was significantly reduced within seed regions of the affected hemisphere (left intrahemispheric fcMRI) and between the TPJ of the 2 hemispheres. In patients, the left TPJ node showed the greatest decrease of functional connectivity within the LN.

CONCLUSIONS

The presence of a brain tumor in the left hemisphere significantly reduced the degree of fcMRI between language-related brain regions. The pattern of fcMRI was influenced by tumor position but was not restricted to the area immediately surrounding the tumor because the connectivity between remote and contralateral areas was also affected.

The effect of recurrent severe hypoglycemia on cognitive performance in children with type 1 diabetes: a meta-analysis

The purpose of this study was to investigate the existence and extent of cognitive impairment in type 1 diabetic children with episodes of recurrent severe hypoglycemia, using meta-analysis to synthesize data across studies. The meta-analysis sample included: 441 children with diabetes and recurrent severe hypoglycemia, 560 children with diabetes and without recurrent severe hypoglycemia. Overall, children with type 1 diabetes and recurrent severe hypoglycemia had slightly lower performance than diabetic children without severe hypoglycemia, only in some cognitive domains: intelligence, memory, learning, and verbal fluency/language. Greater impairment was found in memory and learning. No impairment was found for motor speed. Our results seem to confirm the hypothesis that recurrent severe hypoglycemia has a selective negative effect on the children's cognitive functions. However, these results must be considered with caution taking into account factors such as small sample sizes, the different definitions of severe hypoglycemia, and the variety of neuropsychological tests used.

Comparison of hypothesis- and a novel hybrid data/hypothesis-driven method of functional MR imaging analysis in patients with brain gliomas

BACKGROUND AND PURPOSE

An alternative technique, which is less influenced by tumor- and patient-related factors, is required to overcome the limits of GLM analysis of fMRI data in patients. The aim of this study was to statistically assess differences in the identification of language regions and hemispheric lateralization of language function between controls and patients as estimated by both the GLM and a novel combined ICA-GLM procedure.

MATERIALS AND METHODS

We retrospectively evaluated 42 patients with pathologically confirmed brain gliomas of the left frontal and/or temporoparietal lobes and a control group of 14 age-matched healthy volunteers who underwent BOLD fMRI to lateralize language functions in the cerebral hemispheres. Data were processed by using a classic GLM and ICA-GLM.

RESULTS

ICA-GLM demonstrated a higher sensitivity in detecting language activation, specifically in the left TPJ of patients. There were no significant differences between the GLM and ICA-GLM in controls; however, statistically significant differences were observed by using ICA-GLM for the LI in patients. For the computation of the LI, ICA-GLM was less influenced by the chosen statistical threshold compared with the GLM.

CONCLUSIONS

We suggest the use of the ICA-GLM as a valid alternative to the classic GLM method for presurgical mapping in patients with brain tumors and to replicate the present results in a broader sample of patients.

Finger thermoregulatory model assessing functional impairment in Raynaud's phenomenon

Raynaud's Phenomenon (RP) is a paroxysmal vasospastic disorder of small arteries, pre-capillary arteries, and cutaneous arteriovenous shunts of the extremities, typically induced by cold exposure and emotional stress. RP is either primary (PRP) or secondary to systemic sclerosis. In this study we use Control System Theory to model finger thermoregulatory processes in response to a standardized cold challenge (a diagnostic test routinely performed for differential diagnosis of RP). The proposed model is based on a homeostatic negative feedback loop, characterized by five distinct parameters which describe how the control mechanisms are activated and maintained. Thermal infrared imaging data from 14 systemic sclerosis subjects (SSc), 14 PRP, and 16 healthy control subjects (HCS) were processed. HCS presented the fastest active recovery, with the highest gain. PRP presented the slowest and weakest recovery, mostly due to passive heat exchange with the environment. SSc presented an intermediate behavior, with the longest delay of response onset. The estimated model parameters elucidated the level of functional impairment expressed in the various forms of this disease.

New morphologic variants of the hand motor cortex as seen with MR imaging in a large study population

BACKGROUND AND PURPOSE

The hand motor cortex (HMC) has been classically described as having an omega or epsilon shape in axial-plane images obtained with CT and MR imaging. The aim of this study was to use MR imaging and Talairach normalization in a large sample population that was homogeneous for age and handedness to evaluate in a sex model a new classification with 5 morphologic variants of the HMC in the axial plane (omega, medially asymmetric epsilon, epsilon, laterally asymmetric epsilon, and null).

MATERIALS AND METHODS

Structural brain MR images were obtained from 257 right-handed healthy subjects (143 men and 114 women; mean age, 23.1 +/- 1.1 years) via a Talairach space transformed 3D magnetization-prepared rapid acquisition of gradient echo sequence. The frequencies of the different HMC variants were reported for hemisphere and sex.

RESULTS

The new variants of the HMC (medially asymmetric epsilon, laterally asymmetric epsilon, and null) were observed in 2.9%, 7.0%, and 1.8% of the hemispheres, respectively. Statistically significant sex differences were observed: The epsilon variant was twice as frequent in men, and an interhemispheric concordance for morphologic variants was observed only for women.

