Predicting Incident Adenocarcinoma of the Esophagus or Gastric Cardia Using Machine Learning of Electronic Health Records

BACKGROUND & AIMS

Tools that can automatically predict incident esophageal adenocarcinoma (EAC) and gastric cardia adenocarcinoma (GCA) using electronic health records to guide screening decisions are needed.

METHODS

The Veterans Health Administration (VHA) Corporate Data Warehouse was accessed to identify Veterans with 1 or more encounters between 2005 and 2018. Patients diagnosed with EAC (n = 8430) or GCA (n = 2965) were identified in the VHA Central Cancer Registry and compared with 10,256,887 controls. Predictors included demographic characteristics, prescriptions, laboratory results, and diagnoses between 1 and 5 years before the index date. The Kettles Esophageal and Cardia Adenocarcinoma predictioN (K-ECAN) tool was developed and internally validated using simple random sampling imputation and extreme gradient boosting, a machine learning method. Training was performed in 50% of the data, preliminary validation in 25% of the data, and final testing in 25% of the data.

RESULTS

K-ECAN was well-calibrated and had better discrimination (area under the receiver operating characteristic curve [AuROC], 0.77) than previously validated models, such as the Nord-Trøndelag Health Study (AuROC, 0.68) and Kunzmann model (AuROC, 0.64), or published guidelines. Using only data from between 3 and 5 years before index diminished its accuracy slightly (AuROC, 0.75). Undersampling men to simulate a non-VHA population, AUCs of the Nord-Trøndelag Health Study and Kunzmann model improved, but K-ECAN was still the most accurate (AuROC, 0.85). Although gastroesophageal reflux disease was strongly associated with EAC, it contributed only a small proportion of gain in information for prediction.

CONCLUSIONS

K-ECAN is a novel, internally validated tool predicting incident EAC and GCA using electronic health records data. Further work is needed to validate K-ECAN outside VHA and to assess how best to implement it within electronic health records.

Abstract 1890: A solution to T-cell engager toxicity: An anti-CD3 Prodrug DARPin (CD3-PDD) shows no toxicity, but potent anti-tumor activity in a humanized mouse model

T-cell engagers (TCEs) direct cytotoxic T-cell response towards tumor cells by binding simultaneously to a tumor-associated antigen (TAA) on target cells and to CD3 on T-cells, thereby forming an artificial immune synapse. They have been shown to be very potent anti-tumor drugs, as exemplified by blinatumomab, an α-CD19 x α-CD3 bispecific. However, the development of TCEs for hematological and solid tumors has been hampered by several factors, amongst them severe toxicity, elicited by on-target/off-tumor recruitment of T-cells and cytokine release syndrome (CRS).

In order to overcome this challenge, an anti-CD3 Prodrug DARPin® (CD3-PDD) has been developed, consisting of a mouse cross-reactive EGFR-binder and a CD3-binder, linked via a protease-cleavable linker to an anti-idiotypic anti-CD3 binder (termed blocker hereafter). This α-EGFR x α-CD3 x blocker Prodrug is unable to bind and recruit T-cells in its non-cleaved state, but is designed to become activated in the tumor microenvironment upon cleavage of the linker by tumor-associated proteases.

A control Prodrug DARPin® with a non-cleavable linker showed neither tumor cell killing, nor T-cell activation at concentrations >1'000-fold over the EC50 of the active, non-blocked TCE DARPin® in in vitro tumor cell killing and T-cell activation assays. In contrast, a CD3-PDD containing a cleavable linker was partially activated by proteases secreted from the tumor cells (HCT 116). Pre-treatment of the CD3-PDD with recombinant protease prior to the in vitro assay fully activated the molecule, with EC50 values comparable to the active, non-blocked TCE.

Next, an in vivo proof-of-principle study was performed in a human colon carcinoma xenograft model (HCT 116) using immunodeficient mice humanized with hematopoietic stem cells (CD34+) and optimized for the presence of human myeloid cells. Due to the mouse cross-reactivity of the EGFR-binder, this animal model allowed to assess both anti-tumor efficacy and safety (therapeutic window). The cleavable CD3-PDD demonstrated a robust anti-tumor activity, similar to the one observed with active, non-blocked TCE. Most importantly, while the active, non-blocked TCE elicited strong toxicity, leading to loss of animals and requiring treatment stop, the cleavable CD3-PDD could be dosed without significant safety findings.

In summary, a conditionally activated CD3-PDD shows similar efficacy but none of the toxicity of the active, non-blocked TCE. Our approach therefore holds great promise for the development of future CD3-PDD as therapeutics, enabling the utilization of less tumor-specific targets for highly potent TCEs. Ultimately, the ability of the versatile DARPin® technology to generate tailor-made anti-idiotypic DARPin® molecules can unlock novel therapeutic design spaces, which we are exploring beyond the conditionally activated CD3-PDD format.

Citation Format: Andreas Bosshart, Julia Katharina Ahlskog, Aline Eggenschwiler, Dieter Schiegg, Yvonne Grübler, Sandra Wandel, Simon Fontaine, Maria Paladino, Susanne Mangold, Tanja Hospodarsch, Alexandra Neculcea, Chloé Iss, Christel Herzog, Bernd Schlereth. A solution to T-cell engager toxicity: An anti-CD3 Prodrug DARPin (CD3-PDD) shows no toxicity, but potent anti-tumor activity in a humanized mouse model [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 1890.

