Unsupervised synthesis of realistic coronary artery X-ray angiogram

PURPOSE

Medical image analysis suffers from a sparsity of annotated data necessary in learning-based models. Cardiorespiratory simulators have been developed to counter the lack of data. However, the resulting data often lack realism. Hence, the proposed method aims to synthesize realistic and fully customizable angiograms of coronary arteries for the training of learning-based biomedical tasks, for cardiologists performing interventions, and for cardiologist trainees.

METHODS

3D models of coronary arteries are generated with a fully customizable realistic cardiorespiratory simulator. The transfer of X-ray angiography style to simulator-generated images is performed using a new vessel-specific adaptation of the CycleGAN model. The CycleGAN model is paired with a vesselness-based loss function that is designed as a vessel-specific structural integrity constraint.

RESULTS

Validation is performed both on the style and on the preservation of the shape of the arteries of the images. The results show a PSNR of 14.125, an SSIM of 0.898, and an overlapping of 89.5% using the Dice coefficient.

CONCLUSION

We proposed a novel fluoroscopy-based style transfer method for the enhancement of the realism of simulated coronary artery angiograms. The results show that the proposed model is capable of accurately transferring the style of X-ray angiograms to the simulations while keeping the integrity of the structures of interest (i.e., the topology of the coronary arteries).

Fetal cardiac and neonatal cerebral hemodynamics and oxygen metabolism in transposition of the great arteries

OBJECTIVES

Hemodynamic abnormalities and brain development disorders have been reported previously in fetuses and infants with transposition of the great arteries and intact ventricular septum (TGA-IVS). A ventricular septal defect (VSD) is thought to be an additional risk factor for adverse neurodevelopment, but literature describing this population is sparse. The objectives of this study were to assess fetal cardiac hemodynamics throughout pregnancy, to monitor cerebral hemodynamics and oxygen metabolism in neonates, and to compare these data between patients with TGA-IVS, those with TGA-VSD and age-matched controls.

METHODS

Cardiac hemodynamics were assessed in TGA-IVS and TGA-VSD fetuses and compared with healthy controls matched for gestational age (GA) during three periods: ≤ 22 + 5 weeks (GA1), 27 + 0 to 32 + 5 weeks (GA2) and ≥ 34 + 5 weeks (GA3). Left (LVO), right (RVO) and combined (CVO) ventricular outputs, ductus arteriosus flow (DAF, sum of ante- and retrograde flow in systole and diastole), diastolic DAF, transpulmonary flow (TPF) and foramen ovale diameter were measured. Aortic (AoF) and main pulmonary artery (MPAF) flows were derived as a percentage of CVO. Fetal middle cerebral artery and umbilical artery (UA) pulsatility indices (PI) were measured and the cerebroplacental ratio (CPR) was derived. Bedside optical brain monitoring was used to measure cerebral hemoglobin oxygen saturation (SO2 ) and an index of microvascular cerebral blood flow (CBFi ), along with peripheral arterial oxygen saturation (SpO2 ), in TGA-IVS and TGA-VSD neonates. Using hemoglobin (Hb) concentration measurements, these parameters were used to derive cerebral oxygen delivery and extraction fraction (OEF), as well as an index of cerebral oxygen metabolism (CMRO2i ). These data were acquired in the early preoperative period (within 3 days after birth and following balloon atrial septostomy) and compared with those of age-matched healthy controls, and repeat measurements were collected before discharge when vital signs were stable.

RESULTS

LVO was increased in both TGA groups compared with controls throughout pregnancy. Compared with controls, TPF was increased and diastolic DAF was decreased in TGA-IVS fetuses throughout pregnancy, but only during GA1 and GA2 in TGA-VSD fetuses. Compared with controls, DAF was decreased in TGA-IVS fetuses throughout pregnancy and in TGA-VSD fetuses at GA2 and GA3. At GA2, AoF was higher in TGA-IVS and TGA-VSD fetuses than in controls, while MPAF was lower. At GA3, RVO and CVO were higher in the TGA-IVS group than in the TGA-VSD group. In addition, UA-PI was lower at GA2 and CPR higher at GA3 in TGA-VSD fetuses compared with TGA-IVS fetuses. Within 3 days after birth, SpO2 and SO2 were lower in both TGA groups than in controls, while Hb, cerebral OEF and CMRO2i were higher. Preoperative SpO2 was also lower in TGA-VSD neonates than in those with TGA-IVS. From preoperative to predischarge periods, SpO2 and OEF increased in both TGA groups, but CBFi and CMRO2i increased only in the TGA-VSD group. During the predischarge period, SO2 was higher in TGA-IVS than in TGA-VSD neonates, while CBFi was lower.

CONCLUSIONS

Fetal cardiac and neonatal cerebral hemodynamic/metabolic differences were observed in both TGA groups compared with controls. Compared to those with TGA-IVS, fetuses with TGA-VSD had lower RVO and CVO in late gestation. A higher level of preoperative hypoxemia was observed in the TGA-VSD group. Postsurgical cerebral adaptive mechanisms probably differ between TGA groups. Patients with TGA-VSD have a specific physiology that warrants further study to improve neonatal care and neurodevelopmental outcome. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Clinical differences in a multidisciplinary pediatric pain unit between primary and secondary chronic pain

INTRODUCTION

Chronic pain affects an important part of the pediatric population in developed countries. secondary chronic pain (SCP) can have a well-defined medical cause, but primary chronic pain (PCP) can have an unknown etiology. In Spain, there is as yet no information on the clinical differences between patients treated in multidisciplinary units.

METHODS

Retrospective analysis of the clinical records of patients seen in 2018 at the Children's Chronic Pain Unit in University La Paz Hospital.

