T-independent responses to polysaccharides in humans mobilize marginal zone B cells prediversified against gut bacterial antigens

Marginal zone (MZ) B cells are one of the main actors of T-independent (TI) responses in mice. To identify the B cell subset(s) involved in such responses in humans, we vaccinated healthy individuals with Pneumovax, a model TI vaccine. By high-throughput repertoire sequencing of plasma cells (PCs) isolated 7 days after vaccination and of different B cell subpopulations before and after vaccination, we show that the PC response mobilizes large clones systematically, including an immunoglobulin M component, whose diversification and amplification predated the pneumococcal vaccination. These clones could be mainly traced back to MZ B cells, together with clonally related IgA+ and, to a lesser extent, IgG+CD27+ B cells. Recombinant monoclonal antibodies isolated from large PC clones recognized a wide array of bacterial species from the gut flora, indicating that TI responses in humans largely mobilize MZ and switched B cells that most likely prediversified during mucosal immune responses against bacterial antigens and acquired pneumococcal cross-reactivity through somatic hypermutation.

Observations of a Solar Energetic Particle Event From Inside and Outside the Coma of Comet 67P

We analyze observations of a solar energetic particle (SEP) event at Rosetta's target comet 67P/Churyumov-Gerasimenko during 6-10 March 2015. The comet was 2.15 AU from the Sun, with the Rosetta spacecraft approximately 70 km from the nucleus placing it deep inside the comet's coma and allowing us to study its response. The Eastern flank of an interplanetary coronal mass ejection (ICME) also encountered Rosetta on 6 and 7 March. Rosetta Plasma Consortium data indicate increases in ionization rates, and cometary water group pickup ions exceeding 1 keV. Increased charge exchange reactions between solar wind ions and cometary neutrals also indicate increased upstream neutral populations consistent with enhanced SEP induced surface activity. In addition, the most intense parts of the event coincide with observations interpreted as an infant cometary bow shock, indicating that the SEPs may have enhanced the formation and/or intensified the observations. These solar transient events may also have pushed the cometopause closer to the nucleus. We track and discuss characteristics of the SEP event using remote observations by SOHO, WIND, and GOES at the Sun, in situ measurements at Solar Terrestrial Relations Observatory Ahead, Mars and Rosetta, and ENLIL modeling. Based on its relatively prolonged duration, gradual and anisotropic nature, and broad angular spread in the heliosphere, we determine the main particle acceleration source to be a distant ICME which emerged from the Sun on 6 March 2015 and was detected locally in the Martian ionosphere but was never encountered by 67P directly. The ICME's shock produced SEPs for several days which traveled to the in situ observation sites via magnetic field line connections.

Human anti-smallpox long-lived memory B cells are defined by dynamic interactions in the splenic niche and long-lasting germinal center imprinting

Memory B cells (MBCs) can persist for a lifetime, but the mechanisms that allow their long-term survival remain poorly understood. Here, we isolated and analyzed human splenic smallpox/vaccinia protein B5-specific MBCs in individuals who were vaccinated more than 40 years ago. Only a handful of clones persisted over such an extended period, and they displayed limited intra-clonal diversity with signs of extensive affinity-based selection. These long-lived MBCs appeared enriched in a CD21hiCD20hi IgG+ splenic B cell subset displaying a marginal-zone-like NOTCH/MYC-driven signature, but they did not harbor a unique longevity-associated transcriptional or metabolic profile. Finally, the telomeres of B5-specific, long-lived MBCs were longer than those in patient-paired naive B cells in all the samples analyzed. Overall, these results imply that separate mechanisms such as early telomere elongation, affinity selection during the contraction phase, and access to a specific niche contribute to ensuring the functional longevity of MBCs.

[Mother's experience of planned caesarean section in the absence of the father or companion: Impact of Covid-19 pandemic-related lockdown]

BACKGROUND

The presence of the father or companion during planned caesarean section presents several benefits. However, we found no study regarding the mother's experience of his presence or absence.

MATERIAL AND METHODS

We conducted an observational, prospective, two-centre study based on the data of women who had a planned caesarean section in Bel Air and Mercy Maternities between November 17th 2020 and June 4th 2021. Two groups were formed : a control group, including women who had a c-section in the presence of the father or companion, and a case group, including women who had a c-section without the father or companion due to Covid-19 pandemic-related containment measures. The primary endpoint was to assess the mother's anxiety regarding the presence or absence of the father or companion during planned c-section, by the use of a numerical scale of stress and STAI YA inventory. The secondary endpoint was the appraisal of information given by the medical team concerning c-section and the containment measures.

RESULTS

Regarding the level of stress during the c-section, we did not find a significant difference by the use of the numerical scale of stress. With a mean of 53 in the case group and 49 in the focus group (P=0,048), the STAI YA scores showed a significant difference. Between the day before and the day of the c-section, we found no significant difference by the use of the numerical scale of stress. STAI YA scores showed a significant difference, with a delta of 5 in the case group against 1 in the focus group (P=0,01). Most patients estimated that the information given by the medical team helped to reduce their stress. 93 % of the patients in the focus group reckoned they would have been more stressed in the absence of the father or companion.

DISCUSSION AND CONCLUSION

The significant results of this study suggest the absence of the father or companion during planned caesarean section has an impact on mother's experience. Therefore, this should be considered in order to better our practices and improve mother's experience. In the long term, we could imagine making their presence possible during emergency caesarean sections as well (general anesthesia excluded). We could also envision adding to preparation courses to c-section to birth preparation courses, for mothers (to reduce psychological impact) but also for fathers or companions (to allow their presence in the operation room).