CONCLUSION

The large study population permitted the description of a new morphologic classification that included 3 new variants of the HMC. This new morphologic classification should facilitate the identification of the precentral gyrus in subsequent studies and in everyday practice.

Antioxidant vitamin supplementation in cardiovascular diseases

Cardiovascular disease is the most important adult health problem in wealthy countries, where biological factors such as obesity, hypertension, dyslipidemia, diabetes, inappropriate diet, cigarette smoking, and sedentary life-style have contributed to its dissemination. Research concerning nutritional regimens has shown that persons who consume large amounts of fruit and vegetables have lower incidences of cardiovascular diseases, stroke, and tumors, although the precise mechanisms for this protective effect are elusive. Possible explanations include (a) increased consumption of dietary fiber, (b) reduced consumption of dietary cholesterol and other lipids, and (c) increased intake of the antioxidant vitamins (A, C, and E). Numerous studies have raised the question whether vitamin supplements help to prevent cardiovascular diseases. Results of randomized controlled trials of antioxidant vitamin supplements in large numbers of participants has been ambiguous or contradictory. This minireview examines the relevant clinical reports on dietary supplements of vitamins A, C, and E to determine whether they support the premise that patients at risk of cardiovascular disease may be candidates for this therapeutic option.

Airway obstruction during arthroscopic shoulder surgery: anesthesia for the patient or for the surgeon?

Two cases of airway obstruction as a result of oedema of laryngeal structures which arose during protracted arthroscopic shoulder surgery, in which single-shot interscalene blocks had been performed, are reported. In these 2 cases, the complexity of the pathologies and the fact that the surgeons were at the beginning of their surgical experience are the most likely causes of the conditions which led to tracheal compression from extra-articular leakage of fluid. Therefore, we recommend a combined peripheral block and general anaesthesia with tracheal intubation for procedures performed by surgeons without an adequate experience and on obese patients, patients placed in a lateral decubitus, or procedures in which difficulties are expected. The advantages of regional anaesthesia with a constant control of the airways are underlined.

Is nasal polyposis a determinant of bronchial hyperresponsiveness and altered quality of life in asthmatic subjects? A case-control study

Asthmatic patients with nasal polyposis (NP) have been reported to have a high prevalence of bronchial hyperresponsiveness (BHR) and a worsening of quality of life (QoL). The aim of this case-control study was to evaluate if NP is a determinant of BHR and is responsible for modifying the QoL in asthmatic subjects. Eighty-nine asthmatic subjects, including 24 patients with NP and 65 patients without NP (controls), underwent spirometry, methacholine challenge test (MCHt), skin prick tests, and were evaluated with the Asthma Quality of Life Questionnaire (AQLQ). Results of the MCHt test are expressed as the provocative concentration of methacholine that causes 20% (PC20) fall of forced expiratory volume at 1 sec (FEV1). The PC20 (mean +/- SD) in NP cases was 1149 +/- 668 microg/ml vs 894 +/- 691 microg/ml in controls (p <0.001). This demonstrates that BHR was not enhanced by the presence of NP in asthmatic subjects. No significant differences were found between the NP cases and controls for overall QoL or for single QoL domains. This study shows that the presence of NP did not impair the QoL of asthmatic patients, as indicated by the items included in the AQLQ questionnaire.

Superficial inflammatory and primary neoplastic lymphadenopathy: diagnostic accuracy of power-doppler sonography

OBJECTIVE

To evaluate the sensitivity, specificity and diagnostic accuracy of a cut-off of the resistive index of 0.5 for the differentiation between inflammatory and neoplastic primary lymphadenopathies.

SUBJECTS AND METHODS

We measured the resistive index of superficial enlarged lymph nodes in a total of 50 patients (29 males and 21 females; age range 12-72 years, mean age 41.6 year) using an ATL 5000 HDI. A resistive index greater than or equal to 0.5 indicated an inflammatory lymph node and a resistive index <0.5 was consistent with neoplastic primary lymphadenopathies. The gold standard was either surgical biopsy or lymph-node reduction seen with ultrasound examination after antibiotic therapy.

RESULTS

The sensitivity of the resistive index for distinguishing inflammatory from neoplastic lymphadenopathy was 84.6%, the specificity 100% and the diagnostic accuracy 95.7% (P < 0.001, statistically significant).

CONCLUSION

The results of this study indicate that power-Doppler using a resistive index cut-off of 0.5 was a valid technique for distinguishing between inflammatory and primary neoplastic lymph nodes in patients with superficial lymphadenopathies.

