Collaborative approach to paediatric chronic non-bacterial osteomyelitis of the mandible: Great Ormond Street Hospital case series

This paper outlines a 10-patient case series of chronic non-bacterial osteomyelitis (CNO) of the mandible at a tertiary paediatric hospital in the UK. Our findings highlight the homogeneous presenting signs and symptoms of an intermittently painful, swollen angle and ramus of the mandible. We present the typical laboratory investigative findings (normal inflammatory markers) and imaging appearances (sclerosis and periosteal oedema). Our paper outlines an investigation protocol, including recommendations for extraoral bone biopsies and systemic magnetic resonance imaging (MRI). We explain the importance of multidisciplinary care, with combined care by rheumatologists and infectious disease specialists. Finally we demonstrate the efficacy of our treatment algorithm for oral non-steroidal anti-inflammatory drugs (NSAIDs), and in those cases refractory to NSAIDS, intravenous pamidronate. This paper provides a useful addition to the literature by informing OMF surgeons of this rare condition and given the clinical equipoise in treatments, it can hopefully guide clinicians in an investigation pathway and management protocol.

HAEMATOSPERMIA: CAUSES AND ASSOCIATED CHANGES IN SEMEN ANALYSIS IN NORTH OF IRAQ

Haematospermia is the medical term used to describe the presence of blood in semen. It can occur due to a variety of reasons and can be a benign or serious condition. The present study aimed to identify the prevalence and characterization of haematospermia in patients visiting hospital clinics. To do so, a total of 44 patients were recruited and characterized regarding their demographic variation, symptoms, severity, associated diseases, and measured prostate-specific-antigen (PSA). Results confirmed that patients were middle-aged (around 40 years) and the duration (days) of haematospermia is around 16±12. Only a few of these patients have shown an association with chronic diseases such as hypertension and diabetes or other vascular diseases. Less than 50% of these patients have shown past-surgical history and few of them were using anticoagulants 16±12. The majority of patients had painless haematospermia while only (13.6%) had painful haematospermia, irritative urinary symptoms were found in (13.6%) while obstructive urinary symptoms in (4.5%). Ultrasound (US) examination of the abdomen, pelvis, and scrotum was normal in more than 50% of them while others have shown prostatic involvement. Few of these patients experienced pus on laboratory examination. To sum up, haematospermia is represented as an inconvenient disease in our sample leading to interference with daily quality of life, with no clear understanding aetiology of the disease and its progression.

Predictive risk factors for persistent pain following total prosthetic temporomandibular joint replacement

The aim of this study was to determine the rate of persistent pain following total TMJ replacement and to identify potential predictive risk factors. A retrospective review of case notes treated by a single surgeon in a tertiary unit was performed. For each patient a number of variables were recorded including visual analogue pain scores (0 to 10) and opioid usage pre surgery and at 12 months or last follow up beyond 12 months. Persistent pain scores of 5 to 7 were regarded as moderate and 8 to 10 as severe. The mean pain score at last follow-up was significantly lower than preoperatively (2.1 vs. 6.3, p < 0.001) with a mean follow-up time of 40.1 months (range 12-44). 16.4% of the patients reported moderate to severe pain and 13.7% were still on regular opioids at the last follow-up. Therefore 15 patients (20.5%) suffered from chronic postoperative pain after TMJ replacement surgery. Patients reporting severe preoperative pain scores (p = 0.04), regular opioid use (p = 0.001) or multiple previous open TMJ surgeries (p = 0.03) were more likely to suffer from chronic persistent pain and these should be regarded as predictive risk factors. The identification of these factors allows for better risk stratification of patients, informed consent and the agreement of expected outcomes. Patients with true articular disease and a single failed surgery should be considered for early total TMJ replacement to minimise multifactorial persistent pain.

Patients with NSTEMI have fewer symptoms and higher quality of life three months after admission for acute chest pain

Background

A substantial proportion of patients admitted for possible non-ST elevation acute coronary syndrome (NSTE-ACS) who are not diagnosed with non-ST elevation myocardial infarction (NSTEMI) suffer from conditions (e.g. chronic myocardial injury [CMI]) that may imply serious cardiac risk and impaired quality of life. It is unknown what predicts quality of life and recurrence of symptoms in chest pain patients.

Purpose

To investigate which demographic and clinical characteristics, including discharge diagnosis, that predict recurrent symptoms and quality of life three months after hospitalization for acute chest pain.

Methods

A total of 1506 patients ≥18 years admitted with suspected NSTE-ACS at Haukeland University Hospital, Bergen, Norway, were included in the WESTCOR study. The final diagnosis was adjudicated by two independent cardiologists based on all clinical data including routine cTnT (5th gen, Roche Diagnostics). Three months after discharge patients received questionnaires assessing general health (SF-12v1), angina-related health (SAQ-7) and dyspnea (Rose Dyspnea Scale). In all, 774 (51.3%) patients responded and were included in the analyses. Univariable and multivariable regression models were applied to identify predictors of symptoms and quality of life scores after adjusting for a subset of candidate predictors. A subgroup analysis was undertaken in patients with stable troponin concentrations (N=658).

Results

Based on the discharge diagnosis the patients were grouped as NSTEMI (14.2%), unstable angina pectoris (UAP) (16.9%), non-coronary cardiac disease (6.6%), non-cardiac disease (6.3%) and non-cardiac chest pain (NCCP) (56.0%). After three months the NSTEMI patients had the highest quality of life scores and the lowest prevalence of symptoms (angina and dyspnea), while the inverse was true for the UAP patients (Fig 1). Revascularized patients had a better quality of life compared to those treated conservatively (P&lt;0.001). Adjusted multivariable analysis also demonstrated that revascularization (β=0.19, P=0.002) and a diagnosis of UAP (β=−0.18, P=0.007) succeeded to predict angina frequency. Additionally, current smoking and hypertension were also associated with worse quality of life outcomes (Table 1). NCCP patients had high median prevalence of symptoms after three months, with 50% of the group reporting chest pain in the last four weeks, and 33% reporting dyspnea. In the subgroup analysis, current smoking predicted worse quality of life in all domains (all P&lt;0.05) except SAQ7-Angina frequency.

