Interdependence of placenta and fetal cardiac development

The placenta and fetal heart undergo development concurrently during early pregnancy, and, while human studies have reported associations between placental abnormalities and congenital heart disease (CHD), the nature of this relationship remains incompletely understood. Evidence from animal studies suggests a plausible cause and effect connection between placental abnormalities and fetal CHD. Biomechanical models demonstrate the influence of mechanical forces on cardiac development, whereas genetic models highlight the role of confined placental mutations that can cause some forms of CHD. Similar definitive studies in humans are lacking; however, placental pathologies such as maternal and fetal vascular malperfusion and chronic deciduitis are frequently observed in pregnancies complicated by CHD. Moreover, maternal conditions such as diabetes and pre-eclampsia, which affect placental function, are associated with increased risk of CHD in offspring. Bridging the gap between animal models and human studies is crucial to understanding how placental abnormalities may contribute to human fetal CHD. The next steps will require new methodologies and multidisciplinary approaches combining innovative imaging modalities, comprehensive genomic testing, and histopathology. These studies may eventually lead to preventative strategies for some forms of CHD by targeting placental influences on fetal heart development.

White matter microstructure organization across the transition to fatherhood

The transition to parenthood remains an understudied window of potential neuroplasticity in the adult brain. White matter microstructural (WMM) organization, which reflects structural connectivity in the brain, has shown plasticity across the lifespan. No studies have examined how WMM organization changes from the prenatal to postpartum period in men becoming fathers. This study investigates WMM organization in men transitioning to first-time fatherhood. We performed diffusion-weighted imaging to identify differences in WMM organization, as indexed by fractional anisotropy (FA). We also investigated whether FA changes were associated with fathers' postpartum mental health. Associations between mental health and WMM organization have not been rarely examined in parents, who may be vulnerable to mental health problems. Fathers exhibited reduced FA at the whole-brain level, especially in the cingulum, a tract associated with emotional regulation. Fathers also displayed reduced FA in the corpus callosum, especially in the forceps minor, which is implicated in cognitive functioning. Postpartum depressive symptoms were linked with increases and decreases in FA, but FA was not correlated with perceived or parenting stress. Findings provide novel insight into fathers' WMM organization during the transition to parenthood and suggest postpartum depression may be linked with fathers' neuroplasticity during the transition to parenthood.

Non-invasive in-utero quantification of vascular reactivity in human placenta

OBJECTIVE

Placental vascular reactivity (PlVR) indicates the ability of the placental vasculature to match blood supply to fetal demand. Many pregnancy disorders alter the characteristics of PlVR, resulting in suboptimal oxygen delivery, although current understanding is limited by the lack of non-invasive, repeatable methods to measure PlVR in utero. Our objective was to quantify PlVR by measuring the placental response to transient changes in maternal carbon dioxide (CO2) using blood-oxygen-level-dependent (BOLD) magnetic resonance imaging (MRI). We hypothesized that PlVR will increase with gestational age to meet the changing demands of a growing fetus, and that PlVR will be driven by a maternal response to changes in CO2 concentration.

METHODS

This was a cross-sectional study of 35 women with a healthy singleton pregnancy, of whom 31 were included in the analysis. The median gestational age was 32.6 (range, 22.6-38.4) weeks. Pregnant women were instructed to follow audiovisual breathing cues during a MRI scan. Maternal end-tidal CO2 (EtCO2) was measured concurrently with resting placental BOLD MRI for a total of 7-8 min. Preprocessing of magnetic resonance images consisted of manual delineation of placental anatomy and motion correction. In each placental voxel, vascular reactivity was computed using a coherence-weighted general linear model between MRI signal and EtCO2 stimulus. Global PlVR was computed as the mean of voxel-wise PlVR values across the placenta.

RESULTS

PlVR, quantified by the placental response to induced, transient changes in maternal CO2, was consistently measured in utero using BOLD MRI. PlVR increased non-linearly with advancing gestational age (P < 0.001) and was higher on the fetal side of the placenta. PlVR was associated positively with fetal brain volume after accounting for gestational age. PlVR did not show any significant associations with maternal characteristics.

CONCLUSIONS

We present, for the first time, a non-invasive paradigm to quantify PlVR in ongoing human pregnancies without the use of exogenous gases or contrast agents. Our findings suggest that PlVR is driven by a fetal response to changes in maternal CO2. Ease of translation to the clinical setting makes PlVR a promising biomarker for the identification and management of high-risk pregnancies. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Experiences of Irritable Bowel Syndrome Patients in a Virtual Yoga Program: Qualitative Findings from a Clinical Trial

BACKGROUND AND AIMS

In-person yoga interventions have shown feasibility and effectiveness in improving the outcomes of patients with irritable bowel syndrome (IBS), but experiences in virtual yoga interventions have not been examined. This study aimed to explore patients' experiences of a virtually delivered yoga intervention for IBS.

METHODS

An embedded qualitative substudy was included in a randomized controlled trial examining the feasibility and effectiveness of a virtual yoga program among adult patients with IBS. Semi-structured interviews captured participants' past and current experiences, program satisfaction, perceived impact on IBS symptoms and overall physical and mental health, facilitators and barriers to participation, perceptions of social support and supervised learning, and input on improving future programming. Data were coded and analyzed in duplicate using NVivo 12. An analytic template based on the interview guide was developed and thematic analysis identified themes, as well as the relationship between themes and subthemes.

RESULTS

Among the 14 participants (all female, mean age 47.7 years), three major themes were identified: (1) positive experience in the yoga program, (2) incorporating yoga into IBS management post-study, and (3) recommendations for program improvement.

CONCLUSION

Patients with IBS experience in a virtual yoga program was positive with improvements in physical and mental health outcomes. Considering the barriers and facilitators to participating in an online yoga program along with participant recommendations may improve future intervention design and delivery to increase self-efficacy and confidence among patients with IBS.

Neuroimaging and Neurodevelopmental Outcomes Among Individuals With Complex Congenital Heart Disease: JACC State-of-the-Art Review

Although neuroimaging advances have deepened our understanding of brain health in individuals with congenital heart disease (CHD), it is less clear how neuroimaging findings relate to neurodevelopmental and mental health outcomes across the lifespan. We systematically synthesized and critically evaluated evidence on associations between neuroimaging and neurodevelopmental, neurocognitive, psychiatric, or behavioral outcomes among individuals with transposition of great arteries or single-ventricle CHD (Protocol CRD42021229617). Six databases were searched and 45 papers from 25 unique studies were identified. Structural brain injury was generally linked to poorer neurodevelopment in infancy. Brain volumes and microstructural and functional brain changes appear linked to neurocognitive outcomes, including deficits in attention, learning, memory, and executive function in children and adolescents. Fetal neuroimaging studies were limited. Four papers investigated psychiatric outcomes; none found associations with neuroimaging. Multicenter, longitudinal studies incorporating functional neuroimaging and mental health outcomes are much-needed to inform early neuroprotective and therapeutic strategies in CHD.

Identification and Evaluation of Mobile Applications for Self-Management of Diet and Lifestyle for Patients with Inflammatory Bowel Disease

Background

Mobile health applications (apps) providing diet and lifestyle self-management programs to patients with inflammatory bowel disease (IBD) are emerging. The objective of this study was to evaluate current apps available in the US and Canada based on app quality, perceived impact on diet and mental health and comprehensiveness to support self-management.