Multifocal recurrence on the transaxillary robotic thyroidectomy incision

INTRODUCTION

Robotic thyroidectomy (RT) has been reported to achieve satisfactory results. However, its long-term oncological results have not been validated. The use of RT to treat thyroid cancer comprises specific risks that are not encountered with open thyroidectomy (OT).

CASE SUMMARY

We report the case of a patient operated by two-stage RT for stage pT3a follicular carcinoma, followed by tumour seeding along the incision despite adjuvant Iodine-131 therapy and external beam radiotherapy.

DISCUSSION

This case illustrates the limitations and insufficient perspective of RT for thyroid cancer, with the recent discovery of a risk of tumour seeding along the incision. Rigorous patient selection should help to avoid this risk of tumour seeding.

Abstract 4552: Tumor-restricted immune modulation by multispecific molecules from the DARPin toolbox

During the last years, immune-modulating drugs became an important cornerstone in the treatment of cancer patients. In particular, the PD1/PDL-1 and CTLA-4 antagonists revolutionized the field. However, only a limited number of patients benefit from these antagonistic molecules and more combination therapies are on the way to increase the number of patients benefiting from these novel therapies. Among the combinations, drugs that are T-cell or myeloid cell agonists belonging to the TNFR-superfamily show first promising clinical results. However, systemic immune activation bears the risk of severe side effects that will not allow using these powerful drugs at an effective dose. We have developed a new class of DARPin molecules that enable tumor-restricted immune cell activation of TNFR-superfamily agonists in the tumor only, thereby preventing systemic immune-activation. We generated DARPin molecules that bind with high affinity to TNFR-superfamily members (CD134, CD137 and CD40) and DARPin molecules that bind to tumor-specific antigens such as HER2 and EGFR or targets restricted to the tumor stroma compartment like FAP and extra-domain B of fibronectin (ED-B). Using these building blocks from our DARPin toolbox, we constructed a variety of multi-specific molecules consisting of a TNFR-superfamily receptor targeting DARPin molecule and a tumor-localizing DARPin molecule. In reporter cell assays the multi-specific DARPin molecules activate the respective TNF-superfamily receptor only in the presence of a cell expressing the tumor-localizer; e.g. the FAP-CD134 molecule activates CD134 only in the presence of a stromal cell expressing FAP and not in its absence. Moreover, activation of CD134 was dependent on the density of FAP expression on cells, showing that CD134 only becomes activated if a certain level of the tumor-localizing target is expressed. These finding were confirmed in experiments with primary immune cells where we see immune-cell activation only upon binding to the tumor-localizing target. This could be shown for multiple combinations (>8) and supports the concept that multi-specific DARPin molecules are powerful drug-candidates allowing tumor-restricted immune cell activation.

Citation Format: Ulrike Fiedler, Christian Reichen, Joanna Taylor, Patricia Schildknecht, Sophie Barsin, Clara Metz, Anja Schlegel, Simon Fontaine, Denis Villemagne, Julia Ahlskog, Yvonne Kaufmann, Alexander Link, Nicolo Rigamonti, Julia Hepp, Michael T. Stumpp. Tumor-restricted immune modulation by multispecific molecules from the DARPin toolbox [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 4552.

Comparison of an FAP-targeted, CD137 activating DARPin drug candidate with a non-targeted, CD137 activating antibody in a human PBMC transplanted HT-29 mouse tumor model

e14626

Background: Urelumab (BMS-663513) is a humanized monoclonal antibody binding to CD137 which, upon Fc-clustering, leads to activation of T-cells. Urelumab is currently in Phase 2 clinical development and has been reported to cause significant hepatotoxicities (around 15% Grade ≥2 ALT and AST elevation) when given as infusion every 3 weeks at doses ≥0.3 mg/kg. Currently ongoing clinical trials report decreased systemic toxicity but limited efficacy at lower doses of urelumab. We hypothesized that more effective triggering of CD137 without associated systemic toxicity may be achieved by targeting a CD137 agonistic engager without Fc to fibroblast activation protein (FAP) which is abundantly expressed in the stroma of many solid tumors. To achieve this, a targeted molecule belonging to the DARPin family of binding proteins was composed of one FAP- and two CD137-binding domains in a “beads on a string” format and tested in a mouse model with human PBMCs. Methods: Human PBMCs were used to reconstitute the immune system in NOG mice implanted subcutaneously with HT-29 human colon cancer cells. Mice were monitored for survival, body weight, and tumor size during the treatment phase of two weeks. Results: None of the mice in the control group died and no significant body weight loss was observed. Six of ten (60%) mice in the CD137 antibody group showed strong signs of graft vs. host disease and either died or reached the termination criterion of ≥20% body weight loss and were sacrificed. One of 30 (3%) mice died in the DARPin drug candidate groups but none of the animals showed body weight loss of ≥20% (p < 0.001, Log-rank test). Tumor growth inhibition was comparable for all treatment groups (around 20-30% at Day 18, p < 0.05 vs. control, Mann Whitney Test). Conclusions: This study confirms the hypothesis that systemic toxicities caused by the urelumab mode of action can be circumvented by FAP-targeting of a CD137 agonistic DARPin drug candidate while achieving comparable tumor growth inhibition. Consequently, higher clinical doses of tumor stroma-targeted agonistic DARPin drug candidates might be possible, and may result in stronger tumor growth inhibition.

