Whole-brain MR-registered cryo-imaging of a porcine-human glioma model to compare contrast agent biodistributions.

As rapidly accelerating technology, fluorescence guided surgery (FGS) has the potential to place molecular information directly into the surgeon's field of view by imaging administered fluorescent contrast agents in real time, circumnavigating pre-operative MR registration challenges with brain deformation. The most successful implementation of FGS is 5-ALA-PpIX guided glioma resection which has been linked to improved patient outcomes. While FGS may offer direct in-field guidance, fluorescent contrast agent distributions are not as familiar to the surgical community as Gd-MRI uptake, and may provide discordant information from previous Gd-MRI guidance. Thus, a method to assess and validate consistency between fluorescence-labeled tumor regions and Gd-enhanced tumor regions could aid in understanding the correlation between optical agent fluorescence and Gd-enhancement. Herein, we present an approach for comparing whole-brain fluorescence biodistributions with Gd-enhancement patterns on a voxel-by-voxel basis using co-registered fluorescent cryo-volumes and Gd-MRI volumes. In this initial study, a porcine-human glioma xenograft model was administered 5-ALA-PpIX, imaged with MRI, and euthanized 22 hours following 5-ALA administration. Following euthanization, the extracted brain was imaged with the cryo-macrotome system. After image processing steps and non-rigid, point-based registration, the fluorescence cryo-volume and Gd-MRI volume were compared for similarity metrics including: image similarity, tumor shape similarity, and classification similarity. This study serves as a proof-of-principle in validating our screening approach for quantitatively comparing 3D biodistributions between optical agents and Gd-based agents.

A hyperspectral approach for recovering agent excretion biodistributions using whole-body fluorescence cryo-imaging.

Understanding the uptake and clearance kinetics of new drugs and contrast agents is an important aspect of drug development that typically involves a combination of imaging and analysis of harvested organs. Although these techniques are well-established and can be quantitative, they generally do not preserve high resolution biodistribution information. In this context, fluorescence whole-body cryo-imaging is a promising technique for recovering 3D drug/agent biodistributions at a high resolution throughout an entire study animal at specific time points. A common challenge associated with fluorescence imaging in tissue is that agent signal can be confounded by endogenous fluorescence signal which is often observed in the visible window. One method to address this issue is to acquire hyperspectral images and spectrally unmix agent signal from confounding autofluorescence signals using known spectral bases. Herein, we apply hyperspectral whole-body cryo-imaging and spectral unmixing to examine the distribution of multiple fluorescent agents in excretion organ regions.

Killing of bacterial spores by dodecylamine and its effects on spore inner membrane properties.

AIMS: The objective of this study was to determine the effects of Ca-dipicolinic acid (CaDPA), cortex-lytic enzymes (CLEs), the inner membrane (IM) CaDPA channel and coat on spore killing by dodecylamine. METHODS AND RESULTS: Bacillus subtilis spores, wild-type, CaDPA-less due to the absence of DPA synthase or the IM CaDPA channel, or lacking CLEs, were dodecylamine-treated and spore viability and vital staining were all determined. Dodecylamine killed intact wild-type and CaDPA-less B. subtilis spores similarly, and also killed intact Clostridiodes difficile spores ± CaDPA, with up to 99% killing with 1 mol l-1 dodecylamine in 4 h at 45°C with spores at ~108  ml-1 . Dodecylamine killing of decoated wild type and CLE-less B. subtilis spores was similar, but ~twofold faster than for intact spores, and much faster for decoated CaDPA-less spores, with ≥99% killing in 5 min. Propidium iodide stained intact spores ± CaDPA minimally, decoated CaDPA-replete spores or dodecylamine-killed CLE-less spores peripherally, and cores of decoated CaDPA-less spores and dodecylamine-killed intact spores with CLEs. The IM of some decoated CaDPA-less spores was greatly reorganized. CONCLUSIONS: Dodecylamine spore killing does not require CaDPA channels, CaDPA or CLEs. The lack of CaDPA in decoated spores allowed strong PI staining of the spore core, indicating loss of these spores IM permeability barrier. SIGNIFICANCE AND IMPACT OF THE STUDY: This work gives new information on killing bacterial spores by dodecylamine, and how spore IM's relative impermeability is maintained.

