ENIGMA-anxiety working group: Rationale for and organization of large-scale neuroimaging studies of anxiety disorders

Anxiety disorders are highly prevalent and disabling but seem particularly tractable to investigation with translational neuroscience methodologies. Neuroimaging has informed our understanding of the neurobiology of anxiety disorders, but research has been limited by small sample sizes and low statistical power, as well as heterogenous imaging methodology. The ENIGMA-Anxiety Working Group has brought together researchers from around the world, in a harmonized and coordinated effort to address these challenges and generate more robust and reproducible findings. This paper elaborates on the concepts and methods informing the work of the working group to date, and describes the initial approach of the four subgroups studying generalized anxiety disorder, panic disorder, social anxiety disorder, and specific phobia. At present, the ENIGMA-Anxiety database contains information about more than 100 unique samples, from 16 countries and 59 institutes. Future directions include examining additional imaging modalities, integrating imaging and genetic data, and collaborating with other ENIGMA working groups. The ENIGMA consortium creates synergy at the intersection of global mental health and clinical neuroscience, and the ENIGMA-Anxiety Working Group extends the promise of this approach to neuroimaging research on anxiety disorders.

Mega-analysis methods in ENIGMA: The experience of the generalized anxiety disorder working group

The ENIGMA group on Generalized Anxiety Disorder (ENIGMA-Anxiety/GAD) is part of a broader effort to investigate anxiety disorders using imaging and genetic data across multiple sites worldwide. The group is actively conducting a mega-analysis of a large number of brain structural scans. In this process, the group was confronted with many methodological challenges related to study planning and implementation, between-country transfer of subject-level data, quality control of a considerable amount of imaging data, and choices related to statistical methods and efficient use of resources. This report summarizes the background information and rationale for the various methodological decisions, as well as the approach taken to implement them. The goal is to document the approach and help guide other research groups working with large brain imaging data sets as they develop their own analytic pipelines for mega-analyses.

Cortical and subcortical brain structure in generalized anxiety disorder: findings from 28 research sites in the ENIGMA-Anxiety Working Group

The goal of this study was to compare brain structure between individuals with generalized anxiety disorder (GAD) and healthy controls. Previous studies have generated inconsistent findings, possibly due to small sample sizes, or clinical/analytic heterogeneity. To address these concerns, we combined data from 28 research sites worldwide through the ENIGMA-Anxiety Working Group, using a single, pre-registered mega-analysis. Structural magnetic resonance imaging data from children and adults (5-90 years) were processed using FreeSurfer. The main analysis included the regional and vertex-wise cortical thickness, cortical surface area, and subcortical volume as dependent variables, and GAD, age, age-squared, sex, and their interactions as independent variables. Nuisance variables included IQ, years of education, medication use, comorbidities, and global brain measures. The main analysis (1020 individuals with GAD and 2999 healthy controls) included random slopes per site and random intercepts per scanner. A secondary analysis (1112 individuals with GAD and 3282 healthy controls) included fixed slopes and random intercepts per scanner with the same variables. The main analysis showed no effect of GAD on brain structure, nor interactions involving GAD, age, or sex. The secondary analysis showed increased volume in the right ventral diencephalon in male individuals with GAD compared to male healthy controls, whereas female individuals with GAD did not differ from female healthy controls. This mega-analysis combining worldwide data showed that differences in brain structure related to GAD are small, possibly reflecting heterogeneity or those structural alterations are not a major component of its pathophysiology.

