Lesion-based fibertracking in image guided neurosurgery : an innovative tractography step for improved data analysis

Einführung Seit Einführung der Diffusionstensorbildgebung- (DTI) basierten Traktographie von zerebralen Bahnsystemen besteht der Verdacht einer zu dünnen Ausdehnung der Faserbahnen in der unmittelbaren Nachbarschaft von zerebralen Läsionen. Der gegenüber der tatsächlichen Ausdehnung verminderte Durchmesser verjüngt sich zusätzlich mit zunehmendem Abstand von dem sog. seed-Volume (“seed-VOI”). Die unterrepräsentierte Ausdehnung der Faserbahnen stellt in der neurochirurgischen Operationsplanung und intraoperativen Neuronavigation ein erhebliches Problem bei der Beurteilung der Resektionsgrenzen von Tumoren bzw. der Grenze dringlich zu erhaltender eloquenter Faserbahnen dar. Mit einem zusätzlichen, auf die Läsion fokussierten Traktographie-Algorithmus – Lesion-based Fibertracking (LBFT) – soll die Auswertbarkeit von Faserbahnen in der Umgebung von intrazerebralen Läsionen verbessert werden. Der Algorithmus von LBFT wird vorgestellt und das Verfahren anhand der Darstellung von Bahnen des Tractus corticospinalis (TCS) mit dem Standardverfahren verglichen. Methode In 40 Patienten mit intrazerebralen Läsionen in Nachbarschaft zu kortikospinalen Bahnen (Pyramidenbahn) wurde eine Diffusionstensor-bildgebung und fMRT basierte Faserbahndarstellung des Tractus corticospinalis auf Grundlage eines „tensor-deflection-Algorithmus“ (TEND) durchgeführt. Hierfür wurden Bahnen von den kortikalen motorischen Repräsentationen der Hand, des Fußes und der Zunge zum Hirnstamm visualisiert. Im Standardverfahren wird ein würfelförmiges Volumen – das sog. seed-Volume oder Ursprungsvolumen – im Gyrus praecentralis entsprechend der anatomischen und funktionellen Bildgebung definiert. Ein zweites würfelförmiges Volumen, lokalisiert im Hirnstamm selektiert ausschließlich Fasern welche durch beide Volumen verlaufen. Die resultierenden Fasern werden bezüglich ihres Verlaufes durch typische anatomische Landmarken kontrolliert und ggf. korrigiert. Anschließend wird das Faserbündel mittels einer Oberflächenrekonstruktionstechnik („surface rendering“) dreidimensional rekonstruiert (iPlan 2.5Cranial, BrainLab®, Feldkirchen, Germany). Für das neue Verfahren des LBFT wird die Region definiert, in welcher die Faserbahn des Standardverfahrens der Läsion am nächsten kommt und hier, um die Faserbahn des Standardverfahrens, ein neues seed-Volume platziert, welches das Standardfaserbündel um 10 mm überragt. Traktographie und Segmentierung werden analog dem Standardverfahren durchgeführt. Fasern, die nicht den Gyrus praecentralis erreichen oder nicht durch den Pedunculus cerebri verlaufen, werden eliminiert. Die Faserzahl, die Größe der Faserbahnen und die Größendifferenz zwischen den Bahnen des Standardverfahrens und LBFT werden verglichen und das Verfahren auf inter- und intra-rater Reliabilität geprüft. Ergebnisse Das Standardverfahren und LBFT waren in allen 40 Patienten durchführbar. Die Faserzahl bei LBFT erhöhte sich signifikant gegenüber dem Standardverfahren um 383,27% (p<0,0001). Der maximale Durchmesser in der Ebene, in welcher das Faserbündel der Läsion am nächsten kommt, sowie der Durchmesser in Richtung der Läsion erhöhen sich signifikant um 171,75 % bzw. 196,45 % (jeweils p<0.0001). Daraus folgt eine durchschnittliche Zunahme des Durchmessers in Richtung der Läsion um 4.48mm (± 2.35). Fazit Die Fehleinschätzung des Durchmessers und der Distanz des TCS zu subkortikalen Läsionen bei Anwendung des Standardverfahrens DTI-basierter Traktographie stellt ein erhebliches Problem in der funktionellen neurochirurgischen Operationsplanung und intraoperativen Neuronavigation dar. Durch den zusätzlichen Schritt des LBFT kann die Fehleinschätzung korrigiert und der in vorhergehenden Studien eingeforderte Sicherheitsabstand standardisiert robust und reliabel realisiert werden.Objective Since introduction of indirect white matter tractography by diffusion-tensor-imaging (DTI)-based fibertracking (FT), evidence has emerged that the circumference of the resulting fiber bundle is underestimated in the vicinity of lesions with increasing distance from the seed-volume (“seed-VOI”). This uncertainty represents a major problem for perioperative planning and intraoperative neuronavigation based on DTI-data. To provide more accurate information concerning the size of the bundle near the lesion, we evaluated a standard approach for visualization of the cortico-spinal tract (CST), based on an additional Lesion-based fibertracking step. Methods In 40 patients with white matter lesions adjacent to the CST, diffusion tensor imaging (3 Tesla, 12 diff. directions) and FT (based on a tensor deflection algorithm TEND) of the CST were performed in a standardized fMRI based approach, tracing fibers from the precentral gyrus to the brainstem. The standard approach defined seed-volumes along the precentral gyrus according to anatomical and functional imaging. The second seed-volume was located in the brainstem, selecting only fibers passing through both seed-volumes. The resulting bundle was confirmed by anatomical landmarks and segmented three-dimensionally by surface rendering (iPlan 2.5Cranial, BrainLab®, Feldkirchen, Germany). For Lesion-based FT (LBFT), a new seed-volume was selected in the area with smallest distance between the lesion and the CST, incorporating the bundle from the standard approach with an additional margin of 10mm. Fiber tracking and segmentation was performed by selecting fibers reaching both, the cerebral peduncle and the precentral gyrus. The number of fibers, the size of the resulting bundles, and the gain in diameter were compared with that of standard FT. The procedure was furthermore tested for intra- and inter-observer reliability. Results Standard and Lesion-based FT succeeded in all 40 patients. Lesion-based FT lead to a significant increase in numbers of fibers by 383,27% (p<0,0001) compared to standard FT. Accordingly, the maximum diameter of the fiber-bundles and the diameter in direction of the lesion’s center increased significantly by 171,75 % and 196,45 %, respectively (p<0.0001 for both). Thus, a mean gain in diameter in direction of lesion’s center of 4.48mm (± 2.35) was observed. Conclusions The underestimation of the size of the CST and its distance to subcortical lesions by the standard approach for DTI-based fiber tracking, representing a major problem in DTI-based neuronavigation, can be reliably improved by implementing an additional tracking step. The resulting gain in the size of the visualized CST enhances the surgical safety margin, as demanded in former studies

