A Giant Stent for Giant Cerebral Aneurysms-The Accero®-Rex-Stent

OBJECTIVE

Until now, giant intracranial aneurysms (GIAs) have in many cases been a vascular disease that was difficult or impossible to treat, not least due to the lack of availability of a large-format stent. In this multicentre study, we report on the first five clinical applications of the Accero®-Rex-Stents (Acandis, Pforzheim, Germany) in the successful treatment of fusiform cerebral giant aneurysms.

MATERIAL AND METHODS

The Accero®-Rex-Stents are self-expanding, braided, fully radiopaque Nitinol stents designed for aneurysm treatment. The stent is available in three different sizes (diameter 7-10 mm, length 30-60 mm) and intended for endovascular implantation in vessels with diameters of 5.5-10 mm.

RESULTS

Five patients (all male, age 54.4 ± 8.1 years) with large fusiform aneurysms of the posterior circulation were treated endovascularly using the Accero®-Rex-Stents. There were no technical complications. One major ischemic complication occurred. A significant remodeling and reduction in the size of the stent-covered aneurysms was already seen in the short-term post-interventional course.

CONCLUSIONS

The Accero®-Rex-Stents were successfully and safely implanted in all five patients with fusiform giant aneurysms, showing technical feasibility with promising initial results and significant aneurysm size reduction in already available follow-up imaging.

KEY POINT

With the Accero-Rex-Stents, a new device is available that offers another treatment option for rare cerebral fusiform giant aneurysms with very large parent vessels.

LVIS EVO stent-through-balloon after hydrocoil embolization of intracranial aneurysms: One-year results

BACKGROUND AND PURPOSE

To evaluate the durability and safety of complete intracranial aneurysm occlusion at one year using the low-profile braided intracranial LVIS EVO stent.

MATERIALS AND METHODS

This is a retrospective, monocentric, observational study of unruptured wide-necked intracranial aneurysms treated with the LVIS EVO stent-through-balloon technique after balloon-assisted hydrocoil embolization. Imaging and clinical data were assessed by two blinded independent neuroradiologists and neurologists, respectively. Primary endpoint was complete angiographic occlusion on day 0 and at 12 months. Secondary endpoints included clinical safety using the modified Rankin scale (mRS), ischemic and hemorrhagic adverse events, parent vessel stenosis > 50% or occlusion and retreatment rate.

RESULTS

103 aneurysms in 103 patients were included (53 years-old, 77% women). Mean aneurysm size and neck were 7 and 4 mm, respectively. Complete occlusion was 97% initially and 90% at 12 months, with pending follow up in 17.5% patients. Five patients (5%) with partially stented necks were retreated with a second stent in a T-configuration. Two stents failed to open initially and were immediately retrieved. Asymptomatic parent vessel occlusion and severe in-stent stenosis occurred in 1% and 3%, respectively. The 12-month procedure-related permanent neurological deficit and mortality rates (mRS 3-6) were 2% and 1%, respectively. There was one fatal bleeding but no large ischemic complications.

CONCLUSION

Delivering the LVIS EVO stent through a dual lumen balloon after balloon-assisted hydrocoil embolization yields a high and stable rate of complete aneurysm occlusion at one year with a reasonable immediate and delayed complication rate.

NuCLS: A scalable crowdsourcing approach and dataset for nucleus classification and segmentation in breast cancer

Background

Deep learning enables accurate high-resolution mapping of cells and tissue structures that can serve as the foundation of interpretable machine-learning models for computational pathology. However, generating adequate labels for these structures is a critical barrier, given the time and effort required from pathologists.

Results

This article describes a novel collaborative framework for engaging crowds of medical students and pathologists to produce quality labels for cell nuclei. We used this approach to produce the NuCLS dataset, containing >220,000 annotations of cell nuclei in breast cancers. This builds on prior work labeling tissue regions to produce an integrated tissue region- and cell-level annotation dataset for training that is the largest such resource for multi-scale analysis of breast cancer histology. This article presents data and analysis results for single and multi-rater annotations from both non-experts and pathologists. We present a novel workflow that uses algorithmic suggestions to collect accurate segmentation data without the need for laborious manual tracing of nuclei. Our results indicate that even noisy algorithmic suggestions do not adversely affect pathologist accuracy and can help non-experts improve annotation quality. We also present a new approach for inferring truth from multiple raters and show that non-experts can produce accurate annotations for visually distinctive classes.

