Combined transesophageal and surface MRI provides optimal imaging in aortic atherosclerosis.

OBJECTIVE: Surface magnetic resonance imaging (MRI) for aortic plaque assessment is limited by the trade-off between penetration depth and signal-to-noise ratio (SNR). For imaging the deep seated aorta, a combined surface and transesophageal MRI (TEMRI) technique was developed 1) to determine the individual contribution of TEMRI and surface coils to the combined signal, 2) to measure the signal improvement of a combined surface and TEMRI over surface MRI, and 3) to assess for reproducibility of plaque dimension analysis. METHODS AND RESULTS: In 24 patients six black blood proton-density/T2-weighted fast-spin echo images were obtained using three surface and one TEMRI coil for SNR measurements. Reproducibility of plaque dimensions (combined surface and TEMRI) was measured in 10 patients. TEMRI contributed 68% of the signal in the aortic arch and descending aorta, whereas the overall signal gain using the combined technique was up to 225%. Plaque volume measurements had an intraclass correlation coefficient of as high as 0.97. CONCLUSION: Plaque volume measurements for the quantification of aortic plaque size are highly reproducible for combined surface and TEMRI. The TEMRI coil contributes considerably to the aortic MR signal. The combined surface and TEMRI approach improves aortic signal significantly as compared to surface coils alone. CONDENSED ABSTRACT: Conventional MRI aortic plaque visualization is limited by the penetration depth of MRI surface coils and may lead to suboptimal image quality with insufficient reproducibility. By combining a transesophageal MRI (TEMRI) with surface MRI coils we enhanced local and overall image SNR for improved image quality and reproducibility.

Long-term effects of ACTH combined with angiotensin II on steroidogenesis and adrenal zona glomerulosa morphology in the rat.

To test the hypothesis that the trophic action of angiotensin II on the adrenal zona glomerulosa may allow a sustained stimulation of aldosterone by ACTH by preventing the morphological changes of the zona glomerulosa cells into zona fasciculata-like elements we investigated the effects in rats of a 6-day treatment with ACTH (100 micrograms/kg/day) alone or combined with angiotensin II (300 ng/kg/day) on corticosterone and aldosterone production and adrenal morphology. The responsiveness of both steroids to an acute ACTH dose was also studied on the last day of long-term treatment. Morphologic data showed that prolonged ACTH treatment stimulated the growth of zona glomerulosa cells, though it transformed the tubulo-lamellar cristae of mitochondria into a homogeneous population of vesicles. Angiotensin II furthered the trophic effects of ACTH but prevented the mitochondrial transformation. Despite its ability to conserve the well differentiated aspect of the zona glomerulosa cells, the administration of angiotensin II was unable to prevent the fall in the secretion of aldosterone caused by chronic ACTH treatment and its subsequent unresponsiveness to ACTH stimulation.

Combined audit report on the institutions under the control of the Iowa Department of Corrections for the five years ended June 30, 2006

Combined audit report on the institutions under the control of the Iowa Department of Corrections for the five years ended June 30, 2006

Combined audit report on the eight Judicial District Departments of Correctional Services for the year ended June 30, 2006

Combined audit report on the eight Judicial District Departments of Correctional Services for the year ended June 30, 2006

Combined audit report on the institutions under the control of the Iowa Department of Human Services including findings and recommendations and average cost per resident/patient information for the five years ended June 30, 2006

Combined audit report on the institutions under the control of the Iowa Department of Human Services including findings and recommendations and average cost per resident/patient information for the five years ended June 30, 2006

Combined islet-lung transplantation in a cystic fibrosis patient.

The prevalence of insulin-dependent diabetes mellitus (IDDM) in cystic fibrosis patients ranges from 2 to 8% and glucose intolerance up to 15%. In recent years, lung transplantation has helped to prolong life expectancy of cystic fibrosis patients and represents 10 to 30% of all indications for lung transplantation. The postoperative need for immunosuppressive therapy using diabetogenic agents has decompensatory effects on glucose regulation and will probably increase the number of insulin-dependent cystic fibrosis patients. We report the case of an insulin-dependent cystic fibrosis patient transplanted with a combined islet-lung allograft. The pre-transplantation C-peptide level was below 0.04 nmol/l and preoperative insulin requirement was some 100 U per day. A sequential bipulmonary lung transplantation was performed and, using the pancreas of the same donor, we isolated and purified the islets of Langerhans by a modified automated method. We obtained 232,200 islets equivalent, which were injected into the liver by portal embolization. The postoperative course was uncomplicated, the insulin requirement decreased to 50% of the preoperative need and the C-peptide value increased to normal values and remained with the normal range during a follow-up period of 15 months. In conclusion, we believe that, besides type I diabetic patients, insulin-dependent cystic fibrosis patients with a negative C-peptide value could also be good candidates for combined islet-lung allotransplantation.