Increased 18F-fluorodeoxyglucose uptake in the cardiac atria: an evidence for increased atrial inflammation in patients with atrial fibrillation?

Funding Acknowledgements

Type of funding sources: None.

Background

Atrial inflammation and fibrotic remodelling underlie the pathophysiology of atrial cardiomyopathy, which is associated with the development of atrial fibrillation (AF) and atrial flutter (AFL). 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG-PET/CT) has been used to detect inflammatory processes. Recent studies have revealed an increased FDG-uptake in the atria of patients with AF, but also in patients with diagnosis of cardiac sarcoidosis with ventricular inflammation.

Purpose

This study aimed to assess the capability of PET/CT to detect and quantify the degree of atrial inflammation (FDG-uptake) in a population with dedicated cardiac FDG-PET/CT.

Methods

We investigated 101 patients suspected of sarcoidosis (57±12 years, 72% male) who underwent 18F-FDG PET/CT scan with dedicated cardiac specific preparation (heparin infusion, 12 hours fasting, and high-fat low-carbohydrate diet). We excluded patients with active ventricular cardiac sarcoidosis or undergoing high-dose immunosuppressive therapy (prednisolone ≥20mg/day or prednisolone combined with other immunotherapy like methotrexate). We measured the maximum standardized uptake value (SUVmax) in atrial myocardium and mean standardized uptake value (SUVmean) in blood pool and calculated the target-to-background ratio (TBR) of SUVmax in atrial myocardium to SUVmean in blood pool. All medical records, ECG data on arrhythmia type and diagnosis of systemic sarcoidosis (with absence of ventricular involvement) were used for the analysis. Sarcoidosis was diagnosed based on the criteria established in 2006 by the Japanese Ministry of Health and Welfare. The collected data were sorted according to presence of arrhythmia and systemic sarcoidosis and TBR of each group were compared.

Results

AF or AFL was found in 30/101 patients. Systemic sarcoidosis was found in 37/101 patients. Patients with known AF/AFL had significantly increased TBR within the atrial tissue compared to those without AF/AFL: (median: 1.26, 1st-3rd quartile: 1.20-1.33) versus (median: 1.22, 1st-3rd quartile: 1.14-1.25; p = 0.004; figure A). Arrhythmia-associated atrial inflammation was consistently observed, independently of presence of concomitant systemic sarcoidosis (figure B). Patients with both atrial arrhythmias and systemic sarcoidosis had the highest atrial inflammation level, as identified by TBR (figure B).

Conclusion

Development of atrial fibrillation or flutter is associated with an increased atrial FDG-uptake as metabolic marker of atrial inflammation. The level of atrial inflammation is further enhanced by additional presence of systemic sarcoidosis.

Risk factors for keratoconus progression after treatment by accelerated cross-linking (A-CXL): A prospective 24-month study

PURPOSE

Identification of potential predictive factors for keratoconus progression after treatment by accelerated Cross-linking (A-CXL) SECONDARY OBJECTIVES: Evaluation of clinical and topographic outcomes for two years following accelerated cross-linking treatment for progressive keratoconus including: best spectacle corrected visual acuity (BSCVA), thinnest pachymetry, maximum keratometry (Kmax), cylinder.

STUDY

Prospective, interventional, monocentric study. SITE: Metz-Thionville Regional Medical Center, Lorraine University, Mercy Hospital, Metz, France.

PATIENTS AND METHODS

We included 82 eyes of 60 patients between March 2014 and June 2016 who underwent accelerated corneal cross-linking (A-CXL) with epithelial debridement for progressive keratoconus, with a minimum follow-up of 2 years. A complete clinical evaluation and corneal topography were performed before cross-linking, and subsequently at 6, 12 and 24 months post-procedure. The following parameters were monitored during follow-up: best spectacle corrected visual acuity (BSCVA), minimal pachymetry, maximum keratometry (Kmax), mean anterior and posterior curvatures, maximum posterior curvature, presence of optical aberrations, subdivided into spherical aberration, coma, astigmatism, higher order optical aberrations and residual optical aberrations. After a 2-year follow-up, two groups, defined as "responders" and "non-responders" to treatment, were separated for analysis, and their initial characteristics were compared.

RESULTS

Data for 82 eyes of 60 patients with progressive keratoconus with a mean age of 24±7 years were studied. Fourteen eyes (17.1%) showed signs of progression after treatment by A-CXL (non-responders), and 68 eyes (82.9%) showed stabilization of the disease (responders). Characteristics of non-responding eyes after A-CXL included a younger mean age (20±5 vs. 25±7 years) (P=0.04) and a lower initial mean BCVA for non-responders of 0.44±0.16 logMAR vs. 0.29±0.19 logMAR (P=0.03). Non-responders also had a higher mean maximal posterior curvature (AKB) of -10.84±1.72D vs. -9.46± 1.12D (P=0.03). They also showed more higher order optical aberrations (3.84±1.72D vs. 2.4±1.02D; P=0.01), including coma (3.85±1.81D vs. 2.1±1.01D; P=0.03) and more residual aberrations than responders (1.05±0.44D vs. 0.45±0.6D; P=0.005). No significant differences were found between responders and non-responders for the other parameters in our study.

CONCLUSION

Eyes with progressive keratoconus who did not respond to A-CXL treatment were the most aggressive cases in the youngest patients, with highest maximum corneal curvatures and most pronounced optical aberrations. These patients should be informed in advance of the high risk of non-response to A-CXL treatment, and of the potential need for additional treatment in the future.