Methods

The Apple iOS and Google Play app stores were searched for terms related to IBD. Apps were included if they targeted diet and lifestyle behaviours for patients living with IBD and were available to the general public. Apps were excluded if they were not specific to IBD, not available in English, did not target diet or lifestyle therapy, were not available in the US and Canada, or did not offer stand-alone self-management programs. The Mobile App Rating Scale was used to assess mobile app quality.

Results

A total of 1,512 apps were identified through the app stores. Six apps met inclusion criteria. My IBD Care: Crohn's and Colitis received the highest quality rating and LyfeMD received the highest overall app rating. Only these two apps provided behaviour tracking over time, and three (50 percent) apps provided good-quality information.

Conclusions

While many IBD-related apps exist, few support self-management of diet and lifestyle behaviours. The My IBD Care and LyfeMD apps had the highest ratings and can be used to track lifestyle behaviours. The effectiveness of these apps to improve behaviours, and subsequently impact the disease course and quality of life, should be explored in future studies.

Infants with Congenital Adrenal Hyperplasia Exhibit Thalamic Discrepancies in Early Brain Structure

INTRODUCTION

Patients with classical congenital adrenal hyperplasia (CAH) have prenatal and postnatal hormonal imbalances. To characterize the ontogeny of reported brain and behavior changes in older children with CAH, we aimed to study the brain structure in infants with CAH compared to healthy controls.

METHODS

We performed neuroimaging in 16 infants with classical CAH due to 21-hydroxylase deficiency (8 males, gestational age 38.2 ± 1.7 weeks, post-conceptional age [PCA] 42.2 ± 3.0 weeks) and 14 control infants (9 males, gestational age 38.5 ± 1.8 weeks, PCA 42.5 ± 2.4 weeks) utilizing 3-Tesla magnetic resonance imaging. Regional brain volumes were adjusted for PCA and sex, along with an additional adjustment for total brain volume (TBV), for group comparisons by regression analyses (mean, 95% confidence interval [CI]). The degree to which each brain region was differentiated between CAH and control infants was examined by relaimpo analyses, adjusting for all other brain regions, PCA, and sex.

RESULTS

Infants with CAH had significantly smaller thalamic volumes (8,606 mm3, 95% CI [8,209, 9,002]) compared to age-matched control infants (9,215 mm3, 95% CI [8,783, 9,647]; β = -609; p = 0.02) which remained smaller after further adjustment for TBV. Upon further adjustment for TBV, the temporal lobe was larger in infants with CAH (66,817 mm3, CI [65,957, 67,677]) compared to controls (65,616 mm3, CI [64,680, 66,551]; β = 1,202, p = 0.03). The brain regions most differentiated between CAH versus controls were the thalamus (22%) and parietal lobe (10%).

CONCLUSIONS

Infants with CAH exhibit smaller thalamic regions from early life, suggesting a prenatal influence on brain development in CAH. Thalamic emergence at 8-14 weeks makes the region particularly vulnerable to changes in the intrauterine environment, with potential implications for later maturing brain regions. These changes may take time to manifest, meriting longitudinal study through adolescence in CAH.

Long-term benefits of breastfeeding on brain and body development among 9-10-year-olds: modulated by socioeconomic environment

Importance

It is yet unknown if breastfeeding (bf) benefits, to brain and body development of children, persist into peri-adolescence and vary by socioeconomic environments (SEEs).

Objective

We aim to investigate SEE-independent and SEE-modulated relationships between bf duration and child brain structure and adiposity markers during peri-adolescence.

Design setting and participants

This was a cross-sectional study of children aged 9-10 enrolled in the multi-center Adolescent Brain and Cognitive Development (ABCD) Study®.

Exposures

Bf duration was self-reported. Neighborhood-level SEE was assessed using area deprivation index (ADI).

Main Outcomes

T1-weighted magnetic resonance imaging was used to assess global brain measures: volumes of white, cortical, and subcortical gray matter (GM), cortical thickness, and surface area (SA). Adiposity markers included age- and sex-specific body mass index (BMI z- scores), waist circumference, and waist-to-height ratio (WHtR). Mixed effects models examined associations of bf duration with brain structure and adiposity markers controlling for sociodemographic, pre- and post-natal covariates. Stratified analysis was performed by tertiles of ADI.

Results

The sample consisted of 7,511 children (51.7% males; 18.8% no bf, 35.3% 1-6 months, 24.9% 7-12 months, 21.0% >12 months). Child's total SA (β (95% CI) = 0.053 (0.033, 0.074); FDR corrected P <0.001), cortical (β (95% CI) = 0.021 (0.010, 0.032); FDR corrected P <0.001) and subcortical GM volume (β (95% CI) = 0.016 (0.003, 0.030); FDR corrected P <0.001) increased monotonically with bf duration, after controlling for covariates. Child's BMI z -scores (β (95% CI) = -0.040 (-0.063, -0.016); FDR corrected P =0.001), waist circumference (β (95% CI) = -0.037 (-0.060, -0.014), FDR corrected P =0.002) and WHtR (β (95% CI) = -0.040 (-0.064, -0.018), FDR corrected P =0.001) decreased monotonically with increased bf duration, after controlling for covariates. Bf duration was inversely associated with adiposity in children from high- and medium-ADI neighborhoods. Bf duration was positively associated with SA across ADI tertiles.

Conclusions and Relevance

Our results imply that long-term benefits of bf on body and brain development in offspring increase as bf duration increases, particularly in children from low SEEs. Policies and social support aimed to incremental increases in bf duration among women from low SEEs would confer long-term benefits for offspring.

Key Points

Question: Do benefits of breastfeeding(bf), on children's brain and body development, persist long-term and are these benefits uniform across socioeconomic environments (SEEs)?Findings: Longer bf duration is associated with lower adiposity, greater cortical and subcortical gray matter volume, and cortical surface area in 9-10-year-old children. Children from lower SEEs showed stronger negative relationships between bf duration and adiposity. Children across all SEEs demonstrated positive relationships between bf duration and surface area.Meaning: Our results imply that long-term benefits to child brain and body development increase with bf duration; and children from lower SEEs benefited more from longer bf duration.

Clinical factors associated with microstructural connectome related brain dysmaturation in term neonates with congenital heart disease

Objective

Term congenital heart disease (CHD) neonates display abnormalities of brain structure and maturation, which are possibly related to underlying patient factors, abnormal physiology and perioperative insults. Our primary goal was to delineate associations between clinical factors and postnatal brain microstructure in term CHD neonates using diffusion tensor imaging (DTI) magnetic resonance (MR) acquisition combined with complementary data-driven connectome and seed-based tractography quantitative analyses. Our secondary goal was to delineate associations between mild dysplastic structural brain abnormalities and connectome and seed-base tractography quantitative analyses. These mild dysplastic structural abnormalities have been derived from prior human infant CHD MR studies and neonatal mouse models of CHD that were collectively used to calculate to calculate a brain dysplasia score (BDS) that included assessment of subcortical structures including the olfactory bulb, the cerebellum and the hippocampus.

