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Menashe SJ, Zavaletta V, McCoy MN, Wright JN. Advocacy in gender affirming care. Pediatr Radiol 2024:10.1007/s00247-024-05885-w. [PMID: 38436706 DOI: 10.1007/s00247-024-05885-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 02/08/2024] [Accepted: 02/09/2024] [Indexed: 03/05/2024]
Abstract
Healthcare advocacy is the duty and privilege of all healthcare providers, but especially for those who care for children. Intersex and gender diverse youth face significant barriers across many aspects of life, with access to competent gender affirming healthcare chief among them. Understanding the importance of both institutional and individual efforts in healthcare advocacy is paramount to improving healthcare access and outcomes for this population.
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Affiliation(s)
- Sarah J Menashe
- Department of Radiology, Seattle Children's Hospital, University of Washington, MA.7.220, 4800 Sandpoint Way NE, Seattle, WA, 98105, USA.
| | - Vaz Zavaletta
- Department of Pediatric Radiology, Children's Hospital Chicago, University of Colorado Hospital, Aurora, CO, USA
| | | | - Jason N Wright
- Department of Radiology, Seattle Children's Hospital, University of Washington, MA.7.220, 4800 Sandpoint Way NE, Seattle, WA, 98105, USA
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2
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Tam LT, Cole B, Stasi SM, Paulson VA, Wright JN, Hoeppner C, Holtzclaw S, Crotty EE, Ellenbogen RG, Lee A, Ermoian RP, Lockwood CM, Leary SES, Ronsley R. Somatic Versus Germline: A Case Series of Three Children With ATM-Mutated Medulloblastoma. JCO Precis Oncol 2024; 8:e2300333. [PMID: 38207225 DOI: 10.1200/po.23.00333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 09/03/2023] [Accepted: 11/07/2023] [Indexed: 01/13/2024] Open
Abstract
Somatic versus Germline-A Case Series of Three Children with ATM- mutated Medulloblastoma.
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Affiliation(s)
- Lydia T Tam
- Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA
| | - Bonnie Cole
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA
- Department of Laboratories, Seattle Children's Hospital, Seattle, WA
| | - Shannon M Stasi
- Department of Laboratories, Seattle Children's Hospital, Seattle, WA
- Division of Hematology, Oncology, Bone Marrow Transplant & Cellular Therapy, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA
| | - Vera A Paulson
- Genetics Division, Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA
| | - Jason N Wright
- Department of Radiology, Seattle Children's Hospital, University of Washington, Seattle, WA
| | - Corrine Hoeppner
- Division of Hematology, Oncology, Bone Marrow Transplant & Cellular Therapy, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA
| | - Susan Holtzclaw
- Division of Hematology, Oncology, Bone Marrow Transplant & Cellular Therapy, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA
| | - Erin E Crotty
- Division of Hematology, Oncology, Bone Marrow Transplant & Cellular Therapy, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA
- Department of Neurological Surgery, Seattle Children's Hospital, University of Washington, Seattle, WA
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - Richard G Ellenbogen
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, WA
| | - Amy Lee
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, WA
| | | | - Christina M Lockwood
- Genetics Division, Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA
| | - Sarah E S Leary
- Division of Hematology, Oncology, Bone Marrow Transplant & Cellular Therapy, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA
- Department of Neurological Surgery, Seattle Children's Hospital, University of Washington, Seattle, WA
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - Rebecca Ronsley
- Division of Hematology, Oncology, Bone Marrow Transplant & Cellular Therapy, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA
- Department of Neurological Surgery, Seattle Children's Hospital, University of Washington, Seattle, WA
- Department of Radiation Oncology, University of Washington, Seattle, WA
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3
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Feldman KW, Sokoloff M, Otjen JP, Wright JN, Lee A, Ebel B, Blair AB. Reply to Melville Re: Short Falls Occasionally Cause Major Brain Injuries. Pediatr Emerg Care 2023; 39:734. [PMID: 37079696 DOI: 10.1097/pec.0000000000002947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
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Feldman KW, Wright JN, Menashe SJ, Otjen JP, Pidaparti V. Symptomatic Cervical Spinal Cord Injury Without Accompanying Intracranial Injury Because of Child Abuse. Pediatr Emerg Care 2023; 39:371-373. [PMID: 35413043 DOI: 10.1097/pec.0000000000002696] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Although spinal ligamentous injuries and extra-axial hemorrhages are known to commonly accompany abusive head trauma (AHT), symptomatic and radiological apparent cervical spinal cord injuries are rare. Of the 16 previously reported cases, 3 such cord injuries lacked the accompanying intracranial injuries of AHT. We report an additional child who developed symptomatic central cervical cord syndrome, with accompanying cervical imaging findings, but no intracranial AHT injuries. The mechanism of trauma for this child and the other children without intracranial injury remains unclear. However, 1 additional reported child sustained similar injuries when she was held by her head and shaken. It is likely that as cervical magnetic resonance imaging becomes more common in AHT, more cases will be recognized.
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5
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Intrapiromkul J, Wangaryattawanich P, Patay Z, Huisman T, Wright JN, Jones JY, Ramakrishnaiah R, Patel R, Goldman-Yassen A, Kralik S, Mamlouk M, Desai NK. Imaging of pediatric calvarial and skull base tumors: A COG Diagnostic Imaging Committee/SPR Oncology Committee/ASPNR White Paper. Pediatr Blood Cancer 2023; 70 Suppl 4:e30165. [PMID: 36565281 PMCID: PMC10644274 DOI: 10.1002/pbc.30165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 11/30/2022] [Indexed: 12/25/2022]
Abstract
A standardized imaging protocol for pediatric oncology patients is essential for accurate and efficient imaging, while simultaneously promoting collaborative understanding of pathologies and radiologic assessment of treatment response. The objective of this article is to provide standardized pediatric imaging guidelines and parameters for evaluation of tumors of the pediatric orbit, calvarium, skull base, and temporal bone. This article was drafted based on current scientific literature as well as consensus opinions of imaging experts in collaboration with the Children's Oncology Group Diagnostic Imaging Committee, Society of Pediatric Radiology Oncology Committee, and American Society of Pediatric Neuroradiology.
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Affiliation(s)
- Jarunee Intrapiromkul
- The Russell H. Morgan Department of Radiology and Radiological Sciences, the Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | | | - Zoltan Patay
- St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Thierry Huisman
- Edward B. Singleton Department of Radiology, Texas Children’s Hospital, Houston, TX, USA
| | - Jason N Wright
- Department of Radiology, University of Washington, Seattle Children’s Hospital, Seattle, WA, USA
| | - Jeremy Y Jones
- Department of Radiology, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Raghu Ramakrishnaiah
- Department of Radiology, University of Arkansas of Medical Sciences, Arkansas Children’s Hospital, Little Rock, AR, USA
| | - Rajan Patel
- Edward B. Singleton Department of Radiology, Texas Children’s Hospital, Houston, TX, USA
| | | | - Stephen Kralik
- Edward B. Singleton Department of Radiology, Texas Children’s Hospital, Houston, TX, USA
| | - Mark Mamlouk
- Department of Radiology, The Permanente Medical Group, Kaiser Permanente Medical Center, Santa Clara, CA, USA
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - Nilesh K Desai
- Edward B. Singleton Department of Radiology, Texas Children’s Hospital, Houston, TX, USA
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6
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Feldman KW, Sokoloff M, Otjen JP, Wright JN, Lee A, Ebel B, Blair AB. Short Falls in Childhood Occasionally Cause Major Brain Injuries Because of Unusual Circumstances. Pediatr Emerg Care 2023; 39:335-341. [PMID: 37115991 DOI: 10.1097/pec.0000000000002749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
METHODS Records and imaging were reviewed for children younger than 6 years, hospitalized between 2015 and 2020 for major closed head injuries following less than 4-ft falls. Major injury was defined as intensive care admission more than 2 days, neurosurgical intervention, death, or disability at hospital discharge. Subjects were identified through Seattle and Spokane, Washington abuse consultations. Harborview Medical Center's trauma registry and Seattle Children's Hospital's Hemophilia Treatment Program and Radiology were searched for subjects. RESULTS We identified 12 young children who sustained major closed head injury due to short falls. Seven developed major space-occupying epidural hemorrhages. One child developed internal hydrocephalus after intraventricular hemorrhage. One child with prior meningomyelocele, Chiari 2 malformation, and ventriculoperitoneal shunt developed shunt decompensation after an acute-on-chronic subdural hemorrhage. One child developed an internal capsule stroke because of a previously undiagnosed calcifying angiopathy. Another child developed space-occupying subdural hemorrhage associated with previously unrecognized platelet pool disorder. Only this child had abuse concerns, which were resolved with his coagulopathy diagnosis. One child had a diastatic skull fracture leading to pseudomeningocele.At Harborview Medical Center, 140 children were seen for short falls in the emergency department or inpatient service. Among the 40 needing intensive care, 4 (12.5%) had major injuries after short falls. Our hemophilia treatment program did not see any children who had sustained major injury following a short fall in a 5½ year period. CONCLUSIONS Although young children rarely sustain major head injury following short falls, serious head injuries do occasionally occur because of unusual injury mechanisms or preexisting conditions. It is important to fully evaluate these patients to differentiate these unintentional falls from abusive head injury.
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Patel PB, Patrick KE, Benedetti GM, Morgan LA, Bowen KS, Wright JN, Wainwright MS. A Multidisciplinary Pediatric Neurology Clinic for Systematic Follow-up of Children with Neurologic Sequelae of COVID-19. J Child Neurol 2023; 38:121-129. [PMID: 36991568 DOI: 10.1177/08830738231156950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
Clinical guidance on outpatient follow-up of children hospitalized with acute neurologic complications of SARS-CoV2 infection is needed. We describe the clinical infrastructure of our pediatric neurology post-Covid clinic, including our clinical evaluation and cognitive testing battery specific to this patient population, and a case series of our initial patient cohort. Our findings demonstrate cognitive sequelae in all 4 of our patients months following acute SARS-CoV2 infection with neurologic complications including acute disseminated encephalomyelitis, posterior reversible encephalopathy syndrome, viral encephalitis, and gait difficulties. Verbal and executive function domains were predominantly affected in our cohort, even in patients who did not endorse symptomatic or academic complaints at follow-up. Our recommendations include systematic clinical follow-up for children following hospitalization with SARS-CoV2 infection with a comprehensive cognitive battery to monitor for cognitive sequalae and to assist with developing an individualized education plan for the child as they return to school.
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Affiliation(s)
- Payal B Patel
- Department of Neurology, Division of Pediatric Neurology, Seattle Children's Hospital, Seattle, WA, USA
| | - Kristina E Patrick
- Department of Neurology, Division of Pediatric Neurology, Seattle Children's Hospital, Seattle, WA, USA
| | | | - Lindsey A Morgan
- Department of Neurology, Division of Pediatric Neurology, Seattle Children's Hospital, Seattle, WA, USA
| | - Katherine S Bowen
- Department of Neurology, Division of Pediatric Neurology, Seattle Children's Hospital, Seattle, WA, USA
| | - Jason N Wright
- Department of Neurology, Division of Pediatric Neurology, Seattle Children's Hospital, Seattle, WA, USA
| | - Mark S Wainwright
- Department of Neurology, Division of Pediatric Neurology, Seattle Children's Hospital, Seattle, WA, USA
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Vitanza NA, Wilson AL, Huang W, Seidel K, Brown C, Gustafson JA, Yokoyama JK, Johnson AJ, Baxter BA, Koning RW, Reid AN, Meechan M, Biery MC, Myers C, Rawlings-Rhea SD, Albert CM, Browd SR, Hauptman JS, Lee A, Ojemann JG, Berens ME, Dun MD, Foster JB, Crotty EE, Leary SE, Cole BL, Perez FA, Wright JN, Orentas RJ, Chour T, Newell EW, Whiteaker JR, Zhao L, Paulovich AG, Pinto N, Gust J, Gardner RA, Jensen MC, Park JR. Intraventricular B7-H3 CAR T Cells for Diffuse Intrinsic Pontine Glioma: Preliminary First-in-Human Bioactivity and Safety. Cancer Discov 2023; 13:114-131. [PMID: 36259971 PMCID: PMC9827115 DOI: 10.1158/2159-8290.cd-22-0750] [Citation(s) in RCA: 58] [Impact Index Per Article: 58.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 09/13/2022] [Accepted: 10/13/2022] [Indexed: 01/16/2023]
Abstract
Diffuse intrinsic pontine glioma (DIPG) remains a fatal brainstem tumor demanding innovative therapies. As B7-H3 (CD276) is expressed on central nervous system (CNS) tumors, we designed B7-H3-specific chimeric antigen receptor (CAR) T cells, confirmed their preclinical efficacy, and opened BrainChild-03 (NCT04185038), a first-in-human phase I trial administering repeated locoregional B7-H3 CAR T cells to children with recurrent/refractory CNS tumors and DIPG. Here, we report the results of the first three evaluable patients with DIPG (including two who enrolled after progression), who received 40 infusions with no dose-limiting toxicities. One patient had sustained clinical and radiographic improvement through 12 months on study. Patients exhibited correlative evidence of local immune activation and persistent cerebrospinal fluid (CSF) B7-H3 CAR T cells. Targeted mass spectrometry of CSF biospecimens revealed modulation of B7-H3 and critical immune analytes (CD14, CD163, CSF-1, CXCL13, and VCAM-1). Our data suggest the feasibility of repeated intracranial B7-H3 CAR T-cell dosing and that intracranial delivery may induce local immune activation. SIGNIFICANCE This is the first report of repeatedly dosed intracranial B7-H3 CAR T cells for patients with DIPG and includes preliminary tolerability, the detection of CAR T cells in the CSF, CSF cytokine elevations supporting locoregional immune activation, and the feasibility of serial mass spectrometry from both serum and CSF. This article is highlighted in the In This Issue feature, p. 1.