RESULTS

A total of 92 patients were included, (age between 3 and 19 years), with a mean age of 12.4 (SD = 4.1) years, mostly female (55%), with a mean duration of pain of 11.3 (SD = 10.4) months. A comparison of patients with PCP (n = 31) and SCP (n = 61) showed that both groups, on average, presented intense pain (X = 5.9; SD = 2.2; range = 0-10), with similar duration and functional repercussions, although PCP was less likely to be associated with neuropathic descriptors than SCP (p = 0.040), and was more extensive (p < 0.001). Both groups received similar treatment, based on rehabilitation, psychotherapy, invasive techniques and analgesic medication, although patients in the PCP group received less analgesic medication (gabapentinoids and opioids) than the SCP (p = 0.011).

CONCLUSION

Patients treated in a multidisciplinary Child Pain Unit for PCP or SCP present a very similar clinical profile, though with differences in the number and type of analgesic drugs used. This shows the importance of etiologic diagnosis for adequate pharmacological treatment.

Patient-specific Cardio-respiratory Motion Prediction in X-ray Angiography using LSTM Networks

Objective.To develop a novel patient-specific cardio-respiratory motion prediction approach for X-ray angiography time series based on a simple long short-term memory (LSTM) model.Approach.The cardio-respiratory motion behavior in an X-ray image sequence was represented as a sequence of 2D affine transformation matrices, which provide the displacement information of contrasted moving objects (arteries and medical devices) in a sequence. The displacement information includes translation, rotation, shearing, and scaling in 2D. A many-to-many LSTM model was developed to predict 2D transformation parameters in matrix form for future frames based on previously generated images. The method was developed with 64 simulated phantom datasets (pediatric and adult patients) using a realistic cardio-respiratory motion simulator (XCAT) and was validated using 10 different patient X-ray angiography sequences.Main results.Using this method we achieved less than 1 mm prediction error for complex cardio-respiratory motion prediction. The following mean prediction error values were recorded over all the simulated sequences: 0.39 mm (for both motions), 0.33 mm (for only cardiac motion), and 0.47 mm (for only respiratory motion). The mean prediction error for the patient dataset was 0.58 mm.Significance.This study paves the road for a patient-specific cardio-respiratory motion prediction model, which might improve navigation guidance during cardiac interventions.

Balloon Atrial Septostomy: Does the Balloon Size Matter?

Background

Dextro-transposition of the great arteries is a congenital heart defect with eventually lethal life-threatening consequences of hypoxic low cardiac output. When a balloon atrial septostomy (BAS) is needed, it is performed shortly after birth to create an interatrial shunt and improve systemic blood oxygenation and haemodynamic conditions. In 2019 and 2020, the withdrawal of some balloon atrioseptostomy catheters from the market led to increased use of catheters with different materials, shapes, and sizes. The main objective of this study was to investigate whether the size of the Miller and Fogarty balloon (Edwards Lifesciences) in its 2 variations, the 4.0 cc and the 1.8 cc, had a different impact on the systemic oxygen saturation, on the atrial septal defect (ASD) size, or on the type and frequency of procedure-related complications.

Methods

We conducted a retrospective study on 134 consecutive patients diagnosed with dextrotransposition of the great arteries between 2002 and 2018 who underwent BAS in a tertiary paediatric hospital in Canada.

Results

BAS resulted in a significant increase in oxygen saturation of 18.91% ± 12.95% points (P < 0.0001) and a significant increase in the resulting ASD by 3.92 ± 1.58 mm (P < 0.0001). There was no significant difference in resulting oxygen saturation (P = 0.8370) or the final ASD size (P = 0.2193) based on the balloon size. Severe or life-threatening complications were rare (1%) with no subsequent patient demise.

Conclusions

This is the first study to show that the small balloon is as efficient as the large balloon catheter including in premature patients. This raises the question whether different balloon sizes are necessary.

Characterization of blood-mimicking fluids for echocardiography imaging of ventricular septal defects

PURPOSE

Ventricular septal defects (VSD) are congenital heart malformations and, in severe cases, they require complex interventions under echocardiography guidance. Heart phantoms can be helpful to train and to understand the complex hemodynamics of VSD. The goal of this study was to characterize the best blood mimicking fluids in such heart phantoms for modelling the hemodynamics of VSD patients using echocardiography.

METHODS

Four fluid compositions were considered. Distilled water was used as a baseline, while the other three fluids were developed based on physical properties of human blood, such as the viscosity and the refractive index. Three bi-ventricular heart phantoms of three different pediatric patients with complex VSD were designed from preoperative CT imaging. Custom molds were printed in 3-D and the anatomical structure was casted in polyvinyl alcohol cryogel. The VSD in each heart phantom were observed using echocardiography and color Doppler imaging was used for the hemodynamic study.

RESULTS

Heart phantoms with blood mimicking fluids of 30% glycerol and 27% glycerol, 10% sodium iodide were found to be anatomically realistic under echocardiography imaging. Hemodynamic parameters such as the pressure gradient and the volume of the shunt were characterized using color Doppler imaging.

CONCLUSION

Proper composition of blood mimicking fluids are important for improving the realism in echocardiographic heart phantoms and they contribute to better understand the complex hemodynamic of VSD under echocardiography.

Generative learning approach for radiation dose reduction in X-ray guided cardiac interventions

BACKGROUND

Navigation guidance in cardiac interventions is provided by X-ray angiography. Cumulative radiation exposure is a serious concern for pediatric cardiac interventions.

PURPOSE

A generative learning-based approach is proposed to predict X-ray angiography frames to reduce the radiation exposure for pediatric cardiac interventions while preserving the image quality.

METHODS

Frame predictions are based on a model-free motion estimation approach using a Long Short Term Memory (LSTM) architecture and a content predictor using a Convolutional Neural Network (CNN) structure. The presented model thus estimates contrast-enhanced vascular structures such as the coronary arteries and their motion in X-ray sequences in an end-to-end system. This work was validated with 56 simulated and 52 patients' X-ray angiography sequences.

RESULTS

Using the predicted images can reduce the number of pulses by up to 3 new frames without affecting the image quality. The average required acquisition can drop by 30% per second for a 15 frame per second acquisition. The average Structural Similarity Index Measurement (SSIM) was 97% for the simulated dataset and 82% for the patients' dataset.