Brain structural changes in late-life generalized anxiety disorder

Late-life Generalized Anxiety Disorder (GAD) is relatively understudied and the underlying structural and functional neuroanatomy has received little attention. In this study, we compare the brain structural characteristics in white and gray matter in 31 non-anxious older adults and 28 late-life GAD participants. Gray matter indices (cortical thickness and volume) were measured using FreeSurfer parcellation and segmentation, and mean diffusivity was obtained through Diffusion Tensor Imaging (DTI). We assessed both macroscopic white matter changes [using white matter hyperintensity (WMH) burden] and microscopic white matter integrity [using fractional anisotropy (FA)]. No differences in macro- or microscopic white matter integrity were found between GAD and non-anxious controls (HC). GAD participants had lower cortical thickness in the orbitofrontal cortex (OFC), inferior frontal gyrus, and pregenual anterior cingulate cortex (ACC). Higher worry severity was associated with gray matter changes in OFC, ACC and the putamen. The results did not survive the multiple comparison correction, but the effect sizes indicate a moderate effect. The study suggests that late-life GAD is associated with gray matter changes in areas involved in emotion regulation, more so than with white matter changes. We conclude that anxiety-related chronic hypercortisolemia may have a dissociative effect on gray and white matter integrity.

Roux-en-Y gastric bypass and sleeve gastrectomy: mechanisms of diabetes remission and role of gut hormones

CONTEXT

In obese patients with type 2 diabetes (T2DM), Roux-en-Y-gastric-bypass (RYGB) and sleeve gastrectomy (SLG) improve glycemic control.

OBJECTIVE

The objective of this study was to investigate the mechanisms of surgery-induced T2DM improvement and role of gastrointestinal hormones. PATIENTS, SETTING, AND INTERVENTION: In 35 patients with T2DM, we performed a mixed-meal test before and 15 days and 1 year after surgery (23 RYGB and 12 SLG).

MAIN OUTCOME MEASURES

Insulin sensitivity, β-cell function, and amylin, ghrelin, PYY, pancreatic polypeptide (PP), glucagon, and glucagon-like peptide-1 (GLP-1) responses to the meal were measured.

RESULTS

T2DM remission occurred in 13 patients undergoing RYGB and in 7 patients undergoing SLG. Similarly in the RYGB and SLG groups, β-cell glucose sensitivity improved both early and long term (P < .005), whereas insulin sensitivity improved long term only (P < .006), in proportion to body mass index changes (P < .001). Early after RYGB, glucagon and GLP-1 responses to the meal increased, whereas the PP response decreased. At 1 year, PYY was increased, and PP, amylin, ghrelin, and GLP-1 were reduced. After SLG, hormonal responses were similar to those with RYGB except that PP was increased, whereas amylin was unchanged. In remitters, fasting GLP-1 was higher (P = .04), but its meal response was flat compared with that of nonremitters; postsurgery, however, the GLP-1 response was higher. Other hormone responses were similar between the 2 groups. In logistic regression, presurgery β-cell glucose sensitivity (positive, P < .0001) and meal-stimulated GLP-1 response (negative, P = .004) were the only predictors of remission.

CONCLUSIONS

RYGB and SLG have a similar impact on diabetes remission, of which baseline β-cell glucose sensitivity and a restored GLP-1 response are the chief determinants. Other hormonal responses are the consequences of the altered gastrointestinal anatomy.

Enhancing the educational value of video games

Lowering the barrier between education and real entertainment is an important challenge in order to better exploit the potential of computers and reach a demographic that is traditionally averse to learning. To this end, it is important to investigate how to exploit the appeal of video games (VGs) to also favor and induce learning via playing video games. Achieving this goal is not only a matter of content, since simply “superimposed” educational content risks being perceived as boring. Hence we believe that the game should feature mechanisms for acquiring knowledge and skill that are smoothly embedded in a meaningful, homogeneous, and compelling whole.

Thus, there is a need to compartmentalize components of a game engine so that it becomes easy and efficient to integrate the graphics/interface—which has already been done very well by state-of-the-art successful video games and the educational aspect which is typically poor in those same games. Hence we have defined a general set of mechanisms and modules that can be inserted in state-of-the-art VG environments and are aimed at promoting various kinds of knowledge and procedural skill acquisition.

In order to investigate and validate this concept, we have built an educational game, SeaGame , using a state-of-the-art commercial game development approach, and enriched the environment with instances of developed educational modules.