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Affiliation(s)
- Nicholas A. Vitanza
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, Washington.,Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, Washington.,Corresponding Author: Nicholas A. Vitanza, Seattle Children's Research Institute, M/S JMB-8, 1900 9th Avenue, Seattle, WA 98101. Phone: 206-884-4084; E-mail:
| | | | - Wenjun Huang
- Seattle Children's Therapeutics, Seattle, Washington
| | - Kristy Seidel
- Seattle Children's Therapeutics, Seattle, Washington
| | - Christopher Brown
- Seattle Children's Therapeutics, Seattle, Washington.,Therapeutic Cell Production Core, Seattle Children's Research Institute, Seattle, Washington
| | | | | | | | | | | | | | - Michael Meechan
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, Washington
| | - Matthew C. Biery
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, Washington
| | - Carrie Myers
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, Washington
| | | | - Catherine M. Albert
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, Washington.,Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Samuel R. Browd
- Division of Neurosurgery, Seattle Children's Hospital and Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Jason S. Hauptman
- Division of Neurosurgery, Seattle Children's Hospital and Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Amy Lee
- Division of Neurosurgery, Seattle Children's Hospital and Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Jeffrey G. Ojemann
- Division of Neurosurgery, Seattle Children's Hospital and Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Michael E. Berens
- Cancer and Cell Biology Division, The Translational Genomics Research Institute (TGen), Phoenix, Arizona
| | - Matthew D. Dun
- School of Biomedical Sciences and Pharmacy, College of Health, Medicine and Wellbeing, Callaghan, Australia.,Precision Medicine Research Program, Hunter Medical Research Institute, New Lambton Heights, Australia
| | - Jessica B. Foster
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Erin E. Crotty
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, Washington.,Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Sarah E.S. Leary
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, Washington.,Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Bonnie L. Cole
- Department of Laboratories, Seattle Children's Hospital, Seattle, Washington.,Department of Laboratory Medicine and Pathology, University of Washington School of Medicine, Seattle, Washington
| | - Francisco A. Perez
- Department of Radiology, Seattle Children's Hospital, Seattle, Washington
| | - Jason N. Wright
- Department of Radiology, Seattle Children's Hospital, Seattle, Washington
| | - Rimas J. Orentas
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, Washington.,Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Tony Chour
- Department of Laboratory Medicine and Pathology, University of Washington School of Medicine, Seattle, Washington.,Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Evan W. Newell
- Department of Laboratory Medicine and Pathology, University of Washington School of Medicine, Seattle, Washington.,Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | - Lei Zhao
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Amanda G. Paulovich
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Navin Pinto
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, Washington.,Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Juliane Gust
- Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, Washington.,Division of Pediatric Neurology, Department of Neurology, University of Washington, Seattle, Washington
| | - Rebecca A. Gardner
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, Washington.,Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, Washington.,Seattle Children's Therapeutics, Seattle, Washington
| | | | - Julie R. Park
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, Washington.,Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, Washington.,Seattle Children's Therapeutics, Seattle, Washington
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Serrallach BL, Schafer ES, Kralik SK, Tran BH, Huisman TAGM, Wright JN, Morgan LA, Desai NK. Imaging Findings in Children Presenting with CNS Nelarabine Toxicity. AJNR Am J Neuroradiol 2022; 43:1802-1809. [PMID: 36328408 DOI: 10.3174/ajnr.a7692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 09/29/2022] [Indexed: 11/06/2022]
Abstract
Nelarabine is a nucleoside analog critical for the treatment of patients with T-cell acute lymphoblastic leukemia/lymphoma. However, clinical peripheral and central neurologic adverse events associated with nelarabine administration have been reported. Neuroimaging of brain neurotoxicity has only been described in very few reports in pediatric patients so far. Six children with diagnosed T-cell acute lymphoblastic leukemia who clinically experienced possible, probable, or definite nelarabine-induced toxicity and underwent spine and/or brain MR imaging were reviewed. Neuroimaging findings showed a mixture of patterns including features of acute toxic leukoencephalopathy (seen in 6 cases), posterior reversible encephalopathy syndrome (2 cases), involvement of deep gray structures (1 case) and brainstem (2 cases), cranial and spinal neuropathy (2 cases each), and myelopathy (2 cases). Even though neuroimaging findings are nonspecific, the goal of this article was to alert the pediatric neuroradiologists, radiologists, and clinicians about the possibility of nelarabine-induced neurotoxicity and its broad neuroimaging spectrum.
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Affiliation(s)
- B L Serrallach
- From the Edward B. Singleton Department of Radiology (B.L.S., S.K.K., B.H.T., T.A.G.M.H., N.K.D.)
| | - E S Schafer
- Department of Pediatrics (E.S.S.), Section of Hematology-Oncology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - S K Kralik
- From the Edward B. Singleton Department of Radiology (B.L.S., S.K.K., B.H.T., T.A.G.M.H., N.K.D.)
| | - B H Tran
- From the Edward B. Singleton Department of Radiology (B.L.S., S.K.K., B.H.T., T.A.G.M.H., N.K.D.)
| | - T A G M Huisman
- From the Edward B. Singleton Department of Radiology (B.L.S., S.K.K., B.H.T., T.A.G.M.H., N.K.D.)
| | | | - L A Morgan
- Neurology (L.A.M.), Division of Child Neurology, Seattle Children's Hospital, Seattle, Washington
| | - N K Desai
- From the Edward B. Singleton Department of Radiology (B.L.S., S.K.K., B.H.T., T.A.G.M.H., N.K.D.)
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Radhakrishnan R, Shea LAG, Pruthi S, Silvera VM, Bosemani T, Desai NK, Gilbert DL, Glenn OA, Guimaraes CV, Ho ML, Lam HFS, Maheshwari M, Mirsky DM, Nadel HR, Partap S, Schooler GR, Udayasankar UK, Whitehead MT, Wright JN, Rigsby CK. ACR Appropriateness Criteria® Ataxia-Child. J Am Coll Radiol 2022; 19:S240-S255. [PMID: 36436955 DOI: 10.1016/j.jacr.2022.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 09/07/2022] [Indexed: 11/27/2022]
Abstract
Childhood ataxia may be due to multifactorial causes of impairment in the coordination of movement and balance. Acutely presenting ataxia in children may be due to infectious, inflammatory, toxic, ischemic, or traumatic etiology. Intermittent or episodic ataxia in children may be manifestations of migraine, benign positional vertigo, or intermittent metabolic disorders. Nonprogressive childhood ataxia suggests a congenital brain malformation or early prenatal or perinatal brain injury, and progressive childhood ataxia indicates inherited causes or acquired posterior fossa lesions that result in gradual cerebellar dysfunction. CT and MRI of the central nervous system are the usual modalities used in imaging children presenting with ataxia, based on the clinical presentation. This document provides initial imaging guidelines for a child presenting with acute ataxia with or without a history of recent trauma, recurrent ataxia with interval normal neurological examination, chronic progressive ataxia, and chronic nonprogressive ataxia. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
- Rupa Radhakrishnan
- Associate Division Chief, Neuroradiology, Indiana University Health, Indianapolis, Indiana.
| | - Lindsey A G Shea
- Research Author, Indiana University School of Medicine, Indianapolis, Indiana
| | - Sumit Pruthi
- Panel Chair, Vanderbilt Children's Hospital, Nashville, Tennessee
| | | | | | | | - Donald L Gilbert
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; American Academy of Neurology
| | - Orit A Glenn
- Director, Pediatric Neuroradiology, University of California, San Francisco, San Francisco, California
| | - Carolina V Guimaraes
- Division Chief, Pediatric Radiology, Lucile Packard Children's Hospital at Stanford, Stanford, California
| | - Mai-Lan Ho
- Nationwide Children's Hospital, Columbus, Ohio
| | - H F Samuel Lam
- Sutter Medical Center Sacramento, Sacramento, California; American College of Emergency Physicians
| | - Mohit Maheshwari
- Director of Pediatric Neuroradiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - David M Mirsky
- Director of the Pediatric Neuroradiology Fellowship, Children's Hospital Colorado, Aurora, Colorado
| | - Helen R Nadel
- Lucile Packard Children's Hospital at Stanford, Stanford, California
| | - Sonia Partap
- Neuro-Oncology Fellowship Director, Stanford University, Stanford, California; American Academy of Pediatrics
| | - Gary R Schooler
- Associate Division Director, Pediatric Radiology, UT Southwestern Medical Center, Dallas, Texas
| | | | | | | | - Cynthia K Rigsby
- Specialty Chair; Chair, Medical Imaging Department, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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11
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Goldstein HE, Poliakov A, Shaw DW, Barry D, Tran K, Novotny EJ, Saneto RP, Marashly A, Warner MH, Wright JN, Hauptman JS, Ojemann JG, Shurtleff HA. Precision medicine in pediatric temporal epilepsy surgery: optimization of outcomes through functional MRI memory tasks and tailored surgeries. J Neurosurg Pediatr 2022; 30:272-283. [PMID: 35901731 DOI: 10.3171/2022.5.peds22148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 05/27/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The goal of epilepsy surgery is both seizure cessation and maximal preservation of function. In temporal lobe (TL) cases, the lack of functional MRI (fMRI) tasks that effectively activate mesial temporal structures hampers preoperative memory risk assessment, especially in children. This study evaluated pediatric TL surgery outcome optimization associated with tailored resection informed by an fMRI memory task. METHODS The authors identified focal onset TL epilepsy patients with 1) TL resections; 2) viable fMRI memory scans; and 3) pre- and postoperative neuropsychological (NP) evaluations. They retrospectively evaluated preoperative fMRI memory scans, available Wada tests, pre- and postoperative NP scores, postoperative MRI scans, and postoperative Engel class outcomes. To assess fMRI memory task outcome prediction, the authors 1) overlaid preoperative fMRI activation onto postoperative structural images; 2) classified patients as having "overlap" or "no overlap" of activation and resection cavities; and 3) compared these findings with memory improvement, stability, or decline, based on Reliable Change Index calculations. RESULTS Twenty patients met the inclusion criteria. At a median of 2.1 postoperative years, 16 patients had Engel class IA outcomes and 1 each had Engel class IB, ID, IIA, and IID outcomes. Functional MRI activation was linked to NP memory outcome in 19 of 20 cases (95%). Otherwise, heterogeneity characterized the cohort. CONCLUSIONS Functional MRI memory task activation effectively predicted individual NP outcomes in the context of tailored TL resections. Patients had excellent seizure and overall good NP outcomes. This small study adds to extant literature indicating that pediatric TL epilepsy does not represent a single clinical syndrome. Findings support individualized surgical intervention using fMRI memory activation to help guide this precision medicine approach.
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Affiliation(s)
- Hannah E Goldstein
- 1Neurosciences Center, Seattle Children's Hospital, Seattle
- 2Department of Neurological Surgery, University of Washington School of Medicine, Seattle
- 3Division of Neurosurgery, Seattle Children's Hospital, Seattle
- 9Center for Integrated Brain Research, Seattle Children's Hospital, Seattle, Washington; and
| | - Andrew Poliakov
- 1Neurosciences Center, Seattle Children's Hospital, Seattle
- 3Division of Neurosurgery, Seattle Children's Hospital, Seattle
- 4Department of Radiology, Seattle Children's Hospital, Seattle
| | - Dennis W Shaw
- 4Department of Radiology, Seattle Children's Hospital, Seattle
- 5Department of Radiology, University of Washington School of Medicine, Seattle
| | - Dwight Barry
- 6Clinical Analytics, Seattle Children's Hospital, Seattle
| | - Kieu Tran
- 2Department of Neurological Surgery, University of Washington School of Medicine, Seattle
- 3Division of Neurosurgery, Seattle Children's Hospital, Seattle
| | - Edward J Novotny
- 1Neurosciences Center, Seattle Children's Hospital, Seattle
- 7Division of Pediatric Neurology, Seattle Children's Hospital, Seattle
- 8Department of Neurology, University of Washington School of Medicine, Seattle
- 9Center for Integrated Brain Research, Seattle Children's Hospital, Seattle, Washington; and
| | - Russell P Saneto
- 1Neurosciences Center, Seattle Children's Hospital, Seattle
- 7Division of Pediatric Neurology, Seattle Children's Hospital, Seattle
- 8Department of Neurology, University of Washington School of Medicine, Seattle
- 9Center for Integrated Brain Research, Seattle Children's Hospital, Seattle, Washington; and
| | - Ahmad Marashly
- 10Epilepsy Center, Department of Neurology, The Johns Hopkins University Medical Center, Baltimore, Maryland
| | - Molly H Warner
- 1Neurosciences Center, Seattle Children's Hospital, Seattle
- 7Division of Pediatric Neurology, Seattle Children's Hospital, Seattle
- 9Center for Integrated Brain Research, Seattle Children's Hospital, Seattle, Washington; and
| | - Jason N Wright
- 4Department of Radiology, Seattle Children's Hospital, Seattle
- 5Department of Radiology, University of Washington School of Medicine, Seattle
| | - Jason S Hauptman
- 1Neurosciences Center, Seattle Children's Hospital, Seattle
- 2Department of Neurological Surgery, University of Washington School of Medicine, Seattle
- 3Division of Neurosurgery, Seattle Children's Hospital, Seattle
- 9Center for Integrated Brain Research, Seattle Children's Hospital, Seattle, Washington; and
| | - Jeffrey G Ojemann
- 1Neurosciences Center, Seattle Children's Hospital, Seattle
- 2Department of Neurological Surgery, University of Washington School of Medicine, Seattle
- 3Division of Neurosurgery, Seattle Children's Hospital, Seattle
- 5Department of Radiology, University of Washington School of Medicine, Seattle
- 9Center for Integrated Brain Research, Seattle Children's Hospital, Seattle, Washington; and
| | - Hillary A Shurtleff
- 1Neurosciences Center, Seattle Children's Hospital, Seattle
- 7Division of Pediatric Neurology, Seattle Children's Hospital, Seattle
- 9Center for Integrated Brain Research, Seattle Children's Hospital, Seattle, Washington; and
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12
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Zhang M, Wong SW, Wright JN, Wagner MW, Toescu S, Han M, Tam LT, Zhou Q, Ahmadian SS, Shpanskaya K, Lummus S, Lai H, Eghbal A, Radmanesh A, Nemelka J, Harward S, Malinzak M, Laughlin S, Perreault S, Braun KRM, Lober RM, Cho YJ, Ertl-Wagner B, Ho CY, Mankad K, Vogel H, Cheshier SH, Jacques TS, Aquilina K, Fisher PG, Taylor M, Poussaint T, Vitanza NA, Grant GA, Pfister S, Thompson E, Jaju A, Ramaswamy V, Yeom KW. MRI Radiogenomics of Pediatric Medulloblastoma: A Multicenter Study. Radiology 2022; 304:406-416. [PMID: 35438562 PMCID: PMC9340239 DOI: 10.1148/radiol.212137] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 11/09/2021] [Accepted: 02/08/2022] [Indexed: 08/03/2023]
Abstract
Background Radiogenomics of pediatric medulloblastoma (MB) offers an opportunity for MB risk stratification, which may aid therapeutic decision making, family counseling, and selection of patient groups suitable for targeted genetic analysis. Purpose To develop machine learning strategies that identify the four clinically significant MB molecular subgroups. Materials and Methods In this retrospective study, consecutive pediatric patients with newly diagnosed MB at MRI at 12 international pediatric sites between July 1997 and May 2020 were identified. There were 1800 features extracted from T2- and contrast-enhanced T1-weighted preoperative MRI scans. A two-stage sequential classifier was designed-one that first identifies non-wingless (WNT) and non-sonic hedgehog (SHH) MB and then differentiates therapeutically relevant WNT from SHH. Further, a classifier that distinguishes high-risk group 3 from group 4 MB was developed. An independent, binary subgroup analysis was conducted to uncover radiomics features unique to infantile versus childhood SHH subgroups. The best-performing models from six candidate classifiers were selected, and performance was measured on holdout test sets. CIs were obtained by bootstrapping the test sets for 2000 random samples. Model accuracy score was compared with the no-information rate using the Wald test. Results The study cohort comprised 263 patients (mean age ± SD at diagnosis, 87 months ± 60; 166 boys). A two-stage classifier outperformed a single-stage multiclass classifier. The combined, sequential classifier achieved a microaveraged F1 score of 88% and a binary F1 score of 95% specifically for WNT. A group 3 versus group 4 classifier achieved an area under the receiver operating characteristic curve of 98%. Of the Image Biomarker Standardization Initiative features, texture and first-order intensity features were most contributory across the molecular subgroups. Conclusion An MRI-based machine learning decision path allowed identification of the four clinically relevant molecular pediatric medulloblastoma subgroups. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Chaudhary and Bapuraj in this issue.