Conclusions

Three months after hospitalization for chest pain revascularized patients had better quality of life and less symptoms compared to other patient groups. A diagnosis of UAP predicted recurrent symptoms and impaired quality of life in patients, suggesting that closer monitoring should be considered in order to minimize re-hospitalization.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): The study is funded by grants from the Western Norway Regional Health Authority, Haukeland and Stavanger University hospitals. Figure 1Table 1

1527 A Rare Case of Facial Skin Necrosis Following Subdermal Poly-L-Lactic Acid Injection

Introduction

Non-surgical / minimally invasive aesthetic procedures are a growing trend in the UK. A range of devices are available for soft tissue augmentation, including injectable Poly-L-Lactic acid (PLLA). PLLA is used for soft tissue augmentation and is thought effective for the correction of contour deficiencies, facial wrinkles and in restoring subcutaneous volume in patients with HIV-associated lipoatrophy.

Method

In this case report, we present a rare but serious complication of subdermal injection of Poly-L-Lactic acid. A 45-year-old lady presented to our service approximately 24 hours after administration of self-sourced poly-L-Lactic acid.

Results

A 4cm ovaloid patch of full thickness skin necrosis over the zygomatic region was evident on presentation, with reactive/inflammatory changes in the adjacent skin. Vascular compromise is deemed the most likely cause, with loss of the transverse facial artery mapping to the area of necrosis. This patient was managed conservatively, with dressings and a prophylactic course of antibiotics.

Conclusions

Vascular compromise is a recognised and rare complication of subdermal injectable devices for facial soft tissue augmentation. The transverse facial artery branches from the superficial temporal artery within the substance of the parotid gland. Cadaveric and imaging studies alike demonstrate that the most common anatomical variant is a single TFA (70%), originating at the level of the temporofacial trunk of the facial nerve. It typically has a 5cm course, giving off on average 1.9 cutaneous perforators. This case highlights the importance of a detailed understanding of facial anatomy to ensure safe and effective placement of dermal fillers/devices.

Biodiversity of orb-web spiders (family: araneidae) of buner valley, Pakistan

The present research was carried out to explore the spider fauna of Buner valley with taxonomic study from February 2018 to January 2019. For this purpose samples were collected, four times at each month from 4 tehsils: Daggar, Gagra, Mandan and Totalai. Two methods were used, hand picking and sweep net for collection of samples. During day and night, three habitats, arid area, agriculture land and building area were search for collection. A total of 534 samples of spider were collected from four sampling sites, in which 379 were belonging to family Araniedae. After confirmation, the identified species were belonging to 8 genera (Neoscona, Argiope, Cyclosa, Araneus, Cyrtophora, Larinia, Erivoxia and Poltys) and 19 species. 18 of them were identified to specie level while a single specie to its generic level. The genus Neoscona was the dominant genus 26.31% having 5 species while the genus Argiope 21.05% is the second dominant having 4 species followed by Cyclosa 15.78% having 3 species followed by Cyrtophora and Araneus 10.52% having two species both. The Poltys and Larinia 5.26% are the rarest genera represent single-single specie both. Statistical analysis show that specie richness (D) = 5.77, Simpson index (1-D) = 0.87, Shannon index (H) = 2.33. Diversity of spiders was evenly distributed and calculated Evenness value was H/InS = 0.5408. There is also few atypical species and Fisher alpha estimate high value (Fisher α) = 4.42. Chao-1 estimated we have reported 22 species.

Systematic analysis of leisler's bat Nyctalus leisleri (Kuhl, 1817) captured from FATA region, Pakistan

Extensive field surveys were carried out to explore the distribution of Leisler's Bat Nyctalus leisleri (Kuhl, 1819) in selected area of FATA regions, Pakistan. Specimens of Leisler's Bat Nyctalus leisleri (Kuhl, 1819) (n5) were collected from Kurram Agency (Shublan) (N33.8229788 E70.1634414) at elevation 1427m and Khyber Agency (Landi Kotel) (N34.0909899 E71.1457517) at elevation 1091m for two years survey extending from May 2013 through August 2015. The mean head and body length, hind foot length, ear length and tail length the Nyctalus leisleri specimens captured from the study area was 65.08 ± 1.58 mm, 44.06 ± 0.52 mm, 8.38 ± 0.60 mm, 13.20 ± 0.99 mm and 39.46 ± 1.46 mm, respectively. For molecular analysis the sequences of COI gene were obtained and analyzed. The mean intraspecific divergences of Nyctalus leisleri was 0.04%. The mean interspecific divergences of Nyctalus noctula and Nyctalus leisleri was 0.2%. The mean concentration of each nucleotides was A = (26.3%), T = (32.8%), G = (15.9%) and C = (25.0%). The mean A+T contents were 59.2%and C+G were 40.9%. In the phylogenetic tree Nyctalus leisleri and Nyctalus noctula clustered with significant bootstrap support value.

Molecular detection of carbapenem resistance genes in rectal swabs from patients in Gulf Cooperation Council hospitals

BACKGROUND

Gram-negative organisms harbouring carbapenem resistance genes (CRGs) are spreading globally, including in Gulf Cooperation Council (GCC) countries. However, relatively few data are available about carriage of CRGs in hospitalized patients in this region.

AIM

To determine prevalence of CRG carriage and risk factors for colonization among patients in GCC hospitals.

