Exploratory Multisite MR Spectroscopic Imaging Shows White Matter Neuroaxonal Loss Associated with Complications of Type 1 Diabetes in Children.

BACKGROUND AND PURPOSE: Type 1 diabetes affects over 200,000 children in the United States and is associated with an increased risk of cognitive dysfunction. Prior single-site, single-voxel MRS case reports and studies have identified associations between reduced NAA/Cr, a marker of neuroaxonal loss, and type 1 diabetes. However, NAA/Cr differences among children with various disease complications or across different brain tissues remain unclear. To better understand this phenomenon and the role of MRS in characterizing it, we conducted a multisite pilot study. MATERIALS AND METHODS: In 25 children, 6-14 years of age, with type 1 diabetes across 3 sites, we acquired T1WI and axial 2D MRSI along with phantom studies to calibrate scanner effects. We quantified tissue-weighted NAA/Cr in WM and deep GM and modeled them against study covariates. RESULTS: We found that MRSI differentiated WM and deep GM by NAA/Cr on the individual level. On the population level, we found significant negative associations of WM NAA/Cr with chronic hyperglycemia quantified by hemoglobin A1c (P < .005) and a history of diabetic ketoacidosis at disease onset (P < .05). We found a statistical interaction (P < .05) between A1c and ketoacidosis, suggesting that neuroaxonal loss from ketoacidosis may outweigh that from poor glucose control. These associations were not present in deep GM. CONCLUSIONS: Our pilot study suggests that MRSI differentiates GM and WM by NAA/Cr in this population, disease complications may lead to neuroaxonal loss in WM in children, and deeper investigation is warranted to further untangle how diabetic ketoacidosis and chronic hyperglycemia affect brain health and cognition in type 1 diabetes.

Sustaining better care for patients undergoing emergency laparotomy.

Emergency laparotomy is associated with high mortality. Implementation of an evidence-based care bundle has been shown to improve patient outcomes. A quality improvement project to implement a six-component care bundle was undertaken between July 2015 and May 2018. As part of this project, we worked with 27 hospitals in the Emergency Laparotomy Collaborative. Previous pilot implementation of the same bundle in our hospital between December 2012 and July 2013 had shown marked improvement, maintained until April 2014, but then deterioration. Understanding the reasons for this deterioration informed our work to re-implement the bundle and sustain improvement. A cohort of 930 consecutive patients requiring emergency laparotomy between October 2014 and April 2019 were included. Baseline data were collected between October 2014 and June 2015, and the bundle was re-implemented in July 2015. Thirty-day mortality decreased from 11% in the baseline group to 7.3% after bundle implementation. Hospital length of stay decreased from 19.5 to 17.9 days. Full bundle compliance improved from < 60% to > 80% for all patients, with improvement in application of all individual bundle components. This study provides further evidence that outcomes for high-risk surgical patients can be improved with an evidence-based care bundle, but attention must be paid to maintaining bundle compliance. Issues around sustaining improvement must be considered from project initiation.

American Society of Hematology 2020 guidelines for sickle cell disease: prevention, diagnosis, and treatment of cerebrovascular disease in children and adults.

BACKGROUND: Central nervous system (CNS) complications are among the most common, devastating sequelae of sickle cell disease (SCD) occurring throughout the lifespan. OBJECTIVE: These evidence-based guidelines of the American Society of Hematology are intended to support the SCD community in decisions about prevention, diagnosis, and treatment of the most common neurological morbidities in SCD. METHODS: The Mayo Evidence-Based Practice Research Program supported the guideline development process, including updating or performing systematic evidence reviews. The panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, including GRADE evidence-to-decision frameworks, to assess evidence and make recommendations. RESULTS: The panel placed a higher value on maintaining cognitive function than on being alive with significantly less than baseline cognitive function. The panel developed 19 recommendations with evidence-based strategies to prevent, diagnose, and treat CNS complications of SCD in low-middle- and high-income settings. CONCLUSIONS: Three of 19 recommendations immediately impact clinical care. These recommendations include: use of transcranial Doppler ultrasound screening and hydroxyurea for primary stroke prevention in children with hemoglobin SS (HbSS) and hemoglobin Sß0 (HbSß0) thalassemia living in low-middle-income settings; surveillance for developmental delay, cognitive impairments, and neurodevelopmental disorders in children; and use of magnetic resonance imaging of the brain without sedation to detect silent cerebral infarcts at least once in early-school-age children and once in adults with HbSS or HbSß0 thalassemia. Individuals with SCD, their family members, and clinicians should become aware of and implement these recommendations to reduce the burden of CNS complications in children and adults with SCD.