Modular fluorescence complementation sensors for live cell detection of epigenetic signals at endogenous genomic sites

Investigation of the fundamental role of epigenetic processes requires methods for the locus-specific detection of epigenetic modifications in living cells. Here, we address this urgent demand by developing four modular fluorescence complementation-based epigenetic biosensors for live cell microscopy applications. These tools combine engineered DNA-binding proteins with domains recognizing target epigenetic marks, both fused to non-fluorescent fragments of a fluorescent protein. The presence of the epigenetic mark at the target DNA sequence leads to the reconstitution of a functional fluorophore. With this approach, we could for the first time directly detect DNA methylation and histone 3 lysine 9 trimethylation at endogenous genomic sites in live cells and follow dynamic changes in these marks upon drug treatment, induction of epigenetic enzymes and during the cell cycle. We anticipate that this versatile technology will improve our understanding of how specific epigenetic signatures are set, erased and maintained during embryonic development or disease onset

Prospective Multicenter Trial of Cervical Arthroplasty with the ROTAIO® Cervical Disc Prosthesis.

STUDY DESIGN Clinical observational study. OBJECTIVE The ROTAIO® cervical disc prosthesis is a novel unconstrained implant with a variable center of rotation aiming at physiological motion. The objective of this multicenter prospective trial was to evaluate clinical outcome and complications within 2 years. MATERIAL AND METHODS 120 patients (72 females and 48 males with median age of 43.0 years [23-60 yrs] underwent ACDA (ROTAIO®, SIGNUS Medical, Alzenau, Germany) and were prospectively followed for 24 months. Preoperative complaints were mainly associated with radiculopathy (n = 104) or myelopathy (n=16). There were 108 monosegmental and 12 bisegmental procedures including 6 hybrid constructs. Clinical outcome was evaluated at 3, 12 and 24 months in 100%, 96% and 77% of the cohort by VAS, NDI, WL-26, Patient`s Satisfaction Index (PSI), SF-36, Nurick Score, mJOA, Composite Success Rate, complications, patient`s overall satisfaction and analgesics use. RESULTS Highly significant clinical improvements were observed according to NDI and VAS (P < .0001 (arm); P < .001 (neck); P = .002 (head)) at all time points. Analgetic use could be reduced in 87.1 to 95.2%. Doctor`s visits have been reduced in 93.8% after 24 months. Patient`s overall satisfaction was high with 78.4 to 83.5% of patients. The composite success rate was 77.5% after 12 months and 76.9% after 24 months. There were no major complications in this series. Slight subsidence of the prosthesis was observed in 2 patients and 3 patients demonstrated fusion after 24 months. 2 patients developed symptomatic foraminal stenosis, so that implant removal and fusion was performed resulting in a revision rate of 1.7% in 2 years. CONCLUSION The ROTAIO® cervical disc prosthesis is a safe and efficient treatment option for symptomatic degenerative disc disease demonstrating highly significant clinical improvement and high patient`s overall satisfaction with very low revision rates at 2 years