Use of accelerometry to investigate physical activity in dogs receiving chemotherapy

OBJECTIVES

To perform a preliminary study to assess whether single-agent palliative or adjuvant chemotherapy has an impact on objectively measured physical activity in dogs.

METHODS

Fifteen dogs with neoplasia (treatment group) wore ActiGraph™ accelerometers for 5-day periods before, during and after receiving single-agent adjuvant or palliative chemotherapy. Mean 5-day total physical activity and time spent in three different intensities of activity (sedentary, light-moderate and vigorous) before, during and after receiving chemotherapy were compared to a group of 15 healthy dogs (control group). Results were also compared within the treatment group across time.

RESULTS

Prior to chemotherapy, treated dogs tended to be less active than control dogs. Treatment group dogs were slightly more active at restaging than they were prior to treatment but had similar activity levels to control dogs. Marked effects of chemotherapy on physical activity were not detected. Physical activity was slightly lower in treated dogs during chemotherapy when compared to control dogs but there was a slight increase in physical activity of treated dogs during chemotherapy when compared with pretreatment recordings. There was little change in the mean 5-day total physical activity between treated dogs during chemotherapy and at restaging but a mild decrease in time spent sedentary and increase in time spent in light-moderate activity at this comparison of time points.

CLINICAL SIGNIFICANCE

Single-agent adjuvant or palliative chemotherapy had minimal impact on physical activity levels in dogs with neoplasia.

[The impact of mellitus diabetes on the lower urinary tract: A review of Neuro-urology Committee of the French Association of Urology]

OBJECTIVES

Specify urinary functional impairment associated with diabetic pathology. Propose guidance for screening, monitoring of clinical signs of lower urinary tract (LUTS) and describe the specifics of the urological treatment of patients.

METHODS

A review of literature using PubMed library was performed using the following keywords alone or in combination: "diabetes mellitus", "diabetic cystopathy", "overactive bladder", "bladder dysfunction", "urodynamics", "nocturia".

RESULTS

LUTS are more common in the diabetic population with an estimated prevalence between 37 and 70 %, and are probably underevaluated in routine practice. They are heterogeneous and are frequently associated with other diabetic complications. Both storage and voiding symptoms can coexist. Despite a major evaluation in the literature, no recommendation supervises the assessment and management of LUTS in this specific population. An annual screening including medical history, bladder and kidney ultrasound and post-void residual measurement is required in the follow-up of diabetic patients. Specific urologial referral and urodynamic investigations will be performed according to the findings of first-line investigations. The type of bladder dysfunction, the risk of urinary tract infections and dysautonomia should be considered in the specific urological management of these patients.

CONCLUSION

Diabetes mellitus significantly impacts on the lower urinary tract function. A screening of LUTS is required as well as other complications of diabetes. The management of LUTS must take into consideration the specific risks of the diabetic patient regarding the loss of bladder contractility, the possibility of dysautonomia and infectious complications.

The PIP training programme: building of ACP experts capacities in crop protection and food safety to support local companies to comply with EU regulations on pesticides residues

Regulatory requirements, and in particular phytosanitary quality standards change rapidly. As ACP producers/exporters race to become more competitive, to keep their market share and to satisfay their customers' commercial demands (e.g. EUREP-GAP certification), the need for competent staff who are aware of the company's quality objectives and trained to follow instructions is crucial. Mastering sanitary quality is only possible if matched with a programme to build the skills of companies' human resources. The Pesticide Initiative Programme (PIP), mindful of the importance of making operators autonomous and of training them to monitor EU food safety regulations and technology on their own, has successfully developed a training programme while building a quality network of local/ACP service providers. By building the capacities of ACP experts and then securing their services as trainers, PIP also guarantees companies' access to expertise and the sustainability of their efforts to comply with new EU regulations. The training strategy developed by PIP rests on two pilars: instructor training and collective training. Instructor training consists in reinforcing the technical knowledge of local experts (agronomists, hygienists, etc.) by providing them with active teaching methods. Once the ACP experts have gained enough technical knowledge of the key areas of crop protection--mainly pesticides management--and food safety, and have demonstrated their capacity to train the technical staff of local companies, the PIP has carried out a collective training programme in 2004, 2005 and 2006. To date, more than 130 consultants covering about 15 ACP countries have received instructor training, and more than 700 people have participated in collective and in-company training sessions.

Prenatal diagnosis and characterization of an analphoid marker chromosome 16

We report on a fetus with intrauterine growth retardation and multiple malformations diagnosed on ultrasound at 32 weeks. Examination of amniotic fluid cells in culture showed a 47,XY, i(16)(q10), +mar karyotype. Chromosome analysis of both parents was normal. Using spectral karyotyping, we identified the marker chromosome as a mitotically stable acentric marker chromosome derived from chromosome 16. Further studies using subtelomeric fluorescent probes confirmed the presence of an isochromosome for the long arm of chromosome 16 and showed that the acentric marker chromosome derived from the short arm of chromosome 16 leading to a trisomy for the long arm of chromosome 16. After genetic counseling, the parents decided to terminate the pregnancy. Fetal autopsy showed a male fetus with ambiguous external genitalia, cardiac malformation, megacystis and limbs anomalies as observed in other cases of trisomy for the long arm of chromosome 16. In addition, fetal brain examination showed vermian and olfactory bulb hypoplasia.