The Contribution of Common Surgically Implanted Hardware to Functional MR Imaging Artifacts.

BACKGROUND AND PURPOSE: Blood oxygenation level-dependent MR imaging is increasingly used clinically to noninvasively assess cerebrovascular reactivity and/or language and motor function. However, many patients have metallic implants, which will induce susceptibility artifacts, rendering the functional information uninformative. Here, we calculate and interpret blood oxygenation level-dependent MR imaging artifact impact arising from surgically implanted hardware. MATERIALS AND METHODS: A retrospective analysis of all blood oxygenation level-dependent MRIs (n = 343; B0 = 3T; TE = 35 ms; gradient echo EPI) acquired clinically (year range = 2006-2014) at our hospital was performed. Blood oxygenation level-dependent MRIs were most commonly prescribed for patients with cerebrovascular disease (n = 80) or patients undergoing language or motor localization (n = 263). Artifact volume (cubic centimeters) and its impact on clinical interpretation were determined by a board-certified neuroradiologist. RESULTS: Mean artifact volume associated with intracranial hardware was 4.3 ± 3.2 cm(3) (range = 1.1-9.4 cm(3)). The mean artifact volume from extracranial hardware in patients with cerebrovascular disease was 28.4 ± 14.0 cm(3) (range = 6.1-61.7 cm(3)), and in patients with noncerebrovascular disease undergoing visual or motor functional mapping, it was 39.9 (3)± 27.0 cm(3) (range = 6.9-77.1 cm(3)). The mean artifact volume for ventriculoperitoneal shunts was 95.7 ± 39.3 cm(3) (range = 64.0-139.6 cm(3)). Artifacts had no-to-mild effects on clinical interpretability in all patients with intracranial implants. Extracranial hardware artifacts had no-to-moderate impact on clinical interpretability, with the exception of 1 patient with 12 KLS-Martin maxDrive screws with severe artifacts precluding clinical interpretation. All examined ventriculoperitoneal shunts resulted in moderate-to-severe artifacts, limiting clinical interpretation. CONCLUSIONS: Blood oxygenation level-dependent MR imaging yields interpretable functional maps in most patients beyond a small (30-40 cm(3)) artifact surrounding the hardware. Exceptions were ventriculoperitoneal shunts, particularly those with programmable valves and siphon gauges, and large numbers of KLS-Martin maxDrive screws.

Collaborating for social change: the black psychologist and the black community.

Several prominent Black scholars have argued that the predicament of Black intellectuals is inseparable from that of Black communities (C. West, 1994), and that Black psychologists should be at the forefront in developing culturally relevant psychological interventions (J. A. Baldwin, 1989). Yet, for Black psychologists there are a number of challenges to conducting successful interventions in Black communities, including historical abuses of Black communities by the "helping" professions and divergences in values, goals, and behaviors of professionals as compared to community members. In order for community psychologists to design interventions that are respectful of the cultural traditions and norms of Black communities, these obstacles to collaboration need to be addressed. This paper outlines some of the challenges faced by Black community psychologists, as well as the unique strengths they can mobilize when collaborating on research and interventions in Black communities. The paper also addresses methods of empowering Black communities and improving the training of community psychologists.

Marrow stromal cells embedded in alginate for repair of osteochondral defects.

Articular cartilage defects of sufficient size ultimately degenerate with time, leading to arthritic changes. Numerous strategies have been used to address full-thickness cartilage defects, yet none thus far has been successful in restoring the articular surface to its preinjury state. We compared the effects of agarose, alginate, and type I collagen gels on the expression of cartilage-specific markers from rabbit marrow stromal cells and then assessed the in vivo effects of cells seeded in alginate beads on the repair of full-thickness osteochondral defects in the rabbit model. Marrow aspirates from rabbits were cultured and the stromal population selected. Marrow stromal cells were then placed in either 1.2% w/v alginate, type I collagen gels (3 mg/mL), or 0.5% agarose suspension culture. After 2, 5, 10, and 20 days in culture, the RNA was extracted and analyzed by reverse transcription polymerase chain reaction for the cartilage-specific markers aggrecan and type II collagen. The strongest increase in aggrecan and type II collagen gene expression was found in the agarose suspension followed by alginate; type I collagen gels induced the lowest levels. Alginate beads were chondrogenic and maintained their size and consistency over time in culture, whereas the cell-seeded collagen gels invariably contracted. Full-thickness defects measuring 3 x 6 mm x 3 mm deep were then created in the medial femoral condyles of rabbit knees and filled with alginate beads, alginate beads seeded with stromal cells, or left empty. Alginate beads containing stromal cells remained within the defects and progressively filled the defects with regenerate tissue. Histologic analysis showed viable, phenotypically chondrogenic cells in the defects. The matrix stained positive with safranin O, indicating proteoglycan synthesis, and bonding between the regenerate and host tissue was excellent. We have shown quantitative differences in the chondrogenic effects of the biomaterials tested. Alginate induces the chondrogenic phenotype in marrow stromal cells in vitro, and possesses the necessary physical characteristics and handling properties to support cells and serve as a carrier to fill full-thickness osteochondral defects in vivo.

