The impact of water exchange on estimates of myocardial extracellular volume calculated using contrast enhanced T1 measurements: A preliminary analysis in patients with severe aortic stenosis

PURPOSE

Guidelines recommend measuring myocardial extracellular volume (ECV) using T1 -mapping before and 10-30 min after contrast agent administration. Data are then analyzed using a linear model (LM), which assumes fast water exchange (WX) between the ECV and cardiomyocytes. We investigated whether limited WX influences ECV measurements in patients with severe aortic stenosis (AS).

METHODS

Twenty-five patients with severe AS and 5 healthy controls were recruited. T1 measurements were made on a 3 T Siemens system using a multiparametric saturation-recovery single-shot acquisition (a) before contrast; (b) 4 min post 0.05 mmol/kg gadobutrol; and (c) 4 min, (d) 10 min, and (e) 30 min after an additional gadobutrol dose (0.1 mmol/kg). Three LM-based ECV estimates, made using paired T1 measurements (a and b), (a and d), and (a and e), were compared to ECV estimates made using all 5 T1 measurements and a two-site exchange model (2SXM) accounting for WX.

RESULTS

Median (range) ECV estimated using the 2SXM model was 25% (21%-39%) for patients and 26% (22%-29%) for controls. ECV estimated in patients using the LM at 10 min following a cumulative contrast dose of 0.15 mmol/kg was 21% (17%-32%) and increased significantly to 22% (19%-35%) at 30 min (p = 0.0001). ECV estimated using the LM was highest following low dose gadobutrol, 25% (19%-38%).

CONCLUSION

Current guidelines on contrast agent dose for ECV measurements may lead to underestimated ECV in patients with severe AS because of limited WX. Use of a lower contrast agent dose may mitigate this effect.

Compartmental anisotropy of filtered exchange imaging (FEXI) in human white matter: What is happening in FEXI?

PURPOSE

To investigate the effects of compartmental anisotropy on filtered exchange imaging (FEXI) in white matter (WM).

THEORY AND METHODS

FEXI signals were measured using multiple combinations of diffusion filter and detection directions in five healthy volunteers. Additional filters, including a trace-weighted diffusion filter with trapezoidal gradients, a spherical b-tensor encoded diffusion filter, and a T2 filter, were tested with trace-weighted diffusion detection.

RESULTS

A large range of apparent exchange rates (AXR) and both positive and negative filter efficiencies (σ) were found depending on the mutual orientation of the filter and detection gradients relative to WM fiber orientation. The data demonstrated that the fast-diffusion compartment suppressed by diffusional filtering is not exclusively extra-cellular, but also intra-cellular. While not comprehensive, a simple two-compartment diffusion tensor model with water exchange was able to account qualitatively for the trends in positive and negative filtering efficiencies, while standard model imaging (SMI) without exchange could not. This two-compartment diffusion tensor model also demonstrated smaller AXR variances across subjects. When employing trace-weighted diffusion detection, AXR values were on the order of the R1 (=1/T1) of water at 3T for crossing fibers, while being less than R1 for parallel fibers.

CONCLUSION

Orientation-dependent AXR and σ values were observed when using multi-orientation filter and detection gradients in FEXI, indicating that WM FEXI models need to account for compartmental anisotropy. When using trace-weighted detection, AXR values were on the order of or less than R1, complicating the interpretation of FEXI results in WM in terms of biological exchange properties. These findings may contribute toward better understanding of FEXI results in WM.

Diffusional kurtosis time dependence and the water exchange rate for the multi-compartment Kärger model

PURPOSE

To demonstrate an analytic formula giving the time dependence of the diffusional kurtosis for the Kärger model (KM) with an arbitrary number of exchanging compartments and its application in estimating the mean KM water exchange rate.

THEORY AND METHODS

The general formula for the kurtosis is derived from a power series solution for the multi-compartment KM. A lower bound on the exchange rate is established from the observation that the kurtosis is always a logarithmically convex function of time. Both the kurtosis time dependence and the lower bound are illustrated with numerical calculations. The lower bound is also applied to previously published data for the time dependence of the kurtosis in both brain and tumors.

RESULTS

The kurtosis for the multi-compartment KM is given by a sum in which each term is associated with an eigenvector of the exchange rate matrix. The lower bound is determined from the most negative value for the logarithmic derivative of the kurtosis with respect to time. In the cerebral cortex, the lower bound is found to vary from 15 to 76 s-1 , depending on the experimental details, while for the tumors considered, it varies from 2 to 4 s-1 .

CONCLUSION

The time dependence of the kurtosis for the multi-compartment KM has a simple analytic solution that allows a lower bound for the mean KM water exchange rate to be determined directly from experiment. This may be useful in tissues with complex microstructure that is difficult to model explicitly.

Transpiration Dynamics of Esparto Grass (Macrochloa tenacissima (L.) Kunth) in a Semi-Arid Mediterranean Climate: Unraveling the Impacts of Pine Competition

Macrochloa tenacissima (M. tenacissima), or esparto, is a perennial tussock grass that coexists with Pinus halepensis (P. halepensis) in semi-arid Mediterranean woodlands. This research was carried out to explore diurnal transpiration at leaf level in esparto grass under different levels of pine-esparto competition and in contrasting environmental soil water conditions. The measurement period spanned from the summer of 2020 to the spring of 2021. The relationship between transpiration and competition was conducted in open and closed P. halepensis stands, and the type of leaf (green, senescent) and the maturity of the esparto grass were taken into account. We observed a higher control of transpiration in green leaves, and the correlations between the transpiration and pine competition were noted exclusively in this type of leaf. Our results demonstrated a significant impact of pine competitors (closed stands) on the transpiration of esparto grass, particularly during seasons characterized by scenarios of high water demand: the summer drought period and the commencement of the growing and flowering period (spring). Furthermore, our findings revealed a greater response to transpiration in mature bushes compared to young ones under severe water stress, indicating a higher adaptation to drought by esparto as it ages. Although our results confirmed that PAR increased transpiration in all seasons and in both stands, which is attributable to the heliophilia of esparto grass, the site effects on transpiration could also be attributable to competition for water, especially during periods of drought. These results may have important implications for the dynamics and management of these semi-arid mixed woodlands, as well as the planning of reforestation programs aimed at restoring esparto grass formations.

The effect of aquaporin-4 inhibition on cerebrospinal fluid-tissue water exchange in mouse brain detected by magnetization transfer indirect spin labeling MRI

The fluid transport of cerebrospinal fluid (CSF) and interstitial fluid in surrounding tissues plays an important role in the drainage pathway that facilitates waste clearance from the brain. This pathway is known as the glymphatic or perivascular system, and its functions are dependent on aquaporin-4 (AQP4). Recently, magnetization transfer indirect spin labeling (MISL) magnetic resonance imaging (MRI) has been proposed as a noninvasive and noncontrast-enhanced method for detecting water exchange between CSF and brain tissue. In this study, we first optimized the MISL sequence at preclinical 3 T MRI, and then studied the correlation of MISL in CSF with magnetization transfer (MT) in brain tissue, as well as the altered water exchange under AQP4 inhibition, using C57BL/6 mice. Results showed a strong correlation of MISL signal with MT signal. With the AQP4 inhibitor, we observed a significant decrease in MISL value (P < 0.05), suggesting that the hampered AQP4 activity led to decreased water exchange between CSF and brain tissue or the impairment of the glymphatic function. Overall, our findings demonstrate the potential application of MISL in assessing brain water exchange at 3 T MRI and its potential clinical translation.

ENDOANGEL versus water exchange for the detection of colorectal adenomas

Background

Recently, the ENDOANGEL (EN) system, a computer-assisted detection technique, and water exchange (WE) assisted colonoscopy have both been shown to increase the colorectal adenoma detection rate (ADR).

Objectives

The aim of this study was to compare the ADR between EN- and WE-assisted colonoscopy.

Design

This was a retrospective study.

Methods

Data from patients who underwent either EN- or WE-assisted colonoscopy between October 2021 and August 2022 were analysed consecutively. The primary outcome measure was the ADR.

Results

The ADR was found to be similar between the EN and WE groups, with 80 out of 199 (40.2%) patients in the EN group compared to 78 out of 174 (44.8%) patients in the WE group [1.21; 95% confidence interval (CI), 0.80-1.83]. In the analysis using stabilized inverse probability treatment weighting after adjustment for confounding factors, both colonoscopy methods had similar performance in terms of ADR (1.41; 95% CI, 0.88-2.27).

Conclusion

EN was found to be comparable to WE in terms of ADR during colonoscopy, and both methods may be effectively used in clinical practice.

The Consistence of Dynamic Contrast-Enhanced MRI and Filter-Exchange Imaging in Measuring Water Exchange Across the Blood-Brain Barrier in High-Grade Glioma

BACKGROUND

Water exchange across blood-brain barrier (BBB) (WEXBBB ) is an emerging biomarker of BBB dysfunction with potential applications in many brain diseases. Several MRI methods have been proposed to measure WEXBBB , but evidence remains scarce whether different methods can produce comparable WEXBBB .

PURPOSE

To explore whether dynamic contrast-enhanced (DCE)-MRI and vascular water exchange imaging (VEXI) could produce comparable WEXBBB in high-grade glioma (HGG) patients.

STUDY TYPE

Prospective cross-sectional.

