Ontogeny and Function of Plasmacytoid Dendritic Cells.

Plasmacytoid dendritic cells (pDCs) represent a unique cell type within the innate immune system. Their defining property is the recognition of pathogen-derived nucleic acids through endosomal Toll-like receptors and the ensuing production of type I interferon and other soluble mediators, which orchestrate innate and adaptive responses. We review several aspects of pDC biology that have recently come to the fore. We discuss emerging questions regarding the lineage affiliation and origin of pDCs and argue that these cells constitute an integral part of the dendritic cell lineage. We emphasize the specific function of pDCs as innate sentinels of virus infection, particularly their recognition of and distinct response to virus-infected cells. This essential evolutionary role of pDCs has been particularly important for the control of coronaviruses, as demonstrated by the recent COVID-19 pandemic. Finally, we highlight the key contribution of pDCs to systemic lupus erythematosus, in which therapeutic targeting of pDCs is currently underway.

Transitional dendritic cells are distinct from conventional DC2 precursors and mediate proinflammatory antiviral responses.

High-dimensional approaches have revealed heterogeneity amongst dendritic cells (DCs), including a population of transitional DCs (tDCs) in mice and humans. However, the origin and relationship of tDCs to other DC subsets has been unclear. Here we show that tDCs are distinct from other well-characterized DCs and conventional DC precursors (pre-cDCs). We demonstrate that tDCs originate from bone marrow progenitors shared with plasmacytoid DCs (pDCs). In the periphery, tDCs contribute to the pool of ESAM+ type 2 DCs (DC2s), and these DC2s have pDC-related developmental features. Different from pre-cDCs, tDCs have less turnover, capture antigen, respond to stimuli and activate antigen-specific naïve T cells, all characteristics of differentiated DCs. Different from pDCs, viral sensing by tDCs results in IL-1ß secretion and fatal immune pathology in a murine coronavirus model. Our findings suggest that tDCs are a distinct pDC-related subset with a DC2 differentiation potential and unique proinflammatory function during viral infections.

Self-renewing resident arterial macrophages arise from embryonic CX3CR1(+) precursors and circulating monocytes immediately after birth.

Resident macrophages densely populate the normal arterial wall, yet their origins and the mechanisms that sustain them are poorly understood. Here we use gene-expression profiling to show that arterial macrophages constitute a distinct population among macrophages. Using multiple fate-mapping approaches, we show that arterial macrophages arise embryonically from CX3CR1(+) precursors and postnatally from bone marrow-derived monocytes that colonize the tissue immediately after birth. In adulthood, proliferation (rather than monocyte recruitment) sustains arterial macrophages in the steady state and after severe depletion following sepsis. After infection, arterial macrophages return rapidly to functional homeostasis. Finally, survival of resident arterial macrophages depends on a CX3CR1-CX3CL1 axis within the vascular niche.

Dynamic Contrast-enhanced MRI Quantification of Altered Vascular Permeability in Autoimmune Encephalitis.

Background Blood-brain barrier (BBB) permeability change is a possible pathologic mechanism of autoimmune encephalitis. Purpose To evaluate the change in BBB permeability in patients with autoimmune encephalitis as compared with healthy controls by using dynamic contrast-enhanced (DCE) MRI and to explore its predictive value for treatment response in patients. Materials and Methods This single-center retrospective study included consecutive patients with probable or possible autoimmune encephalitis and healthy controls who underwent DCE MRI between April 2020 and May 2021. Automatic volumetric segmentation was performed on three-dimensional T1-weighted images, and volume transfer constant (Ktrans) values were calculated at encephalitis-associated brain regions. Ktrans values were compared between the patients and controls, with adjustment for age and sex with use of a nonparametric approach. The Wilcoxon rank sum test was performed to compare Ktrans values of the good (improvement in modified Rankin Scale [mRS] score of at least two points or achievement of an mRS score of ≤2) and poor (improvement in mRS score of less than two points and achievement of an mRS score >2) treatment response groups among the patients. Results Thirty-eight patients with autoimmune encephalitis (median age, 38 years [IQR, 29-59 years]; 20 [53%] female) and 17 controls (median age, 71 years [IQR, 63-77 years]; 12 [71%] female) were included. All brain regions showed higher Ktrans values in patients as compared with controls (P < .001). The median difference in Ktrans between the patients and controls was largest in the right parahippocampal gyrus (25.1 × 10-4 min-1 [95% CI: 17.6, 43.4]). Among patients, the poor treatment response group had higher baseline Ktrans values in both cerebellar cortices (P = .03), the left cerebellar cortex (P = .02), right cerebellar cortex (P = .045), left cerebral cortex (P = .045), and left postcentral gyrus (P = .03) than the good treatment response group. Conclusion DCE MRI demonstrated that BBB permeability was increased in all brain regions in patients with autoimmune encephalitis as compared with controls, and baseline Ktrans values were higher in patients with poor treatment response in the cerebellar cortex, left cerebral cortex, and left postcentral gyrus as compared with the good response group. © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Filippi and Rocca in this issue.

