Impact of metabolic syndrome on postoperative outcomes of transsphenoidal pituitary surgery: analysis of U.S. nationwide inpatient sample data 2005-2018

Introduction

Transsphenoidal surgery (TSS) is the preferred surgical method for most pituitary adenomas owing to high efficacy and low mortality. This study aimed to evaluate the influence of metabolic syndrome (MetS) on postoperative outcomes of TSS for pituitary adenoma.

Methods

This population-based, retrospective observational study extracted data of adults 20-79 y receiving TSS for pituitary adenoma from the US Nationwide Inpatient Sample (NIS) between 2005-2018. Primary outcomes were pituitary-related complications, poor outcomes (i.e., in-hospital mortality or unfavorable discharge), prolonged length of stay (LOS), and patient safety indicators (PSIs). Univariate and multivariate regressions were performed to determine the associations between study variables and outcomes.

Results

19,076 patients (representing a 93,185 US in-patient population) were included, among which 2,109 (11.1%) patients had MetS. After adjustment, pre-existing MetS was not significantly associated with presence of pituitary-related complications and poor outcomes. In contrast, MetS was significantly associated with an increased risk for prolonged LOS (adjusted OR (aOR) = 1.19; 95% CI: 1.05-1.34), PSIs (aOR = 1.31; 95% CI: 1.07-1.59) and greater hospital costs (adjusted β = 8.63 thousand USD; 95% CI: 4.98-12.29). Among pituitary-related complications, MetS was independently associated with increased risk of cerebrospinal fluid (CSF) rhinorrhea (aOR = 1.22, 95% CI: 1.01, 1.47) but lowered diabetes insipidus (aOR = 0.83, 95% CI: 0.71, 0.97).

Discussion

MetS does not pose excessive risk of in-hospital mortality or unfavorable discharge. However, MetS independently predicted having PSIs, prolonged LOS, greater hospital costs, and CSF rhinorrhea. Study findings may help clinicians achieve better risk stratification before TSS.

The impact of surgeon's academic leave on surgical outcomes for endoscopic transsphenoidal resection of pituitary tumors

Background

Endoscopic surgery has become the mainstay of pituitary surgery, but requires comprehensive surgical training. We evaluate the impact of a surgeon's academic leave during endoscopic training on surgical outcomes of patients with pituitary tumors.

Methods

This retrospective study reviewed the surgical outcomes of endoscopic transsphenoidal surgery for pituitary tumors performed by a single surgeon. The last 56 surgical cases were performed between July 2010 and August 2014 before academic leave (Phase 1 surgery group), while another 56 consecutive cases were performed between November 2017 and March 2020 immediately after the surgeon's academic leave (Phase 2 surgery group). Demographic and clinical characteristics were collected and compared between the two surgery groups.

Results

Overall, most surgical outcomes of endoscopic transsphenoidal surgery were not affected adversely by the period of academic leave. The operative time and length of hospital stay was lower in the Phase 2 surgery group compared to the Phase 1 surgery group (P<0.05). Postoperative tumor residual, intraoperative cerebrospinal fluid (CSF) leaks and reoperation also decreased significantly in the Phase 2 group compared to the Phase 1 group (P<0.05). Similar results were observed in patients operated using a one-hand/mono-nostril and two-hand/one-and-half nostril technique.

Conclusions

Academic leave had no negative impact on most surgical outcomes for endoscopic transsphenoidal resection of pituitary tumors. Moreover, a trend toward shorter operative times and length of hospital stays was noted for patients receiving surgery immediately after surgeon's return from leave.

Psoriatic arthritis increases the risk of venous thromboembolism following degenerative lumbar spine surgery: An analysis of U.S. Nationwide Inpatient Sample 2005-2018

Background

This retrospective study aimed to determine the risk of venous thromboembolism (VTE) in patients with PsA after surgery for lumbar degenerative disease (LDD).

Methods

The study data of adults aged ≥20 years admitted to U.S. hospitals with diagnoses of LDD and undergoing spinal decompression or fusion between 2005 and 2018 were extracted from the National Inpatient Sample (NIS) database. Patients were further divided into two groups based on a diagnosis of PsA or not via codes ICD-9: 696.0 and ICD-10: L40.50. Patients with missing information were excluded. Propensity score matching (PSM) was employed to enhance comparability between groups. Logistic regression was used to determine associations between PsA and various outcomes, including complications, unfavorable discharge, and prolonged length of stay (LOS).

Results

Data on 471,283 patients with LDD was extracted from the NIS database.from 2005 to 2018. Before propensity score matching, patients with PsA had higher proportions of overall morbidity (8.8 % vs. 6.9 %), VTE (1.4 % vs. 0.7 %), and unfavorable discharge (20.8 % vs. 16.9 %). After matching, patients with PsA still had higher VTE incidence and unfavorable discharge proportions. After adjustments, multivariable regression analysis indicated that patients with PsA had a higher risk of unfavorable discharge (aOR: 1.26, 95 % CI: 1.03-1.55) and VTE (aOR: 1.99, 95 % CI: 1.05-3.75).

Conclusions

Among patients undergoing surgery for LDD, pre-existing PsA may be associated with increased risks of unfavorable discharge and VTE occurrence. The findings may benefit preoperative risk stratifications before LDD surgeries.

Prognostic value of interim CT-based peritumoral and intratumoral radiomics in laryngeal and hypopharyngeal cancer patients undergoing definitive radiotherapy

BACKGROUND AND PURPOSE

We aimed to investigate the prognostic value of peritumoral and intratumoral computed tomography (CT)-based radiomics during the course of radiotherapy (RT) in patients with laryngeal and hypopharyngeal cancer (LHC).

MATERIALS AND METHODS

A total of 92 eligible patients were 1:1 randomly assigned into training and validation cohorts. Pre-RT and mid-RT radiomic features were extracted from pre-treatment and interim CT. LASSO-Cox regression was used for feature selection and model construction. Time-dependent area under the receiver operating curve (AUC) analysis was applied to evaluate the models' prognostic performances. Risk stratification ability on overall survival (OS) and progression-free survival (PFS) were assessed using the Kaplan-Meier method and Cox regression. The associations between radiomics and clinical parameters as well as circulating lymphocyte counts were also evaluated.

RESULTS

The mid-RT peritumoral (AUC: 0.77) and intratumoral (AUC: 0.79) radiomic models yielded better performance for predicting OS than the pre-RT intratumoral model (AUC: 0.62) in validation cohort. This was confirmed by Kaplan-Meier analysis, in which risk stratification depended on the mid-RT peritumoral (p = 0.009) and intratumoral (p = 0.003) radiomics could be improved for OS, in comparison to the pre-RT intratumoral radiomics (p = 0.199). Multivariate analysis identified mid-RT peritumoral and intratumoral radiomic models as independent prognostic factors for both OS and PFS. Mid-RT peritumoral and intratumoral radiomics were correlated with treatment-related lymphopenia.

CONCLUSION

Mid-RT peritumoral and intratumoral radiomic models are promising image biomarkers that could have clinical utility for predicting OS and PFS in patients with LHC treated with RT.

Outcomes of hemorrhagic stroke in patients with autoimmune rheumatic diseases: An analysis of the US Nationwide Inpatient Sample

AIM

To determine whether and how rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and systemic sclerosis (SSc) affect outcomes in patients admitted for hemorrhagic stroke.

METHODS

This study screened the Nationwide Inpatient Sample database for adults aged ≥20 years admitted to US hospitals with a principal diagnosis of intracerebral hemorrhage (ICH) between 2005 and 2018. Diagnoses were determined using the International Classification of Diseases, 9th and 10th revisions (ICD-9 and ICD-10) diagnostic codes for ICH (ICD-9: 431, 432; ICD-10: I61, I62). Study outcomes were: (1) in-hospital mortality; (2) unfavorable discharge, defined as transfer to nursing homes or long-term care facilities; and (3) prolonged length of stay (LOS), defined as LOS >75th centile.

RESULTS

Associations between comorbid RA, SLE, and SSc and clinical outcomes show a significantly lower risk of in-hospital mortality and prolonged LOS in RA patients. After admissions for ICH, the risk for in-hospital mortality and prolonged LOS was decreased in RA patients, and the risk for unfavorable discharge (long-term care) was reduced in SLE patients.