SUBJECTS

13 HGG patients (58.4 ± 9.4 years, 9 females, 4 WHO III and 9 WHO IV).

FIELD STRENGTH/SEQUENCE

A 3 T, spoiled gradient-recalled-echo DCE-MRI and VEXI containing two pulsed-gradient spin-echo blocks separated by a mixing block.

ASSESSMENTS

The enhanced tumor and contralateral normal-appearing white matter (cNAWM) volume-of-interests (VOIs) were drew by two neuroradiologists. And whole-brain NAWM and normal-appearing gray matter (NAGM) without tumor-affected regions were segmented by automated segmentation algorithm in FSL.

STATISTICAL TESTS

Student's t-test was used to evaluate parameters difference between cNAWM and tumor, NAGM and NAWM, respectively. The correlation between vascular water efflux rate constant (kbo ) from DCE-MRI and apparent exchange rate across BBB (AXRBBB ) from VEXI was evaluated by Pearson correlation. P < 0.05 was considered statistically significant.

RESULTS

Compared with cNAWM, both kbo and AXRBBB were significantly reduced in tumor (kbo  = 3.50 ± 1.18 sec-1 vs. 1.03 ± 0.75 sec-1 ; AXRBBB  = 3.54 ± 1.11 sec-1 vs. 1.94 ± 1.04 sec-1 ). Both kbo and AXRBBB showed significantly higher values in NAWM than NAGM (kbo  = 3.50 ± 0.59 sec-1 vs. 2.10 ± 0.56 sec-1 ; AXRBBB  = 3.35 ± 0.77 sec-1 vs. 2.07 ± 0.52 sec-1 ). The VOI-averaged kbo and AXRBBB were also linearly correlated in tumor, NAWM, and NAGM (r = 0.59).

DATA CONCLUSION

DCE-MRI and VEXI showed comparable and correlated WEXBBB in HGG patients, suggesting that the consistence and reliability of these two MRI methods in measuring WEXBBB .

EVIDENCE LEVEL

2.

TECHNICAL EFFICACY

Stage 1.

Blood-brain barrier water exchange measurements using contrast-enhanced ASL

A technique for quantifying regional blood-brain barrier (BBB) water exchange rates using contrast-enhanced arterial spin labelling (CE-ASL) is presented and evaluated in simulations and in vivo. The two-compartment ASL model describes the water exchange rate from blood to tissue,k b , but to estimatek b in practice it is necessary to separate the intra- and extravascular signals. This is challenging in standard ASL data owing to the small difference inT 1 values. Here, a gadolinium-based contrast agent is used to increase thisT 1 difference and enable the signal components to be disentangled. The optimal post-contrast bloodT 1 (T 1 , b post ) at 3 T was determined in a sensitivity analysis, and the accuracy and precision of the method quantified using Monte Carlo simulations. Proof-of-concept data were acquired in six healthy volunteers (five female, age range 24-46 years). The sensitivity analysis identified the optimalT 1 , b post at 3 T as 0.8 s. Simulations showed thatk b could be estimated in individual cortical regions with a relative error ϵ < 1 % and coefficient of variation CoV = 30 %; however, a high dependence on bloodT 1 was also observed. In volunteer data, mean parameter values in grey matter were: arterial transit timet A = 1 . 15 ± 0 . 49  s, cerebral blood flow f = 58 . 0 ± 14 . 3  mL blood/min/100 mL tissue and water exchange ratek b = 2 . 32 ± 2 . 49 s-1 . CE-ASL can provide regional BBB water exchange rate estimates; however, the clinical utility of the technique is dependent on the achievable accuracy of measuredT 1 values.

Novel Nanogels Loaded with Mn(II) Chelates as Effective and Biologically Stable MRI Probes

Here it is described nanogels (NG) based on a chitosan matrix, which are covalently stabilized by a bisamide derivative of Mn-t-CDTA (t-CDTA = trans-1,2-diaminocyclohexane-N,N,N',N'-tetraacetic acid). the Mn(II) complex acts both as a contrast medium and as a cross-linking agent. These nanogels are proposed as an alternative to the less stable paramagnetic nanogels obtained by electrostatic interactions between the polymeric matrix and paramagnetic Gd(III) chelates. The present novel nanogels show: i) relaxivity values seven times higher than that of typical monohydrated Mn(II) chelates at the clinical fields, thanks to the combination of a restricted mobility of the complex with a fast exchange of the metal-bound water molecule; ii) high stability of the formulation over time at pH 5 and under physiological conditions, thus excluding metal leaking or particles aggregation; iii) good extravasation and accumulation, with a maximum contrast achieved at 24 h post-injection in mice bearing subcutaneous breast cancer tumor; iv) high T1 contrast (1 T) in the tumor 24 h post-injection. These improved properties pave the way for the use of these paramagnetic nanogels as promising magnetic resonance imaging (MRI) probes for in vitro and in vivo preclinical applications.

A survey among Flemish gastroenterologists about endoscopic sedation practices in colorectal cancer screening

Background & study aims

The sedation levels and methods used for colonoscopy in colorectal cancer screening programs vary from country to country and from continent to continent. Little is known in the literature about how frequently the different sedation levels are used in colorectal cancer screening colonoscopies. We made a survey among all Flemish gastroenterologists (GI) to determine how frequently they use the different sedation modalities in this target population and to determine the motives of the GI to opt for one or another sedation modality.

Patient and methods

An online survey was sent to all 329 Flemish GI by e-mail. A reminder e-mail was sent one month later. Participants could indicate how frequently (by percentage) they used the different sedation methods (no sedation, minimal sedation, conscious sedation, deep sedation) and which sedative medication they administered. In addition, they were asked to indicate their main motives for choosing a specific sedation method. Descriptive statistics were used.

Results

112 out of 329 GI answered the questionnaire (response rate 34%). Anesthesia monitored care is the most frequently used sedation modality, followed by conscious sedation. Patient preference is the main motive for most GI to use each sedation modality.

Conclusions

Anesthesia monitored care is currently the most frequently used sedation regimen to perform a colonoscopy in the FIT positive population or in the colorectal cancer screening program in Flanders. The motives given by the GI for choosing one or another sedation modality are not always congruent with current scientific evidence or guidelines.

Blood-brain barrier water exchange measurements using FEXI: Impact of modeling paradigm and relaxation time effects

PURPOSE

To evaluate potential modeling paradigms and the impact of relaxation time effects on human blood-brain barrier (BBB) water exchange measurements using FEXI (BBB-FEXI), and to quantify the accuracy, precision, and repeatability of BBB-FEXI exchange rate estimates at 3 T $$ \mathrm{T} $$ .

METHODS

Three modeling paradigms were evaluated: (i) the apparent exchange rate (AXR) model; (ii) a two-compartment model (2 CM $$ 2\mathrm{CM} $$ ) explicitly representing intra- and extravascular signal components, and (iii) a two-compartment model additionally accounting for finite compartmentalT 1 $$ {\mathrm{T}}_1 $$ andT 2 $$ {\mathrm{T}}_2 $$ relaxation times (2 CM r $$ 2{\mathrm{CM}}_r $$ ). Each model had three free parameters. Simulations quantified biases introduced by the assumption of infinite relaxation times in the AXR and2 CM $$ 2\mathrm{CM} $$ models, as well as the accuracy and precision of all three models. The scan-rescan repeatability of all paradigms was quantified for the first time in vivo in 10 healthy volunteers (age range 23-52 years; five female).

RESULTS

The assumption of infinite relaxation times yielded exchange rate errors in simulations up to 42%/14% in the AXR/2 CM $$ 2\mathrm{CM} $$ models, respectively. Accuracy was highest in the compartmental models; precision was best in the AXR model. Scan-rescan repeatability in vivo was good for all models, with negligible bias and repeatability coefficients in grey matter ofRC AXR = 0 . 43 $$ {\mathrm{RC}}_{\mathrm{AXR}}=0.43 $$  s - 1 $$ {\mathrm{s}}^{-1} $$ ,RC 2 CM = 0 . 51 $$ {\mathrm{RC}}_{2\mathrm{CM}}=0.51 $$  s - 1 $$ {\mathrm{s}}^{-1} $$ , andRC 2 CM r = 0 . 61 $$ {\mathrm{RC}}_{2{\mathrm{CM}}_r}=0.61 $$  s - 1 $$ {\mathrm{s}}^{-1} $$ .

CONCLUSION

Compartmental modelling of BBB-FEXI signals can provide accurate and repeatable measurements of BBB water exchange; however, relaxation time and partial volume effects may cause model-dependent biases.

Vascular-water-exchange MRI (VEXI) enables the detection of subtle AXR alterations in Alzheimer's disease without MRI contrast agent, which may relate to BBB integrity

Blood-brain barrier (BBB) impairment is an important pathophysiological process in Alzheimer's disease (AD) and a potential biomarker for early diagnosis of AD. However, most current neuroimaging methods assessing BBB function need the injection of exogenous contrast agents (or tracers), which limits the application of these methods in a large population. In this study, we aim to explore the feasibility of vascular water exchange MRI (VEXI), a diffusion-MRI-based method proposed to assess the BBB permeability to water molecules without using a contrast agent, in the detection of the BBB breakdown in AD. We tested VEXI on a 3T MRI scanner on three groups: AD patients (AD group), mild cognitive impairment (MCI) patients due to AD (MCI group), and the age-matched normal cognition subjects (NC group). Interestingly, we find that the apparent water exchange across the BBB (AXR_BBB) measured by VEXI shows higher values in MCI compared with NC, and this higher AXR_BBB happens specifically in the hippocampus. This increase in AXR_BBB value gets larger and extends to more brain regions (medial orbital frontal cortex and thalamus) from MCI group to the AD group. Furthermore, we find that the AXR_BBB values of these three regions is correlated significantly with the impairment of respective cognitive domains independent of age, sex and education. These results suggest VEXI is a promising method to assess the BBB breakdown in AD.

