Projected all-cause deaths attributable to COVID-19-related unemployment in Croatia in 2020.

OBJECTIVES: In 2020, Croatia reported the first increase in the unemployment rate after six consecutive years of reduction in the number of unemployed persons. Unemployment is associated with an increase in morbidity and mortality among unemployed persons. We estimated the number of potential excess deaths that could be associated with an increase in unemployment seen after the beginning of the COVID-19 pandemic in 2020. STUDY DESIGN: This was a cross-sectional analytic study. METHODS: We used previously published meta-analyzed hazard ratios for the unemployment-mortality association and unemployment and mortality data from the Croatian Bureau of Statistics to estimate 1-year age-standardized deaths potentially attributable to COVID-19-related unemployment for persons aged 20-64 in Croatia. RESULTS: In January 2021, we observed a 19% increase in unemployment among persons aged 20-64 years compared with February 2020 (prepandemic). This increase in unemployment could lead to 23 excess deaths among newly unemployed persons. This would constitute a 42% increase in the number of deaths and 29% of all deaths among this group. Deaths were disproportionately higher among men and those aged >40 years. CONCLUSIONS: To mitigate the negative impact of COVID-19-related unemployment on population health, interventions that will reduce the further spread of SARS-CoV-2 and policies that will ensure economic recovery and reduction of unemployment are needed. Job skills training and provision of legal and welfare advice programs for unemployed persons should be integrated with health interventions.

Solid-phase analysis method for (S)-[18F]fluorocarazolol and its metabolites.

(S)-[18F]Fluorocarazolol is a radiopharmaceutical developed to quantitatively assess beta-adrenergic receptors in vivo via positron emission tomography imaging. Since radioactive metabolites of (S)-[18F]fluorocarazolol rapidly appear in the plasma, methods for conveniently and reliably evaluating plasma for (S)-[18F]fluorocarazolol content are required. Here we present methods and validation of an approach using commercial extraction cartridges that is faster and more convenient than an approach using internal-surface reverse-phase chromatography but yields comparable results.

Usefulness and pitfalls of planar gamma-scintigraphy for measuring aerosol deposition in the lungs: a Monte Carlo investigation.

UNLABELLED: Planar gamma-scintigraphy is often used to quantify pulmonary deposition patterns from aerosol inhalers. The results are quite different from those obtained using 3-dimensional PET and SPECT. The purpose of this study was to characterize the effects of scatter and tissue attenuation on the distribution of radiolabeled aerosol as measured by planar scintigraphy using Monte Carlo simulations. This study also investigated the applicability of a few correction methods used in inhalation studies. METHODS: Body density maps were derived from CT scans. Regions of interest-lungs, major airways, and esophagus-were defined from the same CT volume. Two radioactivity source distribution patterns in the lung, uniform and nonuniform, were used. A Monte Carlo program, SIMIND, was used to generate anterior and posterior gamma-images of the composed inhalation distributions for 2 energy windows, photopeak (127-153 keV) and scatter (92-125 keV). The effects of scatter and attenuation were estimated on the basis of the imaging components separated from the simulation. A scatter correction method and 2 attenuation correction methods, all applied to inhalation scintigraphy, were evaluated using the simulated images. RESULTS: The amount of scatter ranges from 24% to approximately 29% in the lungs and from 29% to approximately 35% in the central (airway or esophagus) region on the planar images. Significant differences were found among regions and between source distributions (P < 0.05). The fraction k used for dual-energy-based scatter correction also varied and was found to be less than the commonly used k = 0.5. The simplified narrow-beam attenuation correction and the effective (broad-beam) correction methods were found to either under- or overcorrect the regional activities. CONCLUSION: The amount of scatter and tissue attenuation in the thorax region depends on source distribution and body attenuation. In applying planar scintigraphy for aerosol inhalation studies, it is difficult to obtain precise quantitative measurements because of the uncertainties associated with scatter and attenuation corrections. Accurate corrections require knowledge of both source and density distributions.

The dynamic in vivo distribution of bone marrow-derived mesenchymal stem cells after infusion.

