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Multimodal architectonic mapping of human superior temporal gyrus.

Although it is generally accepted that human superior temporal gyrus is activated by a huge variety of auditory and linguistic tasks, little is known about the exact positions and extents of cortical areas that are located on the lateral convexity of the gyrus (e.g., Brodmann's area 22). Such information, however, is relevant for a rigorous testing of structural-functional relationships in both normal volunteers and patients suffering from disorders of auditory and language perception. The present combined cytoarchitectonic and receptorarchitectonic study identifies a distinct area (Te3) in the lateral bulge of the superior temporal gyrus by using an algorithm-based approach for the detection of cortical borders. Our mapping data show that, in contrast to Brodmann's area (BA) 22, only small portions of Te3 reach the dorsal and ventral banks of the gyrus. Therefore, we labelled the newly defined area as "Te3" and not as "BA 22". The cytoarchitectonically defined borders of Te3 coincide with abrupt changes in the receptorarchitecture of several classical neurotransmitters, suggesting that Te3 represents a functionally relevant area of the human superior temporal gyrus. Since position and extent of area Te3 varied considerably between subjects, probability maps were created that show for each voxel of the standard references space, the frequency with which Te3 was present in it. These maps, in combination with previously published maps of the primary auditory cortex, can directly be compared with functional imaging data, and may open new perspectives for the analysis of structural-functional correlations in the human auditory and language systems.

Algorithms↗

Comparative follow-up of enhancement phenomena with MRI and Proton MR Spectroscopic Imaging after intralesional immunotherapy in glioblastoma--Report of two exceptional cases.

The morphologic pattern of contrast enhancement in magnetic resonance imaging (MRI) of glioblastoma patients could be non specific and metabolic investigations can be useful for the differentiation of tumorous and non tumorous enhancement. Following initial therapy secondary tissue changes can occur and non specific non tumorous enhancement phenomena have been observed after local immuno- and gene therapy strategies. Magnetic resonance spectroscopic imaging (MRSI) has the potential to give more specific information on the metabolism of the suspective tissue and to differentiate enhancing phenomena. We demonstrate two cases of patients suffering from a glioblastoma with simultaneous MRI and MRSI follow-up after multimodal treatment with surgery, radiation, intralesional immunotherapy (IL-4 toxin) and ongoing chemotherapy. MRI demonstrated extensive and increasing enhancement. This was highly suspicious of rapid progressive local tumor recurrency in both patients. Simultaneously obtained MRSI did not show the expected result of extensive and increasing choline concentration within these enhancing areas. This indicated that the enhancement did most likely not reflect vital tumor tissue. Chemotherapy treatment was continued and further MRI follow up revealed nearly complete regression of all enhancement. In pretreated glioblastoma metabolic data of MRSI seem to be potentially helpful to differentiate tumorous and non tumorous enhancement phenomena after local immunotherapy, which might be useful for further treatment decisions.

Adult↗

Acute pain after thoracic surgery predicts long-term post-thoracotomy pain.

OBJECTIVE: Long-term pain is a common sequela of thoracotomy, occurring in approximately 50% of patients 2 years after thoracic surgery. Despite this alarming statistic, little is known about the factors responsible for the transition of acute to chronic pain. The aim of the present study is to identify predictors of long-term post-thoracotomy pain. DESIGN: Follow-up was for 1.5 years for patients who had participated in a prospective, randomized, controlled trial of preemptive, multimodal analgesia. SETTING: Subjects were recruited from a tertiary care center. PATIENTS: Thirty patients who had undergone lateral thoracotomy were followed up by telephone, administered a structured interview, and classified according to long-term pain status. MAIN OUTCOME MEASURES: Present pain status was measured by a verbal rating scale (VAS). Measures obtained within the first 48 h after surgery were compared between patients with and without pain 1.5 years later. These include VAS pain scores at rest and after movement, McGill Pain Questionnaire data, patient-controlled morphine consumption (mg), and pain thresholds to pressure applied to a rib contralateral to the thoracotomy incision. RESULTS: Fifty-two percent of patients reported long-term pain. Early postoperative pain was the only factor that significantly predicted long-term pain. Pain intensity 24 h after surgery, at rest, and after movement was significantly greater among patients who developed long-term pain compared with pain-free patients. A significant predictive relationship was also found at 24 and 48 h using the McGill Pain Questionnaire. Cumulative morphine was comparable for the two groups. Pain thresholds to pressure applied to a rib contralateral to the incision did not differ significantly between the groups. CONCLUSION: Aggressive management of early postoperative pain may reduce the likelihood of long-term post-thoracotomy pain.