Blood-brain barrier permeability in response to caffeine challenge

PURPOSE

Caffeine is known to alter brain perfusion by acting as an adenosine antagonist, but its effect on blood-brain barrier (BBB) permeability is not fully elucidated. This study aimed to dynamically monitor BBB permeability to water after a single dose of caffeine tablet using a non-contrast MRI technique.

METHODS

Ten young healthy volunteers who were not regular coffee drinkers were studied. The experiment began with a pre-caffeine measurement, followed by four measurements at the post-caffeine stage. Water-extraction-with-phase-contrast-arterial-spin-tagging (WEPCAST) MRI was used to assess the time dependence of BBB permeability to water following the ingestion of 200 mg caffeine. Other cerebral physiological parameters including cerebral blood flow (CBF), venous oxygenation (Yv ), and cerebral metabolic rate of oxygen (CMRO2 ) were also examined. The relationships between cerebral physiological parameters and time were studied with mixed-effect models.

RESULTS

It was found that, after caffeine ingestion, CBF and Yv showed a time-dependent decrease (p < 0.001), while CMRO2 did not change significantly. The fraction of arterial water crossing the BBB (E) showed a significant increase (p < 0.001). In contrast, the permeability-surface-area product (PS), i.e., BBB permeability to water, remained constant (p = 0.94). Additionally, it was observed that changes in physiological parameters were non-linear with regard to time and occurred at as early as 9 min after caffeine tablet ingestion.

CONCLUSION

These results suggest an unchanged BBB permeability despite alterations in perfusion during a vasoconstrictive caffeine challenge.

Molecular Parameters Promoting High Relaxivity in Cluster-Nanocarrier Magnetic Resonance Imaging Contrast Agents

We have investigated the mechanism of relaxivity for two magnetic resonance imaging contrast agents that both employ a cluster-nanocarrier design. The first system termed Mn8Fe4-coPS comprises the cluster Mn8Fe4O12(L)16(H2O)4 or Mn8Fe4 (1) (L = carboxylate) co-polymerized with polystyrene to form ∼75 nm nanobeads. The second system termed Mn3Bpy-PAm used the cluster Mn3(O2CCH3)6(Bpy)2 or Mn3Bpy (2) where Bpy = 2,2'-bipyridine, entrapped in ∼180 nm polyacrylamide nanobeads. Here, we investigate the rate of water exchange of the two clusters, and corresponding cluster-nanocarriers, in order to elucidate the mechanism of relaxivity in the cluster-nanocarrier. Swift-Connick analysis of O-17 NMR was used to determine the water exchange rates of the clusters and cluster-nanocarriers. We found distinct differences in the water exchange rate between Mn8Fe4 and Mn8Fe4-coPS, and we utilized these differences to elucidate the nanobead structure. Using the transverse relaxivity from O-17 NMR line widths, we were able to determine the hydration state of the Mn3Bpy (2) cluster as well as Mn3Bpy-PAm. Using these hydration states in the Swift-Connick analysis of O-17 NMR, we found the water exchange rate to be extremely close in value for the cluster Mn3Bpy and cluster-nanocarrier Mn3Bpy-PAm.

A Simulation Experiment on Quality Dynamics of Reclaimed Water under Different Flow Exchanges

Reclaimed water plays an important role in maintaining urban aquatic ecosystems, especially in areas with water shortages. However, there is little information on water quality dynamics and its driving mechanism in reclaimed water bodies. The simulated experiments were conducted to investigate the effect of flow exchange on water quality dynamics and soil microbial diversity for 100% reclaimed water and mixed water (50% reclaimed and 50% stream water), and the exchange periods ranged from 2 to 40 days. The results showed that the degradation coefficients (K) of COD_Mn and NH₃-N were 0.015 d^-1 and 0.001 d^-1 for the mixed water, while their K values were negative for the reclaimed water. The flow exchange had little effect on water quality dynamics for the mixed water, which may be attributed to the relatively low concentration of TP in this reclaimed water. A small or great exchange period led to a relatively high fluctuation in K during the experimental period and corresponded to a worse soil microbial diversity. These results indicate that it is not recommended to fill an isolated urban lake with 100% reclaimed water and that a suitable flow exchange period of 5~10 days could help self-purify the water quality.

A survey of colonoscopists with and without in-depth knowledge of water-aided colonoscopy

BACKGROUND AND AIM

Endoscopy featured water-aided colonoscopy (WAC) as novel in the Innovation Forum in 2011. Gastrointestinal Endoscopy published a modified Delphi consensus review (MDCR) that supports WAC for clinical practice in 2021. We tested the hypothesis that experience was an important predictor of WAC use, either as water immersion (WI), water exchange (WE), or a combination of WI and WE.

METHODS

A questionnaire was sent by email to the MDCR authors with an in-depth knowledge of WAC. They responded and also invited colleagues and trainees without in-depth knowledge to respond. Logistic regression analysis was used with the reasons for WAC use treated as the primary outcome. Reports related to WAC post MDCR were identified.

RESULTS

Of 100 respondents, > 80% indicated willingness to adopt and modify practice to accommodate WAC. Higher adenoma detection rate (ADR) incentivized WE use. Procedure time slots ≤ 30 and > 30 min significantly predicted WI and WE use, respectively. Co-authors of the MDCR were significantly more likely to perform WAC (odds ratio [OR] = 7.5, P = 0.037). Unfamiliarity with (OR = 0.11, P = 0.02) and absence of good experience (OR = 0.019, P = 0.002) were associated with colonoscopists less likely to perform WAC. Reports related to WAC post MDCR revealed overall and right colon WE outcomes continued to improve. Network meta-analyses showed that WE was superior to Cap and Endocuff. On-demand sedation with WE shortened nursing recovery time.

CONCLUSIONS

An important predictor of WAC use was experience. Superior outcomes continued to be reported with WE.

Factors associated with prolonged cecal insertion time in patients undergoing water exchange colonoscopy

BACKGROUND AND AIM

Water exchange is superior to air insufflation in reducing discomfort and increasing adenoma detection during colonoscopy. However, prolonged cecal insertion time is a drawback. This study aims to investigate the factors affecting cecal insertion during water exchange colonoscopy.

METHODS

We pooled data from five randomized clinical trials that included patients undergoing water exchange colonoscopy. Logistic analysis was performed to determine the independent factors associated with prolonged cecal insertion time (> 15 min).

RESULTS

The cohort included 912 patients (493 men and 419 women) with a median age of 57 years (interquartile range, 49-64 years). The median cecal insertion time was 13.5 min (interquartile range, 10.9-17.0 min). Multivariate logistic regression analysis indicated that female sex, body mass index < 25 kg/m² , a history of constipation, no sedation, less experienced endoscopist, Boston Bowel Preparation Scale score ≤ 6, infused water volume during insertion ≥ 1000 mL, and scope length at the cecum ≥ 85 cm were associated with prolonged cecal insertion time. With increasing volume of infused water (1000-2000 mL), the median cecal insertion time increased gradually from 11.4 to 23.0 min (P < 0.001).

CONCLUSIONS

The current study identified independent factors associated with prolonged cecal insertion time during water exchange colonoscopy. Several factors are modifiable to achieve a shorter insertion time, including better bowel preparation, the use of sedation, more experienced endoscopist, infusing less water during insertion, and maintaining a shorter scope length.

Root grafts matter for inter-tree water exchange - a quantification of water translocation between root grafted mangrove trees using field data and model based indication

BACKGROUND AND AIMS

Trees interconnected through functional root grafts can exchange resources, but the effect of exchange on trees remains under debate. A mechanistic understanding of resources exchange via functional root grafts will help understand their ecological implications for tree water exchange for individual trees, groups of trees, and forest stands.

METHODS

To identify the main patterns qualitatively describing the movement of sap between grafted trees, we reviewed available literature on root grafting in woody plants that focus on tree allometry and resource translocation via root grafts. We then extended the BETTINA model, which simulates mangrove (Avicennia germinans) tree growth on the individual tree scale, in order to synthesize the available empirical information. Using allometric data from a field study in mangrove stands, we simulated potential water exchange and analyzed movement patterns between grafted trees.

KEY RESULTS

In the simulations, relative water exchange ranged between -9.17 and 20.3 %, and was driven by gradients of water potential, i.e. differences in tree size and water availability. Moreover, the exchange of water through root grafts alters the water balance of trees and their feedback with the soil: grafted trees that receive water from their neighbors reduce their water uptake.

CONCLUSIONS

Our individual-tree modelling study is a first theoretical attempt to quantify root graft-mediated water exchange between trees. Our findings indicate that functional root grafts represent a vector of hydraulic redistribution, helping to maintain the water balance of grafted trees. This non-invasive approach can serve as a fundament for designing empirical studies to better understand the role of grafted root interaction networks on a broader scale.