An unusual form of Riedel's thyroiditis: a case report and review of the literature

We report the case of a 36-year old woman with a history of long-term fever associated with a biologic inflammatory syndrome that was not corrected by several courses of corticosteroid treatment. The only remarkable result during previous investigations was the presence of a positive Epstein-Barr virus (EBV) serology. Clinical examination revealed an heterogenous thyroid with a nodule on the right lobe. Serum thyrotropin (TSH) concentration was normal. The levels of antiperoxidase antibodies and thyrocalcitonin were normal. Ultrasound examination of the neck showed a 3-cm hypoechogenous nodule in the right lobe of the thyroid. A total thyroidectomy was performed. Histopathologic findings led to the diagnosis of Riedel's thyroiditis. We observed a dramatic improvement after surgery with absence of fever and normalization of inflammatory parameters. The role of EBV infection in the process of this unusual form of Riedel's thyroiditis is discussed.

Assessment of suspected dementia

At the Second Canadian Consensus Conference on Dementia (CCCD) (February, 1998), a group of neurologists, geriatricians, and psychiatrists met to consider guidelines for evaluation of dementia in Canada. This review paper formed a background paper for their discussion of dementia diagnosis. These experts from across the country concluded that diagnosis of suspected dementia cases continued to rest on skilled clinical assessment. Mental status exam, preferably in some quantifiable form, has become an essential part of the assessment. Selected laboratory tests are advisable in all cases (CBC, TSH, electrolytes, calcium, and glucose), but the CCCD continued to advise that CT scanning was mandatory only in selected cases where clinical findings pointed to another possibility besides Alzheimer's disease. The growing list of other diagnostic measures with potential usefulness in diagnosis of Alzheimer's disease or dementia in general was reviewed, but the evidence was judged as insufficient to support routine use of these tests by physicians. As new treatments for Alzheimer's disease become available, neurologists face new diagnostic challenges--differentiating Mild Cognitive Impairment, Frontotemporal dementias and Mixed dementias, and Lewy Body Dementia. Guidelines to aid in differential diagnosis are presented.

History of Joubert syndrome and a 30-year follow-up of the original proband

The 1960s were a period of great flowering in the recognition of neurologic disorders in children. The so-called ataxic cerebral palsies were an especially fertile field waiting for clarification. Congenital ataxia coupled with hyperpnea-apnea, abnormal eye movements, and retardation was identified as an autosomal-recessive syndrome eponimically associated with the senior author, Marie Joubert. The disorder, though rare, is increasingly recognized and a lay society dedicated to family support and research has been formed. In preparation for a recent symposium the original proband was re-examined 30 years later and the manifestations in adults clarified. Severe dysarthria was the most striking feature in this man, the hyperpnea-apnea had diminished, and the abnormal eye movements were less striking. Ataxia was still present but not severe. Poor judgment and borderline intelligence rounded out the clinical picture. Modern imaging has clarified, in part, the anatomic basis of this syndrome.

Diagnosis of subtle focal dysplastic lesions: curvilinear reformatting from three-dimensional magnetic resonance imaging

Focal cortical dysplasia is a frequent cause of medically intractable partial epilepsy. These lesions are being increasingly identified by high quality images provided by magnetic resonance imaging (MRI), resulting in improved seizure control of surgically treated patients. Small dysplastic lesions are often missed by conventional MRI methods. The identification of subtle structural abnormalities by rectilinear slices is often limited by the complex convolutional pattern of the brain. We developed a method of curvilinear reformatting of three-dimensional MRI data that improves the anatomical display of the gyral structure of the hemispheric convexities. It also reduces the asymmetric sampling of gray-white matter that may lead to false-positive results. We present 5 patients in whom conventional two-dimensional and three-dimensional MRI with multiplanar reformatting was initially considered normal. Subsequent studies using curvilinear reformatting identified lesions in all. Four patients underwent surgery with histological diagnosis of focal cortical dysplasia. Three patients are seizure-free and 1 had significant improvement in seizure control. These results indicate that an increase in the detection of subtle focal dysplastic lesions may be accomplished when one improves the anatomical display of the brain gyral structure by performing curvilinear reformatting.

[Impact of demographic changes on drug utilization related to diabetes in Aquitaine]

Diabetes is a chronic disease highly correlated to age. In 1998, the Sickness Find of the Aquitaine region has reimbursed 273 million French Francs for expenditures related to diabetes pharmaceuticals. The amount would increase to 300 million French Francs in 2005, a growth of nearly 10%, whereas the Aquitaine population would increase only 4%, from 2,909,000 in 1998 to 3,024,000 seven years later. The difference comes from population aging, as the calculations are undertaken "other things being equal": the insurance coverage rate, the disease prevalence rate, the consumption of pharmaceuticals per patient are supposed unchanged during the period.

