Diterpene Ginkgolides Meglumine Injection inhibits apoptosis induced by optic nerve crush injury via modulating MAPKs signaling pathways in retinal ganglion cells

ETHNOPHARMACOLOGICAL RELEVANCE

Diterpene Ginkgolides Meglumine Injection (DGMI) is made of extracts from Ginkgo biloba L, including Ginkgolides A, B, and K and some other contents, and has been widely used as the treatment of cerebral ischemic stroke in clinic. It can be learned from the "Compendium of Materia Medica" that Ginkgo possesses the effect of "dispersing toxin". The ancient Chinese phrase "dispersing toxin" is now explained as elimination of inflammation and oxidative state in human body. And it led to the original ideas for today's anti-oxidation studies of Ginkgo in apoptosis induced by optic nerve crush injury.

AIM OF THE STUDY

To investigate the underlying molecular mechanism of the DGMI in retinal ganglion cells (RGCs) apoptosis.

MATERIALS AND METHODS

TUNEL staining was used to observe the anti-apoptotic effects of DGMI on the adult rat optic nerve injury (ONC) model, and flow cytometry and hoechst 33,342 staining were used to observe the anti-apoptotic effects of DGMI on the oxygen glucose deprivation (OGD) induced RGC-5 cells injury model. The regulation of apoptosis and MAPKs pathways were investigated with Immunohistochemistry and Western blotting.

RESULTS

This study demonstrated that DGMI is able to decrease the conduction time of F-VEP and ameliorate histological features induced by optic nerve crush injury in rats. Immunohistochemistry and TUNEL staining results indicated that DGMI can also inhibit cell apoptosis via modulating MAPKs signaling pathways. In addition, treatment with DGMI markedly improved the morphological structures and decreased the apoptotic index in RGC-5 cells. Mechanistically, DGMI could significantly inhibit cell apoptosis by inhibiting p38, JNK and Erk1/2 activation.

CONCLUSION

The study shows that DGMI and ginkgolides inhibit RGCs apoptosis by impeding the activation of MAPKs signaling pathways in vivo and in vitro. Therefore, the present study provided scientific evidence for the underlying mechanism of DGMI and ginkgolides on optic nerve crush injury.

T1-Mapping and extracellular volume estimates in pediatric subjects with Duchenne muscular dystrophy and healthy controls at 3T

BACKGROUND

Cardiovascular disease is the leading cause of death in patients with Duchenne muscular dystrophy (DMD)-a fatal X-linked genetic disorder. Late gadolinium enhancement (LGE) imaging is the current gold standard for detecting myocardial tissue remodeling, but it is often a late finding. Current research aims to investigate cardiovascular magnetic resonance (CMR) biomarkers, including native (pre-contrast) T1 and extracellular volume (ECV) to evaluate the early on-set of microstructural remodeling and to grade disease severity. To date, native T1 measurements in DMD have been reported predominantly at 1.5T. This study uses 3T CMR: (1) to characterize global and regional myocardial pre-contrast T1 differences between healthy controls and LGE + and LGE- boys with DMD; and (2) to report global and regional myocardial post-contrast T1 values and myocardial ECV estimates in boys with DMD, and (3) to identify left ventricular (LV) T1-mapping biomarkers capable of distinguishing between healthy controls and boys with DMD and detecting LGE status in DMD.

METHODS

Boys with DMD (N = 28, 13.2 ± 3.1 years) and healthy age-matched boys (N = 20, 13.4 ± 3.1 years) were prospectively enrolled and underwent a 3T CMR exam including standard functional imaging and T1 mapping using a modified Look-Locker inversion recovery (MOLLI) sequence. Pre-contrast T1 mapping was performed on all boys, but contrast was administered only to boys with DMD for post-contrast T1 and ECV mapping. Global and segmental myocardial regions of interest were contoured on mid LV T1 and ECV maps. ROI measurements were compared for pre-contrast myocardial T1 between boys with DMD and healthy controls, and for post-contrast myocardial T1 and ECV between LGE + and LGE- boys with DMD using a Wilcoxon rank-sum test. Results are reported as median and interquartile range (IQR). p-Values < 0.05 were considered significant. Receiver Operating Characteristic analysis was used to evaluate a binomial logistic classifier incorporating T1 mapping and LV function parameters in the tasks of distinguishing between healthy controls and boys with DMD, and detecting LGE status in DMD. The area under the curve is reported.

RESULTS

Boys with DMD had significantly increased global native T1 [1332 (60) ms vs. 1289 (56) ms; p = 0.004] and increased within-slice standard deviation (SD) [100 (57) ms vs. 74 (27) ms; p = 0.001] compared to healthy controls. LGE- boys with DMD also demonstrated significantly increased lateral wall native T1 [1322 (68) ms vs. 1277 (58) ms; p = 0.001] compared to healthy controls. LGE + boys with DMD had decreased global myocardial post-contrast T1 [565 (113) ms vs 635 (126) ms; p = 0.04] and increased global myocardial ECV [32 (8) % vs. 28 (4) %; p = 0.02] compared to LGE- boys. In all classification tasks, T1-mapping biomarkers outperformed a conventional biomarker, LV ejection fraction. ECV was the best performing biomarker in the task of predicting LGE status (AUC = 0.95).

CONCLUSIONS

Boys with DMD exhibit elevated native T1 compared to healthy, sex- and age-matched controls, even in the absence of LGE. Post-contrast T1 and ECV estimates from 3T CMR are also reported here for pediatric patients with DMD for the first time and can distinguish between LGE + from LGE- boys. In all classification tasks, T1-mapping biomarkers outperform a conventional biomarker, LVEF.

Is a timely assessment of the hematocrit necessary for cardiovascular magnetic resonance-derived extracellular volume measurements?

BACKGROUND

Cardiovascular magnetic resonance (CMR)-derived extracellular volume (ECV) requires a hematocrit (Hct) to correct contrast volume distributions in blood. However, the timely assessment of Hct can be challenging and has limited the routine clinical application of ECV. The goal of the present study was to evaluate whether ECV measurements lead to significant error if a venous Hct was unavailable on the day of CMR.

METHODS

109 patients with CMR T1 mapping and two venous Hcts (Hct0: a Hct from the day of CMR, and Hct1: a Hct from a different day) were retrospectively identified. A synthetic Hct (Hctsyn) derived from native blood T1 was also assessed. The study used two different ECV methods, (1) a conventional method in which ECV was estimated from native and postcontrast T1 maps using a region-based method, and (2) an inline method in which ECV was directly measured from inline ECV mapping. ECVs measured with Hct0, Hct1, and Hctsyn were compared for each method, and the reference ECV (ECV0) was defined using the Hct0. The error between synthetic (ECVsyn) and ECV0was analyzed for the two ECV methods.

RESULTS

ECV measured using Hct1 and Hctsyn were significantly correlated with ECV0 for each method. No significant differences were observed between ECV0 and ECV measured with Hct1 (ECV1; 28.4 ± 6.6% vs. 28.3 ± 6.1%, p = 0.789) and between ECV0 and ECV calculated with Hctsyn (ECVsyn; 28.4 ± 6.6% vs. 28.2 ± 6.2%, p = 0.45) using the conventional method. Similarly, ECV0 was not significantly different from ECV1 (28.5 ± 6.7% vs. 28.5 ± 6.2, p = 0.801) and ECVsyn (28.5 ± 6.7% vs. 28.4 ± 6.0, p = 0.974) using inline method. ECVsyn values revealed relatively large discrepancies in patients with lower Hcts compared with those with higher Hcts.

CONCLUSIONS

Venous Hcts measured on a different day from that of the CMR examination can still be used to measure ECV. ECVsyn can provide an alternative method to quantify ECV without needing a blood sample, but significant ECV errors occur in patients with severe anemia.

Hyper-acute cardiovascular magnetic resonance T1 mapping predicts infarct characteristics in patients with ST elevation myocardial infarction

BACKGROUND

Myocardial recovery after primary percutaneous coronary intervention in acute myocardial infarction is variable and the extent and severity of injury are difficult to predict. We sought to investigate the role of cardiovascular magnetic resonance T1 mapping in the determination of myocardial injury very early after treatment of ST-segment elevation myocardial infarction (STEMI).

METHODS

STEMI patients underwent 3 T cardiovascular magnetic resonance (CMR), within 3 h of primary percutaneous intervention (PPCI). T1 mapping determined the extent (area-at-risk as %left ventricle, AAR) and severity (average T1 values of AAR) of acute myocardial injury, and related these to late gadolinium enhancement (LGE), and microvascular obstruction (MVO). The characteristics of myocardial injury within 3 h was compared with changes at 24-h to predict final infarct size.

RESULTS

Forty patients were included in this study. Patients with average T1 values of AAR ≥1400 ms within 3 h of PPCI had larger LGE at 24-h (33% ±14 vs. 18% ±10, P = 0.003) and at 6-months (27% ±9 vs. 12% ±9; P < 0.001), higher incidence and larger extent of MVO (85% vs. 40%, P = 0.016) & [4.0 (0.5-9.5)% vs. 0 (0-3.0)%, P = 0.025]. The average T1 value was an independent predictor of acute LGE (β 0.61, 95%CI 0.13 to 1.09; P = 0.015), extent of MVO (β 0.22, 95%CI 0.03 to 0.41, P = 0.028) and final infarct size (β 0.63, 95%CI 0.21 to 1.05; P = 0.005). Receiver-operating-characteristic analysis showed that T1 value of AAR obtained within 3-h, but not at 24-h, predicted large infarct size (LGE > 9.5%) with 100% positive predictive value at the optimal cut-off of 1400 ms (area-under-the-curve, AUC 0.88, P = 0.006).

CONCLUSION

Hyper-acute T1 values of the AAR (within 3 h post PPCI, but not 24 h) predict a larger extent of MVO and infarct size at both 24 h and 6 months follow-up. Delayed CMR scanning for 24 h could not substitute the significant value of hyper-acute average T1 in determining infarct characteristics.

4D flow vs. 2D cardiac MRI for the evaluation of pulmonary regurgitation and ventricular volume in repaired tetralogy of Fallot: a retrospective case control study

Lengthy exams and breath-holding limit the use of pediatric cardiac MRI (CMR). 3D time-resolved flow MRI (4DF) is a free-breathing, single-sequence exam that obtains magnitude (anatomic) and phase contrast (PC) data. We compare the accuracy of gadobenate dimeglumine-enhanced 4DF on a 1.5 T magnet to 2D CMR in children with repaired tetralogy of Fallot (rTOF) to measure pulmonary net flow (PNF) as a reflection of pulmonary regurgitation, forward flow (FF) and ventricular volumetry. Thirty-four consecutive cases were included. 2D PCs were obtained at the valve level. Using 4DF, we measured PNF at the valve and at the main and branch pulmonary arteries. PNF measured at the valve by 4DF demonstrated the strongest correlation (r = 0.87, p < 0.001) and lowest mean difference (3.5 ± 9.4 mL/beat) to aortic net flow (ANF). Semilunar FF and stroke volume of the respective ventricle demonstrated moderate-strong correlation by 4DF (r = 0.66-0.81, p < 0.001) and strong correlation by 2D (r = 0.81-0.84, p < 0.001) with similar correlations and mean differences between techniques (p > 0.05). Ventricular volumes correlated strongly between 2D and 4DF (r = 0.75-0.96, p < 0.001), though 4DF overestimated right ventricle volumes by 11.8-19.2 mL/beat. Inter-rater reliability was excellent for 2D and 4DF volumetry (ICC = 0.91-0.99). Ejection fraction moderately correlated (r = 0.60-0.75, p < 0.001) with better reliability by 4DF (ICC: 0.80-0.85) than 2D (ICC: 0.69-0.89). 4DF exams were shorter than 2D (9 vs. 71 min, p < 0.001). 4DF provides highly reproducible and accurate measurements of flow with slight overestimation of RV volumes compared to 2D in pediatric rTOF. 4DF offers important advantages in this population with long-term monitoring needs.