Prospective Multicenter Trial of Cervical Arthroplasty With the ROTAIO® Cervical Disc Prosthesis

Objective Anterior Cervical Discectomy and Arthroplasty (ACDA) is an established treatment for degenerative cervical disc disease and seems to be an alternative to fusion in minimizing the risk of Adjacent Segment Disease (ASD). The ROTAIO® cervical disc prosthesis is a novel unconstrained implant with a variable center of rotation aiming at physiological motion. The objective of this multicenter prospective trial was to evaluate clinical outcome and complications within 2 years. Material and Methods 120 patients (72 females and 48 males with a median age of 43.0 years; range: 23 to 60 years) underwent ACDA (ROTAIO®, SIGNUS Medical, Alzenau, Germany) and were prospectively followed for 24 months. Preoperative complaints were mainly associated with radiculopathy (n=104) or myelopathy (n=16). There were 108 monosegmental and 12 bisegmental procedures including 6 hybrid constructs. Clinical outcome was evaluated at 3, 12 and 24 months by the Visual Analogue Scale (VAS) for head, neck and arm pain, the Neck Disability Index (NDI), the Work Limitation Questionnaire (WL-26), the Patient`s Satisfaction Index (PSI) and a Quality of Life Questionnaire (SF-36). The Nurick Score, the Modified Japanese Orthopaedic Association Score (mJOA) plus a Composite Success Rate have been additionally applied. Finally, complications, the patient`s overall satisfaction and the amount of analgesics were assessed. Results Highly significant clinical improvements were observed according to NDI and VAS (p<0.0001 (arm); p<0.001 (neck); p=0.002 (head)) at all postoperative time points. Analgetic medication could be reduced after 3 months in 91.3%, after 12 months in 87.1% and after 24 months in 95.2% of patients. Doctor`s visits for cervical spine problems have been reduced in 93.8% after 24 months. Patient`s overall satisfaction was high after 3, 12 and 24 months with 83.5%, 78.4% and 79.1% of patients, while 4.1%, 6.8% and 7.0% respectively were not satisfied. The composite success rate was 77.5% after 12 months and 76.9% after 24 months. There were no major complications in this series. Slight subsidence of the prosthesis was observed in 2 patients and 3 patients demonstrated fusion after 24 months. 2 patients developed symptomatic foraminal stenosis, so that implant removal and fusion was performed. Conclusion The ROTAIO® cervical disc prosthesis is a safe and efficient treatment option for symptomatic degenerative disc disease demonstrating excellent clinical results at 2 years. Outcome proves to be stable over time with very low revision rates

Chromatin-dependent allosteric regulation of DNMT3A activity by MeCP2

Despite their central importance in mammalian development, the mechanisms that regulate the DNA methylation machinery and thereby the generation of genomic methylation patterns are still poorly understood. Here, we identify the 5mC-binding protein MeCP2 as a direct and strong interactor of DNA methyltransferase 3( DNMT3) proteins. We mapped the interaction interface to the transcriptional repression domain of MeCP2 and the ADD domain of DNMT3A and find that binding of MeCP2 strongly inhibits the activity of DNMT3A in vitro. This effect was reinforced by cellular studies where a global reduction of DNA methylation levels was observed after overexpression of MeCP2 in human cells. By engineering conformationally locked DNMT3A variants as novel tools to study the allosteric regulation of this enzyme, we show that MeCP2 stabilizes the closed, autoinhibitory conformation of DNMT3A. Interestingly, the interaction with MeCP2 and its resulting inhibition were relieved by the binding of K4 unmodified histone H3 N-terminal tail to the DNMT3A-ADD domain. Taken together, our data indicate that the localization and activity of DNMT3A are under the combined control of MeCP2 and H3 tailmodifications where, depending on the modification status of the H3 tail at the binding sites, MeCP2 can act as either a repressor or activator of DNA methylation

The gap between policy and practice: a systematic review of patient-centred care interventions in chronic heart failure