CONCLUSIONS

Frame prediction using a learning-based method is promising for minimizing radiation dose exposure. The required pulse rate is reduced while preserving the frame rate and the image quality. With proper integration in X-ray angiography systems, this method can pave the way for improved dose management. This article is protected by copyright. All rights reserved.

Predictors of the perceived risk of COVID-19 and adherence to confinement guidelines in the context of the COVID-19 pandemic

Introduction

Complete adherence to public health guidelines is essential to reduce the spread of COVID-19. Studies on the factors associated with increased/decreased adherence to these measures have the potential to inform public policies directed at increasing adherence, and thus helping to control the spread of the current pandemic.

Objectives

This study aimed at assessing the demographic and psychosocial predictors of the perceived risk of the COVID-19 and adherence to confinement guidelines during the first mandatory lockdown in Portugal.

Methods

A convenience sample of 430 adults living in Portugal between March 19th and May 2nd, 2020 completed an online survey asking participants about the perceived risk of the COVID-19 and adherence to confinement guidelines. Participants also completed a sociodemographic questionnaire and measures of psychological function. Multiple regression analysis was performed.

Results

Teleworking and Risk and COVID-19 controllability were significant predictors of the perceived risk of COVID-19 as measured by the perceived risk of being infected with COVID-19. Teleworking participants and those perceiving COVID-19 as less controllable reported a higher perceived risk of being infected with COVID-19 than those who were not in telework and perceived COVID-19 as a controllable condition. Adherence to confinement guidelines was predicted by the mental health status and perceived risk of COVID-19. Participants who reported worse mental health status, who perceived COVID-19 as a dangerous condition, and who trusted the public health system reported greater adherence to confinement guidelines.

Conclusions

The results of this study will be discussed considering their implications to public health policymaking to promote adherence to public health policies.

Disclosure

No significant relationships.

P–051 Differential resilience of sperm from different mammals to DNA decondensation

Study question

Does sperm from different species with different protamine 1/protamine 2 ratios have different resilience to sperm decondensation?

Summary answer

Sperm cells from species whose DNA is condensed with both protamine 1 and protamine 2 require less time in deprotamination steps.

What is known already

Sperm cells present a highly particular DNA condensation that is acquired during sperm differentiation, where most part of histones are replaced by protamines. Protamines are key elements for DNA condensation and, while protamine 1 is more conserved among species, protamine 2 has evolved differentially, existing only a few species that retain the mature protein in their sperm DNA. Changes in protamine expression rates have been described to be associated to head sperm size and shape. In addition, reduced amounts of protamine 2 are related to male infertility in species in which this protein is present.

Study design, size, duration

Cryopreserved sperm samples were treated with lysis solutions to induce DNA decondensation and formation of sperm haloes. In these treatments, the effect of different incubation times with proteinase K added to the lysis solution upon DNA decondensation was tested by analyzing core diameter, halo diameter and the Halo/core ratio in at least 50 sperm per sample.

Participants/materials, setting, methods

Species included in the study were Human, Equine, Donkey, Porcine and Bovine. Sperm samples from five different individuals for each species were included in the study. DNA decondensation included three lysis steps: first, a SDS + DTT incubation for 30 minutes; second, a DTT + NaCl treatment for 30 minutes; and third, a DTT + NaCl + Proteinase K treatment with a variable time of 0, 30 or 180 minutes.

Main results and the role of chance

The halo/core diameter, used as a representation of the degree of DNA decondensation, for 0 minutes, 30 minutes and 180 minutes of proteinase K incubation were: 4.68±0.51, 4.32±0.51 and 4.77±0.64, respectively for human sperm; 4.15±0.41, 4.57±0.53 and 4.68±0.63, respectively for Equine sperm; 4.40±0.64, 4.00±0.37 and 4.17±0.19, respectively for donkey sperm; 1.77±0.2, 3.05±0.14 and 4.13±0.39, respectively for porcine sperm; and 2.40±0.40, 3.36±0.22 and 4.19±0.38, respectively for bovine sperm. Differences of halo/core ratio in different times were only observed in porcine and bovine sperm, where increasing degrees of DNA decondensation were found (p &lt; 0.05). Therefore, these results show that while longer incubations in lysis solutions with proteinase K lead to higher DNA decondensation in porcine and bovine, they do not induce higher decondensation in human, equine and donkey. This evidence, coupled to the fact that porcine and bovine sperm present null or very low protamine 2 content, suggests that its presence might confer higher DNA decondensation susceptibility.

Limitations, reasons for caution

Only sperm cells with normal sperm haloes were analyzed in the present study. As multiple studies show, haloes exhibited by sperm cells with DNA damage display higher diameter, that is why they were strictly excluded in this study with the aim to elucidate the average DNA decondensation.

Wider implications of the findings: Sperm DNA might have different degrees of DNA condensation, which can be associated to a higher difficulty of DNA decondensation, thus having implications in the sensitivity tests that assess sperm DNA integrity.

Trial registration number

Not applicable.

Design of heart phantoms for ultrasound imaging of ventricular septal defects

PURPOSE

Ventricular septal defects (VSDs) are common congenital heart malformations. Echocardiography used during VSD hybrid cardiac procedures requires extensive training for image acquisition and interpretation. Cardiac surgery simulators with heart phantoms have shown usefulness for such training, but they are limited in visualization and characterization of complex VSD. This study explores a new method to build patient-specific heart phantoms with VSD, with proper tissue echogenicity for ultrasound imaging.

METHODS

Heart phantoms were designed from preoperative imaging of three patients with complex VSDs. Each whole heart phantom, including atrial and ventricular septums, was obtained by manual segmentation and by surface reconstruction, then by molding and by casting in different materials. Heart phantoms in silicone and polyvinyl alcohol cryogel (PVA-C) were considered, and they were reconstructed in 3-D using 2-D freehand ultrasound imaging.