Methods

Neonates undergoing cardiac surgery for CHD were prospectively recruited from two large centers. Both pre- and postoperative MR brain scans were obtained. DTI in 42 directions was segmented into 90 regions using a neonatal brain template and three weighted methods. Clinical data collection included 18 patient-specific and 9 preoperative variables associated with preoperative scan and 6 intraoperative (e.g., cardiopulmonary bypass and deep hypothermic circulatory arrest times) and 12 postoperative variables associated with postoperative scan. We compared patient specific and preoperative clinical factors to network topology and tractography alterations on a preoperative neonatal brain MRI, and intra and postoperative clinical factors to network topology alterations on postoperative neonatal brain MRI. A composite BDS was created to score abnormal findings involving the cerebellar hemispheres and vermis, supratentorial extra-axial fluid, olfactory bulbs and sulci, hippocampus, choroid plexus, corpus callosum, and brainstem. The neuroimaging outcomes of this study included (1) connectome metrics: cost (number of connections) and global/nodal efficiency (network integration); (2) seed based tractography methods of fractional anisotropy (FA), radial diffusivity, and axial diffusivity. Statistics consisted of multiple regression with false discovery rate correction (FDR) comparing the clinical risk factors and BDS (including subcortical components) as predictors/exposures and the global connectome metrics, nodal efficiency, and seed based- tractography (FA, radial diffusivity, and axial diffusivity) as neuroimaging outcome measures.

Results

A total of 133 term neonates with complex CHD were prospectively enrolled and 110 had analyzable DTI. Multiple patient-specific factors including d-transposition of the great arteries (d-TGA) physiology and severity of impairment of fetal cerebral substrate delivery (i.e., how much the CHD lesion alters typical fetal circulation such that the highest oxygen and nutrient rich blood from the placenta are not directed toward the fetal brain) were predictive of preoperative reduced cost (p < 0.0073) and reduced global/nodal efficiency (p < 0.03). Cardiopulmonary bypass time predicted postoperative reduced cost (p < 0.04) and multiple postoperative factors [extracorporeal membrane oxygenation (ECMO), seizures and cardiopulmonary resuscitation (CPR)] were predictive of postoperative reduced cost and reduced global/nodal efficiency (p < 0.05). Anthropometric measurements (weight, length, and head size) predicted tractography outcomes. Total BDS was not predictive of brain network topology. However, key subcortical components of the BDS score did predict key global and nodal network topology: abnormalities of the cerebellum predicted reduced cost (p < 0.0417) and of the hippocampus predicted reduced global efficiency (p < 0.0126). All three subcortical structures predicted unique alterations of nodal efficiency (p < 0.05), including hippocampal abnormalities predicting widespread reduced nodal efficiency in all lobes of the brain, cerebellar abnormalities predicting increased prefrontal nodal efficiency, and olfactory bulb abnormalities predicting posterior parietal-occipital nodal efficiency.

Conclusion

Patient-specific (d-TGA anatomy, preoperative impairment of fetal cerebral substrate delivery) and postoperative (e.g., seizures, need for ECMO, or CPR) clinical factors were most predictive of diffuse postnatal microstructural dysmaturation in term CHD neonates. Anthropometric measurements (weight, length, and head size) predicted tractography outcomes. In contrast, subcortical components (cerebellum, hippocampus, olfactory) of a structurally based BDS (derived from CHD mouse mutants), predicted more localized and regional postnatal microstructural differences. Collectively, these findings suggest that brain DTI connectome and seed-based tractography are complementary techniques which may facilitate deciphering the mechanistic relative contribution of clinical and genetic risk factors related to poor neurodevelopmental outcomes in CHD.

Impact of COVID-19 related maternal stress on fetal brain development: A Multimodal MRI study

Background

Disruptions in perinatal care and support due to the COVID-19 pandemic was an unprecedented but significant stressor among pregnant women. Various neurostructural differences have been re-ported among fetuses and infants born during the pandemic compared to pre-pandemic counterparts. The relationship between maternal stress due to pandemic related disruptions and fetal brain is yet unexamined.

Methods

Pregnant participants with healthy pregnancies were prospectively recruited in 2020-2022 in the greater Los Angeles Area. Participants completed multiple self-report assessments for experiences of pandemic related disruptions, perceived stress, and coping behaviors and underwent fetal MRI. Maternal perceived stress exposures were correlated with quantitative multimodal MRI measures of fetal brain development using ltivariate models.

Results

Fetal brain stem volume increased with increased maternal perception of pandemic related stress positively correlated with normalized fetal brainstem volume (suggesting accelerated brainstem maturation). In contrast, increased maternal perception of pandemic related stress correlated with reduced global fetal brain temporal functional variance (suggesting reduced functional connectivity).

Conclusions

We report alterations in fetal brainstem structure and global functional fetal brain activity associated with increased maternal stress due to pandemic related disruptions, suggesting altered fetal programming. Long term follow-up studies are required to better understand the sequalae of these early multi-modal brain disruptions among infants born during the COVID-19 pandemic.

Harmonization of Multi-Center Diffusion Tensor Tractography in Neonates with Congenital Heart Disease: Optimizing Post-Processing and Application of ComBat

Advanced brain imaging of neonatal macrostructure and microstructure, which has prognosticating importance, is more frequently being incorporated into multi-center trials of neonatal neuroprotection. Multicenter neuroimaging studies, designed to overcome small sample sized clinical cohorts, are essential but lead to increased technical variability. Few harmonization techniques have been developed for neonatal brain microstructural (diffusion tensor) analysis. The work presented here aims to remedy two common problems that exist with the current state of the art approaches: 1) variance in scanner and protocol in data collection can limit the researcher's ability to harmonize data acquired under different conditions or using different clinical populations. 2) The general lack of objective guidelines for dealing with anatomically abnormal anatomy and pathology. Often, subjects are excluded due to subjective criteria, or due to pathology that could be informative to the final analysis, leading to the loss of reproducibility and statistical power. This proves to be a barrier in the analysis of large multi-center studies and is a particularly salient problem given the relative scarcity of neonatal imaging data. We provide an objective, data-driven, and semi-automated neonatal processing pipeline designed to harmonize compartmentalized variant data acquired under different parameters. This is done by first implementing a search space reduction step of extracting the along-tract diffusivity values along each tract of interest, rather than performing whole-brain harmonization. This is followed by a data-driven outlier detection step, with the purpose of removing unwanted noise and outliers from the final harmonization. We then use an empirical Bayes harmonization algorithm performed at the along-tract level, with the output being a lower dimensional space but still spatially informative. After applying our pipeline to this large multi-site dataset of neonates and infants with congenital heart disease (n= 398 subjects recruited across 4 centers, with a total of n=763 MRI pre-operative/post-operative time points), we show that infants with single ventricle cardiac physiology demonstrate greater white matter microstructural alterations compared to infants with bi-ventricular heart disease, supporting what has previously been shown in literature. Our method is an open-source pipeline for delineating white matter tracts in subject space but provides the necessary modular components for performing atlas space analysis. As such, we validate and introduce Diffusion Imaging of Neonates by Group Organization (DINGO), a high-level, semi-automated framework that can facilitate harmonization of subject-space tractography generated from diffusion tensor imaging acquired across varying scanners, institutions, and clinical populations. Datasets acquired using varying protocols or cohorts are compartmentalized into subsets, where a cohort-specific template is generated, allowing for the propagation of the tractography mask set with higher spatial specificity. Taken together, this pipeline can reduce multi-scanner technical variability which can confound important biological variability in relation to neonatal brain microstructure.

