Rigor mortis at the myocardium investigated by post-mortem magnetic resonance imaging

INTRODUCTION Post-mortem cardiac MR exams present with different contraction appearances of the left ventricle in cardiac short axis images. It was hypothesized that the grade of post-mortem contraction may be related to the post-mortem interval (PMI) or cause of death and a phenomenon caused by internal rigor mortis that may give further insights in the circumstances of death. METHOD AND MATERIALS The cardiac contraction grade was investigated in 71 post-mortem cardiac MR exams (mean age at death 52y, range 12-89y; 48 males, 23 females). In cardiac short axis images the left ventricular lumen volume as well as the left ventricular myocardial volume were assessed by manual segmentation. The quotient of both (LVQ) represents the grade of myocardial contraction. LVQ was correlated to the PMI, sex, age, cardiac weight, body mass and height, cause of death and pericardial tamponade when present. In cardiac causes of death a separate correlation was investigated for acute myocardial infarction cases and arrhythmic deaths. RESULTS LVQ values ranged from 1.99 (maximum dilatation) to 42.91 (maximum contraction) with a mean of 15.13. LVQ decreased slightly with increasing PMI, however without significant correlation. Pericardial tamponade positively correlated with higher LVQ values. Variables such as sex, age, body mass and height, cardiac weight and cause of death did not correlate with LVQ values. There was no difference in LVQ values for myocardial infarction without tamponade and arrhythmic deaths. CONCLUSION Based on the observation in our investigated cases, the phenomenon of post-mortem myocardial contraction cannot be explained by the influence of the investigated variables, except for pericardial tamponade cases. Further research addressing post-mortem myocardial contraction has to focus on other, less obvious factors, which may influence the early post-mortem phase too.

Dynamic changes of intramural hematoma in patients with acute spontaneous internal carotid artery dissection.

BACKGROUND We prospectively investigated temporal and spatial evolution of intramural hematomas in patients with acute spontaneous internal carotid artery dissection using repeated magnetic resonance imaging over six-months. AIM The aim of the present study was to assess dynamic changes of intramural hematoma in patients with acute spontaneous internal carotid artery dissection at multiple follow-up time-points with T1w, PD/T2w, and magnetic resonance angiography. METHODS We performed serial multiparametric magnetic resonance imaging in 10 patients with spontaneous internal carotid artery dissection on admission, at days 1, 3, 7-14 and at months 1·5, 3, and 6. We calculated the volume and extension of the hyperintense intramural hematoma using T1w and PD/T2w fat suppressed sequences and assessed the degree of stenosis due to the hematoma using magnetic resonance angiography. RESULTS Mean interval from symptom onset to first magnetic resonance imaging was two-days (SD 2·7). Two patients presented with ischemic stroke, three with transient ischemic attacks, and five with pain and local symptoms only. Nine patients had a transient increase of the intramural hematoma volume, mainly up to day 10 after symptom onset. Fifty percent had a transient increase in the degree of the internal carotid artery stenosis on MRA, one resulting in a temporary occlusion. Lesions older than one-week were predominantly characterized by a shift from iso- to hyperintese signal on T2w images. At three-month follow-up, intramural hematoma was no longer detectable in 80% of patients and had completely resolved in all patients after six-months. CONCLUSIONS Spatial and temporal dynamics of intramural hematomas after spontaneous internal carotid artery dissection showed an early volume increase with concomitant progression of the internal carotid artery stenosis in 5 of 10 patients. Although spontaneous internal carotid artery dissection overall carries a good prognosis with spontaneous hematoma resorption in all our patients, early follow-up imaging may be considered, especially in case of new clinical symptoms.

Application of NMR techniques for the evaluation of fruit internal quality and physical properties of food