The dynamics of extracellular gadolinium-based contrast agent excretion into pleural and pericardial effusions quantified by T1 mapping cardiovascular magnetic resonance

INTRODUCTION

Excretion of cardiovascular magnetic resonance (CMR) extracellular gadolinium-based contrast agents (GBCA) into pleural and pericardial effusions, sometimes referred to as vicarious excretion, has been described as a rare occurrence using T1-weighted imaging. However, the T1 mapping characteristics as well as presence, magnitude and dynamics of contrast excretion into these effusions is not known.

AIMS

To investigate and compare the differences in T1 mapping characteristics and extracellular GBCA excretion dynamics in pleural and pericardial effusions.

METHODS

Clinically referred patients with a pericardial and/or pleural effusion underwent CMR T1 mapping at 1.5 T before, and at 3 (early) and at 27 (late) minutes after administration of an extracellular GBCA (0.2 mmol/kg, gadoteric acid). Analyzed effusion characteristics were native T1, ΔR1 early and late after contrast injection, and the effusion-volume-independent early-to-late contrast concentration ratio ΔR1early/ΔR1late, where ΔR1 = 1/T1post-contrast - 1/T1native.

RESULTS

Native T1 was lower in pericardial effusions (n = 69) than in pleural effusions (n = 54) (median [interquartile range], 2912 [2567-3152] vs 3148 [2692-3494] ms, p = 0.005). Pericardial and pleural effusions did not differ with regards to ΔR1early (0.05 [0.03-0.10] vs 0.07 [0.03-0.12] s- 1, p = 0.38). Compared to pleural effusions, pericardial effusions had a higher ΔR1late (0.8 [0.6-1.2] vs 0.4 [0.2-0.6] s- 1, p < 0.001) and ΔR1early/ΔR1late (0.19 [0.08-0.30] vs 0.12 [0.04-0.19], p < 0.001).

CONCLUSIONS

T1 mapping shows that extracellular GBCA is excreted into pericardial and pleural effusions. Consequently, the previously used term vicarious excretion is misleading. Compared to pleural effusions, pericardial effusions had both a lower native T1, consistent with lesser relative fluid content in relation to other components such as proteins, and more prominent early excretion dynamics, which could be related to inflammation. The clinical diagnostic utility of T1 mapping to determine quantitative contrast dynamics in pericardial and pleural effusions merits further investigation.

Gadoterate Meglumine Administration in Multiple Sclerosis has no Effect on the Dentate Nucleus and the Globus Pallidus Signal Intensities

RATIONALE AND OBJECTIVES

Previous studies on possible accumulation of gadolinium-based contrast agents (GBCA) in the brain suggest that macrocyclic GBCA are less likely to accumulate than linear GBCA. However, conflicting results have been reported, especially in MS. The aim of this study is to investigate retrospectively the correlation between gadoterate-meglumine (macrocyclic GBCA) use and T1 signal intensity changes (SI) in the dentate nucleus and the GP on unenhanced T1-weighted images in a large cohort of MS patients.

MATERIALS AND METHODS

Unenhanced T1-weighted images of 232 MS patients who previously received multiple intravenous administrations of 0.1 mmol/kg of gadoterate-meglumine were reviewed. The change in T1 SI ratios of dentate nucleus/central pons (DN/CP) and globus pallidus/centrum semiovale (GP/CSO) was calculated between the first and last MRIs and correlated with age, number of injections, time interval between MRIs, disease duration, activity, and therapy.

RESULTS

DN/CP ratio showed no significant changes whereas the GP/CSO ratio showed a significant decrease (p < 0.0001) between the first and last MRIs. Multivariable analyses of both ratios, controlling for age, disease duration, and time interval between MRIs, showed no significant correlation between the number of gadolinium injections and the differences in DN/CP (standardized beta = -0.018, p = 0.811) or GP/CSO SI ratios (standardized beta = -0.049, p = 0.499).

CONCLUSION

Repeated administration of gadoterate-meglumine in MS patients did not result in increased T1 SI in the DN or the GP. The significant decrease of GP/CSO ratio between the first and last MRIs is not due to gadolinium accumulation but rather to varying MR parameters.

mDixon ECG-gated 3-dimensional cardiovascular magnetic resonance angiography in patients with congenital cardiovascular disease

BACKGROUND

Cardiovascular magnetic resonance (CMR) angiography (CMRA) is an important non-invasive imaging tool for congenital heart disease (CHD) and aortopathy patients. The conventional 3D balanced steady-state free precession (bSSFP) sequence is often confounded by imaging artifacts. We sought to compare the respiratory navigated and electrocardiogram (ECG) gated modified Dixon (mDixon) CMRA sequence to conventional non-gated dynamic multi-phase contrast enhanced CMRA (CE-CMRA) and bSSFP across a variety of diagnoses.

METHODS

We included 24 patients with CHD or aortopathy with CMR performed between September 2017 to December 2017. Each patient had undergone CE-CMRA, followed by a bSSFP and mDixon angiogram. Patients with CMR-incompatible implants or contraindications to contrast were excluded. The studies were rated according to image quality at a scale from 1 (poor) to 4 (excellent) based on diagnostic adequacy, artifact burden, vascular border delineation, myocardium-blood pool contrast, and visualization of pulmonary and systemic veins and coronaries. Contrast-to-noise ratio (CNR), signal-to-noise ratio (SNR) and quantitative vascular measurements were compared between the two gated sequences. Bland-Altman plots were generated to compare paired measures.

RESULTS

All scans were diagnostically adequate. Mean (SD) quality scores were 3.4 (0.7) for the mDixon, 3.2 (0.5) for the bSSFP and 3.4 (0.5) for the CE-CMRA. Qualitatively, the intracardiac anatomy and myocardium-blood pool definition were better in the bSSFP; however, mDixon images showed enhanced vessel wall sharpness with less blurring surrounding the anatomical borders distally. Coronary origins were identified in all cases. Pulmonary veins were visualized in 92% of mDixon sequences, 75% of bSSFP and 96% of CE-CMRA. Similarly, neck veins were identified in 92, 83 and 96% respectively. Artifacts prevented vascular measurement in 6/192 (3%) and 4/192 (2%) of total vascular measurements for the mDixon and bSSFP, respectively. However, the size of signal void and field distortion were significantly worse in the latter, particularly for flow and metal induced artifacts.

CONCLUSION

In patients with congenital heart disease, ECG gated mDixon angiography yields high fidelity vascular images including better delineation of head and neck vasculature and pulmonary veins and fewer artifacts than the comparable bSSFP sequence. It should be considered as the preferred strategy for successful CHD imaging in patients with valve stenosis, vascular stents, or metallic implants.

The aorta after coarctation repair - effects of calibre and curvature on arterial haemodynamics

BACKGROUND

Aortic shape has been proposed as an important determinant of adverse haemodynamics following coarctation repair. However, previous studies have not demonstrated a consistent relationship between shape and vascular load. In this study, 3D aortic shape was evaluated using principal component analysis (PCA), allowing investigation of the relationship between 3D shape and haemodynamics.

METHODS

Sixty subjects (38 male, 25.0 ± 7.8 years) with repaired coarctation were recruited. Central aortic haemodynamics including wave intensity analysis were measured noninvasively using a combination of blood pressure and phase contrast cardiovascular magnetic resonance (CMR). 3D curvature and radius data were derived from CMR angiograms. PCA was separately performed on 3D radius and curvature data to assess the role of arch geometry on haemodynamics. Clinical findings were corroborated using 1D vascular models.

RESULTS

There were no independent associations between 3D curvature and any hemodynamic parameters. However, the magnitude of the backwards compression wave was related to the 1st (r = - 0.36, p = 0.005), 3rd (r = 0.27, p = 0.036) and 4th (r = - 0.31, p = 0.017) principle components of radius. The 4th principle componentof radius also correlated with central aortic systolic pressure. These aortas had larger aortic roots, more transverse arch hypoplasia and narrower aortic isthmuses.

CONCLUSIONS

There are major modes of variation in 3D aortic shape after coarctation repair witha modest association between variation in aortic radius and pathological wave reflections, but not with 3D curvature. Taken together, these data suggest that shape is not the major determinant of vascular load following coarctation repair, and calibre is more important than curvature.

Comparison of myocardial fibrosis quantification methods by cardiovascular magnetic resonance imaging for risk stratification of patients with suspected myocarditis

BACKGROUND

Although the presence of late gadolinium enhancement (LGE) using cardiovascular magnetic resonance imaging (CMR) is a significant discriminator of events in patients with suspected myocarditis, no data are available on the optimal LGE quantification method.

METHODS

Six hundred seventy consecutive patients (48 ± 16 years, 59% male) with suspected myocarditis were enrolled between 2002 and 2015. We performed LGE quantitation using seven different signal intensity thresholding methods based either on 2, 3, 4, 5, 6, 7 standard deviations (SD) above remote myocardium or full width at half maximum (FWHM). In addition, a LGE visual presence score (LGE-VPS) (LGE present/absent in each segment) was assessed. For each of these methods, the strength of association of LGE results with major adverse cardiac events (MACE) was determined. Inter-and intra-rater variability using intraclass-correlation coefficient (ICC) was performed for all methods.

RESULTS

Ninety-eight (15%) patients experienced a MACE at a medium follow-up of 4.7 years. LGE quantification by FWHM, 2- and 3-SD demonstrated univariable association with MACE (hazard ratio [HR] 1.05, 95% confidence interval [CI]:1.02-1.08, p = 0.001; HR 1.02, 95%CI:1.00-1.04; p = 0.001; HR 1.02, 95%CI: 1.00-1.05, p = 0.035, respectively), whereas 4-SD through 7-SD methods did not reach significant association. LGE-VPS also demonstrated association with MACE (HR 1.09, 95%CI: 1.04-1.15, p < 0.001). In the multivariable model, FWHM, 2-SD methods, and LGE-VPS each demonstrated significant association with MACE adjusted to age, sex, BMI and LVEF (adjusted HR of 1.04, 1.02, and 1.07; p = 0.009, p = 0.035; and p = 0.005, respectively). In these, FWHM and LGE-VPS had the highest degrees of inter and intra-rater reproducibility based on their high ICC values.

CONCLUSIONS

FWHM is the optimal semi-automated quantification method in risk-stratifying patients with suspected myocarditis, demonstrating the strongest association with MACE and the highest technical consistency. Visual LGE scoring is a reliable alternative method and is associated with a comparable association with MACE and reproducibility in these patients.