RESULTS

An electromagnetic measurement system was used to measure the mean VSD diameters from the heart phantoms. Errors were evaluated below 1.0 mm for mean VSD diameters between 6.2 and 7.5 mm.

CONCLUSION

Patient-specific heart phantoms promise for representing complex heart malformations such as VSDs. PVA-C showed better tissue echogenicity than silicone for VSDs visualization and characterization.

Supravalvular and Valvular Pulmonary Stenosis: Predictive Features and Responsiveness to Percutaneous Dilation

Supravalvular pulmonary stenosis (SVPS) is considered a rare form of pulmonary stenosis (PS) and represents both a diagnostic and therapeutic challenge. There currently exist no reliable echocardiographic criteria to accurately predict the supravalvular form. The aims of the study were to describe the response to treatment of the different PS presentations and to outline the diagnostic capacity of echocardiogram to differentiate the SVPS from valvular PS (VPS). This retrospective study included 106 patients who underwent percutaneous angioplasty between 2006 and 2017. Interventional outcomes of patients with SVPS were compared to those of patients with VPS. Diagnosis of VPS vs. SVPS by echocardiogram was compared to diagnosis obtained by angiogram. Echocardiogram yielded a sensitivity of 56%, a specificity of 82.5%, a positive predictive value of 50%, and a negative predictive value of 85.7%. Patients with SVPS had a significantly smaller pulmonary artery to pulmonary valve (PA:PV) ratio. At 6-12 months of follow-up, the VPS group had a mean right ventricular to pulmonary artery (RV-PA) gradient of 21.68 ± 19.85 mmHg compared to 45.27 ± 24.58 mmHg in the SVPS group. Patients with SVPS had a higher rate of reintervention than patients with VPS (32% vs. 6.2%, p < 0.001). There was no difference in major complications between groups, whereas VPS patients had a higher proportion of pulmonary insufficiency. Percutaneous angioplasty for PS is less effective in patients with a supravalvular component. A better understanding of the underlying histopathology of different PS subtypes could lead to development of different techniques to improve outcomes, with fewer reinterventions, in this population.

Personalized stent design for congenital heart defects using pulsatile blood flow simulations

Stent size selection and placement are among the most challenging tasks in the treatment of pulmonary artery stenosis in congenital heart defects (CHD). Patient-specific 3D model from CT or MR improves the understanding of the patient's anatomy and information about the hemodynamics aid in patient risk assessment and treatment planning. This work presents a new approach for personalized stent design in pulmonary artery interventions combining personalized patient geometry and hemodynamic simulations. First, the stent position is initialized using a geometric approach. Second, the stent and artery expansion, including the foreshortening behavior of the stent is simulated. Two stent designs are considered, a regular stent and a Y-stent for bifurcations. Computational fluid dynamics (CFD) simulations of the blood flow in the initial and expanded artery models are performed using patient-specific boundary conditions in form of a pulsatile inflow waveform, 3-element Windkessel outflow conditions, and deformable vessel walls. The simulations have been applied to 16 patient cases with a large variability of anatomies. Finally, the simulations have been clinically validated using retrospective imaging from angiography and pressure measurements. The simulated pressure, volume flow and flow velocity values were on the same order of magnitude as the reference values obtained from clinical measurements, and the simulated stent placement showed a positive impact on the hemodynamic values. Simulation of geometric changes combined with CFD simulations offers the possibility to optimize stent type, size, and position by evaluating different configurations before the intervention, and eventually allow to test customized stent geometries and new deployment techniques in CHD.

Percutaneous transmitral balloon commissurotomy using a single balloon with arteriovenous loop stabilisation: an alternative when there is no Inoue balloon

Background

The Inoue balloon technique is the standard technique for mitral valve balloon commissurotomy at this stage. However, the hardware for this technique is expensive and may not always be available in resource-limited settings.

Objectives

This article reports our experience with percutaneous transmitral balloon commissurotomy using a single balloon (Nucleus) with arteriovenous loop stabilisation.

Methods

Eleven young patients, aged 12–26 years and weighing 23–48 kg, underwent transmitral balloon commissurotomy using the described technique at our centre from April to May 2014.

Results

Mean fluoroscopy time was 22.6 ± 6.4 min (18.5– 30.0). Mean transmitral gradient decreased from 24.1 ± 5.9 (16–35) to 6.6 ± 3.8 (3–14) mmHg, as measured on transoesophageal echocardiography. Mean mitral valve area increased from 0.69 ± 0.13 cm² (range 0.5–0.9) before dilation to 1.44 ± 0.25 cm² (1.1–1.9) after dilation (p < 0.001). Mean estimated pulmonary artery systolic pressure decreased from 110.0 ± 35 mmHg (75–170) before dilation to 28.0 ± 14.4 mmHg (range 10–60) after dilation.

Conclusion

Our modified Nucleus balloon technique for mitral valve dilation in young patients with mitral stenosis is effective and safe. The technique differs from other over-thewire techniques in that it avoids placing stiff wire in the left ventricle. It also offers better balloon stability and control owing to the arteriovenous loop. This technique may be easier for use by paediatric interventionists who might not be familiar with the Inoue balloon technique.

Automatic evaluation of vessel diameter variation from 2D X-ray angiography

PURPOSE

Early detection of blood vessel pathologies can be made through the evaluation of functional and structural abnormalities in the arteries, including the arterial distensibility measure. We propose a feasibility study on computing arterial distensibility automatically from monoplane 2D X-ray sequences for both small arteries (such as coronary arteries) and larger arteries (such as the aorta).

METHODS

To compute the distensibility measure, three steps were developed: First, the segment of an artery is extracted using our graph-based segmentation method. Then, the same segment is tracked in the moving sequence using our spatio-temporal segmentation method: the Temporal Vessel Walker. Finally, the diameter of the artery is measured automatically at each frame of the sequence based on the segmentation results.