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13
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Monroe EJ, Otjen JP, Wright JN, Perez FA, Chick JFB, Hallam DK, Ferguson MR. Prospective Determination of Orbital Perfusion Dominance before Intra-Arterial Chemotherapy for Retinoblastoma Using Time-of-Flight Magnetic Resonance Angiography. Journal of Clinical Interventional Radiology ISVIR 2022. [DOI: 10.1055/s-0042-1743498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Abstract
Purpose Intra-arterial chemotherapy (IAC) represents a mainstay in the treatment of retinoblastoma. In a minority of cases, the external carotid artery (ECA) serves as the dominant supply to the central retinal artery and is associated with prolonged fluoroscopy times and higher intraprocedural radiation doses. The aim of this study was to evaluate the utility of time-of-flight (TOF) magnetic resonance angiography (MRA) for prospective determination of internal (ICA) versus ECA dominance for procedural planning.
Technique Between April 2017 and December 2020 (44 months), staging MR prior to IAC for retinoblastoma included variant spatial saturation band position TOF angiography. Exams were then retrospectively reviewed for concordance of ICA versus ECA dominance between the two modalities. Eight consecutive patients were included in the study. Mean patient age at time of diagnosis was 20.3 ± 10.7 months (range: 2.7–33.2 months). Ten affected eyes were included (2 cases of bilateral disease), with stage D disease in eight eyes and stage B disease in two eyes. MRA techniques demonstrated antegrade ophthalmic artery (OA) flow in 9/10 (90%) of affected eyes. Subsequent catheter angiography confirmed ICA dominant supply in 9/9 (100%). For a single affected eye (10%), the OA was demonstrated as orthotopic by T2 flow void, nonvisualized on anterior saturation TOF sequences, and faintly visualized on posterior saturation TOF sequences. Aggregate MRA to catheter angiographic concordance was 10/10 (100%).
Conclusion Variant saturation TOF MRA predicts ICA versus ECA dominant supply to the central retinal artery in retinoblastoma.
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Affiliation(s)
- Eric J. Monroe
- Department of Radiology, Section of Interventional Radiology, American Family Children's Hospital and University of Wisconsin, Madison, Wisconsin, United States
| | - Jeffrey P. Otjen
- Department of Radiology, Section of Pediatric Radiology; Seattle Children's Hospital and University of Washington, Seattle, Washington, United States
| | - Jason N. Wright
- Department of Radiology, Section of Pediatric Radiology; Seattle Children's Hospital and University of Washington, Seattle, Washington, United States
| | - Francisco A. Perez
- Department of Radiology, Section of Pediatric Radiology; Seattle Children's Hospital and University of Washington, Seattle, Washington, United States
| | - Jeffrey Forris Beecham Chick
- Department of Radiology, Section of Interventional Radiology; Seattle Children's Hospital and University of Washington, Seattle, Washington, United States
| | - Danial K. Hallam
- Department of Radiology, Section of Neurointerventional Radiology, Seattle Children's Hospital and University of Washington, Seattle, Washington, United States
| | - Mark R. Ferguson
- Department of Radiology, Section of Pediatric Radiology; Seattle Children's Hospital and University of Washington, Seattle, Washington, United States
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14
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Cheeney S, Wright JN, Sie KC, Chapman T. Pearls of Temporal Bone Imaging in Children with Hearing Loss. Semin Ultrasound CT MR 2022; 43:3-18. [PMID: 35164907 DOI: 10.1053/j.sult.2021.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Hearing loss is one of the most common indications for temporal bone imaging in children. Hearing loss may be congenital or acquired, and it may be conductive, sensorineural, or mixed audiologically. Temporal bone imaging plays an important role in the assessment and management of this condition. An understanding of the embryology of ear structures better enables the radiologist to interpret abnormalities on imaging of the temporal bone. Here, we provide a general review of ear development and a description of known genetic defects that contribute to congenital ear anomalies associated with hearing loss. We provide appropriate imaging techniques for the temporal bone depending on the clinical presentation and a systematic approach to imaging for children with hearing loss. Diagnostic imaging for developmental anomalies of the ear and cholesteatoma will be discussed.
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Affiliation(s)
- Safia Cheeney
- Department of Radiology, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Jason N Wright
- Department of Radiology, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Kathleen C Sie
- Department of Otolaryngology, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Teresa Chapman
- Department of Radiology, Seattle Children's Hospital, University of Washington, Seattle, Washington.
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15
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Shurtleff HA, Poliakov A, Barry D, Wright JN, Warner MH, Novotny EJ, Marashly A, Buckley R, Goldstein HE, Hauptman JS, Ojemann JG, Shaw DWW. A clinically applicable functional MRI memory paradigm for use with pediatric patients. Epilepsy Behav 2022; 126:108461. [PMID: 34896785 DOI: 10.1016/j.yebeh.2021.108461] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 11/19/2021] [Accepted: 11/24/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Clinically employable functional MRI (fMRI) memory paradigms are not yet established for pediatric patient epilepsy surgery workups. Seeking to establish such a paradigm, we evaluated the effectiveness of memory fMRI tasks we developed by quantifying individual activation in a clinical pediatric setting, analyzing patterns of activation relative to the side of temporal lobe (TL) pathology, and comparing fMRI and Wada test results. METHODS We retrospectively identified 72 patients aged 6.7-20.9 years with pathology (seizure focus and/or tumor) limited to the TL who had attempted memory and language fMRI tasks over a 9-year period as part of presurgical workups. Memory fMRI tasks required visualization of autobiographical memories in a block design alternating with covert counting. Language fMRI protocols involved verb and sentence generation. Scans were both qualitatively interpreted and quantitatively assessed for blood oxygenation level dependent (BOLD) signal change using region of interest (ROI) masks. We calculated the percentage of successfully scanned individual cases, compared 2 memory task activation masks in cases with left versus right TL pathology, and compared fMRI with Wada tests when available. Patients who had viable fMRI and Wada tests had generally concordant results. RESULTS Of the 72 cases, 60 (83%), aged 7.6-20.9 years, successfully performed the memory fMRI tasks and 12 (17%) failed. Eleven of 12 unsuccessful scans were due to motion and/or inability to perform the tasks, and the success of a twelfth was indeterminate due to orthodontic metal artifact. Seven of the successful 60 cases had distorted anatomy that precluded employing predetermined masks for quantitative analysis. Successful fMRI memory studies showed bilateral mesial temporal activation and quantitatively demonstrated: (1) left activation (L-ACT) less than right activation (R-ACT) in cases with left temporal lobe (L-TL) pathology, (2) nonsignificant R-ACT less than L-ACT in cases with right temporal lobe (R-TL) pathology, and (3) lower L-ACT plus R-ACT activation for cases with L-TL versus R-TL pathology. Patients who had viable fMRI and Wada tests had generally concordant results. SIGNIFICANCE This study demonstrates evidence of an fMRI memory task paradigm that elicits reliable activation at the individual level and can generally be accomplished in clinically involved pediatric patients. This autobiographical memory paradigm showed activation in mesial TL structures, and cases with left compared to right TL pathology showed differences in activation consistent with extant literature in TL epilepsy. Further studies will be required to assess outcome prediction.
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Affiliation(s)
- Hillary A Shurtleff
- Neurosciences Institute, Seattle Children's Hospital, United States; Center for Integrated Brain Research Seattle Children's, United States.
| | | | - Dwight Barry
- Clinical Analytics, Seattle Children's Hospital, United States
| | - Jason N Wright
- Radiology, Seattle Children's Hospital, United States; Department of Radiology, University of Washington School of Medicine, United States
| | - Molly H Warner
- Neurosciences Institute, Seattle Children's Hospital, United States; Center for Integrated Brain Research Seattle Children's, United States
| | - Edward J Novotny
- Neurosciences Institute, Seattle Children's Hospital, United States; Center for Integrated Brain Research Seattle Children's, United States; Neurology, Seattle Children's Hospital, United States; Department of Neurology, University of Washington School of Medicine, United States
| | - Ahmad Marashly
- Neurosciences Institute, Seattle Children's Hospital, United States; Center for Integrated Brain Research Seattle Children's, United States; Neurology, Seattle Children's Hospital, United States; Department of Neurology, University of Washington School of Medicine, United States
| | - Robert Buckley
- Department of Neurological Surgery, University of Washington School of Medicine, United States
| | - Hannah E Goldstein
- Neurosciences Institute, Seattle Children's Hospital, United States; Department of Neurological Surgery, University of Washington School of Medicine, United States; Neurological Surgery, Seattle Children's Hospital, United States
| | - Jason S Hauptman
- Neurosciences Institute, Seattle Children's Hospital, United States; Department of Neurological Surgery, University of Washington School of Medicine, United States; Neurological Surgery, Seattle Children's Hospital, United States
| | - Jeffrey G Ojemann
- Neurosciences Institute, Seattle Children's Hospital, United States; Center for Integrated Brain Research Seattle Children's, United States; Department of Neurological Surgery, University of Washington School of Medicine, United States; Neurological Surgery, Seattle Children's Hospital, United States
| | - Dennis W W Shaw
- Radiology, Seattle Children's Hospital, United States; Department of Radiology, University of Washington School of Medicine, United States
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16
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Mayock DE, Gogcu S, Puia-Dumitrescu M, Shaw DWW, Wright JN, Comstock BA, Heagerty PJ, Juul SE. Association between Term Equivalent Brain Magnetic Resonance Imaging and 2-Year Outcomes in Extremely Preterm Infants: A Report from the Preterm Erythropoietin Neuroprotection Trial Cohort. J Pediatr 2021; 239:117-125.e6. [PMID: 34454953 PMCID: PMC9052881 DOI: 10.1016/j.jpeds.2021.08.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 08/06/2021] [Accepted: 08/20/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES To compare the term equivalent brain magnetic resonance imaging (MRI) findings between erythropoietin (Epo) treated and placebo control groups in infants 240/7-276/7 weeks of gestational age and to assess the associations between MRI findings and neurodevelopmental outcomes at 2 years corrected age. STUDY DESIGN The association between brain abnormality scores and Bayley Scales of Infant Development, Third Edition at 2 years corrected age was explored in a subset of infants enrolled in the Preterm Erythropoietin Neuroprotection Trial. Potential risk factors for neurodevelopmental outcomes such as treatment assignment, recruitment site, gestational age, inpatient complications, and treatments were examined using generalized estimating equation models. RESULTS One hundred ten infants were assigned to Epo and 110 to placebo groups. 27% of MRI scans were rated as normal, and 60%, 10%, and 2% were rated as having mild, moderate, or severe abnormality. Brain abnormality scores did not significantly differ between the treatment groups. Factors that increased the risk of higher brain injury scores included intubation; bronchopulmonary dysplasia; retinopathy of prematurity; opioid, benzodiazepine, or antibiotic treatment >7 days; and periventricular leukomalacia or severe intraventricular hemorrhage diagnosed on cranial ultrasound. Increased global brain abnormality and white matter injury scores at term equivalent were associated with reductions in cognitive, motor, and language abilities at 2 years of corrected age. CONCLUSIONS Evidence of brain injury on brain MRIs obtained at term equivalent correlated with adverse neurodevelopmental outcomes as assessed by the Bayley Scales of Infant and Toddler Development, Third Edition at 2 years corrected age. Early Epo treatment had no effect on the MRI brain injury scores compared with the placebo group.