METHODS

Rectal swabs were obtained from ∼50 intensive care unit (ICU) patients from each of 11 hospitals in five GCC countries between March and November 2019. The swabs were tested for the presence of bla_KPC, bla_NDM, bla_VIM, bla_IMP, and bla_OXA-48 CRG using a commercial polymerase chain reaction test. Data on risk factors for colonization were collected and analysed.

FINDINGS

Of 529 specimens screened, 138 (26.1%) were positive for one or more CRGs. The positivity rates among the hospitals ranged from 8.0% to 67.3%; ∼20% of the positive specimens harboured ≥2 CRGs. The most common CRG detected was bla_OXA-48, which was present in 82 specimens (15.5%). Additional CRGs included bla_NDM, bla_VIM, bla_KPC, and bla_IMP either alone or in combination. Overall, 31.1% of patients on antibiotics on admission to the ICU were positive for CRGs compared to 16.5% not on antibiotic therapy (P < 0.001). CRG detection was also more common among patients aged >65 years (P = 0.027) and increased with hospital length of stay (P = 0.025).

CONCLUSION

The rate of CRGs detected in hospitalized patients in GCC countries varied considerably. Prior antibiotic exposure, increasing age, and prolonged length of stay were associated with CRG detection.

Trend of bacterial meningitis in Bahrain from 1990 to 2013 and effect of introduction of new vaccines

Meningitis is among the 10 commonest infectious causes of death worldwide. This retrospective analysis of reported cases of meningitis in Bahrain aimed to assess the trend in the incidence of bacterial meningitis from 1990 to 2013, before and after the introduction of new vaccines. Of 1455 reported cases of meningitis during the study period 73.1% were viral and 26.9% were bacterial etiology (tuberculous meningitis 8.3%; Streptococcus pneumoniae 4.9%, Haemophilus influenzae 3.6% and Neisseria meningitidis 1.7%). There was a peak of meningitis cases in 1995-1996. The incidence of meningitis due to H. influenzae and N. meningitidis showed a marked reduction after the introduction of the corresponding vaccines in 1998 and 2001 respectively, and S. pneumoniae became the predominant organism after Mycobacterium tuberculosis. The changing trend in the etiology of bacterial meningitis points to the need to study vaccination programme modifications, such as pneumococcal vaccine for the adult population, especially high-risk groups.

Invasive candidiasis in Pakistan: clinical characteristics, species distribution and antifungal susceptibility

This study reports for the first time, to our knowledge, descriptive epidemiological data for 188 invasive Candida isolates from Pakistan, including species identification and antifungal susceptibility against fluconazole, itraconazole, voriconazole, caspofungin, micafungin, anidulafungin and amphotericin. Risk factors for invasive candidiasis (IC) were determined for 96 patients from Karachi, Pakistan. In adults and neonates, Candida tropicalis (38 and 36 %, respectively) was the most common species, followed in adults by Candida parapsilosis (17.8 %), Candida glabrata (15.9 %) and Candida albicans (12.3 %). C. albicans (21 %) was the second most common in neonates. In children, C. albicans (31.9 %), C. tropicalis (26.4 %) and C. parapsilosis (19.4 %) were the most common. C. albicans IC was significantly associated with paediatric age [crude odds ratio (COR) 3.46, 95 % confidence interval (CI) 1.63-7.32]. Rare species made up 17.5 % of the total isolates studied. Resistance to fluconazole was seen in C. glabrata (15 .0%) and Candida krusei (100 .0%). Only one isolate (C. glabrata) was resistant to all three echinocandins. Low MICs of fluconazole for 98 % (184/188) of isolates tested support its continued use as an empiric therapy for IC. Non-C. albicans IC was associated with the use of β-lactam inhibitor combinations (COR 3.16, 95 % CI 1.05-9.57). Use of healthcare devices was documented in 85.4 % of IC patients, whilst 75 .0% had been admitted to special care units. Surprisingly, 66.7 % of patients with IC were not obviously immunosuppressed. The high frequency of modifiable risk factors in this population indicates that candidaemia can be reduced with stringent antibiotic and infection control measures. These data will be useful for empiric selection of antifungals in Karachi, and contribute to global assessments of antifungal resistance.

Genetic analysis of NaCl tolerance in tomato

We attempted to find the suitable parents for the development of tomato hybrids for high salt soils by exploiting combining ability, gene action and heterosis. Six salt-tolerant and three salt-intolerant genotypes, along with their 18 F1 crosses, were evaluated at seedling stage under 10 and 15 dS/m (NaCl) salinity stress, compared to the control level of salinity. The experiment was laid out based on a two-way complete randomized design factorial arrangement with two replications; data on root and shoot length, fresh and dry weights, leaf area, plant length, Na(+), K(+) and K(+)/Na(+) concentrations were recorded. There was significant variation within genotypes, lines, testers, crosses, and line × tester interaction for all plant characters studied under normal and two salinity levels. Estimates of combining ability indicated that under low (10 dS/m) and high (15 dS/m) salinities, line BL1176 and tester LO2875 showed significant GCA effects for most of the traits studied. The cross-combinations 6233 × LO2875, CLN2498A x LO2875 and BL1176 × 17902 showed highest SCA values for most of the characters under 10 and 15 dS/m, respectively. Potence ratio showed that under low and high salinities, all the traits showed over dominant type of gene action except leaf area and K(+) concentration (in 10 dS/m) and shoot length, and leaf area (in 15 dS/m). The highest heterosis for most of the parameters was observed in cross-combinations BL1176 × LO2875 and CLN2498A x LO2875.