Los alimentos son sistemas complejos, formados por diversas estructuras a diferentes escalas: macroscópica y microscópica. Muchas propiedades de los alimentos, que son importantes para su procesamiento, calidad y tratamiento postcosecha, están relacionados con su microestructura. La presente tesis doctoral propone una metodología completa para la determinación de la estructura de alimentos desde un punto de vista multi-escala, basándose en métodos de Resonancia Magnética Nuclear (NMR). Las técnicas de NMR son no invasivas y no destructivas y permiten el estudio tanto de macro- como de microestructura. Se han utilizado distintos procedimientos de NMR dependiendo del nivel que se desea estudiar. Para el nivel macroestructural, la Imagen de Resonancia Magnética (MRI) ha resultado ser muy útil para la caracterización de alimentos. Para el estudio microestructural, la MRI requiere altos tiempos de adquisición, lo que hace muy difícil la transferencia de esta técnica a aplicaciones en industria. Por tanto, la optimización de procedimientos de NMR basados en secuencias relaxometría 2D T1/T2 ha resultado ser una estrategia primordial en esta tesis. Estos protocolos de NMR se han implementado satisfactoriamente por primera vez en alto campo magnético. Se ha caracterizado la microestructura de productos alimentarios enteros por primera vez utilizando este tipo de protocolos. Como muestras, se han utilizado dos tipos de productos: modelos de alimentos y alimentos reales (manzanas). Además, como primer paso para su posterior implementación en la industria agroalimentaria, se ha mejorado una línea transportadora, especialmente diseñada para trabajar bajo condiciones de NMR en trabajos anteriores del grupo LPF-TAGRALIA. Se han estudiado y seleccionado las secuencias más rápidas y óptimas para la detección de dos tipos de desórdenes internos en manzanas: vitrescencia y roturas internas. La corrección de las imágenes en movimiento se realiza en tiempo real. Asimismo, se han utilizado protocolos de visión artificial para la clasificación automática de manzanas potencialmente afectadas por vitrescencia. El presente documento está dividido en diferentes capítulos: el Capítulo 2 explica los antecedentes de la presente tesis y el marco del proyecto en el que se ha desarrollado. El Capítulo 3 recoge el estado del arte. El Capítulo 4 establece los objetivos de esta tesis doctoral. Los resultados se dividen en cinco sub-secciones (dentro del Capítulo 5) que corresponden con los trabajos publicados bien en revistas revisadas por pares, bien en congresos internacionales o bien como capítulos de libros revisados por pares. La Sección 5.1. es un estudio del desarrollo de la vitrescencia en manzanas mediante MRI y lo relaciona con la posición de la fruta dentro de la copa del árbol. La Sección 5.2 presenta un trabajo sobre macro- y microestructura en modelos de alimentos. La Sección 5.3 es un artículo en revisión en una revista revisada por pares, en el que se hace un estudio microestrcutural no destructivo mediante relaxometría 2D T1/T2. la Sección 5.4, hace una comparación entre manzanas afectadas por vitrescencia mediante dos técnicas: tomografía de rayos X e MRI, en manzana. Por último, en la Sección 5.5 se muestra un trabajo en el que se hace un estudio de secuencias de MRI en línea para la evaluación de calidad interna en manzanas. Los siguientes capítulos ofrecen una discusión y conclusiones (Capítulo 6 y 7 respectivamente) de todos los capítulos de esta tesis doctoral. Finalmente, se han añadido tres apéndices: el primero con una introducción de los principios básicos de resonancia magnética nuclear (NMR) y en los otros dos, se presentan sendos estudios sobre el efecto de las fibras en la rehidratación de cereales de desayuno extrusionados, mediante diversas técnicas. Ambos trabajos se presentaron en un congreso internacional. Los resultados más relevantes de la presente tesis doctoral, se pueden dividir en tres grandes bloques: resultados sobre macroestructura, resultados sobre microestructura y resultados sobre MRI en línea. Resultados sobre macroestructura: - La imagen de resonancia magnética (MRI) se aplicó satisfactoriamente para la caracterización de macroestructura. En particular, la reconstrucción 3D de imágenes de resonancia magnética permitió identificar y caracterizar dos tipos distintos de vitrescencia en manzanas: central y radial, que se caracterizan por el porcentaje de daño y la conectividad (número de Euler). - La MRI proveía un mejor contraste para manzanas afectadas por vitrescencia que las imágenes de tomografía de rayos X (X-Ray CT), como se pudo verificar en muestras idénticas de manzana. Además, el tiempo de adquisición de la tomografía de rayos X fue alrededor de 12 veces mayor (25 minutos) que la adquisición de las imágenes de resonancia magnética (2 minutos 2 segundos). Resultados sobre microestructura: - Para el estudio de microestructura (nivel subcelular) se utilizaron con éxito secuencias de relaxometría 2D T1/T2. Estas secuencias se usaron por primera vez en alto campo y sobre piezas de alimento completo, convirtiéndose en una forma no destructiva de llevar a cabo estudios de microestructura. - El uso de MRI junto con relaxometría 2D T1/T2 permite realizar estudios multiescala en alimentos de forma no destructiva. Resultados sobre MRI en línea: - El uso de imagen de resonancia magnética en línea fue factible para la identificación de dos tipos de desórdenes internos en manzanas: vitrescencia y podredumbre interna. Las secuencias de imagen tipo FLASH resultaron adecuadas para la identificación en línea de vitrescencia en manzanas. Se realizó sin selección de corte, debido a que la vitrescencia puede desarrollarse en