Optimizing DyNaChron instrument for assessing chronic nasal dysfunction symptoms by Rasch analysis

BACKGROUND

The DyNaChron (Dysfonctionnement Nasal Chronique) questionnaire is a self-reporting 78-item instrument assessing six symptoms and their consequences of chronic nasal dysfunction. Patients complete items of a symptom domain only when it is present but in case the patient presents several or all symptoms, its length can limit its use. Here, we aimed to optimize, or shorten, the DyNaChron for clinical use.

METHODS

A total of 640 patients in 14 rhinology outpatient clinics all over France completed the original DyNaChron questionnaire before the first rhinologic clinic and 15 days later. The optimization process involved Rasch analysis and then qualitative content analyses. Rasch analysis flagged items with a floor/ceiling effect or with important differential item functioning and an expert committee decided whether to retain the flagged items on the basis of clinical importance and statistical characteristics. The psychometric properties of the optimized version were studied according to classical test theory and Rasch analysis.

RESULTS

Rasch analysis revealed 4 items with underfit, 6 with an extreme score, 2 that were highly locally dependent and 16 with differential item functioning which 5 of these 16 items were retained after content analysis. In total, 19 flagged items were removed. Factorial analysis confirmed the preservation of the initial instrument structure in the optimized scale; psychometrics properties and scale calibration were the same as or better than the original version.

CONCLUSION

The shortened DyNaChron optimizes the quality of assessment by deleting redundant items and reduces the burden on respondents; the structure is preserved and the psychometrics properties are improved.

Ability of Emergency Department Physicians Using a Functional Autonomy-Assessing Version of the Triage Risk Screening Tool to Detect Frail Older Patients Who Require Mobile Geriatric Team Consultation

OBJECTIVES

Frailty in older people associates with poor outcomes. Screening by ED physicians would greatly facilitate detection of frail older patients but our previous attempt to introduce routine ED-physician screening with Short Emergency Geriatric Assessment (SEGA), a 13-item frailty tool that French geriatricians use to identify frail patients, failed due to its length and complexity. A national committee recently generated a new version of the fast and simple 5-item Triage Risk Screening Tool (TRST) in which a subjective item ('nurse concern') was replaced by an item assessing basic activities of daily living. The ability of ED physicians using this French-TRST to accurately detect frail patients who require comprehensive geriatric assessment was assessed.

DESIGN

Prospective cross-sectional study on diagnostic accuracy relative to the gold standard, namely, geriatrician-administered SEGA.

SETTING

Tertiary-care hospital, France.

SUBJECTS AND MEASUREMENTS

The participants were 498 ≥75-year-old patients who visited the ED in 2018-2019 and were administered French-TRSTs by first ED physicians and then geriatricians, followed by SEGA, all within 24 hours. Diagnostic accuracy variables were calculated. Geriatrician-TRST was used to identify TRST items that associated with ED physician misclassification of frail patients.

RESULTS

Emergency-TRST was significantly less sensitive than Geriatrician-TRST (88% vs. 93%; p=0.04) and tended to have lower negative predictive value (66% vs. 77%; p=0.09). Emergency-TRSTs rated four French-TRST items less well than Geriatrician-TRSTs.

CONCLUSIONS

As a substitute for SEGA in the ED, the French-TRST performed quite well overall but the ED physicians detected frail patients less well than the geriatricians. Modifications of the French-TRST that may improve the diagnostic performance of ED physicians are discussed.

[Determinants of time required by medical information technicians for quality control of hospital activity coding, in French medico-administrative system]

BACKGROUND

Since 2008, in France, hospital funding is determined by the nature of activities provided (activity-based funding). Quality control of hospital activity coding is essential to optimize hospital remuneration. There is a need for reliable tools to allocate human resources wisely in order to improve these controls.

METHODS

The main objective of this study was to identify the determinants of time needed by medical information technicians to control hospital activity coding in a Regional Hospital Center. From March 2016 to the beginning of January 2017, medical information technicians reported the time they spent on each quality control, and the time they needed when they had to code the entire stay. Multiple linear regressions were performed to identify the determinants of quality control or coding duration. A split sample validation was used: model was created on one half of the sample and validated on the remaining half.

RESULTS

Among the controls, 5431 were included in the analysis of determinants of control duration (2715 kept aside for model validation). Seven determinants have been identified (stay duration, level of complexity, month of control, type of control, medical information technician, rank of classing information, and major diagnostic category). The correlation coefficient between predicted and real control duration was 0.71 (P<10^-4); 808 stays were included in the analysis of determinants of coding duration (404 kept aside for model validation). Two determinants have been identified. The correlation coefficient, between predicted and real coding duration, was 0.47 (P<10^-3). We performed the same multiple regression, on 2017 activity data, to estimate the weight of each hospital activity pole, regarding quality control of hospital activity coding.

CONCLUSION

We succeeded in modeling time needed for quality control of hospital stays. These results helped to estimate human resources required for quality control of each hospital pole. Nevertheless, the second analysis did not give satisfactory results: we failed in modeling time needed to code hospital stays.

A De Novo Dominant Negative Mutation in DNM1L Causes Sudden Onset Status Epilepticus with Subsequent Epileptic Encephalopathy

Mitochondrial dynamics such as fission and fusion play a vital role in normal brain development and neuronal activity. DNM1L encodes a dynamin-related protein 1 (Drp1), which is a GTPase essential for proper mitochondrial fission. The clinical phenotype of DNM1L mutations depends on the degree of mitochondrial fission deficiency, ranging from severe encephalopathy and death shortly after birth to initially normal development and then sudden onset of refractory status epilepticus with very poor neurologic outcome. We describe a case of a previously healthy 3-year-old boy with a mild delay in speech development until the acute onset of a refractory status epilepticus with subsequent epileptic encephalopathy and very poor neurologic outcome. The de novo missense mutation in DNM1L (c.1207C > T, p.R403C), which we identified in this case, seems to determine a unique clinical course, strikingly similar to four previously described patients in literature with the identical de novo heterozygous missense mutation in DNM1L.