Acute Disease↗

[Serum concentrations of trace elements and microcirculation during laser therapy for pneumonia].

The impact of laser therapy in the multimodality treatment for pneumonia on the serum levels of trace elements and microcirculation was studied. A total of 105 patients with pneumonia were examined. The patients were divided into 2 groups: 1) 68 patients received laser therapy and 2) 37 patients took drug therapy alone. There was a more substantial reduction in the permeability of cellular membranes, a significant increase in the serum levels of iron and chromium, better circulation at the expense of a vascular component. The above changes highly correlated with laboratory data and external respiratory function parameters.

Adolescent↗

Mininvasive abdominal aortic surgery. Early recovery and reduced hospitalization after multidisciplinary approach.

AIM: Clinical experience in gastrointestinal surgery demonstrated that a multimodal approach can improve the outcome and reduce the length of hospital stay. In this paper we investigate the impact of a multimodal clinical program, based on mininvasive surgery, epidural anesthesia and early feeding and mobilization, on postoperative morbidity and hospitalization after abdominal aortic surgery. METHODS: A 2-armed study was designed. All patients undergoing abdominal aortic surgery between May 2000 and April 2001 were enrolled in a multidisciplinary clinical program including thoracic epidural anesthesia and analgesia, left sub-costal minilaparotomy without evisceration, encouragement to feed and mobilize soon after surgery (Multidisciplinary group: n=82). For comparison purposes, a retrospective analysis was conducted using the data of all patients operated on between January and December 1997, receiving standard anesthesia care and a standard surgical and nursing program (Standard group: n=64). RESULTS: In the Multidisciplinary group we observed significantly better pain relief (p<0.01), earlier restoration of ambulation (p<0.01), earlier feeding (p<0.01) and passage of stools (p<0.01). The incidence of complications was significantly lower in the Multidisciplinary group: pulmonary (0% vs 14.1%), cardiac (2.4% vs 9.4% ) and gastrointestinal (0% vs 10.9%). None of the patients in the Multidisciplinary group required admission to Intensive Care. Median postoperative hospitalization was 3 days in the Multidisciplinary group compared to 9 days in the Standard group (p<0.01). CONCLUSION: These results suggest that a multidisciplinary intervention with review of the traditional surgical care program would enhance recovery, decrease morbidity and hospitalization after abdominal aortic surgery.

Aged↗

Congenital diaphragmatic hernia survival and use of extracorporeal life support at selected level III nurseries with multimodality support.

BACKGROUND: Congenital diaphragmatic hernia (CDH) has been cited to have a mortality rate of 50%. There have been multiple studies at individual institutions demonstrating potential benefits from various strategies including extracorporeal life support (ECLS), delayed repair, and lower levels of ventilator support. There has been no multicenter survey of institutions offering these modalities to describe the current use of ECLS and survival of these infants. In addition, the relationship between the number of patients with CDH managed at an individual institution and outcome has not been evaluated. METHODS: We queried 16 level III neonatal intensive care centers on the use of ECLS and survival of infants with CDH who were treated during 2 consecutive years (1993 to 1995). Data are presented as mean +/- SEM, median, and range. RESULTS: Data were collected on 411 patients. Of these, 71% +/- 8% were outborn and 8% +/- 3% were considered nonviable. Overall survival of CDH infants was 69% +/- 4% (range, 39% to 95%). The survival rate of infants on ECLS was 55% +/- 4%, whereas survival of infants not requiring ECLS was significantly increased at 81% +/- 5% (p = 0.005). The mean rate of ECLS use was 46% +/- 2%. There was no correlation between the number of cases per year at an individual institution and overall survival, ECLS survival, or ECLS use (r = 0.341, 0.305, and 0.287, respectively). There was also no correlation between case volume at an individual institution and ECLS survival (r = 0.271). CONCLUSIONS: The current survival rate and rate of ECLS use in infants with CDH at level III neonatal intensive care units in the United States are 69% +/- 4% and 46% +/- 2%, respectively. There is no correlation between the yearly individual center experience with managing CDH and rate of ECLS use or outcome.