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Affiliation(s)
- Dennis E. Mayock
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA
| | - Semsa Gogcu
- Division of Neonatology, Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC
| | - Mihai Puia-Dumitrescu
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA
| | | | - Jason N. Wright
- Department of Radiology, University of Washington, Seattle, WA
| | | | | | - Sandra E. Juul
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA
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17
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Zhang M, Wang E, Yecies D, Tam LT, Han M, Toescu S, Wright JN, Altinmakas E, Chen E, Radmanesh A, Nemelka J, Oztekin O, Wagner MW, Lober RM, Ertl-Wagner B, Ho CY, Mankad K, Vitanza NA, Cheshier SH, Jacques TS, Fisher PG, Aquilina K, Said M, Jaju A, Pfister S, Taylor MD, Grant GA, Mattonen S, Ramaswamy V, Yeom KW. Radiomic Signatures of Posterior Fossa Ependymoma: Molecular Subgroups and Risk Profiles. Neuro Oncol 2021; 24:986-994. [PMID: 34850171 DOI: 10.1093/neuonc/noab272] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The risk profile for posterior fossa ependymoma (EP) depends on surgical and molecular status [Group A (PFA) versus Group B (PFB)]. While subtotal tumor resection is known to confer worse prognosis, MRI-based EP risk-profiling is unexplored. We aimed to apply machine learning strategies to link MRI-based biomarkers of high-risk EP and also to distinguish PFA from PFB. METHODS We extracted 1800 quantitative features from presurgical T2-weighted (T2-MRI) and gadolinium-enhanced T1-weighted (T1-MRI) imaging of 157 EP patients. We implemented nested cross-validation to identify features for risk score calculations and apply a Cox model for survival analysis. We conducted additional feature selection for PFA versus PFB and examined performance across three candidate classifiers. RESULTS For all EP patients with GTR, we identified four T2-MRI-based features and stratified patients into high- and low-risk groups, with 5-year overall survival rates of 62% and 100%, respectively (p < 0.0001). Among presumed PFA patients with GTR, four T1-MRI and five T2-MRI features predicted divergence of high- and low-risk groups, with 5-year overall survival rates of 62.7% and 96.7%, respectively (p = 0.002). T1-MRI-based features showed the best performance distinguishing PFA from PFB with an AUC of 0.86. CONCLUSIONS We present machine learning strategies to identify MRI phenotypes that distinguish PFA from PFB, as well as high- and low-risk PFA. We also describe quantitative image predictors of aggressive EP tumors that might assist risk-profiling after surgery. Future studies could examine translating radiomics as an adjunct to EP risk assessment when considering therapy strategies or trial candidacy.
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Affiliation(s)
- Michael Zhang
- Department of Neurosurgery, Stanford Hospital and Clinics, Stanford, CA, USA.,Department of Radiology, Lucile Packard Children's Hospital, Stanford, CA, USA
| | - Edward Wang
- Department of Medical Biophysics, Western University, London, ON, Canada
| | - Derek Yecies
- Department of Neurosurgery, Stanford Hospital and Clinics, Stanford, CA, USA.,Department of Radiology, Lucile Packard Children's Hospital, Stanford, CA, USA
| | - Lydia T Tam
- Stanford School of Medicine, Stanford University, Stanford, CA, USA
| | - Michelle Han
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Sebastian Toescu
- Department of Neurosurgery, Great Ormond Street Institute of Child Health, London, UK
| | - Jason N Wright
- Department of Radiology, Seattle Children's Hospital, and Harborview Medical Center, Seattle, WA, USA
| | - Emre Altinmakas
- Department of Radiology, Koç University School of Medicine, Istanbul, Turkey
| | - Eric Chen
- Department of Clinical Radiology & Imaging Sciences, Riley Children's Hospital, Indianapolis, IA, USA
| | - Alireza Radmanesh
- Department of Radiology, New York University Grossman School of Medicine, New York, NY, USA
| | - Jordan Nemelka
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Huntsman Cancer Institute, University of Utah School of Medicine, Intermountain Healthcare Primary Children's Hospital, Salt Lake City, UT, USA
| | - Ozgur Oztekin
- Department of Neuroradiology, Cigli Education and Research Hospital, and Tepecik Education and Research Hospital, Izmir, Turkey
| | - Matthias W Wagner
- Department of Diagnostic Imaging, The Hospital for Sick Children, ON, Canada
| | - Robert M Lober
- Division of Neurosurgery, Dayton Children's Hospital, Dayton, OH, USA
| | - Birgit Ertl-Wagner
- Department of Diagnostic Imaging, The Hospital for Sick Children, ON, Canada
| | - Chang Y Ho
- Department of Clinical Radiology & Imaging Sciences, Riley Children's Hospital, Indianapolis, IA, USA
| | - Kshitij Mankad
- Department of Radiology, Great Ormond Street Institute of Child Health, London, UK
| | - Nicholas A Vitanza
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Seattle Children's Hospital, Seattle WA, USA
| | - Samuel H Cheshier
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Huntsman Cancer Institute, University of Utah School of Medicine, Intermountain Healthcare Primary Children's Hospital, Salt Lake City, UT, USA
| | - Tom S Jacques
- Department of Developmental Biology & Cancer, University College London Great Ormond Street Institute of Child Health, and Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Paul G Fisher
- Department of Neurology, Lucile Packard Children's Hospital, Stanford University, Palo Alto, CA, USA
| | - Kristian Aquilina
- Department of Neurosurgery, Great Ormond Street Institute of Child Health, London, UK
| | - Mourad Said
- Radiology Department Centre International Carthage Médicale, Monastir, Tunisia
| | - Alok Jaju
- Department of Medical Imaging, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Stefan Pfister
- Department of Pediatrics, Hopp Children' Cancer Center, Heidelberg, Germany
| | - Michael D Taylor
- Division of Neurosurgery, The Hospital for Sick Children, Toronto, ON, Canada
| | - Gerald A Grant
- Department of Neurosurgery, Lucile Packard Children's Hospital, Stanford, CA, USA
| | - Sarah Mattonen
- Department of Medical Biophysics, Western University, London, ON, Canada
| | - Vijay Ramaswamy
- Division of Haematology/Oncology, Programme in Developmental and Stem Cell Biology, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
| | - Kristen W Yeom
- Department of Radiology, Lucile Packard Children's Hospital, Stanford, CA, USA
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18
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Zhang M, Wong SW, Wright JN, Toescu S, Mohammadzadeh M, Han M, Lummus S, Wagner MW, Yecies D, Lai H, Eghbal A, Radmanesh A, Nemelka J, Harward S, Malinzak M, Laughlin S, Perreault S, Braun KRM, Vossough A, Poussaint T, Goetti R, Ertl-Wagner B, Ho CY, Oztekin O, Ramaswamy V, Mankad K, Vitanza NA, Cheshier SH, Said M, Aquilina K, Thompson E, Jaju A, Grant GA, Lober RM, Yeom KW. Machine Assist for Pediatric Posterior Fossa Tumor Diagnosis: A Multinational Study. Neurosurgery 2021; 89:892-900. [PMID: 34392363 DOI: 10.1093/neuros/nyab311] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 06/09/2021] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Clinicians and machine classifiers reliably diagnose pilocytic astrocytoma (PA) on magnetic resonance imaging (MRI) but less accurately distinguish medulloblastoma (MB) from ependymoma (EP). One strategy is to first rule out the most identifiable diagnosis. OBJECTIVE To hypothesize a sequential machine-learning classifier could improve diagnostic performance by mimicking a clinician's strategy of excluding PA before distinguishing MB from EP. METHODS We extracted 1800 total Image Biomarker Standardization Initiative (IBSI)-based features from T2- and gadolinium-enhanced T1-weighted images in a multinational cohort of 274 MB, 156 PA, and 97 EP. We designed a 2-step sequential classifier - first ruling out PA, and next distinguishing MB from EP. For each step, we selected the best performing model from 6-candidate classifier using a reduced feature set, and measured performance on a holdout test set with the microaveraged F1 score. RESULTS Optimal diagnostic performance was achieved using 2 decision steps, each with its own distinct imaging features and classifier method. A 3-way logistic regression classifier first distinguished PA from non-PA, with T2 uniformity and T1 contrast as the most relevant IBSI features (F1 score 0.8809). A 2-way neural net classifier next distinguished MB from EP, with T2 sphericity and T1 flatness as most relevant (F1 score 0.9189). The combined, sequential classifier was with F1 score 0.9179. CONCLUSION An MRI-based sequential machine-learning classifiers offer high-performance prediction of pediatric posterior fossa tumors across a large, multinational cohort. Optimization of this model with demographic, clinical, imaging, and molecular predictors could provide significant advantages for family counseling and surgical planning.
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Affiliation(s)
- Michael Zhang
- Department of Neurosurgery, Stanford Hospital and Clinics, Stanford, California, USA.,Department of Radiology, Lucile Packard Children's Hospital, Stanford, California, USA
| | - Samuel W Wong
- Department of Statistics, Stanford University, Stanford, California, USA
| | - Jason N Wright
- Department of Radiology, Seattle Children's Hospital, Seattle, Washington, USA.,Department of Radiology, Harborview Medical Center, Seattle, Washington, USA
| | - Sebastian Toescu
- Department of Neurosurgery, Great Ormond Street Hospital, London, United Kingdom
| | | | - Michelle Han
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Seth Lummus
- Department of Physiology and Nutrition, University of Colorado Colorado Springs, Colorado Springs, Colorado, USA
| | - Matthias W Wagner
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Canada
| | - Derek Yecies
- Department of Neurosurgery, Lucile Packard Children's Hospital, Stanford, California, USA
| | - Hollie Lai
- Department of Radiology, Children's Hospital of Orange County, Orange, California, USA
| | - Azam Eghbal
- Department of Radiology, Children's Hospital of Orange County, Orange, California, USA
| | - Alireza Radmanesh
- Department of Radiology, New York University Grossman School of Medicine, New York, New York, USA
| | - Jordan Nemelka
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Stephen Harward
- Department of Neurosurgery, Duke Children's Hospital & Health Center, Durham, North Carolina, USA
| | - Michael Malinzak
- Department of Radiology, Duke Children's Hospital & Health Center, Durham, North Carolina, USA
| | - Suzanne Laughlin
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Canada
| | - Sebastien Perreault
- Division of Child Neurology, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montreal, Canada
| | - Kristina R M Braun
- Department of Clinical Radiology & Imaging Sciences, Riley Children's Hospital, Indianapolis, Iowa, USA
| | - Arastoo Vossough
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Tina Poussaint
- Department of Radiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Robert Goetti
- Department of Medical Imaging, The Children's Hospital at Westmead, The University of Sydney, Sydney, Australia
| | - Birgit Ertl-Wagner
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Canada
| | - Chang Y Ho
- Department of Clinical Radiology & Imaging Sciences, Riley Children's Hospital, Indianapolis, Iowa, USA
| | - Ozgur Oztekin
- Department of Neuroradiology, Cigli Education and Research Hospital, Izmir, Turkey.,Department of Neuroradiology, Tepecik Education and Research Hospital, Izmir, Turkey
| | - Vijay Ramaswamy
- Division of Haematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
| | - Kshitij Mankad
- Department of Radiology, Great Ormond Street Hospital, London, United Kingdom
| | - Nicholas A Vitanza
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Seattle Children's Hospital, Seattle Washington, USA
| | - Samuel H Cheshier
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Mourad Said
- Radiology Department, Centre International Carthage Médicale, Monastir, Tunisia
| | - Kristian Aquilina
- Department of Neurosurgery, Great Ormond Street Hospital, London, United Kingdom
| | - Eric Thompson
- Department of Neurosurgery, Duke Children's Hospital & Health Center, Durham, North Carolina, USA
| | - Alok Jaju
- Department of Medical Imaging, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Gerald A Grant
- Department of Neurosurgery, Lucile Packard Children's Hospital, Stanford, California, USA
| | - Robert M Lober
- Division of Neurosurgery, Dayton Children's Hospital, Dayton, Ohio, USA
| | - Kristen W Yeom
- Department of Radiology, Lucile Packard Children's Hospital, Stanford, California, USA
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Keblawi SS, Wright JN, Otjen JP, Verma A, Brown EC, Ness KD, Feldman KW. Multiple Abusive Fractures in an Infant With a Concurrent Parathyroid Hormone-Related Peptide-Secreting Renal Tumor: Abusive Fractures Accompanying a Parathyroid Hormone-Related Peptide-Secreting Tumor. Pediatr Emerg Care 2021; 37:e339-e341. [PMID: 30973495 DOI: 10.1097/pec.0000000000001796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND When evaluating an infant with unexplained fractures for child abuse, it is important to evaluate for possible causes of underlying bone fragility. CASE A 7-month-old infant was found to have a parathyroid hormone (PTH)-related peptide-secreting mesoblastic nephroma. In spite of having an elevated serum calcium, depressed serum phosphate, and high levels of PTH-related peptide, he had no demineralization or other hyper parathyroid-related bone changes. Instead, he had multiple classic metaphyseal lesions, fractures of differing ages including a proximal clavicle fracture, and current and past bruising. No fractures typical of bone insufficiency were present. These findings are highly indicative of abuse in addition to his hormone-secreting tumor. CONCLUSIONS In spite of this child's abuse findings, endogenous or tumor-related hyper PTH should be in the differential of underlying bone fragility. Children with disorders that could cause injury susceptibility can also be abused.