CONCLUSIONS

Among patients admitted to US hospitals for hemorrhagic stroke, patients with RA had decreased risk for in-hospital mortality and prolonged LOS.

Artificial Intelligence Model Trained with Sparse Data to Detect Facial and Cranial Bone Fractures from Head CT

The presence of cranial and facial bone fractures is an important finding on non-enhanced head computed tomography (CT) scans from patients who have sustained head trauma. Some prior studies have proposed automatic cranial fracture detections, but studies on facial fractures are lacking. We propose a deep learning system to automatically detect both cranial and facial bone fractures. Our system incorporated models consisting of YOLOv4 for one-stage fracture detection and improved ResUNet (ResUNet++) for the segmentation of cranial and facial bones. The results from the two models mapped together provided the location of the fracture and the name of the fractured bone as the final output. The training data for the detection model were the soft tissue algorithm images from a total of 1,447 head CT studies (a total of 16,985 images), and the training data for the segmentation model included 1,538 selected head CT images. The trained models were tested on a test dataset consisting of 192 head CT studies (a total of 5,890 images). The overall performance achieved a sensitivity of 88.66%, a precision of 94.51%, and an F1 score of 0.9149. Specifically, the cranial and facial regions were evaluated and resulted in a sensitivity of 84.78% and 80.77%, a precision of 92.86% and 87.50%, and F1 scores of 0.8864 and 0.8400, respectively. The average accuracy for the segmentation labels concerning all predicted fracture bounding boxes was 80.90%. Our deep learning system could accurately detect cranial and facial bone fractures and identify the fractured bone region simultaneously.

Augmented Reality Surgical Navigation System Integrated with Deep Learning

Most current surgical navigation methods rely on optical navigators with images displayed on an external screen. However, minimizing distractions during surgery is critical and the spatial information displayed in this arrangement is non-intuitive. Previous studies have proposed combining optical navigation systems with augmented reality (AR) to provide surgeons with intuitive imaging during surgery, through the use of planar and three-dimensional imagery. However, these studies have mainly focused on visual aids and have paid relatively little attention to real surgical guidance aids. Moreover, the use of augmented reality reduces system stability and accuracy, and optical navigation systems are costly. Therefore, this paper proposed an augmented reality surgical navigation system based on image positioning that achieves the desired system advantages with low cost, high stability, and high accuracy. This system also provides intuitive guidance for the surgical target point, entry point, and trajectory. Once the surgeon uses the navigation stick to indicate the position of the surgical entry point, the connection between the surgical target and the surgical entry point is immediately displayed on the AR device (tablet or HoloLens glasses), and a dynamic auxiliary line is shown to assist with incision angle and depth. Clinical trials were conducted for EVD (extra-ventricular drainage) surgery, and surgeons confirmed the system's overall benefit. A "virtual object automatic scanning" method is proposed to achieve a high accuracy of 1 ± 0.1 mm for the AR-based system. Furthermore, a deep learning-based U-Net segmentation network is incorporated to enable automatic identification of the hydrocephalus location by the system. The system achieves improved recognition accuracy, sensitivity, and specificity of 99.93%, 93.85%, and 95.73%, respectively, representing a significant improvement from previous studies.

Augmented Reality Surgical Navigation System for External Ventricular Drain

Augmented reality surgery systems are playing an increasing role in the operating room, but applying such systems to neurosurgery presents particular challenges. In addition to using augmented reality technology to display the position of the surgical target position in 3D in real time, the application must also display the scalpel entry point and scalpel orientation, with accurate superposition on the patient. To improve the intuitiveness, efficiency, and accuracy of extra-ventricular drain surgery, this paper proposes an augmented reality surgical navigation system which accurately superimposes the surgical target position, scalpel entry point, and scalpel direction on a patient’s head and displays this data on a tablet. The accuracy of the optical measurement system (NDI Polaris Vicra) was first independently tested, and then complemented by the design of functions to help the surgeon quickly identify the surgical target position and determine the preferred entry point. A tablet PC was used to display the superimposed images of the surgical target, entry point, and scalpel on top of the patient, allowing for correct scalpel orientation. Digital imaging and communications in medicine (DICOM) results for the patient’s computed tomography were used to create a phantom and its associated AR model. This model was then imported into the application, which was then executed on the tablet. In the preoperative phase, the technician first spent 5–7 min to superimpose the virtual image of the head and the scalpel. The surgeon then took 2 min to identify the intended target position and entry point position on the tablet, which then dynamically displayed the superimposed image of the head, target position, entry point position, and scalpel (including the scalpel tip and scalpel orientation). Multiple experiments were successfully conducted on the phantom, along with six practical trials of clinical neurosurgical EVD. In the 2D-plane-superposition model, the optical measurement system (NDI Polaris Vicra) provided highly accurate visualization (2.01 ± 1.12 mm). In hospital-based clinical trials, the average technician preparation time was 6 min, while the surgeon required an average of 3.5 min to set the target and entry-point positions and accurately overlay the orientation with an NDI surgical stick. In the preparation phase, the average time required for the DICOM-formatted image processing and program import was 120 ± 30 min. The accuracy of the designed augmented reality optical surgical navigation system met clinical requirements, and can provide a visual and intuitive guide for neurosurgeons. The surgeon can use the tablet application to obtain real-time DICOM-formatted images of the patient, change the position of the surgical entry point, and instantly obtain an updated surgical path and surgical angle. The proposed design can be used as the basis for various augmented reality brain surgery navigation systems in the future.

Using a consensus acupoints regimen to explore the relationship between acupuncture sensation and lumbar spinal postoperative analgesia: A retrospective analysis of prospective clinical cooperation

OBJECTIVE

This study evaluated the effectiveness of acupuncture treatment on postoperative pain in patients with degenerative lumbar spine disease, and explored the relationship between the postoperative analgesic effect of acupuncture and the sensation of acupuncture experienced by the patients.

METHODS

This retrospective study analyzed the medical records of 97 patients who had undergone an operation by the same surgeon due to degenerative lumbar disease. These patients were divided into acupuncture group (n = 32), patient-controlled analgesia (PCA) group (n = 27), and oral analgesia group (n = 38) according to the different postoperative analgesic methods. During their hospitalization, patients completed daily evaluations of their pain using a visual analogue scale (VAS), and injection times of supplemental meperidine were recorded. Also, the Chinese version of the Massachusetts General Hospital Acupuncture Sensation Scale (C-MASS) was used in the acupuncture group.

RESULTS

Each of the three treatment groups showed significant reductions in postoperative pain, as shown by reduced VAS scores. The acupuncture group, however, had less rebound pain (P < 0.05) than the other two groups. Both the acupuncture and PCA groups experienced acute analgesic effects that were superior to those in the oral analgesia group. In addition, the higher the C-MASS index on the second day after surgery, the lower the VAS score on the fourth day after surgery. There was also a significant difference in the "dull pain" in the acupuncture sensation.

CONCLUSION

The results demonstrated that acupuncture was beneficial for postoperative pain and discomfort after simple surgery for degenerative spinal disease. It is worth noting that there was a disproportionate relevance between the patient's acupuncture sensation and the improvement of pain VAS score.

Frequency-Domain Analysis for Accurate and Robust Gait Cycle Time Detection with Clinical Data

Gait tasks have become a topic of increasing inter-est in biological engineering research in recent years. One way to obtain the gait cycle time (GCT) is to analyze a subject's gait acceleration signal as recorded by an inertial measurement unit (IMU) [1]. An accurate peak detection of the IMU acceleration has thus become a requirement for GCT analysis. This study proposes a detection procedure for accurately detecting the peaks in a noisy IMU acceleration signal based on a frequency-domain analysis of the acceleration.

Surgical Outcome and Evaluation of Strategies in the Management of Growth Hormone-Secreting Pituitary Adenomas After Initial Transsphenoidal Pituitary Adenectomy Failure

Acromegaly is a systemic disease that requires multidisciplinary treatment to achieve the best clinical outcome. This study aimed to evaluate the outcomes of the endoscopic transsphenoidal approach (TSA) as the primary treatment for somatotroph adenomas and further investigate patients who had suboptimal surgical results. This retrospective study included 83 patients with somatotroph adenomas treated by TSA at our institution from 1999 to 2010. Biochemical remission was defined as hGH <1 and <2.5 ng/ml. Factors associated with failure of TSA and strategy of secondary treatments for refractory and recurrent disease were analyzed. The mean age of patients was 41.1 ± 11.3 years, and the mean follow-up time was 54.2 ± 44.3 months. Approximately 44.5% of patients had residual tumors after TSA. Larger tumor size, higher GH level before the operation, and the existence of residual tumors were associated with TSA failure. Forty-one patients had an inadequate response to TSA or a recurrent lesion, and of these patients, 37 had residual tumor after TSA. Octreotide results in good outcomes in the treatment of DGSA patients, and SRS/EXRT generates good results in treating patients who receive second treatments when remission cannot be reached 6 months after TSA operation.