DC-SIGN(+) Macrophages Control the Induction of Transplantation Tolerance.

Tissue effector cells of the monocyte lineage can differentiate into different cell types with specific cell function depending on their environment. The phenotype, developmental requirements, and functional mechanisms of immune protective macrophages that mediate the induction of transplantation tolerance remain elusive. Here, we demonstrate that costimulatory blockade favored accumulation of DC-SIGN-expressing macrophages that inhibited CD8(+) T cell immunity and promoted CD4(+)Foxp3(+) Treg cell expansion in numbers. Mechanistically, that simultaneous DC-SIGN engagement by fucosylated ligands and TLR4 signaling was required for production of immunoregulatory IL-10 associated with prolonged allograft survival. Deletion of DC-SIGN-expressing macrophages in vivo, interfering with their CSF1-dependent development, or preventing the DC-SIGN signaling pathway abrogated tolerance. Together, the results provide new insights into the tolerogenic effects of costimulatory blockade and identify DC-SIGN(+) suppressive macrophages as crucial mediators of immunological tolerance with the concomitant therapeutic implications in the clinic.

Sialylated IVIg binding to DC-SIGN+ Hofbauer cells induces immune tolerance through the caveolin-1/NF-kB pathway and IL-10 secretion.

Although the use of IVIg has increased in various immune-driven diseases and even in pregnancy, the exact action mechanisms of IVIg are not fully understood. Dendritic cell-specific intercellular adhesion molecule-3 grabbing non-integrin (DC-SIGN) is a known receptor for α-2,6-sialylated IgG (sIVIg), which is responsible for the anti-inflammatory effect of IVIg. DC-SIGN is expressed on Hofbauer cells (HBCs) of the fetal villi of the placenta which act as an innate immune modulator at the maternal-fetal interface. Preeclampsia is a major complication in pregnancy and is related to IL-10, a cytokine with an important role in immune tolerance. DC-SIGN interaction with sIVIg in HBCs promoted IL-10 secretion through the activation of the caveolin-1/NF-κB pathway, especially in plasma lipid rafts. Consistent results were obtained for HBCs from patients with preeclampsia. Collectively, the stimulation of DC-SIGN+ HBCs with sIVIg enhanced immune tolerance in the feto-maternal environment, suggesting the therapeutic application of sIVIg to prevent preeclampsia.

Deep learning-based reconstruction for acceleration of lumbar spine MRI: a prospective comparison with standard MRI.