Supracapsular phacoemulsification: Description of the "Garde à vous" technique and comparative clinical results

Phacoemulsification techniques can be divided into 2 categories: endocapsular and supracapsular techniques. Supracapsular techniques involve phacoemulsification of the nucleus outside and above the capsular plane. The "Garde-à-vous" technique described in this manuscript is a modified and improved version of the supracapsular procedure with up-to-date technology in micro-coaxial surgery. It maintains the known advantages of supracapsular techniques such as faster surgical times and lower rates of capsular tears and brings a standardized technique with well-defined surgical steps in order to achieve tilting of the nucleus in a vertical or oblique position in almost 100% of cases by performing a double-wave hydro-dissection. The authors also give the results of a non-randomized prospective study, comparing the "Garde-à-vous" technique and the standard "cracking" technique in 2856 cases. The results show that for the "Garde-à-vous group", the patients were significantly younger (P<0.001), the power of ultrasound used was greater (P<0.001) for lower UST (ultrasound time or average phacoemulsification time APT) and EPT (effective phacoemulsication time) (P<0.001), the duration of the procedure was shorter (P<0.001), patient discomfort was less (P<0.001), and the power of the implants used was lower (P<0.01). With regard to the gender of the patients, the percentage of topical anesthesia and the rate of intraoperative complications (posterior capsular rupture), there was no statistically significant difference.

Lateral tarsal strip versus lateral tarsal strip with three-snip punctoplasty for managing epiphora in involutional ectropion

PURPOSE

To compare the efficacy of two surgical techniques-lateral tarsal strip (canthoplasty) alone, and lateral tarsal strip with three-snip punctoplasty-in reducing epiphora arising from involutional ectropion with partial punctal stenosis.

METHODS

Fourty patients with involutional ectropion and partial stenosis of the lacrimal punctum were randomly allocated to two treatment groups. Group 1 patients received lateral tarsal strip alone with only non-invasive stenting of the punctum, and group 2 patients received tarsal strip plus three-snip punctoplasty. Subjective assessment of epiphora was achieved via completion of a quality of life (QoL) questionnaire preoperatively and at postoperative month 3. Eyelid position, adverse outcomes and corneal dryness (via Oxford grading scheme) were also assessed postoperatively. Only patients with unilateral problems were included in the study.

RESULTS

Forty eyes of 40 patients were included: 20 in each group. The mean ages of group 1 and group 2 patients were 79±11 and 80±9 years, respectively. All patients reported significantly reduced eye watering after surgery, with no significant intergroup difference in subjective outcomes, except that computer usage and night driving (P<0.05), improved in a more significant way in group 2. Eyelid malposition was corrected in all cases, there were no cases of postoperative punctal eversion, and no significant adverse events or complications occurred. Finally, the mean improvements in the dryness/keratitis score (using the Oxford scheme) were comparable between the 2 groups (P=0.34).

CONCLUSION

The study findings indicate that treatment of involutional ectropion with partial punctal stenosis by lateral tarsal strip with three snip punctoplasty does not provide greater reduction in discomfort secondary to epiphora than conventional lateral tarsal strip alone, except for specific situations such as night driving or computer use.

[Practical assessment of DSAEK in the management of endothelial decompensation following penetrating keratoplasty]

PURPOSE

To report our anatomical and functional results as well as possible complications of the first six Descemet's stripping endothelial keratoplasties (DSAEK) performed in our department for endothelial decompensation after penetrating keratoplasty (PK) METHODS: This was a retrospective and observational monocentric study of six patients with DSAEK after prior PK between January 2015 and July 2016. The data collected were: demographic characteristics (age, sex), ophthalmological comorbidities, initial indication for PK, delay between PK and DSAEK. Best corrected visual acuity (BCVA) preoperatively and at 1, 3 and 6 months postoperatively were collected in Monoyer's and Parinaud scale and converted to log MAR for statistical analysis. The central cornea and graft thickness measured on OCT as well as postoperative complications were also collected.

RESULTS

Mean follow-up duration was 7.2 months [3-10]. The average time after PK was 7.7 years. The mean age of the patients was 67.5 years [32-87]. The initial indication for PK was Fuchs dystrophy (3/6), pseudophakic bullous keratopathy (1/6), corneal laceration (1/6) and other corneal dystrophy (1/6). The authors report one case a combined phaco-DSAEK surgery. The complications observed were: an early graft detachment treated by an additional air bubble injection (1/6) and cystoid macular edema in one other case. The average central corneal thickness decreased from 780μm at day 7 postoperatively to 656μm at 6 months. The average thickness of the graft decreased from 154μm at day 7 to 122μm at 6 months. The mean preoperative BCVA was 1.52 log MAR [1.0-1.7], compared to the mean postoperative BCVA which was 1.5 log MAR [1.1-2.3] at 1 month, 1.15 log MAR [0.5-1.7] at 3 months and 1.1 log MAR [0.7-1.7] at 6 months (data available for 4 patients at 6 months). The recovery of visual acuity was limited in 2 cases, despite corneal clarity restored in all our patients.

DISCUSSION

Our results can be compared to those described in literature. As more penetrating keratoplasty grafts reach the end of their lives, this will allow for more powerful studies.