Survival after multiple nail gun injuries to the brain, lung, and heart: a case report and a review of the literature

Most nail gun injuries involve the extremities and result from work-related accidents. Injuries to the brain or thorax are relatively rare, and cases with injuries to both regions are even rarer and often lethal. Initial evaluation, resuscitation, and surgical planning can be challenging for emergency physicians and surgeons. We present the details of a man with multiple nail gun injuries to the brain, lung, and heart following a suicide attempt. The patient presented to the emergency department in shock. After immediate resuscitation, emergent sternotomy, and subsequent craniotomy, he was discharged without significant morbidity. According to the literature, this is the only reported case involving multiple nail gun injuries to the brain, lungs, and heart. The mortality rate of multiple nail gun injuries involving the head and chest is approximately 20%. Rapid evaluation, immediate resuscitation, and appropriate imaging and surgery are crucial for increasing survival and achieving a good prognosis. Emergency sternotomy for cardiac injury is the foremost priority, and the timing of craniotomy depends on the patient’s vital sign status and whether brain injury is evident.

A preprint of this article is available online: DOI: 10.21203/rs.3.rs-35448/v1.

Endoscopic transsphenoidal surgery for resection of pituitary macroadenoma: A retrospective study

BACKGROUND

The endoscopic transsphenoidal approach is an efficient minimally invasive procedure for removal of pituitary tumors that can be accomplished through a one-hand or two-hand approach. The one-hand procedure through one nostril is more intuitive for surgeons, but maneuvering the instruments can be restrictive. The two-hand procedure using a one-and-half nostril approach provides more precise manipulation. This study aimed to compare the surgical outcomes of one-hand/mono-nostril and two-hand/one-and-half nostril surgeries for resection of large pituitary tumors by a single neurosurgeon.

MATERIALS AND METHODS

The surgical data of 78 consecutive cases with pituitary macroadenoma (diameter >1 cm) were reviewed retrospectively. Altogether, 30 cases received one-hand/mono-nostril surgery, while 48 cases received two-hand/one-and-half nostril surgery. Postoperative outcomes of the two operations were compared.

RESULTS

The operative time, hospital stay, residual rate of pituitary macroadenoma, visual field, surgical complications, and re-operative rates were slightly improved in the two-hand/one-and-half nostril surgery group compared with that in the one-hand/mono-nostril surgery group (all p>0.05). However, postoperative hypopituitarism was less frequent (1/48; 2.0%) with the two-hand/one-and-half nostril approach than with the mono-nostril approach (p = 0.004). Similar surgical outcomes were found in all patients with either small or large pituitary tumors, except that the difference in postoperative improvement in visual field change reached statistical significance (p = 0.044).

CONCLUSION

A single-surgeon endoscopic endonasal transsphenoidal surgery with two-hand/one-and-half nostril approach is an effective and safe procedure for removal of large pituitary tumors.

A Neural Network Approach to Identify Glioblastoma Progression Phenotype from Multimodal MRI

The phenotypes of glioblastoma (GBM) progression after treatment are heterogeneous in both imaging and clinical prognosis. This study aims to apply radiomics and neural network analysis to preoperative multimodal MRI data to characterize tumor progression phenotypes. We retrospectively reviewed 41 patients with newly diagnosed cerebral GBM from 2009-2016 who comprised the machine learning training group, and prospectively included 18 patients from 2017-2018 for data validation. Preoperative MRI examinations included structural MRI, diffusion tensor imaging, and perfusion MRI. Tumor progression patterns were categorized as diffuse or localized. A supervised machine learning model and neural network-based models (VGG16 and ResNet50) were used to establish the prediction model of the pattern of progression. The diffuse progression pattern showed a significantly worse prognosis regarding overall survival (p = 0.032). A total of 153 of the 841 radiomic features were used to classify progression patterns using different machine learning models with an overall accuracy of 81% (range: 77.5-82.5%, AUC = 0.83-0.89). Further application of the pretrained ResNet50 and VGG 16 neural network models demonstrated an overall accuracy of 93.1 and 96.1%. The progression patterns of GBM are an important prognostic factor and can potentially be predicted by combining multimodal MR radiomics with machine learning.

Three-Dimensional Volumetric Changes and Clinical Outcomes after Decompression with DIAM™ Implantation in Patients with Degenerative Lumbar Spine Diseases

Background and objectives: The prevalence of degenerative lumbar spine diseases has increased. In addition to standard lumbar decompression and/or fusion techniques, implantation of interspinous process devices (IPDs) can provide clinical benefits in highly selected patients. However, changes in spinal structures after IPD implantation using magnetic resonance imaging (MRI) have rarely been discussed. This volumetric study aimed to evaluate the effect of IPD implantation on the intervertebral disc and foramen using three-dimensional assessment. Materials and Methods: We retrospectively reviewed patients with lumbar degenerative disc diseases treated with IPD implantation and foraminotomy and/or discectomy between January 2016 and December 2019. The mean follow-up period was 13.6 months. The perioperative lumbar MRI data were processed for 3D-volumetric analysis. Clinical outcomes, including the Prolo scale and visual analog scale (VAS) scores, and radiographic outcomes, such as the disc height, foraminal area, and translation, were analyzed. Results: Fifty patients were included in our study. At the one-year follow-up, the VAS and Prolo scale scores significantly improved (both p < 0.001). The disc height and foraminal area on radiographs also increased significantly, but with limited effects up to three months postoperatively. MRI revealed an increased postoperative disc height with a mean difference of 0.5 ± 0.1 mm (p < 0.001). Although the mean disc volume difference did not significantly increase, the mean foraminal volume difference was 0.4 ± 0.16 mm³ (p < 0.05). Conclusions: In select patients with degenerative disc diseases or lumbar spinal stenosis, the intervertebral foramen was enlarged, and disc loading was reduced after IPD implantation with decompression surgery. The 3D findings were compatible with the clinical benefits.

A Neural Network Approach to Identify the Peritumoral Invasive Areas in Glioblastoma Patients by Using MR Radiomics

The challenge in the treatment of glioblastoma is the failure to identify the cancer invasive area outside the contrast-enhancing tumour which leads to the high local progression rate. Our study aims to identify its progression from the preoperative MR radiomics. 57 newly diagnosed cerebral glioblastoma patients were included. All patients received 5-aminolevulinic acid (5-ALA) fluorescence guidance surgery and postoperative temozolomide concomitant chemoradiotherapy. Preoperative 3 T MRI data including structure MR, perfusion MR, and DTI were obtained. Voxel-based radiomics features extracted from 37 patients were used in the convolutional neural network to train and as internal validation. Another 20 patients of the cohort were tested blindly as external validation. Our results showed that the peritumoural progression areas had higher signal intensity in FLAIR (p = 0.02), rCBV (p = 0.038), and T1C (p = 0.0004), and lower intensity in ADC (p = 0.029) and DTI-p (p = 0.001) compared to non-progression area. The identification of the peritumoural progression area was done by using a supervised convolutional neural network. There was an overall accuracy of 92.6% in the training set and 78.5% in the validation set. Multimodal MR radiomics can demonstrate distinct characteristics in areas of potential progression on preoperative MRI.

Aggressive cytoreduction and multiple subpial cortical transections may obtain good surgical outcomes in refractory epilepsy with multiple epileptic foci

Backgrounds

Epilepsy surgery is the most efficacious therapeutic modality for patients with medical refractory epilepsy, especially resective surgery. However, the variable etiologies and multiple epileptic foci are usually associated with the outcomes. The aim of this study was to demonstrate that combination of different intervention procedures might be an alternative option for patients of refractory epilepsy.

