Follitropin Alpha for assisted reproduction: an analysis based on a non-interventional study in Greece.

OBJECTIVE: To conduct an economic evaluation estimating the cost per live birth after controlled ovarian stimulation (COS) using Follitropin Alpha (Gonal-F), in the Greek National Health System setting. A secondary objective was to predict the live birth rateof the In Vitro Fertilization (IVF) procedure. METHODS: A single arm, multi-center, prospective, non-interventional study was conducted on which economic, efficacy and safety data were collected by six of the largest IVF centers. The participants were 350 female patients. Three statistical methods were employed for the analysis of the study outcomes, namely (a) Generalized Linear Modeling for the estimation of the costs of IVF treatment, (b) multivariable logistic regression and (c) an Artificial Neural Network (ANN) model for live birth prediction. RESULTS: The mean total cost of IVF therapy per patient was estimated at €3728 (95% CI: €3679-€3780), while the total cost per live birth was €14,872 (95% CI: €12,441-€17,951). The live birth rate after 3 complete IVF cycles was estimated at 22.9%, while the percentage of those suffering from OHSS was limited at 0.57%. In logistic regression, the Ovarian Sensitivity Index (OSI) was a factor found to be positively associated with live birth (OR 7.39, 95% CI: 1.84-29.71). For the ANN, important predictors included number of gestational sacs and the duration of infertility. CONCLUSION: The present study constitutes the largest single-arm study based on real data in Greece to date. The cost of IVF treatment and the cost per live birth are not insignificant in this NHS setting. The live birth rate, cost per oocyte, and the cost per live birth are in line with literature. OSI was a main contributing factor to the accurate prediction of the live birth rate, while age and BMI were found to be negatively correlated.

Neurocraft: software for microscale brain network dynamics.

The brain operates at millisecond timescales but despite of that, the study of its functional networks is approached with time invariant methods. Equally, for a variety of brain conditions treatment is delivered with fixed temporal protocols unable to monitor and follow the rapid progression and therefore the cycles of a disease. To facilitate the understanding of brain network dynamics we developed Neurocraft, a user friendly software suite. Neurocraft features a highly novel signal processing engine fit for tracking evolving network states with superior time and frequency resolution. A variety of analytics like dynamic connectivity maps, force-directed representations and propagation models, allow for the highly selective investigation of transient pathophysiological dynamics. In addition, machine-learning tools enable the unsupervised investigation and selection of key network features at individual and group-levels. For proof of concept, we compared six seizure-free and non seizure-free focal epilepsy patients after resective surgery using Neurocraft. The network features were calculated using 50 intracranial electrodes on average during at least 120 epileptiform discharges lasting less than one second, per patient. Powerful network differences were detected in the pre-operative data of the two patient groups (effect size = 1.27), suggesting the predictive value of dynamic network features. More than one million patients are treated with cardiac and neuro modulation devices that are unable to track the hourly or daily changes in a subject's disease. Decoding the dynamics of transition from normal to abnormal states may be crucial in the understanding, tracking and treatment of neurological conditions. Neurocraft provides a user-friendly platform for the research of microscale brain dynamics and a stepping stone for the personalised device-based adaptive neuromodulation in real-time.

Abnormal microscale neuronal connectivity triggered by a proprioceptive stimulus in dystonia.

We investigated modulation of functional neuronal connectivity by a proprioceptive stimulus in sixteen young people with dystonia and eight controls. A robotic wrist interface delivered controlled passive wrist extension movements, the onset of which was synchronised with scalp EEG recordings. Data were segmented into epochs around the stimulus and up to 160 epochs per subject were averaged to produce a Stretch Evoked Potential (StretchEP). Event-related network dynamics were estimated using a methodology that features Wavelet Transform Coherency (WTC). Global Microscale Nodal Strength (GMNS) was introduced to estimate overall engagement of areas into short-lived networks related to the StretchEP, and Global Connectedness (GC) estimated the spatial extent of the StretchEP networks. Dynamic Connectivity Maps showed a striking difference between dystonia and controls, with particularly strong theta band event-related connectivity in dystonia. GC also showed a trend towards higher values in dystonia than controls. In summary, we demonstrate the feasibility of this method to investigate event-related neuronal connectivity in relation to a proprioceptive stimulus in a paediatric patient population. Young people with dystonia show an exaggerated network response to a proprioceptive stimulus, displaying both excessive theta-band synchronisation across the sensorimotor network and widespread engagement of cortical regions in the activated network.