Extracorporeal Circulation↗

A methodology for specifying PET VOI's using multimodality techniques.

Volume-of-interest (VOI) extraction for radionuclide and anatomical measurements requires correct identification and delineation of the anatomical feature being studied. We have developed a toolset for specifying three-dimensional (3-D) VOI's on a multislice positron emission tomography (PET) dataset. The software is particularly suited for specifying cerebral cortex VOI's which represent a particular gyrus or deep brain structure. A registered 3-D magnetic resonance image (MRI) dataset is used to provide high-resolution anatomical information, both as oblique two-dimensional (2-D) sections and as volume renderings of a segmented cortical surface. VOI's are specified indirectly in two dimensions by drawing a stack of 2-D regions on the MRI data. The regions are tiled together to form closed triangular mesh surface models, which are subsequently transformed into the observation space of the PET scanner. Quantification by this method allows calculation of radionuclide activity in the VOI's, as well as their statistical uncertainties and correlations. The methodology for this type of analysis and validation results are presented.

Brain↗

Population genetics of hypervariable loci: analysis of PCR based VNTR polymorphism within a population.

Using a polymerase chain reaction (PCR) based method, genotypes at two hypervariable loci (3' to the Apo-B-structural gene and at the ApoC-II gene) were determined by size classification of alleles. Genotype data at the Apo-B locus (Apo-B VNTR) were obtained on 240 French Caucasians; the sample size for the ApoC-II VNTR was 162. For 160 individuals two-locus genotype data were available. Applications of some recently developed statistical methods to these data indicate that both of these loci are at Hardy-Weinberg equilibrium (HWE) and there is no indication of allelic associations between these two unlinked loci. In addition, the observed numbers of alleles (12 for the Apo-B and 11 for the ApoC-II VNTR loci) are also consistent with their respective expectations based on the observed heterozygosities (76.9% for the Apo-B and 85.9% for the ApoC-II loci) suggesting genetic homogeneity of this population-based sample. The multimodal distribution of allele sizes observed for both loci indicate that the production of new alleles at such VNTR loci may be caused by more than one molecular mechanism. The utility of such highly polymorphic loci for human genetic research and forensic applications are discussed in the context of these findings.

Alleles↗

Systemic chemotherapy in the management of malignant peritoneal mesothelioma.

AIM: To review available evidence on the efficacy of chemotherapy in malignant mesothelioma of any origin. METHODS: All original research and review papers related to the role of systemic chemotherapy in the treatment of malignant mesothelioma, published from 1966 through February 2005, were identified through a MEDLINE search of the literature using the following search terms: "mesothelioma", "peritoneal", "chemotherapy", "antifolates", "cancer therapy". This search was supplemented by a manual search of the Proceedings of the Annual Meetings of the American Association for Cancer Research, American Society of Clinical Oncology, and the American Association for Cancer Research (AACR)-European Organization for Research and Treatment of Cancer (EORTC)-National Cancer Institute (NCI) Symposium on New Anticancer Drugs. RESULTS: Pemetrexed in combination with cisplatin is the first treatment regimen that demonstrates a survival improvement in patients with unresectable malignant pleural mesothelioma. Data from uncontrolled studies suggest similar antineoplastic efficacy in patients with mesothelioma of peritoneal origin. Preliminary results also suggest a possible survival advantage for a combination of cisplatin and raltitrexed as compared to cisplatin alone. Other cytotoxic agents that have shown to be active in this setting include vinorelbine and gemcitabine, either alone or combined with platinum compounds. CONCLUSION: The pemetrexed-cisplatin combination has become the new standard of care for patients with unresectable malignant mesothelioma. Future strategies shall incorporate these novel agents into multimodality approaches at earlier stages of the disease. Given the low incidence of this disease, encouraging physicians to refer these patients to specialized centers and patients to participate in clinical trials is of utmost importance.