Methods

We retrospectively analyzed pre-operative and post-surgical outcomes in 30 patients who received epilepsy surgery between January 1, 2010 and December 31, 2014 at Chang Gung Memorial Hospital (CGMH), Linkou, according to Engel's classification.

Results

Twenty-six of the 30 patients (86.7%) had good outcomes, sum of class I and class II after epilepsy surgery. The good outcome rate of our complicated group was 80.0% (12/15), compared to 93.3% (14/15) in the simple group, but no significant differences between the two groups (p = 0.569). Four patients whose epileptic foci involved eloquent area and received multiple subpial cortical transection, and good outcome rate was 75% (3/4). At last, six patients had previously failed epilepsy surgery and received a reoperation, with a good outcome rate of 83.3% (5/6).

Conclusion

After complete pre-surgical evaluation and combined interventional procedures, the patients with refractory epilepsy had satisfactory outcomes and few neurological complications. Moreover, re-operation can improve the outcome in some patients who previously failed epilepsy surgery.

Phosphorus spectroscopy in acute TBI demonstrates metabolic changes that relate to outcome in the presence of normal structural MRI

Metabolic dysfunction is a key pathophysiological process in the acute phase of traumatic brain injury (TBI). Although changes in brain glucose metabolism and extracellular lactate/pyruvate ratio are well known, it was hitherto unknown whether these translate to downstream changes in ATP metabolism and intracellular pH. We have performed the first clinical voxel-based in vivo phosphorus magnetic resonance spectroscopy (³¹P MRS) in 13 acute-phase major TBI patients versus 10 healthy controls (HCs), at 3T, focusing on eight central 2.5 × 2.5 × 2.5 cm³ voxels per subject. PCr/γATP ratio (a measure of energy status) in TBI patients was significantly higher (median = 1.09) than that of HCs (median = 0.93) (p < 0.0001), due to changes in both PCr and ATP. There was no significant difference in PCr/γATP between TBI patients with favourable and unfavourable outcome. Cerebral intracellular pH of TBI patients was significantly higher (median = 7.04) than that of HCs (median = 7.00) (p = 0.04). Alkalosis was limited to patients with unfavourable outcome (median = 7.07) (p < 0.0001). These changes persisted after excluding voxels with > 5% radiologically visible injury. This is the first clinical demonstration of brain alkalosis and elevated PCr/γATP ratio acutely after major TBI. ³¹P MRS has potential for non-invasively assessing brain injury in the absence of structural injury, predicting outcome and monitoring therapy response.

Inferior Vena Cava Volume Is an Independent Predictor of Massive Transfusion in Patients With Trauma

OBJECTIVES

Early adequate resuscitation of patients with trauma is crucial in preventing shock and early mortality. Thus, we aimed to determine the performance of the inferior vena cava (IVC) volume and other risk factors and scores in predicting massive transfusion and mortality.

METHODS

We included all patients with trauma who underwent computed tomography (CT) scan of the torso, which included the abdominal area, in our emergency department (ED) from January 2014 to January 2017. We calculated the 3-dimensional IVC volume from the left renal vein to the IVC bifurcation. The primary outcome was the performance of IVC volume in predicting massive transfusion, and the secondary outcome was the performance of IVC volume in predicting 24-hour and 30-day in-hospital mortality.

RESULTS

Among the 236 patients with trauma, 7.6% received massive transfusions. The IVC volume and revised trauma score (RTS) were independent predictors of massive transfusion (adjusted odds ratio [OR]: 0.79 vs 1.86, 95% confidence interval [CI], 0.71-0.89 vs 1.4-2.47, respectively). Both parameters showed the good area under the curve (AUC) for the prediction of massive transfusion (adjusted AUC: 0.83 and 0.82, 95% CI, 0.74-0.92 vs 0.72-0.93, respectively). Patients with a large IVC volume (fourth quartile) were less likely to receive massive transfusion than those with a small IVC volume (first quartile, ≥28.29 mL: 0% vs <15.08 mL: 20.3%, OR: 0.13, 95% CI, 0.03-0.66).

CONCLUSIONS

The volume of IVC measured on CT scan and RTS are independent predictors of massive transfusion in patients with trauma in the ED.

Ventricle contact is associated with lower survival and increased peritumoral perfusion in glioblastoma

OBJECTIVE

The purpose of this study was to prospectively investigate outcome and differences in peritumoral MRI characteristics of glioblastomas (GBMs) that were in contact with the ventricles (ventricle-contacting tumors) and those that were not (noncontacting tumors). GBMs are heterogeneous tumors with variable survival. Lower survival is suggested for patients with ventricle-contacting tumors than for those with noncontacting tumors. This might be supported by aggressive peritumoral MRI features. However, differences in MRI characteristics of the peritumoral environment between ventricle-contacting and noncontacting GBMs have not yet been investigated.

METHODS

Patients with newly diagnosed GBM underwent preoperative MRI with contrast-enhanced T1-weighted, FLAIR, diffusion-weighted, and perfusion-weighted sequences. Tumors were categorized into ventricle-contacting or noncontacting based on contrast enhancement. Survival analysis was performed using log-rank for univariate analysis and Cox regression for multivariate analysis. Normalized perfusion (relative cerebral blood volume [rCBV]) and diffusion (apparent diffusion coefficient [ADC]) values were calculated in 2 regions: the peritumoral nonenhancing FLAIR region overlapping the subventricular zone and the remaining peritumoral nonenhancing FLAIR region.

RESULTS

Overall survival was significantly lower for patients with contacting tumors than for those with noncontacting tumors (434 vs 747 days, p < 0.001). Progression-free survival showed a comparable trend (260 vs 375 days, p = 0.094). Multivariate analysis confirmed a survival difference for both overall survival (HR 3.930, 95% CI 1.740-8.875, p = 0.001) and progression-free survival (HR 2.506, 95% CI 1.254-5.007, p = 0.009). Peritumoral perfusion was higher in contacting than in noncontacting tumors for both FLAIR regions (p = 0.04). There was no difference in peritumoral ADC values between the 2 groups.

CONCLUSIONS

Patients with ventricle-contacting tumors had poorer outcomes than patients with noncontacting tumors. This disadvantage of ventricle contact might be explained by higher peritumoral perfusion leading to more aggressive behavior.

Intratumoral Heterogeneity of Glioblastoma Infiltration Revealed by Joint Histogram Analysis of Diffusion Tensor Imaging

BACKGROUND

Glioblastoma is a heterogeneous disease characterized by its infiltrative growth, rendering complete resection impossible. Diffusion tensor imaging (DTI) shows potential in detecting tumor infiltration by reflecting microstructure disruption.

OBJECTIVE

To explore the heterogeneity of glioblastoma infiltration using joint histogram analysis of DTI, to investigate the incremental prognostic value of infiltrative patterns over clinical factors, and to identify specific subregions for targeted therapy.

METHODS

A total of 115 primary glioblastoma patients were prospectively recruited for surgery and preoperative magnetic resonance imaging. The joint histograms of decomposed anisotropic and isotropic components of DTI were constructed in both contrast-enhancing and nonenhancing tumor regions. Patient survival was analyzed with joint histogram features and relevant clinical factors. The incremental prognostic values of histogram features were assessed using receiver operating characteristic curve analysis. The correlation between the proportion of diffusion patterns and tumor progression rate was tested using Pearson correlation.

RESULTS

We found that joint histogram features were associated with patient survival and improved survival model performance. Specifically, the proportion of nonenhancing tumor subregion with decreased isotropic diffusion and increased anisotropic diffusion was correlated with tumor progression rate (P = .010, r = 0.35), affected progression-free survival (hazard ratio = 1.08, P < .001), and overall survival (hazard ratio = 1.36, P < .001) in multivariate models.

CONCLUSION

Joint histogram features of DTI showed incremental prognostic values over clinical factors for glioblastoma patients. The nonenhancing tumor subregion with decreased isotropic diffusion and increased anisotropic diffusion may indicate a more infiltrative habitat and potential treatment target.

Multi-parametric and multi-regional histogram analysis of MRI: modality integration reveals imaging phenotypes of glioblastoma

OBJECTIVES

Integrating multiple imaging modalities is crucial for MRI data interpretation. The purpose of this study is to determine whether a previously proposed multi-view approach can effectively integrate the histogram features from multi-parametric MRI and whether the selected features can offer incremental prognostic values over clinical variables.

