Lessons Learned From Developing an Eradication Investment Case for Lymphatic Filariasis.

In the last few years, the concepts of disease elimination and eradication have again gained consideration from the global health community, with Guinea worm disease (dracunculiasis) on track to become the first parasitic disease to be eradicated. Given the many complex and interlinking issues involved in committing to a disease eradication initiative, such commitments must be based on a solid assessment of a broad range of factors. In this chapter, we discuss the value and implications of undertaking a systematic and fact-based analysis of the overall situation prior to embarking on an elimination or eradication programme. As an example, we draw upon insights gained from a series of lymphatic filariasis (LF) studies from our research group that adopted an eradication investment case (EIC) framework. The justification for EICs, and related epidemiological, geospatial and other mathematical/operational research modelling, stems from the necessity for proper planning prior to committing to disease eradication. Across all considerations for LF eradication, including: time, treatments, level of investments necessary, health impact, cost-effectiveness, and broader economic benefits, scaling-up mass drug administration coverage to all endemic communities immediately provided the most favourable results. The coherent and consistent pursuit of eradication goals, operationally tailored to a given socioecological system and based on integrated measures of available tools will lead relatively rapidly to elimination in many parts of endemic areas and provide the cornerstone towards eradication.

Psychosomatic Aspects of Urinary Incontinence in Women.

Urinary incontinence in women is a common problem. With increasing age its prevalence and severity of its manifestations increase. Among nursing home residents the frequency is between 43 and 77 %, 6 to 10 % of all admissions to nursing homes are due to urinary incontinence. The risk for urinary incontinence among women with cognitive deficits is 1.5- to 3.4-fold higher than for women without mental disorders. The most common form is stress incontinence (50 %), followed by mixed stress-urge incontinence (40 %) and purely urge incontinence (OAB = overactive bladder, 20 %). With regard to its cause, the latter remains unclarified in about 80 % of the cases. It is often difficult to treat. There are also cases in which urge incontinence is related to traumatic events. In such cases behavioural and psychotherapeutic options may be helpful. Almost inevitably every form of incontinence has psychological consequences: shame and insecurity are often results of uncontrolled loss of urine. Among others, in the long term, they lead to the avoidance of social contacts and possibly to depression and isolation. Consideration of the psychosomatics is important in the therapy for female urinary incontinence from three points of view: 1) the efficacy of treatment is better suited to the patient, 2) the treatment costs are lower, 3) the professional satisfaction of the responsible physician increases.

Differential distribution of hypoxia-inducible factor 1-beta (ARNT or ARNT2) in mouse substantia nigra and ventral tegmental area.

Hypoxia has been proposed as a mechanism underlying gene-environment interactions in the neurodevelopmental model of schizophrenia, and hypoxia-inducible factor 1 (HIF-1) could mediate the interactions. In the current study, we analyzed the HIF-1 beta subunit, as formed by aryl hydrocarbon receptor nuclear translocator (ARNT) or ARNT2, in the mouse substantia nigra (SN) and the ventral tegmental area (VTA). We performed immunohistochemical studies of ARNT and ARNT2 in the adult mouse brain, and colocalization analyses, with specific emphasis on dopaminergic cells, i.e. tyrosine hydroxylase (TH) immunoreactive cells. Bioinformatic analyses identified shared protein partners for ARNT and ARNT2. ARNT immunoreactivity showed widespread neuronal labeling without overt regional specificity. We observed co-localization of ARNT and TH in the SN compacta and VTA. Nuclei strongly labeled for ARNT2 were observed in the SN reticulata, while only weak immunoreactivity for ARNT2 was found in TH-immunoreactive neurons in SN compacta and VTA. Stereological analysis showed that ARNT was preferentially expressed in dopaminergic neurons in SN compacta and VTA. Nuclei strongly labeled for ARNT2 were present in neocortex and CA1 of hippocampus. Differential expression of ARNT and ARNT2 in dopaminergic neurons may relate to the vulnerability of distinct dopaminergic projections to hypoxia and to functional vulnerability in schizophrenia and other neuropsychiatric disorders.

Rapid identification of compound mutations in patients with Philadelphia-positive leukaemias by long-range next generation sequencing.