CONCLUSION

DSAEK on eyes previously treated with PK is a good alternative to a new PK in the case of endothelial decompensation of the graft. The possibility of a posterior lamellar graft allows for faster visual recovery, with preservation of the anterior corneal power and a lower rate of complications.

Central corneal thickness assessment after phacoemulsification: Subluxation versus Divide-and-Conquer

PURPOSE

To compare the impact of two phacoemulsification techniques (subluxation versus divide-and-conquer) on postoperative corneal edema at postoperative hour 1 and day 4.

DESIGN

Comparative study.

METHOD

Ninety-six consecutive patients (110 eyes; 43 men and 53 women, mean age 70.9±9.8 years) with equivalent cataract grades underwent cataract surgery and were followed up for 6 months. The presence of corneal edema was determined using central corneal thickness (CCT). CCT was measured preoperatively, and at postoperative hour 1 and day 4.

MAIN OUTCOME MEASURES

Ultrasound power (US %), duration of ultrasound (TPA), effective ultrasound time (TPE), surgical duration and final suture (%).

RESULTS

Eyes of participants were divided into two phacoemulsification technique groups: subluxation (n=50 eyes) and divide-and-conquer (n=60 eyes). Non-inferiority analysis revealed similar CCT increases at postoperative hour 1 in both groups, with 69.9±44.9μm and 64.4±42.9μm, observed in the subluxation and divide-and-conquer groups, respectively (P=0.033). TPE was similar in both groups, taking 6.2±3.4 and 7.3±4.5seconds in the subluxation and divide-and-conquer groups, respectively (P=0.150). No correlation was seen between TPE and edema at postoperative hour 1, or between TPE and day 4 edema. Rate of final suture use was similar between the subluxation and divide and conquer groups, at 36% and 30%, respectively.

CONCLUSION

The study findings suggest that cataract surgery performed using the subluxation technique does not result in greater CCT than the divide-and-conquer technique. CCT appears to normalize by postoperative day 4, regardless of the technique used.

An illustrative review to understand and manage metal-induced artifacts in musculoskeletal MRI: a primer and updates

This article reviews and explains the basic physical principles of metal-induced MRI artifacts, describes simple ways to reduce them, and presents specific reduction solutions. Artifacts include signal loss, pile-up artifacts, geometric distortion, and failure of fat suppression. Their nature and origins are reviewed and explained though schematic representations that ease the understanding. Then, optimization of simple acquisition parameters is detailed. Lastly, dedicated sequences and options specifically developed to reduce metal artifacts (VAT, SEMAC, and MAVRIC) are explained.

Roscovitine has anti-proliferative and pro-apoptotic effects on glioblastoma cell lines: A pilot study

Purine analogue roscovitine, a cyclin-dependent kinase (CDK) inhibitor, has shown strong anti-proliferative and pro-apoptotic effects in solid and hematologic cancers such as non small-cell lung cancer and lymphomas. It targets CDK2, 7 and 9 preferentially, which are also overexpressed in glioblastoma. Τherefore, the biological effects of roscovitine in glioblastoma cell lines were investigated. Glioblastoma A172 and G28 cell lines were incubated with serial concentrations of roscovitine for 24-120 h. Proliferation was measured using the xCELLigence Real-Time Cell Analyzer, an impedance‑based cell viability system. Cell cycle distribution was assessed by flow cytometry and gene expression was quantified by quantitative RT-PCR and western blot analysis. Roscovitine exhibited a clear dose-dependent anti‑proliferative and pro‑apoptotic effect in the A172 cell line, while G28 cells showed a anti-proliferative effect only at 100 µM. The results of the flow cytometric (FACS) analysis revealed a dose-dependent increase of the G2/M and sub-G1 fractions in A172 cells, while G28 cells responded with an elevated sub-G1 fraction only at the highest concentration. Roscovitine led to a dose‑dependent decrease of transcripts of p53, CDK 7 and cyclins A and E and an increase of >4-fold of p21 in A172 cells. In G28 cells, a dose‑dependent induction of CDK2, p21 and cyclin D was observed between 10 and 50 µM roscovitine after 72 h, however, at the highest concentration of 100 µM, all investigated genes were downregulated. Roscovitine exerted clear dose-dependent anti-proliferative and pro-apoptotic effects in A172 cells and less distinct effects on G28 cells. In A172 cells, roscovitine led to G2/M arrest and induced apoptosis, an effect accompanied by induced p21 and a reduced expression of CDK2, 7 and 9 and cyclins A and E. These effects requre further studies on a larger scale to confirm whether roscovitine can be used as a therapeutic agent against glioblastoma.

Optimized surgical treatment for normal pressure hydrocephalus: comparison between gravitational and differential pressure valves

OBJECTIVES

In idiopathic normal pressure hydrocephalus (NPH) ventriculoperitoneal (VP) shunt insertion is the method of choice to improve cardinal symptoms such as gait disturbance, urge incontinence and/or dementia. With reduced compliance, the brain of the elderly is prone for overdrainage complications. This was especially true with the use of differential pressure valve implantation. The present study compares clinical outcome and complication rates after VP shunt insertion with differential pressure valves in the early years and gravitational valves since 2005.

METHODS

The authors reviewed patients treated at our institution for NPH since 1995. Differential pressure valves were solely used in the initial years, while the treatment regimen changed to gravitational valves in 2005. Clinical improvement/surgical success rates as well as complications were compared between the two groups.