Co-activation of rhythms during alpha band oscillations as an interictal biomarker of exploding head syndrome.

BACKGROUND: Exploding head syndrome is a rarely reported benign sensory parasomnia that may nonetheless have significant impact on patients' quality of life and their perceived well-being. To date, the mechanisms underlying attacks, characterised by a painless perception of abrupt, loud noises at transitional sleep-wake or wake-sleep states, are by and large unclear. METHODS AND RESULTS: In order to address the current gap in the knowledge of potential underlying pathophysiology, a retrospective case-control study of polysomnographic recordings of patients presenting to a tertiary sleep disorders clinic with exploding head syndrome was conducted. Interictal (non-attack associated) electroencephalographic biomarkers were investigated by performing macrostructural and event-related dynamic spectral analyses of the whole-night EEG. In patients with exploding head syndrome, additional oscillatory activity was recorded during wakefulness and at sleep/wake periods. This activity differed in its frequency, topography and source from the alpha rhythm that it accompanied. CONCLUSION: Based on these preliminary findings, we hypothesise that at times of sleep-wake transition in patients with exploding head syndrome, aberrant attentional processing may lead to amplification and modulation of external sensory stimuli.

Cross-subject network investigation of the EEG microstructure: A sleep spindles study.

BACKGROUND: The microstructural EEG elements and their functional networks relate to many neurophysiological functions of the brain and can reveal abnormalities. Despite the blooming variety of methods for estimating connectivity in the EEG of a single subject, a common pitfall is seen in relevant studies; grand averaging is used for estimating the characteristic connectivity patterns of a group of subjects. This averaging may distort results and fail to account for the internal variability of connectivity results across the subjects of a group. NEW METHOD: In this study, we propose a novel methodology for the cross-subject network investigation of EEG graphoelements. We used dimensionality reduction techniques in order to reveal internal connectivity properties and to examine how consistent these are across a number of subjects. In addition, graph theoretical measures were utilized to prioritize regions according to their network attributes. RESULTS: As proof of concept, we applied this method on fast sleep spindles across 10 healthy subjects. Neurophysiological findings revealed subnetworks of the spindle events across subjects, highlighting a predominance for occipito-parietal areas and their connectivity with frontal regions. COMPARISON WITH EXISTING METHODS: This is a new approach for the examination of within-group connectivities in EEG research. The results accounted for more than 85% of the overall data variance and the detected subnetworks were found to be meaningful down-projections of the grand average of the group, suggesting sufficient performance for the proposed methodology. CONCLUSION: We conclude that the proposed methodology can serve as an observatory tool for the EEG connectivity patterns across subjects, providing a supplementary analysis of the existing topography techniques.

Ultra-wide range field-dependent measurements of the relaxivity of Gd1-xEuxVO4 nanoparticle contrast agents using a mechanical sample-shuttling relaxometer.

The current trend for Magnetic Resonance Imaging points towards higher magnetic fields. Even though sensitivity and resolution are increased in stronger fields, T1 contrast is often reduced, and this represents a challenge for contrast agent design. Field-dependent measurements of relaxivity are thus important to characterize contrast agents. At present, the field-dependent curves of relaxivity are usually carried out in the field range of 0 T to 2 T, using fast field cycling relaxometers. Here, we employ a high-speed sample shuttling device to switch the magnetic fields experienced by the nuclei between virtually zero field, and the center of any commercial spectrometer. We apply this approach on rare-earth (mixed Gadolinium-Europium) vanadate nanoparticles, and obtain the dispersion curves from very low magnetic field up to 11.7 T. In contrast to the relaxivity profiles of Gd chelates, commonly used for clinical applications, which display a plateau and then a decrease for increasing magnetic fields, these nanoparticles provide maximum contrast enhancement for magnetic fields around 1-1.5 T. These field-dependent curves are fitted using the so-called Magnetic Particle (MP) model and the extracted parameters discussed as a function of particle size and composition. We finally comment on the new possibilities offered by this approach.