An emerging problem in patients with Philadelphia (Ph)-positive leukaemias is the occurrence of cells with multiple mutations in the BCR-ABL1 tyrosine kinase domain (TKD) associated with high resistance to different tyrosine kinase inhibitors. Rapid and sensitive detection of leukaemic subclones carrying such changes, referred to as compound mutations, is therefore of increasing clinical relevance. However, current diagnostic methods including next generation sequencing (NGS) of short fragments do not optimally meet these requirements. We have therefore established a long-range (LR) NGS approach permitting massively parallel sequencing of the entire TKD length of 933bp in a single read using 454 sequencing with the GS FLX+ instrument (454 Life Sciences). By testing a series of individual and consecutive specimens derived from six patients with chronic myeloid leukaemia, we demonstrate that long-range NGS analysis permits sensitive identification of mutations and their assignment to the same or to separate subclones. This approach also facilitates readily interpretable documentation of insertions and deletions in the entire BCR-ABL1 TKD. The long-range NGS findings were reevaluated by an independent technical approach in select cases. Polymerase chain reaction (PCR) amplicons of the BCR-ABL1 TKD derived from individual specimens were subcloned into pGEM®-T plasmids, and >100 individual clones were subjected to analysis by Sanger sequencing. The NGS results were confirmed, thus documenting the reliability of the new technology. Long-range NGS analysis therefore provides an economic approach to the identification of compound mutations and other genetic alterations in the entire BCR-ABL1 TKD, and represents an important advancement of the diagnostic armamentarium for rapid assessment of impending resistant disease.

An environmental analysis of genes associated with schizophrenia: hypoxia and vascular factors as interacting elements in the neurodevelopmental model.

Investigating and understanding gene-environment interaction (G × E) in a neurodevelopmentally and biologically plausible manner is a major challenge for schizophrenia research. Hypoxia during neurodevelopment is one of several environmental factors related to the risk of schizophrenia, and links between schizophrenia candidate genes and hypoxia regulation or vascular expression have been proposed. Given the availability of a wealth of complex genetic information on schizophrenia in the literature without knowledge on the connections to environmental factors, we now systematically collected genes from candidate studies (using SzGene), genome-wide association studies (GWAS) and copy number variation (CNV) analyses, and then applied four criteria to test for a (theoretical) link to ischemia-hypoxia and/or vascular factors. In all, 55% of the schizophrenia candidate genes (n=42 genes) met the criteria for a link to ischemia-hypoxia and/or vascular factors. Genes associated with schizophrenia showed a significant, threefold enrichment among genes that were derived from microarray studies of the ischemia-hypoxia response (IHR) in the brain. Thus, the finding of a considerable match between genes associated with the risk of schizophrenia and IHR and/or vascular factors is reproducible. An additional survey of genes identified by GWAS and CNV analyses suggested novel genes that match the criteria. Findings for interactions between specific variants of genes proposed to be IHR and/or vascular factors with obstetric complications in patients with schizophrenia have been reported in the literature. Therefore, the extended gene set defined here may form a reasonable and evidence-based starting point for hypothesis-based testing of G × E interactions in clinical genetic and translational neuroscience studies.

Impact of medical and demographic factors on long-term quality of life and body image of breast cancer patients.

BACKGROUND: The impact of various medical and demographic factors on the quality of life (QoL) of breast cancer patients has been discussed controversially. We investigated the influence of six different factors on long-term QoL and body image of women with primary breast cancer. PATIENTS AND METHODS: Two-hundred and seventy-four breast cancer patients were administered the QoL questionnaire following a mean interval of 4.2 years after primary diagnosis. All women had been primarily treated for stage I to III breast cancer without evidence of distant metastases. QoL was evaluated by using the QLQ-C30 questionnaire Version 2.0. Supplementary scales included body image, satisfaction with surgical treatment, cosmetic result and fear of recurrence. We analyzed the impact of tumor stage, surgical treatment, adjuvant radiotherapy, adjuvant cytotoxic therapy, age and length of follow-up period on the examined outcome parameters. RESULTS: At the time of the follow-up examination, patients showed minor impairment of QoL (mean 67.8) and body image (mean 24.8), but more fear of recurrence (mean 60.7). None of the studied factors had a significant impact on overall QoL (P >0.05) according to the QLQ-C30 questionnaire. In contrast, with the exception of the factors 'cytotoxic therapy' and 'radiotherapy' all investigated variables influenced at least one of the additional psychological scales (P <0.05). The primary surgical treatment modality had the strongest impact and affected all four scales. Patients treated with breast conservation reported a more favorable body image, compared to those treated with mastectomy (17.2 versus 37.5, P <0.01), more satisfaction with surgical treatment (4.0 versus 10.7, P = 0.01), rated a better cosmetic result (75.5 versus 57.1, P <0.01), but presented more fear of recurrence (63.9 versus 55.3, P = 0.04). CONCLUSION: Current QoL questionnaires do not sufficiently cover all relevant aspects of QoL, but might be complemented by breast cancer specific aspects such as body image and fear.