Bone marrow-derived mesenchymal stem cells (MSCs) have the potential to differentiate along different mesenchymal lineages including those forming bone, cartilage, tendon, fat, muscle and marrow stroma that supports hematopoiesis. This differentiation potential makes MSCs candidates for cell-based therapeutic strategies for mesenchymal tissue injuries and for hematopoietic disorders by both local and systemic application. In the present study, rat marrow-derived MSCs were ex vivo culture-expanded, labeled with (111)In-oxine, and infused into syngeneic rats via intra-artery (i.a.), intravenous (i.v.) and intraperitoneal cavity (i.p.) infusions. In addition, for i.a. and i.v. infusions, a vasodilator, sodium nitroprusside, was administered prior to the cell infusion and examined for its effect on MSC circulation. The dynamic distribution of infused MSCs was monitored by real-time imaging using a gamma camera immediately after infusion and at 48 h postinfusion. After 48 h, radioactivity in excised organs, including liver, lungs, kidneys, spleen and long bones, was measured in a gamma well counter and expressed as a percentage of injected doses. After both i.a. and i.v. infusion, radioactivity associated with MSCs was detected primarily in the lungs and then secondarily in the liver and other organs. When sodium nitroprusside was used, more labeled MSCs cleared the lungs resulting in a larger proportion detected in the liver. Most importantly, the homing of labeled MSCs to the marrow of long bones was significantly increased by the pretreatment with vasodilator. These results indicate multiple homing sites for injected MSCs and that the distribution of MSCs can be influenced by administration of vasodilator.

COMKAT: compartment model kinetic analysis tool.

UNLABELLED: Compartment models are the basis for most physiologically based quantification of nuclear medicine data. Although some software packages are available for this purpose, many are expensive, run on relatively few types of computers or are of limited capability, and cannot be extended because of the unavailability of source code. Consequently, institutions with modeling expertise often develop software for themselves, which has the disadvantages of lack of standardization and possible replication of effort. Therefore, general-purpose compartment-modeling software distributed with source code would be a welcome resource for the nuclear medicine community. METHODS: We formulated a mathematic framework within which compartment models containing unimolecular and bimolecular (receptor saturation) kinetics can be described. We implemented this framework within MATLAB and call the resultant software COMKAT (Compartment Model Kinetic Analysis Tool). RESULTS: COMKAT simplifies the process of defining and solving standard blood flow, 18F-FDG, and receptor models as well as models of a user's own design. In particular, COMKAT automatically defines and implements state, analytic sensitivity, and Jacobian equations. Given these, COMKAT can perform simulations in which model outputs are solved for specified parameter values, thereby allowing the user to predict how sensitive data are to these parameters. In addition, COMKAT can be used to estimate values for the parameters by fitting model output to experimental data. COMKAT is equipped with command-line and graphic user interfaces from which the user can access these features. Examples of these applications are presented along with validation and performance summaries. CONCLUSION: COMKAT is a useful software tool and is available without cost to researchers, at www.nuclear.uhrad.com/comkat.

Higher brain blood flow at amygdala and lower frontal cortex blood flow in PTSD patients with comorbid cocaine and alcohol abuse compared with normals.

Posttraumatic stress disorder (PTSD) patients with histories of cocaine and alcohol abuse (CA-PTSD) were compared with normal volunteers. Positron emission tomography (PET) scans with 15O-butanol were used to compare regional cerebral blood flow (rCBF) between the groups during rest and during an auditory continuous performance task (ACPT). CA-PTSD patients had significantly higher rCBF in right amygdala and left parahippocampal gyrus than normals during the ACPT. Normals had higher rCBF at frontal cortex during the resting scan and during the ACPT. The role of the amygdala in attention and fear conditioning suggests that increased amygdala rCBF may be related to clinical features of PTSD. Cocaine use may be associated with increased amygdala rCBF in PTSD patients. Amygdala and frontal cortex attention system components may be reciprocally related and their relative contributions to processing of neutral stimuli perturbed in CA-PTSD.

Iterative optimal design of PET experiments for estimating beta-adrenergic receptor concentration.