Topography of generalized periodic epileptiform discharges in postanoxic nonconvulsive status epilepticus.

We studied slow (≤2.5 Hz) nonevolving generalized periodic epileptiform discharges (GPEDs) in the electroencephalogram (EEG) of comatose patients after cardiac arrest (CA) in search of evidence that could assist early diagnosis of possible hypoxic nonconvulsive status epilepticus (NCSE) and its differentiation from terminal brain anoxia (BA), which can present with a similar EEG pattern. We investigated the topography of the GPEDs in the first post-CA EEGs of 13 patients, using voltage-mapping, and compared findings between two patients with NCSE and GPEDs > 2.5 Hz (group 1), and 11 with GPEDs ≤ 2 Hz, of whom six had possible NCSE (group 2) and five had terminal BA (group 3). Voltage mapping showed frontal maximum for the negative phase of the GPEDs in all patients of groups 1 and 2, but not in any of the patients of group 3, who invariably showed maximization of the negative phase posteriorly. Morphology, amplitude, and duration of the GPEDs varied across the groups, without distinctive features for possible NCSE. These findings provide evidence that, in hypoxic coma after CA with slow GPEDs, anterior topography of the maximum GPED negativity on voltage mapping may be a distinctive biomarker for possible NCSE contributing to the coma.

High sensitivity high-resolution full range relaxometry using a fast mechanical sample shuttling device and a cryo-probe.

Field-dependent NMR studies of bio-molecular systems using a sample shuttling hardware operating on a high-field NMR apparatus have provided valuable structural and dynamic information. We have recently published a design of a compact sample transportation device, called "field-cycler", which was installed in a commercial spectrometer and which provided highly precise positioning and stability during high speed shuttling. In this communication, we demonstrate the first use of a sample shuttling device on a commercial high field standard bore NMR spectrometer, equipped with a commercial triple resonance cryogenically cooled NMR probe. The performance and robustness of the hardware operating in 1D and 2D field cycling experiments, as well as the impact of the sample shuttling time on the signal intensity are discussed.

Connectivity Measures in EEG Microstructural Sleep Elements.

During Non-Rapid Eye Movement sleep (NREM) the brain is relatively disconnected from the environment, while connectedness between brain areas is also decreased. Evidence indicates, that these dynamic connectivity changes are delivered by microstructural elements of sleep: short periods of environmental stimuli evaluation followed by sleep promoting procedures. The connectivity patterns of the latter, among other aspects of sleep microstructure, are still to be fully elucidated. We suggest here a methodology for the assessment and investigation of the connectivity patterns of EEG microstructural elements, such as sleep spindles. The methodology combines techniques in the preprocessing, estimation, error assessing and visualization of results levels in order to allow the detailed examination of the connectivity aspects (levels and directionality of information flow) over frequency and time with notable resolution, while dealing with the volume conduction and EEG reference assessment. The high temporal and frequency resolution of the methodology will allow the association between the microelements and the dynamically forming networks that characterize them, and consequently possibly reveal aspects of the EEG microstructure. The proposed methodology is initially tested on artificially generated signals for proof of concept and subsequently applied to real EEG recordings via a custom built MATLAB-based tool developed for such studies. Preliminary results from 843 fast sleep spindles recorded in whole night sleep of 5 healthy volunteers indicate a prevailing pattern of interactions between centroparietal and frontal regions. We demonstrate hereby, an opening to our knowledge attempt to estimate the scalp EEG connectivity that characterizes fast sleep spindles via an "EEG-element connectivity" methodology we propose. The application of the latter, via a computational tool we developed suggests it is able to investigate the connectivity patterns related to the occurrence of EEG microstructural elements. Network characterization of specified physiological or pathological EEG microstructural elements can potentially be of great importance in the understanding, identification, and prediction of health and disease.

Simple method for the generation of multiple homogeneous field volumes inside the bore of superconducting magnets.