[Projective identification and denial of pregnancy--considerations of the reasons and background of unrecognized pregnancy also undiagnosed by a physician]. / Projektive Identifizierung und Schwangerschaftsverdrängung--Uberlegungen zu Ursachen und Hintergründen der auch ärztlicherseits nicht erkannten Schwangerschaft.

BACKGROUND: In denial of pregnancy, the pregnant woman does not consciously perceive the pregnancy and, in extreme cases, awareness occurs only during delivery. The attending physicians also often fail to recognize the pregnancy, even though the somatic complaints leading to consultation with a physician are typically pregnancy associated. This "iatrogenic participation" was described in the earliest historical publications. Different theories are presented in this paper to elaborate this phenomenon. Elementary deficiencies in perception or incompetence do not explain most cases. PATIENTS AND METHODS: Twenty five women with denial of pregnancy, interviews PSYCHODYNAMIC EXPLANATIONS: Based on the deep-rooted subjective attitude of not being pregnant, the pregnant woman is able to include family, friends, and associates into the denial of pregnancy mindset. In a similar way, she is able to influence her doctor. The woman's autosuggestive wishful notions of not being pregnant receive suggestive confirmation by the physician's misdiagnosis and lead to a continuing denial of pregnancy. PROJECTIVE IDENTIFICATION: In 1946, M. Klein introduced this term to describe a certain defense mechanism relating to fantasies and accompanying object relationships. The self initially successfully disposes of unwanted aspects, splits them off, and transfers them to another person, to finally reclaim them in a modified form. Certain elements of this psychoanalytical concept can characterize the interaction between physician and pregnant woman, which, in the case of denied pregnancies, does not lead to a diagnosis of pregnancy. Through projection, the pregnant woman is capable of manipulating the physician so that he perceives her, according to her wishes, as not being pregnant and misdiagnoses her correspondingly as "service in return". Opportunities for more mature handling of the denied content in terms of psychological development through accurate diagnosis of the pregnancy are indicated.

Hypoxia and hypoxia-inducible factor modulated gene expression in brain: involvement in neuroprotection and cell death.

Hypoxia, due to impaired cerebral blood flow, has hazardous effects on brain structure and function. Therefore, mechanisms should exist to meet the needs for hypoxic adaptation via regulation of gene expression. Signaling between the O2 sensor and the regulator(s) of transcription is only partially characterized and requires regulatory transcription factors. Among these regulatory proteins, hypoxia-inducible factor-1 (HIF-1) appears to have a key role. HIF-1 modulates gene activity in response to low O2 tensions in the developing and in the adult brain. Moderate hypoxia may elicit autoprotective mechanisms or hypoxia-induced regulators can contribute to mechanisms leading to cell death. Moreover, reactivation of embryonic gene expression may occur after injury-induced hypoxia. Thus, analyses of embryonic and pathogenic models should help to understand how hypoxia-mediated proliferative/cell death processes are involved in brain development and in the pathogenesis of acute or chronic neurodegenerative brain diseases.

Transient changes of brain-derived neurotrophic factor (BDNF) mRNA expression in hippocampus during moderate ischemia induced by chronic bilateral common carotid artery occlusions in the rat.