Conclusions

This study is the most extensive systematic exploration of the large-scale use of wisdom-of-the-crowd approaches to generate data for computational pathology applications.

Optimizing chair time in infusion centers using intravenous cetirizine premedication for the prevention of hypersensitivity infusion reactions

e13508

Background: Oncology infusion centers are increasingly focused on improving operational efficiencies and patient satisfaction, while maintaining quality care. One key component is optimizing chair time, which has been especially important for patient safety during the COVID-19 pandemic to reduce risk of transmission. Many infusions require antihistamine premedication to reduce the risk of hypersensitivity infusion reactions (IRs). The two IV options are IV diphenhydramine and IV cetirizine, which have a quicker onset than oral options and can be administered IV push. In treating acute urticaria, IV cetirizine was shown to be comparable to IV diphenhydramine, with fewer side effects, and it may be effective for preventing IRs with improved chair time. Methods: A randomized, double-blind phase 2 study evaluating premedication with single dose IV cetirizine 10 mg versus IV diphenhydramine 50 mg was conducted in 34 patients receiving paclitaxel, rituximab, its biosimilar or obinutuzumab (first cycle, retreatment after 6 months or with persistent IRs). The primary objective was the incidence of IRs after premedication. Secondary endpoints included sedation due to antihistamines and time to readiness for discharge. Sedation was reported by patients on a scale of 0-4 (0 = none to 4 = extremely severe). No formal statistical analyses were planned given the exploratory nature of the study. Results: Adults primarily with cancer (n = 31 [91%]) were enrolled during the COVID-19 pandemic, from March 25 to November 23, 2020. The median age was 65 and 67 years in the IV cetirizine and diphenhydramine groups, respectively. The number of patients with IRs was 2/17 (11.8%) with IV cetirizine versus 3/17 (17.6%) with IV diphenhydramine. The mean sedation score in the IV cetirizine group compared to the IV diphenhydramine group was lower at all time points, including at discharge (0.1 vs 0.4, respectively). Mean time to discharge was 24 minutes less with IV cetirizine (4.3 hours [1.5]) versus IV diphenhydramine (4.7 hours [1.2]). This difference was greater (30 minutes less) in those ≥65 years of age (4.4 [1.3] vs 4.9 [1.0] hours). Regardless of whether patients received paclitaxel (n = 9) or an anti-CD20 (n = 25), patients had less chair time when premedicated with IV cetirizine. There were fewer treatment-related adverse events (AEs) with IV cetirizine (2 events) than with IV diphenhydramine (4 events). Conclusions: This was the first randomized, controlled trial evaluating IV antihistamine premedication for IRs and chair time. It was shown that IV cetirizine can prevent IRs, with less sedation, fewer related AEs and reduced chair time compared to IV diphenhydramine. This improves infusion center operations and patient experience. Clinical trial information: NCT04189588.

CTX-M-15 extended-spectrum beta-lactamases in Enterobacteriaceae in the intensive care unit of Tlemcen Hospital, Algeria

The aim of this study was to detect extended-spectrum beta-lactamases (ESBL) in Enterobacteriaceae isolates in the intensive care unit (ICU) of Tlemcen hospital in north-western Algeria. Antimicrobial susceptibility testing, molecular typing, characterization of ESBL-encoding genes and the genetic environment, conjugation experiments and plasmid analysis were carried out. In all, 28 Enterobacteriaceae isolates were isolated from specimens recovered from patients in the ICU and 2 from surfaces of the unit. Of these, 11 isolates (4 Escherichia coli, 5 Klebsiella pneumoniae and 2 Enterobacter cloacae) produced ESBL of the CT-X-M-15 type. Molecular typing of the isolates showed the clonal nature of 4 K. pneumoniae isolates. The bla(CTXM-15) gene was genetically linked to insertion sequence lSEcp1B and was transferable by conjugation from 3 isolates. Regular monitoring of resistance mechanisms, the establishment of a prevention strategy, and more rational and appropriate use of antibiotics are needed.