cualquier punto del volumen de la manzana. Se consiguió reducir el tiempo de adquisición, de modo que se llegaron a adquirir 1.3 frutos por segundos (758 ms por fruto). Las secuencias de imagen tipo UFLARE fueron adecuadas para la detección en línea de la podredumbre interna en manzanas. En este caso, se utilizó selección de corte, ya que se trata de un desorden que se suele localizar en la parte central del volumen de la manzana. Se consiguió reducir el tiempo de adquisicón hasta 0.67 frutos por segundo (1475 ms por fruto). En ambos casos (FLASH y UFLARE) fueron necesarios algoritmos para la corrección del movimiento de las imágenes en tiempo real. ABSTRACT Food is a complex system formed by several structures at different scales: macroscopic and microscopic. Many properties of foods that are relevant to process engineering or quality and postharvest treatments are related to their microstructure. This Ph.D Thesis proposes a complete methodology for food structure determination, in a multiscale way, based on the Nuclear Magnetic Resonance (NMR) phenomenon since NMR techniques are non-invasive and non-destructive, and allow both, macro- and micro-structure study. Different NMR procedures are used depending on the structure level under study. For the macrostructure level, Magnetic Resonance Imaging (MRI) revealed its usefulness for food characterization. For microstructure insight, MRI required high acquisition times, which is a hindrance for transference to industry applications. Therefore, optimization of NMR procedures based on T1/T2 relaxometry sequences was a key strategy in this Thesis. These NMR relaxometry protocols, are successfully implemented in high magnetic field. Microstructure of entire food products have been characterized for the first time using these protocols. Two different types of food products have been studied: food models and actual food (apples). Furthermore, as a first step for the food industry implementation, a grading line system, specially designed for working under NMR conditions in previous works of the LPF-TAGRALIA group, is improved. The study and selection of the most suitable rapid sequence to detect two different types of disorders in apples (watercore and internal breakdown) is performed and the real time image motion correction is applied. In addition, artificial vision protocols for the automatic classification of apples potentially affected by watercore are applied. This document is divided into seven different chapters: Chapter 2 explains the thesis background and the framework of the project in which it has been worked. Chapter 3 comprises the state of the art. Chapter 4 establishes de objectives of this Ph.D thesis. The results are divided into five different sections (in Chapter 5) that correspond to published peered reviewed works. Section 5.1 assesses the watercore development in apples with MRI and studies the effect of fruit location in the canopy. Section 5.2 is an MRI and 2D relaxometry study for macro- and microstructure assessment in food models. Section 5.3 is a non-destructive microstructural study using 2D T1/T2 relaxometry on watercore affected apples. Section 5.4 makes a comparison of X-ray CT and MRI on watercore disorder of different apple cultivars. Section 5.5, that is a study of online MRI sequences for the evaluation of apple internal quality. The subsequent chapters offer a general discussion and conclusions (Chapter 6 and Chapter 7 respectively) of all the works performed in the frame of this Ph.D thesis (two peer reviewed journals, one book chapter and one international congress).Finally, three appendices are included in which an introduction to NMR principles is offered and two published proceedings regarding the effect of fiber on the rehydration of extruded breakfast cereal are displayed. The most relevant results can be summarized into three sections: results on macrostructure, results on microstructure and results on on-line MRI. Results on macrostructure: - MRI was successfully used for macrostructure characterization. Indeed, 3D reconstruction of MRI in apples allows to identify two different types of watercore (radial and block), which are characterized by the percentage of damage and the connectivity (Euler number). - MRI provides better contrast for watercore than X-Ray CT as verified on identical samples. Furthermore, X-Ray CT images acquisition time was around 12 times higher (25 minutes) than MRI acquisition time (2 minutes 2 seconds). Results on microstructure: - 2D T1/T2 relaxometry were successfully applied for microstructure (subcellular level) characterization. 2D T1/T2 relaxometry sequences have been applied for the first time on high field for entire food pieces, being a non-destructive way to achieve microstructure study. - The use of MRI together with 2D T1/T2 relaxometry sequences allows a non-destructive multiscale study of food. Results on on-line MRI: - The use of on-line MRI was successful for the identification of two different internal disorders in apples: watercore and internal breakdown. FLASH imaging was a suitable technique for the on-line detection of watercore disorder in apples, with no slice selection, since watercore is a physiological disorder that may be developed anywhere in the apple volume. 1.3 fruits were imaged per second (768 ms per fruit). UFLARE imaging is a suitable sequence for the on-line detection of internal breakdown disorder in apples. Slice selection was used, as internal breakdown is usually located in the central slice of the apple volume. 0.67 fruits were imaged per second (1475 ms per fruit). In both cases (FLASH and UFLARE) motion correction was performed in real time, during the acquisition of the images.