Comparison of Procedural Sequences in Sedated Same-Day Bidirectional Endoscopy with Water-Exchange Colonoscopy: A Randomized Controlled Trial

Background: Previous studies have favored esophagogastroduodenoscopy (EGD) followed by colonoscopy as the optimal sequence in bidirectional endoscopy (BDE) with air insufflation. However, the optimal sequence in same-day BDE with WE colonoscopy is unclear. Methods: A total of 200 patients undergoing BDE with propofol sedation from May 2018 to January 2021 were randomized to either the EGD-first group (n = 100) or the colonoscopy-first group (n = 100). Results: The EGD-first group required a longer cecal-intubation time (median 16.0 min vs. 13.7 min, p < 0.001) and a lower Boston Bowel Preparation Scale score (8.5 vs. 9, p = 0.030) compared with the colonoscopy-first group. However, the EGD-first group needed a significantly lower dose of propofol (200 mg vs. 250 mg, p < 0.001) and a shorter recovery time (7 min vs. 13.5 min, p < 0.001), resulting in a shorter turnover time of the endoscopy room (39.5 min vs. 42.6 min, p = 0.004). There were no differences in the sedation-related adverse events, patients’ satisfaction scores, adenoma-detection rates, or the outcomes of EGD between the two groups. Conclusions: During propofol-sedated BDE, EGD followed by WE colonoscopy was more efficient with a shorter turnover time despite a longer cecal-intubation time (NCT03638713).

A New Oxygen Containing Pyclen-Type Ligand as a Manganese(II) Binder for MRI and 52Mn PET Applications: Equilibrium, Kinetic, Relaxometric, Structural and Radiochemical Studies

A new pyclen-3,9-diacetate derivative ligand (H₂3,9-OPC2A) was synthesized possessing an etheric O-atom opposite to the pyridine ring, to improve the dissociation kinetics of its Mn(II) complex (pyclen = 3,6,9,15-tetraazabicyclo(9.3.1)pentadeca-1(15),11,13-triene). The new ligand is less basic than the N-containing analogue (H₂3,9-PC2A) due to the non-protonable O-atom. In spite of its lower basicity, the conditional stability of the [Mn(3,9-OPC2A)] (pMn = −log(Mn(II)), c_L = c_Mn(II) = 0.01 mM. pH = 7.4) remains unaffected (pMn = 8.69), compared to the [Mn(3,9-PC2A)] (pMn = 8.64). The [Mn(3,9-OPC2A)] possesses one water molecule, having a lower exchange rate with bulk solvents (k_ex²⁹⁸ = 5.3 ± 0.4 × 10⁷ s⁻¹) than [Mn(3,9-PC2A)] (k_ex²⁹⁸ = 1.26 × 10⁸ s⁻¹). These mild differences are rationalized by density-functional theory (DFT) calculations. The acid assisted dissociation of [Mn(3,9-OPC2A)] is considerably slower (k₁ = 2.81 ± 0.07 M⁻¹ s⁻¹) than that of the complexes of diacetates or bisamides of various 12-membered macrocycles and the parent H₂3,9-PC2A. The [Mn(3,9-OPC2A)] is inert in rat/human serum as confirmed by ⁵²Mn labeling (nM range), as well as by relaxometry (mM range). However, a 600-fold excess of EDTA (pH = 7.4) or a mixture of essential metal ions, propagated some transchelation/transmetalation in 7 days. The H₂3,9-OPC2A is labeled efficiently with ⁵²Mn at elevated temperatures, yet at 37 °C the parent H₂3,9-PC2A performs slightly better. Ultimately, the H₂3,9-OPC2A shows advantageous features for further ligand designs for bifunctional chelators.

Water exchange rate across the blood-brain barrier is associated with CSF amyloid-β 42 in healthy older adults

INTRODUCTION

We tested if water exchange across the blood-brain barrier (BBB), estimated with a noninvasive magnetic resonance imaging (MRI) technique, is associated with cerebrospinal fluid (CSF) biomarkers of Alzheimer's disease (AD) and neuropsychological function.

METHODS

Forty cognitively normal older adults (67-86 years old) were scanned with diffusion-prepared, arterial spin labeling (DP-ASL), which estimates water exchange rate across the BBB (kw ). Participants also underwent CSF draw and neuropsychological testing. Multiple linear regression models were run with kw as a predictor of CSF concentrations and neuropsychological scores.

RESULTS

In multiple brain regions, BBB kw was positively associated with CSF amyloid beta (Aβ)42 concentration levels. BBB kw was only moderately associated with neuropsychological performance.

DISCUSSION

Our results suggest that low water exchange rate across the BBB is associated with low CSF Aβ42 concentration. These findings suggest that kw may be a promising noninvasive indicator of BBB Aβ clearance functions, a possibility which should be further tested in future research.

Imaging Blood-Brain Barrier Permeability Through MRI in Pediatric Sickle Cell Disease: A Feasibility Study

BACKGROUND

Blood-brain barrier (BBB) disruption may lead to endothelium dysfunction and inflammation in sickle cell disease (SCD). However, abnormalities of BBB in SCD, especially in pediatric patients for whom contrast agent administration less than optimal, have not been fully characterized.

PURPOSE

To examine BBB permeability to water in a group of pediatric SCD participants using a non-invasive magnetic resonance imaging technique. We hypothesized that SCD participants will have increased BBB permeability.

STUDY TYPE

Prospective cross-sectional.

POPULATION

Twenty-six pediatric participants (10 ± 1 years, 15F/11M) were enrolled, including 21 SCD participants and 5 sickle cell trait (SCT) participants, who were siblings of SCD patients.

FIELD STRENGTH/SEQUENCE

3 T. Water extraction with phase-contrast arterial spin tagging with echo-planer imaging, phase-contrast and T₁ -weighted magnetization-prepared rapid acquisition of gradient echo.

ASSESSMENT

Water extraction fraction (E), BBB permeability-surface area product (PS), cerebral blood flow, hematological measures (hemoglobin, hematocrit, hemoglobin S), neuropsychological scores (including domains of intellectual ability, attention and executive function, academic achievement and adaptive function, and a composite score). Regions of interest were drawn by Z.L. (6 years of experience).

STATISTICAL TESTS

Wilcoxon rank sum test and chi-square test for group comparison of demographics. Multiple linear regression analysis of PS with diagnostic category (SCD or SCT), hematological measures, and neuropsychological scores. A two-tailed P value of 0.05 or less was considered statistically significant.

RESULTS

Compared with SCT participants, SCD participants had a significantly higher BBB permeability to water (SCD: 207.0 ± 33.3 mL/100 g/minute, SCT: 171.2 ± 27.2 mL/100 g/minute). SCD participants with typically more severe phenotypes also had a significantly leakier BBB than those with typically milder phenotypes (severe: 217.3 ± 31.7 mL/100 g/minute, mild: 193.3 ± 31.8 mL/100 g/minute). Furthermore, more severe BBB disruption was associated with worse hematological symptoms, including lower hemoglobin concentrations (β = -8.84, 95% confidence interval [CI] [-14.69, -3.00]), lower hematocrits (β = -2.96, 95% CI [-4.84, -1.08]), and higher hemoglobin S fraction (β = 0.77, 95% CI [0.014, 1.53]).

DATA CONCLUSION

These findings support a potential role for BBB dysfunction in SCD pathogenesis of ischemic injury.

LEVEL OF EVIDENCE

2 TECHNICAL EFFICACY: Stage 2.

Computer-Aided Detection False Positives in Colonoscopy

Randomized control trials and meta-analyses comparing colonoscopies with and without computer-aided detection (CADe) assistance showed significant increases in adenoma detection rates (ADRs) with CADe. A major limitation of CADe is its false positives (FPs), ranked 3rd in importance among 59 research questions in a modified Delphi consensus review. The definition of FPs varies. One commonly used definition defines an FP as an activation of the CADe system, irrespective of the number of frames or duration of time, not due to any polypoid or nonpolypoid lesions. Although only 0.07 to 0.2 FPs were observed per colonoscopy, video analysis studies using FPs as the primary outcome showed much higher numbers of 26 to 27 per colonoscopy. Most FPs were of short duration (91% < 0.5 s). A higher number of FPs was also associated with suboptimal bowel preparation. The appearance of FPs can lead to user fatigue. The polypectomy of FPs results in increased procedure time and added use of resources. Re-training the CADe algorithms is one way to reduce FPs but is not practical in the clinical setting during colonoscopy. Water exchange (WE) is an emerging method that the colonoscopist can use to provide salvage cleaning during insertion. We discuss the potential of WE for reducing FPs as well as the augmentation of ADRs through CADe.

Monte Carlo Simulator for Diffusion-weighted Imaging Sequences

We developed a Monte Carlo simulator for diffusion-weighted imaging sequences which displays the motion of water molecules and computes the dynamic phase dispersion due to the applied motion probing gradients. This simulator can be used to validate the analytical equations of diffusion models and understand their limitations due to their approximations. Here, we introduce the software and some specific use cases. The software can be downloaded from the following website: https://www.nirs.qst.go.jp/amr_diag.

