Two cases of acute severe flaccid myelitis associated with enterovirus D68 infection in children, Norway, autumn 2014.

Enterovirus D68 (EV-D68), phylogenetic clade B was identified in nasopharyngeal specimens of two cases of severe acute flaccid myelitis. The cases were six and five years-old and occurred in September and November 2014. EV-D68 is increasingly associated with acute flaccid myelitis in children, most cases being reported in the United States. Awareness of this possible neurological complication of enterovirus D68 infection is needed.

The effect of vildagliptin relative to sulphonylureas in Muslim patients with type 2 diabetes fasting during Ramadan: the VIRTUE study.

AIMS: To assess, in a real-world setting, the effect of vildagliptin compared with sulphonylurea (SU) treatment on hypoglycaemia in Muslim patients with type 2 diabetes mellitus (T2DM) fasting during Ramadan. METHODS: This multinational, non-interventional study, conducted in Asia and the Middle East, included Muslim adult patients with T2DM who received treatment with vildagliptin or SU as add-on to metformin or monotherapy. During a ~16-week observation period, data were collected up to 6 weeks before and 6 weeks after Ramadan fasting. The primary study objective was to compare the proportion of patients with ≥ 1 hypoglycaemic event (HE) during fasting. RESULTS: Of > 1300 patients enrolled in the study, 684 were treated with vildagliptin and 631 with SUs. Significantly fewer patients experienced ≥ 1 HE with vildagliptin compared with those receiving SUs (5.4% vs. 19.8%, respectively; p < 0.001); no vildagliptin-treated patients reported a grade 2 HE, vs. 4 SU-treated patients (p = 0.053). Mean HbA1c changes from baseline were vildagliptin: -0.24%, SUs: +0.02% (p < 0.001). Mean body weight reductions from baseline were vildagliptin: -0.76 kg, SUs: -0.13 kg (p < 0.001). A higher proportion of SU-treated patients experienced adverse events (AEs) compared with vildagliptin (22.8% vs. 10.2%). This difference was driven by hypoglycaemia as the most common AE. CONCLUSIONS: In this real-world study of fasting Muslim patients with T2DM, vildagliptin was associated with significantly fewer hypoglycaemic episodes compared with SU therapy. This outcome is particularly meaningful when viewed in the context of good glycaemic and weight control observed in vildagliptin-treated patients. Vildagliptin was well tolerated in this patient population.

Measurements of hyperpolarized gas properties in the lung. Part III: (3)He T(1).

Hyperpolarized (3)He spin-lattice relaxation was investigated in the guinea pig lung using spectroscopy and imaging techniques with a repetitive RF pulse series. T(1) was dominated by interactions with oxygen and was used to measure the alveolar O(2) partial pressure. In animals ventilated with a mixture of 79% (3)He and 21% O(2), T(1) dropped from 19.6 sec in vivo to 14.6 sec after cardiac arrest, reflecting the termination of the intrapulmonary gas exchange. The initial difference in oxygen concentration between inspired and alveolar air, and the temporal decay during apnea were related to functional parameters. Estimates of oxygen uptake were 29 +/- 11 mL min(-1) kg(-1) under normoxic conditions, and 9.0 +/- 2.0 mL min(-1) kg(-1) under hypoxic conditions. Cardiac output was estimated to be 400 +/- 160 mL min(-1) kg(-1). The functional residual capacity derived from spirometric magnetic resonance experiments varied with body mass between 5.4 +/- 0.3 mL and 10.7 +/- 1.1 mL. Magn Reson Med 45:421-430, 2001.

Detection of emphysema in rat lungs by using magnetic resonance measurements of 3He diffusion.

Emphysema is a pulmonary disease characterized by alveolar wall destruction, resulting in enlargement of gas exchange spaces without fibrosis. This condition is a part of chronic obstructive pulmonary disease (COPD), which causes 3.5% of deaths worldwide [Anonymous (1990) World Health Stat. Q. Special, 1-51] and contributes greatly to the global burden of disease [Murray, C. J. & Lopez, A. D. (1996) Science 274, 740-743]. Alveolar regeneration has been shown in animal models and could have potential for clinical treatment of early-stage emphysema. However, current techniques for detection of emphysema are not sensitive at the initial stages. Early-stage human panacinar emphysema is modeled in elastase-treated animals. Here, we provide an in vivo imaging method for differentiating normal and emphysematous rat lungs by measuring the apparent diffusion coefficient (ADC) of hyperpolarized (3)He by using magnetic resonance imaging. These data show that the ADC is significantly larger in elastase-treated rats, indicating alveolar expansion. Whereas these rats were clinically asymptomatic, conventional histology confirmed presence of injury. Our results indicate that measurement of the hyperpolarized (3)He ADC can be a valuable research tool and has potential application in the clinical setting.