TRIAL REGISTRATION NUMBER

NCT03470571 . Registered 13th March 2018. Retrospectively registered.

Visualization of coronary arteries in paediatric patients using whole-heart coronary magnetic resonance angiography: comparison of image-navigation and the standard approach for respiratory motion compensation

AIMS

To investigate the use of respiratory motion compensation using image-based navigation (iNAV) with constant respiratory efficiency using single end-expiratory thresholding (CRUISE) for coronary magnetic resonance angiography (CMRA), and compare it to the conventional diaphragmatic navigator (dNAV) in paediatric patients with congenital or suspected heart disease.

METHODS

iNAV allowed direct tracking of the respiratory heart motion and was generated using balanced steady state free precession startup echoes. Respiratory gating was achieved using CRUISE with a fixed 50% efficiency. Whole-heart CMRA was acquired with 1.3 mm isotropic resolution. For comparison, CMRA with identical imaging parameters were acquired using dNAV. Scan time, visualization of coronary artery origins and mid-course, imaging quality and sharpness was compared between the two sequences.

RESULTS

Forty patients (13 females; median weight: 44 kg; median age: 12.6, range: 3 months-17 years) were enrolled. 25 scans were performed in awake patients. A contrast agent was used in 22 patients. The scan time was significantly reduced using iNAV for awake patients (iNAV 7:48 ± 1:26 vs dNAV 9:48 ± 3:11, P = 0.01) but not for patients under general anaesthesia (iNAV = 6:55 ± 1:50 versus dNAV = 6:32 ± 2:16; P = 0.32). In 98% of the cases, iNAV image quality had an equal or higher score than dNAV. The visual score analysis showed a clear difference, favouring iNAV (P = 0.002). The right coronary artery and the left anterior descending vessel sharpness was significantly improved (iNAV: 56.8% ± 10.1% vs dNAV: 53.7% ± 9.9%, P < 0.002 and iNAV: 55.8% ± 8.6% vs dNAV: 53% ± 9.2%, P = 0.001, respectively).

CONCLUSION

iNAV allows for a higher success-rate and clearer depiction of the mid-course of coronary arteries in paediatric patients. Its acquisition time is shorter in awake patients and image quality score is equal or superior to the conventional method in most cases.

[Combined application of NPWT-therapy and reamberin infusion in treatment of lower limb trophic ulcer (clinical case)]

A clinical case of successful combined use of NPWT-therapy and Reamberin infusion in the treatment of a non-healing (over 5 months) trophic ulcer of the lower limb in an elderly patient is presented. It was manifested that introduction of antioxidant/antihypoxant drug reamberin on the background of NPWT-therapy in patient with slow healing wounds has a positive effect on metabolic processes, resulting in more active and rapid cleansing of wound surface from opportunistic microflora by the 5th day of therapy. Absence of adverse effects to drug application allows to recommend its inclusion in the complex treatment scheme in patients with this pathology.

Myocardial Partition Coefficient of Gadolinium: A Pilot Study in Patients With Acute Myocarditis, Chronic Myocardial Infarction, and in Healthy Volunteers

BACKGROUND

The tissue-blood partition coefficient (PC) of gadolinium, derived from T1 measurements, reflects myocardial connective tissue fraction and tissue injury, increasing in proportion with edema or fibrosis. We determined the myocardial PC of gadolinium in patients with acute myocarditis, chronic myocardial infarction (MI), and healthy volunteers. We hypothesized that the characteristics of the injured myocardium in patients with MI and myocarditis may differ and that the PC will be higher in chronically injured myocardium (MI) compared with acutely injured myocardium (myocarditis).

METHODS

We performed late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) imaging and T1 mapping before and after administration of gadolinium (0.1 mmol/kg Gd-BOPTA) at 3 Tesla in 10 healthy volunteers (47.1 ± 12.4 years), 18 patients with chronic MI (62.5 ± 8.1 years), and 16 patients with acute myocarditis (42.5 ± 13.9 years).

RESULTS

In patients with chronic MI and focal scar by LGE, the whole left ventricular myocardial PC (0.45 ± 0.05) was higher compared with patients with MI without focal scar (0.39 ± 0.03, P = 0.02) but not significantly different from whole myocardial PC in volunteers (0.40 ± 0.05) or patients with myocarditis (0.41 ± 0.05). The PC in myocarditis scars was lower than in chronic MI scars (0.60 ± 0.12 vs 0.77 ± 0.16, P = 0.016). The relationships of PC and scar burden, expressed as % LGE, were similar and significant for the 2 groups (P = 0.042).

CONCLUSION

The tissue-blood partition coefficient of Gd-BOPTA is elevated in areas of acute and chronic myocardial injury and may serve as a marker for disease activity and density of scars, which was found to be higher in chronic MI than in acute myocarditis.

Dynamic changes in injured myocardium, very early after acute myocardial infarction, quantified using T1 mapping cardiovascular magnetic resonance

BACKGROUND

It has recently been suggested that myocardial oedema follows a bimodal pattern early post ST-segment elevation myocardial infarction (STEMI). Yet, water content, quantified using tissue desiccation, did not return to normal values unlike oedema quantified by cardiovascular magnetic resonance (CMR) imaging. We studied the temporal changes in the extent and intensity of injured myocardium using T1-mapping technique within the first week after STEMI.

METHODS

A first group (n = 31) underwent 3 acute 3 T CMR scans (time-point (TP) < 3 h, 24 h and 6 days), including cine, native shortened modified look-locker inversion recovery T1 mapping, T2* mapping and late gadolinium enhancement (LGE). A second group (n = 17) had a single scan at 24 h with an additional T2-weighted sequence to assess the difference in the extent of area-at-risk (AAR) compared to T1-mapping.

RESULTS

The mean T1 relaxation time value within the AAR of the first group was reduced after 24 h (P < 0.001 for TP1 vs.TP2) and subsequently increased at 6 days (P = 0.041 for TP2 vs.TP3). However, the extent of AAR quantified using T1-mapping did not follow the same course, and no change was detected between TP1&TP2 (P = 1.0) but was between TP2 &TP3 (P = 0.019). In the second group, the extent of AAR was significantly larger on T1-mapping compared to T2-weighted (42 ± 15% vs. 39 ± 15%, P = 0.025). No change in LGE was detected while microvascular obstruction and intra-myocardial haemorrhage peaked at different time points within the first week of reperfusion.

CONCLUSION

The intensity of oedema post-STEMI followed a bimodal pattern; while the extent of AAR did not track the same course. This discrepancy has implications for use of CMR in this context and may explain the previously reported disagreement between oedema quantified by imaging and tissue desiccation.

Cardiovascular magnetic resonance imaging in the prospective, population-based, Hamburg City Health cohort study: objectives and design

BACKGROUND

The purpose of this work is to describe the objectives and design of cardiovascular magnetic resonance (CMR) imaging in the single center, prospective, population-based Hamburg City Health study (HCHS). The HCHS aims at improving risk stratification for coronary artery disease (CAD), atrial fibrillation (AF) and heart failure (HF).

METHODS

The HCHS will finally include 45,000 inhabitants of the city of Hamburg (Germany) between 45 and 74 years who undergo an extensive cardiovascular evaluation and collection of biomaterials. Risk-scores for CAD, AF and HF are used to create enriched subpopulations who are invited for CMR. A total number of approximately 12,362 subjects will undergo CMR and incident CAD, AF and HF will be assessed after 6 years follow-up. The standard CMR protocol includes cine-CMR, T1 and T2 mapping, aortic/mitral valve flow measurements, Late gadolinium enhancement, angiographies and measurements of aortic distensibility. A stress-perfusion scan is added in individuals at risk for CAD. The workflow of CMR data acquisition and analyses was evaluated in a pilot cohort of 200 unselected subjects.

RESULTS

The obtained CMR findings in the pilot cohort agree with current reference values and demonstrate the ability of the established workflow to accomplish the objectives of HCHS.

CONCLUSIONS

CMR in HCHS promises novel insights into major cardiovascular diseases, their subclinical precursors and the prognostic value of novel imaging biomarkers. The HCHS database will facilitate combined analyses of imaging, clinical and molecular data ("Radiomics").

High-resolution three-dimensional late gadolinium-enhanced cardiac magnetic resonance imaging to identify the underlying substrate of ventricular arrhythmia

Aims

Cardiac magnetic resonance (CMR) is recommended as a second-line method to diagnose ventricular arrhythmia (VA) substrate. We assessed the diagnostic yield of CMR including high-resolution late gadolinium-enhanced (LGE) imaging.

Methods and results

Consecutive patients with sustained ventricular tachycardia (VT), non-sustained VT (NSVT), or ventricular fibrillation/aborted sudden death (VF/SCD) underwent a non-CMR diagnostic workup according to current guidelines, and CMR including LGE imaging with both a conventional breath-held and a free-breathing method enabling higher spatial resolution (HR-LGE). The diagnostic yield of CMR was compared with the non-CMR workup, including the incremental value of HR-LGE. A total of 157 patients were enrolled [age 54 ± 17 years; 75% males; 88 (56%) sustained VT, 52 (33%) NSVT, 17 (11%) VF/SCD]. Of these, 112 (71%) patients had no history of structural heart disease (SHD). All patients underwent electrocardiography and echocardiography, 72% coronary angiography, and 51% exercise testing. Pre-CMR diagnoses were 84 (54%) no SHD, 39 (25%) ischaemic cardiomyopathy (ICM), 11 (7%) non-ischaemic cardiomyopathy (NICM), 3 (2%) arrhythmogenic right ventricular cardiomyopathy (ARVC), 2 (1%) hypertrophic cardiomyopathy (HCM), and 18 (11%) other. CMR modified these diagnoses in 48 patients (31% of all and 43% of those with no SHD history). New diagnoses were 9 ICM, 28 NICM, 8 ARVC, 1 HCM, and 2 other. CMR modified therapy in 19 (12%) patients. In patients with no SHD after non-CMR tests, SHD was found in 32 of 84 (38%) patients. Eighteen of these patients showed positive HR-LGE and negative conventional LGE. Thus, HR-LGE significantly increased the CMR detection of SHD (17-38%, P < 0.001).

Conclusion

CMR including HR-LGE imaging has high diagnostic value in patients with VAs. This has major prognostic and therapeutic implications, particularly in patients with negative pre-CMR workup.

Successful treatment against American cutaneous leishmaniasis by intralesional infiltration of a generic antimonial compound-lidocaine combination. A follow up study

One hundred and twenty-two lesions caused by Leishmania braziliensis in 92 patients were treated using weekly intralesional (IL) infiltrations of a generic pentavalent antimonial compound, combined with local anesthetics. The topical therapy produced satisfactory healing in all the included patients, bearing from single-small ulcers to multiple or big lesions, after receiving an average 6 ± 3 IL infiltrations (90 mgSb⁵⁺each). The rapid effect of this compound was demonstrated by the observed decrease of the Leishmania-amastigote population following microscopical grading in complicated ulcers after receiving two infiltrations. Neither discomfort nor side effects after infiltrations were recorded from the treated patients at any time. In addition, no signs of cutaneous relapse or mucosal lesion were detected during follow up after a decade clinical healing in 22% of the treated patients. Investment to produce the generic antimonial-IL treatment resulted significantly lower than the standard antimonial systemic therapy, and its cost/risk is discussed. The minimal dose of Sb⁵⁺ causing non-side effects or patient discomfort, the low production cost and the here demonstrated successful results, lead us to propose this generic antimonial compound as an alternative therapy for leishmanial-control in areas where American cutaneous leishmaniasis is endemic.