OBJECTIVE: To compare the image quality and diagnostic performance between standard turbo spin-echo MRI and accelerated MRI with deep learning (DL)-based image reconstruction for degenerative lumbar spine diseases. MATERIALS AND METHODS: Fifty patients who underwent both the standard and accelerated lumbar MRIs at a 1.5-T scanner for degenerative lumbar spine diseases were prospectively enrolled. DL reconstruction algorithm generated coarse (DL_coarse) and fine (DL_fine) images from the accelerated protocol. Image quality was quantitatively assessed in terms of signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) and qualitatively assessed using five-point visual scoring systems. The sensitivity and specificity of four radiologists for the diagnosis of degenerative diseases in both protocols were compared. RESULTS: The accelerated protocol reduced the average MRI acquisition time by 32.3% as compared to the standard protocol. As compared with standard images, DL_coarse and DL_fine showed significantly higher SNRs on T1-weighted images (T1WI; both p < .001) and T2-weighted images (T2WI; p = .002 and p < 0.001), higher CNRs on T1WI (both p < 0.001), and similar CNRs on T2WI (p = .49 and p = .27). The average radiologist assessment of overall image quality for DL_coarse and DL_fine was higher on sagittal T1WI (p = .04 and p < .001) and axial T2WI (p = .006 and p = .01) and similar on sagittal T2WI (p = .90 and p = .91). Both DL_coarse and DL_fine had better image quality of cauda equina and paraspinal muscles on axial T2WI (both p = .04 for cauda equina; p = .008 and p = .002 for paraspinal muscles). Differences in sensitivity and specificity for the detection of central canal stenosis and neural foraminal stenosis between standard and DL-reconstructed images were all statistically nonsignificant (p ≥ 0.05). CONCLUSION: DL-based protocol reduced MRI acquisition time without degrading image quality and diagnostic performance of readers for degenerative lumbar spine diseases. CLINICAL RELEVANCE STATEMENT: The deep learning (DL)-based reconstruction algorithm may be used to further accelerate spine MRI imaging to reduce patient discomfort and increase the cost efficiency of spine MRI imaging. KEY POINTS: • By using deep learning (DL)-based reconstruction algorithm in combination with the accelerated MRI protocol, the average acquisition time was reduced by 32.3% as compared with the standard protocol. • DL-reconstructed images had similar or better quantitative/qualitative overall image quality and similar or better image quality for the delineation of most individual anatomical structures. • The average radiologist's sensitivity and specificity for the detection of major degenerative lumbar spine diseases, including central canal stenosis, neural foraminal stenosis, and disc herniation, on standard and DL-reconstructed images, were similar.

Quantifying infarct core volume in ischemic stroke: What is the optimal threshold and parameters of computed tomography perfusion?

OBJECTIVE: Although computed tomography perfusion (CTP) is used to select and guide decision-making processes in patients with acute ischemic stroke, there is no clear standardization of the optimal threshold to predict ischemic core volume accurately. The infarct core volume with a relative cerebral blood flow(rCBF) threshold of < 30% is commonly used. We aimed to assess the volumetric agreement of the infarct core volume with different CTP parameters and thresholds using CTP software (RAPID, VITREA) and the infarct volume on diffusion-weighted imaging (DWI), with a short interval time (within 60 min) between CTP and follow-up DWI. MATERIALS AND METHODS: This retrospective study included 42 acute ischemic stroke patients with occlusion of the large artery in the anterior circulation between April 2017-November 2020. RAPID identified infarct core as tissue rCBF < 20-38%. VITREA defined the infarct core as cerebral blood volume (CBV) < 26-56%. Olea Sphere was used to measure infarct core volume on DWI. The CTP-infarct core volume with different thresholds of perfusion parameters (CBF threshold vs CBV threshold) were compared with DWI-infarct core volumes. RESULTS: The median time between CTP and DWI was 37.5min. The commonly used threshold of CBV< 41% (4.3 mL) resulted in lower median infarct core volume difference compared to the commonly used thresholds of rCBF < 30% (8.2mL). On the other hand, the optimal thresholds of CBV < 26% (-1.0mL; 95% CI, -53.9 to 58.1 mL; 0.945) resulted in the lowest median infarct core volume difference, narrowest limits of agreement, and largest interclass correlation coefficient compared with the optimal thresholds of rCBF < 38% (4.9 mL; 95% CI, -36.4 to 62.9 mL; 0.939). CONCLUSION: Our study found that the both optimal and commonly used thresholds of CBV provided a more accurate prediction of the infarct core volume in patients with AIS than rCBF.

Computed tomography complements ultrasound for the differential diagnosis of traumatic neuroma from recurrent tumor in patients with postoperative thyroid cancer.