METHODS

Eighty newly-diagnosed glioblastoma patients underwent surgery and chemoradiotherapy. Histogram features of diffusion and perfusion imaging were extracted from contrast-enhancing (CE) and non-enhancing (NE) regions independently. An unsupervised patient clustering was performed by the multi-view approach. Kaplan-Meier and Cox proportional hazards regression analyses were performed to evaluate the relevance of patient clustering to survival. The metabolic signatures of patient clusters were compared using multi-voxel spectroscopy analysis. The prognostic values of histogram features were evaluated by survival and ROC curve analyses.

RESULTS

Two patient clusters were generated, consisting of 53 and 27 patients respectively. Cluster 2 demonstrated better overall survival (OS) (p = 0.007) and progression-free survival (PFS) (p < 0.001) than Cluster 1. Cluster 2 displayed lower N-acetylaspartate/creatine ratio in NE region (p = 0.040). A higher mean value of anisotropic diffusion in NE region was associated with worse OS (hazard ratio [HR] = 1.40, p = 0.020) and PFS (HR = 1.36, p = 0.031). The seven features selected by this approach showed significantly incremental value in predicting 12-month OS (p = 0.020) and PFS (p = 0.022).

CONCLUSIONS

The multi-view clustering method can provide an effective integration of multi-parametric MRI. The histogram features selected may be used as potential prognostic markers.

KEY POINTS

• Multi-parametric magnetic resonance imaging captures multi-faceted tumor physiology. • Contrast-enhancing and non-enhancing tumor regions represent different tumor components with distinct clinical relevance. • Multi-view data analysis offers a method which can effectively select and integrate multi-parametric and multi-regional imaging features.

Multimodal MRI characteristics of the glioblastoma infiltration beyond contrast enhancement

Our inability to identify the invasive margin of glioblastomas hampers attempts to achieve local control. Diffusion tensor imaging (DTI) has been implemented clinically to delineate the margin of the tumor infiltration, its derived anisotropic (q) values can extend beyond the contrast-enhanced area and correlates closely with the tumor. However, its correlation with tumor infiltration shown on multivoxel proton magnetic resonance spectroscopy¹ (MRS) and perfusion magnetic resonance imaging (MRI) should be investigated. In this study, we aimed to show tissue characteristics of the q-defined peritumoral invasion on MRS and perfusion MRI. Patients with a primary glioblastoma were included (n = 51). Four regions of interest were analyzed; the contrast-enhanced lesion, peritumoral abnormal q region, peritumoral normal q region, and contralateral normal-appearing white matter. MRS, including choline (Cho)/creatinine (Cr), Cho/N-acetyl-aspartate (NAA) and NAA/Cr ratios, and the relative cerebral blood volume (rCBV) were analyzed. Our results showed an increase in the Cho/NAA (p = 0.0346) and Cho/Cr (p = 0.0219) ratios in the peritumoral abnormal q region, suggestive of tumor invasion. The rCBV was marginally elevated (p = 0.0798). Furthermore, the size of the abnormal q regions was correlated with survival; patients with larger abnormal q regions showed better progression-free survival (median 287 versus 53 days, p = 0.001) and overall survival (median 464 versus 274 days, p = 0.006) than those with smaller peritumoral abnormal q regions of interest. These results support how the DTI q abnormal area identifies tumor activity beyond the contrast-enhanced area, especially correlating with MRS.

Low perfusion compartments in glioblastoma quantified by advanced magnetic resonance imaging and correlated with patient survival

BACKGROUND AND PURPOSE

Glioblastoma exhibits profound intratumoral heterogeneity in perfusion. Particularly, low perfusion may induce treatment resistance. Thus, imaging approaches that define low perfusion compartments are crucial for clinical management.

MATERIALS AND METHODS

A total of 112 newly diagnosed glioblastoma patients were prospectively recruited for maximal safe resection. The apparent diffusion coefficient (ADC) and relative cerebral blood volume (rCBV) were calculated from diffusion and perfusion imaging, respectively. Based on the overlapping regions of lowest rCBV quartile (rCBVL) with the lowest ADC quartile (ADCL) and highest ADC quartile (ADCH) in each tumor, two low perfusion compartments (ADCH-rCBVL and ADCL-rCBVL) were identified for volumetric analysis. Lactate and macromolecule/lipid levels were determined from multivoxel MR spectroscopic imaging. Progression-free survival (PFS) and overall survival (OS) were analyzed using Kaplan-Meier's and multivariate Cox regression analyses, to evaluate the effects of compartment volume and lactate level on survival.

RESULTS

Two compartments displayed higher lactate and macromolecule/lipid levels compared to contralateral normal-appearing white matter (each P < 0.001). The proportion of the ADCL-rCBVL compartment in the contrast-enhancing tumor was associated with a larger infiltration on FLAIR (P < 0.001, rho = 0.42). The minimally invasive phenotype displayed a lower proportion of the ADCL-rCBVL compartment than the localized (P = 0.031) and diffuse phenotypes (not significant). Multivariate Cox regression showed higher lactate level in the ADCL-rCBVL compartment was associated with worsened survival (PFS: HR 2.995, P = 0.047; OS: HR 4.974, P = 0.005).

CONCLUSIONS

Our results suggest that the ADCL-rCBVL compartment may potentially indicate a clinically measurable resistant compartment.

Characterizing tumor invasiveness of glioblastoma using multiparametric magnetic resonance imaging

OBJECTIVE

The objective of this study was to characterize the abnormalities revealed by diffusion tensor imaging (DTI) using MR spectroscopy (MRS) and perfusion imaging, and to evaluate the prognostic value of a proposed quantitative measure of tumor invasiveness by combining contrast-enhancing (CE) and DTI abnormalities in patients with glioblastoma.

METHODS

Eighty-four patients with glioblastoma were recruited preoperatively. DTI was decomposed into isotropic (p) and anisotropic (q) components. The relative cerebral blood volume (rCBV) was calculated from the dynamic susceptibility contrast imaging. Values of N-acetylaspartate, myoinositol, choline (Cho), lactate (Lac), and glutamate + glutamine (Glx) were measured from multivoxel MRS and normalized as ratios to creatine (Cr). Tumor regions of interest (ROIs) were manually segmented from the CE T1-weighted (CE-ROI) and DTI-q (q-ROI) maps. Perfusion and metabolic characteristics of these ROIs were measured and compared. The relative invasiveness coefficient (RIC) was calculated as a ratio of the characteristic radii of CE-ROI and q-ROI. The prognostic significance of RIC was tested using Kaplan-Meier and multivariate Cox regression analyses.

RESULTS

The Cho/Cr, Lac/Cr, and Glx/Cr in q-ROI were significantly higher than CE-ROI (p = 0.004, p = 0.005, and p = 0.007, respectively). CE-ROI had significantly higher rCBV values than q-ROI (p < 0.001). A higher RIC was associated with worse survival in a multivariate overall survival (OS) model (hazard ratio [HR] 1.40, 95% confidence interval [CI] 1.06-1.85, p = 0.016) and progression-free survival (PFS) model (HR 1.55, 95% CI 1.16-2.07, p = 0.003). An RIC cutoff value of 0.89 significantly predicted shorter OS (median 384 vs 605 days, p = 0.002) and PFS (median 244 vs 406 days, p = 0.001).

CONCLUSIONS

DTI-q abnormalities displayed higher tumor load and hypoxic signatures compared with CE abnormalities, whereas CE regions potentially represented the tumor proliferation edge. Integrating the extents of invasion visualized by DTI-q and CE images into clinical practice may lead to improved treatment efficacy.

Neuroimaging classification of progression patterns in glioblastoma: a systematic review

BACKGROUND

Our primary objective was to report the current neuroimaging classification systems of spatial patterns of progression in glioblastoma. In addition, we aimed to report the terminology used to describe 'progression' and to assess the compliance with the Response Assessment in Neuro-Oncology (RANO) Criteria.

METHODS

We conducted a systematic review to identify all neuroimaging studies of glioblastoma that have employed a categorical classification system of spatial progression patterns. Our review was registered with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) registry.

RESULTS

From the included 157 results, we identified 129 studies that used labels of spatial progression patterns that were not based on radiation volumes (Group 1) and 50 studies that used labels that were based on radiation volumes (Group 2). In Group 1, we found 113 individual labels and the most frequent were: local/localised (58%), distant/distal (51%), diffuse (20%), multifocal (15%) and subependymal/subventricular zone (15%). We identified 13 different labels used to refer to 'progression', of which the most frequent were 'recurrence' (99%) and 'progression' (92%). We identified that 37% (n = 33/90) of the studies published following the release of the RANO classification were adherent compliant with the RANO criteria.

