Impact of diabetes on COVID-19-related in-hospital mortality: a retrospective study from Northern Italy.

PURPOSE: The purpose of this study was to evaluate the impact of pre-existing diabetes on in-hospital mortality in patients admitted for Coronavirus Disease 2019 (COVID-19). METHODS: This is a single center, retrospective study conducted at Policlinico di Monza hospital, located in the Lombardy region, Northern Italy. We reviewed medical records of 373 consecutive adult patients who were hospitalized with COVID-19 between February 22 and May 15, 2020. Data were collected on diabetes status, comorbid conditions and laboratory findings. Multivariable logistic regression was performed to evaluate the effect of diabetes on in-hospital mortality after adjustment for potential confounding variables. RESULTS: Mean age of the patients was 72 ± 14 years (range 17-98), 244 (65.4%) were male and 69 (18.5%) had diabetes. The most common comorbid conditions were hypertension (237 [64.8%]), cardiovascular disease (140 [37.7%]) and malignant neoplasms (50 [13.6%]). In-hospital death occurred in 142 (38.0%) patients. In the multivariable model older age (Relative Risk [RR] 1.06 [1.04-1. 09] per year), diabetes (RR 1.56 [1.05-2.02]), chronic obstructive pulmonary disease (RR 1.82 [1.13-2.35]), higher values of lactic dehydrogenase and C-reactive protein were independently associated with in-hospital mortality. CONCLUSION: In this retrospective single-center study, diabetes was independently associated with a higher in-hospital mortality. More intensive surveillance of patients with this condition is to be warranted.

Intrathecal drug delivery in the era of nanomedicine.

Administration of substances directly into the cerebrospinal fluid (CSF) that surrounds the brain and spinal cord is one approach that can circumvent the blood-brain barrier to enable drug delivery to the central nervous system (CNS). However, molecules that have been administered by intrathecal injection, which includes intraventricular, intracisternal, or lumbar locations, encounter new barriers within the subarachnoid space. These barriers include relatively high rates of turnover as CSF clears and potentially inadequate delivery to tissue or cellular targets. Nanomedicine could offer a solution. In contrast to the fate of freely administered drugs, nanomedicine systems can navigate the subarachnoid space to sustain delivery of therapeutic molecules, genes, and imaging agents within the CNS. Some evidence suggests that certain nanomedicine agents can reach the parenchyma following intrathecal administration. Here, we will address the preclinical and clinical use of intrathecal nanomedicine, including nanoparticles, microparticles, dendrimers, micelles, liposomes, polyplexes, and other colloidalal materials that function to alter the distribution of molecules in tissue. Our review forms a foundational understanding of drug delivery to the CSF that can be built upon to better engineer nanomedicine for intrathecal treatment of disease.

Impact of using different biomarkers of liver fibrosis on hepatologic referral of individuals with severe obesity and NAFLD.

PURPOSE: The purpose of this study was to estimate how many individuals with severe obesity and NAFLD should be referred to hepatologists according to the EASL-EASD-EASO guidelines and whether the choice of specific indicators of liver fibrosis would significantly impact the number of referrals. METHODS: This was a single-center retrospective study of 495 individuals with severe obesity screened at our institution between 2012 and 2018 for a bariatric surgery intervention. The guidelines were applied using the NAFLD Liver Fat Score (NLFS) to assess the presence of steatosis and the NAFLD fibrosis score (NFS), Fibrosis-4 (FIB-4) and Hepamet Fibrosis Score (HFS) to assess the risk of advanced fibrosis. RESULTS: Three hundred and seventy-nine patients (76.6%) had evidence of liver steatosis. The application of the guidelines would lead to referral of 66.3% of patients using NFS, 31.7% using FIB-4 and 34.2% using HFS. When referrals due to abnormal liver function tests were excluded, these percentages dropped to 55.8%, 7.3% and 12.1%, respectively. The strongest inter-biomarker agreement was found between FIB-4 and HFS (κ = 0.86, 95% CI 0.815-0.910). CONCLUSION: Strict application of the guidelines in individuals with severe obesity would probably lead to over-referral, although a great variability exists among the different scores.

Lymphatic delivery of etanercept via nanotopography improves response to collagen-induced arthritis.