Genetic variability of NaCl tolerance in tomato

Cultivation of crops in soils with high salt (NaCl) content can affect plant development. We examined the morphological and physiological mechanisms of salt tolerance in tomato. The responses of 72 accessions of tomato (Solanum lycopersicum) to salinity were compared by measuring shoot and root lengths, and fresh shoot and root weights relative to those of controls (plants grown in normal salt levels). All traits were reduced at the seedling stage when salinity levels were increased. The accession x salinity interaction was significant for all traits. Root length had higher heritability than other traits and was used as a selection criterion to identify salt-tolerant and -non-tolerant accessions. On the basis of root length, accessions LA2661, CLN2498A, CLN1621L, BL1176, 6233, and 17870 were considered to be more tolerant than accessions 17902, LO2875 and LO4360. The degree of salt tolerance was checked by analyzing K+ and Na+ concentrations and K+/Na+ ratio in tissues of plants treated with 10 and 15 dS/m salinity levels. Tolerance of these accessions to salinity was most associated with low accumulation of Na+ and higher K+/Na+ ratios.

Applications of multi-nuclear magnetic resonance spectroscopy at 7T

AIM: To discuss the advantages of ultra-high field (7T) for ¹H and ¹³C magnetic resonance spectroscopy (MRS) studies of metabolism.

METHODS: Measurements of brain metabolites were made at both 3 and 7T using ¹H MRS. Measurements of glycogen and lipids in muscle were measured using ¹³C and ¹H MRS respectively.

RESULTS: In the brain, increased signal-to-noise ratio (SNR) and dispersion allows spectral separation of the amino-acids glutamate, glutamine and γ-aminobutyric acid (GABA), without the need for sophisticated editing sequences. Improved quantification of these metabolites is demonstrated at 7T relative to 3T. SNR was 36% higher, and measurement repeatability (% coefficients of variation) was 4%, 10% and 10% at 7T, vs 8%, 29% and 21% at 3T for glutamate, glutamine and GABA respectively. Measurements at 7T were used to compare metabolite levels in the anterior cingulate cortex (ACC) and insula. Creatine and glutamate levels were found to be significantly higher in the insula compared to the ACC (P < 0.05). In muscle, the increased SNR and spectral resolution at 7T enables interleaved studies of glycogen (¹³C) and intra-myocellular lipid (IMCL) and extra-myocellular lipid (EMCL) (¹H) following exercise and re-feeding. Glycogen levels were significantly decreased following exercise (-28% at 50% VO₂ max; -58% at 75% VO₂ max). Interestingly, levels of glycogen in the hamstrings followed those in the quadriceps, despite reduce exercise loading. No changes in IMCL and EMCL were found in the study.

CONCLUSION: The demonstrated improvements in brain and muscle MRS measurements at 7T will increase the potential for use in investigating human metabolism and changes due to pathologies.

Regional grey matter volumetric changes in forensic schizophrenia patients: an MRI study comparing the brain structure of patients who have seriously and violently offended with that of patients who have not

BACKGROUND

The aim was to carry out the first voxel-based morphometry study of grey matter changes in the whole brain in schizophrenia associated with a history of seriously and violently offending.

METHODS

Structural cerebral magnetic resonance imaging scans of 26 patients with schizophrenia were analyzed using voxel-based morphometry: 13 of the patients had seriously and violently offended directly as a result of schizophrenia prior to admission, the offences consisting of homicide, attempted murder or wounding with intent to cause grievous bodily harm; the other 13 patients did not have a history of violence. There was no history of comorbid psychoactive substance misuse disorder in any of the patients. Voxelwise generalized linear modelling was applied to the processed magnetic resonance data using permutation-based non-parametric testing, forming clusters at t > 2.3 and testing clusters for significance at p < 0.05, corrected for multiple comparisons across space.

RESULTS

The two groups of patients were matched with respect to age, gender and duration of illness, but the group with a history of serious violence was on average receiving a higher dose of antipsychotic medication than the group without a history of violence. There were local regions of reduced grey matter volume in the schizophrenia patient group with a history of serious and violent offending, compared with the schizophrenia patient group without such a history. Significant voxels (p < 0.05, corrected for multiple comparisons) were noted bilaterally in the cerebellum and in BA 39 and 40.

CONCLUSION

These regions are important in verbal working memory. The cerebellum may integrate inputs from ventrolateral prefrontal cortex and parietal regions, providing a corrective signal that refines the process of rehearing the contents of the phonological store. A strong connection has been hypothesized between the supramarginal region corresponding to BA 39/40 and Broca's area, which may correspond largely to the arcuate fasciculus, with the connectional pattern of the language regions of this model fitting the network of parietotemporal-prefrontal connections that participate in working memory. Therefore our results point to the possibility of an abnormality in neural circuits involved in verbal working memory in this group of patients.

Automatic quantification of changes in bone in serial MR images of joints

Recent innovations in drug therapies have made it highly desirable to obtain sensitive biomarkers of disease progression that can be used to quantify the performance of candidate disease modifying drugs. In order to measure potential image-based biomarkers of disease progression in an experimental model of rheumatoid arthritis (RA), we present two different methods to automatically quantify changes in a bone in in-vivo serial magnetic resonance (MR) images from the model. Both methods are based on rigid and nonrigid image registration to perform the analysis. The first method uses segmentation propagation to delineate a bone from the serial MR images giving a global measure of temporal changes in bone volume. The second method uses rigid body registration to determine intensity change within a bone, and then maps these into a reference coordinate system using nonrigid registration. This gives a local measure of temporal changes in bone lesion volume. We detected significant temporal changes in local bone lesion volume in five out of eight identified candidate bone lesion regions, and significant difference in local bone lesion volume between male and female subjects in three out of eight candidate bone lesion regions. But the global bone volume was found to be fluctuating over time. Finally, we compare our findings with histology of the subjects and the manual segmentation of bone lesions.