Physical Activity in Patients With Inflammatory Bowel Disease: A Narrative Review

BACKGROUND

Despite advancement in the treatment of inflammatory bowel disease (IBD), induction and maintenance of remission remain challenging to achieve in many patients and a significant proportion of patients with IBD experience mental health conditions, including anxiety, depression, and fatigue, which impair their quality of life (QoL). We aim to describe the available evidence regarding the effects of physical activity (PA) on the onset of IBD, its disease course, and important patient-reported outcome measures (PROMs), such as QoL, fatigue, and mental health.

METHODS

A literature search was performed using electronic databases to identify original articles that assessed the effects of PA in patients with IBD using PROMs.

RESULTS

Prospective cohort and case-control studies demonstrate inverse relationships between PA and new-onset IBD in Crohn's disease but not in ulcerative colitis; however, they have small sample sizes and caution must be taken in considering associations versus causation. Small randomized controlled trials suggest promise for PA and beneficial outcomes, such as maintenance of clinical remission and improvement in QoL, fatigue, depression, and anxiety. However, these studies were small and underpowered, and limited by outcome measurements and durations of follow-up.

CONCLUSIONS

Physicians may consider discussing PA interventions with their patients on an individual basis, especially if they report impaired QoL, fatigue, depression, or anxiety, until disease-specific guidelines are available. Including PA as part of a primary prevention strategy in high-risk patients could be considered.

A Case of Prenatally Diagnosed Congenital Adrenal Hyperplasia With Brain Morphometric Differences

We report a case of a fetus with a prenatal diagnosis of classical congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency. Although CAH is typically assessed postnatally, this fetal case had multiple prenatal clinical assessments made feasible by an interdisciplinary CAH center. The approach facilitated the development and delivery of comprehensive and earlier care for the fetus, and the family living with this complex, congenital condition, with perinatology, endocrinology, genetic counseling, psychology, and urology involvement. As well, the addition of fetal MRI to standard ultrasound revealed significant deficits in the biparietal diameter, occipitofrontal diameter, and total intracranial volume of the fetal CAH brain. These early anomalies in the brain suggest that neurological comorbidities observed in older children and adults with CAH should be studied as early as prenatally, with the addition of fetal MRI to ultrasound potentially being useful for identifying and understanding prenatal anomalies in CAH.

Meditation and yoga for irritable bowel syndrome: study protocol for a randomised clinical trial (MY-IBS study)

INTRODUCTION

When delivered in person, yoga has been shown to be effective in managing irritable bowel syndrome (IBS) symptoms. Research is needed to test the feasibility and effectiveness of yoga as a therapeutic option when delivered virtually. The primary aim of the mind and yoga for IBS randomised controlled trial is to determine the effects of an 8-week virtual meditation and yoga intervention on IBS symptom severity compared with an advice-only active control group.

METHODS AND ANALYSIS

Adults diagnosed with IBS will be randomised to receive either a Upa Yoga intervention or an advice-only control group. The intervention will consist of weekly online classes for 8 weeks delivered by a facilitator using Microsoft Office Teams and daily home practice. Feasibility will be evaluated by examining recruitment and attrition rates, adherence, participant satisfaction with the programme and safety. The primary outcome is IBS symptom severity, and key secondary outcomes include (but not limited to) quality of life, anxiety and depression symptoms, COVID-19-related stress and anxiety, and fatigue. Outcomes will be assessed at baseline, 4 weeks and 8 weeks. An embedded design experimental model substudy will be conducted post intervention using qualitative research methods to identify participants' experiences in the yoga programme.

ETHICS AND DISSEMINATION

This study has been approved by the Conjoint Health Research Ethics Board (REB ID 20-0084). Findings will be disseminated through peer-reviewed publication, conference presentation and social media.

TRIAL REGISTRATION NUMBER

NCT04302623.

A247 MEDITATION AND YOGA FOR IRRITABLE BOWEL SYNDROME (MY-IBS): A RANDOMIZED CONTROLLED TRIAL

Background

When delivered in person, yoga is effective in managing Irritable Bowel Syndrome (IBS) symptoms. However, research is needed to determine the feasibility and effectiveness of yoga as a therapeutic option when delivered virtually.

Aims

The aim was to explore the feasibility and effectiveness of a yoga program, delivered virtually, for patients with IBS. We hypothesized the program would be feasible and effective in improving outcomes in the intervention group compared to the control group.

Methods

Adults diagnosed with IBS were randomized to receive either a Hatha yoga intervention or to an advice-only control group. The intervention consisted of facilitator-led weekly online classes for eight weeks delivered using Microsoft Office Teams and daily home practice. Yoga sessions included sequential delivery of postures, chanting, breathing exercises, and meditation over four weeks, with integrated practice over the final four weeks. Feasibility was evaluated with recruitment and attrition rates, adherence, and safety. The primary outcome was severity of IBS symptoms (IBS-Symptom Severity Score, IBS-SSS). Secondary outcomes included anxiety (General Anxiety Disorder-7), depression (Patient Health Questionnaire-9), and stress (Perceived Stress Scale) assessed at baseline and eight weeks. Unadjusted and adjusted analysis of variance (and covariance) models compared baseline and post-intervention data between groups using intent to treat analysis.

Results

Sixty-five participants participated (32 treatment, 33 control). The mean age was 44.2±14.1 years and 91% identified as female. Participants had been living with IBS for 11.7±11 years. Fifteen participants were lost to follow-up (20% attrition rate). Participants attended on average 5.9±1.7 out of a possible 8 sessions (74% adherence) and accumulated 1,187±545 minutes in daily practice over eight weeks. No adverse events were reported. The groups did not differ at baseline (P>0.05). From baseline to post intervention, unadjusted ANOVA models indicated the yoga program was not statistically superior to the control group for IBS-symptoms (-17.5 points; 95% CI -62.6 to 27.6; P = 0.440), anxiety (-0.91 points; 95% CI -2.47 to 0.64; P = 0.245) and stress (-0.65 points; 95% CI -1.73 to 0.44; P = 0.239). Significant differences between groups were seen for depression (-1.82 points; 95% CI -3.49 to -0.15; P = 0.033). A second model considered relevant covariates including age, comorbidities, and years since diagnosis (i.e., ANCOVA), and the results were similar to the unadjusted model.

Conclusions

Our virtual Hatha yoga and mediation program was feasible, and participants showed improvement in their depression scores. However, they did not experience a significant improvement in their IBS symptoms, anxiety, or stress, perhaps due to the short timeframe of the intervention.

Funding Agencies

None

Is fetal MRI ready for neuroimaging prime time? An examination of progress and remaining areas for development

A major challenge in designing large-scale, multi-site studies is developing a core, scalable protocol that retains the innovation of scientific advances while also lending itself to the variability in experience and resources across sites. In the development of a common Healthy Brain and Child Development (HBCD) protocol, one of the chief questions is "is fetal MRI ready for prime-time?" While there is agreement about the value of prenatal data obtained non-invasively through MRI, questions about practicality abound. There has been rapid progress over the past years in fetal and placental MRI methodology but there is uncertainty about whether the gains afforded outweigh the challenges in supporting fetal MRI protocols at scale. Here, we will define challenges inherent in building a common protocol across sites with variable expertise and will propose a tentative framework for evaluation of design decisions. We will compare and contrast various design considerations for both normative and high-risk populations, in the setting of the post-COVID era. We will conclude with articulation of the benefits of overcoming these challenges and would lend to the primary questions articulated in the HBCD initiative.