Study of the combined radial post-feeding dispersion of the blowflies Chrysomya megacephala (Fabricius) and C. albiceps (Wiedemann) (Diptera, Calliphoridae)

Blowflies use discrete and ephemeral substrates to feed their larvae. After they run out of food, the larvae begin to disperse in order to find adequate places for pupation or additional food sources, a process named post-feeding larval dispersion. Some important aspects of this process were studied in a circular arena allowing the combined radial post-feeding dispersion from the center of the arena of C. albiceps and C. megacephala larvae. To determine the location of each pupa, the arena was divided in 72 identical sections starting from the center. The distance from the center, the depth and weight of each pupa were evaluated. Statistical tests were done to verify the relation between weight, depth and distance for pupation. From the total an average of 976 larvae released (488 for each species) were collected considering both experiments 456 C. megacephala pupae and 488 of C. albiceps. This demonstrates that C. albiceps probably preyed on 32 C. megacephala larvae during post-feeding dispersion. The study of this dispersion process can be used to estimate the postmortem interval (PMI) of human cadavers in legal medicine.

Seeing the Wood through the Trees: The Current State of Higher Systematics in the Strepsirhini.

Strepsirhines comprise 10 living or recently extinct families, ≥50% of extant primate families. Their phylogenetic relationships have been intensively studied, but common topologies have only recently emerged; e.g. all recent reconstructions link the Lepilemuridae and Cheirogaleidae. The position of the indriids, however, remains uncertain, and molecular studies have placed them as the sister to every clade except Daubentonia, the preferred sister group of morphologists. The node subtending Afro-Asian lorisids has been similarly elusive. We probed these phylogenetic inconsistencies using a test data set including 20 strepsirhine taxa and 2 outgroups represented by 3,543 mtDNA base pairs, and 43 selected morphological characters, subjecting the data to maximum parsimony, maximum likelihood and Bayesian inference analyses, and reconstructing topology and node ages jointly from the molecular data using relaxed molecular clock analyses. Our permutations yielded compatible but not identical evolutionary histories, and currently popular techniques seem unable to deal adequately with morphological data. We investigated the influence of morphological characters on tree topologies, and examined the effect of taxon sampling in two experiments: (1) we removed the molecular data only for 5 endangered Malagasy taxa to simulate 'extinction leaving a fossil record'; (2) we removed both the sequence and morphological data for these taxa. Topologies were affected more by the inclusion of morphological data only, indicating that palaeontological studies that involve inserting a partial morphological data set into a combined data matrix of extant species should be interpreted with caution. The gap of approximately 10 million years between the daubentoniid divergence and those of the other Malagasy families deserves more study. The apparently contemporaneous divergence of African and non-daubentoniid Malagasy families 40-30 million years ago may be related to regional plume-induced uplift followed by a global period of cooling and drying. © 2013 S. Karger AG, Basel.

Combined analysis of grey matter voxel-based morphometry and white matter tract-based spatial statistics in late-life bipolar disorder.

Background: Previous magnetic resonance imaging (MRI) studies in young patients with bipolar disorder indicated the presence of grey matter concentration changes as well as microstructural alterations in white matter in various neocortical areas and the corpus callosum. Whether these structural changes are also present in elderly patients with bipolar disorder with long-lasting clinical evolution remains unclear. Methods: We performed a prospective MRI study of consecutive elderly, euthymic patients with bipolar disorder and healthy, elderly controls. We conducted a voxel-based morphometry (VBM) analysis and a tract-based spatial statistics (TBSS) analysis to assess fractional anisotropy and longitudinal, radial and mean diffusivity derived by diffusion tensor imaging (DTI). Results: We included 19 patients with bipolar disorder and 47 controls in our study. Fractional anisotropy was the most sensitive DTI marker and decreased significantly in the ventral part of the corpus callosum in patients with bipolar disorder. Longitudinal, radial and mean diffusivity showed no significant between-group differences. Grey matter concentration was reduced in patients with bipolar disorder in the right anterior insula, head of the caudate nucleus, nucleus accumbens, ventral putamen and frontal orbital cortex. Conversely, there was no grey matter concentration or fractional anisotropy increase in any brain region in patients with bipolar disorder compared with controls. Limitations: The major limitation of our study is the small number of patients with bipolar disorder. Conclusion: Our data document the concomitant presence of grey matter concentration decreases in the anterior limbic areas and the reduced fibre tract coherence in the corpus callosum of elderly patients with long-lasting bipolar disorder.