Towards a standard protocol for antimony intralesional infiltration technique for cutaneous leishmaniasis treatment

BACKGROUND Despite its recognised toxicity, antimonial therapy continues to be the first-line drug for cutaneous leishmaniasis (CL) treatment. Intralesional administration of meglumine antimoniate (MA) represents an alternative that could reduce the systemic absorption of the drug and its side effects. OBJECTIVES This study aims to validate the standard operational procedure (SOP) for the intralesional infiltration of MA for CL therapy as the first step before the assessment of efficacy and safety related to the procedure. METHODS The SOP was created based on 21 trials retrieved from the literature, direct monitoring of the procedure and consultation with experts. This script was submitted to a formal computer-aided inspection to identify readability, clarity, omission, redundancy and unnecessary information (content validation). For criterion and construct validations, the influence of critical condition changes (compliance with the instructions and professional experience) on outcome conformity (saturation status achievement), tolerability (pain referred) and safety (bleeding) were assessed. FINDINGS The median procedure length was 12 minutes and in 72% of them, patients classified the pain as mild. The bleeding was also classified as mild in 96.6% of the procedures. Full compliance with the SOP was observed in 66% of infiltrations. Despite this, in 100% of the inspected procedures, lesion saturation was observed at the end of infiltration, which means that it tolerates some degree of modification in its execution (robustness) without prejudice to the result. CONCLUSIONS The procedure is reproducible and can be used by professionals without previous training with high success and safety rates.

Myocardial Fibrosis in Competitive Triathletes Detected by Contrast-Enhanced CMR Correlates With Exercise-Induced Hypertension and Competition History

OBJECTIVES

This study analyzed the presence of myocardial fibrosis detected by late gadolinium-enhancement (LGE) cardiac magnetic resonance (CMR) in correlation with the performance of competitive triathletes objectified by an exercise test and individual competition history.

BACKGROUND

Myocardial fibrosis detected by LGE CMR has been reported to occur in 0% to 50% of asymptomatic athletes. However, the cause and mechanisms of myocardial fibrosis are unclear.

METHODS

Eighty-three asymptomatic triathletes undergoing >10 training h per week (43 ± 10 years of age; 65% male) and 36 sedentary controls were studied by using LGE and extracellular volume (ECV) CMR. Parameters of physical fitness were measured by spiroergometry. Triathletes reported their lifetime competition results.

RESULTS

LGE CMR revealed focal nonischemic myocardial fibrosis in 9 of 54 (17%) male triathletes (LGE⁺) but in none of the female triathletes (p < 0.05). LGE⁺ triathletes had higher peak exercise systolic blood pressure (213 ± 24 mm Hg) than LGE^- triathletes (194 ± 26 mm Hg; p < 0.05). Furthermore, left ventricular mass index was higher in LGE⁺ triathletes (93 ± 7 g/m²) than in LGE^- triathletes (84 ± 11 g/m²; p < 0.05). ECV in LGE^- myocardium was higher in LGE⁺ triathletes (26.3 ± 1.8%) than in LGE^- triathletes (24.4 ± 2.2%; p < 0.05). LGE⁺ triathletes completed longer cumulative distances in swimming and cycling races and participated more often in middle and Iron Man distances than LGE^- triathletes. A cycling race distance of >1,880 km completed during competition had the highest accuracy to predict LGE, with an area under the curve value of 0.876 (p < 0.0001), resulting in high sensitivity (89%) and specificity (79%). Multivariate analysis identified peak exercise systolic blood pressure (p < 0.05) and the swimming race distance (p < 0.01) as independent predictors of LGE presence.

CONCLUSIONS

Myocardial fibrosis in asymptomatic triathletes seems to be associated with exercise-induced hypertension and the race distances. There appears to be a safe upper limit, beyond which exercise may result in myocardial fibrosis.

Prospective comparison of novel dark blood late gadolinium enhancement with conventional bright blood imaging for the detection of scar

BACKGROUND

Conventional bright blood late gadolinium enhancement (bright blood LGE) imaging is a routine cardiovascular magnetic resonance (CMR) technique offering excellent contrast between areas of LGE and normal myocardium. However, contrast between LGE and blood is frequently poor. Dark blood LGE (DB LGE) employs an inversion recovery T2 preparation to suppress the blood pool, thereby increasing the contrast between the endocardium and blood. The objective of this study is to compare the diagnostic utility of a novel DB phase sensitive inversion recovery (PSIR) LGE CMR sequence to standard bright blood PSIR LGE.

METHODS

One hundred seventy-two patients referred for clinical CMR were scanned. A full left ventricle short axis stack was performed using both techniques, varying which was performed first in a 1:1 ratio. Two experienced observers analyzed all bright blood LGE and DB LGE stacks, which were randomized and anonymized. A scoring system was devised to quantify the presence and extent of gadolinium enhancement and the confidence with which the diagnosis could be made.

RESULTS

A total of 2752 LV segments were analyzed. There was very good inter-observer correlation for quantifying LGE. DB LGE analysis found 41.5% more segments that exhibited hyperenhancement in comparison to bright blood LGE (248/2752 segments (9.0%) positive for LGE with bright blood; 351/2752 segments (12.8%) positive for LGE with DB; p < 0.05). DB LGE also allowed observers to be more confident when diagnosing LGE (bright blood LGE high confidence in 154/248 regions (62.1%); DB LGE in 275/324 (84.9%) regions (p < 0.05)). Eighteen patients with no bright blood LGE were found to have had DB LGE, 15 of whom had no known history of myocardial infarction.

CONCLUSIONS

DB LGE significantly increases LGE detection compared to standard bright blood LGE. It also increases observer confidence, particularly for subendocardial LGE, which may have important clinical implications.

[Inferior myocardial infarction complicated by complete heart block and cardiac arrest following a gadolinium injection: A case of Kounis syndrome]

Kounis syndrome is an allergic acute coronary syndrome. It occurs on healthy or pathological arteries. Its complications, although often benign, can lead to cardiac arrest and death. Its triggering factors are multiple and include contrast products used in diagnostic imaging. We report the case of an 81 years old patient affected by hepatocellular carcinoma, who presented a type 2 Kounis syndrome with inferior myocardial infarction, complicated by cardiac arrest related to complete heart block following a gadoteric acid injection.

Leishmania infantum-specific IFN-γ production in stimulated blood from dogs with clinical leishmaniosis at diagnosis and during treatment

There is limited data regarding Leishmania infantum specific T cell mediated immunity in naturally infected sick dogs at the time of diagnosis and during anti-Leishmania treatment. Our aim was to investigate the kinetics of L. infantum specific IFN-γ production in dogs with leishmaniosis at the time of diagnosis and during treatment and to correlate it with specific L. infantum antibodies, blood parasitemia and clinicopathological findings. Thirty-four dogs were diagnosed with leishmaniosis based on physical examination, routine laboratory tests and L. infantum-specific antibody levels by quantitative ELISA. Heparinized whole blood was stimulated with L. infantum soluble antigen (LSA) and concanavalin A (ConA) and incubated for 5days. IFN-γ concentration was evaluated in supernatants of stimulated blood using a commercial sandwich ELISA. Leishmania real-time PCR was also performed for assessing blood parasitemia. Dogs were treated with meglumine antimoniate and allopurinol. Sixteen dogs were classified as IFN-γ non-producers after LSA stimulation (mean±SD: 0±0pg/mL) and 18 dogs as IFN-γ producers (mean±SD: 2885.3±4436.1pg/mL) at the time of diagnosis (P<0.0001). IFN-γ non-producers were classified in a more severe clinical staging than IFN-γ producers that presented a mild to moderate clinical staging (P=0.03). In the IFN-γ non-producer group, production of IFN-γ after LSA stimulation was significantly increased during treatment especially at day 365 (P=0.018) together with clinical improvement when compared with day 0. In contrast, IFN-γ producers maintained their IFN-γ production after LSA stimulation and no statistically significant changes were found during treatment follow-up. At diagnosis, IFN-γ non-producers showed a significantly higher blood parasitemia versus IFN-γ -producers (P=0.005). IFN-γ non-producers drastically reduced blood parasitemia to minimum values at day 365 when compared with day 0 (P=0.017). No significant differences were found at day 365 in blood parasitemia of IFN-γ producers compared to pre-treatment. At diagnosis, L. infantum specific antibodies were higher in IFN-γ non-producers than IFN-γ producers (P=0.014). A marked reduction of antibody levels was found at day 365 when compared with day 0 in IFN-γ non-producers (P=0.005) and producers (P=0.001). These results demonstrate that IFN-γ concentration increases with long-term anti-Leishmania treatment together with clinical improvement in dogs that do not produce IFN-γ at diagnosis. Together with clinical recovery, reduction in blood parasitemia and L. infantum specific antibodies, tracking IFN-γ concentration could constitute an important prognostic tool for immune monitoring in CanL.

Adenosine stress CMR T1-mapping detects early microvascular dysfunction in patients with type 2 diabetes mellitus without obstructive coronary artery disease

BACKGROUND

Type 2 diabetes mellitus (T2DM) is associated with coronary microvascular dysfunction in the absence of obstructive coronary artery disease (CAD). Cardiovascular magnetic resonance (CMR) T1-mapping at rest and during adenosine stress can assess coronary vascular reactivity. We hypothesised that the non-contrast T1 response to vasodilator stress will be altered in patients with T2DM without CAD compared to controls due to coronary microvascular dysfunction.

METHODS

Thirty-one patients with T2DM and sixteen matched healthy controls underwent CMR (3 T) for cine, rest and adenosine stress non-contrast T1-mapping (ShMOLLI), first-pass perfusion and late gadolinium enhancement (LGE) imaging. Significant CAD (>50% coronary luminal stenosis) was excluded in all patients by coronary computed tomographic angiography.

RESULTS

All subjects had normal left ventricular (LV) ejection and LV mass index, with no LGE. Myocardial perfusion reserve index (MPRI) was lower in T2DM than in controls (1.60 ± 0.44 vs 2.01 ± 0.42; p = 0.008). There was no difference in rest native T1 values (p = 0.59). During adenosine stress, T1 values increased significantly in both T2DM patients (from 1196 ± 32 ms to 1244 ± 44 ms, p < 0.001) and controls (from 1194 ± 26 ms to 1273 ± 44 ms, p < 0.001). T2DM patients showed blunted relative stress non-contrast T1 response (T2DM: ΔT1 = 4.1 ± 2.9% vs.

CONTROLS

ΔT1 = 6.6 ± 2.6%, p = 0.007) due to a blunted maximal T1 during adenosine stress (T2DM 1244 ± 44 ms vs. controls 1273 ± 44 ms, p = 0.045).