Brain biomarkers and neuropsychological outcomes of pediatric posterior fossa brain tumor survivors treated with surgical resection with or without adjuvant chemotherapy

PURPOSE

Children with brain tumors experience cognitive late effects, often related to cranial radiation. We sought to determine differential effects of surgery and chemotherapy on brain structure and neuropsychological outcomes in children who did not receive cranial radiation therapy (CRT).

METHODS

Twenty-eight children with a history of posterior fossa tumor (17 treated with surgery, 11 treated with surgery and chemotherapy) underwent neuroimaging and neuropsychological assessment a mean of 4.5 years (surgery group) to 9 years (surgery + chemotherapy group) posttreatment, along with 18 healthy sibling controls. Psychometric measures assessed IQ, language, executive functions, processing speed, memory, and social-emotional functioning. Group differences and correlations between diffusion tensor imaging findings and psychometric scores were examined.

RESULTS

The z-score mapping demonstrated fractional anisotropy (FA) values were ≥2 standard deviations lower in white matter tracts, prefrontal cortex gray matter, hippocampus, thalamus, basal ganglia, and pons between patient groups, indicating microstructural damage associated with chemotherapy. Patients scored lower than controls on visuoconstructional reasoning and memory (P ≤ .02). Lower FA in the uncinate fasciculus (R = -0.82 to -0.91) and higher FA in the thalamus (R = 0.73-0.91) associated with higher IQ scores, and higher FA in the thalamus associated with higher scores on spatial working memory (R = 0.82).

CONCLUSIONS

Posterior fossa brain tumor treatment with surgery and chemotherapy affects brain microstructure and neuropsychological functioning years into survivorship, with spatial processes the most vulnerable. Biomarkers indicating cellular changes in the thalamus, hippocampus, pons, prefrontal cortex, and white matter tracts associate with lower psychometric scores.

Fetal neurodevelopmental recovery in donors after laser surgery for twin-twin transfusion syndrome

BACKGROUND

Fetal magnetic resonance imaging (MRI) and spectroscopy (MRS) provide a unique opportunity to non-invasively measure markers of neurodevelopment in survivors of twin-twin transfusion syndrome (TTTS).

OBJECTIVE

To characterize fetal brain maturation after laser surgery for TTTS by measuring brain volumes and cerebral metabolite concentrations using fetal MRI + MRS.

STUDY DESIGN

Prospective study of dual surviving fetuses treated with laser surgery for TTTS. At 4-5 postoperative weeks, fetal MRI was used together with novel image analysis to automatically extract major brain tissue volumes. Fetal MRS was used to measure major metabolite concentrations in the fetal brain.

RESULTS

Twenty-one twin pairs were studied. The average (±SD) gestational age at MRI was 25.89 (±2.37) weeks. Total brain volume (TBV) was lower in the donors, although cerebral volumes were not different between twin pairs. Recipients showed lower proportions of cortical and cerebellar volumes, normalized to TBV and cerebral volumes. MRS data showed that biochemical differences between twin brains were related to discrepancy in their brain volumes.

CONCLUSION

Although donors have a smaller TBV compared to recipients, proportionality of brain tissue volumes are preserved in donors. MRS maturational markers of fetal brain development show that recovery in donors persists 4 weeks after surgery.

NCOG-72. DIFFERENTIAL EFFECTS OF SURGERY AND CHEMOTHERAPY ON CHILDREN WITH POSTERIOR FOSSA BRAIN TUMORS

BACKGROUND

Few neuroimaging studies of children with brain tumors treated with chemotherapy without radiation exist, and the neuropsychological effects of chemotherapy remain unclear. We aimed to differentiate the effects of surgery and chemotherapy on brain microstructure and cognition.

METHODS

Twenty-eight children with a history of posterior fossa tumor (17 treated with surgery alone; 11 treated with surgery + chemotherapy), and 21 sibling controls (n= 49) underwent diffusion tensor imaging (DTI) and neuropsychological assessment a mean of 4.5 (surgery group) to 9 years (surgery + chemotherapy group) after treatment. Psychometric measures focused on general intelligence, executive functions, processing speed, learning and memory, and social-emotional functioning. Age at diagnosis and time since diagnosis were covariates in the analyses. Group differences in DTI findings and psychometric scores, and correlations between psychometric scores and DTI results were examined.

RESULTS

Mean fractional anisotropy (FA) in the prefrontal cortex, white matter tracts, hippocampus, putamen, globus pallidus, thalamus, and pons were significantly (z≥ 2SD) lower in children treated with surgery + chemotherapy compared to those treated with surgery alone. In neuropsychological evaluation, the patient groups differed only in receptive vocabulary (p= 0.05), with children treated with surgery + chemotherapy scoring lower. Both patient groups scored lower than healthy sibling controls on measures of visuoconstructional reasoning (p= 0.02) and delayed visual (p= 0.02) and spatial memory (p= 0.01). Lower FA in the uncinate fasciculus and higher FA in the right thalamus associated with higher scores on general intelligence (p= 0.003, p= 0.002), and higher FA in the right thalamus associated with higher scores on spatial learning (p= 0.01) and memory (p= 0.01) in children treated with surgery + chemotherapy.

CONCLUSIONS

Chemotherapy is associated with injury to the microstructure of white and gray matter and neuropsychological deficits not seen in children with posterior fossa tumors treated with surgery alone.

Neurocranium thickness mapping in early childhood

The neurocranium changes rapidly in early childhood to accommodate the growing brain. Developmental disorders and environmental factors such as sleep position may lead to abnormal neurocranial maturation. Therefore, it is important to understand how this structure develops, in order to provide a baseline for early detection of anomalies. However, its anatomy has not yet been well studied in early childhood due to the lack of available imaging databases. In hospitals, CT is typically used to image the neurocranium when a pathology is suspected, but the presence of ionizing radiation makes it harder to construct databases of healthy subjects. In this study, instead, we use a dataset of MRI data from healthy normal children in the age range of 6 months to 36 months to study the development of the neurocranium. After extracting its outline from the MRI data, we used a conformal geometry-based analysis pipeline to detect local thickness growth throughout this age span. These changes will help us understand cranial bone development with respect to the brain, as well as detect abnormal variations, which will in turn inform better treatment strategies for implicated disorders.

2-Deoxy-2-[18 F]fluoro-d-glucose positron emission tomography, cortical thickness and white matter graph network abnormalities in brains of patients with amyotrophic lateral sclerosis and frontotemporal dementia suggest early neuronopathy rather than axonopathy

BACKGROUND AND PURPOSE

Amyotrophic lateral sclerosis (ALS) is a motor neuron disorder, although extra-motor degeneration is well recognized, especially in frontotemporal regions manifested as ALS with frontotemporal dementia (ALS-FTD). Previous neuroimaging studies of the brains of ALS-FTD patients have measured abnormalities of either grey matter (GM) or white matter (WM) structures but not of both together. Therefore, the aim was to evaluate both GM and WM in the same ALS-FTD patient using functional and structural neuroimaging. By doing so, insights could be gained into whether neurodegeneration in ALS-FTD is primarily a neuronopathy or axonopathy.