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20
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Tam LT, Yeom KW, Wright JN, Jaju A, Radmanesh A, Han M, Toescu S, Maleki M, Chen E, Campion A, Lai HA, Eghbal AA, Oztekin O, Mankad K, Hargrave D, Jacques TS, Goetti R, Lober RM, Cheshier SH, Napel S, Said M, Aquilina K, Ho CY, Monje M, Vitanza NA, Mattonen SA. MRI-based radiomics for prognosis of pediatric diffuse intrinsic pontine glioma: an international study. Neurooncol Adv 2021; 3:vdab042. [PMID: 33977272 PMCID: PMC8095337 DOI: 10.1093/noajnl/vdab042] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background Diffuse intrinsic pontine gliomas (DIPGs) are lethal pediatric brain tumors. Presently, MRI is the mainstay of disease diagnosis and surveillance. We identify clinically significant computational features from MRI and create a prognostic machine learning model. Methods We isolated tumor volumes of T1-post-contrast (T1) and T2-weighted (T2) MRIs from 177 treatment-naïve DIPG patients from an international cohort for model training and testing. The Quantitative Image Feature Pipeline and PyRadiomics was used for feature extraction. Ten-fold cross-validation of least absolute shrinkage and selection operator Cox regression selected optimal features to predict overall survival in the training dataset and tested in the independent testing dataset. We analyzed model performance using clinical variables (age at diagnosis and sex) only, radiomics only, and radiomics plus clinical variables. Results All selected features were intensity and texture-based on the wavelet-filtered images (3 T1 gray-level co-occurrence matrix (GLCM) texture features, T2 GLCM texture feature, and T2 first-order mean). This multivariable Cox model demonstrated a concordance of 0.68 (95% CI: 0.61–0.74) in the training dataset, significantly outperforming the clinical-only model (C = 0.57 [95% CI: 0.49–0.64]). Adding clinical features to radiomics slightly improved performance (C = 0.70 [95% CI: 0.64–0.77]). The combined radiomics and clinical model was validated in the independent testing dataset (C = 0.59 [95% CI: 0.51–0.67], Noether’s test P = .02). Conclusions In this international study, we demonstrate the use of radiomic signatures to create a machine learning model for DIPG prognostication. Standardized, quantitative approaches that objectively measure DIPG changes, including computational MRI evaluation, could offer new approaches to assessing tumor phenotype and serve a future role for optimizing clinical trial eligibility and tumor surveillance.
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Affiliation(s)
- Lydia T Tam
- Stanford University School of Medicine, Stanford, California, USA.,Department of Radiology, Lucile Packard Children's Hospital, Stanford University School of Medicine, Stanford, California, USA
| | - Kristen W Yeom
- Stanford University School of Medicine, Stanford, California, USA.,Department of Radiology, Lucile Packard Children's Hospital, Stanford University School of Medicine, Stanford, California, USA
| | - Jason N Wright
- Department of Radiology, Seattle Children's Hospital, Seattle, Washington, USA.,Harborview Medical Center, Seattle, Washington, USA
| | - Alok Jaju
- Department of Medical Imaging, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Alireza Radmanesh
- Department of Radiology, New York University Grossman School of Medicine, New York, New York, USA
| | - Michelle Han
- Stanford University School of Medicine, Stanford, California, USA.,Department of Radiology, Lucile Packard Children's Hospital, Stanford University School of Medicine, Stanford, California, USA
| | - Sebastian Toescu
- University College London, Great Ormond Street Institute of Child Health, London, UK
| | - Maryam Maleki
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Eric Chen
- Departments of Clinical Radiology & Imaging Sciences, Riley Children's Hospital, Indiana University, Indianapolis, Indiana, USA
| | - Andrew Campion
- Department of Radiology, Lucile Packard Children's Hospital, Stanford University School of Medicine, Stanford, California, USA
| | - Hollie A Lai
- Department of Radiology, CHOC Children's Hospital, Orange, California, USA.,University of California, Irvine, California, USA
| | - Azam A Eghbal
- Department of Radiology, CHOC Children's Hospital, Orange, California, USA.,University of California, Irvine, California, USA
| | - Ozgur Oztekin
- Department of Neuroradiology, Bakircay University, Cigli Education and Research Hospital, Izmir, Turkey.,Department of Neuroradiology, Health Science University, Tepecik Education and Research Hospital, Izmir, Turkey
| | - Kshitij Mankad
- University College London, Great Ormond Street Institute of Child Health, London, UK.,Department of Radiology, Great Ormond Street Hospital for Children, London, UK
| | - Darren Hargrave
- University College London, Great Ormond Street Institute of Child Health, London, UK
| | - Thomas S Jacques
- University College London, Great Ormond Street Institute of Child Health, London, UK
| | - Robert Goetti
- Department of Medical Imaging, The Children's Hospital at Westmead, The University of Sydney, Westmead, Australia
| | - Robert M Lober
- Department of Neurosurgery, Dayton Children's Hospital, Wright State University Boonshoft School of Medicine, Dayton, Ohio, USA
| | - Samuel H Cheshier
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Sandy Napel
- Department of Radiology, Stanford University, Stanford, California, USA
| | - Mourad Said
- Radiology Department Centre International Carthage Médicale, Monastir, Tunisia
| | - Kristian Aquilina
- University College London, Great Ormond Street Institute of Child Health, London, UK
| | - Chang Y Ho
- Departments of Clinical Radiology & Imaging Sciences, Riley Children's Hospital, Indiana University, Indianapolis, Indiana, USA
| | - Michelle Monje
- Stanford University School of Medicine, Stanford, California, USA.,Department of Neurology and Neurological Sciences, Stanford University, Stanford, California, USA
| | - Nicholas A Vitanza
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Seattle Children's Hospital, Seattle, Washington, USA.,Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Sarah A Mattonen
- Department of Medical Biophysics, Western University, London, Onatrio, Canada.,Department of Oncology, Western University, London, Ontario, Canada
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21
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Wright JN, Shaw DWW, Ishak G, Perez FA, Doherty D. Reply. AJNR Am J Neuroradiol 2020; 41:E61. [PMID: 32586961 DOI: 10.3174/ajnr.a6673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
| | | | | | | | - D Doherty
- Department of Pediatrics, Division of Development and Genetic Medicine University of Washington and Seattle Children's HospitalSeattle, Washington
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22
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Wright JN, Feyma TJ, Ishak GE, Abeshaus S, Metz JB, Brown ECB, Friedman SD, Browd SR, Feldman KW. Correction to: Subdural hemorrhage rebleeding in abused children: frequency, associations and clinical presentation. Pediatr Radiol 2020; 50:1161. [PMID: 32444953 DOI: 10.1007/s00247-020-04687-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The original article included a statement which is not fully accurate. This correction clarifies the original statement.
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Affiliation(s)
- Jason N Wright
- Department of Radiology, Seattle Children's Hospital, Harborview Medical Center, Seattle, WA, USA.,University of Washington, Seattle, WA, USA
| | - Timothy J Feyma
- Department of Neurology, Gillette Children's Specialty Health Care, St. Paul, MN, USA
| | - Gisele E Ishak
- Department of Radiology, Seattle Children's Hospital, Harborview Medical Center, Seattle, WA, USA.,University of Washington, Seattle, WA, USA
| | - Sergey Abeshaus
- Department of Neurosurgery, Rambam Health Care Campus, Haifa, Israel
| | - James B Metz
- Department of Pediatrics, University of Vermont School of Medicine, Burlington, VT, USA
| | - Emily C B Brown
- University of Washington, Seattle, WA, USA.,Department of Pediatrics, Children's Protection Program, M/S SB-250, Seattle Children's Hospital, Harborview Medical Center, 4800 Sand Point Way NE, Seattle, WA, 98105, USA
| | - Seth D Friedman
- Department of Radiology, Seattle Children's Hospital, Harborview Medical Center, Seattle, WA, USA.,University of Washington, Seattle, WA, USA
| | - Samuel R Browd
- University of Washington, Seattle, WA, USA.,Department of Neurological Surgery, Seattle Children's Hospital, Harborview Medical Center, Seattle, WA, USA
| | - Kenneth W Feldman
- University of Washington, Seattle, WA, USA. .,Department of Pediatrics, Children's Protection Program, M/S SB-250, Seattle Children's Hospital, Harborview Medical Center, 4800 Sand Point Way NE, Seattle, WA, 98105, USA.
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23
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Leary S, Blatt JE, Cohen AR, Cohen KJ, Cole B, Governale L, Gupta N, Hauptman JS, Jackson EM, Kebriaei MA, Kline C, Kobets A, Lee A, Miller DM, Mueller S, Ojemann J, Prados M, Rahman M, Wright JN, Bendel AE. A phase II/III randomized, blinded study of tozuleristide for fluorescence imaging detection during neurosurgical resection of pediatric primary central nervous system (CNS) tumors: PNOC012 (Pacific Pediatric Neuro-oncology Consortium). J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.tps2575] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
TPS2575 Background: Tozuleristide (also known as BLZ-100 or Tumor Paint) is a fluorescent imaging drug designed to specifically label and accumulate in tumor tissue, thus enabling more precise surgical tumor resection intraoperatively. Tozuleristide achieves tumor targeting through the peptide portion of the molecule, a modified chlorotoxin peptide, and its imaging properties from a coupled near-infrared fluorescent dye, an indocyanine green. Tozuleristide has been studied in 4 Phase 1 studies, including a trial in pediatric brain cancer subjects. No tozuleristide SAEs or dose limiting toxicity were observed in the 97 subjects treated in the Phase 1 program at doses up to 30 mg in adults or 17.3 mg/m2 in pediatrics (Hansen S et al, WMIC 2018, P196). Eighty percent of pediatric subjects receiving tozuleristide had tumors considered fluorescence positive, including high and low grade glioma, ependymoma, and medulloblastoma. Methods: This study randomizes subjects in a 1:10 ratio to standard of care or tozuleristide arms. The primary efficacy objectives and endpoints are based on equivocal regions of tissue encountered in surgery. Prior to fluorescence assessment, the surgeon assesses the suspected nature of the tissue (more likely tumor/less likely tumor). Tissue specimens of equivocal regions are collected for blinded central pathology assessment. Sensitivity and specificity of the surgeon’s designation, fluorescence assessment, and ratios of surgeon to fluorescence assessments comprise the primary efficacy analyses. Tozuleristide is given as an IV bolus dose of 15 mg/m2 to pediatric subjects 1 to 36 hours prior to surgery. Subjects must have a MRI documented lesion consistent with a CNS tumor for which resection is planned. Measures of safety include adverse events, laboratory measures of hematology, liver and kidney function and changes in vital signs and ECGs. Pharmacokinetic blood samples are collected up to 3 hr post dose. Fluorescence imaging is assessed during surgery using an investigational “Canvas System” imaging device attached to a surgical microscope. Collected pathology specimens will also be subjected to further genetic, molecular and pathology studies, including fluorescence assessment of frozen tissue sections. SAEs and patient reported outcomes are collected for 3 months. The SMC for the study last reviewed the data for this study in July 2019 and recommended the trial continue as planned. Clinical trial information: NCT03579602 .
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Affiliation(s)
| | | | | | - Kenneth J. Cohen
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | | | | | - Nalin Gupta
- University of California, San Francisco, San Francisco, CA
| | | | | | | | - Cassie Kline
- University of California, San Francisco, San Francisco, CA
| | | | - Amy Lee
- Seattle Children's, Seattle, WA
| | | | - Sabine Mueller
- University of California, San Francisco, San Francisco, CA
| | | | - Michael Prados
- University of California, San Francisco, San Francisco, CA
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24
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Ryan ME, Pruthi S, Desai NK, Falcone RA, Glenn OA, Joseph MM, Maheshwari M, Marin JR, Mazzola C, Milla SS, Mirsky DM, Myseros JS, Niogi SN, Partap S, Radhakrishnan R, Robertson RL, Soares BP, Udayasankar UK, Whitehead MT, Wright JN, Karmazyn B. ACR Appropriateness Criteria® Head Trauma-Child. J Am Coll Radiol 2020; 17:S125-S137. [PMID: 32370957 DOI: 10.1016/j.jacr.2020.01.026] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 01/22/2020] [Indexed: 12/15/2022]
Abstract
Head trauma is a frequent indication for cranial imaging in children. The majority of accidental pediatric head trauma is minor and sustained without intracranial injury. Well-validated pediatric-specific clinical decision guidelines should be used to identify very low-risk children who can safely forgo imaging. In those who require acute imaging, CT is considered the first-line imaging modality for suspected intracranial injury because of the short duration of the examination and its high sensitivity for acute hemorrhage. MRI can accurately detect traumatic complications, but often necessitates sedation in children, owing to the examination length and motion sensitivity, which limits rapid assessment. There is a paucity of literature regarding vascular injuries in pediatric blunt head trauma and imaging is typically guided by clinical suspicion. Advanced imaging techniques have the potential to identify changes that are not seen by standard imaging, but data are currently insufficient to support routine clinical use. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
- Maura E Ryan
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
| | - Sumit Pruthi
- Panel Chair, Vanderbilt Children's Hospital, Nashville, Tennessee
| | | | - Richard A Falcone
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; American Pediatric Surgical Association
| | - Orit A Glenn
- University of California San Francisco, San Francisco, California
| | - Madeline M Joseph
- University of Florida College of Medicine Jacksonville, Jacksonville, Florida; American College of Emergency Physicians
| | | | - Jennifer R Marin
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania; Society for Academic Emergency Medicine
| | - Catherine Mazzola
- Rutgers, New Jersey Medical School, Newark, New Jersey; Neurosurgery expert
| | - Sarah S Milla
- Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | | | - John S Myseros
- Children's National Health System, Washington, District of Columbia; Neurosurgery Expert
| | | | - Sonia Partap
- Stanford University, Stanford, California; American Academy of Pediatrics
| | | | | | - Bruno P Soares
- The University of Vermont Medical Center, Burlington, Vermont
| | | | | | | | - Boaz Karmazyn
- Specialty Chair, Riley Hospital for Children Indiana University, Indianapolis, Indiana
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25
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Wright JN, Shaw DWW, Ishak G, Doherty D, Perez F. Cerebellar Watershed Injury in Children. AJNR Am J Neuroradiol 2020; 41:923-928. [PMID: 32327437 DOI: 10.3174/ajnr.a6532] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 03/16/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Focal signal abnormalities at the depth of the cerebellar fissures in children have recently been reported to represent a novel pattern of bottom-of-fissure dysplasia. We describe a series of patients with a similar distribution and appearance of cerebellar signal abnormality attributable to watershed injury. MATERIALS AND METHODS Twenty-three children with MR imaging findings of focal T2 prolongation in the cerebellar gray matter and immediate subjacent white matter at the depth of the fissures were included. MR imaging examinations were qualitatively analyzed for the characteristics and distribution of signal abnormality within posterior fossa structures, the presence and distribution of volume loss, the presence of abnormal contrast enhancement, and the presence and pattern of supratentorial injury. RESULTS T2 prolongation was observed at the depths of the cerebellar fissures bilaterally in all 23 patients, centered at the expected location of the deep cerebellar vascular borderzone. Diffusion restriction was associated with MR imaging performed during acute injury in 13/16 patients. Five of 23 patients had prior imaging, all demonstrating a normal cerebellum. The etiology of injury was hypoxic-ischemic injury in 17/23 patients, posterior reversible encephalopathy syndrome in 3/23 patients, and indeterminate in 3/23 patients. Twenty of 23 patients demonstrated an associated classic parasagittal watershed pattern of supratentorial cortical injury. Injury in the chronic phase was associated with relatively preserved gray matter volume in 8/15 patients, closely matching the published appearance of bottom-of-fissure dysplasia. CONCLUSIONS In a series of patients with findings similar in appearance to the recently described bottom-of-fissure dysplasia, we have demonstrated a stereotyped pattern of injury attributable to cerebellar watershed injury.