RESULTS

Eighty-nine patients were enrolled for the present study. Mean age at the time of surgery was 73.5 ± 6.3 years. Male patients predominated with 73, compared with 16 female patients. Median follow-up time was 28 ± 26 months. Date of last follow-up was 1st October 2013. Forty-nine patients received a gravitational valve, while 40 were treated with differential pressure valves. In the gravitational group a significant improvement was observed after shunt insertion for gait disorder, cognitive impairment and urge incontinence (p < 0.0001, resp. p = 0.004), while a significant change in the differential pressure group was only seen for gait disorder (p = 0.03) but not for cognition or urinary incontinency (p > 0.05). The risk of hygroma as a sign of shunt overdrainage requiring surgical intervention was significantly higher in the differential pressure group (5 versus 0 in the gravitational group).

CONCLUSIONS

Patients with NPH treated with gravitational valves in the present cohort showed a more profound improvement in their initial symptoms, including gait disorder, cognitive impairment and urinary incontinency without the risk of overdrainage complications requiring surgical intervention when compared with patients who received differential pressure valves in previous years.

Interstitial iodine-125 radiosurgery alone or in combination with microsurgery for pediatric patients with eloquently located low-grade glioma: a pilot study

PURPOSE

The optimal therapeutic management of children with World Health Organization grade I and II gliomas not accessible to complete resection is poorly defined. Radical surgical resection is the first-line treatment for large hemispheric tumors, whereas interstitial iodine-125 radiosurgery (IRS) might be an attractive treatment concept for selected patients with small (tumor diameter in the range of 4 cm) and circumscribed tumors in any location of the brain. Precise high-dose application, maximal sparing of surrounding normal tissue, and the absence of long-term complications have been reported to be the hallmark of IRS. Therefore, the therapeutic impact and the risk of IRS alone or in combination with microsurgery (in case of larger tumor volumes) were prospectively examined.

METHODS

Seven boys and four girls were included (mean age, 6.8 years; range, 11 months to 16 years). IRS (after stereotactic biopsy) was considered to be indicated for circumscribed tumors with a diameter in the range of 4 cm (four cases). For larger tumors, a combined microsurgical/radiosurgical approach was preferred (seven patients). Temporary iodine-125 seeds were used exclusively (tumor dose calculated to the boundary, 54 Gy; dose rate, 10 cGy/h). Tumor location was hypothalamic/suprasellar in four, lobar in three, deep (thalamus and pineal gland) in two, and within the brain stem in two children. Treatment effects of IRS were estimated according to the MacDonald criteria.

RESULTS

A complete response after IRS was seen in four patients, and a partial response was seen in seven patients (median follow-up, 31.5 months). There was no perioperative morbidity after microsurgery and/or IRS, and no radiogenic complications occurred during the follow-up period. Five patients experienced an improvement in their deficits, and no deterioration in neurological/endocrine function was seen in any of the patients at the time of last follow-up evaluation.

CONCLUSION

IRS alone or in combination with microsurgery (in the case of larger tumors) is a safe, effective, and minimally invasive treatment strategy for eloquently located pediatric low-grade gliomas and deserves further prospective evaluation.

Rasagiline-associated motor improvement in PD occurs without worsening of cognitive and behavioral symptoms

BACKGROUND

Cognitive and behavioral adverse events (AEs) such as hallucinations, confusion, depression, somnolence and other sleep disorders commonly limit effective management of motor symptoms in PD. Rasagiline (N-propargyl-1(R)-aminoindan) mesylate is a novel, second-generation, selective, irreversible monoamine oxidase type B inhibitor, demonstrated in monotherapy and adjunctive trials to be effective for PD with excellent tolerability.

METHODS

The occurrence of cognitive and behavioral AEs and the change from baseline in the Unified Parkinson's Disease Rating Scale (UPDRS) part I mental subscores were reviewed in two multicenter, randomized, placebo-controlled, 26-week trials of rasagiline for early and moderate-to-advanced patients with PD. The UPDRS is a multi-item rating scale specific to PD; part I rates the patient's intellectual impairment, thought disorders, depression and motivation/initiative.

RESULTS

The TEMPO study evaluated rasagiline monotherapy in early PD patients (n=404). The PRESTO study evaluated rasagiline as adjunctive therapy in moderate-to-advanced PD patients with motor complications who were receiving optimized levodopa/carbidopa (n=472). In the analysis of adverse event reporting for both studies, no cognitive and behavioral AE in either the rasagiline 1 mg or placebo groups exceeded 10% of the study population and the frequency differences between rasagiline 1 mg and placebo never exceeded 3%. There was no adverse effect on the UPDRS mental subscore relative to placebo in either of the two studies.

CONCLUSION

Rasagiline 1 mg once daily improves PD symptoms and motor fluctuations in early and moderate-to-advanced PD patients without causing significant cognitive and behavioral AE or adverse changes in mentation, behavior and mood.

Thermography - a valuable tool to test hydrocephalus shunt patency

INTRODUCTION

Shunt-function in hydrocephalic patients is verified by clinical examination and repeated cranial computed tomography (CCT) in most cases. Because of the disadvantages of multiple radiation especially in children it was our aim to introduce video-thermography as a simple and non-invasive methodology to evaluate shunt function.

METHODS

54 patients treated with shunts for hydrocephalus were tested. A ventriculo-peritoneal shunt had been implanted in 38 patients, a ventriculo-atrial shunt in 16 patients. Recent CCT-scans were available for all patients and served as control. None of the patients presented with clinical signs of shunt-dysfunction. The temperature of the skin covering the drainage catheter distal to the valve was recorded real-time by a calibrated infrared camera. After cooling the skin area downstream of the valve for exactly 1 min with an ice pack, changes of the skin temperature in the area downstream were registered by a thermocamera. The signals were transferred to a video screen and recorded on videotape. By off-line analysis of the obtained pseudo colour images variations of 0.1 degrees C in skin temperature could be measured.