METHODS

After high-resolution brain 2-deoxy-2-[¹⁸ F]fluoro-D-glucose (¹⁸ F-FDG) positron emission tomography (PET) and magnetic resonance imaging (MRI) scans were obtained in ALS-FTD patients and in age- and sex-matched neurological controls, changes in metabolic rate, cortical thickness (CT) and WM network analysis using graph theory were analyzed.

RESULTS

Significant reductions in ¹⁸ F-FDG PET metabolism, CT and WM connections were observed in motor and extra-motor brain regions of ALS-FTD patients compared to controls. Both CT and underlying WM networks were abnormal in frontal, temporal, parietal and occipital lobes of ALS-FTD patients with 86 of 90 brain regions showing reductions of CT.

CONCLUSION

Abnormalities in significantly fewer WM networks underlying the affected cortical regions suggest that neurodegeneration in brains of ALS-FTD patients is primarily a 'neuronopathy' rather than an 'axonopathy.'

AB1344-HPR POOLED ANALYSIS OF ASSOCIATION BETWEEN ABATACEPT OR OTHER TARGET DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (TDMARD) AND TYPE 2 DIABETES MELLITUS (T2DM)-RELATED HEALTHCARE RESOURCE UTILIZATION (HCRU) AND COSTS IN TNFI-NAÏVE RHEUMATOID ARTHRITIS (RA) PATIENTS WITH T2DM

Background:

Limited information is available on the impact of target disease-modifying anti-rheumatic drugs (tDMARD) on patients with rheumatoid arthritis (RA) and type 2 diabetes mellitus (T2DM).

Objectives:

The objective was to compare T2DM-related healthcare resource utilization (HCRU) and cost for TNF inhibitors (TNFi)-naive patients pooled from two commercial databases with RA and T2DM receiving abatacept, other non-TNFi, or TNFi.

Methods:

A retrospective, observational study was conducted with MarketScan and PharMetrics (January 2008-September 2018). The study population included TNFi-naïve adult patients with RA and T2DM newly initiating abatacept, TNFi (adalimumab, certolizumab pegol, etanercept, golimumab, infliximab) or other non-TNFi (tocilizumab, anakinra, sarilumab, rituximab, tofacitinib). Date of tDMARD initiation was the index date. Patients had ≥2 RA diagnoses separated by ≥7 days, ≥1 T2DM diagnosis, and had ≥12 months of pre-index continuous enrollment. Follow-up ended at the end of patient insurance enrollment, study period or index treatment. T2DM-related HCRU and costs including inpatient stay, outpatient visits, ER visits, and pharmacy use were measured on a per-patient-per-month (PPPM) basis (2018 USD). Patients treated with abatacept were matched to TNFi and non-TNFi cohorts separately by propensity score adjusted with patients baseline comorbidities, HCRU, and costs.

Results:

A total of 16,236 patients meeting criteria were identified. Most patients were female (74.3%), and the overall average age of 55.4 years (Table 1). After matching, 850 pairs of abatacept vs non-TNFi patients, and 1,096 pairs of abatacept vs TNFi patients were included in the adjusted results. Patients initiating abatacept had $144 lower adjusted T2DM-related costs as compared to non-TNFi and $79 lower costs than TNFi cohorts (Table 2).

Table 1.

Patient Characteristics

Abataceptn=1,134Non-TNFin=1,353TNFin=13,749TotalN=16,236Age, mean years (SD)58.5 (11.3)57.7 (11.2)54.9 (10.6)55.41 (10.7)Gender, female, n (%)936 (82.5)993 (73.4)10,142 (73.8)12,071 (74.3)CCI, mean (SD)2.2 (1.4)2.3 (1.4)1.8 (1.1)1.89 (1.14)DCSI, n (%) Cardiovascular361 (31.8)406 (30.0)2,500 (18.2)3,267 (20.1) Neuropathy294 (25.9)374 (27.6)3,161 (23.0)3,829 (23.6) Nephropathy146 (12.9)193 (14.3)1,151 (8.4)1,490 (9.2) PVD131 (11.6)155 (11.5)874 (6.4)1,160 (7.1) Retinopathy103 (9.1)119 (8.8)922 (6.7)1,144 (7.0) Cerebrovascular74 (6.5)102 (7.5)620 (4.5)796 (4.9) Metabolic9 (0.8)20 (1.5)141 (1.0)170 (1.0)

CCI: Charlson comorbidity index; DCSI: diabetes complications severity index; PVD: peripheral vascular disease.

Table 2.

Adjusted T2DM-related HCRU and Costs after Propensity Score Matching

Abataceptn=850Non-TNFin=850Diff (ABA- Non-TNF)Abataceptn=1,096TNFin=1,096Diff (ABA- TNF)T2DM-related HCRU (per 1000 Patients per Month)Number of Hospitalizations13.920.4-6.5*12.614.9-2.3*Number ofER Visits22.016.15.9*18.416.32.0*Number ofOutpatient Visits311334.8-23.7*299.3286.912.4T2DM-related Costs (PPPM $)Inpatient Costs507535-28413475-62ER Costs271710*2225-3Outpatient Costs190323-13318617016*Pharmacy Costs1071007*97128-31Total Costs831975-144719798-79*

*P<0.05

Conclusion:

TNFi-naive RA patients with T2DM newly initiating abatacept had lower adjusted rates of T2DM-related hospitalizations compared to patients who initiated a non-TNFi or a TNFi. Total costs were lower among patients initiating abatacept vs. patients who initiated a non-TNFi or a TNFi. Findings suggest that initial abatacept among TNFi-naïve patients may be able to reduce healthcare utilization arising from T2DM complications and reduce T2DM-related costs in RA patients.

Disclosure of Interests:

Xue Han Employee of: BMS, Qian Xia Shareholder of: I own shares of Bristol-Myers Squibb Company, Employee of: I am a paid employee of Bristol-Myers Squibb Company, Ying Bao Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb, Vardhaman PATEL Employee of: Bristol Myers Squibb, Amrina Roy Employee of: Mu-Sigma, Varshini Rajagopalan Employee of: Mu-Sigma, Francis Lobo Shareholder of: Bristol-Myers Squibb (US), Employee of: Bristol-Myers Squibb (US)

Fetuses with single ventricle congenital heart disease manifest impairment of regional brain growth

OBJECTIVE

Anomalous neurological development associated with congenital heart disease (CHD) has been reported as early as third trimester of fetal development. While several studies have characterized variations in CHD neurodevelopmental outcomes in early childhood, these reports are often confounded by postnatal factors such as surgical outcome. Recent studies have focused on the comparing neurological variations between fetuses with CHD and normal controls. In this work, we present a comparison of in utero variations in brain development between fetuses with different types of CHD, by analyzing them under categories of single ventricle versus biventricular cardiac anatomy.

METHODS

Using recent advances in fetal magnetic resonance imaging (MRI), we quantify the volumetric trajectories of various brain tissues (such as cortical plate, developing white matter, cerebrospinal fluid [CSF], and cerebellum).

RESULTS

Our study is the first to differentiate between intraventricular and extra-axial CSF thereby allowing us to better identify variations in brain composition of the fetuses.

CONCLUSIONS

Overall, our findings show that while total brain volume is similar between fetuses with single and biventricular anatomy, they exhibit statistically significant disparity in brain composition.