Patient-centred care (PCC) is recommended in policy documents for chronic heart failure (CHF) service provision, yet it lacks an agreed definition. A systematic review was conducted to identify PCC interventions in CHF and to describe the PCC domains and outcomes. Medline, Embase, CINAHL, PsycINFO, ASSIA, the Cochrane database, clinicaltrials.gov, key journals and citations were searched for original studies on patients with CHF staged II–IV using the New York Heart Association (NYHA) classification. Included interventions actively supported patients to play informed, active roles in decision-making about their goals of care. Search terms included ‘patient-centred care’, ‘quality of life’ and ‘shared decision making’. Of 13,944 screened citations, 15 articles regarding 10 studies were included involving 2540 CHF patients. Three studies were randomised controlled trials, and seven were non-randomised studies. PCC interventions focused on collaborative goal setting between patients and healthcare professionals regarding immediate clinical choices and future care. Core domains included healthcare professional-patient collaboration, identification of patient preferences, patient-identified goals and patient motivation. While the strength of evidence is poor, PCC has been shown to reduce symptom burden, improve health-related quality of life, reduce readmission rates and enhance patient engagement for patients with CHF. There is a small but growing body of evidence, which demonstrates the benefits of a PCC approach to care for CHF patients. Research is needed to identify the key components of effective PCC interventions before being able to deliver on policy recommendations. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1007/s10741-015-9508-5) contains supplementary material, which is available to authorized users

Prospective Multicenter Trial of Cervical Arthroplasty With the ROTAIO® Cervical Disc Prosthesis

Objective Anterior Cervical Discectomy and Arthroplasty (ACDA) is an established treatment for degenerative cervical disc disease and seems to be an alternative to fusion in minimizing the risk of Adjacent Segment Disease (ASD). The ROTAIO® cervical disc prosthesis is a novel unconstrained implant with a variable center of rotation aiming at physiological motion. The objective of this multicenter prospective trial was to evaluate clinical outcome and complications within 2 years. Material and Methods 120 patients (72 females and 48 males with a median age of 43.0 years; range: 23 to 60 years) underwent ACDA (ROTAIO®, SIGNUS Medical, Alzenau, Germany) and were prospectively followed for 24 months. Preoperative complaints were mainly associated with radiculopathy (n=104) or myelopathy (n=16). There were 108 monosegmental and 12 bisegmental procedures including 6 hybrid constructs. Clinical outcome was evaluated at 3, 12 and 24 months by the Visual Analogue Scale (VAS) for head, neck and arm pain, the Neck Disability Index (NDI), the Work Limitation Questionnaire (WL-26), the Patient`s Satisfaction Index (PSI) and a Quality of Life Questionnaire (SF-36). The Nurick Score, the Modified Japanese Orthopaedic Association Score (mJOA) plus a Composite Success Rate have been additionally applied. Finally, complications, the patient`s overall satisfaction and the amount of analgesics were assessed. Results Highly significant clinical improvements were observed according to NDI and VAS (p<0.0001 (arm); p<0.001 (neck); p=0.002 (head)) at all postoperative time points. Analgetic medication could be reduced after 3 months in 91.3%, after 12 months in 87.1% and after 24 months in 95.2% of patients. Doctor`s visits for cervical spine problems have been reduced in 93.8% after 24 months. Patient`s overall satisfaction was high after 3, 12 and 24 months with 83.5%, 78.4% and 79.1% of patients, while 4.1%, 6.8% and 7.0% respectively were not satisfied. The composite success rate was 77.5% after 12 months and 76.9% after 24 months. There were no major complications in this series. Slight subsidence of the prosthesis was observed in 2 patients and 3 patients demonstrated fusion after 24 months. 2 patients developed symptomatic foraminal stenosis, so that implant removal and fusion was performed. Conclusion The ROTAIO® cervical disc prosthesis is a safe and efficient treatment option for symptomatic degenerative disc disease demonstrating excellent clinical results at 2 years. Outcome proves to be stable over time with very low revision rates

The histone chaperone CAF-1 safeguards somatic cell identity

Cellular differentiation involves profound remodeling of chromatic landscapes, yet the mechanisms by which somatic cell identity is subsequently maintained remain incompletely understood. To further elucidate regulatory pathways that safeguard the somatic state, we performed two comprehensive RNAi screens targeting chromatin factors during transcription factor-mediated reprogramming of mouse fibroblasts to induced pluripotent stem cells (iPSCs). Remarkably, subunits of the chromatin assembly factor-1 (CAF-1) complex emerged as the most prominent hits from both screens, followed by modulators of lysine sumoylation and heterochromatin maintenance. Optimal modulation of both CAF-1 and transcription factor levels increased reprogramming efficiency by several orders of magnitude and facilitated iPSC formation in as little as 4 days. Mechanistically, CAF-1 suppression led to a more accessible chromatin structure at enhancer elements early during reprogramming. These changes were accompanied by a decrease in somatic heterochromatin domains, increased binding of Sox2 to pluripotency-specific targets and activation of associated genes. Notably, suppression of CAF-1 also enhanced the direct conversion of B cells into macrophages and fibroblasts into neurons. Together, our findings reveal the histone chaperone CAF-1 as a novel regulator of somatic cell identity during transcription factor-induced cell fate transitions and provide a potential strategy to modulate cellular plasticity in a regenerative setting