Evaluating uptake of multiple fluorescent contrast agents in brain tumors simultaneously using whole animal multi-spectral cryo-imaging.

MRI images of gadolinium-based contrast agents (GBCA's) acquired before surgery are often registered to patients and used to guide surgical resection of intracranial tumors. Yet, the accuracy of these MR images in describing the surgical field degrades as surgery progresses; a well-recognized problem which has prompted efforts to develop new techniques that provide updated guidance information on residual tumor location. These efforts span a wide array of technologies, including image updating with deformation models, intraoperative MRI, and fluorescence guided surgery, among others. However, introduction of a straightforward technique that provides surgeons with a current view of GBCA distribution in real time remains an important goal. In this context, development of a fluorescent agent that recapitulates the kinetic behavior of GBCA's could provide familiar information directly in the surgical field in real time. To advance this strategy, we have begun identifying fluorescent contrast agents that show similar kinetic behavior to GBCA's. Using a novel hyperspectral whole body cryo-imaging system, we acquired high-resolution 3-D volumes of the distribution of multiple candidate fluorophores in whole heads bearing orthotopic brain tumors. Preliminary results reveal significant differences in the distribution of candidate optical agents, some of which show strong similarity to the GBCA uptake. Identification and eventual translation of a reliable GBCA-optical analog could improve and simplify surgical resection of brain tumors.

Considerations for NIR-I and short-wave infrared (SWIR) fluorescence imaging within a clinical operating room.

Short-wave infrared (SWIR/NIR-II) fluorescence imaging has received increased attention for use in fluorescence-guided surgery (FGS) due to the potential for higher resolution imaging of subsurface structures and reduced autofluorescence compared to conventional NIR-I imaging. As with any fluorescence imaging modality introduced in the operating room, an appropriate accounting of contaminating background signal from other light sources in the operating room is an important step. Herein, we report the background signals in the SWIR and NIR-I emitted from commonly-used equipment in the OR, such as ambient and operating lights, LCD screens and surgical guidance systems. These results can guide implementation of protocols to reduce background signal.

Multi-angle projection imaging of short-wave infrared (SWIR) fluorescence for small animal optical tomography.

Short-wave infrared imaging in tissue in the 1000-2000 nm range is characterized by reduced photon scatter and comparable or higher absorption compared to the NIR-I regime. These characteristics have implications for the performance of fluorescence molecular tomography (FMT) techniques, potentially improving the resolution of sub-surface structure, possibly at the expense of depth sensitivity. To examine these questions, we have developed a SWIR small animal fluorescence tomography system. This instrument acquires multi-angle SWIR projection images of a stationary platform through a rotating gantry technique. These images are then processed for tomographic reconstruction of the SWIR fluorescence activity. Herein, we describe the development of this system and show multi-angle images from a mouse carcass containing a SWIR-specific fluorophore inclusion.

Potential for populations of Aedes j. japonicus to transmit Rift Valley fever virus in the USA.

Aedes japonicus japonicus was introduced into the northeastern USA in 1998 and has since spread to more than 25 states. Because this species has been shown to be a competent laboratory vector of several viruses, readily feeds on large mammals, and has become a pest in several areas, there is concern that it might serve as a vector of Rift Valley fever virus (RVFV) should that virus be introduced into North America. Infection with RVFV causes mortality in > 90% of young domestic ungulates (e.g., calves, kids, and lambs), as well as causing a febrile illness and occasional deaths in humans. Therefore, we evaluated Ae. j. japonicus captured in North Carolina and in Maryland for their ability to serve as potential vectors for RVFV. After feeding on infected adult hamsters, these mosquitoes were tested for infection, dissemination, and the ability to transmit RVFV after incubation at 26 degrees C for 7-28 days. Both the Maryland and North Carolina populations of Ae. j. japonicus were highly efficient laboratory vectors of RVFV, with infection rates > 90% and dissemination rates > 84% for those mosquitoes that fed on hamsters with viremias > or = 10(8.5) plaque-forming units/ml. Thus, Ae. j. japonicus should be targeted for immediate control should RVFV be introduced into an area where this mosquito is now present.