Mixing oxygen with hyperpolarized (3)He for small-animal lung studies.

Hyperpolarized helium (HP (3)He) is useful for direct MR imaging of the gas spaces of small animal lungs. Previously, breaths of 100% HP (3)He were alternated with breaths of air to maximize helium signal in the lungs and to minimize the depolarizing effects of O(2). However, for high-resolution imaging requiring many HP (3)He breaths (hundreds) and for pulmonary disease studies, a method was needed to simultaneously deliver O(2) and HP (3)He with each breath without significant loss of polarization. We modified our existing computer-controlled ventilator by adding a plastic valve, additional relays and a controller. O(2) and HP (3)He are mixed at the beginning of each breath within the body of a breathing valve, which is attached directly to the endotracheal tube. With this mixing method, we found that T(1) relaxation of HP (3)He in the guinea pig lung was about 20 s compared to 30 s with alternate air/HP (3)He breathing. Because imaging times during each breath are short (about 500 ms), the HP (3)He signal loss from O(2) contact is calculated to be less than 5%. We concluded that the advantages of mixing HP (3)He with O(2), such as shorter imaging times (reduced T(1) losses in reservoir) and improved physiologic stability, outweigh the small signal loss from the depolarizing effects of oxygen on HP (3)He.

Hyperpolarized 3He microspheres as a novel vascular signal source for MRI.

Hyperpolarized (HP) 3He can be encapsulated within biologically compatible microspheres while retaining sufficient polarization to be used as a signal source for MRI. Two microsphere sizes were used, with mean diameters of 5.3 +/- 1.3 microm and 10.9 +/- 3.0 microm. These suspensions ranged in concentration from 0.9-7.0% gas by volume. Spectroscopic measurements in phantoms at 2 T yielded 3He relaxation times that varied with gas concentration. At the highest 3He concentration, the spinlattice relaxation time, T1, was 63.8 +/- 9.4 sec, while the transverse magnetization decayed with a time constant of T2* = 11.0 +/- 0.4 msec. In vivo MR images of the pelvic veins in a rat were acquired during intravenous injection of 3He microspheres (SNR approximately equal 15). Advantages such as intravascular confinement, lack of background signal, and limited recirculation indicate quantitative perfusion measurements may be improved using this novel signal source.

Spatially resolved measurements of hyperpolarized gas properties in the lung in vivo. Part I: diffusion coefficient.

In imaging of hyperpolarized noble gases, a knowledge of the diffusion coefficient (D) is important both as a contrast mechanism and in the design of pulse sequences. We have made diffusion coefficient maps of both hyperpolarized (3)He and (129)Xe in guinea pig lungs. Along the length of the trachea, (3)He D values were on average 2.4 cm(2)/sec, closely reproducing calculated values for free gas (2.05 cm(2)/sec). The (3)He D values measured perpendicular to the length of the trachea were approximately a factor of two less, indicating restriction to diffusion. Further evidence of restricted diffusion was seen in the distal pulmonary airspaces as the average (3)He D was 0.16 cm(2)/sec. An additional cause for the smaller (3)He D in the lung was due to the presence of air, which is composed of heavier and larger gases. The (129)Xe results show similar trends, with the trachea D averaging 0.068 cm(2)/sec and the lung D averaging 0.021 cm(2)/sec. Magn Reson Med 42:721-728, 1999.

Spatially resolved measurements of hyperpolarized gas properties in the lung in vivo. Part II: T *(2).

The transverse relaxation time, T *(2), of hyperpolarized (HP) gas in the lung in vivo is an important parameter for pulse sequence optimization and image contrast. We obtained T *(2) maps of HP (3)He and (129)Xe in guinea pig lungs (n = 17) and in human lungs. Eight different sets of (3)He guinea pig studies were acquired, with variation of slice selection, tidal volume, and oxygen level. For example, for a (3)He tidal volume of 3 cm(3) and no slice selection, the average T *(2) in the trachea was 14.7 ms and 8.0 ms in the intrapulmonary airspaces. The equivalent (129)Xe experiment yielded an average T *(2) of 40.8 ms in the trachea and 18.5 ms in the intrapulmonary airspaces. The average (3)He T *(2) in the human intrapulmonary airspaces was 9.4 ms. The relaxation behavior was predicted by treating the lung as a porous medium, resulting in good agreement between estimated and measured T *(2) values in the intrapulmonary airspaces. Magn Reson Med 42:729-737, 1999.

Functional MR microscopy of the lung using hyperpolarized 3He.