Differentiating lumbar disc protrusions, disc bulges, and discs with normal contour but abnormal signal intensity. Magnetic resonance imaging with discographic correlations

STUDY DESIGN

Independent evaluation by two observers of 132 lumbar discs in 45 patients with chronic low back pain investigated by both magnetic resonance imaging and discography.

OBJECTIVES

To assess some of the fundamental differences between lumbar disc protrusions, disc bulges, and discs with normal contour but abnormal signal intensity on T2-weighted magnetic resonance images.

SUMMARY OF BACKGROUND DATA

Moderate interobserver agreement has been reported when the morphologic terms normal, bulge, protrusion, and extrusion are used. The validity of this nomenclature remains unknown.

METHODS

Discs were evaluated on magnetic resonance images for central and peripheral signal characteristics, height, contour, and nerve root compression. Discograms were classified according to degrees of disc degeneration, disruption, and pain reproduction.

RESULTS

Loss of intervertebral height or abnormal signal intensity on magnetic resonance imagery was significantly associated with disc disruptions extending into or beyond the outer anulus on discograms. All 23 protrusions (100%) and 12 of 15 disc bulges (80%) were associated with Stage 2 or 3 anular disruptions and, in most instances, similar or exact reproduction of pain during disc injection. There was no significant difference between disc protrusions, disc bulges, and discs with normal contour but abnormal signal, with respect to degree of disc degeneration, extent of disruptions, or presence of discogenic pain.

CONCLUSIONS

In patients with chronic low back pain, loss of disc height or abnormal signal intensity is highly predictive of symptomatic tears extending into or beyond the outer anulus. Disc bulges and disc protrusions do not represent discs with significantly different internal architecture, based on the findings of discography, and are no more suggestive of symptomatic tears than discs showing normal contour but decreased height or abnormal signal intensity.

[Role of transcranial ultrasonography in neuroradiological diagnosis]

Blood flow within the major arteries supplying the brain can be studied with transcranial Doppler sonography, a noninvasive, portable procedure. We describe the technique of examination, as well as indications in children and adults such as the investigation of intracranial stenosis, collateral pathways, vasospasm, cerebral emboli and arteriovenous malformations.

[Dissociations between music and language functions after cerebral resection: A new case of amusia without aphasia]

We present the neuropsychological study of a patient, I.R., who sustained bilateral damage to the temporal lobes and to the right frontal lobe as a result of successive brain surgeries that occurred ten years earlier. The patient is 40 years old and right-handed; she had no special training in music or in language, representing, therefore, the large majority of listeners. Her performance is compared to that of four neurologically intact subjects who are closely matched in terms of education, sex and age. In the present study, we report I.R.'s performance on various tests aiming at assessing her general cognitive functioning with a particular focus on auditory aspects. The results show that, despite extensive damage to her auditory cortex, I.R.'s speech abilities are essentially intact (see Tables 1 and 2). The only impairments that are detected in the language domain are related to a short-term memory deficit, to some abnormal sensitivity to retroactive interference in long-term memory (see Table 3) and to articulation. These difficulties do not, however, affect linguistic communication, which is obviously undisturbed I.R. is not aphasic). Similarly, I.R. does not experience any difficulty in the recognition and memorization of familiar sounds such as animal cries, traffic noises and the like (see Tables 5 and 7). In contrast, I.R. is severely impaired in most musical abilities: She can no longer discriminate nor identify melodies that were once highly familiar to her; she can no longer discriminate nor memorize novel melodies (see Table 4). Her pattern of musical losses is compatible with a basic and severe perceptual deficit that compromises access to and registration in memory systems. The observation that the auditory impairment affects music and spares language and environmental sounds refers to a neuropsychological condition that is known as music agnosia. I.R. represents, to our knowledge, the fourth case of music agnosia available in the literature (Peretz et al., 1994; Griffiths et al., 1997). The existence of such cases suggests that music processing is not mediated by a general-purpose auditory architecture but by specialized cortical subsystems. Not only does I.R. suffer from music agnosia, but she is also impaired in the discrimination and recognition of musical instruments and of human voices (see Table 5). These latter two deficits probably do not result from the music agnosic condition. Rather, they seem to reflect damage to adjacent brain areas that are specialized in timbre processing (see Peretz. et al., 1994, for the relevant discussion). It is also worth mentioning that I.R. appears to be impaired in musical expressive abilities as well: I.R. can no longer sing a single note. Thus, her losses are rather general in the musical domain, hence justifying the classification of her case as amusia. Cases of amusia without aphasia are relatively frequent in the neuropsychological literature. However, all of these reported cases are anecdotal. Thus, in the present study, special focus is given to the measurement and direct comparison of performance in the language and music domain; in both domains, task characteristics and materials were as similar as possible. To this aim, the lyrics and the tune of the same popular song excerpts were used. The musical and the spoken parts were presented separately in a primed familiarity decision task and in a memory recognition task. In both situations, I.R. performs at or close to chance when she has to deal with music, whereas she recognizes easily and performs normally on the spoken material (see Tables 6 and 7). These results clearly argue for the autonomy of music and language in the processing of auditory information.