Antineoplastic Combined Chemotherapy Protocols↗

Assessing infants' cortical response to speech using near-infrared spectroscopy.

Sensitivity to spoken language is an integral part of infants' formative development, yet relatively little is known about the neural mechanisms that underlie the emerging ability to perceive and process speech. This is in large part because there are a limited number of non-invasive techniques available to measure brain functioning in human infants. Near-infrared spectroscopy (NIRS), an optical imaging technique that estimates changes in neuronal activity by measuring changes in total hemoglobin concentration and oxygenation, may be a viable procedure for assessing the relation between speech processing and brain function in human infants. While auditory processing data have been gathered from newborn and preterm infants using NIRS, such data have not been collected from older infants. Many behavioral measures used to establish linguistic sensitivity in this population are accompanied by visual stimuli; however, it is unclear how coupling of auditory and visual stimuli influences neural processing. Here we studied cortical activity in infants aged 6-9 months, as measured by NIRS, during exposure to linguistic stimuli paired with visual stimuli and compared this to the activity observed in the same regions during exposure to visual stimuli alone. Results dissociate infants' hemodynamic responses to multimodal and unimodal stimuli, demonstrating the utility of NIRS for studying perceptual development in infants. In particular, these findings support the use of NIRS to study the neurobiology of language development in older infants, a task that is difficult to accomplish without the use of attention-getting visual stimuli.

Female↗

Appraisal of compliance with the UICC/AJCC staging system in the staging of gastric cancer. Union Internacional Contra la Cancrum/American Joint Committee on Cancer.

BACKGROUND: In the surgical management of gastric carcinoma, regional lymphatic spread is of prognostic importance. The fifth edition of the Union Internacional Contra la Cancrum classification has been shown to be reproducible, practical and of significant prognostic use. The tumour node metastasis (TNM) system requires at least 15 lymph nodes to be acquired and examined for staging to be accurate. This has raised concern over the consistency with which the requisite numbers of nodes would be acquired. This study was performed to assess how consistently surgically managed cases of gastric cancer in the West Midlands fulfilled this requirement to allow accurate staging. METHODS: Data from the West Midlands Cancer Intelligence Unit on all cases of gastric cancer registered from 1998 to 1999 were obtained and the number of lymph nodes documented for each surgically managed case was assessed. RESULTS: Overall, only 31.0 per cent of surgically resected cases could be assessed accurately according to the TNM system. The proportion staged accurately varied widely across hospitals from 10.9 to 76.0 per cent. CONCLUSION: These results reflect the need for improved N staging across the region to aid the appropriate multimodal treatment of patients.

Guideline Adherence↗

The influence of prophylactic orthoses on abdominal strength and low back injury in the workplace.

This study was designed to determine the effect of multimodal intervention and the prevention of back injury, and to evaluate the adverse side effects of using a lumbosacral corset in the workplace. Subjects were 90 male warehouse workers randomly selected from over 800 employees at a grocery distribution center. Subjects were assigned to three groups: true controls, no back school, no brace orthoses; back school only; and back school plus wearing a custom molded lumbosacral orthosis. Comparisons of pre-testing and 6-month follow-up post-testing for abdominal strength, cognitive data, work injury incidence and productivity and use of health care services were evaluated. Controls and training-only group showed no changes in strength productivity or lost time. Orthoses and training-group showed no changes in strength productivity or accident rate; however, they showed substantially less lost time. This study supports the concept of using education and prophylactic bracing to prevent back injury and reduce time loss. It appears that the use of intermittent prophylactic bracing has no adverse affects on abdominal muscle strength and may contribute to decreased lost time from work injuries.