Complementary cortical gray and white matter developmental patterns in healthy, preterm neonates

Preterm birth is associated with brain injury and altered cognitive development. However, the consequences of extrauterine development are not clearly distinguished from perinatal brain injury. Therefore, we characterized cortical growth patterns from 30 to 46 postmenstrual weeks (PMW) in 27 preterm neonates (25-32 PMW at birth) without detectable brain injury on magnetic resonance imaging. We introduce surface-based morphometric descriptors that quantify radial (thickness) and tangential (area) change rates. Within a tensor-based morphometry framework, we use a temporally weighted formulation of regression to simultaneously model local age-related changes in cortical gray matter (GM) and underlying white matter (WM) mapped onto the cortical surface. The spatiotemporal pattern of GM and WM development corresponded to the expected gyrification time course of primary sulcal deepening and branching. In primary gyri, surface area and thickness rates were below average along sulcal pits and above average on gyral banks and crests in both GM and WM. Above average surface area rates in GM corresponded to emergence of secondary and tertiary folds. These findings map the development of neonatal cortical morphometry in the context of extrauterine brain development using a novel approach. Future studies may compare this developmental trajectory to preterm populations with brain injury. Hum Brain Mapp 38:4322-4336, 2017. © 2017 Wiley Periodicals, Inc.

BOLD delay times using group delay in sickle cell disease

Sickle cell disease (SCD) is an inherited blood disorder that effects red blood cells, which can lead to vasoocclusion, ischemia and infarct. This disease often results in neurological damage and strokes, leading to morbidity and mortality. Functional Magnetic Resonance Imaging (fMRI) is a non-invasive technique for measuring and mapping the brain activity. Blood Oxygenation Level-Dependent (BOLD) signals contain also information about the neurovascular coupling, vascular reactivity, oxygenation and blood propagation. Temporal relationship between BOLD fluctuations in different parts of the brain provides also a mean to investigate the blood delay information. We used the induced desaturation as a label to profile transit times through different brain areas, reflecting oxygen utilization of tissue. In this study, we aimed to compare blood flow propagation delay times between these patients and healthy subjects in areas vascularized by anterior, middle and posterior cerebral arteries. In a group comparison analysis with control subjects, BOLD changes in these areas were found to be almost simultaneous and shorter in the SCD patients, because of their increased brain blood flow. Secondly, the analysis of a patient with a stenosis on the anterior cerebral artery indicated that signal of the area vascularized by this artery lagged the MCA signal. These findings suggest that sickle cell disease causes blood propagation modifications, and that these changes could be used as a biomarker of vascular damage.

Low-frequency fluctuation amplitude analysis of resting-state fMRI in sickle cell disease

Sickle cell disease may result in neurological damage and strokes, leading to morbidity and mortality. Currently, there are no dependable biomarkers to predict impending strokes. In this study, we analyzed neuronal processes at resting state and more particularly how this disease affects the default mode network. The amplitude of low frequency fluctuations was used to reflect areas of spontaneous BOLD signal across brain regions. We compared the activations of sickle cell disease patients to a control group using variance analysis and t-test. Significant regional differences among the two groups were observed, especially in the default mode network areas and cortical regions near large cerebral arteries. These findings suggest that sickle cell disease causes activation modifications near vessels, and these changes could be used as a biomarker of the disease.

Effect of Data Acquisition and Analysis Method on Fiber Orientation Estimation in Diffusion MRI

In this paper we investigate the effect of single-shell q-space diffusion sampling strategies and applicable multiple-fiber analysis methods on fiber orientation estimation in Diffusion MRI. Specifically, we develop a simulation based on an in-vivo data set and compare a two-compartment "ball-and-stick" model, a constrained spherical deconvolution approach, a generalized Fourier transform approach, and three related methods based on transforms of Fourier data on the sphere. We evaluate each method for N = 20, 30, 40, 60, 90 and 120 angular diffusion-weighted samples, at SNR = 18 and diffusion-weighting b = 1000s/mm², common to clinical studies. Our results quantitatively show the methods' are most distinguished from each other by their fiber detection ability. Overall, the "ball-and-stick" model and spherical deconvolution approach were found to perform best, yielding the least orientation error, and greatest detection rate of fibers.

Secondary lymphangioma of vulva: a report of two cases

Secondary lymphangiomas or acquired lymphangiomas of vulva represent dilatation of upper dermal lymphatics following damage to previously normal deep lymphatics. They have been reported to occur following various infections, surgeries and radiotherapy which can cause damage to deep lymphatics.Treatment options in the management of secondary lymphangiomas include surgical resection, carbon dioxide laser vaporisation, sclerosing agents etc. We report two cases of secondary lymphangioma of vulva that followed radiotherapy for carcinoma of cervix. Both the patients were treated successfully by surgery.

Volumetric and surface-based 3D MRI analyses of fetal isolated mild ventriculomegaly: brain morphometry in ventriculomegaly

Diagnosis of fetal isolated mild ventriculomegaly (IMVM) is the most common brain abnormality on prenatal ultrasound. We have set to identify potential alterations in brain development specific to IMVM in tissue volume and cortical and ventricular local surface curvature derived from in utero magnetic resonance imaging (MRI). Multislice 2D T2-weighted MRI were acquired from 32 fetuses (16 IMVM, 16 controls) between 22 and 25.5 gestational weeks. The images were motion-corrected and reconstructed into 3D volumes for volumetric and curvature analyses. The brain images were automatically segmented into cortical plate, cerebral mantle, deep gray nuclei, and ventricles. Volumes were compared between IMVM and control subjects. Surfaces were extracted from the segmentations for local mean surface curvature measurement on the inner cortical plate and the ventricles. Linear models were estimated for age-related and ventricular volume-associated changes in local curvature in both the inner cortical plate and ventricles. While ventricular volume was enlarged in IMVM, all other tissue volumes were not different from the control group. Ventricles increased in curvature with age along the atrium and anterior body. Increasing ventricular volume was associated with reduced curvature over most of the ventricular surface. The cortical plate changed in curvature with age at multiple sites of primary sulcal formation. Reduced cortical folding was detected near the parieto-occipital sulcus in IMVM subjects. While tissue volume appears to be preserved in brains with IMVM, cortical folding may be affected in regions where ventricles are dilated.

Bias field inconsistency correction of motion-scattered multislice MRI for improved 3D image reconstruction

A common solution to clinical MR imaging in the presence of large anatomical motion is to use fast multislice 2D studies to reduce slice acquisition time and provide clinically usable slice data. Recently, techniques have been developed which retrospectively correct large scale 3D motion between individual slices allowing the formation of a geometrically correct 3D volume from the multiple slice stacks. One challenge, however, in the final reconstruction process is the possibility of varying intensity bias in the slice data, typically due to the motion of the anatomy relative to imaging coils. As a result, slices which cover the same region of anatomy at different times may exhibit different sensitivity. This bias field inconsistency can induce artifacts in the final 3D reconstruction that can impact both clinical interpretation of key tissue boundaries and the automated analysis of the data. Here we describe a framework to estimate and correct the bias field inconsistency in each slice collectively across all motion corrupted image slices. Experiments using synthetic and clinical data show that the proposed method reduces intensity variability in tissues and improves the distinction between key tissue types.