RESULTS

The method was evaluated using one simulated sequence and 4 patients' angiograms depicting the coronary arteries and three depicting the ascending aorta. Results of the simulated sequence achieved a Dice index of 98%, with a mean squared error in diameter measurement of [Formula: see text] mm. Results obtained from patients' X-ray sequences are consistent with manual assessment of the diameter by experts.

CONCLUSIONS

The proposed method measures changes in diameter of a specific segment of a blood vessel during the cardiac sequence, automatically based on monoplane 2D X-ray sequence. Such information might become a key to help physicians in the detection of variations of arterial stiffness associated with early stages of various vasculopathies.

Agreement between child self-reported and parent-reported scores for chronic pain secondary to specific pediatric diseases

BACKGROUND

Parental report on a child's secondary chronic pain is commonly requested by anesthesiologists when the child cannot directly provide information. Daily pain intensity is reported as highest, average and lowest. However, it is unclear whether the parents' score is a valid indicator of the child's pain experience.

METHODS

Nineteen children (aged 6-18years) with secondary chronic pain attending our anesthesiologist-run pediatric pain unit participated in this study. Identification of highest, average and lowest pain intensity levels were requested during initial screening interviews with the child and parents. Pain intensity was scored on a 0-10 numerical rating scale. Agreement was examined using: (i) intraclass correlation coefficient (ICC), and (ii) the Bland-Altman method.

RESULTS

The ICC's between the children and the parents' pain intensity reports were: 0.92 for the highest, 0.68 for the average, and 0.50 for the lowest pain intensity domains. The limits of agreement set at 95% between child and parental reports were respectively +2.19 to -2.07, +3.17 to -3.88 and +5.15 to -5.50 for the highest, average and lowest pain domains.

CONCLUSIONS

For the highest pain intensity domain, agreement between parents and children was excellent. If replicated this preliminary finding would suggest the highest pain intensity is the easiest domain for reporting pain intensity when a child cannot directly express him or herself.

Rufinamide in children and adults in routine clinical practice

OBJECTIVE

To explore the long-term effectiveness of rufinamide in managing Lennox-Gastaut Syndrome (LGS), other epileptic encephalopathies, and intractable focal epilepsies in adults and children in routine clinical practice.

METHODS

A multicentre, retrospective chart review of patients prescribed adjunctive rufinamide at seven Spanish epilepsy centres, with assessments at six and 12 months.

RESULTS

We evaluated data from 58 patients (40 male, age range 7-57 years), 25 of whom were diagnosed with LGS, 12 with other epileptic encephalopathies and 21 of whom were diagnosed with focal epilepsies, mainly frontal lobe. The mean daily rufinamide dose was 32.0 mg/kg (range 12.5-66.7 mg/kg) in children and 24.7 mg/kg (range 5.0-47.0 mg/kg) in adults, and the most commonly used concomitant antiepileptic drugs were levetiracetam and valproate. Rufinamide was discontinued in 25 patients (43.1%) during the 1-year follow-up, and the most common reason was lack of effectiveness (n = 12, 20.7% of total). The frequency of generalized tonic-clonic seizures was significantly reduced from baseline at 6 and 12 months (P = 0.001), both in patients with generalized epilepsies and in patients with focal epilepsies. Significant seizure frequency reduction from baseline was observed at 12 months (P = 0.01) for tonic/atonic seizures and at 6 months (P = 0.001) for focal seizures. Side effects were reported in 21 patients (36.2%): nausea, vomiting and weight loss were most frequent.

CONCLUSIONS

Rufinamide was well tolerated and was effective in reducing frequency of generalized tonic-clonic, tonic/atonic and focal seizures in both children and adults with severe refractory epilepsies, primarily LGS.

A graph-based approach for spatio-temporal segmentation of coronary arteries in X-ray angiographic sequences

The segmentation and tracking of coronary arteries (CAs) are critical steps for the computation of biophysical measurements in pediatric interventional cardiology. In the literature, most methods are focused on either segmenting the vessel lumen or on tracking the vessel centerline. However, they do not simultaneously combine the segmentation and tracking of a specific CA. This paper introduces a novel algorithm for CA segmentation and tracking from 2D X-ray angiography sequences. The proposed algorithm is based on the Temporal Vessel Walker (TVW) segmentation method, which combines graph-based formulation and temporal priors. Moreover, superpixel groups are used by TVW as image primitives to ensure a better extraction of the CA. The proposed algorithm, TVW with superpixels (SP-TVW), returns an accurate result to segment and track the artery along the angiogram. Quantitative results over 12 sequences of young patients show the accuracy of the proposed framework. The results return a mean recall of 84% in the dataset. In addition, the proposed method returned a Dice index of 70% in segmenting and tracking right coronary arteries and circumflex arteries. The performance of the proposed method surpasses the existing polyline method in tracking the centerline of CA with a more precise localization of the centerline, resulting in a smaller distance error of 0.23mm compared to 0.94mm.

Shone Complex: An Under-recognized Congenital Heart Disease With Substantial Morbidity in Adulthood

BACKGROUND

Shone complex consists of a constellation of left-sided, usually obstructive, cardiac lesions, including supravalvar mitral ring, parachute mitral valve, subaortic stenosis, and aortic coarctation. Incomplete Shone complex consists of a mitral valve anomaly associated with lesions involving the subaortic region, aortic valve, or thoracic aorta. There is a paucity of data regarding long-term outcomes in adults with Shone complex.

METHODS

We reviewed records of adults with complete or incomplete Shone complex followed at the Montreal Heart Institute between 1982 and 2014.