Correlation of five radioimmunoassay systems for measurement of bovine plasma pregnancy-associated glycoprotein concentrations at early pregnancy period

The measurement of serum or plasma PAG concentrations is currently used as a specific method for pregnancy diagnosis in cattle. In this study, the correlation between five radioimmunoassay systems (RIA-497, RIA-706, RIA-780, RIA-809 and RIA-Pool) developed for measurement of PAG concentrations in ruminant species was investigated in plasma from pregnant Friesian Holstein females. Plasma PAG concentrations (ng/mL) measured by different RIA systems were significantly correlated between them ( > or = 0.81; P<0.001). PAG concentrations increased significantly from Day 21 (n=27) to 30 (n=37) after AI by use of all PAG-RIA systems. From Day 30 to 80 after AI, lower PAG concentrations were observed when using the homologous system RIA-497. The addition of several proteinase inhibitors changed neither the non specific binding nor the B(0) binding to the tracer. Our results suggest that all tested PAG-RIA (RIA-497, RIA-706, RIA-780, RIA-809 and RIA-Pool) are highly correlated and can be useful to follow PAG concentrations in samples collected during the first trimester of gestation.

Comparison of five radioimmunoassay systems for PAG measurement: ability to detect early pregnancy in cows

This study was conducted to describe the minimum detection limit, reproducibility, accuracy, specificity and parallelism of different pregnancy-associated glycoprotein radioimmunoassay (PAG-RIA) systems: RIA-497, RIA-706, RIA-780, RIA-809 and RIA-Pool. Their ability to distinguish between non-pregnant and pregnant females at day 30 after artificial insemination (AI) was investigated. The antisera were raised in rabbits against different PAG preparations. All RIA systems proved to be sensitive, repeatable and accurate for measuring PAG concentrations. The dilutions of plasma samples taken at an early stage of pregnancy were found to be parallel to the standard curves. No cross-reaction was observed with different carbohydrates, either with Pregnant Mare Serum Gonadotropin (PMSG) or human Chorionic Gonadotropin (hCG). The concentrations of PAG in pregnant females at day 30 after AI were shown to be higher with the use of antisera R#706, R#780, R#809 and Pool when compared with antiserum R#497. All the RIA systems gave 100% sensitivity and negative predictive values. On the other hand, the use of antisera R#780 and R#809 resulted in lower specificity and positive predictive values. The present study clearly shows that the ability of PAG-RIA systems to diagnose pregnancy specifically at day 30 after AI can be improved by using a combination of antisera raised against different forms of PAG.

Influence of progesterone concentrations on secretory functions of trophoblast and pituitary during the first trimester of pregnancy in dairy cattle

The essential role played by progesterone in the maintenance of pregnancy is unequivocal; however, the effects of progesterone on the secretory patterns of placental and pituitary molecules during the gestation period are not well defined. The objective of this study was to describe pregnancy-associated glycoprotein (PAG) concentrations (measured by RIA-497 and RIA-Pool) in pregnant females with progesterone concentrations lower (low-P4 group, n=20) or higher (high-P4 group, n=17) than the mean of 8.74 ng/mL on Day 21 (AI=Day 0). Luteinizing hormone (LH) and prolactin concentrations were also measured in both groups. Throughout the study period, blood samples were collected on Days 0, 21, 45, 60, and 80 from 37 females that were confirmed to be pregnant. PAG concentrations measured by both RIA-497 and RIA-Pool tended to be higher in high-P4 group than in low-P4 group from Day 30 until Day 80. On Day 80, plasma PAG concentrations that were measured using RIA-497 were observed to be higher (P<0.05) in the high-P4 group than in the low-P4 group (10.2+/-8.7 ng/mL versus 6.9+/-3.8 ng/mL). Concentrations of LH on Day 60 and prolactin on Day 80 were observed to be significantly lower (P<0.05) in the high-P4 group. There was a tendency for the concentrations of LH (Days 45 and 80) and prolactin (Days 30, 45, and 60) to be lower in cows in the high-P4 group than in the low-P4 group. Our results suggest the existence of a relationship among the concentration levels of progesterone, PAG, LH, and prolactin during early pregnancy.