Analyzing user test results, we conclude that SeaGame is perceived quite similarly to commercial VGs, which suggests that the proposed mechanisms do not compromise the overall enjoyability of the game, which is key to attracting a wide demographic that is not currently involved in educational activities during their leisure time.

The results of this research can be generalized, since the standards of commercial games and the proposed educational enhancements can be instantiated in a variety of educational contexts and applied to different types of content.

A clinical comparison of two calculus-inhibiting dentifrices

The objective of this double-blind clinical study, conducted in harmony with the Volpe-Manhold design for studies of dental calculus, was to compare the effect on supragingival calculus formation of a dentifrice containing pyrophosphate, tripolyphosphate and a copolymer in a 0.243% sodium fluoride/silica base (Test Dentifrice), to that of a commercially available calculus-inhibiting dentifrice containing tetrapotassium pyrophosphate, disodium pyrophosphate and tetrasodium pyrophosphate in a 0.243% sodium fluoride/silica base (Positive Control Dentifrice). Adult male and female subjects from the Buffalo, New York area were entered into the study, provided a full oral prophylaxis, and assigned the use of a placebo (non-calculus-inhibiting) dentifrice for fourteen weeks. At the completion of this initial period, subjects were assessed for baseline Volpe-Manhold Calculus Index scores, provided another full prophylaxis, and stratified into two treatment groups which were balanced for age, sex and baseline calculus. Subjects were instructed to brush their teeth twice daily (morning and evening) for one minute with their assigned dentifrice, using a soft-bristled toothbrush. Examinations for dental calculus were again performed after twelve weeks' use of the study dentifrices. Ninety-one (91) subjects complied with the protocol and completed the entire study. At the three-month examination, the Test Dentifrice group exhibited a statistically significant 27.3% reduction in mean Volpe-Manhold Calculus Index score as compared to the Positive Control Dentifrice group. The results of this clinical study support the conclusion that a new calculus-inhibiting dentifrice, containing pyrophosphate, tripolyphosphate and a copolymer in a 0.243% sodium fluoride/silica base, is efficacious for the control of the development of supragingival calculus, and provides a level of benefit greater than that provided by a commercially available calculus-inhibiting dentifrice containing tetrapotassium pyrophosphate, disodium pyrophosphate and tetrasodium pyrophosphate in a 0.243% sodium fluoride/silica base.

[Hernia surgery with short hospitalization]

The hospital stay of 55 patients, 47 males and 8 females, admitted to hospital for surgical repair of inguinal (53 procedures) and crural (4 procedures) hernias was analyzed. The mean age was 60.7 years (range from 25 to 82 years), local anesthesia was the method of choice (55 procedures), it has suppressed post-anesthetic respiratory and urinary troubles. The mean hospital stay was 1.18 days. One superficial skin hematoma and 1 wound infection were found, local anesthetic intolerance occurred in 1 case, and low fever in three cases. Over 90 percent of patients were favourable to short stay surgery for hernia repair at 30 days follow-up. The authors conclude on the feasibility, acceptability, social benefits and usefulness of short stay and day care surgery for hernia repair.

Microbial alterations in supragingival dental plaque in response to a triclosan-containing dentifrice