A new strategy designed to provide functional magnetic resonance images of the lung in small animals at microscopic resolution using hyperpolarized 3He is described. The pulse sequence is based on a combination of radial acquisition (RA) and CINE techniques, referred to as RA-CINE, and is designed for use with hyperpolarized 3He to explore lung ventilation with high temporal and spatial resolution in small animal models. Ventilation of the live guinea pig is demonstrated with effective temporal resolution of 50 msec and in-plane spatial resolution of <100 microm using hyperpolarized 3He. The RA-CINE sequence allows one to follow gas inflow and outflow in the airways as well as in the distal part of the lungs. Regional analysis of signal intensity variations can be performed and can help assess functional lung parameters such as residual gas volume and lung compliance to gas inflow.

Sensitivity and resolution in 3D NMR microscopy of the lung with hyperpolarized noble gases.

Three-dimensional magnetic resonance images of the guinea pig lung were acquired in vivo using hyperpolarized (HP) noble gases and radial projection encoding (PE). Results obtained with 3He (voxel size 17 microl) demonstrated high image quality showing airway structure down to the 5th or 6th generations. Signal-to-noise ratios (SNRs) of 129Xe images (voxel size 40 microl) were lower by about 1 order of magnitude as a consequence of the smaller gyromagnetic ratio, a more rapid relaxation in the gas reservoir, and lower polarization and isotope abundance. Comparison between experimentally obtained SNRs and results from calculations based on a model that accounts for the three-dimensional PE acquisition scheme and the non-equilibrium situation in HP gas imaging yielded excellent agreement for small flip angles. A theoretical examination of the potential resolution in HP gas MR microscopy of the lungs suggests that in vivo visualization of alveolar clusters distal to respiratory bronchioles may be possible.

Magnetic resonance angiography with hyperpolarized 129Xe dissolved in a lipid emulsion.

Hyperpolarized (HP) 129Xe can be dissolved in biologically compatible lipid emulsions while maintaining sufficient polarization for in vivo vascular imaging. For xenon in Intralipid 30%, in vitro spectroscopy at 2 T yielded a chemical shift of 197 +/- 1 ppm with reference to xenon gas, a spin-lattice relaxation time T1 = 25.3 +/- 2.1 sec, and a T2* time constant of 37 +/- 5 msec. Angiograms of the abdominal and pelvic veins in the rat obtained with 129Xe MRI after intravenous injection of HP 129Xe/Intralipid 30% into the tail demonstrated signal-to-noise ratios between 8 and 29. An analysis of the inflow effect on time-of-flight images of two segments of the inferior vena cava yielded additional information. The mean blood flow velocity was 34.7 +/- 1.0 mm/sec between the junction of the caudal veins and the kidneys and 13.3 +/- 0.8 mm/sec at the position of the diaphragm. The mean volume flow rates in these segments were 7.2 +/- 3.4 ml/min and 11.0 +/- 2.8 ml/min, respectively. Intravenous delivery of HP 129Xe dissolved in a carrier may lead to novel biomedical applications of laser-polarized gases.

Signal dynamics in magnetic resonance imaging of the lung with hyperpolarized noble gases.

The nonequilibrium bulk magnetic moment of hyperpolarized (HP) noble gases generated by optical pumping has unique characteristics. Based on the Bloch equations, a model was developed describing the signal dynamics of HP gases used in magnetic resonance imaging (MRI) of the lung with special consideration to the breathing cycle. Experimental verification included extensive investigations with HP 3He and 129Xe during both inspiration and held breath in live guinea pigs. Radial acquisition was used to investigate the view variations with a temporal resolution of 5 ms. Agreement between theoretical predictions and in vivo results was excellent. Additionally, information about effects from noble gas diffusion and spin-lattice relaxation was obtained. In vivo results for T1 were 28.8 +/- 1.8 s for 3He and 31.3 +/- 1.8 s for 129Xe. Comparison with in vitro data indicated that relaxation in the pulmonary gas space is dominated by dipolar coupling with molecular oxygen. The results provide a quantitative basis for optimizing pulse sequence design in HP gas MRI of the lung.

In vivo magnetic resonance vascular imaging using laser-polarized 3He microbubbles.

Laser-polarized gases (3He and 129Xe) are currently being used in magnetic resonance imaging as strong signal sources that can be safely introduced into the lung. Recently, researchers have been investigating other tissues using 129Xe. These studies use xenon dissolved in a carrier such as lipid vesicles or blood. Since helium is much less soluble than xenon in these materials, 3He has been used exclusively for imaging air spaces. However, considering that the signal of 3He is more than 10 times greater than that of 129Xe for presently attainable polarization levels, this work has focused on generating a method to introduce 3He into the vascular system. We addressed the low solubility issue by producing suspensions of 3He microbubbles. Here, we provide the first vascular images obtained with laser-polarized 3He. The potential increase in signal and absence of background should allow this technique to produce high-resolution angiographic images. In addition, quantitative measurements of blood flow velocity and tissue perfusion will be feasible.