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Affiliation(s)
- J N Wright
- From the Departments of Radiology (J.N.W., D.W.W.S., G.I., F.P.)
| | - D W W Shaw
- From the Departments of Radiology (J.N.W., D.W.W.S., G.I., F.P.)
| | - G Ishak
- From the Departments of Radiology (J.N.W., D.W.W.S., G.I., F.P.)
| | - D Doherty
- Pediatrics (D.D.), Divisions of Developmental and Genetic Medicine, University of Washington and Seattle Children's Hospital, Seattle, Washington
| | - F Perez
- From the Departments of Radiology (J.N.W., D.W.W.S., G.I., F.P.)
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26
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Wright JN, Rutledge J, Doherty D, Perez F. Cerebellar Heterotopias: Expanding the Phenotype of Cerebellar Dysgenesis in CHARGE Syndrome. AJNR Am J Neuroradiol 2019; 40:2154-2160. [PMID: 31649160 PMCID: PMC6975362 DOI: 10.3174/ajnr.a6280] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 09/03/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND AND PURPOSE Coloboma of the eye, Heart defects, Atresia of the choanae, Retardation of growth and/or development, Genital and/or urinary abnormalities, and Ear abnormalities and deafness (CHARGE) syndrome is a multisystem developmental disorder associated with a number of well-described clinical and imaging findings, including cerebellar hypoplasia. We observed cerebellar heterotopias on MR imaging in 2 patients with CHARGE, confirmed by postmortem examination. We sought to determine the prevalence and define the characteristics of similar findings on MR imaging for a cohort of patients with CHARGE syndrome. MATERIALS AND METHODS We performed a retrospective, observational, cross-sectional study to assess the prevalence and characteristic features of cerebellar heterotopias in 35 patients with CHARGE syndrome with available brain MR imaging studies, as well as to evaluate additional features of cerebellar dysgenesis. RESULTS Cerebellar heterotopias were identified in 27/35 (77%) patients with CHARGE, characteristic in both location and appearance. Additional features of cerebellar dysgenesis were present in 31/34 evaluable patients (91%), including inferior vermian hypoplasia (90%), anteromedial rotation of the inferior tonsils (90%), and disorganized foliation of the cerebellar hemispheres (74%) or superior vermis (16%). CONCLUSIONS Patients with CHARGE syndrome have a high prevalence of characteristic cerebellar heterotopias and disorganized foliation and abnormal cerebellar morphology, thereby expanding the phenotype of cerebellar dysgenesis in this syndrome.
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Affiliation(s)
- J N Wright
- From the Departments of Radiology (J.N.W., F.P.)
| | - J Rutledge
- Department of Pathology (J.R.), Seattle Children's Hospital, Seattle, Washington
| | - D Doherty
- Pediatrics, Divisions of Developmental and Genetic Medicine (D.D.), University of Washington and Seattle Children's Hospital, Seattle, Washington
| | - F Perez
- From the Departments of Radiology (J.N.W., F.P.)
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Abstract
Perinatal stroke is a significant cause of severe epilepsy, including epileptic spasms. Although epileptic spasms due to underlying structural lesion often respond poorly to treatment and evolve into drug-resistant epilepsy, outcomes are not uniformly poor, and predictors of outcomes are not well described. We performed a single-institution retrospective review of epileptic spasms following perinatal stroke to determine if outcome depended on vascular subtype. We identified 24 children with epileptic spasms due to perinatal ischemic stroke: 11 cases of perinatal arterial stroke and 13 cases of perinatal venous infarct. Initial response to treatment was similar between groups; however, although children with perinatal arterial stroke who responded to epileptic spasms therapy had high rates of seizure freedom, many children with perinatal venous infarct, regardless of initial response, had residual drug-resistant epilepsy. We consider whether the mechanism for epileptogenesis may be different between arterial and venous strokes, and whether these 2 groups should be monitored for epileptic spasms, and subsequent epilepsy, differently.
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Affiliation(s)
- Jason P Lockrow
- Department of Neurology, Section of Pediatric Neurology, University of Washington, Seattle, WA, USA
| | - Jason N Wright
- Department of Neurology, Section of Neuroradiology, University of Washington, Seattle, WA, USA
| | - Russell P Saneto
- Department of Neurology, Section of Pediatric Neurology, University of Washington, Seattle, WA, USA
| | - Catherine Amlie-Lefond
- Department of Neurology, Section of Pediatric Neurology, University of Washington, Seattle, WA, USA
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28
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Wright JN, Saneto RP, Friedman SD. β-Hydroxybutyrate Detection with Proton MR Spectroscopy in Children with Drug-Resistant Epilepsy on the Ketogenic Diet. AJNR Am J Neuroradiol 2018; 39:1336-1340. [PMID: 29724763 DOI: 10.3174/ajnr.a5648] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 03/05/2018] [Indexed: 01/04/2023]
Abstract
BACKGROUND AND PURPOSE The ketogenic diet, including both classic and modified forms, is an alternative to antiepileptic medications used in the treatment of drug-resistant epilepsy. We sought to evaluate the utility of proton MR spectroscopy for the detection of β-hydroxybutyrate in a cohort of children with epilepsy treated with the ketogenic diet and to correlate brain parenchymal metabolite ratios obtained from spectroscopy with β-hydroxybutyrate serum concentrations. MATERIALS AND METHODS Twenty-three spectroscopic datasets acquired at a TE of 288 ms in children on the ketogenic diet were analyzed with LCModel using a modified basis set that included a simulated β-hydroxybutyrate resonance. Brain parenchymal metabolite ratios were calculated. Metabolite ratios were compared with serum β-hydroxybutyrate concentrations, and partial correlation coefficients were calculated using patient age as a covariate. RESULTS β-hydroxybutyrate blood levels were highly correlated to brain β-hydroxybutyrate levels, referenced as either choline, creatine, or N-acetylaspartate. They were inversely but more weakly associated with N-acetylaspartate, regardless of the ratio denominator. No strong concordance with lactate was demonstrated. CONCLUSIONS Clinical MR spectroscopy in pediatric patients on the ketogenic diet demonstrated measurable β-hydroxybutyrate, with a strong correlation to β-hydroxybutyrate blood levels. These findings may serve as an effective tool for noninvasive monitoring of ketosis in this population. An inverse correlation between serum β-hydroxybutyrate levels and brain tissue N-acetylaspartate suggests that altered amino acid handling contributes to the antiepileptogenic effect of the ketogenic diet.
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Affiliation(s)
- J N Wright
- From the Department of Radiology (J.N.W., S.D.F.)
| | - R P Saneto
- Department of Neurology, Division of Pediatric Neurology (R.P.S.), University of Washington and Seattle Children's Hospital, Seattle, Washington
| | - S D Friedman
- From the Department of Radiology (J.N.W., S.D.F.)
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29
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Oesch G, Maga AM, Friedman SD, Poliachik SL, Budech CB, Wright JN, Bok LA, Gospe SM. Geometric morphometrics reveal altered corpus callosum shape in pyridoxine-dependent epilepsy. Neurology 2018; 91:e78-e86. [PMID: 29875223 DOI: 10.1212/wnl.0000000000005748] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 04/02/2018] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE To evaluate the features and maturational changes in overall callosal shape in patients with pyridoxine-dependent epilepsy (PDE). METHODS Measurements were conducted through landmark-based geometric morphometrics applied on cerebral MRIs of patients with PDE and age-matched control subjects. The outline of the corpus callosum was manually traced in the midsagittal plane. Three hundred semi-landmarks along the outline were collected and underwent statistical generalized Procrustes analysis. An allometric regression was applied to evaluate the callosal shape due to growth over time. RESULTS Thirty-eight patients with PDE and 38 age- and sex-matched control subjects were included. Mean age at the time of the MRI in the patient group was 9.3 years (median 6.3 years, range 0.01-48 years). Significant differences (p < 0.01) in the mean callosal shape between patients and controls were found. The allometric regression model revealed significant shape variations (p < 0.01) between the 2 study groups across the developmental course after controlling for the effect of callosal size on shape. This latter effect turned out to be significant as well (p < 0.001). CONCLUSIONS Patients with PDE show an altered callosal shape and variations in callosal ontogeny, which are likely secondary to the underlying genetic defect with abnormal function of antiquitin, the product of the ALDH7A1 gene.
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Affiliation(s)
- Gabriela Oesch
- From the Division of Pediatric Neurology (G.O., S.M.G.), Departments of Neurology and Pediatrics, University of Washington, and Seattle Children's Hospital; Division of Craniofacial Medicine (A.M.M.), Department of Pediatrics, University of Washington and Center for Developmental Biology and Regenerative Medicine, Seattle Children's Research Institute; Department of Radiology (S.D.F., S.L.P., C.B.B., J.N.W.), Seattle Children's Hospital, WA; and Department of Pediatrics (L.A.B.), Máxima Medical Center, Veldhoven, the Netherlands
| | - A Murat Maga
- From the Division of Pediatric Neurology (G.O., S.M.G.), Departments of Neurology and Pediatrics, University of Washington, and Seattle Children's Hospital; Division of Craniofacial Medicine (A.M.M.), Department of Pediatrics, University of Washington and Center for Developmental Biology and Regenerative Medicine, Seattle Children's Research Institute; Department of Radiology (S.D.F., S.L.P., C.B.B., J.N.W.), Seattle Children's Hospital, WA; and Department of Pediatrics (L.A.B.), Máxima Medical Center, Veldhoven, the Netherlands
| | - Seth D Friedman
- From the Division of Pediatric Neurology (G.O., S.M.G.), Departments of Neurology and Pediatrics, University of Washington, and Seattle Children's Hospital; Division of Craniofacial Medicine (A.M.M.), Department of Pediatrics, University of Washington and Center for Developmental Biology and Regenerative Medicine, Seattle Children's Research Institute; Department of Radiology (S.D.F., S.L.P., C.B.B., J.N.W.), Seattle Children's Hospital, WA; and Department of Pediatrics (L.A.B.), Máxima Medical Center, Veldhoven, the Netherlands
| | - Sandra L Poliachik
- From the Division of Pediatric Neurology (G.O., S.M.G.), Departments of Neurology and Pediatrics, University of Washington, and Seattle Children's Hospital; Division of Craniofacial Medicine (A.M.M.), Department of Pediatrics, University of Washington and Center for Developmental Biology and Regenerative Medicine, Seattle Children's Research Institute; Department of Radiology (S.D.F., S.L.P., C.B.B., J.N.W.), Seattle Children's Hospital, WA; and Department of Pediatrics (L.A.B.), Máxima Medical Center, Veldhoven, the Netherlands
| | - Christopher B Budech
- From the Division of Pediatric Neurology (G.O., S.M.G.), Departments of Neurology and Pediatrics, University of Washington, and Seattle Children's Hospital; Division of Craniofacial Medicine (A.M.M.), Department of Pediatrics, University of Washington and Center for Developmental Biology and Regenerative Medicine, Seattle Children's Research Institute; Department of Radiology (S.D.F., S.L.P., C.B.B., J.N.W.), Seattle Children's Hospital, WA; and Department of Pediatrics (L.A.B.), Máxima Medical Center, Veldhoven, the Netherlands
| | - Jason N Wright
- From the Division of Pediatric Neurology (G.O., S.M.G.), Departments of Neurology and Pediatrics, University of Washington, and Seattle Children's Hospital; Division of Craniofacial Medicine (A.M.M.), Department of Pediatrics, University of Washington and Center for Developmental Biology and Regenerative Medicine, Seattle Children's Research Institute; Department of Radiology (S.D.F., S.L.P., C.B.B., J.N.W.), Seattle Children's Hospital, WA; and Department of Pediatrics (L.A.B.), Máxima Medical Center, Veldhoven, the Netherlands
| | - Levinus A Bok
- From the Division of Pediatric Neurology (G.O., S.M.G.), Departments of Neurology and Pediatrics, University of Washington, and Seattle Children's Hospital; Division of Craniofacial Medicine (A.M.M.), Department of Pediatrics, University of Washington and Center for Developmental Biology and Regenerative Medicine, Seattle Children's Research Institute; Department of Radiology (S.D.F., S.L.P., C.B.B., J.N.W.), Seattle Children's Hospital, WA; and Department of Pediatrics (L.A.B.), Máxima Medical Center, Veldhoven, the Netherlands
| | - Sidney M Gospe
- From the Division of Pediatric Neurology (G.O., S.M.G.), Departments of Neurology and Pediatrics, University of Washington, and Seattle Children's Hospital; Division of Craniofacial Medicine (A.M.M.), Department of Pediatrics, University of Washington and Center for Developmental Biology and Regenerative Medicine, Seattle Children's Research Institute; Department of Radiology (S.D.F., S.L.P., C.B.B., J.N.W.), Seattle Children's Hospital, WA; and Department of Pediatrics (L.A.B.), Máxima Medical Center, Veldhoven, the Netherlands.