A total of 325 subjects were entered into a double-blind, stratified 2-treatment clinical study that examined the effects of a dentifrice containing 0.3% triclosan, 2% Gantrez copolymer and 0.243% sodium fluoride on supragingival dental plaque and gingivitis. A subset of 159 subjects including 72 men and 87 women participated in the microbiological component of this study, which was designed to detect shifts in supragingival bacterial species in response to triclosan. Subjects were divided into two groups: one performed normal oral hygiene with the triclosan/copolymer dentifrice and a control group used a placebo dentifrice without triclosan. At baseline, 3 and 6 months during treatment and at 6, 12, 18 and 24 weeks post-treatment, supragingival dental plaque was collected from the buccal and lingual surfaces of the 4 first molar teeth and assayed for: 1) bacterial morphotypes by phase-contrast microscopy; 2) select bacterial groups and bacterial species by culture; and 3) target periodontal pathogens including Actinobacillus actinomycetemcomitans, Bacteroides forsythus, Porphyromonas gingivalis and Prevotella intermedia by immunofluorescence microscopy. There were few statistically significant differences between treatment groups in any of the 90 microbiological parameters measured at the 7 different time points. The control group demonstrated significantly higher levels of cultivable Neisseria and higher proportions at the 3-month treatment period of P. gingivalis-infected subjects and mean cells. After 6 months of treatment, the triclosan group demonstrated higher levels of fusiforms. Analysis of triclosan resistance data failed to detect a shift towards increased proportions of bacteria resistant to triclosan, and both treatment groups demonstrated triclosan-resistant strains, predominantly Veillonella dispar. This study confirms the microbiological safety of triclosan-containing dentifrices and suggests that continued use can be associated with beneficial alterations in the bacterial composition of supragingival dental plaque.

When CHIVA treatment could be video guided

BACKGROUND

Hemodynamic correction (CHIVA) is a conservative, ambulatory, and controversial varicose vein treatment. It consists of selected ligatures of the superficial venous system decided by means of preoperative duplex mapping.

OBJECTIVE

Prospective evaluation of 80 patients, operated on according to the CHIVA technique described by Claude Franceschi. Mean follow-up length was 30 months.

METHODS

Fifty-five consecutive patients were operated on after clinical, ultrasonographic, ambulatory venous pressure and light reflection rheography evaluations. After a 3-year follow-up, another 25 consecutive patients were selected applying some exclusion criteria that emerged in the first part of the study. This second series was operated on by means of intraoperative angioscopy. The same preoperative evaluations have been used to study the outcome in all patients.

RESULTS

CHIVA failed in the short saphenous vein territory varices and when the long saphenous vein and the insufficient perforating veins had a preoperative diameter greater than 10 and 4 mm, respectively. The procedure showed a long saphenous vein patency of 90.4% and registered a total recurrence rate of 18.7%.

CONCLUSIONS

CHIVA seems to be a more effective varicose vein treatment than high ligation and distal stab avulsion. It also preserves a higher rate of long saphenous veins, suitable for bypass surgery.

[Laparoscopic treatment of Mirizzi's syndrome]

The Mirizzi syndrome is an unusual benign obstructive jaundice due to extrinsic mechanical compression of the common hepatic duct by gallstone impacted within the neck or cystic duct of the gallbladder. This syndrome is described either as an acute form due only to extrinsic compression of the common bile duct (type I) or as a chronic form resulting in an erosive cholecysto-choledochal fistula (type II). Up to date, the syndrome remains a clinically and surgically challenging problem. The anatomic basic of the syndrome (an anomalous relationship between the cystic duct and the common hepatic duct) when associated with inflammation and interbiliary fistula predisposes to a critical situation to be clearly detected and contributes to technical difficulties when surgical management is performed. The operative diagnosis of Mirizzi syndrome remains elusive and requires careful scrutiny of the biliary tract imaging to recognize the diseased duct system and to facilitate the following operative procedures. The surgical treatment requires a skill and careful operative dissection of the duct system, cholecystectomy and a safe biliary exploration and stone clearance, avoiding any iatrogenic damage to common hepatic duct. Laparotomy is commonly advocated as the safer approach to the diseased biliary tract and it is still employed by most authors. The laparoscopic surgery has not yet entered as the first-choice procedure for this syndrome due to jaundice and acute inflammation considered by some as contraindication to mini-invasive treatment. This paper describes successful surgical management by laparoscopic techniques in two patients affected by Mirizzi type I and type II syndrome treated by cholecystectomy alone and cholecystectomy with choledochal fistula flap repair, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

[A new technique in positioning of Kehr's tube in laparoscopy]

The enlargement of the indications in the use of the laparoscopic technique puts the surgeon in front of the need to project new techniques and to improve new instruments daily. On one hand, the technique and instruments used to perform a video-laparoscopic cholecystectomy are codified. However, there is still a lot of work to do for the laparoscopic treatment of the common bile duct stones. The aim of the present scientific contribution is the exposition of an original methodology for the positioning of the T-tube in laparoscopy which would be a difficult manoeuvre otherwise.