Chronic bilateral common carotid artery occlusion (BCCAO) induces moderate ischemia (oligemia) in the rat forebrain in the absence of overt neuronal damage. In situ hybridization for brain-derived neurotrophic factor (BDNF) mRNA was used to search for a molecular response to moderate ischemia. BDNF mRNA was significantly increased in the hippocampal granule cells at 6 h of occlusion (ANOVA, Tukey test P<0.05). At 1, 7 and 14 days BDNF mRNA levels returned to control levels. The frequency of BDNF gene expression at 6 h was 83%, which was significantly higher than the 7% incidence of histological injury in the hippocampus (Fisher's exact test, P<0.002). Cerebral blood flow was reduced to 75% of control levels in the hippocampus after 1 week of BCCAO when measured with the autoradiographic method. Measurements of tissue flow with a microprobe for laser Doppler flow excluded decreases into the ischemic range during the period when elevated gene expression was observed. Prolonged moderate ischemia (oligemia) is a sufficient stimulus for BDNF gene expression in the hippocampus. These molecular studies provide direct evidence for an involvement of the hippocampus in the BCCAO model.

[Specific concepts of care for pregnant women with drug addiction or HIV infection]. / Spezifische Betreuungskonzepte für schwangere Frauen mit Sucht- bzw. HIV-Konflikten.

In the last 10 years about 130 women with a drug addiction and more than 100 HIV-positive pregnant women were treated at the 1. University Hospital of Obstetrics and Gynaecology in Munich. Besides a specialized medical treatment both groups required intensive psychosocial care. HIV-infected people are still isolated and suffer from the social stigmata. Their essential needs for sexuality and children of their own are often ignored or even condemned because of irrational fears about HIV, which continue despite rapid medical improvements. The life-expectancy for example has increased since the inauguration of protease inhibitors. Vertical transmission of HIV is below 2% through medical treatment in pregnancy, elective cesarean section and renunciation of breastfeeding. Drug addicted pregnant women are given the opportunity to change their life in order to care for their children appropriately. The basis for this is a substitution with levomethadone and elimination of the use of other drugs. The addicted women often can reduce the dosage of levomethadone during the course of their pregnancy and sometimes can cease totally. Normally they are highly motivated and thus can ease the withdrawal symptoms of their newborns following delivery. By establishing a reliable social net during pregnancy mothers learn to recognize the demands of their children after birth and thus emotional and cognitive deficits can be prevented.

Differential changes of bax, caspase-3 and p21 mRNA expression after transient focal brain ischemia in the rat.

Recent studies of transient focal ischemia have focused interest on apoptotic mechanisms of neuronal cell death involving constitutive pro-apoptotic proteins. The finding of specific patterns of novel gene expression might indicate the activation of pro-apoptotic genes in previously ischemic areas. Thus, we investigated gene expression for the pro-apoptotic regulators, Bax and caspase-3, after transient focal brain ischemia, together with the p53-regulated cell cycle inhibitor, p21/WAF1/CIP1. Reversible occlusion of the middle cerebral artery for 2 h was carried out in halothane-anesthetized rats using the poly-L-lysine coated filament method. In situ hybridization was performed at 0, 1, 3, 6 h and 1, 3 and 7 d of recirculation and in sham controls. Radioactive antisense probes served for detection of bax, p21 and caspase-3 mRNAs on brain sections, and quantitative film autoradiography was combined with image-averaging techniques. Bax mRNA tended to decline after focal brain ischemia within 1 d. p21 mRNA was upregulated with a perifocal pattern at 3 h and 1 d after ischemia whereas the ischemic regions themselves failed to show significant upregulation. Caspase-3 mRNA was elevated in the resistant dorsomedial cortex at 1 d. A pro-apoptotic pattern of novel gene expression, involving Bax and caspase-3, was not observed after transient focal brain ischemia. Rather, the perifocal expression of p21 and caspase-3 mRNAs observed at 1 d after ischemia points to reactive changes in resistant brain areas.

Analysis of point mutation in exon 2 of CYP2E1 gene in renal cell/urothelial cancer patients in comparison with control population.

