In support of the Choosing Wisely campaign: Perceived higher risk leads to unnecessary imaging in accelerated partial breast irradiation?

Accelerated partial breast irradiation (APBI) is an increasingly utilized modality for early stage breast cancer as part of breast conservation therapy (BCT). There remains concern regarding local recurrence, requiring more frequent post‐radiation surveillance imaging. The purpose of this study is to determine clinical significance of frequent surveillance in this perceived higher risk population. Patients treated at a community academic medical center from 2005 to 2013 with partial breast radiation were retrospectively identified. All patients were treated with lumpectomy followed by balloon based APBI. Diagnostic, clinical, radiographic, and outcomes data were collected. One hundred and sixty‐nine patients were identified. Median age at time of diagnosis was 63. Stage was 0, I, and II in 27%, 64%, and 9%, respectively. Most patients had pure invasive ductal cancer. Ninety‐two percent and 99% of patients had imaging performed by 6 and 12 months (± 3 months) respectively. Median interval between end of radiation and first image, and subsequent 3 images were 6, 6, 9, and 12 months, respectively. Median follow‐up was 49 months for all patients (range 7‐106). Six patients experienced local recurrence: 4 invasive, all clinically detected, and none within the first 2 years. One patient had mammographically detected recurrent ductal carcinoma in situ. No mammographic images within the first year lead to diagnosis of recurrent cancer. APBI via balloon base brachytherapy offered women excellent locoregional control rates. Frequent mammographic surveillance did not result in increased detection of early recurrent disease. The result of our study are in line with the Choosing Wisely campaign recommendations to perform no more than annual follow‐up for women who have completed radiation as part of BCT, with first imaging done at 6‐12 months. We recommend mammographic surveillance be performed no more frequently than annually, with first image after BCT to be done 12 months from completion of radiation.     

Fenestrated-branched endografts and visceral debranching plus stenting (hybrid) for complex aortic aneurysm repair

Objective

The aim of this study was to assess the immediate postoperative and midterm outcome of complex aortic aneurysm treatment necessitating four-vessel revascularization with either a total endovascular approach (fenestrated-branched stent graft [FBSG]) or a hybrid technique of visceral debranching plus stenting.

Superior Temporal Sulcus Disconnectivity During Processing of Metaphoric Gestures in Schizophrenia

The left superior temporal sulcus (STS) plays an important role in integrating audiovisual information and is functionally connected to disparate regions of the brain. For the integration of gesture information in an abstract sentence context (metaphoric gestures), intact connectivity between the left STS and the inferior frontal gyrus (IFG) should be important. Patients with schizophrenia have problems with the processing of metaphors (concretism) and show aberrant structural connectivity of long fiber bundles. Thus, we tested the hypothesis that patients with schizophrenia differ in the functional connectivity of the left STS to the IFG for the processing of metaphoric gestures. During functional magnetic resonance imaging data acquisition, 16 patients with schizophrenia (P) and a healthy control group (C) were shown videos of an actor performing gestures in a concrete (iconic, IC) and abstract (metaphoric, MP) sentence context. A psychophysiological interaction analysis based on the seed region from a previous analysis in the left STS was performed. In both groups we found common positive connectivity for IC and MP of the STS seed region to the left middle temporal gyrus (MTG) and left ventral IFG. The interaction of group (C>P) and gesture condition (MP>IC) revealed effects in the connectivity to the bilateral IFG and the left MTG with patients exhibiting lower connectivity for the MP condition. In schizophrenia the left STS is misconnected to the IFG, particularly during the processing of MP gestures. Dysfunctional integration of gestures in an abstract sentence context might be the basis of certain interpersonal communication problems in the patients.Key words: coverbal gestures, integration, fMRI, psychophysiological interaction, concretism     

Cystadenocarcinoma of the gallbladder

Biliary cystadenocarcinomas are a very rare set of neoplasms that occur in the liver, the extrahepatic bile duct system, and occasionally in the gallbladder. We report on a 75-year-old man with a cystadenocarcinoma of the gallbladder who presented with mild abdominal discomfort and a palpable mass in the right upper abdomen. The diagnostic workup included ultrasound, magnetic resonance tomography, and fine needle core biopsy and revealed a multicystic tumor 16 cm in diameter. The patient underwent multivisceral resection of the tumor with a resection of the right colon, a partial resection of the stomach and the liver, and a lymph node dissection. The resected specimen weighed 2500 g and the final histopatholical diagnosis was a primary, moderately differentiated cystadenocarcinoma of the gallbladder with two lymph node metastases and invasion of the right colon. The patient remains without evidence of recurrence 12 months after surgery. The clinical presentation, diagnosis, therapeutic options, and classification of hepatobiliary cystadenocarcinomas are discussed.     

Subcortical shape alterations in major depressive disorder: Findings from the ENIGMA major depressive disorder working group

Alterations in regional subcortical brain volumes have been investigated as part of the efforts of an international consortium, ENIGMA, to identify reliable neural correlates of major depressive disorder (MDD). Given that subcortical structures are comprised of distinct subfields, we sought to build significantly from prior work by precisely mapping localized MDD-related differences in subcortical regions using shape analysis. In this meta-analysis of subcortical shape from the ENIGMA-MDD working group, we compared 1,781 patients with MDD and 2,953 healthy controls (CTL) on individual measures of shape metrics (thickness and surface area) on the surface of seven bilateral subcortical structures: nucleus accumbens, amygdala, caudate, hippocampus, pallidum, putamen, and thalamus. Harmonized data processing and statistical analyses were conducted locally at each site, and findings were aggregated by meta-analysis. Relative to CTL, patients with adolescent-onset MDD (≤ 21 years) had lower thickness and surface area of the subiculum, cornu ammonis (CA) 1 of the hippocampus and basolateral amygdala (Cohen's d = ?0.164 to ?0.180). Relative to first-episode MDD, recurrent MDD patients had lower thickness and surface area in the CA1 of the hippocampus and the basolateral amygdala (Cohen's d = ?0.173 to ?0.184). Our results suggest that previously reported MDD-associated volumetric differences may be localized to specific subfields of these structures that have been shown to be sensitive to the effects of stress, with important implications for mapping treatments to patients based on specific neural targets and key clinical features.     