CONCLUSIONS

Patients with well controlled T2DM, even in the absence of arterial hypertension and significant CAD, exhibit blunted maximal non-contrast T1 response during adenosine vasodilatory stress, likely reflecting coronary microvascular dysfunction. Adenosine stress and rest T1 mapping can detect subclinical abnormalities of the coronary microvasculature, without the need for gadolinium contrast agents. CMR may identify early features of the diabetic heart phenotype and subclinical cardiac risk markers in patients with T2DM, providing an opportunity for early therapeutic intervention.

Improved passive catheter tracking with positive contrast for CMR-guided cardiac catheterization using partial saturation (pSAT)

BACKGROUND

Cardiac catheterization is a common procedure in patients with congenital heart disease (CHD). Although cardiovascular magnetic resonance imaging (CMR) represents a promising alternative approach to fluoroscopy guidance, simultaneous high contrast visualization of catheter, soft tissue and the blood pool remains challenging. In this study, a novel passive tracking technique is proposed for enhanced positive contrast visualization of gadolinium-filled balloon catheters using partial saturation (pSAT) magnetization preparation.

METHODS

The proposed pSAT sequence uses a single shot acquisition with balanced steady-state free precession (bSSFP) readout preceded by a partial saturation pre-pulse. This technique was initially evaluated in five healthy subjects. The pSAT sequence was compared to conventional bSSFP images acquired with (SAT) and without (Non-SAT) saturation pre-pulse. Signal-to-noise ratio (SNR) of the catheter balloon, blood and myocardium and the corresponding contrast-to-noise ratio (CNR) are reported. Subjective assessment of image suitability for CMR-guidance and ideal pSAT angle was performed by three cardiologists. The feasibility of the pSAT sequence is demonstrated in two adult patients undergoing CMR-guided cardiac catheterization.

RESULTS

The proposed pSAT approach provided better catheter balloon/blood contrast and catheter balloon/myocardium contrast than conventional Non-SAT sequences. It also resulted in better blood and myocardium SNR than SAT sequences. When averaged over all volunteers, images acquired with a pSAT angle of 20° to 40° enabled simultaneous visualization of the catheter balloon and the cardiovascular anatomy (blood and myocardium) and were found suitable for CMR-guidance in >93% of cases. The pSAT sequence was successfully used in two patients undergoing CMR-guided diagnostic cardiac catheterization.

CONCLUSIONS

The proposed pSAT sequence offers real-time, simultaneous, enhanced contrast visualization of the catheter balloon, soft tissues and blood. This technique provides improved passive tracking capabilities during CMR-guided catheterization in patients.

Quantification of both the area-at-risk and acute myocardial infarct size in ST-segment elevation myocardial infarction using T1-mapping

BACKGROUND

A comprehensive cardiovascular magnetic resonance (CMR) in reperfused ST-segment myocardial infarction (STEMI) patients can be challenging to perform and can be time-consuming. We aimed to investigate whether native T1-mapping can accurately delineate the edema-based area-at-risk (AAR) and post-contrast T1-mapping and synthetic late gadolinium (LGE) images can quantify MI size at 1.5 T. Conventional LGE imaging and T2-mapping could then be omitted, thereby shortening the scan duration.

METHODS

Twenty-eight STEMI patients underwent a CMR scan at 1.5 T, 3 ± 1 days following primary percutaneous coronary intervention. The AAR was quantified using both native T1 and T2-mapping. MI size was quantified using conventional LGE, post-contrast T1-mapping and synthetic magnitude-reconstructed inversion recovery (MagIR) LGE and synthetic phase-sensitive inversion recovery (PSIR) LGE, derived from the post-contrast T1 maps.

RESULTS

Native T1-mapping performed as well as T2-mapping in delineating the AAR (41.6 ± 11.9% of the left ventricle [% LV] versus 41.7 ± 12.2% LV, P = 0.72; R2 0.97; ICC 0.986 (0.969-0.993); bias -0.1 ± 4.2% LV). There were excellent correlation and inter-method agreement with no bias, between MI size by conventional LGE, synthetic MagIR LGE (bias 0.2 ± 2.2%LV, P = 0.35), synthetic PSIR LGE (bias 0.4 ± 2.2% LV, P = 0.060) and post-contrast T1-mapping (bias 0.3 ± 1.8% LV, P = 0.10). The mean scan duration was 58 ± 4 min. Not performing T2 mapping (6 ± 1 min) and conventional LGE (10 ± 1 min) would shorten the CMR study by 15-20 min.

CONCLUSIONS

T1-mapping can accurately quantify both the edema-based AAR (using native T1 maps) and acute MI size (using post-contrast T1 maps) in STEMI patients without major cardiovascular risk factors. This approach would shorten the duration of a comprehensive CMR study without significantly compromising on data acquisition and would obviate the need to perform T2 maps and LGE imaging.

Early myocardial gadolinium enhancement in patients with myocarditis: Validation of "Lake Louise consensus" criteria using a single bolus of 0.1mmol/Kg of a high relaxivity gadolinium-based contrast agent

OBJECTIVES

Global early gadolinium enhancement (EGE) is an accepted cardiac magnetic resonance (CMR) criterion for diagnosis of myocarditis. However, recommended enhancement thresholds are based specifically on standard-relaxivity Gd-chelates. We evaluated the performance of a high relaxivity MR contrast agent for detection of myocardial hyperemia in patients referred for endomyocardial biopsy (EMB).

METHODS

We retrospectively enrolled 54 patients (mean age: 44.1 years [range=18-77years]; 72% men) with suspected myocarditis who underwent CMR and EMB within four weeks of clinical onset. CMR imaging protocol included T2-weighted short tau inversion-recovery sequence, EGE and late gadolinium enhanced (LGE) imaging. For EGE imaging, free-breathing ECG-gated turbo spin echo T1-weighted (TSE T1w) sequences were acquired before and within the first three minutes after gadobenate dimeglumine (0.1mmol/Kg) administration. The ratio (EGEr) between myocardial and musculoskeletal early enhancement was calculated. Myocardial edema, EGE and late gadolinium enhancement (LGE) were correlated with EMB results. Receiver operating characteristic (ROC) curve analysis of EGE values was applied on the overall population.

RESULTS

EMB revealed myocarditis in 34/54 patients. Sensitivity, specificity and accuracy values of 0.61, 0.85 and 0.70, respectively, were obtained for a standard EGE threshold (EGEr>4.0). ROC analysis revealed an area under the curve of 0.701 for EGEr (IC95%:0.556-0.846, p=0.014) and 0.706 for absolute enhancement (IC95%:0.563-0.849, p=0.012). Sensitivity, specificity and accuracy values were 0.67, 0.80 and 0.72, respectively, for myocardial edema and 0.76, 0.75 and 0.76, respectively, for LGE.

CONCLUSIONS

High relaxivity contrast agents provide comparable results to standard-relaxivity chelates for EGE assessment in diagnosing myocarditis.

Low versus high dose of antimony for American cutaneous leishmaniasis: A randomized controlled blind non-inferiority trial in Rio de Janeiro, Brazil

Background

Although high dose of antimony is the mainstay for treatment of American cutaneous leishmaniasis (ACL), ongoing major concerns remain over its toxicity. Whether or not low dose antimony regimens provide non-inferior effectiveness and lower toxicity has long been a question of dispute.

Methods

A single-blind, non-inferiority, randomized controlled trial was conducted comparing high dose with low dose of antimony in subjects with ACL treated at a referral center in Rio de Janeiro, an endemic area of Leishmania (Viannia) braziliensis transmission. The primary outcome was clinical cure at 360 days of follow-up in the modified-intention-to-treat (mITT) and per-protocol (PP) populations. Non-inferiority margin was 15%. Secondary objectives included occurrence of epithelialization, adverse events and drug discontinuations. This study was registered in ClinicalTrials.gov: NCT01301924.

Results

Overall, 72 patients were randomly assigned to one of the two treatment arms during October 2008 to July 2014. In mITT, clinical cure was observed in 77.8% of subjects in the low dose antimony group and 94.4% in the high dose antimony group after one series of treatment (risk difference 16.7%; 90% CI, 3.7–29.7). The results were confirmed in PP analysis, with 77.8% of subjects with clinical cure in the low dose antimony group and 97.1% in the high dose antimony group (risk difference 19.4%; 90% CI, 7.1–31.7). The upper limit of the confidence interval exceeded the 15% threshold and was also above zero supporting the hypothesis that low dose is inferior to high dose of antimony after one series of treatment. Nevertheless, more major adverse events, a greater number of adverse events and major adverse events per subject, and more drug discontinuations were observed in the high dose antimony group (all p<0.05). Interestingly, of all the subjects who were originally allocated to the low dose antimony group and were followed up after clinical failure, 85.7% achieved cure after a further treatment with local therapy or low dose of antimony.

Conclusions

Compared with high dose, low dose of antimony was inferior at the pre-specified margin after one series of treatment of ACL, but was associated with a significantly lower toxicity. While high dose of antimony should remain the standard treatment for ACL, low dose antimony treatment might be preferred when toxicity is a primary concern.

Diagnostic value of gadobenate dimeglumine-enhanced hepatocyte-phase magnetic resonance imaging in evaluating hepatic fibrosis and hepatitis

AIM

To evaluate the diagnostic value of gadobenate dimeglumine (Gd-BOPTA)-enhanced hepatocyte-phase magnetic resonance imaging (MRI) in evaluating hepatic fibrosis and hepatitis.

METHODS

Hepatocyte-phase images of Gd-BOPTA-enhanced MRI were retrospectively evaluated in 76 patients with chronic liver disease. These patients were classified into five groups according to either the histopathological fibrosis stage (S0-S4) or the histopathological hepatitis grade (G0-G4). The relative enhancement ratio (RE) of the liver parenchyma in the T1-vibe sequence was calculated by measuring the signal intensity before (SI pre) and 90 min after (SI post) intravenous injection of Gd-BOPTA using the following formula: RE = (SI post - SI pre)/SI pre. One-way analysis of variance was used to compare the difference between the relative RE in the hepatocyte phase (REh) and the stage of hepatic fibrosis and the grade of hepatitis. Pearson’s product-moment correlation analysis was used to evaluate the relationship between the REh and the levels of serologic liver functional parameters.

RESULTS

According to histopathological hepatic fibrosis stage, the 76 patients were classified into five groups: 16 in S0, 15 in S1, 21 in S2, 9 in S3, and 15 in S4 group. According to histopathological hepatitis grade, the 76 patients were also classified into five groups: 0 in G0, 44 in G1, 22 in G2, 8 in G3, and 2 in G3 group. With regard to the stage of hepatic fibrosis, REh showed significant differences between the S2 and S3 groups and between the S2 and S4 groups (P < 0.05), but no significant difference was observed between the other groups. With regard to the grade of hepatitis, REh showed significant differences between the G1 and G2 groups and between the G1 and G4 groups (P < 0.05), but no significant difference was observed between the other groups. Increased REh showed correlations with decreased serum levels of TB, ALT and AST (P < 0.05).

CONCLUSION

To some extent, measuring the REh using Gd-BOPTA-enhanced MRI might be a noninvasive technique for assessing the stage of hepatic fibrosis. This method is able to differentiate no/mild hepatitis from advanced hepatitis. TB, ALT and AST levels can predict the degree of liver enhancement in the hepatocyte phase of Gd-BOPTA-enhanced MRI.