Plasma concentrations of pregnancy-associated glycoprotein-1 (PAG-1) in high producing dairy cows suffering early fetal loss during the warm season

The present study was designed to establish whether plasma pregnancy-associated glycoprotein-1 (PAG-1) measurements during the early fetal period can be associated with early fetal loss. Blood samples were obtained and ultrasound controls performed on days 35, 42, 49, 56, and 63 of gestation or until pregnancy loss from 98 lactating dairy cows. Radioimmunoassay systems were used to determine PAG-1 and progesterone concentrations. Of the 98 pregnancies investigated 18 (18.4%) suffered early fetal loss: 15 (18.5%) in cows carrying singletons, and 3 (16.7%) in twin pregnancies. In cows suffering pregnancy loss, all living embryos registered on day 35 seemed normal in size and development in all weekly ultrasound controls before fetal expulsion. Using analysis of variance, plasma PAG-1 and progesterone values were not different between no loss and fetal loss groups for every gestation period. Based on the odds ratio, and considering only PAG-1 values obtained on day 35 of gestation, the risk of fetal loss was 10 and 6.8 times more likely in cows with low (<2.5 ng/ml) and high (>4 ng/ml) PAG-1 values, respectively, than in cows with medium PAG-1 values, used as reference. Of the 10 inseminating bulls included in the study, one was related to increased fetal loss by odds ratio of 21.7, whereas one bull was attributed fetal loss rate reduced by odds ratio of 12.5 (1/0.08) These findings can have a clear clinical application: PAG-1 measurements from one single sample taken on day 35 of gestation provided more useful information than a series of values obtained from day 35 to 63 of gestation, and can be indicators of subsequent fetal loss.

Milk production correlates negatively with plasma levels of pregnancy-associated glycoprotein (PAG) during the early fetal period in high producing dairy cows with live fetuses

This study was designed to establish possible factors affecting plasma pregnancy-associated glycoprotein (PAG) concentrations during early pregnancy in high producing dairy cows with live fetuses. Blood samples were obtained on days 35, 42, 49, 56 and 63 of gestation from 80 lactating cows in two herds carrying live fetuses. Radioimmunoassay systems were used to determine PAG (RIA-497 and RIA-706) and progesterone concentrations. We evaluated the effects on PAG concentrations of herd, lactation number, sire of fetus, day of gestation, fetus number, plasma progesterone and milk production at each time point established, along with possible paired interactions. Mean milk production per cow approached 41kg during the study period. PAG concentrations were not affected by herd, lactation number or plasma progesterone concentration. Significant positive effects on PAG concentrations were shown by the gestation day, and the interaction between day of gestation and twin pregnancy. Significant differences between bulls and a significant negative correlation between milk production and PAG values on day 63 of pregnancy were also detected. Proportions of blood samples showing undetectable PAG levels and false negative diagnoses throughout the study period were significantly higher (P<0.001) using the RIA-497 system (2.5% and 5.3%, respectively) compared to RIA-706 (0% and 0.8%, respectively). Our findings suggest that PAG concentrations during the early fetal period are related to the day of gestation, milk production, number of fetuses and sire of fetus in high producing dairy cows. Under our working conditions, the RIA-706 method was better at detecting plasma PAG molecules than the RIA-497 system.

Pregnancy-associated glycoproteins (PAG) as pregnancy markers in the ruminants

In the last years, a polymorphic family of placenta-expressed proteins has been discovered in ruminant species and used for pregnancy diagnosis. Pregnancy diagnosis is an important part in reproduction management of ruminants. The pregnancy-associated glycoproteins (PAG) are synthesized in the mono- and binucleate cells of the ruminant's trophectoderm. Part of them is released into maternal blood circulation where they can be assayed by different RIA and ELISA systems. Due to large variety of expressed molecules and to large variations in the post-translational processing of the glycoproteins, different immuno-systems present different ability to quantify the PAG released in blood. Recent investigations showed that surprisingly the level of milk production in ruminants can modify the concentration of PAG circulating in blood. On the whole, the data show that the RIA methods are very precise for measuring PAG concentrations in the maternal blood and milk of the ruminants. Different studies clearly indicate that milk can be used for pregnancy diagnosis in small ruminants. The sensitivity and specificity of this method are very high. The results showed the possibility of the use PAG in milk and in blood as pregnancy test. It is especially helpful in the diagnosis of gestation and in detection of embryonic mortality as a non stressed method in the pregnancy management in the ruminants.