Expanding the Ligand Classes Used for Mn(II) Complexation: Oxa-aza Macrocycles Make the Difference

We report two macrocyclic ligands based on a 1,7-diaza-12-crown-4 platform functionalized with acetate (tO2DO2A²⁻) or piperidineacetamide (tO2DO2AM^Pip) pendant arms and a detailed characterization of the corresponding Mn(II) complexes. The X−ray structure of [Mn(tO2DO2A)(H₂O)]·2H₂O shows that the metal ion is coordinated by six donor atoms of the macrocyclic ligand and one water molecule, to result in seven-coordination. The Cu(II) analogue presents a distorted octahedral coordination environment. The protonation constants of the ligands and the stability constants of the complexes formed with Mn(II) and other biologically relevant metal ions (Mg(II), Ca(II), Cu(II) and Zn(II)) were determined using potentiometric titrations (I = 0.15 M NaCl, T = 25 °C). The conditional stabilities of Mn(II) complexes at pH 7.4 are comparable to those reported for the cyclen-based tDO2A²⁻ ligand. The dissociation of the Mn(II) chelates were investigated by evaluating the rate constants of metal exchange reactions with Cu(II) under acidic conditions (I = 0.15 M NaCl, T = 25 °C). Dissociation of the [Mn(tO2DO2A)(H₂O)] complex occurs through both proton− and metal−assisted pathways, while the [Mn(tO2DO2AM^Pip)(H₂O)] analogue dissociates through spontaneous and proton-assisted mechanisms. The Mn(II) complex of tO2DO2A²⁻ is remarkably inert with respect to its dissociation, while the amide analogue is significantly more labile. The presence of a water molecule coordinated to Mn(II) imparts relatively high relaxivities to the complexes. The parameters determining this key property were investigated using ¹⁷O NMR (Nuclear Magnetic Resonance) transverse relaxation rates and ¹H nuclear magnetic relaxation dispersion (NMRD) profiles.

Macrocyclic Chelates Bridged by a Diaza-Crown Ether: Towards Multinuclear Bimodal Molecular Imaging Probes

Bridged polymacrocyclic ligands featured by structurally different cages offer the possibility of coordinating multiple trivalent lanthanide ions, giving rise to the exploitation of their different physicochemical properties, e.g., multimodal detection for molecular imaging purposes. Intrigued by the complementary properties of optical and MR-based image capturing modalities, we report the synthesis and characterization of the polymetallic Ln(III)-based chelate comprised of two DOTA-amide-based ligands (DOTA—1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid) bridged via 1,10-diaza-18-crown-6 (DA18C6) motif. The DOTA-amide moieties and the DA18C6 were used to chelate two Eu(III) ions and one Tb(III) ion, respectively, resulting in a multinuclear heterometallic complex Eu₂LTb. The bimetallic complex without Tb(III), Eu₂L, displayed a strong paramagnetic chemical exchange saturation transfer (paraCEST) effect. Notably, the luminescence spectra of Eu₂LTb featured mixed emission including the characteristic bands of Eu(III) and Tb(III). The advantageous features of the complex Eu₂LTb opens new possibilities for the future design of bimodal probes and their potential applicability in CEST MR and optical imaging.

Underwater versus conventional endoscopic resection of nondiminutive nonpedunculated colorectal lesions: a prospective randomized controlled trial (with video)

BACKGROUND AND AIMS

Incomplete resection of colorectal neoplasia decreases the efficacy of colonoscopy. Conventional resection (CR) of polyps, performed in a gas-distended colon, is the current standard, but incomplete resection rates of approximately 2% to 30% for nondiminutive (>5 mm), nonpedunculated lesions are reported. Underwater resection (UR) is a novel technique. The aim of this study was to determine the incomplete resection rates of colorectal lesions removed by UR versus CR.

METHODS

In a randomized controlled trial, patients with small (6-9 mm) and large (≥10 mm) nonpedunculated lesions were assigned to CR (gas-distended lumen) or UR (water-filled, gas-excluded lumen). Small lesions in both arms were removed with a dedicated cold snare. For CR, large lesions were removed with a hot snare after submucosal injection. For UR, large lesions were removed with a hot snare without submucosal injection. Four-quadrant biopsy samples around the resection sites were used to evaluate for incomplete resection.

RESULTS

Four hundred sixty-two eligible polyps (248 UR vs 214 CR) from 255 patients were removed. Incomplete resection rates for UR and CR were low and did not differ (2% vs 1.9%, P = .91). UR was performed significantly faster for lesions ≥10 mm in size (10-19 mm, 2.9 minutes vs 5.6 minutes, P < .0001); ≥20 mm, 7.3 minutes vs 9.5 minutes, P = .015).

CONCLUSIONS

Low incomplete resection rates are achievable with UR and CR. UR is effective and safe with the advantage of faster resection and potential cost savings for removal of larger (≥10 mm) lesions by avoiding submucosal injection. As an added approach, UR has potential to improve the cost-effectiveness of colonoscopy by increasing efficiency and reducing cost while maintaining quality. (Clinical trial registration number: NCT02889679.).

How to increase proximal adenoma detection rate: a meta-analysis comparing water exchange, water immersion and air/CO2 insufflation methods for colonoscopy

Background

Recent meta-analyses have demonstrated a higher adenoma detection rate using the water exchange method (WE), compared to water immersion (WI) and air/CO₂ insufflation (ACI). Proximal adenomas have a high miss rate owing to their location and appearance. We performed a systematic review and meta-analysis of studies comparing the WE and WI methods to the ACI method, with a primary focus on proximal adenoma detection rate.

Methods

The following databases were searched for our systematic review: Medline, Embase, Cochrane Library, CINAHL, and Web of Sciences. We included both randomized controlled trials and cohort studies. The primary outcome was proximal adenoma detection rate, and secondary outcomes were right adenoma detection rate and cecal intubation rate.

Results

A total of 12 studies (17 arms) with 5660 patients (2260 ACI, 2281 WE, and 1119 WI) were included. A higher proximal adenoma detection rate (risk ratio [RR] 1.30, 95% confidence interval [CI] 1.11-1.53; P=0.001) and right adenoma detection rate (RR 1.43, 95%CI 1.19-1.71; P≤0.001; I²=0%) were noted for the WE group compared to the ACI group. The WI group did not demonstrate a better detection rate of proximal or right adenomas.

Conclusions

The water exchange method for colonoscopy holds promise and should be encouraged in the clinical setting to increase proximal and right adenoma detection rates. This will in turn decrease the incidence of colorectal cancer.

Feasibility of sedation on demand in Taiwan using water exchange and air insufflation: A randomized controlled trial

BACKGROUND AND AIM

Completion of colonoscopy without sedation eliminates sedation cost and complications. Reported in the United States and Europe, on-demand sedation is not routine practice in Taiwan. Water exchange (WE), characterized by infusion and nearly complete removal of infused water during insertion, reduces insertion pain compared to air insufflation (AI) during colonoscopy. We evaluated the feasibility of on-demand sedation in Taiwan. In a randomized controlled trial of WE vs AI colonoscopy, we also aimed to determine if WE augmented the implementation by reducing insertion pain and decreasing sedation requirement.

METHODS

This prospective patient-blinded study randomized patients to AI or WE (75 patients/group) to aid insertion. The primary outcome was the proportion of patients completing without sedation.

RESULTS

In the AI and WE groups, 76.0% and 93.3% (P = 0.006) completed without need for sedation, respectively. The WE group had lower insertion pain score (mean [SD]) (4.0 [2.9] vs 2.1 [2.6], P < 0.001), lower doses of propofol (25.7 [52.7] mg vs 9.1 [35.6] mg, P = 0.012), and less time in the recovery room (3.4 [7.4] vs 1.5 [5.5], P = 0.027) than the AI group. Patient satisfaction scores and willingness to repeat if needed in the future were similar.

CONCLUSION

On-demand sedation was feasible in Taiwan. The completion rate without sedation was high in patients (76.0% with standard AI) open to the option (no prior intent to receive the standard of full or minimal sedation). WE augmented the implementation by reducing insertion pain and decreasing sedation requirement without adversely affecting patient satisfaction or willingness to repeat.

An overview of deep learning algorithms and water exchange in colonoscopy in improving adenoma detection

Introduction: Among the Gastrointestinal (GI) Endoscopy Editorial Board top 10 topics in advances in endoscopy in 2018, water exchange colonoscopy and artificial intelligence were both considered important advances. Artificial intelligence holds the potential to increase and water exchange significantly increases adenoma detection.Areas covered: The authors searched MEDLINE (1998-2019) using the following medical subject terms: water-aided, water-assisted and water exchange colonoscopy, adenoma, artificial intelligence, deep learning, computer-assisted detection, and neural networks. Additional related studies were manually searched from the reference lists of publications. Only fully published journal articles in English were reviewed. The latest date of the search was Aug10, 2019. Artificial intelligence, machine learning, and deep learning contribute to the promise of real-time computer-aided detection diagnosis. By emphasizing near-complete suction of infused water during insertion, water exchange provides salvage cleaning and decreases cleaning-related multi-tasking distractions during withdrawal, increasing adenoma detection. The review will address how artificial intelligence and water exchange can complement each other in improving adenoma detection during colonoscopy.Expert opinion: In 5 years, research on artificial intelligence will likely achieve real-time application and evaluation of factors contributing to quality colonoscopy. Better understanding and more widespread use of water exchange will be possible.

Estimation of cellular-interstitial water exchange in dynamic contrast enhanced MRI using two flip angles

PURPOSE

To investigate the feasibility of using multiple flip angles in dynamic contrast enhanced (DCE) MRI to reduce the uncertainty in estimation of intracellular water lifetime (τ_i ).

METHODS

Numerical simulation studies were conducted to assess the uncertainty in estimation of τ_i using dynamic contrast enhanced MRI with one or two flip angles. In vivo experiments with a murine brain tumor model were conducted at 7T using two flip angles. The in vivo data were used to compare τ_i estimation using the single-flip-angle (SFA) protocol with that using the double-flip-angle (DFA) protocol. Data analysis was conducted using the two-compartment exchange model combined with the three-site-two-exchange model for water exchange.