Gender and contraction mode on perceived exertion.

The purpose of this study was to examine perceived exertion responses during concentric and eccentric elbow flexor contractions between young adult men and women. Thirty healthy young adults participated in two experimental sessions. During the first session, subjects performed five concentric isokinetic maximal voluntary contractions (MVC) of elbow flexion, followed by nine, randomly-ordered sub-maximal contractions (10-90% MVC). The same procedures were repeated during the second session, with the exception that eccentric contractions were performed. Subjects rated their perceived exertion following the sub-maximal contractions with the Borg category-ratio scale. Perceived exertion was significantly (p<0.05) less than equivalent values on the CR-10 scale at intensities greater than, and equal to, 30% MVC. A three-factor interaction between 30-40% MVC indicated that perceived exertion increased more during the eccentric, than concentric, contractions in women, while the opposite pattern was evident for the men. There were no significant contraction mode or gender differences. Power function modeling revealed that perceived exertion increased in a negatively accelerating manner, except for the men performing eccentric exercise. Perceived exertion increases in a similar non-linear manner between men and women during concentric contractions, while men exhibited a statistically linear pattern during eccentric contractions.

Does usefulness of potassium supplementation depend on speed?

REASONS FOR PERFORMING STUDY: Electrolyte mixtures given to counter sweat loss usually contain abundant potassium. However, increases in plasma [K+] occur with exercise and supplementation may further increase plasma levels, potentially increasing the risk of neuromuscular hyperexcitability and development of adverse clinical sequellae. This proposition requires study. OBJECTIVES: To compare effects of a K-rich electrolyte supplement (EM+K) to a K-free one (EM-K) on plasma [K+], [Ca++] and acid-base status during an endurance incremental exercise test on the treadmill. METHODS: The test consisted of 3 bouts (simulating loops in an endurance race) of 12 km performed at 6, then 7, then 8 m/sec with 25 min rest stops (S1, S2) between loops on 13 endurance trained Arabian horses (7 EM-K, 6 EM+K). Electrolytes were supplied orally 60 mins before exercise (Pre) and at each stop. Blood samples were taken before exercise and during exercise, each S and 120 mins of recovery (R). Blood was analysed for pH, PCO2, packed cell volume (PCV), plasma [Na+], [K+], [Cl-], [Ca++], glucose, and lactate [La-]; plasma [H+] and osmolality (osm) were calculated. The dietary cation anion difference (DCAD) was calculated to be -27 meq/dose EM-K and 109 meq in EM+K, respectively. RESULTS: Plasma [H+] decreased during the 6 and 7 m/sec loops, increased during the 8 m/sec loop, and returned to Pre at S1, S2 and R. Plasma [K+] was higher at 8 m/sec and plasma [Ca++] was overall lower in the EM+K group compared to EM-K. Other findings included higher overall PCV, overall glucose, and [La-] during the 8 m/sec loop (P<0.040) in EM+K compared to EM-K horses. CONCLUSIONS: EM+K supplementation leads to higher plasma [K+] increasing the risk of neuromuscular hyperexcitability during exercise. Acute effects of a lower DCAD in EM-K may have led to higher plasma [Ca++]. Potassium-rich electrolytes may have triggered the release of epinephrine, contributing to higher PCV, glucose release and increased lactate production. POTENTIAL RELEVANCE: Lower plasma [K+] and higher plasma [Ca++] with EM-K supplementation may help reduce the risk of conditions associated with neuromuscular hyperexcitability occurring especially during higher speeds in endurance races.