OBJECTIVE: Genetic polymorphisms of human cytochrome P450s have been implicated to be of importance for susceptibility to different cancers. Recently, a point mutation was found in the exon 2 of the CYP2E1 gene (CYP2E1*2) [Hu et al. 1997]. In order to evaluate a possible link between the point mutation in exon 2 of the CYP2E1 gene and the susceptibility to renal cell/urothelial cancer, we developed a screening method based on the polymerase chain reaction (PCR) and restriction fragment length polymorphism (RFLP). MATERIAL: DNA of peripheral white blood cells was isolated from 158 renal cell/urothelial cancer patients as well as from 150 controls. METHOD: Primers for PCR were designed by the Primer 3 release 0.1 program. The PCR yield a product of 215 base pairs (bp), which was digested with the restriction enzyme Hha I. The DNA fragments were separated on a 3% agarose gel stained with ethidium bromide. Restriction enzyme digestion of the PCR product obtained from the wild-type DNA resulted in the appearance of a 66 bp, a 43 bp, a 40 bp, a 39 bp and a 28 bp DNA fragment. In contrast to the wild-type, the digestion of the PCR product from DNA carrying the point mutation resulted in the loss of the 39 bp and 40 bp fragments and the appearance of an additional 79 bp fragment. Therefore, the loss of one Hha I restriction site caused by a single nucleotide exchange is suitable for the identification of the point mutation in exon 2 of CYP2E1 gene. RESULTS: However, we could not detect any point mutation in any of the 158 renal cell/urothelial cancer patients or the 150 controls. The distribution of the point mutation in exon 2 of CYP2E1 gene did not show any difference in renal cell/urothelial cancer patients and controls. CONCLUSION: This might indicate a lack of association between this CYP2E polymorphism (CYP2E1*2) and renal cell/urothelial cancer.

Complications after caesarean section in HIV-1-infected women not taking antiretroviral treatment.

HIV-1-infected women have a considerably increased risk of postoperative morbidity after caesarean sections. We showed that this risk was independent of current antiretroviral therapy.

Expression of brain-derived neurotrophic factor, nerve growth factor, and heat shock protein HSP70 following fluid percussion brain injury in rats.

Traumatic brain injury can induce the expression of stress-related and neurotrophic genes both within the injury site and in distant regions. These genes may affect severity of damage and/or be neuroprotective. We used in situ hybridization to assess the alterations in expression of the heat shock protein HSP70, nerve growth factor (NGF), and brain-derived neurotrophic factor (BDNF) genes in rat brain following moderate fluid-percussion (F-P) injury at various survival times. HSP70 gene expression was induced at and surrounding the injury site as early as 30 min after trauma. This elevated signal spread ventrally and laterally through the ipsilateral cortex and into the underlying white matter over the next few hours. In addition, there was elevated expression in the temporal hippocampus. BDNF was strongly upregulated in the granular cells of the dentate gyrus and in the CA3 hippocampus 2-6 h after injury. Cortical regions at and near the injury site showed no response at the mRNA level. NGF mRNA increased over the granular cells of the dentate gyrus at early time points. There was also a weaker secondary induction of the NGF gene in the contralateral dentate gyrus of some animals. Cortical response was observed in the entorhinal cortex, bilaterally, but not at the injury site. All three of the studied genes responded quickly to injury, as early as 30 min. The induction of gene expression for neurotrophins in regions remote from areas with histopathology may reflect coupling of gene expression to neuronal excitation, which may be associated with neuroprotection and plasticity.

Quantitation of multiple gene expression by in situ hybridization autoradiography: accurate normalization using Bayes classifier.

In the method of in situ hybridization autoradiography, quantitative comparisons among multiple mRNA signals have proven difficult for many reasons, attributable both to technical factors (e.g. different probe specific activities) as well as to large differences in the patterns and levels of expression of different genes in pathologic states. Here we report a standardized normalization procedure for in situ hybridization autoradiography, employing a Bayes classifier, which permits the comparison of multiple mRNA probes. Autoradiograms of different probes in individual animals are first digitized and converted to units of radioactivity. Next, pixel-distribution histograms are generated for each mRNA signal. The Bayes classifier is then used to establish an optimal threshold to distinguish activated and non-activated pixels. This threshold also defines the minimal level of mRNA expression. The maximal mRNA signal is defined as the mean + 3 SD of the activated pixel distribution. We then use a linear transformation to convert each pixel from absolute activity to percentage of maximal mRNA signal for that particular probe. The normalized autoradiographic images can then be averaged to represent group trends and can be compared by standard statistical methods. We illustrate this normalization procedure using in situ hybridization autoradiography for three genes (GADD45, HSP70 and MAP2) expressed in the brains of rats studied at various recirculation times following transient (2 h) middle cerebral artery occlusion. The Bayes classifier is reviewed and its analytical application is presented. Step-by-step examples of intermediate steps are presented, construction of averaged data sets, and pixel-based statistical comparisons among expressed genes.

Protein extravasation and cellular uptake after high-dose human-albumin treatment of transient focal cerebral ischemia in rats.