RESULTS

Among 4189 adults with congenital heart disease, 28 (0.67%) patients (mean age, 35 ± 11 years; 50% women) had complete or incomplete Shone complex and were followed for a median of 8 years. Only 39% were previously diagnosed as having Shone complex. The most common defects were congenital mitral stenosis (93%), aortic coarctation (75%), and bicuspid aortic valve (71%). Heart transplantation was required in 2 patients (7.1%) at age 22 and 28 years, respectively. Overall, 48% had cardiovascular hospitalizations during adulthood, predominantly for arrhythmias or heart failure. Freedom from cardiovascular intervention was 55%, 18%, and 8% at 10, 20, and 30 years of age, respectively. Although aortic coarctation was the most common indication for initial intervention (61%), adult interventions occurred predominantly for aortic valve/left ventricular outflow tract (60%) and mitral valve (33%) lesions.

CONCLUSIONS

Shone complex is an under-recognized entity associated with relatively low mortality in adulthood but substantial morbidity related to arrhythmias, heart failure, and interventions. Increased awareness of this condition and associated complications may allow for more tailored follow-up.

Percutaneous recanalization of totally occluded coarctation of the aorta in children using Brockenbrough needle and covered stents

Percutaneous treatment of totally occluded coarctation of the aorta has been reported predominantly in adults. The success and challenges of this procedure in children is reported in few patients. We report an outcome of percutaneous treatment of three children with completely occluded coarctation of the aorta. The age range was 9-14 years. All the patients had upper limb hypertension. One case had severe left ventricular dysfunction. In all cases, a pediatric Brockenbrough needle and a covered stent were implanted. Recanalization and implantation of a covered stent was successful in all patients. One of these patients developed transient postcoarctectomy syndrome. Percutaneous recanalization of totally occluded coarctation of the aorta using Brockenbrough needle and a covered stent in children is feasible and effective.

Genetic relationships among American donkey populations: insights into the process of colonization

This study presents the first insights into the genetic diversity and structure of the American donkey metapopulation. The primary objectives were to detect the main structural features underlying variability among American donkey populations, identify boundaries between differentiated gene pools, and draw the main colonization pathways since the introduction of donkeys into America in the 15th century. A panel of 14 microsatellite markers was applied for genotyping 350 American donkeys from 13 countries. The genetic structure of this metapopulation was analysed using descriptive statistics and Bayesian model-based methods. These populations were then compared to a database containing information on 476 individuals from 11 European breeds to identify the most likely ancestral donor populations. Results showed the presence of two distinct genetic pools, with confluence of the two in Colombia. The southern pool showed a unique genetic signature subsequent to an older founder event, but lacked any significant influence of modern gene flow from Europe. The northern pool, conversely, may have retained more ancestral polymorphisms and/or have experienced modern gene flow from Spanish breeds. The Andalusian and, to a lesser extent, the Catalan breeds have left a more pronounced footprint in some of the American donkey populations analysed.

EEG extreme delta brush: An ictal pattern in patients with anti-NMDA receptor encephalitis

INTRODUCTION

The anti-NMDA receptor (NMDAr) encephalitis-associated syndrome includes neuropsychiatric symptoms, impaired consciousness, seizures, autonomic instability, and hypoventilation. The electroencephalographic (EEG) activity throughout the course of the disease has still not been well documented. We reviewed electroclinical data of patients with NMDAr encephalitis to characterize their EEG and its clinical correlation.

MATERIAL AND METHODS

We retrospectively identified 16 patients with NMDAr encephalitis from 8 Spanish medical centers, 15 of whom underwent video-EEG in the acute phase.

RESULTS

In 15 patients (11 females, median age: 37.4, range: 14-87 years), seizures occurred in 9 (60%) and status epilepticus (SE) in 5 (33.3%). Magnetic resonance imaging (MRI) was abnormal in 10 (66.6%), and CSF (cerebrospinal fluid) was normal in 3 and abnormal in 12, with positive PCR (polymerase chain reaction) for Mycoplasma pneumoniae (1/15) and herpes simple virus (1/15). An ovarian teratoma was found in 1 patient and other malignancies (small cell lung carcinoma) in 1 patient. The EEG was abnormal in the acute phase in 14/15 (93.3%). Extreme delta brush (EDB) was observed in 5 (33.3%), and the presence of EDB was associated with SE in all cases. Rhythmic delta activity without EDB was observed in 5 (33.3%), while excessive beta activity was present in 4 (26.6%). Extreme delta brush can follow a pattern of well-characterized electroclinical seizures.

CONCLUSIONS

Almost invariably, patients with NMDAr encephalitis had abnormal EEG. The presence of EDB, which can follow a pattern of well-characterized electroclinical seizures, in our patients was associated with seizures and SE. These findings suggest that EDB could be an evolutive pattern of an SE in NMDAr encephalitis. This article is part of a Special Issue entitled "Status Epilepticus".

Validity of three rating scales for measuring pain intensity in youths with physical disabilities

BACKGROUND

There is growing evidence confirming that youths with physical disabilities are at risk for chronic pain. Although many scales for assessing pain intensity exist, it is unclear whether they are all equally suitable for youths. The aim of this study was to address this knowledge gap by comparing the validity of the Numerical Rating Scale (NRS-11), the Wong Baker FACES Pain Rating Scale (FACES), and a 6-point categorical Verbal Rating Scale (VRS-6) for assessing pain intensity among youths (aged 8-20) with physical disabilities.

METHODS

One hundred and thirteen youths (mean age = 14.19 years; SD = 2.9) were interviewed and asked to rate their current pain intensity and recalled (in the past week) worst, least, and average pain with the NRS-11 and the FACES. Participants were also asked to rate their average pain intensity during the past 4 weeks using a VRS-6, and were administered measures assessing pain interference, disability and psychological functioning.

RESULTS

Analyses showed that all of the pain intensity measures were associated positively with each other. Nevertheless, the NRS-11 appeared to out-perform both the VRS-6 and in particular the FACES scale with respect to: (1) the associations with the validity criterion (i.e. pain interference, disability and psychological functioning) and (2) a lack of any moderating effect of age on the association between the measure and the criterion variables.

CONCLUSIONS

The findings support the validity of the NRS-11 for assessing pain intensity in youths with physical disabilities between the ages of 8 and 20 years.