Abnormal cortical development after premature birth shown by altered allometric scaling of brain growth

BACKGROUND

We postulated that during ontogenesis cortical surface area and cerebral volume are related by a scaling law whose exponent gives a quantitative measure of cortical development. We used this approach to investigate the hypothesis that premature termination of the intrauterine environment by preterm birth reduces cortical development in a dose-dependent manner, providing a neural substrate for functional impairment.

METHODS AND FINDINGS

We analyzed 274 magnetic resonance images that recorded brain growth from 23 to 48 wk of gestation in 113 extremely preterm infants born at 22 to 29 wk of gestation, 63 of whom underwent neurodevelopmental assessment at a median age of 2 y. Cortical surface area was related to cerebral volume by a scaling law with an exponent of 1.29 (95% confidence interval, 1.25-1.33), which was proportional to later neurodevelopmental impairment. Increasing prematurity and male gender were associated with a lower scaling exponent (p < 0.0001) independent of intrauterine or postnatal somatic growth.

CONCLUSIONS

Human brain growth obeys an allometric scaling relation that is disrupted by preterm birth in a dose-dependent, sexually dimorphic fashion that directly parallels the incidence of neurodevelopmental impairments in preterm infants. This result focuses attention on brain growth and cortical development during the weeks following preterm delivery as a neural substrate for neurodevelopmental impairment after premature delivery.

Schizophrenia syndromes associated with changes in ventricle-to-brain ratios: a serial high-resolution three-dimensional magnetic resonance imaging study in first-episode schizophrenia patients using subvoxel registration and semiautomated quantification

A cohort of patients with first-episode schizophrenia was dichotomised into two age- and sex-matched groups of clinical syndromes, the active and withdrawn, and underwent high-resolution three-dimensional magnetic resonance imaging at baseline and 8 months later. A cohort of age- and sex-matched normal controls was also imaged at the same time intervals. The application of subvoxel registration and semiautomated quantification techniques demonstrated a significantly different outcome in ventricular changes between the two groups of patients. Compared with the controls, the withdrawn patients showed progressive ventricular enlargement, with an increase in ventricle-to-brain volume ratio, whereas the active group showed a reduction in ventricle-to-brain volume ratio, with a change opposite in sign and smaller in magnitude. These findings lend further support for the aetiological validity of this syndromal model of schizophrenia and are likely to be of importance in furthering our understanding of its pathogenesis and in the development of suitable therapeutic strategies.

MR imaging quantification of cerebellar growth following hypoxic-ischemic injury to the neonatal brain

BACKGROUND AND PURPOSE

Cerebellar atrophy may occur as a result of a primary injury, such as infarction or hemorrhage. Impaired growth of a non-injured cerebellum may be seen as a secondary effect related to damage in other remote but connected areas of the brain, or so-called diaschisis. We sought to determine whether perinatal hypoxic-ischemic injury leads to poor cerebellar growth and whether such impairment occurs asymmetrically in infants with predominantly unilateral brain injury.

METHODS

We used a computerized quantification program to measure cerebellar size by using serial MR images. Term-born infants presenting with encephalopathy and/or seizures presumed due to a hypoxic-ischemic insult within 48 hours of delivery were included if they had two or more volume acquisition images obtained at least 3 months apart but within the first 15 months of delivery.

RESULTS

When data were grouped by MR appearances, significant differences in total cerebellum growth were seen between infants with focal infarction and those with basal ganglia and thalamic injury (P <.001). Unilateral forebrain lesions shown on MR imaging were not predictive of asymmetric cerebellar growth.

CONCLUSION

Infants with focal infarction of the cerebral hemisphere had an apparently normal pattern of growth in both cerebellar hemispheres. However, in infants with severe basal ganglia and thalamic lesions, cerebellar growth was reduced, and the vermis showed little or no growth during the first year after birth.

Rapid reversal of hepatic steatosis, and reduction of muscle triglyceride, by rosiglitazone: MRI/S studies in Zucker fatty rats

AIM

This study aimed to chart the time course and durability of the effects of rosiglitazone, a potent thiazolidinedione-based peroxisome proliferator-activated receptor gamma agonist, on hepatic steatosis and intramyocellular lipid in an animal model of obesity, the Zucker Fatty (ZF) rat.

METHODS AND RESULTS

Rosiglitazone (3 mg/kg/day p.o.) significantly reduced both liver fat content (by 59%; p < 0.05) and size (11.5%; p < 0.05) in male ZF rats that received between 3 days and 1 week of treatment, and these reductions were maintained for at least 12 weeks. Liver fat content measured by magnetic resonance spectroscopy (MRS) correlated closely and positively with plasma insulin levels (reduced by 89% within a week, r = 0.8) and with postmortem histological fat fractional volume (r = 0.89). Similarly, liver volume measured by magnetic resonance imaging (MRI) correlated closely with postmortem wet weight (r = 0.99). MRS also showed, and numbers of lipid vacuoles counted in transmission electron micrographs confirmed, that rosiglitazone significantly reduced the elevated intramyocellular lipid seen in ZF rat skeletal muscle by at least 40% (p < 0.05).

CONCLUSIONS

Localized MRS and MRI showed that rosiglitazone reversed the hepatic steatosis, hepatomegaly and intramyocellular lipid, characteristic of the ZF rat, an animal model of obesity.

Subvoxel image registration of multislice (2D) magnetic resonance images in patients with high-grade gliomas of the brain

AIMS

To implement a multislice two-dimensional (2D) T2-weighted sequence suitable for subvoxel image registration and to assess its usefulness in detecting change in high-grade intracranial gliomas.

MATERIALS AND METHODS

Twenty patients with high-grade gliomas were studied on two or more occasions. T2-weighted multislice pulse sequences with a Gaussian slice profile, 50% overlapping slices and nearly isotropic voxels were acquired. The images were registered and subtraction images were produced. The images were compared with three-dimensional (3D) T1-weighted registered images and conventional unregistered T2-weighted images. All images were scored for changes in the lesions and ventricular system.