OBJECTIVES: Traumatic neuromas (TNs) mimic recurrent tumors in US after total thyroidectomy (TT) and lateral neck dissection (LND) for thyroid cancer. We aimed to evaluate whether CT could complement US in the differential diagnosis of TNs from recurrent thyroid cancer in the dissected neck. MATERIAL AND METHODS: We retrospectively included a total of 97 consecutive US-detected lesions (28 TNs and 69 recurrent tumors) in patients with a previous history of TT and LND for thyroid cancer. The lesions were classified as benign, indeterminate, or suspicious according to the presence of benign or suspicious features on US and CT. Imaging features and categories on US and CT were compared between TNs and recurrent tumors. The diagnostic performances of US and CT for differentiating between TNs and recurrent tumors were calculated. RESULTS: On US, most TNs and recurrent tumors showed internal hyperechogenicity without hilar echogenicity or hilar vascularity and were categorized as suspicious lesions (23/28, 82.1% vs. 53/69, 76.8%). On CT, all TNs lacked strong enhancement without hilar fat or hilar vessel enhancement and were categorized as indeterminate lesions (28/28, 100%). In contrast, most recurrent tumors showed strong enhancement and were categorized as suspicious lesions (63/69, 91.3%). The addition of CT to US corrected 23 false-positive diagnoses in 28 TNs and 10 false-negative diagnoses in 69 recurrent tumors. CONCLUSIONS: CT complements US for the correct differentiation of TNs from recurrent tumors in postoperative thyroid cancer patients. The addition of CT to US may prevent unnecessary painful biopsy or surgery. KEY POINTS: • In the dissected neck, traumatic neuromas could mimic US suspicious LNs owing to its internal hyperechogenicity. • CT effectively differentiated traumatic neuromas from recurrent thyroid cancers by demonstrating significantly different enhancement patterns. • CT could complement US and may prevent unnecessary painful biopsy or surgery for US-detected lesions after thyroidectomy and neck dissection.

Prediction of hemorrhagic complications after ultrasound-guided biopsy of the thyroid and neck.

OBJECTIVES: Hemorrhage occasionally occurs after ultrasound (US)-guided biopsy of the thyroid and neck and sometimes leads to serious complications. We aimed to identify predictors of hemorrhagic complications after US-guided biopsy of the thyroid and neck. MATERIAL AND METHODS: In this retrospective study, we analyzed consecutive patients who underwent US-guided biopsy from April 2020 to November 2020. Procedure characteristics, US features, and peri- and post-procedural patient symptoms and signs were compared between patients with and without post-biopsy hemorrhage. Associations between clinical and imaging variables and post-biopsy hemorrhage were analyzed using univariate and multivariate regression analyses. RESULTS: A total of 305 patients who underwent US-guided biopsy of the thyroid and neck were included (219 women, 86 men; age range, 20-89 years). Seventeen (5.7%) cases of post-biopsy hemorrhage were detected 30 min after biopsy and manual compression. Among them, 10 developed hemorrhage at 30 min without immediate hemorrhage. In the multivariate analysis, a high tenderness score on the visual analog scale (VAS) at 30 min after biopsy (odds ratio [OR] 5.05, p < .001) was identified as an independent predictor of post-biopsy hemorrhage. In patients with hemorrhage at 30 min, tenderness scores significantly increased over 30 min of observation. CONCLUSIONS: High tenderness scores at 30 min after biopsy and manual compression were independent predictors of hemorrhage after US-guided biopsy of the thyroid and neck. The tenderness score could serve as a valuable marker to triage patients who require further observation and management after a US-guided biopsy of the thyroid and neck. KEY POINTS: • High tenderness scores at 30 min after compression were associated with the presence of delayed post-biopsy hemorrhage at 30 min. • Patients with hemorrhage at 30 min demonstrated a significant increase in tenderness scores over time. • High tenderness scores after biopsy site compression predicted the presence of delayed post-biopsy hemorrhage in the thyroid and neck.

Response prediction of vestibular schwannoma after gamma-knife radiosurgery using pretreatment dynamic contrast-enhanced MRI: a prospective study.