Combined approach for the management of large vestibular schwannomas: Planned subtotal resection followed by gamma knife surgery in a series of 20 consecutive cases.

INTRODUCTION: The management of large lesions of the skull base, such as vestibular schwannomas (VS) is challenging. Microsurgery remains the main treatment option. Combined approaches (planned subtotal resection followed by gamma knife surgery (GKS) for residual tumor long-term control) are being increasingly considered to reduce the risk of neurological deficits following complete resection. The current study aims to prospectively evaluate the safety-efficacy of combined approach in patients with large VS. MATERIALS AND METHODS: We present our experience with planned subtotal resection followed by gamma knife surgery (GKS) in a consecutive a series of 20 patients with large vestibular schwannomas, treated between 2009 and 2014 in Lausanne University Hospital, Switzerland. Clinical and radiological data and audiograms were prospectively collected for all patients, before and after surgery, before and after GKS, at regular intervals, in dedicated case-report forms. Additionally, for GKS, dose-planning parameters were registered. RESULTS: Twenty patients (6 males and 14 females) with large VS had been treated by this approach. The mean age at the time of surgery was 51.6years (range 34.4-73.4). The mean presurgical diameter was 36.7 (range 26.1-45). The mean presurgical tumor volume was 15.9cm(3) (range 534.9). Three patients (15%) needed a second surgical intervention because of high volume of the tumor remnant considered too large for a safe GKS. The mean follow-up after surgery was 27.2months (range 6-61.3). The timing of GKS was decided on the basis of the residual tumor shape and size following surgery. The mean duration between surgery and GKS was 7.6months (range 413.9, median 6months). The mean tumor volume at the time of GKS was 4.1cm(3) (range 0.5-12.8). The mean prescription isodose volume was 6.3cm(3) (range 0.8-15.5). The mean number of isocenters was 20.4 (range 11-31) and the mean marginal prescription dose was 11.7Gy (range 11-12). We did not have any major complications in our series. Postoperative status showed normal facial nerve function (House-Brackmann grade I) in all patients. Six patients with useful pre-operative hearing (GR class 1) underwent surgery with the aim to preserve cochlear nerve function; of these patients, 5 (83.3%) of them remained in GR class 1 and one (16.7%) lost hearing (GR class 5). Two patients having GR class 3 at baseline remained in the same GR class, but the tonal audiometry improved in one of them during follow-up. Eleven patients (57.8%) were in GR class 5 preoperatively; one patient improved hearing after surgery, passing to GR class 3 postoperatively. Following GKS, there were no new neurological deficits, with facial and hearing function remaining identical to that after surgery. CONCLUSION: Our data suggest that planned subtotal resection followed by GKS has an excellent clinical outcome with respect to retaining facial and cochlear nerve function. This represents a paradigm shift of the treatment goals from a complete tumor excision perspective to that of a surgery designed to preserve neural functions. As long-term results emerge, this approach of a combined treatment (microsurgery and GKS) will most probably become the standard of care in the management of large vestibular schwanomma.

Intraoperative angiography reloaded: a new hybrid operating theater for combined endovascular and surgical treatment of cerebral arteriovenous malformations: a pilot study on 25 patients.

BACKGROUND: Multimodality treatment suites for patients with cerebral arteriovenous malformations (AVM) have recently become available. This study was designed to evaluate feasibility, safety and impact on treatment of a new intraoperative flat-panel (FP) based integrated surgical and imaging suite for combined endovascular and surgical treatment of cerebral AVM. METHODS: Twenty-five patients with AVMs to treat with combined endovascular and surgical interventions were prospectively enrolled in this consecutive case series. The hybrid suite allows combined endovascular and surgical approaches with intraoperative scanner-like imaging (XperCT®) and intraoperative 3D rotational angiography (3D-RA). The impact of intraoperative multimodal imaging on feasibility, workflow of combined interventions, surgery, and unexpected imaging findings were analyzed. RESULTS: Twenty-five patients (mean age 38 ± 18.6 year) with a median Spetzler-Martin grade 2 AVM (range 1-4) underwent combined endovascular and surgical procedures. Sixteen patients presented with a ruptured AVM and nine with an unruptured AVM. In 16 % (n = 4) of cases, intraoperative imaging visualized AVM remnants ≤3 mm and allowed for completion of the resections in the same sessions. Complete resection was confirmed in all n = 16 patients who had follow-up angiography one year after surgery so far. All diagnostic and therapeutical steps, including angiographic control, were performed without having to move the patients CONCLUSION: The hybrid neurointerventional suite was shown to be a safe and useful setup which allowed for unconstrained combined microsurgical and neuroradiological workflow. It reduces the need for extraoperative angiographic controls and subsequent potential surgical revisions a second time, as small AVM remnants can be detected with high security.