RESULTS

The 2D and 3D registered subtraction images were the most sensitive for detecting changes in both the lesions and other regions in the brain. The mean rank scores were significantly higher for the lesions (chi2=86.742; df=5, n=38, P<0.0001) and for the ventricles (chi2=63.837; df=5, n=35, P<0.0001) compared with the unregistered and registered anatomical images. The subtraction images were also most sensitive for detecting signal intensity changes irrespective of the direction of change.

CONCLUSION

Rigid body subvoxel registration can be successfully performed with both multislice 2D and 3D imaging. In principle, virtually all forms of clinical MR images of the brain can be accurately registered and subtracted.

Bispectral index-guided management of anaesthesia in permanent vegetative state

A patient in a permanent vegetative state required general anaesthesia for dental surgery. Because of the uncertainties involved in the appropriate monitoring and assessment of the conscious level of patients in a permanent vegetative state, it was decided to use the bispectral index to help guide the anaesthetic depth during surgery. We found that the bispectral index profile during anaesthesia and surgery was similar to that of a normal subject. The findings raise the possibility that patients in permanent vegetative states might sense noxious stimuli at a cortical level.

Changes in brain size with treatment in patients with hyper- or hypothyroidism

BACKGROUND AND PURPOSE

Although neuropsychological symptoms and signs are common in thyroid disease, their organic substrate is unknown. We performed brain MR imaging in patients with hyperthyroidism or hypothyroidism before and after treatment and correlated the results with hormonal markers.

METHODS

Eight patients with hyperthyroid disease and three with hypothyroid disease underwent imaging within 1-2 days of a thyroid hormone testing. Images were registered, and brain and ventricular sizes were measured by using a semiautomated contour and thresholding technique. Changes in brain and ventricular volume were correlated with serum levels of total thyroxine (T(4)), unbound triiodothyronine (free T(3)), and thyroid-stimulating hormone (TSH) before and after treatment.

RESULTS

With treatment, brain size decreased by 6,329-31,183 mm(3) in the hyperthyroid group and increased by 2,599-48,825 mm(3) in the hypothyroid group. Conversely, with treatment, ventricular size increased by 325-6,279 mm(3) in the hyperthyroid group and decreased by 760-2,376 mm(3) in the hypothyroid group. There was a highly significant correlation between reduction in brain size and reduction in T(4), as well as between the increase in ventricular size and reduction in T(4). There was a significant correlation between reduction in ventricular size and reduction in free T(3). There were highly significant correlations between reduced levels of TSH and increase in brain size, as well as between increased levels of TSH and increase in ventricular size.

CONCLUSION

In thyroid disease, the size of the brain and ventricles significantly change after treatment, and these changes are correlated with T(4), free T(3), and TSH levels. The mechanism of these changes is uncertain, but it may involve osmolyte regulation, the sodium and water balance, and alterations in cerebral hemodynamics.

Magnetic resonance imaging in preeclampsia and eclampsia complicated by visual disturbance and other neurological abnormalities

This study describes magnetic resonance imaging findings in women presenting with neurological complications associated with preeclampsia and eclampsia. One eclamptic and two preeclamptic women were studied after presenting with postpartum neurological events. In two women the brain increased in size on the initial follow-up images, following the same pattern seen in normal pregnancy. In the other woman, the brain was decreased in size at 13 days postpartum but increased in size at six weeks postpartum. This initial reduction in brain size may reflect the resolution of cerebral oedema resulting from underlying pathological processes.

Reconstruction of the temporomandibular joint autogenous compared with alloplastic

The aims of and indications for temporomandibular joint (TMJ) reconstruction are well-established but the method of reconstruction is controversial. We describe a retrospective, two-centre audit of 49 patients treated with costochondral grafting and 50 patients treated with alloplastic joints. The characteristics of the patients were similar in both centres and the minimum follow-up period was 2 years. For each patient a number of variables were recorded including both subjective scores (pain and interference with eating) and objective data (interincisal distance). Patients in both groups showed an improvement in symptoms but more patients required reoperation in the autogenous group.

Cerebellum segmentation employing texture properties and knowledge based image processing: applied to normal adult controls and patients

A semi-automated method is described for segmenting the cerebellum from T(1)-weighted 3-dimensional magnetic resonance imaging scans of adult controls and patients. The method relies on prior knowledge involving a user-defined template as a guide to aid the segmentation of the cerebellum. As the gray and white matter intensity distribution in the cerebellum has a complex pattern, texture information that identified the "graininess" was employed to capture the intensity distribution of voxels. The textural information was used to group voxels in a small circular structuring element as belonging to the cerebellum region. The cerebella from scans of 15 of the 20 subjects were segmented both manually and using the semi-automated procedure; the results were strongly correlated (r = 0.985, n = 15, p < 0.0001), and the volumes obtained from the two methods differed by 2.3%. The cerebellar volumes in 10 normal subjects and 10 age- and sex-matched patients with a neuropsychiatric disorder (schizophrenia) did not differ significantly (p = 0.18). The whole cerebellum was segmented in approximately 30 min using the semi-automated procedure. The method described is robust, easy-to-use, fairly fast and gives objective measurements.

Change in brain size during and after pregnancy: study in healthy women and women with preeclampsia

BACKGROUND AND PURPOSE

Qualitative decreases in maternal brain size have been observed late in pregnancy. The aim of this study was to quantitatively evaluate changes to the maternal brain during and after healthy pregnancy and to compare these changes with those observed in cases of preeclampsia.