Standard Magnetic Resonance magnets produce a single homogeneous field volume, where the analysis is performed. Nonetheless, several modern applications could benefit from the generation of multiple homogeneous field volumes along the axis and inside the bore of the magnet. In this communication, we propose a straightforward method using a combination of ring structures of permanent magnets in order to cancel the gradient of the stray field in a series of distinct volumes. These concepts were demonstrated numerically on an experimentally measured magnetic field profile. We discuss advantages and limitations of our method and present the key steps required for an experimental validation.

Low frequency nonevolving generalized periodic epileptiform discharges and the borderland of hypoxic nonconvulsive status epilepticus in comatose patients after cardiac arrest.

To explore the EEG boundary of nonconvulsive status epilepticus (NCSE) and the concept of "possible NCSE", we studied 14 consecutive patients with ≤ 2-Hz nonevolving periodic generalized epileptiform discharges (GPDs) in their first EEG after out of hospital cardiac arrest (OHCA). The pattern was associated with myoclonus in 11 patients. EG reactivity to antiseizure drugs (benzodiazepines and propofol), but without clinical improvement, was noted in 8 patients, satisfying the diagnostic criteria of "possible NCSE". Resolution of GPDs and emergence of physiological rhythms in follow-up EEGs and/or subsequent clinical improvement were noted in 6 of them, strongly suggesting that the initial slow nonevolving GPD pattern reflected NCSE significantly contributing to their coma. Background rhythms from 10 to 90% of the periods between GPDs were noted in 9 patients and appeared to correlate with reactivity of the GPD pattern to antiseizure drugs when 20% or more. Ten patients died, and four were discharged to longer care rehabilitation centers. Although based on few observations, preliminary evidence appears to indicate that in this context, nonevolving GPD frequencies as low as 0.8 Hz can reflect clinically significant NCSE and, therefore, warrant appropriate testing for possible reactivity. There is also some preliminary indication that background rhythms may be another important diagnostic and, perhaps, prognostic indicator, but this needs to be tested in large prospective studies. This article is part of a Special Issue entitled "Status Epilepticus".

Management of atrial fibrillation in Greece: the MANAGE-AF study.

BACKGROUND: Although atrial fibrillation (AF) is a highly prevalent health problem with high morbidity and mortality, data regarding the clinical characteristics and management of AF in the Greek population are scarce. The "Current Clinical Practice in the MANAGEment of Atrial Fibrillation in Greece" study (MANAGEAF) aimed to assess the epidemiological features as well as the daily clinical practice in the management of Greek patients with AF. METHODS: Taking into consideration the distribution of the Greek population, 603 consecutive patients over 18 years of age, with any type of AF, presenting at the emergency departments or outpatient clinics of 27 different centers, were included in our study. RESULTS: The mean age of the patients was 68.5 ± 12.1 years, with male patients representing 52.5% of the study population. The most common AF type in our cohort was non-paroxysmal AF (60%), including the patients with permanent (24.1%), persistent (17.4%), long-standing (4.8%) and first diagnosed AF (13.8%). Hypertension was the most common comorbidity (70.3%). A history of stroke or transient ischemic attack was detected in 9.2% of the patients, while 6.2% had a history of gastrointestinal bleeding. About half of the patients (49.3%) were treated with anticoagulant drugs, mainly vitamin K antagonists (46.9%), while 34.2% were on antiplatelet drugs, aspirin and/or clopidogrel. The mean INR level (1.7 ± 0.8) was sub-therapeutic, although the mean values for CHADS2 and CHA2DS2-VASc scores were 1.6 ± 1.2 and 3.0 ± 1.7, respectively. CONCLUSION: The MANAGE-AF baseline results indicate unsatisfactory levels of compliance with the current guidelines for the management of AF in Greece. Considering the undisputed effectiveness of anticoagulant treatment for preventing AF-related strokes, MANAGE-AF demonstrates the need for optimization of our therapeutic strategies for the management of cardioembolic stroke risk.

µHigh resolution-magic-angle spinning NMR spectroscopy for metabolic phenotyping of Caenorhabditis elegans.