Cryotolerance of stallion spermatozoa is related to ROS production and mitochondrial membrane potential rather than to the integrity of sperm nucleus

Although cryopreservation of stallion spermatozoa allows long-term preservation of spermatozoa from particular stallions and facilitates international trade, it is understood to inflict damages on sperm cells that may finally reduce their fertilizing ability. In addition, individual differences are known to exist in the sperm ability to withstand freeze-thawing protocols. To date, these differences have mainly been reported on the basis of sperm motility and membrane integrity. For this reason, the present work sought to determine differences between good (good freezability ejaculates: GFE) and poor (poor freezability ejaculates: PFE) freezability stallion ejaculates in other sperm parameters, including peroxide and superoxide levels, potential of mitochondrial membrane and nuclear integrity. With this purpose, a total of 24 stallion ejaculates were cryopreserved and classified into two groups (GFE vs. PFE), depending on their sperm membrane integrity and motility after freeze-thawing. From the total of 24 ejaculates, 13 were classified as GFE and the other 11 were classified as PFE. Apart from differences in sperm membrane permeability and lipid disorder after freeze-thawing, GFE presented significantly (p < 0.05) higher percentages of viable spermatozoa with high content of peroxides and of superoxides than PFE. In contrast, and despite cryopreservation of stallion spermatozoa increasing DNA fragmentation and disrupting disulphide bonds in sperm head proteins, no significant differences between GFE and PFE were seen. We can thus conclude that good and poor freezability stallion ejaculates differ in their reactive oxygen species levels after cryopreservation, but not in the damage extent on sperm nucleus.

Percutaneous angioplasty used to manage native and recurrent coarctation of the aorta in infants younger than 1 year: immediate and midterm results

Balloon angioplasty (BAP) used to manage native coarctation of the aorta (CoAo) in infants remains controversial. This study aimed to compare short- and midterm results of BAP between native CoAo (NaCo) and postsurgical recoarctations (ReCo) in infants younger than 1 year. This retrospective study compared the clinical, echocardiographic, hemodynamic, and angiographic data for infants who underwent BAP between July 2003 and September 2012. The 12 NaCo and 13 ReCo patients in this study underwent BAP at 4.61 ± 3.69 and 4.88 ± 3.07 months (p = 0.84) and weighed 5.49 ± 2.57 and 6.10 ± 2.11 kg (p = 0.52), respectively. Their respective heights were 60.58 ± 10.58 and 61.15 ± 6.74 cm (p = 0.87). All the ReCo patients had their initial surgery before the age of 3 months. The minimal CoAo diameter was 2.81 ± 0.96 mm in the NaCo group and 2.86 ± 1.0 mm in the ReCo group (p = 0.90). The relative gradient reduction was 62.79 ± 32.43 % in the NaCo group and 73.37 ± 20.78 % in the ReCo group (p = 0.33). The in situ complication rate (pseudoaneurysm) was 8.33 % in the NaCo group and 7.69 % in the ReCo group (p = 0.74). During the early follow-up evaluation, five NaCo patients (41.66 %) presented with recoarctation requiring BAP reintervention within 1.75 ± 1.41 months (all had their initial BAP before 3 months of age) compared with 1 ReCo patient (7.69 %) (p = 0.165). The mean follow-up period was 3.09 ± 2.69 years for the NaCo patients and 3.6 ± 3.18 years for the ReCo patients (p = 0.69), during which the blood pressure gradient was 12.33 ± 9.67 for the NaCo patients and 7.80 ± 8.78 for the ReCo patients (p = 0.17), with corresponding Doppler peak instantaneous gradients of 21.29 ± 11.19 and 16.20 ± 10.23 (p = 0.24). The resultant diameter ratio between the minimal isthmus diameter and the aortic diameter at the diaphragmatic level was 0.81 ± 0.15 in the NaCo group and 0.85 ± 0.12 in the ReCo group (p = 0.53). The immediate and midterm results of BAP for the NaCo and ReCo infants were comparable. Accordingly, BAP seems to be an acceptable alternative to surgery for infants older than 3 months.

Low-dose sodium valproate in the treatment of idiopathic generalized epilepsies

OBJECTIVE

Most patients with idiopathic generalized epilepsies (IGEs) have good seizure control when on antiepileptic drugs. To analyze prospectively the response to low-dose sodium valproate (VPA) treatment (<1000 mg/day) together with plasma VPA levels in a cohort of patients with IGE.

METHODS

Patients with IGE were selected and followed for almost 2 years. In patients on VPA with no seizures in the last year, VPA dose was lowered to <1000 mg/day. Newly diagnosed patients with IGE started treatment on VPA directly on this low dose.

RESULTS

Fifty-four patients were included, with juvenile myoclonic epilepsy (JME) in 23 (42.6%), juvenile absence epilepsy (JAE) in 17 (31.5%), and generalized tonic-clonic seizures only (GTCS only) in 14 (25.9%). VPA at low dose was administered to 38 (70%) patients. Mean plasma VPA level was 44.21 mg/l (18-78; SD 15.18). Seizure relapse during the 2-year follow-up was observed in 8 (21%). A reduction in adverse events was observed (P < 0.048). The only factor related to efficacy of VPA at low dose was syndromic diagnosis. Low-dose VPA controlled 92.9% (13) of patients with GTCS only, 78.3% (18) of those with JME, and 29.5% (5) of those with JAE.

CONCLUSIONS

Low-dose VPA was a highly effective treatment for the majority of those with JME and GTCS only. The seizures in JAE tended to be more resistant to treatment, usually requiring higher doses of VPA or polytherapy.

Combination of corpus callosotomy and vagus nerve stimulation in the treatment of refractory epilepsy

BACKGROUND

Palliative techniques such as partial corpus callosotomy (CC) and vagus nerve stimulation (VNS) may be effective for adequate control of seizures in pharmacoresistant patients who are not candidates for resective surgery.