Screening with magnetic resonance imaging and mammography of a UK population at high familial risk of breast cancer: a prospective multicentre cohort study (MARIBS)

Background Women genetically predisposed to breast cancer often develop the disease at a young age when dense breast tissue reduces the sensitivity of X-ray mammography. Our aim was, therefore, to compare contrast enhanced magnetic resonance imaging (CE MRI) with mammography for screening. Methods We did a prospective multicentre cohort study in 649 women aged 35-49 years with a strong family history of breast cancer or a high probability of a BRCA1, BRCA2, or TP53 mutation. We recruited participants from 22 centres in the UK, and offered the women annual screening with CE MRI and mammography for 2-7 years. Findings We diagnosed 35 cancers in the 649 women screened with both mammography and CE MRI (1881 screens): 19 by CE MRI only, six by mammography only, and eight by both, with two interval cases. Sensitivity was significantly higher for CE MRI (77%, 95% CI 60-90) than for mammography (40%, 24-58; p=0.01), and was 94% (81-99) when both methods were used. Specificity was 93% (92-95) for mammography, 81% (80-83) for CE MRI (p

Resonance properties of domain boundaries in quasi-two dimensional antiferromagnets

The so-called "internal modes" localized near the domain boundaries in quasi-two dimensional antiferromagnets are investigated. The possible localized states are classified and their frequency dependences on the system discreteness parameter λ=J/β, which describes the ratio of the magnitudes of the exchange interplane interaction and the magnetic anisotropy, are found. A sudden change in the spectrum of the local internal modes is observed at a critical value of this parameter, λ=λb=3/4, where the domain wall shifts from a collinear to a canted shape. When λ<λb there are one symmetric and two antisymmetric local modes, and when λ>λb the modes are two symmetric, one antisymmetric, and one shear. For discreteness parameters close to the critical value, the frequencies of some of the local modes lie deep inside the gap for the linear AFM magnon spectrum and can be observed experimentally. © 2010 American Institute of Physics.

Cardiac magnetic resonance imaging in the diagnosis and determination of outcome of pulmonary hypertension

Pulmonary hypertension (PH) is a rare but serious condition that causes progressive right ventricular (RV) failure and death. PH may be idiopathic, associated with underlying connective-tissue disease or hypoxic lung disease, and is also increasingly being observed in the setting of heart failure with preserved ejection fraction (HFpEF). The management of PH has been revolutionised by the recent development of new disease-targeted therapies which are beneficial in pulmonary arterial hypertension (PAH), but can be potentially harmful in PH due to left heart disease, so accurate diagnosis and classification of patients is essential. These PAH therapies improve exercise capacity and pulmonary haemodynamics, but their overall effect on the right ventricle remains unclear. Current practice in the UK is to assess treatment response with 6-minute walk test and NYHA functional class, neither of which truly reflects RV function. Cardiac magnetic resonance (CMR) imaging has been established as the gold standard for the evaluation of right ventricular structure and function, but it also allows a non-invasive and accurate study of the left heart. The aims of this thesis were to investigate the use of CMR in the diagnosis of PH, in the assessment of treatment response, and in predicting survival in idiopathic and connective-tissue disease associated PAH. In Chapter 3, a left atrial volume (LAV) threshold of 43 ml/m2 measured with CMR was able to distinguish idiopathic PAH from PH due to HFpEF (sensitivity 97%, specificity 100%). In Chapter 4, disease-targeted PAH therapy resulted in significant improvements in RV and left ventricular ejection fraction (p<0.001 and p=0.0007, respectively), RV stroke volume index (p<0.0001), and left ventricular end-diastolic volume index (p=0.0015). These corresponded to observed improvements in functional class and exercise capacity, although correlation coefficients between Δ 6MWD and Δ RVEF or Δ LVEDV were low. Finally, in Chapter 5, one-year and three-year survival was worse in CTD-PAH (75% and 53%) than in IPAH (83% and 74%), despite similar baseline clinical characteristics, lung function, pulmonary haemodynamics and treatment. Baseline right ventricular stroke volume index was an independent predictor of survival in both conditions. The presence of LV systolic dysfunction was of prognostic significance in CTD-PAH but not IPAH, and a higher LAV was observed in CTD-PAH suggesting a potential contribution from LV diastolic dysfunction in this group.

