Attenuation-Corrected vs. Nonattenuation-Corrected 2-Deoxy-2-[F-18]fluoro-d-glucose-Positron Emission Tomography in Oncology, A Systematic Review

Purpose: To perform a systematic review and meta-analysis to determine the diagnostic accuracy of attenuation-corrected (AC) vs. nonattenuation-corrected (NAC) 2-deoxy-2-[F-18] fluoro-D-glucose-positron emission tomography (FDG-PET) in oncological patients. Procedures: Following a comprehensive search of the literature, two reviewers independently assessed the methodological quality of eligible studies. The diagnostic value of AC was studied through its sensitivity/specificity compared to histology, and by comparing the relative lesion detection rate reported with NAC-PET vs. AC, for full-ring and dual-head coincidence PET (FRand DH-PET, respectively). Results: Twelve studies were included. For FR-PET, the pooled sensitivity/specificity on a patient basis was 64/97 % for AC and 62/99 % for NAC, respectively. Pooled lesion detection with NAC vs. AC was 98 % [95 % confidence interval (95 % CI): 96Y99%, n=1,012 lesions] for FR-PET, and 88 % (95 % CI:81Y94%, n=288 lesions) for DH-PET. Conclusions: Findings suggest similar sensitivity/specificity and lesion detection for NAC vs. AC FR-PET and significantly higher lesion detection for NAC vs. AC DH-PET

When Limb Surgery Has Become the Only Life-Saving Therapy in FOP: A Case Report and Systematic Review of the Literature

Fibrodysplasia ossificans progressiva (FOP) is a rare disease in which heterotopic ossification (HO) is formed in muscles, tendons and ligaments. Traumatic events, including surgery, are discouraged as this is known to trigger a flare-up with risk of subsequent HO. Anesthetic management for patients with FOP is challenging. Cervical spine fusion, ankylosis of the temporomandibular joints, thoracic insufficiency syndrome, restrictive chest wall disease, and sensitivity to oral trauma complicate airway management and anesthesia and pose life-threatening risks. We report a patient with FOP suffering from life-threatening antibiotic resistant bacterial infected ulcers of the right lower leg and foot. The anesthetic, surgical and postoperative challenges and considerations are discussed. In addition, the literature on limb surgeries of FOP patients is systemically reviewed. The 44 year-old female patient was scheduled for a through-knee amputation. Airway and pulmonary evaluation elicited severe abnormalities, rendering standard general anesthesia a rather complication-prone approach in this patient. Thus, regional anesthesia, supplemented with intravenous analgosedation and N2O-inhalation were performed in this case. The surgery itself was securely planned to avoid any unnecessary tissue damage. Postoperatively the patient was closely monitored for FOP activity by ultrasound and [18F]PET/CT-scan. One year after surgery, a non-significant amount of HO had formed at the operated site. The systematic review revealed seventeen articles in which thirty-two limb surgeries in FOP patients were described. HO reoccurrence was described in 90% of the cases. Clinical improvement due to improved mobility of the operated joint was noted in 16% of the cases. It should be noted, though, that follow-up time was limited and no or inadequate imaging modalities were used to follow-up in the majority of these cases. To conclude, if medically urgent, limb surgery in FOP is possible even when general anesthesia is not preferred. The procedure should be well-planned, alternative techniques or procedures should be tested prior to surgery and special attention should be paid to the correct positioning of the patient. According to the literature recurrent HO should be expected after surgery of a limb, even though it was limited in the case described

Improved myocardial perfusion preceding clinical response on bosentan treatment for coronary vasospasm.

Many patients suffer from persistent angina due to coronary vasospasm despite optimal medical treatment. We treated a 46-year-old patient with severe and treatment-resistant coronary vasospasm with the endothelin-receptor antagonist bosentan. Using oxygen-15-labelled water in conjunction with oxygen 15-labelled carbon monoxide positron emission tomography (PET), we measured an impaired coronary flow reserve (CFR) in 6 out of 13 segments directly before the start of bosentan therapy. A repeated PET measurement after 16 weeks of bosentan revealed a completely normalized CFR in this patient. Furthermore, the patient reported less frequent and less severe chest pain. Our data suggest a potential role of endothelin-receptor antagonists for patients with severe coronary vasospasms

Simple vs complex radionuclide methods of assessing capillary protein permeability for diagnosing acute respiratory distress syndrome

PURPOSE: Using injection of gallium Ga 67 transferrin, technetium Tc 99m red cells, probes over the lungs, and blood samples, a pulmonary leak index (PLI) and pulmonary transcapillary escape rate (PTCER) for transferrin can be measured. This may help differentiating between cardiogenic pulmonary edema (CPE) and permeability (noncardiogenic) pulmonary edema of the acute respiratory distress syndrome (ARDS). The purpose of the study was to evaluate the relative importance of red cell labeling, blood sampling, and probe measurements in this assessment. MATERIALS AND METHODS: Analysis of radionuclide data obtained in consecutive patients with radiographic evidence for pulmonary edema, classified as ARDS (n = 13), CPE (n = 8), or mixed (n = 5), was performed. The latter patients met ARDS criteria except for a high pulmonary capillary wedge pressure. RESULTS: The PLI, PTCER, and the (67)Ga-lung/blood radioactivity increase (without (99m)Tc-red cell data) were specific and sensitive indices to differentiate ARDS/mixed from CPE. The blood transcapillary escape rate (TER) of (67)Ga-transferrin was about 2- to 6-fold higher in ARDS and mixed than in CPE. The TER had similar diagnostic value as the PLI, PTCER, and the (67)Ga-lung/blood radioactivity ratio increase. CONCLUSIONS: The diagnostic value of the simple blood TER of (67)Ga-transferrin is similar to that of complex methods, using (99m)Tc-red cells and probe measurements over the lungs, because the complex methods largely depend on the blood TER. Simplification of the method without red cell labeling and probes may facilitate bedside use to diagnose permeability edema of ARDS, particularly in the absence of a pulmonary artery catheter