Mitral valve replacement and endocavitary patch repair for a giant left ventricular pseudoaneurysm.

We present a case of a giant inferior left ventricular (LV) wall pseudoaneurysm. The patient had New York Heart Association class IV heart failure due to severe mitral valve regurgitation and poor LV function. Our operative approach included right thoracotomy, excision of the mitral valve, and patch repair of the pseudoaneurysm neck from inside of the dilated LV cavity followed by mitral valve replacement. Surgery was performed without aortic cross-clamping on a normothermic perfused beating heart. The patient had an uncomplicated cardiac recovery and is doing well 15 months after surgery.

Iatrogenic paradoxical air embolism in pulmonary hypertension.

Paradoxical systemic air embolism (PAE) occurring as a complication of right-to-left intracardiac shunting during evaluation and treatment of pulmonary hypertension (PH) has not been previously reported. We report four cases of PH-associated PAE recently encountered at our center. Two patients with PH experienced transient neurologic deficits during agitated-saline contrast echocardiography (ASCE), and a patent foramen ovale was subsequently diagnosed in both patients. Two patients with Eisenmenger's syndrome (ES), while receiving epoprostenol via multilumen catheters, experienced transient neurologic deficits while flushing the unused port of the catheter. No patient experienced permanent neurologic deficits. We conclude that ASCE poses a risk for PAE in patients with PH and clinically silent, previously undetected, right-to-left intracardiac shunts, and that multilumen catheters used for long-term epoprostenol therapy in ES carry a risk of PAE.

Liver disease in patients with hereditary hemorrhagic telangiectasia.

BACKGROUND: Hereditary hemorrhagic telangiectasia, or Rendu-Osler-Weber disease, is an autosomal dominant disorder characterized by angiodysplastic lesions (telangiectases and arteriovenous malformations) that affect many organs. Liver involvement in patients with this disease has not been fully characterized. METHODS: We studied the clinical findings and results of hemodynamic, angiographic, and imaging studies in 19 patients with hereditary hemorrhagic telangiectasia and symptomatic liver involvement. RESULTS: We evaluated 14 women and 5 men who ranged in age from 34 to 74 years. All but one of the patients had a hyperdynamic circulation (cardiac index, 4.2 to 7.3 liters per minute per square meter of body-surface area). In eight patients, the clinical findings were consistent with the presence of high-output heart failure. The cardiac index and pulmonary-capillary wedge pressure were elevated in the six patients in whom these measurements were performed. After a median period of 24 months, the condition of three of the eight patients had improved, four were in stable condition with medical therapy, and one had died. Six patients had manifestations of portal hypertension such as ascites or variceal bleeding. The hepatic sinusoidal pressure was elevated in the four patients in whom it was measured. After a median period of 19 months, the condition of two of the six patients had improved, and the other four had died. Five patients had manifestations of biliary disease, such as an elevated alkaline phosphatase level and abnormalities on bile duct imaging. After a median period of 30 months, the condition of two of the five had improved, the condition of one was unchanged, heart failure had developed in one, and one had died after an unsuccessful attempt at liver transplantation. CONCLUSIONS: In patients with hereditary hemorrhagic telangiectasia and symptomatic liver-involvement, the typical clinical presentations include high-output heart failure, portal hypertension, and biliary disease.

Long-lasting improvement after septal myectomy for hypertrophic obstructive cardiomyopathy.