Treatment with human albumin administered intravenously in the immediate post-ischemic period following a 2-h period of transient focal cerebral ischemia leads to a reduction of cortical infarction in rat. Immunohistochemistry with antibodies to rat immunoglobulins (IgG), rat albumin and (exogenous) human albumin was used to study blood-brain barrier changes. The degree of IgG extravasation was not changed by human-albumin treatment. Diffuse signals and uptake into necrotic neurons was seen in cortex of saline animals. In animals treated with human albumin, cortical neurons with preserved structural features had taken up human albumin. Treatment with human albumin may provide direct neuronal protection.

Progressive parenchymal deposition of beta-amyloid precursor protein in rat brain following global cerebral ischemia.

In addition to producing acute neuronal necrosis within selectively vulnerable brain regions, our recent studies have shown that global cerebral ischemia may also be followed by protracted degenerative changes occurring over the course of 10 weeks. Chronic brain pathology may be associated with the abnormal deposition of beta-amyloid precursor protein (betaAPP). In the present study, we used a monoclonal antibody to the N-terminal portion of betaAPP to characterize the brains of rats surviving 1-10 weeks following 10 min of global brain ischemia produced by bilateral carotid artery occlusions plus systemic hypotension. After ischemia, increased betaAPP immunolabeling emerged in several brain regions. In the hippocampus, granular deposits appeared in the damaged CA1 area by 2 weeks, and by 4-10 weeks the remnants of necrotic CA1 neurons were also immunolabeled. In striatum and thalamus, regions with necrotic cell death also revealed granular betaAPP deposits. The neocortex was devoid of overt ischemic neuronal damage but revealed prominent betaAPP immunoreactivity. Large ovoid deposits of low-density betaAPP immunostaining occurred in cortical neurons at 1-2 weeks. At 4-10 weeks, large round or oval deposits immunoreactive for betaAPP appeared in several cortical regions. The highest density of deposits was seen in the temporal and piriform cortices. Our results indicate that abnormal betaAPP deposition may result from ischemic as well as chronic neurodegenerative processes.

Pixel-based image analysis of HSP70, GADD45 and MAP2 mRNA expression after focal cerebral ischemia: hemodynamic and histological correlates.

Gene expression studies with in situ hybridization after focal brain ischemia indicate a variety of distinct anatomical patterns. An important question is to what extent such reactive gene expression correlates with neuronal damage or survival. To study these questions, we focused on two stressed-induced genes, heat shock protein 70 (HSP70) and growth-arrest and DNA damage-inducible gene (GADD) 45 mRNA, and we compared reactive changes in mRNA to loss of the constitutive signal for microtubule-associated protein 2 (MAP2) mRNA. A pixel-based image analysis of mRNA signals was carried out using a highly reproducible model of focal brain ischemia. A poly-l-lysine coated filament was used to occlude the origin of the middle cerebral artery (MCA) for 2 h in ventilated, normothermic rats. Brains were collected after 0, 1, 3 and 6 h, and 1, 3 and 7 days. In situ hybridization analysis was carried out for HSP70 mRNA, GADD45 mRNA and MAP2 mRNA. Autoradiographic data sets were averaged and co-mapped into a common template of the rat brain. These data sets were then compared on a pixel-by-pixel basis with previously acquired image data sets derived from quantitative studies of local cerebral blood flow (LCBF) (obtained at the end of 2-h ischemia) of and infarctive histopathology (obtained at 3 days) in the same focal ischemia model. HSP70 mRNA and GADD45 mRNA were grossly elevated in the hemisphere subjected to ischemia during the first day. Pixel-based analysis showed a strong correlation between HSP70 mRNA signals, the degree of early blood-flow reduction and the probability of histological infarction. GADD45 mRNA was expressed in a more variable fashion. Decreases in MAP2 mRNA signals at 1, 3 and 7 days correlated strongly with histological infarction. These co-mapping procedures allow us to conclude that HSP70 mRNA is a robust indicator of ischemic stress and histological outcome after 2 h of focal brain ischemia. The topographic features of GADD45 expression suggest its possible role in conferring resistance to ischemic injury. Finally, our results indicate that local decreases in constitutive MAP2 expression at 1 day and beyond may be used as a robust marker of tissue regions having a high probability of focal infarction.