RESULTS

In the numerical simulation studies with a range of contrast kinetic parameters and signal-to-noise ratio = 20, the median bias of τ_i estimation decreased from 72 ms with SFA to 65 ms with DFA, and the corresponding median inter-quartile range reduced from 523 ms to 156 ms. In the in vivo studies, τ_i estimation with SFA was not successful in most voxels in the tumors, as the estimated τ_i values reached the upper limit of the parameter range (2 s). In contrast, the estimated τ_i values with DFA were mostly between 0.2 and 1.5 s and homogeneously distributed spatially across the tumor. The τ_i estimation with DFA was less sensitive to arterial input function scaling but more sensitive to pre-contrast T₁ than the other contrast kinetic parameters.

CONCLUSION

This study results demonstrate the feasibility of using multiple flip angles to encode the post-contrast time-intensity curve with different weighting of water exchange effect to reduce the uncertainty in τ_i estimation.

Limitations of Deuterium-Labelled Substrates for Quantifying NADPH Metabolism in Heterotrophic Arabidopsis Cell Cultures

NADPH is the primary source of cellular reductant for biosynthesis, and strategies for increasing productivity via metabolic engineering need to take account of the requirement for reducing power. In plants, while the oxidative pentose phosphate pathway is the most direct route for NADPH production in heterotrophic tissues, there is increasing evidence that other pathways make significant contributions to redox balance. Deuterium-based isotopic labelling strategies have recently been developed to quantify the relative production of NADPH from different pathways in mammalian cells, but the application of these methods to plants has not been critically evaluated. In this study, LC-MS was used to measure deuterium incorporation into metabolites extracted from heterotrophic Arabidopsis cell cultures grown on [1-²H]glucose or D₂O. The results show that a high rate of flavin-enzyme-catalysed water exchange obscures labelling of NADPH from deuterated substrates and that this exchange cannot be accurately accounted for due to exchange between triose- and hexose-phosphates. In addition, the duplication of NADPH generating reactions between subcellular compartments can confound analysis based on whole cell extracts. Understanding how the structure of the metabolic network affects the applicability of deuterium labelling methods is a prerequisite for development of more effective flux determination strategies, ensuring data are both quantitative and representative of endogenous biological processes.

My approach to water-assisted colonoscopy

The goal of diagnostic colonoscopy is to achieve procedural completion while maximising effectiveness, patient acceptance and safety. In recent years, international interest in water-assisted colonoscopy (WAC) has been steadily gathering pace. A plethora of high-quality randomised controlled trials and meta-analyses now offer incontrovertible evidence into the benefits of WAC, both for the endoscopist and the patient. Despite this, uptake of WAC within the UK has been limited, with the lack of educational resources representing a significant barrier. This practical step-by-step guide is aimed at both existing practitioners and trainees, with a view to promoting familiarity with WAC and potentially for incorporation into daily practice which may ultimately have a positive effect on quality of colonoscopy and patient experience.

A prospective RCT comparing combined chromoendoscopy with water exchange (CWE) vs water exchange (WE) vs air insufflation (AI) in adenoma detection in screening colonoscopy

Background

A low adenoma detection rate (ADR) increases risks of interval cancers (ICs). Proximal colon flat polyps, e.g. serrated lesions (SLs), are difficult to find. Missed proximal colon flat lesions likely contribute to IC.

Aims

We compared chromoendoscopy with water exchange (CWE), water exchange (WE) and air insufflation (AI) in detecting adenomas in screening colonoscopy.

Methods

After split-dose preparation, 480 veterans were randomized to AI, WE and CWE.

Results

Primary outcome of proximal ADR (55.6% vs 53.4% vs 52.2%, respectively) were similar in all groups. Adenoma per colonoscopy (APC) and adenoma per positive colonoscopy (APPC) were comparable. Detection rate of proximal colon SLs was significantly higher for CWE and WE than AI (26.3%, 23.6% and 11.3%, respectively, p = 0.002). Limitations: single operator; SLs only surrogate markers of but not IC.

Conclusions

When an endoscopist achieves high-quality AI examinations with overall ADR twice (61.6%) the recommended standard (30%), use of WE and CWE does not produce further improvement in proximal or overall ADR. Comparable APC and APPC confirm equivalent withdrawal inspection techniques. WE alone is sufficient to significantly improve detection of proximal SLs. The impact of increased detection of proximal SLs by WE on prevention of IC deserves to be studied. This study is registered at ClinicalTrial.gov (NCT#01607255).

Water Transfer Between Bamboo Culms in the Period of Sprouting

Bamboo culms are connected to neighboring culms via rhizomes, which enable resource exchange between culms. We assessed water transfer between established and neighboring, freshly sprouted culms by thermal dissipation probes (TDP) inserted into culms and the connecting rhizome. During the early phase of sprouting, highest sap flux densities in freshly sprouted culms were observed at night, whereas neighboring established culms had high sap flux densities during daytime. After leaf flushing on freshly sprouted culms, the nighttime peaks disappeared and culms switched to the diurnal sap flux patterns with daytime maxima as observed in established culms. TDP in rhizomes indicated water flowing from the established to the freshly sprouted culms. When the established culms of a clump were cut, freshly sprouted culms without leaves reduced sap flux densities rates by 79%. Our findings thus suggest that bamboos exchange water via rhizomes and that nighttime fluxes are highly important for the support of freshly sprouted culms. The (water) resource support may facilitate the very fast growth of the bamboo shoots, and enable the colonizing of new places.

Reduction of multitasking distractions underlies the higher adenoma detection rate of water exchange compared to air insufflation - blinded analysis of withdrawal phase videos

Background

Experts have hypothesized that a reduction of multitasking distractions and improved bowel cleanliness can explain why insertion water exchange enhances adenoma detection rate.

Objective

The purpose of this study was to test the role of both distractions during withdrawal and bowel cleanliness in enhancing adenoma detection rate using coded video records of colonoscopy.

Methods

The withdrawal phase of videos of 299 consecutive colonoscopies from two randomized controlled trials comparing water exchange versus air insufflation at a regional hospital in Taiwan were coded. The primary outcome was distractions; activities that preclude full attention being paid to inspection of the mucosa for polyps. A single blinded reviewer collected the data.

Results

There were significant agreements in inter-rater reliability indexes. Compared to air insufflation, water exchange had significantly fewer distractions; higher diagnostic yield (intervention time and number), adenoma detection rate, and Boston Bowel Preparation Scale score. Water exchange had a higher withdrawal technique score (predominantly adequacy of cleaning). The association between increased adenoma detection rate and water exchange was mediated by the number of distractions and withdrawal time, but not the Boston Bowel Preparation Scale score.

Conclusion

The speculation by experts that a reduction of multitasking distractions underlies the significantly higher adenoma detection rate of water exchange is supported by the current study. Increased bowel cleanliness did not contribute to the increased adenoma detection rate by use of water exchange.

Water exchange versus air insufflation for colonoscopy: A meta-analysis

BACKGROUND/AIMS

To compare water exchange (WE) method with conventional air insufflation (AI) method for colonoscopy, evaluating the technical quality, screening efficacy, and patients' acceptance.

MATERIALS AND METHODS

Electronic databases were systematically searched for randomized controlled trials comparing WE colonoscopy with AI colonoscopy. The pooled data of procedure-associated and patient-related outcomes were assessed, using the weighted mean difference (WMD) with 95% confidence interval (CI) for continuous variables and relative risk (RR) with 95% CI for dichotomous variables, respectively.

RESULTS

A total of 13 studies involving 7056 patients were included. The cecum intubation rate was similar between WE and AI methods (RR = 1.01, 95% CI = 0.99-1.02,P = 0.37); however, a significantly longer cecum intubation time was shown in WE group (WMD = 1.56, 95% CI = 0.75-2.37,P = 0.002). Compared with AI, WE was associated with a higher risk of adenoma detection rate (ADR) (RR = 1.28, 95% CI = 1.18-1.38,P < 0.00001) and polyp detection rate (PDR) (RR = 1.30, 95% CI = 1.21-1.39,P < 0.00001). Patients in WE group experienced significantly less maximum pain score (WMD = -1.99, 95% CI = -2.68 to -1.30,P < 0.00001) and less requested on-demand sedation (RR = 0.58, 95% CI = 0.44-0.77,P = 0.0002). Likewise, they also experienced less abdominal compression (RR = 0.62, 95% CI = 0.51-0.74,P < 0.00001) and reposition (RR = 0.74, 95% CI = 0.63-0.86,P = 0.0001). Moreover, patients' willingness to repeat colonoscopy was significantly greater for WE (RR = 1.14, 95% CI = 1.07-1.21,P < 0.0001).

CONCLUSION

This meta-analysis confirmed that WE method could significantly increase ADR/PDR and improve patients' acceptance of colonoscopy, while reducing the degree of pain and minimize the need for on-demand sedation and adjunct maneuvers, despite requiring more cecal intubation time.

Brain active transmembrane water cycling measured by MR is associated with neuronal activity

PURPOSE

fMRI is widely used to study brain activity. Unfortunately, conventional fMRI methods assess neuronal activity only indirectly, through hemodynamic coupling. Here, we show that active, steady-state transmembrane water cycling (AWC) could serve as a basis for a potential fMRI mechanism for direct neuronal activity detection.