Cost-effectiveness of meglumine antimoniate versus miltefosine caregiver DOT for the treatment of pediatric cutaneous leishmaniasis

BACKGROUND

Oral miltefosine has been shown to be non-inferior to first-line, injectable meglumine antimoniate (MA) for the treatment of cutaneous leishmaniasis (CL) in children. Miltefosine may be administered via in-home caregiver Directly Observed Therapy (cDOT), while patients must travel to clinics to receive MA. We performed a cost-effectiveness analysis comparing miltefosine by cDOT versus MA for pediatric CL in southwest Colombia.

METHODOLOGY/PRINCIPLE FINDINGS

We developed a Monte Carlo model comparing the cost-per-cure of miltefosine by cDOT compared to MA from patient, government payer, and societal perspectives (societal = sum of patient and government payer perspective costs). Drug effectiveness and adverse events were estimated from clinical trials. Healthcare utilization and costs of travel were obtained from surveys of providers and published sources. The primary outcome was cost-per-cure reported in 2015 USD. Treatment efficacy, costs, and adherence were varied in sensitivity analysis to assess robustness of results. Treatment with miltefosine resulted in substantially lower cost-per-cure from a societal and patient perspective, and slightly higher cost-per-cure from a government payer perspective compared to MA. Mean societal cost-per-cure were $531 (SD±$239) for MA and $188 (SD±$100) for miltefosine, a mean cost-per-cure difference of +$343. Mean cost-per-cure from a patient perspective were $442 (SD ±$233) for MA and $30 (SD±$16) for miltefosine, a mean difference of +$412. Mean cost-per-cure from a government perspective were $89 (SD±$55) for MA and $158 (SD±$98) for miltefosine, with a mean difference of -$69. Results were robust across a variety of assumptions in univariate and multi-way analysis.

CONCLUSIONS/SIGNIFICANCE

Treatment of pediatric cutaneous leishmaniasis with miltefosine via cDOT is cost saving from patient and societal perspectives, and moderately more costly from the government payer perspective compared to treatment with MA. Results were robust over a range of sensitivity analyses. Lower drug price for miltefosine could result in cost saving from a government perspective.

Assessment of myocardial injury after reperfused infarction by T1ρ cardiovascular magnetic resonance

BACKGROUND

The evolution of T1ρ and of other endogenous contrast methods (T2, T1) in the first month after reperfused myocardial infarction (MI) is uncertain. We conducted a study of reperfused MI in pigs to serially monitor T1ρ, T2 and T1 relaxation, scar size and transmurality at 1 and 4 weeks post-MI.

METHODS

Ten Yorkshire swine underwent 90 min of occlusion of the circumflex artery and reperfusion. T1ρ, T2 and native T1 maps and late gadolinium enhanced (LGE) cardiovascular magnetic resonance (CMR) data were collected at 1 week (n = 10) and 4 weeks (n = 5). Semi-automatic FWHM (full width half maximum) thresholding was used to assess scar size and transmurality and compared to histology. Relaxation times and contrast-to-noise ratio were compared in healthy and remote myocardium at 1 and 4 weeks. Linear regression and Bland-Altman was performed to compare infarct size and transmurality.

RESULTS

Relaxation time differences between infarcted and remote myocardial tissue were ∆T1 (infarct-remote) = 421.3 ± 108.8 (1 week) and 480.0 ± 33.2 ms (4 week), ∆T1ρ = 68.1 ± 11.6 and 74.3 ± 14.2, and ∆T2 = 51.0 ± 10.1 and 59.2 ± 11.4 ms. Contrast-to-noise ratio was CNRT1 = 7.0 ± 3.5 (1 week) and 6.9 ± 2.4 (4 week), CNRT1ρ = 12.0 ± 6.2 and 12.3 ± 3.2, and CNRT2 = 8.0 ± 3.6 and 10.3 ± 5.8. Infarct size was not significantly different for T1ρ, T1 and T2 compared to LGE (p = 0.14) and significantly decreased from 1 to 4 weeks (p < 0.01). Individual infarct size changes were ∆T1ρ = -3.8%, ∆T1 = -3.5% and ∆LGE = -2.8% from 1 - 4 weeks, but there was no observed change in infarct size for T2 or histologically.

CONCLUSIONS

T1ρ was highly correlated with alterations left ventricle (LV) pathology at 1 and 4 weeks post-MI and therefore it may be a useful method endogenous contrast imaging of infarction.

Pancreatic neuroendocrine neoplasms: Magnetic resonance imaging features according to grade and stage

AIM

To describe magnetic resonance (MR) imaging features of pancreatic neuroendocrine neoplasms (PanNENs) according to their grade and tumor-nodes-metastases stage by comparing them to histopathology and to determine the accuracy of MR imaging features in predicting their biological behavior.

METHODS

This study was approved by our institutional review board; requirement for informed patient consent was waived due to the retrospective nature of the study. Preoperative MR examinations of 55 PanNEN patients (29 men, 26 women; mean age of 57.6 years, range 21-83 years) performed between June 2013 and December 2015 were reviewed. Qualitative and quantitative features were compared between tumor grades and stages determined by histopathological analysis.

RESULTS

Ill defined margins were more common in G2-3 and stage III-IV PanNENs than in G1 and low-stage tumors (P < 0.001); this feature had high specificity in the identification of G2-3 and stage III-IV tumors (90.3% and 96%, 95%CI: 73.1-97.5 and 77.7-99.8). The mean apparent diffusion coefficient value was significantly lower in G2-3 and stage III-IV lesions compared to well differentiated and low-stage tumors (1.09 × 10^-3 mm²/s vs 1.45 × 10^-3 mm²/s and 1.10 × 10^-3 mm²/s vs 1.53 × 10^-3 mm²/s, P = 0.003 and 0.001). Receiving operator characteristic analysis determined optimal cut-offs of 1.21 and 1.28 × 10^-3 mm²/s for the identification of G2-3 and stage III-IV tumors, with sensitivity and specificity values of 70.8/80.7% and 64.5/64% (95%CI: 48.7-86.6/60-92.7 and 45.4-80.2/42.6-81.3).

CONCLUSION

MR features of PanNENs vary according to their grade of differentiation and their stage at diagnosis and could predict the biological behavior of these tumors.

EFFECT OF SOLUTIONS BASED ON TRICARBONIC ACID CYCLE SUBSTRATES ON TEMPERATURE RATES IN CHILDREN DURING ANESTHESIA

The article describes some characteristics of temperature homeostasis regulation while intraoperative period and its correction methods by infusions of balanced crystalloid solutions on the basis amino acids and the Krebs cycle substrates.

MATERIALS AND METHODS

107 children of different ages were included into the study. All of them underwent surgery on thoracic or abdominal organs. The average age was 13 (7-16) years. All the operations were performed with total intravenous anesthesia and artificial lung ventilation. 0,9% sodium chloride solution, "Mafusol" "Infezol-40" and "Reamberin" were used in order to correct perioperative hypothermia. Results of the study. It was found that solutions based onfumarate (mafusol) and succinate (reamberin) have a significant positive effect on the temperature homeostasis. This fact means they can be recommendfor a broad usage in clinical practice for the purpose ofprevention and elimination of intraoperative hypothermia.

Myocardial T1-mapping at 3T using saturation-recovery: reference values, precision and comparison with MOLLI

BACKGROUND

Myocardial T1-mapping recently emerged as a promising quantitative method for non-invasive tissue characterization in numerous cardiomyopathies. Commonly performed with an inversion-recovery (IR) magnetization preparation at 1.5T, the application at 3T has gained due to increased quantification precision. Alternatively, saturation-recovery (SR) T1-mapping has recently been introduced at 1.5T for improved accuracy. Thus, the purpose of this study is to investigate the robustness and precision of SR T1-mapping at 3T and to establish accurate reference values for native T1-times and extracellular volume fraction (ECV) of healthy myocardium.

METHODS

Balanced Steady-State Free-Precession (bSSFP) Saturation-Pulse Prepared Heart-rate independent Inversion-REcovery (SAPPHIRE) and Saturation-recovery Single-SHot Acquisition (SASHA) T1-mapping were compared with the Modified Look-Locker inversion recovery (MOLLI) sequence at 3T. Accuracy and precision were studied in phantom. Native and post-contrast T1-times and regional ECV were determined in 20 healthy subjects (10 men, 27 ± 5 years). Subjective image quality, susceptibility artifact rating, in-vivo precision and reproducibility were analyzed.

RESULTS

SR T1-mapping showed <4 % deviation from the spin-echo reference in phantom in the range of T1 = 100-2300 ms. The average quality and artifact scores of the T1-mapping methods were: MOLLI:3.4/3.6, SAPPHIRE:3.1/3.4, SASHA:2.9/3.2; (1: poor - 4: excellent/1: strong - 4: none). SAPPHIRE and SASHA yielded significantly higher T1-times (SAPPHIRE: 1578 ± 42 ms, SASHA: 1523 ± 46 ms), in-vivo T1-time variation (SAPPHIRE: 60.1 ± 8.7 ms, SASHA: 70.0 ± 9.3 ms) and lower ECV-values (SAPPHIRE: 0.20 ± 0.02, SASHA: 0.21 ± 0.03) compared with MOLLI (T1: 1181 ± 47 ms, ECV: 0.26 ± 0.03, Precision: 53.7 ± 8.1 ms). No significant difference was found in the inter-subject variability of T1-times or ECV-values (T1: p = 0.90, ECV: p = 0.78), the observer agreement (inter: p > 0.19; intra: p > 0.09) or consistency (inter: p > 0.07; intra: p > 0.17) between the three methods.

CONCLUSIONS

Saturation-recovery T1-mapping at 3T yields higher accuracy, comparable inter-subject, inter- and intra-observer variability and less than 30 % precision-loss compared to MOLLI.

Relationship between native papillary muscle T1 time and severity of functional mitral regurgitation in patients with non-ischemic dilated cardiomyopathy

BACKGROUND

Functional mitral regurgitation is one of the severe complications of non-ischemic dilated cardiomyopathy (DCM). Non-contrast native T1 mapping has emerged as a non-invasive method to evaluate myocardial fibrosis. We sought to evaluate the potential relationship between papillary muscle T1 time and mitral regurgitation in DCM patients.

METHODS

Forty DCM patients (55 ± 13 years) and 20 healthy adult control subjects (54 ± 13 years) were studied. Native T1 mapping was performed using a slice interleaved T1 mapping sequence (STONE) which enables acquisition of 5 slices in the short-axis plane within a 90 s free-breathing scan. We measured papillary muscle diameter, length and shortening. DCM patients were allocated into 2 groups based on the presence or absence of functional mitral regurgitation.

RESULTS

Papillary muscle T1 time was significantly elevated in DCM patients with mitral regurgitation (n = 22) in comparison to those without mitral regurgitation (n = 18) (anterior papillary muscle: 1127 ± 36 msec vs 1063 ± 16 msec, p < 0.05; posterior papillary muscle: 1124 ± 30 msec vs 1062 ± 19 msec, p < 0.05), but LV T1 time was similar (1129 ± 38 msec vs 1134 ± 58 msec, p = 0.93). Multivariate linear regression analysis showed that papillary muscle native T1 time (β = 0.10, 95 % CI: 0.05-0.17, p < 0.05) is significantly correlated with mitral regurgitant fraction. Elevated papillary muscle T1 time was associated with larger diameter, longer length and decreased papillary muscle shortening (all p values <0.05).