Analysis of model organisms, such as the submillimeter-size Caenorhabditis elegans, plays a central role in understanding biological functions across species and in characterizing phenotypes associated with genetic mutations. In recent years, metabolic phenotyping studies of C. elegans based on (1)H high-resolution magic-angle spinning (HR-MAS) nuclear magnetic resonance (NMR) spectroscopy have relied on the observation of large populations of nematodes, requiring labor-intensive sample preparation that considerably limits high-throughput characterization of C. elegans. In this work, we open new platforms for metabolic phenotyping of C. elegans mutants. We determine rich metabolic profiles (31 metabolites identified) from samples of 12 individuals using a (1)H NMR microprobe featuring high-resolution magic-angle coil spinning (HR-MACS), a simple conversion of a standard HR-MAS probe to µHR-MAS. In addition, we characterize the metabolic variations between two different strains of C. elegans (wild-type vs slcf-1 mutant). We also acquire a NMR spectrum of a single C. elegans worm at 23.5 T. This study represents the first example of a metabolomic investigation carried out on a small number of submillimeter-size organisms, demonstrating the potential of NMR microtechnologies for metabolomics screening of small model organisms.

"Paradoxical" EEG response to propofol may differentiate post-cardiac arrest non-convulsive status epilepticus from diffuse irreversible cerebral anoxia.

Current EEG criteria for the diagnosis of non-convulsive status epilepticus in critically ill patients with repetitive generalised or focal epileptiform discharges primarily rely on a widely accepted low cut-off frequency limit of 2.5-3 Hz for non-evolving patterns, or on discharge evolution of frequency, location or mophology. The secondary criterion is a significant clinical or EEG improvement following acute administration of a rapidly acting antiepileptic drug, such as lorazepam. We describe a comatose patient after out-of-hospital cardiac arrest, in whom very slow (1-Hz), non-evolving generalised periodic epileptiform discharges against an almost completely depressed background would suggest substantial anoxic damage and poor neurological outcome. Yet, reloading with propofol for diagnostic purposes completely dispersed generalised periodic epileptiform discharges and revealed previously absent biological activity, raising the possibility of non-convulsive status epilepticus that was subsequently confirmed. Brain MRI showed no significant anoxic brain damage and EEG improved, but the patient died from severe cardiopulmonary complications. These observations suggest that in rare cases, slow, non-evolving generalised periodic epileptiform discharges may reflect non-convulsive status epilepticus rather than diffuse irreversible cerebral anoxia, while reloading with propofol can be used as an additional secondary diagnostic criterion.

Nanosecond time scale motions in proteins revealed by high-resolution NMR relaxometry.

Understanding the molecular determinants underlying protein function requires the characterization of both structure and dynamics at atomic resolution. Nuclear relaxation rates allow a precise characterization of protein dynamics at the Larmor frequencies of spins. This usually limits the sampling of motions to a narrow range of frequencies corresponding to high magnetic fields. At lower fields one cannot achieve sufficient sensitivity and resolution in NMR. Here, we use a fast shuttle device where the polarization builds up and the signals are detected at high field, while longitudinal relaxation takes place at low fields 0.5 < B0 < 14.1 T. The sample is propelled over a distance up to 50 cm by a blowgun-like system in about 50 ms. The analysis of nitrogen-15 relaxation in the protein ubiquitin over such a wide range of magnetic fields offers unprecedented insights into molecular dynamics. Some key regions of the protein feature structural fluctuations on nanosecond time scales, which have so far been overlooked in high-field relaxation studies. Nanosecond motions in proteins may have been underestimated by traditional high-field approaches, and slower supra-τ(c) motions that have no effect on relaxation may have been overestimated. High-resolution relaxometry thus opens the way to a quantitative characterization of nanosecond motions in proteins.

Refined magic-angle coil spinning resonator for nanoliter NMR spectroscopy: enhanced spectral resolution.