Cerebral misery perfusion diagnosed using hypercapnic blood-oxygenation-level-dependent contrast functional magnetic resonance imaging: a case report

Introduction Cerebral misery perfusion represents a failure of cerebral autoregulation. It is animportant differential diagnosis in post-stroke patients presenting with collapses in the presence of haemodynamically significant cerebrovascular stenosis. This is particularly the case when cortical or internal watershed infarcts are present. When this condition occurs, further investigation should be done immediately. Case presentation A 50-year-old Caucasian man presented with a stroke secondary to complete occlusion of his left internal carotid artery. He went on to suffer recurrent seizures. Neuroimaging demonstrated numerous new watershed-territory cerebral infarcts. No source of arterial thromboembolism was demonstrable. Hypercapnic blood-oxygenation-level-dependent-contrast functional magnetic resonance imaging was used to measure his cerebrovascular reserve capacity. The findings were suggestive of cerebral misery perfusion. Conclusions Blood-oxygenation-level-dependent-contrast functional magnetic resonance imaging allows the inference of cerebral misery perfusion. This procedure is cheaper and more readily available than positron emission tomography imaging, which is the current gold standard diagnostic test. The most evaluated treatment for cerebral misery perfusion is extracranial-intracranial bypass. Although previous trials of this have been unfavourable, the results of new studies involving extracranial-intracranial bypass in high-risk patients identified during cerebral perfusion imaging are awaited. Cerebral misery perfusion is an important and under-recognized condition in which emerging imaging and treatment modalities present the possibility of practical and evidence-based management in the near future. Physicians should thus be aware of this disorder and of recent developments in diagnostic tests that allow its detection.

Utility and safety of invasive (fractional flow reserve) and non-invasive (cardiac magnetic resonance imaging) diagnostic tests in patients with NSTEMI

A prospective randomised controlled clinical trial of treatment decisions informed by invasive functional testing of coronary artery disease severity compared with standard angiography-guided management was implemented in 350 patients with a recent non-ST elevation myocardial infarction (NSTEMI) admitted to 6 hospitals in the National Health Service. The main aims of this study were to examine the utility of both invasive fractional flow reserve (FFR) and non-invasive cardiac magnetic resonance imaging (MRI) amongst patients with a recent diagnosis of NSTEMI. In summary, the findings of this thesis are: (1) the use of FFR combined with intravenous adenosine was feasible and safe amongst patients with NSTEMI and has clinical utility; (2) there was discordance between the visual, angiographic estimation of lesion significance and FFR; (3). The use of FFR led to changes in treatment strategy and an increase in prescription of medical therapy in the short term compared with an angiographically guided strategy; (4) in the incidence of major adverse cardiac events (MACE) at 12 months follow up was similar in the two groups. Cardiac MRI was used in a subset of patients enrolled in two hospitals in the West of Scotland. T1 and T2 mapping methods were used to delineate territories of acute myocardial injury. T1 and T2 mapping were superior when compared with conventional T2-weighted dark blood imaging for estimation of the ischaemic area-at-risk (AAR) with less artifact in NSTEMI. There was poor correlation between the angiographic AAR and MRI methods of AAR estimation in patients with NSTEMI. FFR had a high accuracy at predicting inducible perfusion defects demonstrated on stress perfusion MRI. This thesis describes the largest randomized trial published to date specifically looking at the clinical utility of FFR in the NSTEMI population. We have provided evidence of the diagnostic and clinical utility of FFR in this group of patients and provide evidence to inform larger studies. This thesis also describes the largest ever MRI cohort, including with myocardial stress perfusion assessments, specifically looking at the NSTEMI population. We have demonstrated the diagnostic accuracy of FFR to predict reversible ischaemia as referenced to a non-invasive gold standard with MRI. This thesis has also shown the futility of using dark blood oedema imaging amongst all comer NSTEMI patients when compared to novel T1 and T2 mapping methods.

The Impact of Internal Market Orientation on Staff Service Behaviours

The impact of service direction, service training and staff behaviours on perceptions of service delivery are examined. The impact of managerial behaviour in the form of internal market orientation (IMO) on the attitudes of frontline staff towards the firm and its consequent influence on their customer oriented behaviours is also examined. Frontline service staff working in the consumer transport industry were surveyed to provide subjective data about the constructs of interest in this study, and the data were analysed using structural equations modelling employing partial least squares estimation. The data indicate significant relationships between internal market orientation (IMO), the attitudes of the employees to the firm and their consequent behaviour towards customers. Customer orientation, service direction and service training are all identified as antecedents to high levels of service delivery. The study contributes to marketing theory by providing quantitative evidence to support assumptions that internal marketing has an impact on services success. For marketing practitioners, the research findings offer additional information about the management, training and motivation of service staff towards service excellence.