BACKGROUND: Evidence suggests lymphatic function mediates local rheumatoid arthritis (RA) flares. Yet biologics that target the immune system are dosed systemically via the subcutaneous (SC) administration route, thereby inefficiently reaching local lymphatic compartments. Nanotopography has previously been shown to disrupt tight cellular junctions, potentially enhancing local lymphatic delivery and potentially improving overall therapeutic efficacy. METHOD: We first characterized nanotopography (SOFUSA™) delivery of an anti-TNF drug, etanercept, by comparing pharmacokinetic profiles to those obtained by conventional SC, intravenous (IV), and intradermal (ID) routes of administration, and assessed uptake of radiolabeled etanercept in draining lymph nodes (LNs) in single dosing studies. We then compared etanercept efficacy in a progressive rat model of collagen-induced arthritis (CIA), administered systemically via SC route of administration; via the regional lymphatics through ID delivery; or through a nanotopography (SOFUSA™) device at 10, 12, and 14 days post CIA induction. Measurements of hind limb swelling and near-infrared fluorescence (NIRF) imaging of afferent lymph pumping function and reflux were conducted on days 11, 13, and 18 post CIA induction and compared to untreated CIA animals. Univariate and multivariate analysis of variance were used to compare the group differences for percentage swelling and lymphatic contractile activity. RESULTS: Even though all three modes of administration delivered an equal amount of etanercept, SOFUSA™ delivery resulted in increased lymphatic pumping and significantly reduced swelling as compared to untreated, ID, and SC groups. Pharmacokinetic profiles in serum and LN uptake studies showed that using the nanotopography device resulted in the greatest uptake and retention in draining LNs. CONCLUSIONS: Locoregional lymphatic delivery of biologics that target the immune system may have more favorable pharmacodynamics than SC or IV administration. Nanotopography may provide a more efficient method for delivery of anti-TNF drugs to reverse impairment of lymphatic function and reduce swelling associated with RA flares.

A novel mutation in CELSR1 is associated with hereditary lymphedema.

BACKGROUND: Biological evidence reported in the literature supports the role of CELSR1 as being essential for valvular function in murine lymphatics. Yet thus far, there have been no variants in CELSR1 associated with lymphatic dysfunction in humans. CASE PRESENTATION: In this report, a rare early inactivating mutation in CELSR1 is found to be causal for non-syndromic, lower extremity lymphedema in a family across three generations. Near-infrared fluorescence lymphatic imaging shows that instead of being propelled within the lumen of well-defined lymphatic vessels, lymph moved in regions of both legs in an unusual fashion and within sheet-like structures. CONCLUSION: CELSRI may be responsible for primary, non-syndromic lymphedema in humans.

A review of performance of near-infrared fluorescence imaging devices used in clinical studies.

Near-infrared fluorescence (NIRF) molecular imaging holds great promise as a new "point-of-care" medical imaging modality that can potentially provide the sensitivity of nuclear medicine techniques, but without the radioactivity that can otherwise place limitations of usage. Recently, NIRF imaging devices of a variety of designs have emerged in the market and in investigational clinical studies using indocyanine green (ICG) as a non-targeting NIRF contrast agent to demark the blood and lymphatic vasculatures both non-invasively and intraoperatively. Approved in the USA since 1956 for intravenous administration, ICG has been more recently used off label in intradermal or subcutaneous administrations for fluorescence imaging of the lymphatic vasculature and lymph nodes. Herein, we summarize the devices of a variety of designs, summarize their performance in lymphatic imaging in a tabular format and comment on necessary efforts to develop standards for device performance to compare and use these emerging devices in future, NIRF molecular imaging studies.

Concentration of indocyanine green does not significantly influence lymphatic function as assessed by near-infrared imaging.

BACKGROUND: Absorbance of near-infrared (600-800 nm) light by the tissue components water, melanin, and hemoglobin is minimal. This property allows the use of near-infrared-emitting fluorophores for noninvasive, in vivo, real-time imaging of tissue, without the interference of autofluorescence experienced with imaging in other wavelength ranges. Near-infrared (NIR) fluorescence imaging has been used to noninvasively image lymphatic architecture and pumping function in animals, as well as in humans. The effects of different doses of a NIR dye, indocyanine green (ICG), on lymphatic function have been questioned. This study aims to address these concerns in the context of a mouse inguinal-to-axillary lymphatic imaging model. METHODS AND RESULTS: We measured lymph propulsive velocity and frequency using an imaging system composed of a laser diode for excitation of the dye, an image intensifier, and an intensified charge-coupled device (ICCD) camera to capture real-time images. At 0.32, 0.645, and 1.3 mM ICG, no significant differences in lymphatic propulsive velocity or frequency were observed. Additionally, the use of other NIR imaging agents did not result in significant differences. CONCLUSIONS: The use of different concentrations of ICG and the use of other near-infrared fluorophores for optical imaging of lymphatics does not significantly affect lymphatic propulsive velocity or frequency.