Abdomen↗

Multimodality evaluation of pressure relief surfaces.

Multimodality evaluation of six different support surfaces was performed measuring interface pressure, transcutaneous oxygen tension, and blood flow in pressure ulcer-prone areas on healthy subjects. Interface pressure was measured with a flexible force-sensing resistor array. The interface pressure distribution patterns of 10 healthy male volunteers were measured in the supine and lateral positions using a pressure sensor (force sensing resistor) array. Transcutaneous oxygen (TcPO2) and laser Doppler flowmeter probes were placed over the sacrum, the right trochanter, and the right ischium. Data were recorded for 15 minutes each with the subject in the supine and lateral decubitus positions. Statistically significant differences (p < 0.05) between the various surfaces could be observed for blood flow and pressure measurements, especially in the lateral position over the trochanter and for the TcPO2 measurements in the supine position over the sacrum. We conclude that measuring interface pressure, transcutaneous oxygen tension, and blood flow allows a more thorough evaluation of the physiologic effects of special support surfaces than any single technique. Future studies on patients will assess algorithms for using these measurement techniques to predict the efficacy of various support surfaces in minimizing pressure ulceration.

Blood Gas Monitoring, Transcutaneous↗

Athermalized low-loss echelle-grating-based multimode dense wavelength division demultiplexer.

A high-density wavelength division demultiplexer (DEMUX) capable of demultiplexing eight-channel 200-GHz optically spaced signals into a 62.5-microm multimode-fiber array is reported. The wavelength range of operation is from 1549.32 to 1560.61 nm within the International Telecommunication Union grid. The measured wavelength accuracy is within 0.04 nm. The mean insertion loss of this DEMUX is 1.95 dB. Thermal analysis and temperature testing results are reported. The temperature test cycling from 20 degrees C to 60 degrees C indicates that the wavelength thermal drift is less than 0.8 pm/degrees C. Adjacent cross talk is measured to be better than -45 dB. The measured data transmission bit rate of this device is higher than 3.5 Gb/s.

Journal Article↗

[Generation and processing of digital images in radiodiagnosis].

The paper describes universal principles of diagnostic imaging. The attention is focused particularly on digital image generation in medicine. The methodology of display visualization of measured data is discussed. The problems of spatial relation representation and visual perception of image brightness are mentioned. The methodological issues of digital image processing (DIP) are discussed, particularly the relation of DIP to the other related disciplines, fundamental tasks in DIP and classification of DIP operations from the computational viewpoint. The following examples of applying DIP operations in diagnostic radiology are overviewed: local contrast enhancement in digital image, spatial filtering, quantitative texture analysis, synthesis of the 3D pseudospatial image based on the 2D tomogram set, multimodal processing of medical images. New trends of application of DIP methods in diagnostic radiology are outlined: evaluation of the diagnostic efficiency of DIP operations by means of ROC analysis, construction of knowledge-based systems of DIP in medicine. (Fig. 12, Ref. 26.)

Diagnostic Imaging↗

Using economic analysis to evaluate the potential of multimodality therapy for elderly patients with locally advanced pancreatic cancer.