CONCLUSIONS

In DCM, papillary muscle native T1 time is significantly elevated and related to mitral regurgitant fraction.

Contrast-enhanced thoracic 3D-MR angiography in infants and children

Purpose: To optimise breath-hold contrast-enhanced MR angiography (MRA) in infants and children with suspected congenital heart or thoracic vessel malformation.

Material and Methods: Thirty-nine children (median age 1 year) were examined, using five different ultrafast MRA sequences with a TR between 3.2 and 5.0 ms and the contrast agent meglumine gadoterate. A test injection was used to determine contrast travel time. Different parameters for contrast injection were evaluated. Signal-to-noise ratio (SNR) measurements were performed and image quality and injection timing were evaluated.

Results: MRA was successful in all patients and image quality was considered very good in 52%. Adequate SNR was achieved with no significant differences between the MR sequences. SNR decreased only 25-30% between subsequent scans. The mean contrast dose was 0.23 mmol/kg. The mean scan time was 12.5±3.8 s; the shorter scan times made dynamic examinations possible with high temporal resolution. Highest spatial resolution was obtained with TR 4.6/5.0 sequences.

Conclusion: A contrast dose of 0.2 mmol/kg b.w. is recommended with an injection rate of 0.5 to 1.2 ml/s, depending on patient size and scan time. The scan delay time should equal the contrast travel time for optimal vessel enhancement. In the future, contrast-enhanced MRA may be a potential alternative to angiocardiography in infants and children.

Early gadolinium enhancement in hypertrophic cardiomyopathy: a potential premature marker of myocardial damage

Early gadolinium enhancement (EGE), one CMR diagnostic criteria in acute myocarditis, has been related with hyperemia and capillary leakage. The value of EGE in hypertrophic cardiomyopathy (HCM) remains unknown. Our aim was to determine the prevalence of EGE in patients with HCM, and its relation with late gadolinium enhancement (LGE). The association of EGE with morphological and clinical parameters was also evaluated. Sixty consecutive patients with HCM and CMR from our center were included. All the clinical and complementary test information was collected prospectively in our HCM clinic. Left ventricular (LV) measurements were calculated from cine sequences. EGE and LGE were quantified with a dedicated software. Clinical events were collected from medical records. A slow wash-out pattern on EGE was detected in up to 68 % of the patients, being an isolated finding without LGE in 10 (16 %). This cohort showed a greater maximal LV wall thickness (20.1 ± 4 vs. 18.1 ± 3.5 mm, p = 0.010) and asymmetry ratio (1.86 ± 0.42 vs. 1.62 ± 0.46; p = 0.039). The percentage of EGE/slice and the difference with the percentage LGE/slice demonstrated a significant positive correlation with the maximal LV wall thickness (Rho 0.450 and 0.386 respectively). EGE also correlated with number of segments with LVH (LV hypertrophy) and the asymmetry ratio. Neither EGE nor LGE were associated with classical risk factors, the risk score for sudden cardiac death, or with major clinical events. EGE was a frequent finding in HCM, even in absence of LGE. This phenomenon showed a positive correlation with morphological markers of disease burden.

[ADJUVANT ENERGY PROTECTION WITH REAMBERIN IN PRACTICE OF INTENSIVE CARE AND RESUSCITATION: META-ANALYSIS DATA ABOUT EFFECTIVENESS (SYSTEMATIC REVIEW).]

THE AIM

a synthesis of evaluations ofReamberin's clinical efficacy as energy protectorfor the results of a meta-analysis of published data obtained during controlled clinical studies with the same design and a high level of evidence.

MATERIALS AND METHODS

To estimate succinic acid based remedy for infusions (reamberin), the meta-analysis was undertaken with data of reamberin use in intensive care, resuscitation departments, in critical post surgery period, in oncology (multiple chemotherapy of tumors), in emergent toxicology and pediatrics. 32 controlled randomized trials and all together 6221 patients were included.

RESULTS

Unified indicators of clinical efficiency were systemically and thoroughly processed with advanced statistic tools, resulting data were sufficient for association and assessment of their heterogeneity in different articles. The adjuvant effects of reamberin were proven, as good outcome frequency enlarged more than by 25%, absolute and relative treatment benefits increased more than by 50%, positive outcome chance grew twice and more.

CONCLUSIONS

According to sensitivity analysis and this meta-analysis results reamberin may be positioned as adjuvant energetic protector valid to improve effectiveness of pharmacologic correction during the treatment of emergencies joint with hypoxia, energy deficiencies and vegetative disregulations.

Follow-up of atheroma burden with sequential whole body contrast enhanced MR angiography: a feasibility study

Assess the feasibility of whole body magnetic resonance angiography (WB-MRA) for monitoring global atheroma burden in a population with peripheral arterial disease (PAD). 50 consecutive patients with symptomatic PAD referred for clinically indicated MRA were recruited. Whole body MRA (WB-MRA) was performed at baseline, 6 months and 3 years. The vasculature was split into 31 anatomical arterial segments. Each segment was scored according to degree of luminal narrowing: 0 = normal, 1 = <50 %, 2 = 50–70 %, 3 = 71–99 %, 4 = vessel occlusion. The score from all assessable segments was summed, and then normalised to the number of assessable vessels. This normalised score was divided by four (the maximum vessel score) and multiplied by 100 to give a final standardised atheroma score (SAS) with a score of 0–100. Progression was assessed with repeat measure ANOVA. 36 patients were scanned at 0 and 6 months, with 26 patients scanned at the 3 years follow up. Only those who completed all three visits were included in the final analysis. Baseline atherosclerotic burden was high with a mean SAS of 15.7 ± 10.3. No significant progression was present at 6 months (mean SAS 16.4 ± 10.5, p = 0.67), however there was significant disease progression at 3 years (mean SAS 17.7 ± 11.5, p = 0.01). Those with atheroma progression at follow-up were less likely to be on statin therapy (79 vs 100 %, p = 0.04), and had significantly higher baseline SAS (17.6 ± 11.2 vs 10.7 ± 5.1, p = 0.043). Follow up of atheroma burden is possible with WB-MRA, which can successfully quantify and monitor atherosclerosis progression at 3 years follow-up.

[PHARMACOLOGICAL CORRECTION OF METABOLIC DISORDERS IN CHILDREN WITH ACUTE EPSTEIN--BARR VIRAL INFECTION]

The study was aimed to investigate the influence of drug reamberin inclusion in the treatment regimen of patients with acute Epstein-Barr virus (EBV) infection on the effectiveness of therapy. Treatment results were analyzed in a group of 70 children aged 4-15 with a diagnosis of moderate to severe EBV infection. By the method of random sampling distribution, patients were divided into two comparable groups of 35 children, which were representative with respect to gender, age, date of admission, and conducted basic therapy. Patients in the control group were treated by the conventional scheme, while the main group received basic therapy with antibacterial drug (according to indication) and symptomatic agents (antipyretics, desensitizing agents, and local antiseptics for the treatment of rotor and nasopharynx) and, in addition, obtained 1.5% reamberin solution intravenously, 10 mL/kg body weight once a day at a rate of 3-4 mL/min (the treatment course did not exceed 3 days). Treatment efficacy was assessed by a decrease in the duration of intoxication symptoms, relief of their clinical manifestations, and normalization of laboratory data (including, in addition to commonly accepted data, the levels of malonic dialdehyde, ferritin, transferrin and catalase before and after treatment).The inclusion of reamberin in the therapy of acute EBV infection in children favors (in comparison to conventional treatment regimen) more pronounced and rapid decrease the intensity of the oxidative process and improves the functioning of the antioxidant system. This was manifested by normalization of immunobiochemical indicators (reduction of malonic dialdehyde and ferritin and increase in the level of catalase) and decrease in the inflammatory response (leukocytosis, ESR, and the number of atypical mononuclear cells in the blood), This resulted in more rapid relief of the clinical manifestations of infection (sore throat, hyperthermia, lymphadenopathy, and hepatomegaly) and shortened the hospital stay by 38.5% (p < 0.05).

[Optimization of treatment of acute pancreatitis in elderly and senile]

The purpose of this study was to evaluate the efficacy of Reamberin as a component of intensive care edematous form of acute pancreatitis in elderly and senile patients. There were analysed the treatment data of 78 patients of this category diagnosed with «acute pancreatitis edematous form». Based on the regimens, patients were divided into 2 groups: 42 patients of the main group received Reamberin in addition to the standard treatment; patients in the control group (36 patients) received standard basic therapy. Inclusion in Reamberin regimens edematous form of acute pancreatitis in patients older than 60 years increases the effectiveness of treatment due to more rapid relief of symptoms of endogenous intoxication. The drug has a membrane stabilizing action, on the one hand, preventing the progression of the destruction of the pancreas and hence increase endogenous intoxication, the other - limiting structural disorders of the liver, normalizes its detoxification function. In addition, increasing the effectiveness of anticoagulant and fibrinolytic systems Reamberin corrects disturbances in the hemostatic system, contributing to the improvement of organ blood flow hepatopancreatoduodenal zone.

[INCREASING EFFICACY OF PREGRAVIDAR PREPARATION IN MARRIED COUPLES SUFFERING OF INCREASED RISK OF PREGNANCY MISCARRIAGE.]

This study was aimed at revealing clinical and laboratory peculiarities in the health of married couples suffering of pregnancy miscarriage and the possibility of correcting this state by preconception therapy with reamberin, based on analysis of the results of observations and investigations for 196 married couples. At the first stage, we have studied the influence of provoking factors on the miscarriage during first trimester, including the presence and degree of chronic nonspe- cific intoxication. The patients were divided into groups: first (main) group including 40 couples, in which the pregnancy was complicated by the risk of pre- gnancy termination in the first trimester and second (comparison) group of 74 couples, in which abortion in the first trimester was followed by complex precon- ception therapy. The control group included 82 couples with normal course of pregnancy in the first trimester. At the second stage, we have studied the efficacy of including reamberin in the scheme of therapy. For this purpose, patients in the second (comparison) group were separated into subgroups. In subgroup I, 50 male patients received reamberin (i.v., dropwise, 400 mL per day at a rate of 60 - 70 drops/min, over 10 days), while 24 male patients of subgroup II were treated according to commonly accepted schemes (involving recommendations concerning regime and diet, psychological aid, and polyvitamins in prophylac- tic doses). Analysis of the obtained data revealed the presence of nonspecific intoxication in patients of the main group comparison groups, which was related to the increased level of intermediate metabolism products and osmotic state of plasma, and disorders in the hepatobiliary system as manifested by hyperbiliru- binemia, increased level of transaminases, urea, creatinine, etc. In addition, most patients also exhibited changes in spermograms, including astenozospermia (75.9 ? 7.9%) and teratozospermia (69 ? 8.6%) on the background of relative androgenous insufficiency, and bacterospermia in 26.7 ? 8.1% of patients from couples where the pregnancy of females was complicated by risk of miscarriage in the first trimester, and in 34.3 ? 5.8% of patients from couples receiving re- habilitation care upon abortion in the first trimester. The inclusion of reamberin in the scheme of complex preconception therapy of male in pairs with miscarri- age problems increased the efficacy of therapy. This was manifested by decrease in the parameters of intoxication (on the average by 21 % (d = 0.017), positive dynamics of the main indices of spermograms, and improvement of the general state, which led in turn to increased probability of the onset and maintenance of pregnancy.