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Wang AC, Ibrahim GM, Poliakov AV, Wang PI, Fallah A, Mathern GW, Buckley RT, Collins K, Weil AG, Shurtleff HA, Warner MH, Perez FA, Shaw DW, Wright JN, Saneto RP, Novotny EJ, Lee A, Browd SR, Ojemann JG. Corticospinal tract atrophy and motor fMRI predict motor preservation after functional cerebral hemispherectomy. J Neurosurg Pediatr 2018; 21:81-89. [PMID: 29099351 DOI: 10.3171/2017.7.peds17137] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The potential loss of motor function after cerebral hemispherectomy is a common cause of anguish for patients, their families, and their physicians. The deficits these patients face are individually unique, but as a whole they provide a framework to understand the mechanisms underlying cortical reorganization of motor function. This study investigated whether preoperative functional MRI (fMRI) and diffusion tensor imaging (DTI) could predict the postoperative preservation of hand motor function. METHODS Thirteen independent reviewers analyzed sensorimotor fMRI and colored fractional anisotropy (CoFA)-DTI maps in 25 patients undergoing functional hemispherectomy for treatment of intractable seizures. Pre- and postoperative gross hand motor function were categorized and correlated with fMRI and DTI findings, specifically, abnormally located motor activation on fMRI and corticospinal tract atrophy on DTI. RESULTS Normal sensorimotor cortical activation on preoperative fMRI was significantly associated with severe decline in postoperative motor function, demonstrating 92.9% sensitivity (95% CI 0.661-0.998) and 100% specificity (95% CI 0.715-1.00). Bilaterally robust, symmetric corticospinal tracts on CoFA-DTI maps were significantly associated with severe postoperative motor decline, demonstrating 85.7% sensitivity (95% CI 0.572-0.982) and 100% specificity (95% CI 0.715-1.00). Interpreting the fMR images, the reviewers achieved a Fleiss' kappa coefficient (κ) for interrater agreement of κ = 0.69, indicating good agreement (p < 0.01). When interpreting the CoFA-DTI maps, the reviewers achieved κ = 0.64, again indicating good agreement (p < 0.01). CONCLUSIONS Functional hemispherectomy offers a high potential for seizure freedom without debilitating functional deficits in certain instances. Patients likely to retain preoperative motor function can be identified prior to hemispherectomy, where fMRI or DTI suggests that cortical reorganization of motor function has occurred prior to the operation.
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Affiliation(s)
| | - George M Ibrahim
- 3Division of Neurosurgery, Hospital for Sick Children and Toronto Western Hospital, Toronto, Ontario, Canada; Departments of
| | | | | | | | - Gary W Mathern
- Departments of1Neurosurgery and.,2Psychiatry and BioBehavioral Sciences, The Brain Research Institute, University of California, Los Angeles, California
| | | | | | - Alexander G Weil
- 7Division of Pediatric Neurosurgery, Department of Surgery, Sainte Justine Hospital, University of Montreal, Quebec, Canada
| | | | | | - Francisco A Perez
- 6Radiology, University of Washington, Seattle Children's Hospital, Seattle, Washington; and
| | - Dennis W Shaw
- 6Radiology, University of Washington, Seattle Children's Hospital, Seattle, Washington; and
| | - Jason N Wright
- 6Radiology, University of Washington, Seattle Children's Hospital, Seattle, Washington; and
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31
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Wright JN, Wycoco V. Asymmetric Meckel Cave Enlargement: A Potential Marker of PHACES Syndrome. AJNR Am J Neuroradiol 2017; 38:1223-1227. [PMID: 28408631 DOI: 10.3174/ajnr.a5140] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 01/17/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE PHACES syndrome is a complex of morphologic abnormalities of unknown cause and includes posterior fossa abnormalities; head and neck infantile hemangiomas; arterial, cardiac, and eye anomalies; and sternal or abdominal wall defects. Accurate identification of the syndrome is important for optimal treatment. The purpose of this study was to investigate the incidence of asymmetric Meckel cave enlargement, a potential novel imaging marker, in a population of patients referred for evaluation of possible PHACES syndrome. MATERIALS AND METHODS Eighty-five patients referred for neuroimaging evaluation of possible PHACES syndrome were identified and stratified on the basis of their ultimate clinical PHACES diagnosis categorization into PHACES, possible PHACES, or not PHACES. MR imaging studies were subsequently reviewed for the presence or absence of unilateral Meckel cave enlargement, with the reviewer blinded to the ultimate PHACES syndrome categorization. RESULTS Twenty-five of 85 patients (29%) were ultimately categorized as having PHACES or possible PHACES according to consensus guidelines. Asymmetric Meckel cave enlargement was present in 76% (19/25) of these patients and in 82% (19/23) of only those patients with definite PHACES. This finding was present in none of the 60 patients determined not to have PHACES syndrome. In 7/19 patients (37%) with this finding, subtle MR imaging abnormalities consistent with PHACES were missed on the initial MR imaging interpretation. CONCLUSIONS Asymmetric Meckel cave enlargement was a common feature of patients with PHACES in our cohort and may serve as a novel imaging marker. Increased awareness of this imaging feature has the potential to increase the diagnostic accuracy of PHACES.
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Affiliation(s)
- J N Wright
- From the Department of Radiology (J.N.W.), University of Washington and Seattle Children's Hospital, Seattle, Washington
| | - V Wycoco
- Department of Neurological Intervention and Imaging (V.W.), Alterna Wellness Center, Nedlands, Western Australia
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32
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Affiliation(s)
- J J Brand
- Department of Botany, University of Texas, Austin, Texas 78712, USA
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33
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Wright JN. WE-E-J-6B-04: Guided Radiation Therapy: Organ Motion Tracking with Implanted AC Electromagnetic Transponders. Med Phys 2005. [DOI: 10.1118/1.1999743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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34
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Affiliation(s)
- M Akhtar
- School of Biological Sciences, University of Southampton, UK
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35
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Akhtar M, Lee-Robichaud P, Akhtar ME, Wright JN. The impact of aromatase mechanism on other P450s. J Steroid Biochem Mol Biol 1997; 61:127-32. [PMID: 9365181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Experimental findings from a number of laboratories have converged to show that the conversion of androgens into oestrogen, catalysed by aromatase, involves three distinct reactions which occur at a single active site. That each one of these reactions belongs to a different generic type was revealed by chemical consideration, together with our (18)O-experiments. In particular, these findings highlighted the fact that the third reaction in the sequence occurs by a novel process for which a number of plausible mechanisms have been considered. The scrutiny of these mechanisms has involved either studies on aromatase itself, or on related enzymes which catalyse the aromatase type of cleavage reaction as generalized in equation 1: [equation: see text]. The acyl-carbon cleavage reaction of equation 1 is catalysed by sterol 14alpha-demethylases, accounts for several side-chain fission products formed by CYP17 (17alpha-hydroxylase-17,20-lyase), and constitutes a weak property of certain drug metabolizing P450s, when given aliphatic aldehydes as substrates. From cumulative studies on these enzymes, consensus is beginning to emerge that the acyl-carbon fission may be promoted by the FeIII-OOH intermediate, formed during the catalytic cycles of P450s. The precedent for the direct involvement of the FeIII-OOH species in the reaction of equation 1 is influencing our thinking regarding the mechanism of the conventional hydroxylation reaction. The status of knowledge surrounding the current debate on these issues will be reviewed.
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Affiliation(s)
- M Akhtar
- Department of Biochemistry, University of Southampton, U.K
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36
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Lee-Robichaud P, Kaderbhai MA, Kaderbhai N, Wright JN, Akhtar M. Interaction of human CYP17 (P-450(17alpha), 17alpha-hydroxylase-17,20-lyase) with cytochrome b5: importance of the orientation of the hydrophobic domain of cytochrome b5. Biochem J 1997; 321 ( Pt 3):857-63. [PMID: 9032476 PMCID: PMC1218145 DOI: 10.1042/bj3210857] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Human CYP17 (P-450(17alpha), 17alpha-hydroxylase-17,20-lyase)-catalysed side-chain cleavage of 17alpha-hydroxyprogestogens into androgens is greatly dependent on the presence of cytochrome b5. The native form of cytochrome b5 is composed of a globular core, residues 1-98, followed by a membrane insertable C-terminal tail, residues 99-133. In the present study the abilities of five different forms of cytochrome b5 to support the side-chain cleavage activity of CYP17 were compared. The five derivatives were: the native pig cytochrome b5 (native pig), its genetically engineered rat counterpart (core-tail), the soluble core form of the latter (core), the core with the secretory signal sequence of alkaline phosphatase appended to its N-terminal (signal-core) and the latter containing the C-terminal tail of the native rat protein (signal-core-tail). When examined by Edman degradation and MS, the engineered proteins were shown to have the expected N-terminal amino acid sequences and molecular masses. The native pig was found to be acetylated at the N-terminal. The native pig and core-tail enzymes were equally efficient at enhancing the side-chain cleavage activity of human CYP17 and the signal-core-tail was 55% as efficient. The core and signal-core constructs were completely inactive in the aforementioned reaction. All the five derivatives were reduced to varying degrees by NADPH:cytochrome P-450 (NADPH-P450) reductase and the relative efficiencies of this reduction were reminiscent of the behaviour of these derivatives in supporting the side-chain cleavage reaction. In the side-chain cleavage assay, however, NADPH-P450 reductase was used in large excess so that the reduction of cytochrome b5 derivatives was not rate-limiting. The results highlight that productive interaction between cytochrome b5 and CYP17 is governed not only by the presence of a membrane insertable hydrophobic region on the cytochrome b5 but also by its defined spatial orientation at the C-terminal.
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37
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Shyadehi AZ, Lamb DC, Kelly SL, Kelly DE, Schunck WH, Wright JN, Corina D, Akhtar M. The mechanism of the acyl-carbon bond cleavage reaction catalyzed by recombinant sterol 14 alpha-demethylase of Candida albicans (other names are: lanosterol 14 alpha-demethylase, P-45014DM, and CYP51). J Biol Chem 1996; 271:12445-50. [PMID: 8647850 DOI: 10.1074/jbc.271.21.12445] [Citation(s) in RCA: 103] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
The Candida albicans sterol 14 alpha-demethylase gene (P-45014DM, CYP51) was transferred to the yeast plasmid YEp51 placing it under the control of the GAL10 promoter. The resulting construct (YEp51:CYP51) when transformed into the yeast strain GRF18 gave a clone producing 1.5 mu mol of P-450/liter of culture, the microsomal fraction of which contained up to 2.5 nmol of P-450/mg of protein. Two oxygenated precursors for the 14 alpha-demethylase, 3 beta-hydroxylanost-7-en-32-al and 3 beta-hydroxylanost-7-en-32-ol, variously labeled with 2H and 18O at C-32 were synthesized. In this study the conversion of [32-2H,32-16O]- and [32-2H,32-18O]3 beta-hydroxylanost-7-en-32-al with the recombinant 14 alpha-demethylase was performed under 16O2 or 18O2 and the released formic acid analyzed by mass spectrometry. The results showed that in the acyl-carbon bond cleavage step (i.e. the deformylation process) the original carbonyl oxygen at C-32 of the precursor is retained in formic acid and the second oxygen of formate is derived from molecular oxygen; precisely the same scenario that has previously been observed for the acyl-carbon cleavage steps catalyzed by aromatase (P-450arom) and 17 alpha-hydroxylase-17,20-lyase (P-45017 alpha,CYP17). In the light of these results the mechanism of the acyl-carbon bond cleavage step catalyzed by the 14 alpha-demethylase is considered.
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Affiliation(s)
- A Z Shyadehi
- Department of Biochemistry, University of Southampton, United Kingdom
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38
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Lee-Robichaud P, Shyadehi AZ, Wright JN, Akhtar ME, Akhtar M. Mechanistic kinship between hydroxylation and desaturation reactions: acyl-carbon bond cleavage promoted by pig and human CYP17 (P-450(17)alpha; 17 alpha-hydroxylase-17,20-lyase). Biochemistry 1995; 34:14104-13. [PMID: 7578007 DOI: 10.1021/bi00043a015] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Using homogeneous pig and recombinant human CYP17, the mechanism of the acyl-carbon bond fission involved in the direct cleavage of pregnenolone was studied. It was found that the formation of androsta-5,16-dien-3 beta-ol (5,16-diene) and androst-5-ene-3 beta,17 alpha-diol (17 alpha-hydroxyandrogen) from pregnenolone was catalyzed by both the isoforms and that the two conversions were dependent on the presence of cytochrome b5 (cyt b5). 3 beta-Hydroxyandrost-5-ene-17 beta-carbaldehyde (aldehyde), an analogue of the physiological substrate pregnenolone, was handled as a substrate by both isoforms of CYP17. The aldehyde underwent cleavage to produce the 5,16-diene plus the 17 alpha-hydroxyandrogen, at rates approximately 8- and 3-fold higher than any physiological reaction catalyzed, in the absence of cytochrome b5, by the pig and human CYP17 isoforms, respectively. The stereochemistry of the reaction was studied using the aldehyde labeled with 2H at three strategic positions, 16 alpha, 16 beta, and 17 alpha, with incubations performed under both 16O2 and 18O2. The results showed that the formation of the 5,16-diene is attended by the removal of the 16 alpha-hydrogen atom; all three 2H atoms are retained in the formation of 17 alpha-hydroxyandrogen and its 17 alpha-hydroxyl oxygen originates from O2. Irrespective of the nature of the substrate, or the enzymic conditions used, the 5,16-diene and 17 alpha-hydroxyandrogen were produced in similar ratios, suggesting that their genesis is closely linked. Both the compounds may be envisaged to arise from a peroxy adduct that fragments to give a carbon radical that then undergoes either a disproportionation or an oxygen-rebound reaction. The conclusion was supported by isotope-partitioning experiments when the conversion of a mixture of the unlabeled aldehyde and its isotopomer, containing 2H at 16 alpha as well as 16 beta, led to the enrichment of 2H in 17 alpha-hydroxyandrogen. It is suggested that the mechanistic kinship between hydroxylation and olefin formation, revealed by the present study, also applies to conventional hydroxylation and desaturation reactions.