CONCLUSIONS

Our review reports significant heterogeneity in the published systems used to classify glioblastoma spatial progression patterns. Standardization of terminology and classification systems used in studying progression would increase the efficiency of our research in our attempts to more successfully treat glioblastoma.

The effect of succinate on brain NADH/NAD+ redox state and high energy phosphate metabolism in acute traumatic brain injury

A key pathophysiological process and therapeutic target in the critical early post-injury period of traumatic brain injury (TBI) is cell mitochondrial dysfunction; characterised by elevation of brain lactate/pyruvate (L/P) ratio in the absence of hypoxia. We previously showed that succinate can improve brain extracellular chemistry in acute TBI, but it was not clear if this translates to a change in downstream energy metabolism. We studied the effect of microdialysis-delivered succinate on brain energy state (phosphocreatine/ATP ratio (PCr/ATP)) with 31P MRS at 3T, and tissue NADH/NAD+ redox state using microdialysis (L/P ratio) in eight patients with acute major TBI (mean 7 days). Succinate perfusion was associated with increased extracellular pyruvate (+26%, p < 0.0001) and decreased L/P ratio (-13%, p < 0.0001) in patients overall (baseline-vs-supplementation over time), but no clear-cut change in 31P MRS PCr/ATP existed in our cohort (p > 0.4, supplemented-voxel-vs-contralateral voxel). However, the percentage decrease in L/P ratio for each patient following succinate perfusion correlated significantly with their percentage increase in PCr/ATP ratio (Spearman's rank correlation, r = -0.86, p = 0.024). Our findings support the interpretation that L/P ratio is linked to brain energy state, and that succinate may support brain energy metabolism in select TBI patients suffering from mitochondrial dysfunction.

Anomalous phase behavior of first-order fluid-liquid phase transition in phosphorus

Although the existence of liquid-liquid phase transition has become more and more convincing, whether it will terminate at a critical point and what is the order parameter are still open. To explore these questions, we revisit the fluid-liquid phase transition (FLPT) in phosphorus (P) and study its phase behavior by performing extensive first-principles molecular dynamics simulations. The FLPT observed in experiments is well reproduced, and a fluid-liquid critical point (FLCP) at T = 3000 ∼ 3500 K, P = 1.5-2.0 Kbar is found. With decreasing temperature from the FLCP along the transition line, the density difference (Δρ) between two coexisting phases first increases from zero and then anomalously decreases; however, the entropy difference (ΔS) continuously increases from zero. These features suggest that an order parameter containing contributions from both the density and the entropy is needed to describe the FLPT in P, and at least at low temperatures, the entropy, instead of the density, governs the FLPT.

Assessing Metabolism and Injury in Acute Human Traumatic Brain Injury with Magnetic Resonance Spectroscopy: Current and Future Applications

Traumatic brain injury (TBI) triggers a series of complex pathophysiological processes. These include abnormalities in brain energy metabolism; consequent to reduced tissue pO₂ arising from ischemia or abnormal tissue oxygen diffusion, or due to a failure of mitochondrial function. In vivo magnetic resonance spectroscopy (MRS) allows non-invasive interrogation of brain tissue metabolism in patients with acute brain injury. Nuclei with “spin,” e.g., ¹H, ³¹P, and ¹³C, are detectable using MRS and are found in metabolites at various stages of energy metabolism, possessing unique signatures due to their chemical shift or spin–spin interactions (J-coupling). The most commonly used clinical MRS technique, ¹H MRS, uses the great abundance of hydrogen atoms within molecules in brain tissue. Spectra acquired with longer echo-times include N-acetylaspartate (NAA), creatine, and choline. NAA, a marker of neuronal mitochondrial activity related to adenosine triphosphate (ATP), is reported to be lower in patients with TBI than healthy controls, and the ratio of NAA/creatine at early time points may correlate with clinical outcome. ¹H MRS acquired with shorter echo times produces a more complex spectrum, allowing detection of a wider range of metabolites.³¹ P MRS detects high-energy phosphate species, which are the end products of cellular respiration: ATP and phosphocreatine (PCr). ATP is the principal form of chemical energy in living organisms, and PCr is regarded as a readily mobilized reserve for its replenishment during periods of high utilization. The ratios of high-energy phosphates are thought to represent a balance between energy generation, reserve and use in the brain. In addition, the chemical shift difference between inorganic phosphate and PCr enables calculation of intracellular pH.¹³ C MRS detects the ¹³C isotope of carbon in brain metabolites. As the natural abundance of ¹³C is low (1.1%), ¹³C MRS is typically performed following administration of ¹³C-enriched substrates, which permits tracking of the metabolic fate of the infused ¹³C in the brain over time, and calculation of metabolic rates in a range of biochemical pathways, including glycolysis, the tricarboxylic acid cycle, and glutamate–glutamine cycling. The advent of new hyperpolarization techniques to transiently boost signal in ¹³C-enriched MRS in vivo studies shows promise in this field, and further developments are expected.

Subventricular Zone Involvement Characterized by Diffusion Tensor Imaging in Glioblastoma

BACKGROUND

Glioblastomas have a poor prognosis, possibly because of a subpopulation of therapy-resistant stem cells within the heterogeneous glioblastoma. Because the subventricular zone is the main source of neural stem cells, we aimed at characterizing the subventricular zone using diffusion tensor imaging (DTI) to show subventricular zone involvement in glioblastoma.

METHODS

We prospectively included 93 patients with primary glioblastomas who underwent preoperative DTI. The nonenhancing high fluid-attenuated inversion recovery (FLAIR) signal was used to describe the infiltrative tumor margin. We used a 5-mm margin surrounding the lateral ventricles to define the subventricular zone. The subventricular zone with high FLAIR was compared with the subventricular zone without high FLAIR, control high FLAIR outside the subventricular zone and control contralateral normal-appearing white matter. Normalized DTI parameters were calculated and compared between the different regions.

RESULTS

The subventricular zone with high FLAIR showed increased isotropic p values compared with the subventricular zone without high FLAIR (t₁₂₆ = 3.9; P < 0.001) and control regions (t₁₇₉ = 1.9; P = 0.046). Anisotropic q and fractional anisotropy values were lower in regions with high FLAIR compared with the subventricular zone without high FLAIR (t₁₈₁ = 11.6, P < 0.001 and t₁₈₄ =12.4, P < 0.001, respectively).

CONCLUSION

DTI data showed that the subventricular zone is involved in glioblastoma with increased isotropic p values in the subventricular zone with high FLAIR, indicating tumor infiltration.

Extent of resection of peritumoral diffusion tensor imaging–detected abnormality as a predictor of survival in adult glioblastoma patients

OBJECTIVE

Diffusion tensor imaging (DTI) has been shown to detect tumor invasion in glioblastoma patients and has been applied in surgical planning. However, the clinical value of the extent of resection based on DTI is unclear. Therefore, the correlation between the extent of resection of DTI abnormalities and patients' outcome was retrospectively reviewed.

METHODS

A review was conducted of 31 patients with newly diagnosed supratentorial glioblastoma who underwent standard 5-aminolevulinic acid–aided surgery with the aim of maximal resection of the enhancing tumor component. All patients underwent presurgical MRI, including volumetric postcontrast T1-weighted imaging, DTI, and FLAIR. Postsurgical anatomical MR images were obtained within 72 hours of resection. The diffusion tensor was split into an isotropic (p) and anisotropic (q) component. The extent of resection was measured for the abnormal area on the p, q, FLAIR, and postcontrast T1-weighted images. Data were analyzed in relation to patients' outcome using univariate and multivariate Cox regression models controlling for possible confounding factors including age, O6-methylguanine-DNA-methyltrans-ferase methylation status, and isocitrate dehydrogenase–1 mutation.

RESULTS

Complete resection of the enhanced tumor shown on the postcontrast T1-weighted images was achieved in 24 of 31 patients (77%). The mean extent of resection of the abnormal p, q, and FLAIR areas was 57%, 83%, and 59%, respectively. Increased resection of the abnormal p and q areas correlated positively with progression-free survival (p = 0.009 and p = 0.006, respectively). Additionally, a larger, residual, abnormal q volume predicted significantly shorter time to progression (p = 0.008). More extensive resection of the abnormal q and contrast-enhanced area improved overall survival (p = 0.041 and 0.050, respectively).