To estimate in vivo myocardial beta-adrenergic receptor concentration with sufficient precision and to reduce the experimental complexities in positron emission tomography (PET), an iterative optimal design method is applied. An initial three-injection protocol, utilising [F-18]-labelled (R)- and (S)-fluorocarazolol and unlabelled (S)-fluorocarazolol, is optimised for ligand dosages and administration times to maximise the precision of all model parameters using the D-optimal criterion. Using this experimental protocol, PET data are collected in porcine studies, and model parameters are estimated. All model parameters are identified with satisfactory precision. The in vivo myocardial beta-receptor concentration is 7.5+/-0.6 pmol x ml(-1), which corresponds to the in vitro result of 10.1+/-1.3 pmol x ml(-1). With more accurate parameter values, a simplified two-injection protocol is optimally designed, utilising only radiolabelled and unlabelled (S)-fluorocarazolol, based on a new criterion to maximise the precision of the beta-receptor concentration. This revised optimum design predicts that the in vivo beta-receptor concentration can be estimated with good precision but reduced experiment complexity.

Simultaneous recovery of size and radioactivity concentration of small spheroids with PET data.

UNLABELLED: Quantification of tumor activity is used to predict prognosis and discriminate benign from malignant lesions identified by PET. Accurate quantitation of small lesions requires correction for the partial volume effects. Such a correction is often based on the recovery coefficient (RC), which depends on the lesion size, the object-to-background ratio (OBR) and physical properties of the media. The purpose of this investigation was to determine whether a model-based optimization method to simultaneously recover the size and the activity concentration of small spheroids could improve estimates of lesion radioactivity when object size is unknown. For reference, we compared our method with a widely used approach, RC correction, that requires the object size to be known. METHODS: A three-dimensional, spatially varying, object size- and contrast-dependent Gaussian model of the point spread function (PSF) of an ECAT EXACT was developed. The observed dependence of the PSF on random coincidences and measured-peak/background activity were included in the PSF using three adjusting factors. Size and radioactivity concentration of a spheroid were estimated by adjusting size and concentration until model output best matched the image data. Elliptic and circular phantoms both containing seven hot spheroids, with OBRs ranging from 5.6 to 0 background, were evaluated. RESULTS: The proposed quantification method reduced the activity error by 11%-63% of the error obtained without correction. The greatest error reduction occurred for small spheroids. The average error in radius estimation ranged from 2% to 48%, wherein the smallest spheroid produced the largest errors. For spheroids with diameters from 8 to 22 mm, Student t test (paired, one-tail) showed the proposed method significantly improved accuracy (P < 0.05) in comparison with the RC method and also in comparison with optimization without the three adjusting factors. CONCLUSION: The model-based optimization method improved estimation of radioactivity concentration over that corrected by the RC method and that made without any correction. It also provided accurate estimation of size for spheroids larger than 6 mm in diameter.

Loss of D2 receptor binding with age in rhesus monkeys: importance of correction for differences in striatal size.

The relation between striatal dopamine D2 receptor binding and aging was investigated in rhesus monkeys with PET. Monkeys (n = 18, 39 to 360 months of age) were scanned with 11C-raclopride; binding potential in the striatum was estimated graphically. Because our magnetic resonance imaging analysis revealed a concomitant relation between size of striatum and age, the dynamic positron emission tomography (PET) data were corrected for possible partial volume (PV) artifacts before parameter estimation. The age-related decline in binding potential was 1% per year and was smaller than the apparent effect if the age-related change in size was ignored. This is the first in vivo demonstration of a decline in dopamine receptor binding in nonhuman primates. The rate of decline in binding potential is consistent with in vitro findings in monkeys but smaller than what has been measured previously in humans using PET. Previous PET studies in humans, however, have not corrected for PV error, although a decline in striatal size with age has been demonstrated. The results of this study suggest that PV correction must be applied to PET data to accurately detect small changes in receptor binding that may occur in parallel with structural changes in the brain.

PET quantification of specific binding of carbon-11-nicotine in human brain.