METHODS

Three-dimensional T1-weighted MR volume images were obtained in nine healthy participants before and after delivery. Additional images were obtained in some of these participants before pregnancy, during pregnancy, and within 52 weeks after delivery. Five women with preeclampsia were examined before delivery and 6 weeks after delivery. Three of these patients were examined within 52 weeks after delivery. Images were registered, and both brain and ventricular volumes were calculated by using a semiautomated computer program.

RESULTS

Both the healthy and preeclamptic groups had a reduction in brain size during pregnancy that was maximal at term and that reversed by 6 months after delivery. The ventricular size showed a corresponding increase in size during pregnancy and a decrease in size after delivery. In the preeclamptic patients, brain size was significantly smaller (P =.05) than in healthy participants, both before and after delivery.

CONCLUSION

The brain decreases in size during pregnancy and increases in size after delivery. The changes follow a consistent time course in each woman. The mechanism and physiologic importance of these findings are speculative at the present time.

Visceral adipose tissue and metabolic complications of obesity are reduced in Prader-Willi syndrome female adults: evidence for novel influences on body fat distribution

Visceral obesity is detrimental to health, but the mechanisms controlling body fat distribution are not fully understood. In premenopausal adult females (30 nonobese, 14 obese [body mass index >30 kg/m(2)]), variance in fasting insulin, glucose, insulin/glucose ratio, C-peptide/insulin ratio, triglycerides, and high-density lipoprotein/low-density lipoprotein-cholesterol ratio, were independently influenced by visceral but not total sc or abdominal sc adipose tissue, as measured by whole-body magnetic resonance imaging. Adult females with Prader-Willi syndrome (n = 13) had significantly reduced visceral adiposity, compared with obese controls (visceral/total sc adipose tissue ratio: 0.067 +/- 0.017 vs. 0.108 +/- 0.021), independent of their total adiposity (P < 0.001), or use of exogenous sex steroids. This is in contrast to that expected by their physical inactivity, hypogonadism, adult GH deficiency, and psychiatric problems. Females with Prader-Willi syndrome not receiving sex steroids (n = 8) had significantly reduced fasting insulin, insulin/glucose ratio, and triglycerides and increased C-peptide/insulin ratio, compared with obese controls, adjusting for total (P < 0.05) but not visceral adiposity (P = 0.3-0.6), supporting their association. The cause of the reduced visceral adiposity in Prader-Willi syndrome may reflect novel hormonal, hypothalamic, and/or genetic influences on body fat distribution.

A serial longitudinal quantitative MRI study of cerebral changes in first-episode schizophrenia using image segmentation and subvoxel registration

Lateral ventricular enlargement is the most consistently replicated brain abnormality found in schizophrenia. This article reports a first episode, longitudinal study of ventricular volume using high-resolution serial magnetic resonance imaging (MRI) and recently developed techniques for image registration and quantitation. Baseline and follow-up (on average 8 months later) MRI scans were carried out on 24 patients and 12 controls. Accurate subvoxel registration was performed and subtraction images were produced to reveal areas of regional brain change. Whereas there were no differences between patients and controls with respect to the mean change in ventricular volume, the patients were much more variable in this respect and showed larger increases and decreases. The percentage increase in ventricular size was greater than one standard deviation of control values for 14 patients and the percentage decrease exceeded one standard deviation in eight patients. Although the finding of progressive ventricular enlargement in a proportion of patients supports other studies indicating an ongoing neuropathological process in the early stages of schizophrenia, the reduction of ventricular size in the remaining patients is more difficult to explain. It is suggested that this may reflect improvement in nutrition and hydration following treatment.

In vivo evaluation of the effects of continuous exercise on skeletal muscle triglycerides in trained humans

Magnetic resonance spectroscopy (1H MRS) and imaging (MRI) were used to investigate the effects of a bout of moderate prolonged exercise on intra (IMCL)- and extramyocellular lipid (EMCL) utilization in the soleus, tibialis anterior, and gastrocnemius muscles of five trained human subjects. MRI and 1H MRS measurements were obtained before and after a 90 min run on a calibrated treadmill at a velocity corresponding to 64 +/- 1.5% of each subjects' maximal rate of oxygen consumption. There were significant decreases in IMCL following exercise in the tibialis (pre: 22.37 +/- 4.33 vs. post: 15.16 +/- 3.25 mmol/kg dry wt; P < 0.01) and soleus (pre: 36.93 +/- 1.45 vs. post: 29.85 +/- 2.44 mmol/kg dry wt; P < 0.01) muscles. There was also a decrease in the gastrocnemius muscle, although this did not reach the level of significance (pre: 33.78 +/- 5.35 vs. post: 28.48 +/- 5.44 mmol/kg dry weight; P < 0.10). No significant changes were observed in EMCL or subcutaneous fat. In conclusion, this study showed that IMCL were significantly utilized in the tibialis and soleus muscles of aerobically endurance-trained humans. The absence of significant utilization of IMCL in the gastrocnemius may reflect differences in fiber type and/or intensity of contraction for each muscle group.

Reduced development of cerebral cortex in extremely preterm infants

Most growth in cortical connections and complexity occurs after 25 weeks. The cerebral cortex of extremely preterm infants when imaged at gestational age 38-42 weeks had less cortical surface area and was less complex than in normal infants born around term (p<0.0148 and p<0.0002, respectively), despite similar term-corrected cerebral tissue volumes. Since deficits acquired during critical periods of brain development may be permanent, these results suggest a neural substrate for the neurocognitive impairment that is frequent among such preterm infants.