CONCLUSIONS

Longer progression-free survival and overall survival were seen in glioblastoma patients in whom more DTI-documented abnormality was resected, which was previously shown to represent infiltrative tumor. This highlights the potential usefulness and the importance of an extended resection based on DTI-derived maps.

Less Invasive Phenotype Found in Isocitrate Dehydrogenase-mutated Glioblastomas than in Isocitrate Dehydrogenase Wild-Type Glioblastomas: A Diffusion-Tensor Imaging Study

Purpose To explore the diffusion-tensor (DT) imaging-defined invasive phenotypes of both isocitrate dehydrogenase (IDH-1)-mutated and IDH-1 wild-type glioblastomas. Materials and Methods Seventy patients with glioblastoma were prospectively recruited and imaged preoperatively. All patients provided signed consent, and the local research ethics committee approved the study. Patients underwent surgical resection, and tumor samples underwent immunohistochemistry for IDH-1 R132H mutations. DT imaging data were coregistered to the anatomic magnetic resonance study and reconstructed to provide the anisotropic and isotropic components of the DT. The invasive phenotype was determined by using previously published criteria and correlated with IDH-1 mutation status by using the Freeman-Halton extension of the Fisher exact probability test. Results Nine patients had an IDH-1 mutation and 61 had IDH-1 wild type. All of the patients with IDH-1 mutation had a minimally invasive DT imaging phenotype. Among the IDH-1 wild-type tumors, 42 of 61 (69%) were diffusively invasive glioblastomas, 14 of 61 (23%) were locally invasive, and five of 61 (8%) were minimally invasive (P < .001). Conclusion IDH-mutated glioblastomas have a less invasive phenotype compared with IDH wild type. This finding may have implications for individualizing the extent of surgical resection and radiation therapy volumes.

Validation of a semi-automatic co-registration of MRI scans in patients with brain tumors during treatment follow-up

There is an expanding research interest in high-grade gliomas because of their significant population burden and poor survival despite the extensive standard multimodal treatment. One of the obstacles is the lack of individualized monitoring of tumor characteristics and treatment response before, during and after treatment. We have developed a two-stage semi-automatic method to co-register MRI scans at different time points before and after surgical and adjuvant treatment of high-grade gliomas. This two-stage co-registration includes a linear co-registration of the semi-automatically derived mask of the preoperative contrast-enhancing area or postoperative resection cavity, brain contour and ventricles between different time points. The resulting transformation matrix was then applied in a non-linear manner to co-register conventional contrast-enhanced T1 -weighted images. Targeted registration errors were calculated and compared with linear and non-linear co-registered images. Targeted registration errors were smaller for the semi-automatic non-linear co-registration compared with both the non-linear and linear co-registered images. This was further visualized using a three-dimensional structural similarity method. The semi-automatic non-linear co-registration allowed for optimal correction of the variable brain shift at different time points as evaluated by the minimal targeted registration error. This proposed method allows for the accurate evaluation of the treatment response, essential for the growing research area of brain tumor imaging and treatment response evaluation in large sets of patients. Copyright © 2016 John Wiley & Sons, Ltd.

Expression of Magnaporthe oryzae genes encoding cysteine-rich proteins secreted during nitrogen starvation and interaction with its host, Oryza sativa

Previous studies have shown that the blast fungus, Magnaporthe oryzae, may experience nitrogen starvation during infection of its plant host (rice,Oryza sativa). Here, we studied the expression of seven genes encoding cysteine-rich proteins with N-terminal signal peptides during nitrogen limitation and throughout the infection process. Some genes were upregulated to a greater extent in weak pathogenic strains than in strong pathogenic strains when they were cultured in complete media, and the expression of some genes was higher in both weak and strong pathogenic strains cultured in 1/10-N and nitrogen starvation media. Furthermore, the expression of these genes was upregulated to different extents in the early stages of M. oryzae infection. These data demonstrate that the genes of interest are highly expressed in weak and strong pathogenic strains cultured under nitrogen limitation and at the early stage of the infection process. This indicates that cysteine-rich secreted proteins in the blast fungus might be involved in establishing disease in the host and that they are sensitive to nitrogen levels. Thus, their role in sensing nitrogen availability within the host is implied, which provides a basis for further functional identification of these genes and their products during plant infection.

Construction and expression of prokaryotic expression vectors fused with genes of Magnaporthe oryzae effector proteins and mCherry

The aim of the current study was to investigate the prokaryotic expression of the Magnaporthe oryzae effector genes BAS1 and BAS4 fused to the fluorescent protein mCherry. Based on previous polymorphic analysis of BAS1 and BAS4 in rice blast strains using PCR, blast strains containing the PCR products of BAS1 and BAS4 were selected for liquid culture for total RNA extraction. For PCR analysis, cDNA was selected as a template to amplify the coding region of BAS1 and BAS4, the plasmid pXY201 was selected as template to amplify the mCherry sequence, and the three sequences were cloned into pMD®19-T vectors. Positive recombinant plasmids were digested using two restriction enzymes and the cleaved fragments of BAS1 and mCherry and BAS4 and mCherry were ligated to pGEX-4T-1 vectors and expression was induced using IPTG. The PCR results showed that the sequence sizes of BAS1, BAS4, and mCherry were 348, 309, and 711 bp, respectively, and these were cloned into pMD®19-T vectors. After digestion and gel purification, the fragments of BAS1 and mCherry, BAS4 and mCherry were ligated into pGEX-4T-1 vectors and expressed in Escherichia coli BL21 competent cells. The expressed proteins were approximately 60 kDa, corresponding to their theoretical size. Prokaryotic expression products of BAS1 and BAS4 fused to mCherry were presented in this study, providing a base for constructing prokaryotic expression vectors of pathogen effector genes fused to mCherry, which will contribute to further study of the subcellular localization, function, and protein interactions of these effectors.

Construction of overexpression vectors of Magnaporthe oryzae genes BAS1 and BAS4 fusion to mCherry and screening of overexpression strains

The aim of this study was to construct overexpression vectors and selecting strains of the Magnaporthe oryzae effectors BAS1 and BAS4. Primer pairs of BAS1, BAS4, and mCherry were designed based on their known nucleotide sequences. The coding sequences of BAS1 and BAS4 were amplified, and the pXY201 plasmid was selected as a template to amplify the mCherry sequence. Fragments of BAS1 and mCherry, and BAS4 and mCherry were ligated into the pCAMBIA1302 vector. The recombinant pCAMBIA-BAS1-mCherry and pCAMBIA-BAS4-mCherry plasmids were transformed into E. coli DH5α competent cells. Transformants were screened by PCR, and plasmids from the positive transformants were extracted by enzymatic digestion to obtain pCAMBIA-BAS1-mCherry and pCAMBIA-BAS4-mCherry. The pCAMBIA-BAS1-mCherry and pCAMBIA-BAS4-mCherry plasmids were transformed into protoplasts of rice blast strains and the transformed strains were screened by PCR using primer pairs against the hygromycin gene. The result showed that the PCR products corresponded with the theoretical sizes. RT-PCR was used to analyze the expression of BAS1 and BAS4 in five transformed strains of BAS1 and BAS4, and the result showed that the higher expression level of the two genes was occurred in five transformant strains comparing to wild-type strain A3467-40 (the strain containing BAS1 and BAS4), but there was no difference among the five overexpression strains. The sporulation and spore germination of transformed strains was higher than in wild type strain, and there was no difference in the germination time. Construction of overexpression vectors and strains of M. oryzae effectors BAS1 and BAS4 provide reference material for other new effectors.

Tubercular temporalis abscess with skull and dural invasion

BACKGROUND

Mycobacterium tuberculosis infection rarely penetrates both skull and dura with temporalis muscle abscess formation.

METHODS

Case report and review of the literature.

RESULTS

A non-immunocompromised female patient with a right temporal mass underwent surgical resection. The tubercular abscess extended from the temporalis muscle to the skull and through the dura and subdural space with dissemination of the granuloma over the arachnoid membrane.