Effect on plaque removal and gingivitis of a triclosan-copolymer pre-brush rinse: a six-month clinical study in Canada

The effect on plaque removal and gingivitis of using a pre-brush rinse containing 0.03 per cent triclosan (Irgacare MP, Ciba-Geigy Corp.) and 0.125 per cent of a copolymer of polyvinylmethyl ether and maleic acid over a six-month period, versus using a matching placebo pre-brush rinse, was assessed in this clinical study. Subjects were instructed to rinse their mouths for one minute, twice daily (morning and evening), with 15 mL of their assigned pre-brush rinse. Immediately after rinsing, subjects brushed their teeth for 30 seconds using the dentifrice and toothbrush supplied to them at the outset. Subjects were instructed to refrain from any other oral hygiene procedures throughout the duration of the study. Plaque and gingivitis examinations were conducted after three months and again after six months. At the conclusion of the study (six months), the triclosan/copolymer pre-brush rinse demonstrated an advantage of 24.8 per cent for plaque removal and a 22.1 per cent reduction in gingivitis, when compared to the matching placebo pre-brush rinse. These advantages in plaque removal and gingivitis reduction were statistically significant. The six-month effect of the triclosan/copolymer pre-brush rinse was even greater on "the more difficult to brush" surfaces of the teeth, as determined by the use of the Plaque Severity Index and the Gingivitis Severity Index.(ABSTRACT TRUNCATED AT 250 WORDS)

Isolated true atherosclerotic aneurysms of the superficial femoral artery. Case report and literature review

Isolated true atherosclerotic aneurysms of the superficial femoral artery are rare. We report an original case of superficial femoral artery aneurysm (SFAA) not associated with dilatation of the common femoral or popliteal artery. The review of the literature emphasizes the great latency of the disease and the high incidence of complication at presentation, as well as, echosonographic diagnostical advantages over angiography. After surgical treatment the prognosis is favourable. Early recognition and surgical repair are recommended for patients with aneurysms of the superficial femoral artery greater at least twice the normal vessel size. Elective surgical treatment is associated with little risk to the patients and avoids the need for operation in the setting of limb-threatening ischemia.

[Esophageal anastomosis using a stapler: new technical variants]

Stapling techniques are considered the safer alternative for esophageal anastomosis in the Authors experience. In order to further improve results they suggest stapled esophageal anastomoses should be constructed avoiding purse-string sutures and the use of purse-string devices or Satinsky forceps.

On a particular method of isolation of the human placenta trophoblastic cells

With the purpose of demonstrating the presence of different types of cells in the syncytial and cytotrophoblast of the human placenta, a new technique of cell isolation was performed by utilizing a light enzymatic digestion and a separation on density gradients. Normal human placentas of the first trimester of pregnancy have been studied. After an accurate and light washing in saline and anticoagulant substances, whole villi have been incubated in a trypsin solution for various periods of time at 40 degrees C in a thermostatic stirrer. Detached cells have been collected, rinsed and separated by means of different density gradients of Percoll (d = 1.038 and 1.080). Three cellular layers have been collected and processed for the studies at light and electron microscopy. The first layer was mostly composed by multinucleated elements with a morphological pattern closely related to the histological characteristics of the syncytiotrophoblast; the second fraction was composed by mononucleated elements with the structural findings of the Langhans' cells; the third layer was represented almost exclusively by blood cells. The obtained results demonstrated the high utility and accuracy of the suggested method of cell isolation.