OBJECTIVES: There are few known predictive factors for response to gamma-knife radiosurgery (GKRS) in vestibular schwannoma (VS). We investigated the predictive role of pretreatment dynamic contrast-enhanced (DCE)-MRI parameters regarding the tumor response after GKRS in sporadic VS. METHODS: This single-center prospective study enrolled participants between April 2017 and February 2019. We performed a volumetric measurement of DCE-MRI-derived parameters before GKRS. The tumor volume was measured in a follow-up MRI. The pharmacokinetic parameters were compared between responders and nonresponders according to 20% or more tumor volume reduction. Stepwise multivariable logistic regression analyses were performed, and the diagnostic performance of DCE-MRI parameters for the prediction of tumor response was evaluated by receiver operating characteristic curve analysis. RESULTS: Ultimately, 35 participants (21 women, 52 ± 12 years) were included. There were 22 (62.9%) responders with a mean follow-up interval of 30.2 ± 5.7 months. Ktrans (0.036 min-1 vs. 0.057 min-1, p = .008) and initial area under the time-concentration curve within 90 s (IAUC90) (84.4 vs. 143.6, p = .003) showed significant differences between responders and nonresponders. Ktrans (OR = 0.96, p = .021) and IAUC90 (OR = 0.97, p = .004) were significant differentiating variables in each multivariable model with clinical variables for tumor response prediction. Ktrans showed a sensitivity of 81.8% and a specificity of 69.2%, and IAUC90 showed a sensitivity of 100% and a specificity of 53.8% for tumor response prediction. CONCLUSION: DCE-MRI (particularly Ktrans and IAUC90) has the potential to be a predictive factor for tumor response in VS after GKRS. KEY POINTS: •Pretreatment prediction of gamma-knife radiosurgery response in vestibular schwannoma is still challenging. •Dynamic contrast-enhanced MRI could have predictive value for the response of vestibular schwannoma after gamma-knife radiosurgery.

Fetal cardiac parameters for predicting postnatal operation type of fetuses with tetralogy of Fallot.

BACKGROUND: To assess fetal cardiac parameters predictive of postnatal operation type in fetuses with tetralogy of Fallot (TOF). METHODS: Echocardiographic data obtained in the second and third trimesters were retrospectively reviewed for fetuses diagnosed with TOF between 2014 and 2018 at Asan Medical Center. The following fetal cardiac parameters were analyzed: 1) pulmonary valve annulus (PVA) z-score, 2) right pulmonary artery (RPA) z-score, 3) aortic valve annulus (AVA) z-score, 4) pulmonary valve peak systolic velocity (PV-PSV), 5) PVA/AVA ratio, and 6) RPA/descending aorta (DAo) ratio. These cardiac parameters were compared between a primary corrective surgery group and a palliative shunt operation followed by complete repair group. RESULTS: A total of 100 fetuses with TOF were included. Only one neonatal death occurred. Ninety patients underwent primary corrective surgery and 10 neonates underwent a multistage surgery. The PVA z-score, RPA z-score, and RPA/DAo ratio measured in the second trimester and the PVA z-score, RPA z-score, and PVA/AVA raio measured in the third trimester were significantly lower in the multistage surgery group, while the PV-PSV as measured in both trimesters were significantly higher in the multistage surgery group. CONCLUSION: Fetal cardiac parameters are useful for predicting the operation type necessary for neonates with TOF.

The orphan nuclear receptor NR4A3 controls the differentiation of monocyte-derived dendritic cells following microbial stimulation.

In response to microbial stimulation, monocytes can differentiate into macrophages or monocyte-derived dendritic cells (MoDCs) but the molecular requirements guiding these possible fates are poorly understood. In addition, the physiological importance of MoDCs in the host cellular and immune responses to microbes remains elusive. Here, we demonstrate that the nuclear orphan receptor NR4A3 is required for the proper differentiation of MoDCs but not for other types of DCs. Indeed, the generation of DC-SIGN+ MoDCs in response to LPS was severely impaired in Nr4a3-/- mice, which resulted in the inability to mount optimal CD8+ T cell responses to gram-negative bacteria. Transcriptomic analyses revealed that NR4A3 is required to skew monocyte differentiation toward MoDCs, at the expense of macrophages, and allows the acquisition of migratory characteristics required for MoDC function. Altogether, our data identify that the NR4A3 transcription factor is required to guide the fate of monocytes toward MoDCs.

Arterial ischemic stroke in children with congenital heart diseases.