METHODS

AWC and neuronal actitivity in rat organotypic cortical cultures were simultaneously measured with a hybrid MR-fluorescence system. Perfusion with a paramagnetic MRI contrast agent, Gadoteridol, allows NMR determination of the kinetics of transcytolemmal water exchange. Changes in intracellular calcium concentration, [Ca_i ²⁺ ] were used as a proxy of neuronal activity and were monitored by fluorescence imaging.

RESULTS

When we alter neuronal activity by titrating with extracellular [K⁺ ] near the normal value, we see an AWC response resembling Na⁺ -K⁺ -ATPase (NKA) Michaelis-Menten behavior. When we treat with the voltage-gated sodium channel inhibitor, or with an excitatory postsynaptic inhibitor cocktail, we see AWC decrease by up to 71%. AWC was found also to be positively correlated with the basal level of spontaneous activity, which varies in different cultures.

CONCLUSIONS

These results suggest that AWC is associated with neuronal activity and NKA activity is a major contributor in coupling AWC to neuronal activity. Although AWC comprises steady-state, homeostatic transmembrane water exchange, our analysis also yields a simultaneous measure of the average cell volume, which reports any slower net transmembrane water transport.

Is water exchange superior to water immersion for colonoscopy? A systematic review and meta-analysis

Background/Aims

Recently, water exchange (WE) instead of water immersion (WI) for colonoscopy has been proposed to decrease pain and improve adenoma detection rate (ADR). This systematic review and meta-analysis is conducted to assess whether WE is superior to WI based on the published randomized controlled trials (RCTs).

Materials and Methods

We searched studies from PubMed, Cochrane Central Register of Controlled Trials, EMBASE, and MEDLINE. Only RCTs were eligible for our study. The pooled risk ratios (RRs), pooled mean difference (MD), and pooled 95% confidence intervals (CIs) were calculated by using the fixed-effects model or random-effects model based on heterogeneity.

Results

Five RCTs consisting of 2229 colonoscopies were included in this study. WE was associated with a significantly higher ADR than WI (RR = 1.18; CI = 1.05-1.32; P = 0.004), especially in right colon (RR = 1.31; CI = 1.07-1.61; P = 0.01). Compared with WI, WE was confirmed with lower pain score, higher Boston Bowel Preparation Scale score, but more infused water during insertion. There was no statistical difference between WE and WI in cecal intubation rate and the number of patients who had willingness to repeat the examination. Furthermore, both total procedure time and cecal intubation time in WE were significantly longer than that in WI (MD = 2.66; CI = 1.42-3.90; P < 0.0001; vs MD = 4.58; CI = 4.01-5.15; P < 0.0001).

Conclusions

This meta-analysis supports the hypothesis that WE is superior to WI in improving ADR, attenuating insertion pain and providing better bowel cleansing, but inferior in time and consumption of infused water consumption during insertion.

Is water exchange superior to water immersion in detecting adenomas during colonoscopies? Results from a Bayesian network meta-analysis

AIM

Water-assisted colonoscopy (water exchange [WE] and water immersion [WI]) has been shown to improve the adenoma detection rate. However, few studies have compared these two methods head-to-head. Thus, we conducted a network meta-analysis to integrate both direct and indirect evidence comparing the effectiveness of these two procedures.

METHOD

We searched PubMed, Web of Science, and the Cochrane Central Register of Controlled Trials for original papers and abstracts published up to March 2018. Randomized controlled trials (RCTs) reporting data in accordance with the eligibility criteria were included in this study. We performed a Bayesian random effects network meta-analysis with mixed comparisons.

RESULTS

Twenty-nine studies (n = 11464 patients) including 6 direct and 23 indirect comparisons were included in this network meta-analysis. There was a statistically significant difference in the efficacy of adenoma detection when WE was compared with WI (risk ratio [RR]: 1.2, 95% credible interval [CrI]: 1.1-1.3), air insufflation (AI; RR: 1.3, 95% CrI: 1.1-1.4), and carbon dioxide (CO2) insufflation (RR: 1.2, 95% CrI: 1.1-1.5). The different methods were ranked in order from the most to least effective in adenoma detection as follows: WE, WI, AI, and CO2. Moreover, although there were no significant differences in pain scores, willingness to repeat, caecal intubation rate, or total procedure time between WI and WE colonoscopy, WE required a longer caecal intubation time than WI.

CONCLUSION

This network meta-analysis supposes that WE may be superior to WI in detecting adenomas during colonoscopies without affecting other technical features or patient acceptance.

Surface PEG Grafting Density Determines Magnetic Relaxation Properties of Gd-Loaded Porous Nanoparticles for MR Imaging Applications

Surface PEGylation of nanoparticles designed for biomedical applications is a common and straightforward way to stabilize the materials for in vivo administration and to increase their circulation time. This strategy becomes less trivial when MRI active porous nanomaterials are concerned as their function relies on water/proton-exchange between the pores and bulk water. Here we present a comprehensive study on the effects of PEGylation on the relaxometric properties of nanozeolite LTL (dimensions of 20 × 40 nm) ion-exchanged with paramagnetic GdIII ions. We evidence that as long as the surface grafting density of the PEG chains does not exceed the "mushroom" regime (conjugation of up to 6.2 wt % of PEG), Gd-LTL retains a remarkable longitudinal relaxivity (38 s-1 mM-1 at 7 T and 25 °C) as well as the pH-dependence of the longitudinal and transverse relaxation times. At higher PEG content, the more compact PEG layer (brush regime) limits proton/water diffusion and exchange between the interior of LTL and the bulk, with detrimental consequences on relaxivity. Furthermore, PEGylation of Gd-LTL dramatically decreases the leakage of toxic GdIII ions in biological media and in the presence of competing anions, which together with minimal cytotoxicity renders these materials promising probes for MRI applications.

Human whole blood 1 H2 O transverse relaxation with gadolinium-based contrast reagents: Magnetic susceptibility and transmembrane water exchange

PURPOSE

To characterize transverse relaxation in oxygenated whole blood with extracellular gadolinium-based contrast reagents by experiment and simulation.

METHODS

Experimental measurements of transverse ¹ H₂ O relaxation from oxygenated whole human blood and plasma were made at 1.5 and 3.0 Tesla. Spin-echo refocused and free-induction decays are reported for blood and plasma samples containing four different contrast reagents (gadobenate, gadoteridol, gadofosveset, and gadobutrol), each present at concentrations ranging from 1 to 18 mM (i.e., mmol (contrast reagent (CR))/L (blood)). Monte Carlo simulations were conducted to ascertain the molecular mechanisms underlying relaxation. These consisted of random walks of water molecules in a large ensemble of randomly oriented erythrocytes. Bulk magnetic susceptibility (BMS) differences between the extra- and intracellular compartments were taken into account. All key parameters for these simulations were taken from independent published measurements: they include no adjustable variables.

RESULTS

Transverse relaxation is much more rapid in whole blood than in plasma, and the large majority of this dephasing is reversible by spin echo. Agreement between the experimental data and simulated results is remarkably good.

CONCLUSION

Extracellular field inhomogeneities alone make very small contributions, whereas the orientation-dependent BMS intracellular resonance frequencies lead to the majority of transverse dephasing. Equilibrium exchange of water molecules between the intra- and extracellular compartments plays a significant role in transverse dephasing. Magn Reson Med 77:2015-2027, 2017. © 2016 International Society for Magnetic Resonance in Medicine.

Apparent exchange rate for breast cancer characterization

Although diffusion MRI has shown promise for the characterization of breast cancer, it has low specificity to malignant subtypes. Higher specificity might be achieved if the effects of cell morphology and molecular exchange across cell membranes could be disentangled. The quantification of exchange might thus allow the differentiation of different types of breast cancer cells. Based on differences in diffusion rates between the intra- and extracellular compartments, filter exchange spectroscopy/imaging (FEXSY/FEXI) provides non-invasive quantification of the apparent exchange rate (AXR) of water between the two compartments. To test the feasibility of FEXSY for the differentiation of different breast cancer cells, we performed experiments on several breast epithelial cell lines in vitro. Furthermore, we performed the first in vivo FEXI measurement of water exchange in human breast. In cell suspensions, pulsed gradient spin-echo experiments with large b values and variable pulse duration allow the characterization of the intracellular compartment, whereas FEXSY provides a quantification of AXR. These experiments are very sensitive to the physiological state of cells and can be used to establish reliable protocols for the culture and harvesting of cells. Our results suggest that different breast cancer subtypes can be distinguished on the basis of their AXR values in cell suspensions. Time-resolved measurements allow the monitoring of the physiological state of cells in suspensions over the time-scale of hours, and reveal an abrupt disintegration of the intracellular compartment. In vivo, exchange can be detected in a tumor, whereas, in normal tissue, the exchange rate is outside the range experimentally accessible for FEXI. At present, low signal-to-noise ratio and limited scan time allows the quantification of AXR only in a region of interest of relatively large tumors.

Water immersion colonoscopy facilitates straight passage of the colonoscope through the sigmoid colon without loop formation: randomized controlled trial

BACKGROUND AND AIM

One of the major causes of pain during colonoscopy is looping of the instrument during insertion through the sigmoid colon, which causes discomfort by stretching the mesentery. There are many studies in colonoscope techniques, but they have not been assessed objectively with respect to colonoscope passage through the sigmoid colon without loop formation. The aim of the present study was to determine whether cap-fitted colonoscopy and water immersion increase the success rate of insertion through the sigmoid without loop formation.