Hypoproteinemia as a marker of acute respiratory distress syndrome in critically ill patients with pulmonary edema

OBJECTIVE: To assess the value of serum protein levels for differentiating permeability pulmonary edema in the course of acute respiratory distress syndrome (ARDS) from cardiogenic pulmonary edema (CPE). DESIGN AND SETTING: Observational cohort study in intensive care units of 720-bed university hospital. PATIENTS: Twenty-four consecutive patients with clinical evidence of edema, 11 fulfilling the consensus definition of ARDS, 7 having sepsis, 5 with all ARDS consensus criteria and sepsis but a pulmonary capillary wedge pressure above 18 mmHg (mixed), and 8 with CPE. All patients except for one with CPE were mechanically ventilated. MEASUREMENTS AND RESULTS: Radionuclide assessments of pulmonary microvascular protein (transferrin) permeability (pulmonary leak index, PLI) were carried out and serum protein levels determined at admission and for ARDS/mixed patients, at recovery, defined by a decrease in positive end-expiratory pressure to 0 cmH2O. At admission the PLI was higher in ARDS/mixed than in CPE patients. The total protein and transferrin levels were lower in the former. The area under the curve of the receiver operating characteristic for diagnosing ARDS (vs. CPE) was 0.98 for transferrin (cutoff value 1.5 g/l), 0.95 for total protein (cutoff value 59 g/l) and 0.80 for albumin (cutoff value 24 g/l) levels. In various clinical diagnostic groups the transferrin level approached the PLI in diagnostic value. At recovery the PLI had decreased and serum protein levels increased. CONCLUSIONS: The data suggest that hypoproteinemia is a marker of ARDS. This may partially reflect increased permeability in the lungs, systemically, or both

Hyposmia as a marker of (non-)motor disease severity in Parkinson's disease

The aim of this study was to evaluate the relationship of hyposmia in Parkinson’s disease (PD) with other motor and non-motor symptoms and with the degree of nigrostriatal dopaminergic cell loss. A total of 295 patients with a diagnosis of PD were included. Olfactory function was measured using the University of Pennsylvania Smell Identification Test (UPSIT). Motor symptoms were rated using the Unified Parkinson’s Disease Rating Scale motor subscale (UPDRS III). To evaluate other non-motor symptoms, we used the Mini-Mental State Examination (MMSE) as a measure of global cognitive function and validated questionnaires to assess sleep disturbances, psychiatric symptoms, and autonomic dysfunction. A linear regression model was used to calculate correlation coefficients between UPSIT score and motor and non-motor variables [for psychiatric symptoms a Poisson regression was performed]. In a subgroup of patients (n = 155) with a dopamine transporter (DaT) SPECT scan, a similar statistical analysis was performed, now including striatal DaT binding. In the regression models with correction for age, sex, disease duration, and multiple testing, all motor and non-motor symptoms were associated with UPSIT scores. In the subgroup of patients with a DaT-SPECT scan, there was a strong association between olfactory test scores and DaT binding in both putamen and caudate nucleus. Hyposmia in PD is associated with various motor and non-motor symptoms, like cognition, depression, anxiety, autonomic dysfunction and sleep disturbances, and with the degree of nigrostriatal dopaminergic cell loss. This finding adds further confirmation that hyposmia holds significant promise as a marker of disease progression

Analysis of Extrastriatal I-123-FP-CIT Binding Contributes to the Differential Diagnosis of Parkinsonian Diseases

I-123-N-omega-fluoropropyl-2 beta-carbomethoxy-3 beta-(4-iodophenyl) nortropane (I-123-FP-CIT) SPECT can visualize and quantify striatal dopamine transporter (DAT) binding in vivo. In addition, I-123-FP-CIT has modest affinity for the serotonin transporter (SERT), predominantly represented in extrastriatal binding. On the basis of previous imaging studies that have suggested more pronounced degeneration of other monoaminergic systems in multiple-system atrophy (MSA) and progressive supranuclear palsy (PSP) than in Parkinson disease (PD), we hypothesized that, in addition to striatal DAT binding, there would be differences in extrastriatal I-123-FP-CIT SPECT binding to SERT between MSA, PSP, and PD. Methods: We included patients with parkinsonian type MSA (multiple-system atrophy with predominantly parkinsonism [MSA-P], n - 9), cerebellar type MSA (MSA-C, n = 7), PSP (n = 13), and PD (n = 30). I-123-FP-CIT binding was analyzed using region-of-interest (ROI)-as well as voxel-based methods in both the DAT-rich striatum (caudate nucleus and putamen) and the SERT-rich extrastriatal brain regions (thalamus, hypothalamus, and pons). For SERT analysis, patients on selective serotonin reuptake inhibitor were excluded (n = 48 remained). Results: In the ROI analyses, extrastriatal I-123-FP-CIT binding ratios in the hypothalamus were significantly lower in PSP than in MSA-C patients, and we observed significantly lower striatal I-123-FP-CIT binding ratios in the caudate nucleus of PSP patients than in that of both PD and MSA-C patients. In the posterior putamen, binding ratios were significantly lower in MSA-P, PSP, and PD than MSA-C patients. Striatal ROI outcomes were confirmed by the voxel-based analyses that additionally showed a significantly lower hypothalamic binding in PSP and MSA-P than PD. Conclusion: Striatal I-123-FP-CIT binding to DAT and hypothalamic I-123-FP-CIT binding to SERT are significantly lower in MSA-P and PSP than in PD and MSA-C patients and might therefore be of interest for differential diagnosi