Gender differences in the cognitive control of emotion: An fMRI study

The interaction of emotion and cognition has become a topic of major interest. However, the influence of gender on the interplay between the two processes, along with its neural correlates have not been fully analysed so far. In this functional magnetic resonance imaging (fMRI) study we induced negative emotion using negative olfactory stimulation while male (n=21) and female (n=19) participants performed an n-back verbal working memory task. Based on findings indicating increased emotional reactivity in women, we expected the female participants to exhibit stronger activation in characteristically emotion-associated areas during the interaction of emotional and cognitive processing in comparison to the male participants. Both groups were found to be significantly impaired in their working memory performance by negative emotion induction. However, fMRI analysis revealed distinct differences in neuronal activation between groups. In men, cognitive performance under negative emotion induction was associated with extended activation patterns in mainly prefrontal and superior parietal regions. In women, the interaction between emotion and working memory yielded a significantly stronger response in the amygdala and the orbitofrontal cortex (OFC) compared to their male counterparts. Our data suggest that in women the interaction of verbal working memory and negative emotion is associated with relative hyperactivation in more emotion-associated areas whereas in men regions commonly regarded as important for cognition and cognitive control are activated. These results provide new insights in gender-specific cerebral mechanisms.     

Outside-in

In dermatology probiotic microorganisms have primarily been used orally for the prophylaxis and treatment of atopic disorders. In contrast to the successes achieved for gastrointestinal disorders, positive effects for atopic dermatitis only have been found in a few studies. New insights could now fundamentally change the impact of probiotics on dermatology. Probiotics are – like microflora of the skin – non-pathogenic microbes, which do not induce inflammatory responses in the skin. Common pathways for probiotics, non-pathogenic microbes, and microflora are characterized, in order to facilitate their more effective therapeutic use. These microbes display a majority of their effects directly at the site of application and thereby induce natural defense mechanisms. However, promotion of immunological tolerance is just as important in producing positive effects. Tolerance of the resident flora on surface organs developed during evolution and the mechanisms of action are multifaceted. Therefore, the topical application of probiotics and non-pathogenic microbes for prophylaxis and therapy of overwhelming cutaneous pro-inflammatory immune reactions is very promising. Results of recent clinical trials already have demonstrated the efficacy of this new therapeutic concept.     

Neural correlates of metaphor processing

Metaphoric language is used to express meaning that is otherwise difficult to conceptualize elegantly. Beyond semantic analysis, understanding the figurative meaning of a metaphor requires mental linkage of different category domains normally not related to each other. We investigated processing of metaphoric sentences using event-related functional magnetic resonance imaging (fMRI). Stimuli consisted of 60 novel short German sentence pairs with either metaphoric or literal meaning. The pairs differed only in their last one to three words and were matched for syntax structure, word frequency, connotation and tense. Fifteen healthy subjects (six female, nine male, 19-51 years) read these sentences silently and judged by pressing one of two buttons whether they had a positive or negative connotation. Reading metaphors in contrast to literal sentences revealed signal changes in the left lateral inferior frontal (BA 45/47), inferior temporal (BA 20) and posterior middle/inferior temporal (BA 37) gyri. The activation in the left inferior frontal gyrus may reflect semantic inferencing processes during the understanding of a metaphor. This is in line with the results from other functional imaging studies showing an involvement of the left inferior frontal gyrus in integrating word and sentence meanings. Previous results of a right hemispheric involvement in metaphor processing might reflect understanding of complex sentences.     

Genetic variation in the schizophrenia‐risk gene neuregulin 1 correlates with brain activation and impaired speech production in a verbal fluency task in healthy individuals

Impaired performance in verbal fluency tasks is an often replicated finding in schizophrenia. In functional neuroimaging studies, this dysfunction has been linked to signal changes in prefrontal and temporal areas. Since schizophrenia has a high heritability, it is of interest whether susceptibility genes for the disorder, such as NRG1, modulate verbal fluency performance and its neural correlates. Four hundred twenty‐nine healthy individuals performed a semantic and a lexical verbal fluency task. A subsample of 85 subjects performed an overt semantic verbal fluency task while brain activation was measured with functional magnetic resonance imaging (MRI). NRG1 (SNP8NRG221533; rs35753505) status was determined and correlated with verbal fluency performance and brain activation. For the behavioral measure, there was a linear effect of NRG1 status on semantic but not on lexical verbal fluency. Performance decreased with number of risk‐alleles. In the fMRI experiment, decreased activation in the left inferior frontal and the right middle temporal gyri as well as the anterior cingulate gyrus was correlated with the number of risk‐alleles in the semantic verbal fluency task. NRG1 genotype does influence language production on a semantic level in conjunction with the underlying neural systems. These findings are in line with results of studies in schizophrenia and may explain some of the cognitive and brain activation variation found in the disorder. More generally, NRG1 might be one of several genes that influence semantic language capacities. Hum Brain Mapp, 2009. © 2009 Wiley‐Liss, Inc.