Hyperpolarized 3He NMR lineshape measurements in the live guinea pig lung.

Spatially localized lineshapes of hyperpolarized (HP) 3He in guinea pig lungs have been measured in vivo. Three different axial slice locations, each containing different compositions of airway sizes and orientations, were studied. Gas peaks from major bronchi (2 ppm) and alveoli (-2 ppm) were distinguished. The gas phase spectra show structural features that are a result of frequency shifts caused by bulk magnetic susceptibility. For a given slice, the spectral lineshapes reflect the airway composition within the slice location, according to theory. The peak assignments given here also agree with previous studies done by Wagshul et al. with HP 129Xe. At each of the slice locations, data were acquired during two phases of the breathing cycle, resulting in a relative frequency shift of approximately 0.3 ppm in the superior slices. Spectra obtained over a number of breaths show the dynamics of the gas buildup in the lung and provide further evidence supporting the peak assignments.

MR microscopy of lung airways with hyperpolarized 3He.

A technique using hyperpolarized (HP) 3He to image the small airways of the lung by using moderate flip angles and a short scanning period during early inspiration is demonstrated. Flip angles (alpha) ranging from 10-90 degrees were used in guinea pig experiments with scanning during the entire inspiration period. A second series acquired data throughout a short window of the ventilatory cycle with alpha = 45 degrees. The success of the animal studies has motivated implementation of similar imaging techniques in the clinical arena. Human studies involved imaging over the total inspiration period with alpha approximately 10 degrees. The first series of guinea pig experiments demonstrated that larger flip angles (50-90 degrees) destroy the magnetization before it reaches the smaller airways. At moderate flip angles (20-40 degrees), airway branching down to the fourth generation was apparent. Fifth-order branchings were seen in the images of the second series. The trachea down to fourth generation pulmonary airway branching, along with some distal air spaces, was seen in the human lung images.

Serum immunoglobulin status of psychiatric in-patients.

In view of the fact that substantial evidence today links psyche, brain, stress and immune system, the serum immunoglobulin (viz. IgG, IgA, IgM) levels in 40 patients with psychiatric disorders (viz. Schizophrenia, Affective disorder and generalized Anxiety disorders) have been investigated. With the exception of IgA, all psychiatric patients had significantly elevated IgG, IgM levels (p less than 0.001) when compared with healthy controls. Surprisingly these immunoglobulin levels irrespective of prevalent psychiatric disorder were almost similar to those of the hospitalized surgical patients pre-operatively (preferable controls), suggestive of no direct linear causal relationship between the psychiatric disorder and serum immunoglobulin levels. Factors affecting immunoglobulins have been discussed. Considering a probable viral association in Schizophrenia it is felt that simultaneous monitoring of viruses (affecting the nervous system) in the form of antigen/antibodies may be more informative.

Immediate versus postponed combination chemotherapy (CAMP) for unresectable non-small cell lung cancer: a randomized trial.

A randomized control trial was performed in good performance status patients with unresectable non-small cell lung cancer to test a strategy of early aggressive combination chemotherapy (CAMP [cyclophosphamide, doxorubicin, methotrexate, and procarbazine]) versus a strategy of delaying such treatment until clinical deterioration. Thirty-seven patients received immediate CAMP and 35 patients received initial low-dose single-agent CCNU (CAMP was postponed). Immediate CAMP therapy produced an objective response rate of 44% in patients with measurable lesions, and CCNU produced none. Median survival was 193 days for the immediate-CAMP group and 175 days for the postponed-CAMP group (P = 0.26). Measures of quality of life were made and no difference emerged between the two treatment strategies. This trial failed to show substantial benefit from immediate combination chemotherapy in minimally symptomatic patients with non-small cell lung cancer.

Determination of plasma erythropoietin levels: an early marker of tumor activity.

A young female patient developed erythrocytosis during the third recurrence of a cerebellar hemangioblastoma. Elevated erythropoietin levels were found in the patient's plasma with normalization after resection of the tumor. High erythropoietin titers were also found in the tumor saline extract. A fourth recurrence of the tumor was heralded by a rising plasma erythropoietin level and gradual erythrocytosis despite the absence of change in the clinical picture or the brain scan. In this case, serial plasma erythropoietin determinations served as a useful early marker of the tumor activity.