BACKGROUND: We describe the prevalence, thromboembolic risk factors, and neurologic outcomes in children with congenital heart disease (CHD) and arterial ischemic stroke (AIS). METHODS: We retrospectively analyzed the clinical data of children with CHD and AIS from 2000 to 2016. Demographics, procedural and postprocedural data, neuroimaging findings, details of antithrombotic treatment, and neurological status at last follow up were evaluated. RESULTS: Patients with cyanotic CHD accounted for 24 of 30 cases with AIS. The majority of AIS (70%) was procedure related, and the mean time from procedure to diagnosis of stroke was 9.7 (range, 1-30) days. At the time of AIS, 14 (46.7%) patients revealed coexistence of additional thromboembolic causes of AIS. Three patients (10.0%) experienced recurrent AIS and six patients (20.0%) were diagnosed with post-stroke epilepsy. The unfavorable outcomes were found in 13 patients (43.3%), including four deaths. The unfavorable outcome was significantly associated with the main branch involvement of middle cerebral artery (OR = 10.296, 95% CI = 1.335-79.439) and hemorrhagic transformation (OR = 16.264, 95% CI = 1.359-194.690). CONCLUSIONS: Additional thromboembolic risk factors such as systemic or cardiac thrombus, arrhythmia, and surgical procedures for cyanotic CHD were found in patients with CHD and AIS. The main branch involvement of middle cerebral artery and hemorrhagic transformation were significant predictors of unfavorable outcomes. Further studies are required to identify the target for stroke prevention and develop better prophylactic strategies to minimize AIS in patients with CHD.

Paediatric heart transplantation recipients ≥7 years of age receiving donors with pre-existing coronary atherosclerosis showed progressive coronary artery disease.

BACKGROUND: This study aimed to determine the effect of donor-transmitted atherosclerosis on the late aggravation of cardiac allograft vasculopathy in paediatric heart recipients aged ≥7 years. METHODS: In total, 48 patients were included and 23 had donor-transmitted atherosclerosis (baseline maximal intimal thickness of >0.5 mm on intravascular ultrasonography). Logistic regression analyses were performed to identify risk factors for donor-transmitted atherosclerosis. Rates of survival free from the late aggravation of cardiac allograft vasculopathy (new or worsening cardiac allograft vasculopathy on following angiograms, starting 1 year after transplantation) in each patient group were estimated using the Kaplan-Meier method and compared using the log-rank test. The effect of the results of intravascular ultrasonography at 1 year after transplantation on the late aggravation of cardiac allograft vasculopathy, correcting for possible covariates including donor-transmitted atherosclerosis, was examined using the Cox proportional hazards model. RESULTS: The mean follow-up duration after transplantation was 5.97 ± 3.58 years. The log-rank test showed that patients with donor-transmitted atherosclerosis had worse survival outcomes than those without (p = 0.008). Per the multivariate model considering the difference of maximal intimal thickness between baseline and 1 year following transplantation (hazard ratio, 22.985; 95% confidence interval, 1.948-271.250; p = 0.013), donor-transmitted atherosclerosis was a significant covariate (hazard ratio, 4.013; 95% confidence interval, 1.047-15.376; p = 0.043). CONCLUSION: Paediatric heart transplantation recipients with donor-transmitted atherosclerosis aged ≥7 years had worse late cardiac allograft vasculopathy aggravation-free survival outcomes.

Contrast-enhanced MRI T1 Mapping for Quantitative Evaluation of Putative Dynamic Glymphatic Activity in the Human Brain in Sleep-Wake States.

Background Evaluation of the glymphatic system with intrathecal contrast material injection has limited clinical use. Purpose To investigate the feasibility of using serial intravenous contrast-enhanced T1 mapping in the quantitative evaluation of putative dynamic glymphatic activity in various brain regions and to demonstrate the effect of sleep on glymphatic activity in humans. Materials and Methods In this prospective study from May 2019 to February 2020, 25 healthy participants (mean age, 25 years ± 2 [standard deviation]; 15 men) underwent two cycles of MRI (day and night cycles). For each cycle, T1 maps were acquired at baseline and 0.5, 1, 1.5, 2, and 12 hours after intravenous contrast material injection. For the night cycle, participants had a normal night of sleep between 2 and 12 hours. The time (tmin) to reach the minimum T1 value (T1min), the absolute difference between baseline T1 and T1min (peak ΔT1), and the slope between two measurements at 2 and 12 hours (slope[2h-12h]) were determined from T1 value-time curves in cerebral gray matter (GM), cerebral white matter (WM), cerebellar GM, cerebellar WM, and putamen. Mixed-model analysis of variance (ANOVA), Friedman test, and repeated-measures ANOVA were used to assess the effect of sleep on slope(2h-12h) and to compare tmin and peak ΔT1 among different regions. Results The slope(2h-12h) increased from the day to night cycles in cerebral GM, cerebellar GM, and putamen (geometric mean ratio [night/day] = 1.4 [95% CI: 1.2, 1.7], 1.3 [95% CI: 1.1, 1.4], and 2.4 [95% CI: 1.6, 3.6], respectively; P = .001, P < .001, and P < .001, respectively). Median tmin values were 0.5 hour in cerebral and cerebellar GM and putamen for both cycles. Cerebellar GM had the highest mean peak ΔT1, followed by cerebral GM and putamen in both day (159 msec ± 6, 99 msec ± 4, and 62 msec ± 5, respectively) and night (152 msec ± 6, 104 msec ± 6, and 58 msec ± 4, respectively) cycles. Conclusion Clearance of a gadolinium-based contrast agent was greater after sleep compared with daytime wakefulness. These results suggest that sleep was associated with greater glymphatic clearance compared with wakefulness. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Anzai and Minoshima in this issue.