Contribution of CCK1 receptors to cardiovascular and respiratory effects of cholecystokinin in anesthetized rats

The study investigated the share of vagal input at infra- and supra-nodosal level and the contribution of CCK1 and CCK2 receptors to the cardiorespiratory responses produced by an intravenous injection of sulfated cholecystokinin octapeptide (CCK-8) in anesthetized rats. This compound administered intravenously at a dose of 50μg/kg induced short-lived decline in tidal volume and respiratory rate resulting in depression of minute ventilation. Midcervical vagotomy had no effect on CCK-8-evoked ventilatory changes, whereas supranodosal denervation abolished slowing down of breathing. Cardiovascular response to CCK challenge was characterized by a transient decrease followed by an augmentation in the mean blood pressure (MAP) in the intact animals. Vagotomy performed at both levels abrogated the declining phase of MAP. Blood pressure changes were associated with decreased heart rate present in all neural states. All cardiovascular and respiratory effects were antagonized by pre-treatment with devazepide-CCK1 receptors' antagonist, whereas CI988-antagonist of CCK2 receptors was ineffective. In conclusion, our results indicate that CCK-8 modulates slowing down of respiratory rhythm via CCK1 receptors located in the nodose ganglia (NG) and depresses tidal volume via central CCK1 dependent mechanism. CCK-8-evoked decline in blood pressure may be due to activation of vagal afferents, whereas pressor responses seem to be mediated by an activation of CCK1 receptors in the central nervous system. Bradycardia was probably induced by the direct action of CCK-8 on the heart pacemaker cells.

[POSSIBILITY OF CORRECTION OF METABOLIC DISORDERS WITH REAMBERIN IN ACUTE PERIOD OF TRAUMATIC INJURY]

56 patients at the age of 18-60 years with severe trauma were examined. Influence of the polyelectrolytic (Reamberin)solution on an acid-base state, osmolarity and electrolytic composition of plasma in the acute posttraumatic period was evaluated. It was found that patients, who was treated by isotonic sodium chloride solution and Ringer's solution, had metabolic acidosis and hyperchloremia. In contrast, in the reamberin group 82% of patients had lower concentrations of chloride and had nothing acid-base disturbances on the second day after trauma. Reamberin didn't influence on plasma osmolarity and the rate of metabolic alkalosis during the acute period of a trauma.

T1-Weighted Hypersignal in the Deep Cerebellar Nuclei After Repeated Administrations of Gadolinium-Based Contrast Agents in Healthy Rats: Difference Between Linear and Macrocyclic Agents

OBJECTIVES

To prospectively compare in healthy rats the effect of multiple injections of macrocyclic (gadoterate meglumine) and linear (gadodiamide) gadolinium-based contrast agents (GBCAs) on T1-weighted signal intensity in the deep cerebellar nuclei (DCN), including the dentate nucleus.

MATERIALS AND METHODS

Healthy rats (n = 7/group) received 20 intravenous injections of 0.6 mmol of gadolinium (Gd) per kilogram (4 injections per week during 5 weeks) of gadodiamide, gadoterate meglumine, or hyperosmolar saline (control group). Brain T1-weighted magnetic resonance imaging was performed before and once a week during the 5 weeks of injections and during 5 additional weeks (treatment-free period). Gadolinium concentrations were measured with inductively coupled plasma mass spectrometry in plasma and brain. Blinded qualitative and quantitative evaluations of the T1 signal intensity in DCN were performed, as well as a statistical analysis on quantitative data.

RESULTS

A significant and persistent T1 signal hyperintensity in DCN was observed only in gadodiamide-treated rats. The DCN-to-cerebellar cortex signal ratio was significantly increased from the 12th injection of gadodiamide (1.070 ± 0.024) compared to the gadoterate meglumine group (1.000 ± 0.033; P < 0.001) and control group (1.019 ± 0.022; P < 0.001) and did not significantly decrease during the treatment-free period. Total Gd concentrations in the gadodiamide group were significantly higher in the cerebellum (3.66 ± 0.91 nmol/g) compared with the gadoterate meglumine (0.26 ± 0.12 nmol/g; P < 0.05) and control (0.06 ± 0.10 nmol/g; P < 0.05) groups.

CONCLUSIONS

Repeated administrations of the linear GBCA gadodiamide to healthy rats are associated with progressive and persistent T1 signal hyperintensity in the DCN, with Gd deposition in the cerebellum in contrast with the macrocyclic GBCA gadoterate meglumine for which no effect was observed.

Ongoing epidemic of cutaneous leishmaniasis among Syrian refugees, Lebanon

In September 2012, a cutaneous leishmaniasis outbreak began among Syrian refugees in Lebanon. For 948 patients in whom leishmaniasis was not confirmed, we obtained samples for microscopic confirmation and molecular speciation. We identified Leishmania tropica in 85% and L. major in 15% of patients. After 3 months of megulamine antimonite therapy, patients initial cure rate was 82%.

Contrast-enhanced voiding urosonography phantom study: intravenous iodinated and gadolinium-based contrast agents may cause false-negative results in assessment of vesicoureteral reflux in children

BACKGROUND

Contrast-enhanced voiding urosonography (ce-VUS) is commonly requested simultaneously to other diagnostic imaging necessitating intravenous contrast agents. To date there is limited knowldedge about intravesical interactions between different types of contrast agents.

OBJECTIVE

To assess the effect of excreted intravenous iodinated and gadolinium-based contrast agents on the intravesical distribution of ultrasound contrast within contrast-enhanced voiding urosonography.

MATERIALS AND METHODS

Iodinated (iomeprol, iopamidol) and gadolinium-based (gadoterate meglumine) contrast agents were diluted to bladder concentration and injected into balloons filled with saline solution. CT scans were performed to assess the contrast distribution in these phantoms. Regions of interest were placed at the top and bottom side of each balloon and Hounsfield units (HU) were measured. Three other balloons were filled with saline solution and contrast media likewise. The ultrasound contrast agent sulphur hexafluoride was added and its distribution was assessed using sonography.

RESULTS

MDCT scans showed a separation of two liquid layers in all bladder phantoms with the contrast layers located at the bottom and the saline solution at the top. Significant differences of the HU measurements at the top and bottom side were observed (P < 0.001-0.007). Following injection of ultrasound contrast agent, US showed its distribution exclusively among the saline solution.

CONCLUSIONS

False-negative results of contrast-enhanced voiding urosonography may occur if it is performed shortly after imaging procedures requiring intravenous contrast.

[Anxiolytic and antidepressant effects of 3-oxypiridine and succinic acid derivatives in alloxan diabetes]

The effects of 3-oxypyridine and succinic acid derivatives (emoxipine, reamberin and mexidol) on affective disorders in rats with alloxan diabetes were studied. The efficiency of emoxipine, reamberin and mexidol was compared to alpha-lipoic acid, which is considered a "golden standard" in treatment of diabetic neuropathies. Emoxipine, reamberin and mexidol after seven administrations in single doses, that are equivalent to therapeutic range in humans, corrected the anxiety-depressive disorders in rats with alloxan diabetes. Unlike reamberin and alpha-lipoic acid, emoxipine and mexidol corrected the affective status concurrently with the decrease in hyperglycemia. At the same time, emoxipine outperformed mexidol in tranquilizing action (in maximal doses) but yielded mexidol in the antidepressant effect (in minimal doses).

[Effect of succinate-containing solution on the level of metabolism during perioperative period in children]

DESIGN

A randomized prospective study.

PATIENTS AND METHODS

The study included 87 children aged from 5 to 18, ASA I-II. The patients were divided into two groups. We assessed the impact of reamberin 1.5% (succinate-containing infusion solution) on the level of metabolism and recovery after surgery in patients of main group (n = 44) and control group (n = 43) during different surgeries. All patients received general anaesthesia with sevoflurane, fentanyl, and rocuronium.

RESULTS

Reamberin 1.5% promotes to increase the level of basal metabolism in the early postoperative period, decreases the duration of awakening periods, improves recovery of motor activity and adequate breathing.

[THE USE OF "REAMBERIN" AS BIOLOGICAL RESPONSE MODIFIER TO INCREASE THE NATURAL KILLER CELLS' CYTOTOXICITY IN PATIENTS WITH LUNG TUBERCULOSIS]

The effect of the drug "Reamberin" cytotoxic activity of natural killer cells (EC) in an experimental model in the blood samples of patients with pulmonary tuberculosis and healthy donors. Simulation acute systemic inflammation by adding to the culture medium of BCG. After 48 hours, selection was performed mononuclear peripheral blood by gradient centrifugation tests set cytotoxic tumor cell line K-562. Revealed the stimulating effect of the drug "Reamberin" cytotoxic activity of natural killer cells. Metabolic Correction has had a positive impact on the energy metabolism of blood natural killer cells, to increase their survial and cytotoxicity.

Safety and efficacy of sonographically guided high-intensity focused ultrasound for symptomatic uterine fibroids: preliminary study of a modified protocol

OBJECTIVES

We aimed to assess the safety and efficacy of sonographically guided high-intensity focused ultrasound for treating patients with symptomatic uterine fibroids using a modified protocol.

METHODS

This work was part of an ongoing prospective phase 1 study. Twenty patients with 22 symptomatic fibroids were treated with sonographically guided high-intensity focused ultrasound under no anesthesia. The modified protocol consisted of repeated and shortened (<25 minutes) treatment sessions of high-input acoustic intensity (1000-1500 W/cm(2)) and intensified sonication pulses (1500-2000) at each spot. The primary end points were periprocedural complications. The secondary end points were symptomatic improvement and radiologic evidence of treatment responses, including the degree of fibroid infarction and volume shrinkage 3 months after treatment. Symptomatic improvement was assessed by a pain score, a pictorial chart menstrual score, the Urogenital Distress Inventory short form, and the Incontinence Impact Questionnaire short form. The degree of fibroid infarction was assessed by the nonperfused ratio on contrast-enhanced magnetic resonance imaging, defined as the ratio of the nonperfused fibroid volume to the total fibroid volume.

RESULTS

Nineteen patients tolerated the treatment well, with no major adverse events. One patient who received treatment for a fibroid located within 6 cm from the skin had third-degree skin burns at 2 sites of 1 cm in diameter. Fibroid-related abdominal pain, pictorial chart, Urogenital Distress Inventory, and Incontinence Impact Questionnaire scores were significantly improved (P < .05). The median nonperfused ratio at 3 months was 20% (95% confidence interval, 5%-32.5%). Median volume shrinkage at 3 months was 17.2% (95% confidence interval, 4.3%-26.6%).

CONCLUSIONS

Sonographically guided high-intensity focused ultrasound using a modified protocol may be safe and effective for symptomatic uterine fibroids in selected patients to avoid skin burns.