Adaptive approach heuristics for the generalized assignment problem

The Generalized Assignment Problem consists in assigning a setof tasks to a set of agents with minimum cost. Each agent hasa limited amount of a single resource and each task must beassigned to one and only one agent, requiring a certain amountof the resource of the agent. We present new metaheuristics forthe generalized assignment problem based on hybrid approaches.One metaheuristic is a MAX-MIN Ant System (MMAS), an improvedversion of the Ant System, which was recently proposed byStutzle and Hoos to combinatorial optimization problems, and itcan be seen has an adaptive sampling algorithm that takes inconsideration the experience gathered in earlier iterations ofthe algorithm. Moreover, the latter heuristic is combined withlocal search and tabu search heuristics to improve the search.A greedy randomized adaptive search heuristic (GRASP) is alsoproposed. Several neighborhoods are studied, including one basedon ejection chains that produces good moves withoutincreasing the computational effort. We present computationalresults of the comparative performance, followed by concludingremarks and ideas on future research in generalized assignmentrelated problems.

Periphere okklusive Vaskulopathie bei einer Patientin mit kombinierter Präeklampsie und Alpha-Thalassämie minor [Peripheral occlusive retinal vasculopathy in a woman with combined preeclampsia and alpha thalassemia minor].

Normalerweise eine Störung der ersten Schwangerschaft, ist die Präeklampsie charakterisiert durch eine arterielle Hypertonie (> 140 mmHg systolisch oder > 90 mmHg diastolisch), die in der Regel nach der 20. Schwangerschaftswoche auftritt und von einer Proteinurie begleitet wird [1]. Die Präeklampsie wird als ,,schwer" bezeichnet, wenn sie mit einer wesentlichen Erhöhung des Blutdrucks (> 160 mmHg systolisch oder > 110 mmHg diastolisch), schwerer Proteinurie, Oligurie, Lungenödem, abdominalen Schmerzen, Leberfunktionsstörungen, Thrombozytopenie und visuellen oder zerebralen Symptomen einhergeht. Eine Eklampsie wiederum ist durch die Entwicklung von tonisch-klonischen Anfällen bei einer präeklamptischen Patientin charakterisiert. Bei der Alpha-Thalassämie tritt ein Defekt von 2 oder mehr der 4 Alpha-Globin-Gene auf. Von einer Alpha-Thalassämie minor spricht man, wenn 2 Alpha-Ketten-Gene deletiert sind. Sie tritt häufig bei Menschen aus Afrika, Südostasien, dem westindischen und mediterranen Raum auf. Die Alpha-Thalassämie minor verursacht eine milde bis moderate mikrozytäre Anämie. Wir berichten über eine Patientin mit peripherer okklusiver Vaskulopathie im Rahmen einer kombinierten Präeklampsie und Alpha-Thalassämie minor.

Use of a combined ex vivo/in vivo population approach for screening of human genes involved in the human immunodeficiency virus type 1 life cycle for variants influencing disease progression.

Humans differ substantially with respect to susceptibility to human immunodeficiency virus type 1 (HIV-1). We evaluated variants of nine host genes participating in the viral life cycle for their role in modulating HIV-1 infection. Alleles were assessed ex vivo for their impact on viral replication in purified CD4 T cells from healthy blood donors (n = 128). Thereafter, candidate alleles were assessed in vivo in a cohort of HIV-1-infected individuals (n = 851) not receiving potent antiretroviral therapy. As a benchmark test, we tested 12 previously reported host genetic variants influencing HIV-1 infection as well as single nucleotide polymorphisms in the nine candidate genes. This led to the proposition of three alleles of PML, TSG101, and PPIA as potentially associated with differences in progression of HIV-1 disease. In a model considering the combined effects of new and previously reported gene variants, we estimated that their effect might be responsible for lengthening or shortening by up to 2.8 years the period from 500 CD4 T cells/mul to <200 CD4 T cells/mul.