CONCLUSION

Adequate debridement with a full course of antituberculous medication is necessary for complete treatment of these lesions.

Long-term follow-up of patients with surgical intractable acromegaly after linear accelerator radiosurgery

BACKGROUND/PURPOSE

Radiotherapy is a crucial treatment for acromegalic patients with growth hormone (GH)-secreting pituitary tumors. However, its effect takes time. We retrospectively reviewed the long-term outcome of linear accelerator stereotactic radiosurgery (LINAC SRS) for patients with acromegaly from the perspective of biochemical remission and associated factors.

METHODS

Twenty-two patients presenting with residual or recurrent (GH)-secreting functional pituitary tumor between 1994 and 2004 who received LINAC SRS were enrolled and followed up for at least 3 years. Residual or recurrent tumor was defined as persistent elevated GH or insulin-like growth factor-1 (IGF-1) level and image-confirmed tumor after previous surgical treatment. Biochemical remission was defined as fasting GH less than 2.5 ng/mL with normal sex-and-age adjusted IGF-1.

RESULTS

The mean follow-up period was 94.7 months (range 36-161 months). Overall mean biochemical remission time was 53 months (median 30 months). Biochemical control was achieved in 15 patients (68.2%) over the follow up period. One patient experienced recurrence after SRS and underwent another operation. Initial GH at diagnosis and pre-SRS GH correlated with biochemical control (p = 0.005 and p < 0.0001, respectively). Further evaluation demonstrated that biochemical control stabilized after 7.5 years. Overall post-SRS hormone deficit persisted in five patients (22.7%).

CONCLUSION

In comparison to other radiosurgery modalities, LINAC radiosurgery also provides a satisfactory outcome. SRS has maximum effect over the first 2 years and stabilizes after 7.5 years. Moreover, SRS elicits long-term biochemical effects and requires longer follow-up for better biochemical remission.

Cross-cultural adaptation, reliability and validity of the Chinese version of the Fear Avoidance Beliefs Questionnaire

The Fear Avoidance Beliefs Questionnaire (FABQ) was translated and cross-culturally adapted for China. Its psychometric properties were then evaluated in Chinese-speaking patients with low-back pain and the scales were tested for internal consistency, reproducibility, ceiling-and-floor effects, construct validity and responsiveness. A total of 15 patients were selected for pre-testing and a further 230 patients completed the FABQ (and other scales) at baseline and 14 days later. A test-retest reliability analysis was carried out on 61 of the 230 patients. The FABQ was found to be easily understood. Explorative factor analysis by principal components analysis, yielded a two-factor model for the FABQ, relating to work and physical activity, and this was confirmed by confirmatory factor analysis using structural equation modelling. The FABQ yielded high values for internal consistency and reproducibility; no ceiling-and-floor effects were detected. Generally, the FABQ scales and baseline variables were weakly correlated. Cohen's effect size was 0.22 and responsiveness was low. It was concluded that the translation and adaptation of the FABQ into Chinese was successful; the scales had acceptable factor structure, internal consistency, test-retest reliability and construct validity.

Transplanted bone morphogenetic protein/poly(lactic-co-glycolic acid) delayed-release microcysts combined with rat micromorselized bone and collagen for bone tissue engineering

This study was designed to optimize the preparation of delayed-release microcysts containing bone morphogenetic protein 2 (BMP-2) combined with poly(lactic-co-glycolic acid) (PLGA) and to investigate their osteogenic properties when combined with rat autologous micromorselized bone and collagen. Rat autologous micromorselized bone, collagen and BMP-2/PLGA delayed-release microcysts were implanted in various combinations into the rat gluteus maximus muscle sack model. The following post-operative measurements were made: general observations of the implant site, histological observations, osteogenesis measurements and alkaline phosphatase activity. Autologous micromorselized bone combined with collagen and BMP-2/PLGA delayed-release microcysts demonstrated significantly superior osteogenic properties than any of the other combinations of these three components. These findings suggest that micromorselized bone combined with collagen and BMP-2/PLGA delayed-release microcysts could reduce the quantity of BMP-2 and autologous bone required for these procedures, making their use feasible in human bone restoration.

Microbial transformation of 3-hydroxy-5,6-cyclopropanocholestanes--an alternative route to 6-methylsteroids

Incubation of 3beta-hydroxy-5,6alpha-cyclopropano-5alpha-cholestane (4), 3beta-hydroxy-5,6beta-cyclopropano-5beta-cholestane (5), and 3beta-hydroxy-5,6alpha-cyclopropano-5alpha-cholest-7-e ne (6) with Mycobacterium sp. (NRRL B-3805) gave a mixture of side chain cleaved 17-keto steroids as the major products in 52, 57, and 69% yields, respectively. Among these 17-keto steroids, the cyclopropyl ring eliminated product, androst-4-ene-3,17-dione (9), was isolated in 6, 4, and 8% yields, respectively. A cyclopropyl ring migration product, 6alpha,7alpha-cyclopropanoandrost-4-ene-3,17-dione (16), was isolated from the incubation mixture of 6 in 4% yield, also 10% yield of 16 was obtained when 5, 6alpha-cyclopropano-5alpha-androst-7-ene-3,17-dione (12) was incubated. The cyclopropyl ring opening and subsequent reduction followed by oxidation of the two major biotransformation products, 5, 6beta-cyclopropano-5beta-androsta-3,17-dione (10) and 5, 6alpha-cyclopropano-5alpha-androsta-3,17-dione (7), gave 6beta- and 6alpha-methylandrost-4-ene-3,17-dione in 60, and 45% yields, respectively.

Consecutive reaction kinetics involving distributed fraction of methanogens in fluidized-bed bioreactors

A kinetic model involving the distributed fractions of acidogens and methanogens is proposed. To determine the fluxes and biochemical reaction rates of the substrate sucrose and its intermediates, volatile fatty acids (VFAs) in bulk liquid and within the biofilm, a kinetic model was developed by combining the solid-phase model with the liquid-phase model. The predicted substrate removal efficiencies of the conventional and tapered fluidized-bed bioreactors (CFB, TFBs) are in good agreement with the experimental results. The biofilm thickness in TFBs are thicker than that in CFB, resulting in performance enhancement with TFBs. The simulated results obtained from the kinetic model show that methanogenesis is the rate-limiting step of degradation of the simple organic compound (sucrose), and the chemical oxygen demand (COD) concentration in the effluent is mainly contributed by the intermediates VFAs. The distributed fractions of acidogens and methanogens determined experimentally are 0.4 and 0.6, respectively.

Microbial transformation of dihydrosarsasapogenin with Mycobacterium sp

Microbial transformation of sarsasapogenin (1) with Mycobacterium sp. (NRRL B-3805) gave 25(S)-neospirost-4-en-3-one (2) as the sole product in 62% yield. Incubation of dihydrosarsasapogenin (3) led to the isolation of seven products in 0.5 (4), 6.6 (5), 5 (6), 16 (7), 1 (8), 1 (9), and 4.5% (10) yields, respectively, while 15% of 3 was recovered. Among these products, 8 and 9 were C22 steroids, and 10 was a C19 steroid. Isolation of these C19 and C22 steroids indicated that this microorganism is capable of cleaving the ether linkage between C-16 and C-22 in 3. In addition, 12 alpha-hydroxylation was also observed in all these three metabolites.

[Therapeutic effect of carboplatin and etoposide combinative therapy on 123 lung cancer cases]

The clinical effect of Carboplatin and Etoposide (CE regimen) on 58 cases of small cell lung cancer (SCLC) and 65 cases of non small cell lung cancer (NSCLC) was observed, and its influence on immunity was investigated simultaneously. The result showed that the overall response rate of SCLC group was 72.4% (42/58). Among them, the response rate of primary treatment was 81.0% (31/38), and that of secondary treatment was 30.0% In NSCLC group, the response rate of primary treatment was 30.0% (6/20). In NSCLS group, the rate of primary treatment was 22.9% (8/35), and that of secondary treatment was 13.3% (4/30). From the result it was found that the response rate of primary treatment was higher than that of secondary treatment, and that the main side-effect of CE regimen was mild leukopenia, and the other side-effects included gastrointestinal symptoms, alopecia and mild hepatic function changes. The influence of CE regimen on immunity was temporary, and will soon recover. Repeating the regimen is reasonable. So we think that CE regimen is one of the best regimens for SCLC patients.