Plasma pregnancy-associated glycoprotein-1 (PAG-1) concentrations during gestation in Neospora-infected dairy cows

The aim of this study was to determine whether plasma pregnancy-associated glycoprotein-1 (PAG-1) concentrations in pregnancy are affected by persistent Neospora caninum infection in dairy cows. The data analyzed were derived from 22 multiparous cows: 16 N. caninum-seropositive and 6 N. caninum-seronegative animals (used as controls). Three of the 16 seropositive cows aborted during the study period and the corresponding data were analyzed separately. Pregnancy diagnoses were performed on day 40 post-insemination by transrectal ultrasound, and by palpation per rectum on days 90, 120, 150, 180 and 210. Blood samples were collected from each animal immediately before each pregnancy diagnosis, and then at parturition or at the time of abortion detection. Plasma was tested for antibodies against N. caninum and PAG-1 concentrations were determined by radioimmunoassay. In non-aborting animals, the effects of neosporosis (seropositive versus seronegative), N. caninum antibody levels, semen providing bull, sex of the newborn, and day of gestation on PAG-1 concentrations were evaluated by GLM repeated measures analysis of variance. The effect of the gestation period (first half versus second half) on the N. caninum antibody titer was established by the Student's t-test in seropositive cows. A significant positive effect of gestation day on PAG-1 concentrations was observed (d.f.=6; F=12.6; P<0.0001). For all cows, PAG-1 concentrations increased steadily during the course of gestation, with peak concentrations recorded at parturition. Neosporosis (P=0.493), N. caninum antibody levels (P=0.921), sex of the newborn (P=0.856) and semen providing bull (P=0.087) had no effect on plasma PAG-1 concentration. There was a significant 52% increase (P<0.0001) in N. caninum antibody titers during the second half of gestation compared to the first half. The fates of the three aborting cows were abortion on gestation day 215 in one, and fetus mummification diagnosed on gestation days 180 and 210, respectively, in the remaining two cows. A luteolytic dose of prostaglandin was applied 30 days after mummification diagnosis in these last two cows, and fetus expulsion was detected on days 215 and 250, respectively. Two of the aborted fetuses were submitted to laboratory analysis and the presence of N. caninum was confirmed by specific PCR. In the cows with a mummified fetus, PAG-1 concentrations were low or undetectable when the diagnosis was made. These findings suggest that N. caninum infection has no effect on placental function in chronically infected, cows not suffering abortion, while PAG-1 measurements in aborting animals provide a useful indication of feto-placental status.

Image-guided endonasal transsphenoidal microsurgical treatment of recurrent microadenomas of the pituitary gland

BACKGROUND

Neuronavigation is a commonly used technology that provides continuous, three-dimensional information for the precise localization of and surgical trajectory to brain lesions. This study was performed to evaluate the role that navigation can play in assisting microsurgical transsphenoidal surgery for precise localization and removal of recurrent pituitary tumours while simultaneously preserving pituitary gland function.

METHOD

During a 6-month period -- July 2004 until December 2004 -- 9 patients with recurrent pituitary tumours (5 female and 4-male) were treated with navigation-guided transsphenoidal microsurgical resection. Surgery was performed via a paraseptal or endonasal transsphenoidal approach. The navigation system Vector Vision (Brain Lab, Heimstetten, Germany) allowed precise localization of the tumours (7 hormonal active and 2 inactive microadenomas) in respect to the pituitary gland, the carotid arteries and the cavernous sinus.

RESULTS

Postoperative MRI investigations of the 9 patients treated with image-guided transsphenoidal microsurgery, showed total tumour removal in 7 (77 %) patients and subtotal removal in 2 patients (23 %). One patient (11 %) developed a cerebral spinal fluid (CSF) leak and was treated conservatively. One patient (11 %) had preoperative insufficiency of the corticotrope axis which remained unchanged postoperatively. Of the remaining 8 patients who did not have preoperative endocrinological disturbance, only one (12 %) developed postoperative insufficiency of the corticotrope axis. Out of the 7 patients with hormone active tumours, 5 (72 %) patients showed no more postoperative hormonal activity.

CONCLUSION

Microneurosurgical transsphenoidal techniques combined with image-guided systems can precisely define the localization and removal of lesions in the sella region with respect to the margins of important anatomical structures in the neighbourhood and the endocrinological functionality of the pituitary gland.