OBJECTIVE

The objective of this study was to analyze the efficacy of the combination of these two techniques in patients where the first surgery had not achieved adequate control.

MATERIALS AND METHODS

This is a retrospective review of 6 patients with refractory epilepsy in which both types of surgery were performed, CC and VNS. We analyzed variables such as age, sex, age at onset of epilepsy, seizure types, electroencephalogram and magnetic resonance imaging results, and number of pre- and postoperative seizures.

RESULTS

Three patients first underwent VNS and then CC, and 3 patients were treated in reverse order. All patients had some improvement after the first surgery, but they continued to experience persistent falls, so a second palliative technique was used. The mean improvement after both surgeries was 89% (90% in patients first receiving CC and 87% in patients who first underwent VNS).

CONCLUSIONS

In adequately studied patients who are not optimal candidates for resective surgery, palliative surgery is a choice. The combination of VNS and CC shows good results in our series, although the right order to perform both procedures has not been defined. These results should be confirmed in a larger group of patients.

Influence of seminal plasma on leucocyte migration and amount of COX-2 protein in the jenny endometrium after insemination with frozen-thawed semen

After mating, seminal plasma has an immuno-modulatory effect on the endometrium in some mammals. In jennies, achieving conception via artificial insemination (AI) with frozen-thawed semen is generally much more difficult than in mares. The endometrial inflammatory response is hypothesized to be a contributing factor to the lesser fertility. Following a cross-over experimental design, the uterine inflammatory response of six jennies was evaluated at 6h after AI with frozen-thawed semen (deposited in the uterine body) in the presence or absence of autologous seminal plasma (+SP or -SP). The endometrial cytology and histology of the animals were examined by uterine lavage, uterine swabbing and biopsy. The amount of cyclooxygenase-2 (COX-2) protein in endometrial cells was also evaluated. As a control (C), the same examinations were made before any AI procedure (i.e., when the jennies were in oestrus). Large numbers of polymorphonuclear neutrophils (PMN) were observed in the -SP and +SP cytology and biopsy samples; more than in the C samples. The -SP samples also had intense COX-2 labelling; less labelling was detected in the +SP and C samples (no significant difference between these latter two types). Thus, while the presence of SP does not change the post-AI number of PMNs with regard to that detected in its absence, it does reduce COX-2 protein. Further research into the complex mix of molecules in SP and its effects during AI might help increase the pregnancy rates achieved in jennies.

Efficacy of intravenous lacosamide as an add-on treatment in refractory status epilepticus: a multicentric prospective study

OBJECTIVE

Treatment of status epilepticus (SE) has not changed in the last few decades, benzodiazepines plus phenytoin or valproate being the most common treatment. Once this first and second line treatment has failed SE is considered refractory (RSE). This study aimed to assess the efficacy and tolerability of intravenous (iv) lacosamide (LCM) in RSE.

METHOD

Patients with RSE who were treated with ivLCM in six Spanish centers were prospectively included. Efficacy was defined as cessation of seizures after starting ivLCM, with no need for any further antiepileptic drug. All patients had been unsuccessfully treated following the standard protocol (benzodiazepines plus phenytoin or valproate) before ivLCM was added.

RESULTS

Thirty-four patients were included, 52.9% men, with mean age of 60.15 years. In 58.9% of patients the etiology was symptomatic, and the most common type of SE was focal convulsive (82.4%). Mean initial bolus dose of LCM was 323.53mg. ivLCM was effective in more than half of patients (64.7%), with termination of SE before 12h in 50% of them. ivLCM was used as a fourth or later option in 76.5% of patients. No serious adverse events attributable to LCM were reported.

CONCLUSIONS

LCM might be a fast, effective and safe add-on treatment in RSE.

Rheological properties of the anterior vaginal fluid from superovulated dairy heifers at estrus

Anterior vaginal fluid samples were collected from 25 dairy heifers induced to superovulation at 12 to 20 hours after estrus detection. Thixotropy and flow behavior were evaluated. In samples from 19 heifers, structural variation was registered and the fluids were considered to be thixotropic; in the remaining samples (6 heifers), structural variation was not registered and the fluids were considered to be nonthixotropic. The mean estradiol concentration of the thixotropic fluids (20.8 pg/ml) was lower (P=0.0002) than of the nonthixotropic samples (56.7 pg/ml). All the nonthixotropic samples of anterior vaginal fluid exhibited Newtonian behavior. Of the 25 thixotropic anterior vaginal fluid samples, 10 exhibited Newtonian behavior while 9 exhibited non-Newtonian behavior. Heifers in which samples exhibited Newtonian behavior had a higher mean estradiol concentration (38.8 pg/ml; P=0.003) than heifers in which samples exhibited non-Newtonian behavior (12.8 pg/ml). Estradiol concentrations were correlated negatively (P=0.02) with the index of consistency (r = -0.46) and were not related to structural variation (P=0.08), although a certain tendency was shown. These results have shown that thixotropic and flow behavior measurements in the anterior vaginal fluid of superovulated estrous heifers vary over a wide range and even qualitatively. This variation is related to estrogen levels: Fluidity increases with increased plasma estrogen values, and the integrity of the gel structure tends toward elimination.

Transcatheter embolization of anomalous systemic arterial supply with Amplatzer Vascular Plugs II in Scimitar syndrome

A 57-year-old woman suffering from recurrent pneumonia and considered to be high risk for surgical correction of an atrial septal defect (ASD) associated with a right lung sequestration vascularized by arteries coming from the abdominal aorta and an abnormal venous drainage into the inferior vena cava (Scimitar syndrome). Therefore stepwise transcatheter approach was offered as an alternative treatment. We performed ASD closure and embolization of the anomalous systemic arterial supply using Amplatzer Vascular Plugs II. The abnormal venous drainage was conservatively treated (Q(p) /Q(s) : 1.1/1 after ASD closure and anomalous arterial supply embolization). At 24-month follow-up, no recurrent pneumonia was reported, functional class improved and right cardiac cavities normalized.