UNLABELLED: Previous work on the PET measured uptake of (S)-[11C]nicotine presents conflicting findings as to whether it reflects specific binding. METHODS: We studied the uptake of (R)-[11C]nicotine and (S)-[11C]nicotine in normal volunteers at baseline conditions and after a challenge with unlabeled (S)-nicotine to decrease the concentration of free binding sites or with CO2 to increase perfusion. We analyzed the data using two- and three-compartment models. RESULTS: We found tissue pharmacokinetics of (R)- and (S)-[11C]nicotine are adequately described by the two-compartment model. (S)-nicotine challenge induced small but statistically significant reductions in distribution volume (DV) of both (R)- and (S)-[11C]nicotine. The changes in DV could not be attributed to perfusion changes because DV was not affected by CO2 challenge. Although the reduction in DV indicates sensitivity of [11C]nicotine to status of nicotinic binding sites, the small magnitude of the reduction suggests that most nicotine uptake is nonspecific. CONCLUSION: Although differences in DV attributable to specific binding were detected, (R)- and (S)-[11C]nicotine are relatively poor tracers for studying nicotinic binding sites using PET.

A method to correct for scatter, spillover, and partial volume effects in region of interest analysis in PET.

Scatter and spatial resolution effects degrade the accuracy of radioactivity concentration estimates obtained from positron emission tomography (PET) data. We present and evaluate a methodology for region quantification which accounts for these degradations. The method is based on analysis of sinogram data and does not require dynamic data sequences to be reconstructed. Moreover, estimates of region variance are also produced which may be used to define weights for model analyses that use weighted least squares minimization in order to obtain unbiased parameter estimates. We evaluate the method using both simulation and measured data and find that, with an appropriate model of scatter and spatial resolution effects, it is unbiased and capable of quantifying myocardial concentration with no more than a 5% error in accuracy for myocardium as thin as 10 mm.

A nonlinear spatially variant object-dependent system model for prediction of partial volume effects and scatter in PET.

Accurate quantitation of small lesions with positron emission tomography (PET) requires correction for the partial volume effect. Traditional methods that use Gaussian models of the PET system were found to be insufficient. A new approach that models the non-Gaussian object-dependent scatter was developed. The model consists of eight simple functions with a total of 24 parameters. Images of line and disk sources in circular and elliptical cylinders, and an anthropomorphic chest phantom were used to determine the parameter values. Empirical rules to determine these parameter values for various objects based on those for a reference object, a 21.5-cm circular cylinder, were also proposed. For seven spheroids and a 3.4-cm cylinder, pixel values predicted by the model were compared with the measured values. The model-to-measurement-ratio was 1.03+/-0.07 near the center of the spheroids and 0.99+/-0.03 near the center of the 3.4-cm cylinder. In comparison, the standard single Gaussian model had corresponding ratios of 1.27+/-0.09 and 1.24+/-0.03, respectively, and the corresponding ratios for a double Gaussian model were 1.13+/-0.09 and 1.05+/-0.01. Scatter fraction (28.5%) for a line source in the 21.5-cm cylinder was correctly estimated by our model. Because of scatter, we found that errors in the measurement of activity in spheroids with diameters from 0.6 to 3.4 cm were more significant than previously appreciated.

A robust edge detection method for gated radionuclide ventriculograms.

UNLABELLED: We present a myocardial edge detection technique that was developed for fast, reproducible measurements of left ventricular ejection fraction in the clinical setting. METHODS: This myocardial edge detection method compares three edge parameters--count amplitude and first and second count derivatives--in three consecutive locations along a radius to a predetermined template of these values. Each of the radii, defined at 10-degree intervals, has different template values that permit accurate edge detection even though adjacent structures, such as the left atrium and the right ventricle, alter edge parameters. The template for edge detection is based on either the average edge parameters determined from manually defined edges in 15 patients (automatic method) or an operator-defined edge in the first frame (semiautomatic method). RESULTS: The edge detection methods were tested in 100 patients, and intraobserver variabilities as well as comparison with clinically obtained ejection fractions were calculated. The standard error of the estimate was less than 3.1% for all observer comparisons. In 15 patients with both high-count (400,000 counts per image) and low count (50,000 counts per image) studies, the mean absolute difference in ejection fraction was 2.6% for intraobserver comparisons. CONCLUSION: A robust myocardial edge detection technique was developed that is applicable for routine clinical use.