Magnetic resonance of the breast: correlation between enhancement patterns and microvessel density in malignant tumors

The continuous growth of a solid tumor is contingent upon the induction and formation of new vascular structures (angiogenesis). Several studies have established a close correlation between the microvessel density (MVD) of a tumor and its growth capacity. Therefore, a non-invasive method to accurately assess tumor MVD in vivo would be clinically useful. We studied 20 consecutive patients (age range: from 39 to 78 yrs; average age: 58.9 yrs), with malignant breast neoplasms using dynamic MR examinations with a paramagnetic contrast agent and post-operative pathological evaluation. We found that the differences in dynamic MRI enhancement are a direct consequence of microvascular distribution within the neoplasm. This study did not yield a statistically significant correlation between high microcirculation neo-formation and high aggressiveness of the neoplasm, but did indicate that further studies with a larger study populations are necessary.

Osteo-articular, mammographic and thoracic films: clinical evaluation of digital view box versus conventional view box

PURPOSE

To compare in a clinical setting a conventional view box with a digital view box (Smart Light 2000 Digital Film Viewer System, Smart Light, Israel) in the identification of osteo-articular, mammographic and thoracic lesions.

MATERIALS AND METHODS

Six radiologists (two for each imaging procedure), experts in osteo-articular, mammographic and thoracic diseases, independently, compared 600 plain films (100 patient with two projections for each imaging procedure). The radiologists evaluated the films by filling-out a multiple choice questionnaire containing questions concerning the type of pathology seen and the technical quality of the radiography in terms of exposure along with specific questions concerning each of the imaging procedures.

RESULTS

We observed a higher sensitivity of the digital view box for lesion identification (p<0.05); furthermore, we analyzed a greater number of radiographs, recovering technically unsuitable films, because of over or under-exposure (high or low optical density). The interreader agreement was also good (> 0.75). The better lesion perception derived from the increase luminance of the digital view box in the evaluation of higher film densities, such as in overexposed films. DISCUSSION. The technical characteristics of the digital view box reduce or eliminate negative factors that reduce perceptional performance, and often permit the recovery of films that would have otherwise been considered technically unreadable.

Diagnostic utility of an echo-contrast agent in patients with synovitis using power Doppler ultrasound: a preliminary study with comparison to contrast-enhanced MRI

The purpose of this study was to first evaluate Levovist (Schering, Berlin, Germany), an echo-contrast agent, during power Doppler sonography (PDS) in patients with synovitis using asymptomatic joints as controls. Then we evaluated the accuracy of this technique against contrast-enhanced MRI. Forty patients (19 men and 21 women; mean age 40 years) were enrolled on the basis of clinical signs, laboratory tests, and radiographic findings positive for articular inflammatory disease. They were examined with conventional ultrasonography (US) and PDS techniques before and after intravenous contrast medium injection. Fourteen patients then underwent MRI with and without contrast medium 8-14 days after PDS studies. Three expert readers independently evaluated each examination. After contrast medium, synovium in inflammatory arthritis enhanced on PDS compared with normal joints in the same patient. Power Doppler sonography after contrast medium and MRI were concordant in all cases. Power Doppler sonography with contrast medium showed a qualitative increase in signal from synovial vessels, the first sign of synovial changes in inflammatory diseases.

[Digital film viewer versus conventional view boxes in the identification of bone and joint disorders]

PURPOSE

To compare the diagnostic accuracy of a digital film viewer (Smartlight 2000 Plus) versus a conventional view box for the identification of bone and joint disorders.

MATERIAL AND METHODS

In order to evaluate the qualitative and quantitative differences of digital and conventional film viewers, 100 plain films of patients with bone and joint disorders taken in an emergency room January through May 1998 were reviewed utilizing both types of view boxes. Three radiologists expert of bone and joint disorders, independently compared the films, filled a form about the qualitative and quantitative analysis of the lesions depicted for each patient, and reported a few notes on the technical quality of the plain films in terms of exposure. The results were compared using the chi-square test (p < 0.005).

RESULTS

Data analysis showed that the digital film viewer permitted a quicker reading of the film while decreasing the perception threshold for elementary lesions and ocular fatigue. All the radiographs read with the digital film viewer were considered technically adequate: the film quality was considered good in 10 cases and sufficient in 2. Two of the same radiographs read with the conventional view box were considered of good quality, nine were considered sufficient and one was considered insufficient due to overexposure. There were six cases of agreement and six of disagreement for the diagnosis: four were due to overexposure of the radiograph and two to better conspicuity provided by the digital film viewer.

DISCUSSION

Correct image illumination is the first element a radiologist evaluates when reading a radiograph. A conventional view box may, when it is not properly maintained or when the radiograph is overexposed, decrease the radiologist's visual capacity. This increases the time required to read the radiograph and, therefore, physical and ocular fatigue, which in turn increases the risk of missing or misevaluating a lesion. A digital film viewer emits light with a variable intensity which is proportional to the optical density of the film. This increases the visual capacity of the radiologist and the lesion contrast, while reducing the factors which affect the radiograph reading.

CONCLUSIONS

The use of a digital film viewer increased the visual capacity of the radiologist and eliminated the negative elements which complicated the radiograph reading and permitted the use of radiographs that would otherwise have been considered of poor quality due to overexposure. This, combined with the experience of the radiologist, decreased of the risk of missing or misevaluating a lesion.