Gas exchange parameters in radiotherapy patients during breathing of 2%, 3.5% and 5% carbogen gas mixtures.

The gas mixture carbogen may be breathed by patients to enhance the oxygenation level and therefore the radiosensitivity of tumours. However, owing to the high CO2 content, its inhalation is associated with patient intolerance. Our aim was to determine a suitable carbon dioxide and oxygen gas mixture with similar enhancement of arterial oxygenation to 5% carbogen and with improved patient tolerance. 14 patients entered the study; of those 14, 8 were able to tolerate 2%, 3.5% and 5% carbogen mixtures as well as a control gas for sufficient time to allow successful arterial blood gas sampling. Gas exchange parameters were measured using a carbon dioxide monitor and a blood gas analyser. Arterial carbon dioxide tension ranged from 2.9 kPa to 6.82 kPa whilst breathing the carbogen mixtures, and arterial oxygen tension increased at least three-fold from basal values. There were no significant changes in the respiratory rate, heart rate and blood pH. The results suggest that 2% CO2 in O2 enhances arterial oxygen levels to a similar extent as 3.5% and 5% CO2 and that it is well tolerated.

Analysis of postdischarge change in a dual diagnosis population.

Many individuals with serious mental illnesses have co-occurring drug and alcohol problems. The research reported in this article examined an integrated inpatient mental illness-chemical dependency program and compared it with standard inpatient psychiatric treatment for two groups: those demonstrating high change from baseline to two-months postdischarge and those with negative or no change. Univariate analyses revealed significant differences in the change groups on baseline personal-clinical characteristics and on aspects of their social and physical environments. The results have implications for improving mental health practice by better predicting patients who will optimally benefit from inpatient treatment.

Vascularized fibular grafting compared with core decompression in the treatment of femoral head osteonecrosis.

A prospective study was undertaken to compare vascularized fibular grafting (VFG) with core decompression for Ficat Grade II and III femoral head osteonecrosis. The study group included 39 hips in 34 patients-20 VFGs and 19 core decompressions. Independent evaluation of results was performed by an orthopedic surgeon and a radiologist at a minimum of 2 years postoperatively (range: 2 to 5 years). Disease extent was assessed by Ficat radiographic gradings. VFGs failed (conversion to total hip arthroplasty for functionally incapacitating pain) at a rate of 20%, significantly lower than the 58% failure rate of core decompressions (P = .025). Complications included 2 proximal femur fractures in each group, ankle pain in 6 VFGs, and graft vessel thrombosis in 1 VFG. Vascularized fibular grafting appears superior to core decompression in prolonging hip joint survivorship for Ficat Grades II and III femoral head osteonecrosis.

Correlates of functioning in a population with dual diagnoses: an examination of diagnosis and problem history.

This study examines the relationship between diagnosis and life functioning using the Addiction Severity Index (ASI) with 467 hospitalized individuals with mental illness and substance abuse problems. Persons diagnosed with schizophrenia were the best functioning group across most of the ASI domains except employment and psychiatric functioning. More robust relationships were found between problem history (i.e., prior symptomatology or treatment) and current functioning. Respondents with histories of drug treatment, prior experience of anxiety and depression, self-injurious behavior, or violence control problems experienced more severe medical, drug, alcohol, psychiatric, legal, and family/social problems at the time of hospitalization. Violence control problems were related to drug use and criminal involvement, whereas self-injurious behavior was more often related to alcohol use and psychiatric distress. These findings suggest that problem history may be a stronger predictor of treatment need at the time of hospital entry than are more commonly used indexes, such as diagnosis.