BACKGROUND: The most effective treatment of symptomatic patients with hypertrophic obstructive cardiomyopathy is still disputed. Treatment options include medical therapy, pacemaker insertion, percutaneous transluminal septal myocardial ablation, mitral valve replacement, and surgical resection of obstructing muscle. The long-term results of the various treatment options are not well defined. We aimed to demonstrate that septal myectomy is efficacious in reducing or abolishing left ventricular outflow tract gradient and leads to long-lasting symptomatic improvement in most patients. METHODS: Twenty-two consecutive patients had septal myectomy between 1981 and the present. Their records were reviewed to document the details of their preoperative status, hospital course, their subsequent clinical outcome, and current status. RESULTS: Mean age at operation was 31.3 years. Preoperatively all patients were disabled by typical symptoms despite aggressive medical treatment. Mean resting gradient was 78 mm Hg. Nine patients required simultaneous associated cardiac procedures. There were no perioperative deaths and minimal morbidity. Two patients died at 6 and 9 years postoperatively of congestive heart failure and arrhythmias. Long-term survivors have been followed up for a mean of 6.6 years. Currently all have minimal or no symptoms. The mean resting gradient was 12 mm Hg. No patient has required reoperation for residual obstruction. CONCLUSIONS: Septal myectomy reduces or abolishes left ventricular outflow tract gradient in hypertrophic obstructive cardiomyopathy. Myectomy provides long-lasting symptomatic improvement in most patients. The clinical status of patients late postoperatively can be affected by arrhythmias and myocardial dysfunction.

The cytotoxicity and mode of action of 2,3,4-trisubstituted pyrroles and related derivatives in human Tmolt4 leukemia cells.

4-Carbethoxy-1-methyl-2-phenacyl-3-phenylpyrrole (9), 4-carbethoxy-2-(4-methoxybenzoyl)-3-(4-methoxyphenyl)pyrrole (10) and 2-(4-methoxybenzoyl)-3,4-bis-(4-methoxyphenyl)pyrrole (11) proved to be potent cytotoxic agents against the growth of murine and human leukemias and lymphomas. Selective toxicity was demonstrated against the growth of solid tumors, e.g., human adenocarcinoma of the colon SW480 and ileum HCT-8, glioma U-87-MG, and rat UMR-106 osteosarcoma. A mode of action study in Tmolt4 leukemia cells demonstrated that the agents inhibited de novo purine synthesis at the regulatory sites PRPP-amido transferase, IMP dehydrogenase as well as dihydrofolate reductase resulting in significant inhibition of DNA synthesis in 60 min. Other biochemical sites which were affected significantly were thymidylate synthetase, DNA polymerase alpha, RNA polymerases, nucleoside kinase and ribonucleoside reductase.

Echocardiography in infective endocarditis.

BACKGROUND: Echocardiographic demonstration of valvular infection now ranks with positive blood cultures as one of the two major clinical criteria for diagnosis of infective endocarditis (IE), according to new, more accurate guidelines for diagnosis. Because early detection of IE and its complications is essential for determining whether to pursue medical therapy or to intervene surgically, transthoracic echocardiography (TTE) is an essential part of the initial examination of patients with suspected IE. METHODS: Using MEDLINE, we searched and reviewed all articles with the key words infective endocarditis and transesophageal echocardiography. RESULTS: With its superior imaging, transesophageal echocardiography (TEE) has proven to be more sensitive than TTE for the diagnosis of IE as well as in the detection of IE-associated complications. CONCLUSIONS: While superior in predicting which patients with IE have perivalvular abscess or prosthetic valve dysfunction and which are most susceptible to systemic embolism, TEE is more invasive and must be used selectively.

Echocardiographic and biochemical evaluation of the development and progression of carcinoid heart disease.