Differentiation between glioblastoma and primary CNS lymphoma: application of DCE-MRI parameters based on arterial input function obtained from DSC-MRI.

OBJECTIVE: This study aimed to evaluate whether arterial input functions (AIFs) obtained from dynamic susceptibility contrast (DSC)-MRI (AIFDSC) improve the reliability and diagnostic accuracy of dynamic contrast-enhanced (DCE)-derived pharmacokinetic (PK) parameters for differentiating glioblastoma from primary CNS lymphoma (PCNSL) compared with AIFs derived from DCE-MRI (AIFDCE). METHODS: This retrospective study included 172 patients with glioblastoma (n = 147) and PCNSL (n = 25). All patients had undergone preoperative DSC- and DCE-MRI. The volume transfer constant (Ktrans), volume of the vascular plasma space (vp), and volume of the extravascular extracellular space (ve) were acquired using AIFDSC and AIFDCE. The relative cerebral blood volume (rCBV) was obtained from DSC-MRI. Intraclass correlation coefficients (ICC) and ROC curves were used to assess the reliability and diagnostic accuracy of individual parameters. RESULTS: The mean Ktrans, vp, and ve values revealed better ICCs with AIFDSC than with AIFDCE (Ktrans, 0.911 vs 0.355; vp, 0.766 vs 0.503; ve, 0.758 vs 0.657, respectively). For differentiating all glioblastomas from PCNSL, the mean rCBV (AUC = 0.856) was more accurate than the AIFDSC-driven mean Ktrans, which had the largest AUC (0.711) among the DCE-derived parameters (p = 0.02). However, for glioblastomas with low rCBV (≤ 75th percentile of PCNSL; n = 30), the AIFDSC-driven mean Ktrans and vp were more accurate than rCBV (AUC: Ktrans, 0.807 vs rCBV, 0.515, p = 0.004; vp, 0.715 vs rCBV, p = 0.045). CONCLUSION: DCE-derived PK parameters using the AIFDSC showed improved reliability and diagnostic accuracy for differentiating glioblastoma with low rCBV from PCNSL. KEY POINTS: • An accurate differential diagnosis of glioblastoma and PCNSL is crucial because of different therapeutic strategies. • In contrast to the rCBV from DSC-MRI, another perfusion imaging technique, the DCE parameters for the differential diagnosis have been limited because of the low reliability of AIFs from DCE-MRI. • When we analyzed DCE-MRI data using AIFs from DSC-MRI (AIFDSC), AIFDSC-driven DCE parameters showed improved reliability and better diagnostic accuracy than rCBV for differentiating glioblastoma with low rCBV from PCNSL.

Primary Graft Dysfunction After Isolated Heart Transplantation　- Incidence, Risk Factors, and Clinical Implications Based on a Single-Center Experience.

BACKGROUND: Since the international consensus on primary graft dysfunction (PGD) following heart transplantation (HT) was reported in 2014, few clinical studies have been reported. We aimed to analyze the incidence, predictive factors, and clinical implications of PGD following the International Society of Heart and Lung Transplant criteria in a single center.Methods and Results:This study enrolled 570 consecutive adult patients undergoing isolated HT between November 1992 and December 2017. Under a new set of criteria, PGD-left ventricle (PGD-LV) occurred in 35 patients (6.1%; mild, n=1 [0.2%]; moderate, n=14 [2.5%]; severe, n=20 [3.5%]), whereas PGD-right ventricle (PGD-RV) occurred in 3 (0.5%). Multivariable analysis demonstrated that preoperative admission (odds ratio [OR] 4.20; 95% confidence interval [CI] 1.24-14.26; P=0.021), preoperative extracorporeal membrane oxygenation (OR 4.03; 95% CI 1.75-9.26; P=0.001), and prolonged total ischemic time (OR 1.09; 95% CI 1.02-1.15; P=0.006) were significant predictors of moderate to severe PGD-LV. Moderate to severe PGD-LV was an independent and significant risk factor for early death (OR 55.64; 95% CI 11.65-265.73; P<0.001), with its effects extending up to 3 months after HT. CONCLUSIONS: Moderate to severe PGD-LV, as defined by the new guidelines, is an important predictor of early mortality, with effects extending up to 3 months after HT. Efforts to reduce the occurrence of moderate to severe PGD-LV may lead to better outcomes.