Preferential loss of visceral fat following aerobic exercise, measured by magnetic resonance imaging

The aim of this study was to use whole-body magnetic resonance imaging (MRI) together with biochemical and anthropometric measurements to study the influence of regular moderate exercise with no dietary intervention on adipose tissue distribution in nonobese healthy women. We found significant decreases in both total (28.86+/-2.24 vs. 27.00+/-2.27 liters, P < 0.05) and regional fat depots (visceral fat: 1.68+/-0.21 vs. 1.26+/-0.18 liters, P < 0.01) using whole-body MRI despite no significant change in body weight, body mass index, or the waist-to-hip ratio. Interestingly, no changes in body fat content were found using anthropometry or impedance. There was a significant increase in high density lipoprotein cholesterol (1.58+/-0.06 vs. 1.66+/-0.08 mmol/L P < 0.02) following exercise although there were no changes in other blood lipids such as triglycerides. In summary, moderate aerobic exercise over a period of 6 mon resulted in a preferential loss in visceral fat in nonobese healthy women, and this may help to explain some of the health benefits associated with regular and moderate physical activity.

Eicosapentaenoic acid treatment in schizophrenia associated with symptom remission, normalisation of blood fatty acids, reduced neuronal membrane phospholipid turnover and structural brain changes

The administration of the omega-3 fatty acid eicosapentaenoic acid (EPA) to a drug-naive patient with schizophrenia, untreated with conventional antipsychotic medication, led to a dramatic and sustained clinical improvement in both positive and negative symptoms. This was accompanied by a correction in erythrocyte membranes of abnormalities in both n-3 and n-6 highly unsaturated fatty acids and with reduced neuronal membrane phospholipid turnover, as evidenced by serial 31-phosphorus cerebral magnetic resonance spectroscopy. Using recently developed techniques of image segmentation, subvoxel registration and quantitation, analysis of serial high-resolution 3D cerebral MRI scans showed that, in the year before EPA treatment, cerebral atrophy was taking place and that this atrophy was reversed by six months of EPA treatment. These results demonstrate that EPA can reverse both the phospholipid abnormalities previously described in schizophrenia and cerebral atrophy. They provide strong further evidence in support of the membrane phospholipid model of schizophrenia.

Cerebral ventricular asymmetry in schizophrenia: a high resolution 3D magnetic resonance imaging study

Lateral ventricular volume asymmetries in schizophrenia were studied using high resolution 3D magnetic resonance imaging in conjunction with segmentation and quantitation techniques. Comparisons were made between two clinical syndromes that have been associated with opposite patterns of functional hemispheric activation, namely an active and a withdrawn syndrome. Ratios of both left to right ventricular volume and left to right ventricle-to-brain ratios differed significantly between the two groups. These results primarily reflected differences in the left ventricular volume, in keeping with previous reports which have usually implicated left hemispheric structural abnormalities in schizophrenia. It is suggested that a syndromal approach might help to resolve some of the inconsistencies in the existing literature on lateralised neuroanatomical differences in schizophrenia.

Angiotensin-converting-enzyme gene insertion/deletion polymorphism and response to physical training

BACKGROUND

The function of local renin-angiotensin systems in skeletal muscle and adipose tissue remains largely unknown. A polymorphism of the human angiotensin converting enzyme (ACE) gene has been identified in which the insertion (I) rather than deletion (D) allele is associated with lower ACE activity in body tissues and increased response to some aspects of physical training. We studied the association between the ACE gene insertion or deletion polymorphism and changes in body composition related to an intensive exercise programme, to investigate the metabolic effects of local human renin-angiotensin systems.

METHODS

We used three independent methods (bioimpedance, multiple skinfold-thickness assessment of whole-body composition, magnetic resonance imaging of the mid-thigh) to study changes in body composition in young male army recruits over 10 weeks of intensive physical training.

FINDINGS

Participants with the II genotype had a greater anabolic response than those with one or more D alleles for fat mass (0.55 vs -0.20 kg, p=0.04 by bioimpedance) and non-fat mass (1.31 vs -0.15 kg, p=0.01 by bioimpedance). Changes in body morphology with training measured by the other methods were also dependent on genotype.

INTERPRETATION

II genotype, as a marker of low ACE activity in body tissues, may conserve a positive energy balance during rigorous training, which suggests enhanced metabolic efficiency. This finding may explain some of the survival and functional benefits of therapy with ACE inhibitors.

Volumetric change of the lateral ventricles in the human brain following glucose loading

Lateral ventricular volumes were monitored and quantified using accurately registered magnetic resonance images (MRIs) in six healthy individuals 30 min before and up to 4 h after ingestion of a glucose drink. The volume of the lateral ventricles increased by an average (+/- S.E.M.) of 2.4 +/- 0.4% as blood glucose levels rose from 4.8 +/- 0.2 mmol l-1 to 8.4 +/- 0.4 mmol l-1. This was followed by a peak decrease of 5.99 +/- 3.3% below initial fasting volumes as blood glucose levels fell to 5.0 +/- 0.3 mmol l-1. We suggest that the secondary volume decrease demonstrates a homeostatic process of brain volume regulation for which the mechanism remains uncertain.

Two methods for semi-automated quantification of changes in ventricular volume and their use in schizophrenia

Two semi-automated methods for quantification of ventricular volume change from baseline and follow-up magnetic resonance imaging scans have been developed. Technique 1 employs direct segmentation of the ventricles from both the scans using thresholding and contour extraction. Technique 2 operates on difference images produced by voxel based intensity subtraction of the baseline from the registered follow-up images. Here, all voxels with intensities above a noise threshold and in a restricted area are monitored to compute volumetric changes. In phantom measurements the first technique was accurate to 0.0046%, the second to 0.167% of the phantom volume. Results from normal volunteers was that the average ventricular volume changed by 1.52% and 1.54% for images acquired within 9 months using techniques 1 and 2, respectively. With schizophrenic patients mean change of 10.78% and 9.43% were found employing the first and second procedures, respectively. All measurements agreed with a radiologist's visual grading of the changes. Robust, objective, fast, easy-to-use, and fairly accurate procedures have been developed and validated to quantify volumetric changes.