In vivo dynamic imaging of intestinal motions using diet-related autofluorescence.

BACKGROUND: Tissue background autofluorescence induced by standard murine diets containing chlorophyll is a significant problem for fluorescence whole-body imaging. However, as red chlorophyll autofluorescence delineates the gastrointestinal (GI) tract in the abdomen of the mouse, it should be possible to dynamically and non-invasively image intestinal motions. Herein, we non-invasively imaged for the first time intestinal motions, such as peristaltic and segmental motions, without an exogenous imaging agent, using red chlorophyll fluorescence. METHODS: Mice were illuminated with 660-nm light from a laser diode and autofluorescence at 710 nm was acquired dynamically for 5 min with 200-ms exposure time. Fluorescent imaging data were analyzed to generate a three-dimensional spatiotemporal map to quantitate intestinal motions. KEY RESULTS: Peristaltic and segmental motions were observed in vivo in mice. Our quantification showed that the frequency and propagation velocity of peristaltic contractile waves in the small intestine were measured to be 28.6 cycles per min and 1.82 ± 0.56 cm s(-1), respectively. CONCLUSIONS & INFERENCES: This simple, but unexplored imaging technique can provide a means to monitor intestinal motility disorders and response to therapeutic agents.

Validating the sensitivity and performance of near-infrared fluorescence imaging and tomography devices using a novel solid phantom and measurement approach.

With the aid of indocyanine green (ICG), lymphatic architecture and function in both mice and humans has been successfully imaged non-invasively using near-infrared (NIR) fluorescence imaging devices. Maximal measurement sensitivity of NIR fluorescence imaging devices is needed for "first-in-humans" molecularly targeting NIR fluorescence agents that are brighter than non-specific ICG. In this study, we developed a solid phantom and measurement approach for the quantification of excitation light leakage and measurement sensitivity of NIR fluorescence imaging devices. The constructed solid phantom, consisting of quantum dots impregnated onto specularly reflective surface, shows long-term stability and can be used as a traceable fluorescence standard. With the constructed solid phantom, the intensified CCD (ICCD)-based device demonstrated more than 300% higher measurement sensitivity compared to the Electron Multiplying CCD (EMCCD) based device when integration time was maintained less than 1.0 s.

Translation of near-infrared fluorescence imaging technologies: emerging clinical applications.

Technical developments in near-infrared fluorescence (NIRF) imaging and tomography have enabled recent translation into investigational human studies. Noninvasive imaging of the lymphatic vasculature for diagnosis and assessment of function has been uniquely accomplished with NIR using indocyanine green (ICG), a nonspecific dye that has comparatively poor fluorescent properties compared to emerging dyes. Adjunct use of NIRF-ICG for (a) intraoperative sentinel lymph node mapping for cancer staging, (b) video-angiography during surgery, and (c) discrimination of malignant from benign breast lesions detected by mammography and ultrasongraphy also evidences the clinical utility of NIRF. Future NIRF imaging agents that consist of bright fluorescent dyes conjugated to disease-targeting moieties promise molecular imaging and image-guided surgery. In this review, emerging NIRF imaging is described within the context of nuclear imaging technologies that remain the "gold standard" of molecular imaging.

Non-invasive, dynamic imaging of murine intestinal motility.

BACKGROUND: After intravenous (i.v.) administration, indocyanine green (ICG) is known to be secreted into bile from the liver via the biliary tracts, enabling fluorescent delineation of the intestine. In addition, ICG is a near-infrared (NIR) excitable fluorophore, capable of providing exogenous contrast for rapid NIR fluorescence imaging. We sought to quantify the intestinal motility using dynamic NIR fluorescence imaging after injection of ICG. METHODS: C57BL6 mice were dynamically imaged immediately before and up to 24h after i.v. and intradermal (i.d.) injection of 50 and 10µL of ICG, respectively. Necropsy was also performed 1h postinjection and the entire gastrointestinal tract was isolated and exposed for ex vivo fluorescence imaging. KEY RESULTS: The secretion of ICG-laden fluorescent bile into the duodenum was observed in vivo and confirmed in situ. Different patterns of the intestinal motility, such as peristaltic and segmental motions, were dynamically imaged in vivo. Our imaging data showed that the frequency of contractions ranged from 27 to 35cyclesmin(-1) and the propagation velocity of peristaltic waves ranged from 0.82±0.5 to 2.04±1.12cms(-1) . CONCLUSIONS & INFERENCES: Dynamic NIR fluorescence imaging with injection of ICG can provide a method for diagnostic motility testing for intestinal motility disorders or dysfunction and for potential evaluation of therapeutic agents.