RESULTS

Temperature distribution of the area under investigation revealed a significant reduction of the skin temperature according to the location of the downstream catheter segment in 48 patients after cooling. In 6 patients skin temperature remained constant, although clinical evaluation and CCT-scan showed no signs of shunt dysfunction. Shunt patency could be verified in more than 85% of the patients by thermal imaging.

CONCLUSION

Infrared-thermography is a valuable and promising tool for replacing CCT-scanning as a screening method to test shunt function in hydrocephalic patients.

[Supratentorial primitive neuroectodermal tumor: a single center experience and comparison with the literature]

Supratentorial primitive neuroectodermal tumors (stPNETs) are malignant tumors. We saw within three years six children with stPNETs. In four of the six children radical resection could be achieved. All had craniospinal irradiation and chemotherapy according to the HIT-91 protocol. The two children with incomplete resection died due to tumor progression after 7 and 10 months. Two of the 4 children with complete tumor resection had local relapses 8 months after diagnosis and died after 14 and 18 months. One child had a diffuse meningeal relapse 12 months after diagnosis. Despite (high-dose) systemic chemotherapy and intraventricular mafosfamide, he died 21 months after diagnosis due to tumor although remission could be achieved. Only one child is still in remission 86 months after diagnosis.

Locoregional radioimmunotherapy in selected patients with malignant glioma: experiences, side effects and survival times

Prognosis of malignant glioma is very unfavourable mainly due to minimal tumour remnants in the peritumoural tissue. Intralesionally applied radioimmunotherapy is a possible therapeutical option with the potential to improve survival of patients with malignant glioma. We investigated side effects and survival after surgery, conventional radiotherapy and additional radioimmunotherapy with labelled tenascin-antibodies in patients with malignant glioma.

METHODS

Since 1995, 37 patients were treated with radioimmunotherapy after resection and radiotherapy of a malignant glioma. Patients received antibodies labelled with yttrium-90 and iodine-131 in different doses into the tumour cavity via a previously implanted ommaya-reservoir. Treatment was applied in up to 8 cycles (mean 2.96 cycles) in time intervals of 6-8 weeks. Mean age was 46 years, histology was anaplastic astrocytoma in 13 patients and glioblastoma in 24 patients.

RESULTS

For the whole group median survival time has not yet been reached. For glioblastoma the median survival time is 17 months, 5-year survival probability for anaplastic astrocytoma is 85% approximately. Quality of life was acceptable. Acute side effects following treatment were headache, seizures and worsening of pre-existing neurological symptoms. Late side effects were skin necrosis and, in 1 case, a delayed aphasia probably due to a vascular lesion.

CONCLUSION

Radioimmunotherapy prolonged survival time in a selected group of patients with malignant gliomas as compared to a historical control group. Patients with anaplastic astrocytomas seem to have more benefit from this therapy than patients with glioblastomas.

Intralesional radioimmunotherapy in the treatment of malignant glioma: clinical and experimental findings

In the last two decades radioimmunotherapy has been used as an additional treatment option for malignant glioma in several centers. More than 400 patients have been reported, who were treated in the framework of different studies. Most of them received labelled antibodies to tenascin, an extracellular matrix-glycoprotein, which is expressed in high amounts in malignant gliomas. We report side effects and survival time of 46 patients, treated after surgical resection and conventional radiotherapy with intralesionally injected labelled (131-Iodine) antibodies to tenascin. Despite the fact, that many treatments have been performed, little is known about the distribution properties of labelled antibodies after injection in the tumour cavity. For an optimal effect labelled antibodies should be able to reach tumour cells, which have migrated into the surrounding tissue. We investigated the propagation velocity and area of distribution of labelled antibodies and their considerably smaller fragments after the injection in C6-gliomas of Wistar rats. Propagation increased with time and was significantly greater after injection of labelled fragments than after injection of labelled antibodies. According to our results labelled fragments might be better able to reach distant tumour cells in the peritumoural tissue of malignant gliomas than labelled antibodies.

Experimental research photodynamic effects in perifocal, oedematous brain tissue

BACKGROUND

Photodynamic therapy (PDT) has been under discussion as additional treatment option for malignant gliomas. However, damage not only to tumour tissue but also to normal brain has been demonstrated. The mechanisms of this unwanted side effect have not yet been clearly identified. Spreading of photosensitiser with oedema after disruption of the blood-brain-barrier and potential sensitisation of normal tissue has been found previously. The present study investigates the time- and dose-dependency of normal tissue damage to photodynamic therapy using Photofrin II after disruption of the blood-brain-barrier.

METHODS

Male wistar rats anaesthetised with chloral hydrate were subjected to focal, cerebral cold lesions. Simultaneously, Photofrin II (PFII) was injected (2,5 or 5 mg/kg b.w.). Laser irradiation (630 nm) was performed after 4 h, 12 h and 24 h with varying light doses. Control groups were subjected to focal cold lesion alone, cold lesion with laser irradiation, PFII followed by laser irradiation, or laser irradiation alone (n=6 all groups). 24 h later, brains were removed for assessment of necrosis in coronal sections.