The magic-angle coil spinning (MACS) resonator allows a simple approach for nanoliter nuclear magnetic resonance (NMR) detections with enhanced sensitivity and high-resolution under sample magic-angle spinning (MAS). Currently, the spectral resolution acquired with MACS is not efficient for detailed characterization of semisolids like biopsies, where subhertz resolution is necessary. Here, we describe the two sources of line broadening from MACS, sample temperature gradient and anisotropic magnetic susceptibility, and present a refined high-resolution magic-angle coil spinning (HR-MACS) resonator that improves the spectral resolution. We demonstrate with the high quality HR-MACS NMR spectra of micronematodes and tissue biopsy, and illustrate its potential for NMR-based metabolomics of nanoliter tissue samples.

Microfabricated inserts for magic angle coil spinning (MACS) wireless NMR spectroscopy.

This article describes the development and testing of the first automatically microfabricated probes to be used in conjunction with the magic angle coil spinning (MACS) NMR technique. NMR spectroscopy is a versatile technique for a large range of applications, but its intrinsically low sensitivity poses significant difficulties in analyzing mass- and volume-limited samples. The combination of microfabrication technology and MACS addresses several well-known NMR issues in a concerted manner for the first time: (i) reproducible wafer-scale fabrication of the first-in-kind on-chip LC microresonator for inductive coupling of the NMR signal and reliable exploitation of MACS capabilities; (ii) improving the sensitivity and the spectral resolution by simultaneous spinning the detection microcoil together with the sample at the "magic angle" of 54.74° with respect to the direction of the magnetic field (magic angle spinning - MAS), accompanied by the wireless signal transmission between the microcoil and the primary circuit of the NMR spectrometer; (iii) given the high spinning rates (tens of kHz) involved in the MAS methodology, the microfabricated inserts exhibit a clear kinematic advantage over their previously demonstrated counterparts due to the inherent capability to produce small radius cylindrical geometries, thus tremendously reducing the mechanical stress and tearing forces on the sample. In order to demonstrate the versatility of the microfabrication technology, we have designed MACS probes for various Larmor frequencies (194, 500 and 700 MHz) testing several samples such as water, Drosophila pupae, adamantane solid and LiCl at different magic angle spinning speeds.

Evaluation of high resolution magic-angle coil spinning NMR spectroscopy for metabolic profiling of nanoliter tissue biopsies.

High-resolution magic-angle sample spinning (HR-MAS) (1)H NMR spectroscopy of tissue biopsies combined with chemometric techniques has emerged as a valuable methodology for disease diagnosis and environmental assessments. However, the tissue mass required for such experiments is of the order of 10 mg, and this can compromise the metabolic evaluation because of tissue heterogeneity. Tissue availability is often a limitation for clinical studies due to histopathological requirements, which are currently the gold standard for diagnosis, for example, in the case of tumors. Here, we introduce the use of a rotating micro-NMR detector that optimizes the coil filling factor such that mass-limited samples can be measured. We show the results for measuring nanoliter volume tissue biopsies using a commercial HR-MAS probe for the first time. The method has been tested with bovine muscle and human gastric mucosal tumor tissue samples. The gain in mass sensitivity is approximate up to 17-fold, and the adequate spectral resolution (3 Hz) allows the measurement of the metabolite profiles in nanoliter volume samples, thereby limiting the ambiguity resulting from heterogeneous tissues; thus, the approach presents diagnostic potential for studies by metabonomics of mass-limited biopsies.

An expansion of the field modulus suitable for the description of strong field gradients in axisymmetric magnetic fields: application to single-sided magnet design, field mapping and STRAFI.

Mapping (or plotting) the magnetic field has a critical importance for the achievement of the homogeneous magnetic field necessary to standard MR experiments. A powerful tool for this purpose is the Spherical Harmonic Expansion (SHE), which provides a simple way to describe the spatial variations of a field in free space. Well-controlled non-zero spatial variations of the field are critical to MRI. The resolution of the image is directly related to the strength of the gradient used to encode space. As a result, it is desirable to have strong variations of the field. In that case, the SHE cannot be used as is, because the field modulus variations are affected by the variations of all components of the field. In this paper, we propose a method based on the SHE to characterize such variations, theoretically and experimentally, in the limit of an axisymmetric magnetic field. Practical applications of this method are proposed through the examples of single-sided magnet design and characterization, along with Stray-Field Imaging (STRAFI).