Noise pre-filtering techniques in fluorescence-enhanced optical tomography.

In this contribution, different measurement noise pre-filtering techniques were developed using frequency-domain fluorescence measurements of homogeneous breast phantoms. We demonstrated that implementing noise pre-filtering, based on modulation depth and measurement error in amplitude, can improve model match between experimental and simulated data under varying experimental conditions (target depths, 1-3 cm and fluorescence optical contrast, 1:0 and 100:1). Noise pre-filtering also improves the qualitative estimation of target(s) location in reconstructed images in deep target(s) when there was fluorescence in the background. Interestingly, decreases in model mismatch did not necessarily correlate with increases in reconstructed target accuracy. In addition, it was observed that pre-filtering measurement noise using different criteria can help differentiate target(s) from artifacts, thus possibly minimizing the false-positive cases in a clinical environment.

Influence of excitation light rejection on forward model mismatch in optical tomography.

Fluorescence enhanced tomography for molecular imaging requires low background for detection and accurate image reconstruction. In this contribution, we show that excitation light leakage is responsible for elevated background and can be minimized with the use of gradient index (GRIN) lenses when using fibre optics to collect propagated fluorescence light from tissue or other biological media. We show that the model mismatch between frequency-domain photon migration (FDPM) measurements and the diffusion approximation prediction is decreased when GRIN lenses are placed prior to the interference filters to provide efficient excitation light rejection. Furthermore, model mismatch is correlated to the degree of excitation light leakage. This work demonstrates the importance of proper light filtering when designing fluorescence optical imaging and tomography.

Tomographic fluorescence imaging in tissue phantoms: a novel reconstruction algorithm and imaging geometry.

A novel image reconstruction algorithm has been developed and demonstrated for fluorescence-enhanced frequency-domain photon migration (FDPM) tomography from measurements of area illumination with modulated excitation light and area collection of emitted fluorescence light using a gain modulated image-intensified charge-coupled device (ICCD) camera. The image reconstruction problem was formulated as a nonlinear least-squares-type simple bounds constrained optimization problem based upon the penalty/modified barrier function (PMBF) method and the coupled diffusion equations. The simple bounds constraints are included in the objective function of the PMBF method and the gradient-based truncated Newton method with trust region is used to minimize the function for the large-scale problem (39919 unknowns, 2973 measurements). Three-dimensional (3-D) images of fluorescence absorption coefficients were reconstructed using the algorithm from experimental reflectance measurements under conditions of perfect and imperfect distribution of fluorophore within a single target. To our knowledge, this is the first time that targets have been reconstructed in three-dimensions from reflectance measurements with a clinically relevant phantom.

Diagnostic imaging of breast cancer using fluorescence-enhanced optical tomography: phantom studies.

Molecular targeting with exogenous near-infrared excitable fluorescent agents using time-dependent imaging techniques may enable diagnostic imaging of breast cancer and prognostic imaging of sentinel lymph nodes within the breast. However, prior to the administration of unproven contrast agents, phantom studies on clinically relevant volumes are essential to assess the benefits of fluorescence-enhanced optical imaging in humans. Diagnostic 3-D fluorescence-enhanced optical tomography is demonstrated using 0.5 to 1 cm(3) single and multiple targets differentiated from their surroundings by indocyanine green (micromolar) in a breast-shaped phantom (10-cm diameter). Fluorescence measurements of referenced ac intensity and phase shift were acquired in response to point illumination measurement geometry using a homodyned intensified charge-coupled device system modulated at 100 MHz. Bayesian reconstructions show artifact-free 3-D images (3857 unknowns) from 3-D boundary surface measurements (126 to 439). In a reflectance geometry appropriate for prognostic imaging of lymph node involvement, fluorescence measurements were likewise acquired from the surface of a semi-infinite phantom (8x8x8 cm(3)) in response to area illumination (12 cm(2)) by excitation light. Tomographic 3-D reconstructions (24,123 unknowns) were recovered from 2-D boundary surface measurements (3194) using the modified truncated Newton's method. These studies represent the first 3-D tomographic images from physiologically relevant geometries for breast imaging.