FINDINGS

Light dose had a significant impact on the extent of necrosis. Compared to control animals (lesion only: 0.84 +/- 0.2 mm2; lesion and irradiation alone: 0.7 +/- 0.3 mm2), the area of necrosis was increased to 2.8 +/- 0.5 (50 J/cm2), 3.5 +/- 1,1 (100 J/cm2) and 4.3 +/- 0.7 mm2 (200 J/cm2, 5 mg/kg b.w.; p<0.01). This effect was time-dependent. Maximal necrosis (6.3 +/- 1,6 mm2) was observed when brains were irradiated 12 h after PFII injection, with less necrosis occurring at 24 h (2.8 +/- 0.4 mm2, p<0.01). Reducing sensitiser dose to 2.5 mg/kg b.w. resulted in a reduction of necrosis (2.09 +/- 0.2 mm2, p<0.05).

INTERPRETATIONS

Damage to oedematous tissue after photodynamic therapy using i.v. PFII and laser light at 630 nm depends on laser dose, sensitiser dose and the time point of laser irradiation. The time point of PDT should be considered to prevent unwanted tissue reactions. In the clinical setting however, defined damage to peritumoural tissue may be advantageous. This should be achievable by optimised timing and dosage of photodynamic therapy.

Fluorescence-guided resection of glioblastoma multiforme by using 5-aminolevulinic acid-induced porphyrins: a prospective study in 52 consecutive patients

OBJECT

It has been established that 5-aminolevulinic acid (5-ALA) induces the accumulation of fluorescent porphyrins in glioblastoma multiforme (GBM), a phenomenon potentially exploitable to guide tumor resection. In this study the authors analyze the influence of fluorescence-guided resection on postoperative magnetic resonance (MR) imaging and survival in a series of patients who underwent surgery in the authors' department.

METHODS

Fifty-two consecutive patients with GBM received oral doses of 5-ALA (20 mg/kg body weight) 3 hours before induction of anesthesia. Intraoperatively, tumor fluorescence was visualized using a modified operating microscope. Fluorescing tissue was removed whenever it was considered safely possible. Residual enhancement on early postoperative MR imaging was quantified and related to each patient's characteristics to determine which factors influenced resection. Survival was analyzed using the Kaplan-Meier method and multivariate analysis was performed in which the Karnofsky Performance Scale (KPS) score, residual fluorescence, patient age, and residual enhancement on MR images were considered. Intraoperatively, two fluorescence qualities were perceived: solid fluorescence generally reflected coalescent tumor, whereas vague fluorescence mostly corresponded to infiltrative tumor. Complete resection of contrast-enhancing tumor was accomplished in 33 patients (63%). Residual intraoperative tissue fluorescence left unresected for safety reasons predicted residual enhancement on MR images in 18 of the 19 remaining patients. Age, residual solid fluorescence, and absence of contrast enhancement in MR imaging were independent explanatory factors for survival, whereas the KPS score was significant only in univariate analysis. No perioperative deaths and one case of permanent morbidity were encountered.

CONCLUSIONS

The observations in this study indicate the usefulness of 5-ALA-induced tumor fluorescence for guiding tumor resection. The completeness of resection, as determined intraoperatively from residual tissue fluorescence, was related to postoperative MR imaging findings and to survival in patients suffering from GBM.

Subsidence resulting from simulated postoperative neck movements: an in vitro investigation with a new cervical fusion cage

STUDY DESIGN

A biomechanical in vitro subsidence test of different cervical interbody fusion devices was performed using a new testing protocol that simulates physiologic conditions.

OBJECTIVES

To investigate the effect of simulated postoperative neck movements on the subsidence of the new WING cervical interbody fusion cage in comparison with two other cages and bone cement.

SUMMARY OF BACKGROUND DATA

Cervical interbody fusion cages sometimes cause complications because of subsidence into the adjacent vertebrae with collapse of the intervertebral space. Complications such as cage dislocation or nonunion with instability also have been reported. To prevent such complications, the new WING cervical interbody fusion cage (Medinorm AG, Quierschied, Germany) has been developed. Its area of contact with the adjacent vertebrae is supposed to be large enough to resist excessive subsidence and small enough to prevent stress protection of the tissue growing in the cage.

METHODS

In this study, 24 human cervical spine specimens were tested after stabilization with either a WING, BAK/C, AcroMed I/F cage or bone cement. Then, in a new testing protocol, 700 pure-moment loading cycles (+/-2 Nm) were applied in randomized directions (lateral bending, flexion-extension, and axial rotation alone or in combination with each other) to simulate the patient's neck movements during the first few postoperative days. Measurements of the subsidence depth (total height loss) in combination with flexibility tests (+/-2.5 Nm) were performed before cyclic loading and after 50, 100, 200, 300, 500, and 700 loading cycles.

RESULTS

Cyclic loading caused subsidence in all four device groups, most distinct with BAK/C-cages (1.63 mm after 700 loading cycles) followed by the new WING (0.90 mm) and the AcroMed (0.82 mm) cages. No statistically significant difference could be found among the three cage designs. However, all three cage types showed a significantly higher subsidence depth than bone cement (0.48 mm;P = 0.023 between each of the three cage-types and bone cement). A moderate correlation between bone mineral density and subsidence depth could be found only in the BAK/C group (r2 = 0.495). A large subsidence depth after 700 loading cycles was associated with a large flexibility increase in the WING (r2 = 0.786) and AcroMed groups (r2 = 0.21), but with a small flexibility increase in the BAK/C group (r2 = 0.58).

CONCLUSIONS

Postoperative neck movements caused subsidence in all cervical interbody implant types. The new WING cage and the AcroMed cage seemed to have a better resistance against subsidence than the BAK/C cage. However, all three cage types had a significantly higher subsidence tendency than bone cement.