Early folding patterns and asymmetries of the normal human brain detected from in utero MRI

Early cortical folding and the emergence of structural brain asymmetries have been previously analyzed by neuropathology as well as qualitative analysis of magnetic resonance imaging (MRI) of fetuses and preterm neonates. In this study, we present a dedicated image analysis framework and its application for the detection of folding patterns during the critical period for the formation of many primary sulci (20-28 gestational weeks). Using structural information from in utero MRI, we perform morphometric analysis of cortical plate surface development and modeling of early folding in the normal fetal brain. First, we identify regions of the fetal brain surface that undergo significant folding changes during this developmental period and provide precise temporal staging of these changes for each region of interest. Then, we highlight the emergence of interhemispheric structural asymmetries that may be related to future functional specialization of cortical areas. Our findings complement previous descriptions of early sulcogenesis based on neuropathology and qualitative evaluation of 2D in utero MRI by accurate spatial and temporal mapping of the emergence of individual sulci as well as structural brain asymmetries. The study provides the missing starting point for their developmental trajectories and extends our understanding of normal cortical folding.

Growth trajectories of the human fetal brain tissues estimated from 3D reconstructed in utero MRI

In the latter half of gestation (20-40 gestational weeks), human brain growth accelerates in conjunction with cortical folding and the deceleration of ventricular zone progenitor cell proliferation. These processes are reflected in changes in the volume of respective fetal tissue zones. Thus far, growth trajectories of the fetal tissue zones have been extracted primarily from 2D measurements on histological sections and magnetic resonance imaging (MRI). In this study, the volumes of major fetal zones-cortical plate (CP), subplate and intermediate zone (SP+IZ), germinal matrix (GMAT), deep gray nuclei (DG), and ventricles (VENT)--are calculated from automatic segmentation of motion-corrected, 3D reconstructed MRI. We analyzed 48 T2-weighted MRI scans from 39 normally developing fetuses in utero between 20.57 and 31.14 gestational weeks (GW). The supratentorial volume (STV) increased linearly at a rate of 15.22% per week. The SP+IZ (14.75% per week) and DG (15.56% per week) volumes increased at similar rates. The CP increased at a greater relative rate (18.00% per week), while the VENT (9.18% per week) changed more slowly. Therefore, CP increased as a fraction of STV and the VENT fraction declined. The total GMAT volume slightly increased then decreased after 25 GW. We did not detect volumetric sexual dimorphisms or total hemispheric volume asymmetries, which may emerge later in gestation. Further application of the automated fetal brain segmentation to later gestational ages will bridge the gap between volumetric studies of premature brain development and normal brain development in utero.

Non-iterative relative bias correction for 3D reconstruction of in utero fetal brain MR imaging

The slice intersection motion correction (SIMC) method is a powerful tool to compensate for motion that occurs during in utero acquisition of the multislice magnetic resonance (MR) images of the human fetal brain. The SIMC method makes use of the slice intersection intensity profiles of orthogonally planned slice pairs to simultaneously correct for the relative motion occurring between all the acquired slices. This approach is based on the assumption that the bias field is consistent between slices. However, for some clinical studies where there is a strong bias field combined with significant fetal motion relative to the coils, this assumption is broken and the resulting motion estimate and the reconstruction to a 3D volume can both contain errors. In this work, we propose a method to correct for the relative differences in bias field between all slice pairs. For this, we define the energy function as the mean square difference of the intersection profiles, that is then minimized with respect to the bias field parameters of the slices. A non iterative method which considers the relative bias between each slice simultaneously is used to efficiently remove inconsistencies. The method, when tested on synthetic simulations and actual clinical imaging studies where bias was an issue, brought a significant improvement to the final reconstructed image.

3D global and regional patterns of human fetal subplate growth determined in utero

The waiting period of subplate evolution is a critical phase for the proper formation of neural connections in the brain. During this time, which corresponds to 15 to 24 postconceptual weeks (PCW) in the human fetus, thalamocortical and cortico-cortical afferents wait in and are in part guided by molecules embedded in the extracellular matrix of the subplate. Recent advances in fetal MRI techniques now allow us to study the developing brain anatomy in 3D from in utero imaging. We describe a reliable segmentation protocol to delineate the boundaries of the subplate from T2-W MRI. The reliability of the protocol was evaluated in terms of intra-rater reproducibility on a subset of the subjects. We also present the first 3D quantitative analyses of temporal changes in subplate volume, thickness, and contrast from 18 to 24 PCW. Our analysis shows that firstly, global subplate volume increases in proportion with the supratentorial volume; the subplate remained approximately one-third of supratentorial volume. Secondly, we found both global and regional growth in subplate thickness and a linear increase in the median and maximum subplate thickness through the waiting period. Furthermore, we found that posterior regions--specifically the occipital pole, ventral occipito-temporal region, and planum temporale--of the developing brain underwent the most statistically significant increases in subplate thickness. During this period, the thickest region was the developing somatosensory/motor cortex. The subplate growth patterns reported here may be used as a baseline for comparison to abnormal fetal brain development.

Juvenile dermatomyositis associated with lipodystrophy

Lipodystrophy and associated metabolic abnormalities are being increasingly recognized as complications of juvenile dermatomyositis. We report one such case.

Klippel-Trenaunay syndrome associated with pseudo-Kaposi's sarcoma

Pseudo Kaposi's sarcoma is a rare vascular lesion, usually associated with arterio venous malformations of the Parker Weber type, and only occasionally with Klippel Trenaunay syndrome per se. We report one such case.

Tumor necrosis factor-alpha modulation of glycoprotein Ib alpha expression in human endothelial and erythroleukemia cells

Glycoprotein Ib alpha (GpIb alpha) is a platelet membrane Gp that binds von Willebrand factor and mediates platelet adhesion to subendothelium. We have found both GpIb alpha mRNA and protein in human umbilical vein endothelial cells (HUVEC). In previously published work we reported that combined treatment with interferon-gamma (IFN-gamma) and tumor necrosis factor-alpha (TNF-alpha) markedly increased the GpIb alpha mRNA level in HUVEC. We have now documented that TNF-alpha alone induces GpIb alpha mRNA and protein expression, studied the kinetics of this response, and investigated potential mechanisms of the TNF-alpha effect. GpIb alpha mRNA induction by TNF-alpha is detectable as early as 2 hours after exposure to this cytokine, and reaches a maximal level after 20 to 24 hours. Using a nuclear run-on assay we found that GpIb alpha gene transcription is increased approximately 10-fold after 2 hours of TNF-alpha treatment. Furthermore, using two monoclonal antibodies that recognize different epitopes of GpIb alpha, we found that the protein expression in endothelial cells is markedly increased by TNF-alpha. Interleukin-1 (IL-1) and the phorbol ester phorbol myristate acetate, which mimic many effects of TNF-alpha on endothelial cells, have no effect on endothelial or human erytholeukemia (HEL)-cell GpIb alpha mRNA. TNF-alpha treatment for 24 hours increases the HEL cell GpIb alpha mRNA level approximately fourfold, showing a time- and dose-dependent effect similar to that seen in HUVEC. TNF-alpha-induced GpIb alpha mRNA and protein synthesis may play a role in mediating platelet or other cell interaction with activated endothelium. Unlike other endothelial pro-thrombotic and pro-adhesive proteins induced by TNF-alpha, GpIb alpha is not induced by IL-1 treatment, which suggests a novel pathway for induction of this protein.

Jejunogastric intussusception as a technique for in situ resection

A technique for resection of irreducible, gangrenous jejunogastric intussusception is presented. In comparison with previously described resection procedures involving division of the stoma, dismantling of the gastrojejunostomy or higher gastrectomy, in situ resection is simple and safe.