OBJECTIVES: To study the applicability of a newly developed echocardiographic scoring system in the assessment of carcinoid valvular heart disease. BACKGROUND: We investigated prospectively the development, progression and regression of carcinoid valvular heart disease in patients with carcinoid syndrome by serial echocardiography, correlating these features with urinary 5-HIAA levels and clinical data collected during therapy with somatostatin analog. METHODS: Twenty-three patients with carcinoid syndrome underwent serial echocardiographic examinations. An echocardiographic carcinoid valvular heart disease (CVHD) % score was determined from points assigned for tricuspid and pulmonary valve structure and function. RESULTS: Fifteen patients had no CVHD at study entry (group 1), while 8 patients had findings of CVHD (group 2). Five patients in group q developed new CVHD (1B), while one demonstrated progression of CVHD (2B). The remaining patients did not develop (1A) or had no progression of CVHD (2B). Despite major declines in 5-HIAA levels during therapy in most patients, CVHD did not regress. There were significantly lower levels of median baseline 5-HIAA (98.8 vs. 256 mg/24 h), posttreatment 5-HIAA (50.3 vs. 324 mg/24 h) and posttreatment 5-HIAA time integral (37.3 vs. 192 g/24 h* days) in group A vs. B (p < 0.05). However, only posttreatment 5-HIAA levels independently predicted the development or progression of CVHD by multiple step-wise regression analysis (p < 0.005), with a threshold observed in the 100 mg/24 h range. CONCLUSIONS: We designed a new echocardiographic scoring system to evaluate CVHD. Correlating echocardiographic scores with biochemical and clinical markers showed that only posttreatment 5-HIAA levels independently predicted the development or progression of CVHD. This study strengthens the association between serotonin secretion and CVHD, as well as introducing a new technique for serial follow-up of these patients.

Phase III multicenter trial comparing the efficacy of 2% dodecafluoropentane emulsion (EchoGen) and sonicated 5% human albumin (Albunex) as ultrasound contrast agents in patients with suboptimal echocardiograms.

OBJECTIVES: This study was performed to compare the safety and efficacy of intravenous 2% dodecafluoropentane (DDFP) emulsion (EchoGen) with that of active control (sonicated human albumin [Albunex]) for left ventricular (LV) cavity opacification in adult patients with a suboptimal echocardiogram. BACKGROUND: The development of new fluorocarbon-based echocardiographic contrast agents such as DDFP has allowed opacification of the left ventricle after peripheral venous injection. We hypothesized that DDFP was clinically superior to the Food and Drug Administration-approved active control. METHODS: This was a Phase III, multicenter, single-blind, active controlled trial. Sequential intravenous injections of active control and DDFP were given 30 min apart to 254 patients with a suboptimal echocardiogram, defined as one in which the endocardial borders were not visible in at least two segments in either the apical two- or four-chamber views. Studies were interpreted in blinded manner by two readers and the investigators. RESULTS: Full or intermediate LV cavity opacification was more frequently observed after DDFP than after active control (78% vs. 31% for reader A; 69% vs. 34% for reader B; 83% vs. 55% for the investigators, p < 0.0001). LV cavity opacification scores were higher with DDFP (2.0 to 2.5 vs. 1.1 to 1.5, p < 0.0001). Endocardial border delineation was improved by DDFP in 88% of patients versus 45% with active control (p < 0.001). Similar improvement was seen for duration of contrast effect, salvage of suboptimal echocardiograms, diagnostic confidence and potential to affect patient management. There was no difference between agents in the number of patients with adverse events attributed to the test agent (9% for DDFP vs. 6% for active control, p = 0.92). CONCLUSIONS: This Phase III multicenter trial demonstrates that DDFP is superior to sonicated human albumin for LV cavity opacification, endocardial border definition, duration of effect, salvage of suboptimal echocardiograms, diagnostic confidence and potential to influence patient management. The two agents had similar safety profiles.

Resolution of vegetations with anticoagulation after myocardial infarction in primary antiphospholipid syndrome.

We report here a case of primary antiphospholipid syndrome with all three clinical features with acute myocardial infarction. Echocardiography showed large vegetations at both mitral valve leaflets. Laboratory evaluation showed presence of antiphospholipid antibodies. High-intensity anticoagulation was begun, and repeat echocardiographic study in 4 months showed disappearance of the mitral valve vegetations.