Impact of excipient particle size on measurement of active pharmaceutical ingredient absorbance in mixtures using frequency domain photon migration.

A system of dual-component powder mixtures, varying in excipient particle size and concentration of active pharmaceutical ingredient (API), is analyzed using frequency domain photon migration (FDPM) techniques. The results show that the FDPM-measured absorption coefficient increases linearly with increasing API concentration whereas the isotropic scattering coefficient shows no sensitivity to changes in API concentration. It is further seen that the absorption coefficient of blends, owing to the API, is not only linearly dependent on its concentration, but that this relationship is furthermore related to the excipient particle size. Finally, a comparison between near-infrared absorbance and FDPM-measured isotropic scattering as a function of reciprocal particle size is made to highlight FDPM as a powerful particle sizing tool without need for calibration. Overall, this study presents FDPM as a comprehensive method for detection of API concentration independent of excipient particle size.

Fluorescence-enhanced optical imaging of large phantoms using single and simultaneous dual point illumination geometries.

Fluorescence-enhanced optical tomography is typically performed using single point illumination and multiple point collection measurement geometry. Single point illumination is often insufficient to illuminate greater volumes of large phantoms and results in an inadequate fluorescent signal to noise ratio (SNR) for the majority of measurements. In this work, the use of simultaneous multiple point illumination geometry is proposed for acquiring a large number of fluorescent measurements with a sufficiently high SNR. As a feasibility study, dual point excitation sources, which are in-phase, were used in order to acquire surface measurements and perform three-dimensional reconstructions on phantoms of large volume and/or significant penetration depth. Measurements were acquired in the frequency-domain using a modulated intensified CCD imaging system under different experimental conditions of target depth (1.4-2.8 cm deep) with a perfect uptake optical contrast. Three-dimensional reconstructions of the fluorescence absorption from the dual point illumination geometry compare well with the reconstructions from the single point illumination geometry. Targets located up to 2 cm deep were located successfully, establishing the feasibility of reconstructions from simultaneous multiple point excitation sources. With improved excitation light rejection, multiple point illumination geometry may prove useful in reconstructing more challenging domains containing deeply embedded targets. Image quality assessment tools are required to determine the optimal measurement geometry for the largest set off imaging tasks.

A comparison of exact and approximate adjoint sensitivities in fluorescence tomography.

Many approaches to fluorescence tomography utilize some form of regularized nonlinear least-squares algorithm for data inversion, thus requiring repeated computation of the Jacobian sensitivity matrix relating changes in observable quantities, such as emission fluence, to changes in underlying optical parameters, such as fluorescence absorption. An exact adjoint formulation of these sensitivities comprises three terms, reflecting the individual contributions of 1) sensitivities of diffusion and decay coefficients at the emission wavelength, 2) sensitivities of diffusion and decay coefficients at the excitation wavelength, and 3) sensitivity of the emission source term. Simplifying linearity assumptions are computationally attractive in that they cause the first and second terms to drop out of the formulation. The relative importance of the three terms is thus explored in order to determine the extent to which these approximations introduce error. Computational experiments show that, while the third term of the sensitivity matrix has the largest magnitude, the second term becomes increasingly significant as target fluorophore concentration or volume increases. Image reconstructions from experimental data confirm that neglecting the second term results in overestimation of sensitivities and consequently overestimation of the value and volume of the fluorescent target, whereas contributions of the first term are so low that they are probably not worth the additional computational costs.

Assessment of small-angle and angle-averaged structure factor for monitoring electrostatic colloidal interactions using multiply scattered light.

The isotropic scattering coefficients of 143-nm diameter polystyrene latex suspensions were measured using frequency-domain photon migration (FDPM) at 687 and 828 nm as a function of volume fraction (0.05-0.3) and ionic strength (1.0 to 120 mM NaCl equivalents) in order to derive the angle-integrated structure factor, S(q), and structure factor at zero wave vector, S(0). The effective surface charges of the dispersions were estimated by fitting the measured isotropic scattering coefficients at each wavelength as a function of volume fraction to the solution of the Orstein-Zernike integral equation using the hard sphere Yukawa potential model and mean spherical approximation as a closure relation. The estimates of surface charges were comparable at both wavelengths, but decreased with ionic strength. At 120 mM NaCl equivalents, the values of S(0) obtained from FDPM matched those predicted by the Percus-Yevick model, and decreased with volume fraction, consistent with prediction by the Carnahan-Starling equation.