METHODS

A total of 1005 patients were randomized to standard colonoscopy, cap-fitted colonoscopy or water immersion technique. All examinations were carried out under a magnetic endoscope imaging device. Main outcome was the success rate of insertion without loop formation.

RESULTS

Success rate of insertion without loop formation was 37.5%, 40.0%, and 53.8% in the standard, cap, and water groups, respectively (standard vs water P = 0.00014, cap vs water P = 0.00186). There were no significant differences among the groups regarding cecal intubation rate, cecal intubation time and number of polyps ≥5 mm per patient.

CONCLUSIONS

Water immersion increases the success rate of insertion through the sigmoid colon without loop formation. This practical technique, requiring only preparation of a cap and water, is useful without compromising cecal intubation rate, cecal intubation time, or polyp detection rate.

Uncertainty in MR tracer kinetic parameters and water exchange rates estimated from T1-weighted dynamic contrast enhanced MRI

PURPOSE

The aim of this study was to assess the uncertainty in estimation of MR tracer kinetic parameters and water exchange rates in T1-weighted dynamic contrast enhanced (DCE) MRI.

METHODS

Simulated DCE-MRI data were used to assess four kinetic models; general kinetic model with a vascular compartment (GKM2), GKM2 combined with water exchange (SSM2), adiabatic approximation of the tissue homogeneity model (ATH), and ATH combined with water exchange (ATHX).

RESULTS

In GKM2 and SSM2, increase in transfer constant (K(trans)) led to underestimation of vascular volume fraction (vb), and increase in vb led to overestimation of K(trans). Such coupling between K(trans) and vb was not observed in ATH and ATHX. The precision of estimated intracellular water lifetime (τi) was substantially improved in both SSM2 and ATHX when K(trans) > 0.3 min(-1). K(trans) and vb from ATHX model had significantly smaller errors than those from ATH model (P < 0.05).

CONCLUSION

The results of this study demonstrated the feasibility of measuring τi from DCE-MRI data albeit low precision. While the inclusion of water exchange improved the accuracy of K(trans), vb, and the interstitial volume fraction estimation (ve), it lowered the precision of other kinetic model parameters within the conditions investigated in this study.

Water Uptake Performance of Hygroscopic Heat and Moisture Exchangers after 24-Hour Tracheostoma Application

OBJECTIVE

After total laryngectomy, patients suffer from pulmonary complaints due to the shortcut of the upper airways that results in decreased warming and humidification of inspired air. Laryngectomized patients are advised to use a heat and moisture exchanger (HME) to optimize the inspired air. According to manufacturers' guidelines, these medical devices should be replaced every 24 hours. The aim of this study is to determine whether HMEs still function after 24-hour tracheostoma application.

STUDY DESIGN

Assessment of residual water uptake capacity of used HMEs by measuring the difference between wet and dry core weight.

SETTING

Tertiary comprehensive cancer center.

SUBJECTS AND METHODS

Three hygroscopic HME types were tested after use by laryngectomized patients in long-term follow-up. Water uptake of 41 used devices (including 10 prematurely replaced devices) was compared with that of control (unused) devices of the same type and with a control device with a relatively low performance.

RESULTS

After 24 hours, the mean water uptake of the 3 device types had decreased compared with that of the control devices. For only one type was this difference significant. None of the used HMEs had a water uptake lower than that of the low-performing control device.

CONCLUSION

The water uptake capacity of hygroscopic HEMs is clinically acceptable although no longer optimal after 24-hour tracheostoma application. From a functional point of view, the guideline for daily device replacement is therefore justified.

Uncertainty in MR tracer kinetic parameters and water exchange rates estimated from T1-weighted dynamic contrast enhanced MRI

PURPOSE

The aim of this study was to assess the uncertainty in estimation of MR tracer kinetic parameters and water exchange rates in T1-weighted dynamic contrast enhanced (DCE) MRI.

METHODS

Simulated DCE-MRI data were used to assess four kinetic models; general kinetic model with a vascular compartment (GKM2), GKM2 combined with water exchange (SSM2), adiabatic approximation of the tissue homogeneity model (ATH), and ATH combined with water exchange (ATHX).

RESULTS

In GKM2 and SSM2, increase in transfer constant (K(trans)) led to underestimation of vascular volume fraction (vb), and increase in vb led to overestimation of K(trans). Such coupling between K(trans) and vb was not observed in ATH and ATHX. The precision of estimated intracellular water lifetime (τi) was substantially improved in both SSM2 and ATHX when K(trans) > 0.3 min(-1). K(trans) and vb from ATHX model had significantly smaller errors than those from ATH model (P < 0.05).

CONCLUSION

The results of this study demonstrated the feasibility of measuring τi from DCE-MRI data albeit low precision. While the inclusion of water exchange improved the accuracy of K(trans), vb, and the interstitial volume fraction estimation (ve), it lowered the precision of other kinetic model parameters within the conditions investigated in this study.

Cerebral blood volume affects blood-brain barrier integrity in an acute transient stroke model

Insufficient vascular reserve after an ischemic stroke may induce biochemical cascades that subsequently deteriorate the blood-brain barrier (BBB) function. However, the direct relationship between poor cerebral blood volume (CBV) restoration and BBB disruption has not been examined in acute stroke. To quantify BBB integrity at acute stages of transient stroke, in particular for cases in which extravasation of the standard contrast agent (Gd-DTPA) is not observed, we adopted the water exchange index (WEI), a novel magnetic resonance image-derived parameter to estimate the water permeability across the BBB. The apparent diffusion coefficient (ADC) and R2 relaxation rate constant were also measured for outlining the tissue abnormality, while fractional CBV and WEI were quantified for assessing vascular alterations. The significantly decreased ADC and R2 in the ischemic cortices did not correlate with the changes in CBV or WEI. In contrast, a strong negative correlation between the ipsilesional WEI and CBV was found, in which stroke mice were clustered into two groups: (1) high WEI and low CBV and (2) normal WEI and CBV. The low CBV observed for mice with a disrupted BBB, characterized by a high WEI, indicates the importance of CBV restoration for maintaining BBB stability in acute stroke.

Dynamic monitoring of blood-brain barrier integrity using water exchange index (WEI) during mannitol and CO2 challenges in mouse brain

The integrity of the blood-brain barrier (BBB) is critical to normal brain function. Traditional techniques for the assessment of BBB disruption rely heavily on the spatiotemporal analysis of extravasating contrast agents. However, such methods based on the leakage of relatively large molecules are not suitable for the detection of subtle BBB impairment or for the performance of repeated measurements in a short time frame. Quantification of the water exchange rate constant (WER) across the BBB using strictly intravascular contrast agents could provide a much more sensitive method for the quantification of the BBB integrity. To estimate WER, we have recently devised a powerful new method using a water exchange index (WEI) biomarker and demonstrated BBB disruption in an acute stroke model. Here, we confirm that WEI is sensitive to even very subtle changes in the integrity of the BBB caused by: (i) systemic hypercapnia and (ii) low doses of a hyperosmolar solution. In addition, we have examined the sensitivity and accuracy of WEI as a biomarker of WER using computer simulation. In particular, the dependence of the WEI-WER relation on changes in vascular blood volume, T1 relaxation of cellular magnetization and transcytolemmal water exchange was explored. Simulated WEI was found to vary linearly with WER for typically encountered exchange rate constants (1-4 Hz), regardless of the blood volume. However, for very high WER (>5 Hz), WEI became progressively more insensitive to increasing WER. The incorporation of transcytolemmal water exchange, using a three-compartment tissue model, helped to extend the linear WEI regime to slightly higher WER, but had no significant effect for most physiologically important WERs (WER < 4 Hz). Variation in cellular T1 had no effect on WEI. Using both theoretical and experimental approaches, our study validates the utility of the WEI biomarker for the monitoring of BBB integrity.

Is macrocycle a synonym for kinetic inertness in Gd(III) Complexes? Effect of coordinating and noncoordinating substituents on inertness and relaxivity of Gd(III) chelates with DO3A-like ligands

Gadolinium chelates with octadentate ligands are widely used as contrast agents for magnetic resonance imaging (MRI), with macrocyclic ligands based on DO3A being preferred for the high kinetic inertness of their Gd chelates. A major challenge in the design of new bifunctional MRI probes is the need to control the rotational motion of the chelate, which greatly affects its relaxivity. In this work we explored facile alkylation of a secondary amine in macrocyclic DO3A-like ligands to create a short, achiral linkage to limit the undesired internal motion of chelates within larger molecular constructs. The acetate moiety on the trans nitrogen was also replaced with either a bidentate (ethoxyacetate, L1 or methyl picolinate, L2) or bulky monodentate (methyl phosphonate, L3) donor arm to give octa- or heptadentate ligands, respectively. The resultant Gd(III) complexes were all monohydrated (q = 1) and exhibited water residency times that spanned 2 orders of magnitude (τM = 2190 ± 170, 3500 ± 90, and 12.7 ± 3.8 ns at 37 °C for GdL1, GdL2, and GdL3, respectively). Alkylation of the secondary amine with a noncoordinating biphenyl moiety resulted in coordinatively saturated q = 0 complexes of octadentate ligands L1 and L2. Relaxivities were limited by slow water exchange and/or lack of water coligand. All complexes showed decreased inertness compared to [Gd(DO3A)] despite higher ligand denticity, and inertness was further decreased upon N-alkylation. These results demonstrate that high kinetic inertness and in vivo safety of Gd chelates with macrocyclic ligands should not be generalized.