Increased blood manganese in cirrhotic patients: relationship to pallidal magnetic resonance signal hyperintensity and neurological symptoms

Increasing evidence suggests that manganese deposition is responsible for the T1-weighted magnetic resonance imaging (MRI) signal hyperintensity consistently observed in pallidum of cirrhotic patients. However, the relationship between blood manganese and the etiology or severity of liver disease, as well as the neurological symptomatology in these patients, has not been well established. In the present study, blood manganese concentrations were measured by atomic absorption spectrometry together with MRI and neurological evaluation in 57 cirrhotic patients with various etiologies and severity of liver disease. Blood manganese concentrations were elevated in 67% of cirrhotic patients and were significantly higher in patients with previous portacaval anastomoses or transjugular intrahepatic portosystemic shunt (TIPS). Pallidal signal hyperintensity was observed in 88% of patients, and significant correlations were demonstrated between blood manganese and pallidal index (PI) (a measure of pallidal signal hyperintensity), as well as Child-Pugh score. Assessment of extrapyramidal symptoms using the Columbia rating scale revealed a significant incidence of tremor, rigidity, or akinesia in up to 89% of cirrhotic patients. However, there was no significant correlation between blood manganese and extrapyramidal symptoms, although severity of akinesia was significantly greater in Child-Pugh C patients. Extrapyramidal symptoms could result from a toxic effect of manganese on basal ganglia dopaminergic function. These findings further support a role for manganese in the etiology of pallidal MRI signal hyperintensity in patients with chronic liver disease.

Clinical impact of contrast-enhanced MR imaging reports in patients with previous lumbar disk surgery

OBJECTIVE

We wanted to assess the clinical impact of the reports of contrast-enhanced MR imaging on the decision to repeat surgery and on the results of repeat surgery in patients with previous lumbar disk surgery.

SUBJECTS AND METHODS

We interviewed 257 patients who had undergone lumbar disk surgery and who showed symptoms suggesting persistent or new disk herniation. We conducted our interviews 6-18 months after patients had undergone contrast-enhanced MR imaging. We then correlated patient outcome with original MR findings.

RESULTS

Fifty-two patients underwent new surgical procedures after their MR examination. Findings of disk herniation on MR images were associated with a significantly greater frequency of repeat surgery. The size of main herniation seen on MR images was also a significant variable. Patients with Worker's Compensation Insurance files had significantly worse prognoses: Only two (8%) of 26 of these patients reported 50% improvement 1 year after repeat surgery. However, only 6 (23%) of 26 non-Worker's Compensation patients reported 50% improvement 1 year after surgery.

CONCLUSION

Despite its documented high anatomic accuracy, the clinical usefulness of enhanced MR imaging for patients with previous lumbar disk surgery needs further evaluation. In our series, findings of disk herniations on enhanced MR examinations were associated with a greater frequency of repeat surgery, but such surgery relieved symptoms in few patients. The influence of enhanced MR imaging on the decision for repeat surgery and on the type of surgery may be misleading. Selection criteria for repeat surgery need to be reassessed using rigorous outcome research protocols.

Manganese toxicity, dopaminergic dysfunction and hepatic encephalopathy

Patients with chronic liver disease manifest a high incidence (> 75%) of pallidal signal hyperintensity on T1-weighted Magnetic Resonance Imaging (MRI), the intensity of which correlates with blood manganese levels and the presence of extrapyramidal symptoms. A major cause of pallidal hyperintensity on T1-weighted MRI is manganese deposition; chronic manganese intoxication in the absence of liver disease results in pallidal MR signal hyperintensity, in extrapyramidal symptoms and in selective effects on the dopaminergic neurotransmitter system in basal ganglia. Direct measurements in globus pallidus obtained at autopsy from patients with chronic liver disease who died in hepatic coma reveal 2 to 7-fold increases of pallidal manganese and a concomitant loss of dopamine D2 binding sites. Liver transplantation results in normalization of pallidal MR signals and of blood manganese levels. These findings suggest that (1) pallidal MR signal hyperintensity in patients with chronic liver disease is the result of manganese deposition and (2) alterations of dopaminergic function due to the toxic effects of manganese may contribute to the extrapyramidal symptoms in these patients.

Radiating pain to the lower extremities caused by lumbar disk rupture without spinal nerve root involvement

PURPOSE

To locate the origin of the pain during lumbar diskography by means of a limited intradiskal injection of a local anesthetic.

METHODS

Lumbar diskography by the direct central posterior approach was performed in 235 consecutive patients. In 17 patients, severe and persistent low back pain, with unilateral or bilateral radiation to the lower extremities, was provoked by contrast injection into only one disk. One milliliter of 1% lidocaine was then slowly injected in the center of these disks.

RESULTS

A 75% to 100% reduction of the low back pain was experienced by 13 patients, and a 75% to 100% reduction of the radiating pain was experienced by 16 patients within 60 seconds after the intradiskal injection of lidocaine. Radiographs demonstrated radial tears through the entire annulus thickness in 16 of 17 disks.