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Lee-Robichaud P, Wright JN, Akhtar ME, Akhtar M. Modulation of the activity of human 17 alpha-hydroxylase-17,20-lyase (CYP17) by cytochrome b5: endocrinological and mechanistic implications. Biochem J 1995; 308 ( Pt 3):901-8. [PMID: 8948449 PMCID: PMC1136809 DOI: 10.1042/bj3080901] [Citation(s) in RCA: 111] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Using NADPH-cytochrome P-450 reductase as electron donor the homogeneous pig 17 alpha-hydroxylase-17,20-lyase (CYP17) was shown to catalyse the conversion of delta 5, as well as delta 4, steroids (pregnenolone and progesterone respectively) predominantly into the corresponding 17 alpha-hydroxylated products. The latter were then cleaved by the lyase (desmolase) activity of the enzyme into androgens. Cytochrome b5 stimulated both these activities, but its most noticeable effect was on the formation of delta 16-steroids, which compulsorily required the presence of cytochrome b5. These results on the pig enzyme confirm the original findings [Nakajin, Takahashi, Shinoda and Hall (1985) Biochem. Biophys. Res. Commun. 132, 708-713]. The human CYP17 expressed in Escherichia coli [Imai, Globerman, Gertner, Kagawa and Waterman (1993) J. Biol. Chem. 268, 19681-19689] was also purified to homogeneity and was found to catalyse the hydroxylation of pregnenolone and progesterone without requiring cytochrome b5. Like the pig CYP17, the human CYP17 also catalysed the cytochrome b5-dependent direct cleavage of pregnenolone into the delta 5,16-steroid, but unlike it the human enzyme did not cleave progesterone at all. 17 alpha-Hydroxypregnenolone was, however, cleaved into the corresponding androgen but only in the presence of cytochrome b5. 17 alpha-Hydroxyprogesterone was a poor substrate for the human CYP17; although it was converted into androstenedione in the presence of cytochrome b5 its K(m) was 5 times higher and Vmax. 2.6 times lower than those for the hydroxylation of progesterone. The endocrinological and mechanistic implications of these results are discussed.
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Akhtar M, Corina D, Miller S, Shyadehi AZ, Wright JN. Mechanism of the acyl-carbon cleavage and related reactions catalyzed by multifunctional P-450s: studies on cytochrome P-450(17)alpha. Biochemistry 1994; 33:4410-8. [PMID: 8155659 DOI: 10.1021/bi00180a039] [Citation(s) in RCA: 82] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
It is now well-known that conventional cytochrome P-450s catalyze hydroxylation reactions using an iron mono-oxygen species, the structure of which, as inferred from chemical model studies, may be drrepresented by the following canonical forms: FeV==O<-->(.+)FeIV==O<-->FeIV--O(.). Certain multifunctional P-450s, notably those involved in steroid biosynthesis, catalyze, in addition to hydroxylation reactions, an acyl-carbon cleavage process in which the participation of an iron peroxide intermediate, FeIII--OOH, has been suggested. However the possibility still exists that the C--C bond cleavage may also occur using the FeV==O species. We have scrutinized the chemical consequences of involving either an FeV==O or an FeIII--OOH species for five different C--C bond cleavage reactions. With respect to the status as well as the origin of hydrogen and oxygen atoms, in four of the examples the mechanism involving the FeV==O species makes the same prediction as that using the iron peroxide intermediate, that is, the incorporation of an atom of oxygen from O2 into acyl part of the cleaved fragment. The fifth example, however, involving the formation, with pig testes microsomes, of 17 alpha-hydroxyandrogen (androst-5-ene-3 beta,17 alpha-diol) from pregnenolone, presents an interesting contrast--in this case different outcomes are predicted by the two mechanisms. These possibilities have been experimentally evaluated using substrates stereo- and regiospecifically labeled with heavy isotopes and incubated with pig testes microsomes under either 16O2 or 18O2.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- M Akhtar
- Department of Biochemistry, University of Southampton, England
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41
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Abstract
Some P-450 systems, notably aromatase and 14 alpha-demethylase catalyse not only the hydroxylate reaction but also the oxidation of an alcohol into a carbonyl compound as well as a C-C bond cleavage process. All these reactions occur at the same active site. A somewhat analogous situation is noted with 17 alpha-hydroxylase-17,20-lyase that participates in hydroxylation as well as C-C bond cleavage process. The C-C bond cleavage reactions catalysed by the above enzymes conform to the general equation: [formula: see text] It is argued that all three types of reaction catalyzed by these enzymes may be viewed as variations on a common theme. In P-450 dependent hydroxylation the initially formed FeIII-O-O. species is converted into FeIII-O-OH and the heterolysis of the oxygen-oxygen bond of the latter then gives the oxo-derivative for which a number of canonical structures are possible; for example FeV = O<==>(+.)FeIV = O<==>FeIV-O.. One of these, FeIV-O. behaves like an alkoxyl radical and participates in hydrogen abstraction from C-H bond to produce FeIV-OH and carbon radical. The latter is then quenched by the delivery of hydroxyl radical from FeIV-OH. The latter species may thus be regarded as a carrier of hydroxyl radical. We have proposed that the C-C bond cleavage reaction occurs through the participation of the FeIII-O-OH species that is trapped by the electrophilic property of the carbonyl compound giving a peroxide adduct that fragments to produce an acyl-carbon cleavage. Scientific developments leading up to this conclusion are considered. In the first author's views, "The study of mechanisms is not a scientific but a cultural activity. Mechanisms do not aim at an absolute truth but are intended to be a "running" commentary on the status of knowledge in a field. As the structural knowledge in a field advances Mechanisms evolve to take note of the new findings. Just as a constructive "running" commentary provides the stimulus for higher standards of performance, so Mechanisms call for better and firmer structural information from their practitioners".
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Affiliation(s)
- M Akhtar
- Department of Biochemistry, University of Southampton, Highfield, England
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Nagey DA, Blackman JA, Wright JN. The general medical record. Concepts and suggestions for implementation. Ann N Y Acad Sci 1992; 670:109-15. [PMID: 1309078 DOI: 10.1111/j.1749-6632.1992.tb26080.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Our view of a general medical record consists of a combination of distinct departmental- and specialty-specific medical records and an organizing kernel that contains arguably critical information. Because this system allows each clinical entity to evolve its own system, clinical priorities do not have to be negotiated or compromised. Additionally, subsystem or departmental medical records can be easily revised without disturbing the general medical record because of the modular design. Although the system seems robust with respect to design considerations, only implementation can provide adequate tests.
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Affiliation(s)
- D A Nagey
- Department of Obstetrics and Gynecology, University of Maryland School of Medicine, Baltimore 21201
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Abstract
An in-depth study of 79 vehicle crashes on rural roads in an area of about 100 km radius around Adelaide examined sociodemographic and psychophysiological characteristics of the drivers and riders involved. In many respects this sample of crashes was similar to a much larger number of police-reported crashes in the same area but included: relatively more crashes with severe or fatal injuries; more crashes on divided roads, on sealed roads and on curves; and more crashes involving trucks. Alcohol and lack of seat belt use were shown to be major problems in these rural crashes. The drivers and riders most strongly associated with these particular problems were males, in blue collar occupations and with limited education; they tended to be aged 30 years or more in the case of alcohol abuse, and were likely to be under 30 years in the case of restraint misuse. The attitudes of these drivers and riders, and other characteristics likely to have contributed to their involvement in a crash, are discussed. There is a need to develop specific and effective countermeasures to reduce drink-driving and increase seat belt wearing in rural areas.
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Affiliation(s)
- G A Ryan
- NHMRC Road Accident Research Unit, University of Adelaide
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Affiliation(s)
- M Akhtar
- Department of Biochemistry, University of Southampton
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45
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Abstract
A totally nurse-dependent charging system developed specifically for the labor and delivery suite at the University of Maryland Medical System is described in the article. This easy and effective method of charging was incorporated into an already existing patient census and classification system. The number of relative value units has increased by more than 30%, and the amount of revenue billed has increased by more than $800,000 in the first 10 months after implementation.
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Affiliation(s)
- J Monroe
- Greater Baltimore Medical Center, MD 21204
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Abstract
The conversion of androgens into estrogen involves three distinct generic reactions which are catalyzed by a single P450 enzyme (aromatase or P450(aromatase)). The first step in the process is the conversion of 19-methyl into a hydroxymethyl group which requires NADPH + O2, thus representing the well-known hydroxylation process. The next stage, converting the -CH2OH into -CHO, also requires NADPH + O2 and may be rationalized either through a second hydroxylation reaction producing a gem-diol, CH(OH)2 (which dehydrates to the aldehyde), or via another route. The final stage in the process again uses NADPH + O2, culminating in the release of C-19 as formate. Our extensive studies using precursors containing 2H, 3H, and 18O have shown that the carbonyl oxygen of the 19-aldehyde group is the one that was introduced in the first step as the hydroxyl group. The aldehydic oxygen along with another, from O2, used in the third step of the process, is incorporated into the released formate. It was found that at each stage of the process, oxygen atoms were introduced or transferred as "whole numbers." In light of these data, mechanisms in which H2O is used to promote the C-10-C-19 bond cleavage or those in which the conversion of the 19-oxoandrostenedione into estrogen is considered to occur via the sequence -CHO----(-)CH(OH)2----estrogen are eliminated. In addition, our mechanistic analysis makes it unlikely that 1 beta-, 2 beta-, or 10 beta-hydroxysteroids serve as intermediates in estrogen biosynthesis. We consider a free radical mechanism for the hydroxylation process.
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Affiliation(s)
- J N Wright
- Department of Biochemistry, University of Southampton, UK
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47
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Nagey DA, Wright JN, Mulligan K, Crenshaw C. A convertible perinatal database. MD Comput 1989; 6:28-36. [PMID: 2709971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
This is a description of the process and outcome in the development of a large perinatal database. The database is relatively unique, as it utilizes a convenient paper format for initial data entry that can easily serve, in the absence of a computer, as a very complete obstetric and neonatal medical record. With the addition of a moderately priced microcomputer, the database is converted into a computerized medical record that provides admission notes for the labor suite and the nursery, and discharge summaries for abortion, non-delivery, delivery, newborn nursery, and intensive care nursery admissions. The development of the paper forms, the choice of data-entry clerks over health-care providers for computer input, the design of the software to ease use and economize on storage requirements, and the use of the database in research projects are described.
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48
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Abstract
The effects of ductal closure on range-gated pulsed Doppler cerebral blood flow velocity (CBFV) patterns in the internal carotid, anterior cerebral, and middle cerebral arteries were studied in 10 normal term infants (mean birth weight 3302 +/- 294 g (SD) and mean gestational age 39.6 +/- 1.3 weeks). Pulsatility was calculated from flow velocities and used as an estimate of cerebral blood flow (CBF). Ductal closure was associated with a rise in mean blood pressure from 45.0 +/- 4.2 to 51.3 +/- 6.5 mm Hg (P less than 0.05) and a significant decrease in pulsatility in all three vessels (mean = 0.77 +/- 0.07 vs 0.70 +/- 0.05 (P less than 0.02]. Changes in pulsatility were correlated with changes in mean blood pressure (P less than 0.02), providing evidence that systemic blood pressure may influence postnatal cerebral arterial pulsatility indices. We also noted significant differences in the velocity and pulsatility of individual vessels that were independent of blood pressure, suggesting that Doppler flow studies may be useful in describing regional CBF patterns. The temporal association between ductal closure and decreased pulsatility suggests that CBFV patterns reflect ductal shunting in normal term newborn infants. Diastolic runoff and reduced systemic blood pressure in the presence of ductal shunting appear to reduce diastolic flow velocity and increase CBFV pulsatility in normal term infants during the first days of life. Normal mechanisms of cerebral autoregulation compensate for decreased flow with vasodilation; therefore the increased pulsatility associated with ductal shunting may be due to diastolic runoff rather than increased cerebrovascular resistance.
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Affiliation(s)
- L L Wright
- Department of Pediatrics, University of Maryland Medical School, Baltimore
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49
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Abstract
Creatinine phosphokinase and its isoenzymes (myocardial-specific MB and brain-specific BB) are elevated in the presence of specific tissue injury. The value of this serum marker as an objective indicator of perinatal asphyxia was studied. Forty-nine patients with gestational ages ranging from 36 to 42 weeks were prospectively studied. Patients who by interpretation of the fetal heart rate tracing alone were diagnosed as having fetal distress demonstrated significantly lower pH (p = 0.001) and base excess (p less than 0.0001) in umbilical venous blood. Umbilical venous cord MB (p less than 0.05) and BB (p less than 0.01) were increased in this group. Abnormal fetal heart rate patterns correlate well with acid-base abnormalities and elevated creatinine phosphokinase values. These tests may demonstrate more efficient and improved indicators of tissue injury and damage from perinatal asphyxia than clinical observation alone.
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Affiliation(s)
- D I Hollander
- Department of Obstetrics and Gynecology, University of Maryland School of Medicine, Baltimore
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50
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Ludlam JE, Wright JN. Formal instrument counts: yes or no? Hosp Med Staff 1982; 11:6-9. [PMID: 10254547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
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