Downregulation of MHC Class II by Ubiquitination Is Required for the Migration of CD206+ Dendritic Cells to Skin-Draining Lymph Nodes.

Dendritic cells (DCs) are critical players in skin homeostasis. A subset of mannose receptor (CD206)-expressing monocyte-derived DCs was found in skin, and their migratory counterpart is present in skin-draining lymph nodes (sdLNs). Skin CD206+ DCs were shown to upregulate MHC class II (MHCII) progressively, raising the question of whether this feature affects their biology. In this study, we assessed the role of MHCII regulation in the development and migration of these cells in mouse models expressing differential MHCII levels. Using CD206 as a surrogate marker, we found that skin CD206+ DCs develop in an MHCII-independent manner. However, their migration to sdLNs was affected by overexpression rather than absence or lower expression of MHCII. Accordingly, B16 tumor growth was exacerbated in mice overexpressing MHCII in the absence of ubiquitination. Mechanistically, CD206+ DCs from these mice showed decreased IRF4 and CCR7 expression. LPS, which is known to promote monocyte-derived DC recruitment to sdLNs, partially improved these defects. However, GM-CSF delivery restored CD206+ DC migration by promoting IRF4 expression. Collectively, these data show that MHCII downregulation is crucial for IRF4-dependent migration of CD206+ DCs to sdLNs in health and disease.

Clinical implication of intraoperative ventricular-arterial coupling in pediatric patients undergoing ventricular septal defects repair: A retrospective cohort study.

BACKGROUND: Ventricular-arterial coupling is the ratio of arterial elastance to ventricular end-systolic elastance. AIMS: The objective of this study was to determine the clinical implication of intraoperative ventricular-arterial coupling derived from the pressure-area relationship using transesophageal echocardiography. METHODS: This retrospective study reviewed the medical records of 72 pediatric patients with ventricular septal defects who underwent corrective surgery with cardiopulmonary bypass. The single-beat modified method was used to assess ventricular-arterial coupling. Logistic regression analyses were performed to determine the correlation between ventricular-arterial coupling and early postoperative outcomes, including the maximum vasoactive-inotropic score, length of mechanical ventilation, and length of hospital stay. RESULTS: Ventricular-arterial coupling after cardiopulmonary bypass significantly increased (from 1.0 ± 0.4 to 1.4 ± 0.8, p < .001), indicating a disproportionate increase in the arterial elastance index (from 11.5 ± 5.1 to 19.8 ± 7.5 mmHg/cm2 /m2 , p < .001) compared with the ventricular end-systolic elastance index (from 13.0 ± 6.9 to 16.9 ± 9.0 mmHg/cm2 /m2 , p < .001). Logistic regression analyses revealed that high postoperative ventricular-arterial coupling was independently associated with higher postoperative maximum vasoactive-inotropic score (>10; odds ratio [OR], 8.04; 95% confidence interval [CI], 1.38-46.85, p = .020), longer postoperative mechanical ventilation (>15 h; OR: 11.00; 95% CI: 1.26-96.45, p = .030), and longer postoperative hospital stay (>7 days; OR: 2.98; 95% CI: 1.04-8.58, p = .043). CONCLUSIONS: Ventricular-arterial coupling can be easily obtained from the intraoperative transesophageal echocardiography in pediatric patients undergoing ventricular septal defects repair. High postoperative ventricular-arterial coupling is strongly associated with worse early postoperative outcomes. Ventricular-arterial coupling shows promise as an intraoperative analysis tool that can provide insight into the impact of interventions on cardiovascular performance and identify potential targets for treatment in this population.