CONCLUSION

Our results suggest that, in some patients with low back pain and unilateral or bilateral radiation to the lower extremities, the pain arises from within the disk. In these cases, pain radiating to the lower limb seems to be a referred type and seems unrelated to direct nerve root compression or irritation by a disk fragment in the epidural space.

ras may mediate mammary cancer promotion by high fat

High fat consumption has been implicated as a risk factor for breast cancer. Experimental mammary carcinogenesis studies have demonstrated that the effect of high fat consumption is mainly exerted on the postinitiation stage of the disease process. We report data that have recalled in the formulation of a new hypothesis about the effect of dietary fat on mammary carcinogenesis, namely, that it promotes the development of a subpopulation of cells lacking a specific pathogenetic characteristic. In comparison with animals fed a low-fat diet, female Sprague-Dawley rats fed high-fat diets during the promotional stage developed significantly more (number and proportion) 1-methyl-1-nitrosourea-induced mammary adenocarcinomas that did not contain a codon 12 GGA-->GAA mutation in the c-Ha-ras protooncogene. The effect was independent of the types of fat fed, i.e., corn oil vs. fish oil. A model is presented to account for the preferential promotional effect of high fat consumption on 1-methyl-1-nitrosourea-initiated mammary epithelial cells. The hypothesis that the level of dietary fat consumed affects the proportion of mammary carcinomas that occur with a particular pathogenetic characteristic, in this case, the presence or absence of a Ha-ras point mutation, has important implications on the direction of future investigations concerning fat and cancer risk.

Correlations between magnetic resonance imaging-based hippocampal sclerosis and depth electrode investigation in epilepsy of the mesiotemporal lobe

Quantitative analysis of hippocampal formations (HF) by magnetic resonance imaging (MRI) was correlated with depth electrode recordings in 18 patients with partial epilepsy. All had seizures of mesiotemporal origin. Electrodes explored three HF segments: amygdala and HF head and anterior and posterior HF body. Corresponding HF measurements were made on coronal MRI sequences, and atrophy was quantified by one global and three segmental indexes of asymmetry per patient. HF from which seizure originated showed global atrophy in 15 patients. Segmental analysis demonstrated discrete tissue damage in 1 patient; thus, 16 patients (88%) had significant hippocampal atrophy ipsilateral to the mesial focus. The existence of more pronounced atrophy in segments giving rise to ictal onset than in segments without ictal onset was not statistically significant. Nevertheless, in posterior HF, all segments (four) with seizure onset were atrophied and none of the nonatrophied posterior segments (four) were at seizure origin. These findings confirm that MRI-detected hippocampal atrophy is a powerful indicator of a mesiotemporal focus and strongly contributes to consideration of resective surgery without intracerebral EEG monitoring. Study of the distribution of maximal tissue damage may add some information, and help surgeons decide on the posterior extent of hippocampus removal. As illustrated by 3 patients who had multiple sites of seizure onset, however, the presence of this marker should not be interpreted systematically as evidence of pure mesiotemporal epilepsy.

Case report: primary mesenchymal chondrosarcoma of the brain

We report an 11-year-old girl with a very rare tumour, mesenchymal chondrosarcoma of the brain, presenting as a haemorrhagic stroke, in whom angiography originally showed a distal arterial aneurysm. One month later MRI showed a solid tumour in addition to evidence of haemorrhage, and angiography then demonstrated pathological vascularity. The diagnosis was made following craniotomy.

Development of the fetal brain in the second trimester: an anatomic and ultrasonographic demonstration

The authors provide an anatomic and ultrasonographic description of the fetal brain from the 16th to the 27th week of development. During the second trimester the primitive brain is smooth and homogeneous and has few sulci and relatively large lateral ventricles. The cerebral hemispheres consist largely of cells migrating from the periventricular germinal matrix to the primitive cortex. The "featureless" hemispheres yield homogeneous ultrasonographic images very different from the more complex and familiar cerebral anatomy of fetuses and premature babies in the third trimester.

[Transcranial Doppler ultrasound]

Over the last decade, transcranial Doppler examination of the cerebral vessels has been made possible by the development of a high-intensity, low-frequency (2 MHz) pulse probe. The middle, the anterior and the posterior cerebral arteries, the cavernous portion of the carotid artery and the basilar artery can thus be easily studied transtemporally or transorbitally or from below the foramen magnum. The transcranial Doppler examination is already used clinically to study arteriosclerosis and in the diagnosis and follow-up of vasospasm and arteriovenous malformations. This review describes the examination procedure and summarizes and illustrates its major indications.

Panic disorder: vascular evaluation with transcranial Doppler ultrasonography

Several recent studies have shown neurophysiologic and neuroanatomic abnormalities in panic disorder. This study aimed to assess by transcranial Doppler (TCD) ultrasonography the magnitude of the changes in blood flow during panic attacks induced by intravenous sodium lactate infusion. The subjects consisted of 30 patients with panic disorder (DSM-III-R) and 25 controls; all were between the ages of 18 and 40 years and were right-handed. The flow in the middle cerebral artery was recorded bilaterally before the infusion began (to provide baseline readings) and at 3-minute intervals during the infusion. The patients showed a more rapid acceleration of flow (p less than 0.05) than the controls. Higher maximal velocity and higher variations in velocity (p less than 0.05) were observed in the patients sensitive to lactate but only in the right middle cerebral artery. These results suggest that abnormalities of local cerebrovascular autoregulation occurred in the patients with panic disorder during attacks induced by sodium lactate.