PURPOSE: Development of new and expensive drugs with activity against pancreatic cancer has made economic considerations more relevant to treatment decision-making for advanced disease. Economic modeling can be used to explore the potential of such novel therapies and to inform clinical trial design. METHODS AND MATERIALS: We developed a Markov model to evaluate the cost-effectiveness of radiation plus fluorouracil (RT-FU) relative to no treatment in elderly patients with locally advanced pancreatic cancer (LAPC) and to determine the economic potential of radiation plus gemcitabine (RT-GEM), a novel regimen for this disease. We used the SEER-Medicare database to estimate effectiveness and costs supplemented by data from the literature where necessary. RESULTS: Relative to no treatment, RT-FU was associated with a cost-effectiveness ratio (ICER) of $68,724/QALY in the base case analysis. Compared with RT-FU, the ICER for RT-GEM was below $100,000/QALY when the risk of dying with the new regimen was <85% than with the standard regimen. However, >1,000 subjects would be necessary to demonstrate this level of efficacy in a randomized trial. The ICER of RT-GEM was most sensitive to utility values, and, at lower efficacy levels, to costs of gemcitabine and treatment-related toxicity. CONCLUSIONS: In elderly patients with LAPC, RT-FU is a cost-effective alternative to no treatment. The novel regimen of RT-GEM is likely to be cost-effective at any clinically meaningful benefit, but quality-of-life issues, drug acquisition, and toxicity-related costs may be relevant, especially at lower efficacy levels.

Aged↗

Alcoholics also dependent on cocaine in treatment: do they differ from "pure" alcoholics?

Although individuals who exhibit both alcohol and cocaine dependency are seen increasingly in traditional alcoholism rehabilitation settings, their comparability with "pure" alcoholics is unclear. Sociodemographic, psychological, cognitive, and substance abuse status were, therefore, monitored in a group of alcoholics (n = 64) versus a group of cocaine dependent alcoholics (n = 82) on admission and just prior to discharge from 28-day multimodal treatment settings. At admission, cocaine-dependent alcoholics were younger, more likely to be unmarried, have more extensive substance use histories as well as more frequent prior treatments than "pure" alcoholics. Additionally, members of both groups exhibited abnormalities on psychological indices. Both psychological and cognitive indices revealed significant between-group differences which subsequent analyses found to be a confound of the marked age discrepancy between groups. From admission to discharge, scores on both psychological and cognitive indices declined significantly in both groups. Urine assay data revealed a greater tendency for cocaine-dependent alcoholics to relapse during treatment. While the psychological and cognitive data largely argue for the comparability of groups of patients classified as "pure" alcoholics with those who are dependent on both alcohol and cocaine, the latter group may have more difficulty in achieving abstinence during treatment. The interpretability of behavioral indices gathered only at treatment admission is questioned.

Adolescent↗

Personality pathology and cognitive-behavioral treatment of fear of flying.

Studies have been inconclusive about the influence of personality pathology on treatment outcome in anxiety disorders. In general, it has been presumed that treatment outcome is negatively influenced by the presence of personality pathology. This is a study of the prevalence of personality pathology among persons who were seeking help for fear of flying. Moreover, the effects of personality pathology on the results of a multimodal, standardized, cognitive-behavioral fear of flying treatment program employed by an agency that specializes in treating people with fear of flying were studied. Personality pathology was determined with a self-report questionnaire, which provides ICD-10 diagnoses of personality disorders and dimensional severity scores for personality pathology. Treatment outcome was assessed with three different fear of flying questionnaires. Based on clinical judgment after individual-case conceptualization, participants (N=922) were assigned to a particular treatment for fear of flying. Self-report data for fear of flying were collected at pretreatment and at 3, 6 and 12-month follow-ups in 659 participants who followed the 2-day treatment program. Moreover, the number of flights made in the year following treatment was determined.The results of this study showed that participants with personality pathology, mainly from cluster C (anxiety), report greater fear of flying before treatment than participants without personality pathology. After treatment fear of flying was significantly reduced. Presence of personality pathology was not predictive of the number of flights after treatment and scores on the VAFAS scale at short or long term. Only on two questionnaires for fear of flying collected at short-term participants with personality pathology obtained significantly higher scores, although the size of the differences was relatively small. It was concluded that participants with personality pathology also benefited from fear of flying treatment and that the presence of personality pathology although cannot be regarded as a contra indication for a standardized, cognitive-behavioral group treatment.

Adolescent↗