Comparison of high-resolution computed tomography with discography in the evaluation of lumbar disc herniations

After failure of conservative treatment, 100 patients with symptoms suggestive of lumbar herniated nucleus pulposus (HNP) but without objective deficits were investigated both by high-resolution CT (without intravenous or intrathecal contrast) and by discography. The L4-L5 and L5-S1 discs were investigated by both techniques in all patients. In addition, the L3-L4 disc was investigated in 20 patients. The 220 investigated discs were sorted out into 6 CT categories according to morphologic and technical criteria. They were also classified into 3 discographic groups according to morphologic and clinical criteria. Based on morphologic considerations alone, the false-negative CT rates varied from 0 to 64% and the false-positive rates varied from 0 to 19%, depending on the category under consideration. Based on both morphologic and clinical consideration, the false-negative CT rates varied from 34 to 57% and the false-positive CT rates varied from 23 to 50%. Thus, high-resolution CT does not constitute an adequate means of investigation for this category of patients and discography appears justified before considering any form of radical therapy.

Temporal lobe abnormalities in panic disorder: an MRI study

Brain mapping studies have shown abnormal changes in cerebral blood volume and oxygen consumption, or other neurophysiological abnormalities, in panic disorder (PD) patients. Because of these intriguing reports, we decided to assess the neuroanatomical aspects of patients with PD using magnetic resonance imaging (MRI). We included 31 consecutive cases with a diagnosis of PD according to the DSM-III criteria, and 20 controls. All subjects had to be right-handed and between 20 and 40 years of age. The usual exclusion criteria were applied. We carried out the MRI tests with a General Electric Signa Machine operating at 1.5 Tesla. Over 100 images were obtained per patient with an emphasis on assessing temporal lobe. There were no significant differences in age, gender, or weight between the patients and controls. We found a statistically significant higher number of abnormalities in PD patients (40%), as compared with the controls (10%). The most striking findings were focal abnormalities in the temporal lobes: areas of abnormal signal activity, and asymmetric atrophy of the temporal lobe occurred mostly on the right side. These results implicated the limbic system and may prove to be of particular relevance in panic and phobic disorders. However, the significance of our findings remains unknown and challenging. Further MRI studies in PD will be required for a better understanding of the illness.

Outpatient myelography with fine-needle technique: an appraisal

Postmyelography headaches are produced mostly by CSF leakage at the dural puncture site and are therefore largely dependent on the size of the needle used. Our study of 300 consecutive outpatients who had lumbar myelograms performed with 25- and 26-gauge spinal needles shows that the procedure has become virtually innocuous. We recommend that 26-gauge spinal needles be widely adopted as the standard for fluoroscopically controlled intrathecal injections of contrast material.

Correlation of severity of panic disorder and neuroanatomical changes on magnetic resonance imaging

Thirty consecutive lactate-sensitive panic disorder patients were studied with magnetic resonance imaging (MRI) to investigate the relationship between temporal lobe abnormalities and panic disorder. Neuroanatomical abnormalities, most involving the right temporal lobe, were found in 43% of patients, compared with 10% of the control subjects. Patients with temporal lobe abnormalities were significantly younger at the onset of panic disorder and had more panic attacks compared with patients with normal MRI scans (p less than .05). These results suggest that panic disorder could be secondary to temporal lobe dysfunctions and that panic disorder patients with abnormal MRIs could have a worse prognosis than those with normal MRIs and would require long-term pharmacological treatment.

Outpatient myelography with fine-needle technique: an appraisal

Postmyelography headaches are produced mostly by CSF leakage at the dural puncture site and are therefore largely dependent on the size of the needle used. Our study of 300 consecutive outpatients who had lumbar myelograms performed with 25- and 26-gauge spinal needles shows that the procedure has become virtually innocuous. We recommend that 26-gauge spinal needles be widely adopted as the standard for fluoroscopically controlled intrathecal injections of contrast material.

Cavernous hemangiomas of the spinal cord: MR imaging

In three patients with histologically proved cavernous hemangiomas of the spinal cord, magnetic resonance (MR) imaging was superior to myelography, delayed computed tomography (CT) myelography, and contrast-enhanced CT in depicting the lesion. The presence of mixed subacute and chronic hemorrhage, suggested by mixed high- and low-signal-intensity components of these lesions on MR images, may be characteristic of this rare, intramedullary vascular malformation.

Cavernous angiomas of the spinal cord

Five cases of histologically verified cavernous angiomas of the spinal cord are reported. Acute lower-extremity sensory disturbance was the initial symptom in four patients, and one presented with weakness of the hand. Progressive neurological deficit occurred in all patients, but the clinical course and outcome were extremely variable. Myelography revealed an intramedullary lesion in two cases but was completely normal in three; magnetic resonance imaging was diagnostic in these patients. Subtotal removal was accomplished in two cases, and myelotomy and biopsy were carried out in three. Four of the cavernous angiomas were located in the cervicothoracic region, whereas one was found in the thoracolumbar cord. All of the patients exhibited characteristic gross and microscopic features as well as hemosiderin-laden macrophages indicating remote hemorrhage. The diagnostic, therapeutic, and prognostic implications of this rare condition are discussed.