Optimal experiment design for PET quantification of receptor concentration.

The mathematical models used to analyze positron emission tomography (PET) data obtained for receptor quantitation have many unknown parameters which must be estimated from the data. Obtaining unique and precise estimates of the model parameters from PET data is difficult as a result of the complex interdependence of the parameters. Here the authors address the task of estimating the concentration of myocardial beta-adrenergic receptors using unlabeled and (18)F-labeled S(-)-fluorocarazolol as the receptor ligand. For a three-injection study the authors have optimized the ligand injection times and dosages using the D-optimal criterion for estimating receptor concentration. They found that in optimizing a three-injection experimental design, the dose of ligand in the third injection approaches zero so that the optimal three-injection design is actually a two-injection experiment. Using this optimal experiment, the authors demonstrate estimates of receptor concentration that are almost five times as precise as compared to an empirically designed three-injection experiment.

Noninvasive arterial monitor for quantitative oxygen-15-water blood flow studies.

A noninvasive monitor has been developed for monitoring arterial radioactivity in quantitative PET studies of blood flow. The significance of this probe is that quantitative blood flow studies can be performed without the use of arterial catheterization. The method employed is based on the flux of photons emanating from the superior lobe of the right lung following an intravenous bolus of H2(15)O. Calibration of the monitor is obtained by measuring the relationship between lung monitor counts and arterial radioactivity after arterial and venous radioactivity levels have equilibrated following inhalation of C15O. To determine the accuracy of the lung probe as a measure of arterial radioactivity, 44 brain blood flow determinations were made in 11 volunteers using arterial radioactivity measures based both on the lung probe and continuous sampling from a radial artery. Repeated measures analysis of variance found no differences between invasive and noninvasive estimates of blood flow. These results suggest that the lung monitor enables quantitation of cerebral blood flow yet avoids the trauma of an arterial puncture.

Temporal alignment of tissue and arterial data and selection of integration start times for the H(2)(15)O autoradiographic CBF model in PET.

A technique has been developed and tested that provides an automated method of temporally aligning the PET tissue activity curve with the arterial activity curve for quantification of cerebral blood flow using the H(2)(15)O autoradiographic model. This technique not only determines the relative time delay between the two curves, but also provides the start time of integration. Variability in computing global cerebral blood flow using this technique is shown to be less than that obtained by trained observers manually selecting parameters and at least as good as that obtained by using another automated alignment technique.

Measurement of human cerebral blood flow with [15O]butanol and positron emission tomography.

Although H2(15)O is widely used for CBF measurement by positron tomography, it underestimates CBF, especially at elevated flow rates. Several tracers, including butanol, overcome this problem, but the short half-life of 15O provides advantages that cause water to remain the tracer of choice. We report the first use and evaluation of 15O-labeled butanol for CBF measurement. Flow measurements made in a similar fashion with water and butanol at 10-min intervals were compared in normal volunteers under resting and hypercapnic conditions. Regional analysis showed good agreement between the tracers at low flows, and significant underestimation of flow by water relative to butanol in regions of elevated flow. The observed relationship between the tracers and the curve-fitted permeability-surface area product for water (133 ml.100 g-1.min-1) follow the known relationship between water and true flow. These observations indicate that [15O]-butanol provided accurate measurements of human regional CBF under conditions of elevated perfusion. We conclude that butanol is a convenient and accurate method for routine CBF determination by positron emission tomography.

Mathematical simplification of a PET blood flow model.

The positron emission tomography (PET) H(2)(15)O bolus injection model for cerebral blood flow (CBF) requires calculation of a certain double integral that, when calculated, provides the pixel values of a reconstructed image (PET number) in terms of the tissue flow, the arterial input function, a decay constant for (15)O, the partition coefficient and a camera calibration constant that relates the flow-dependent integrated tissue activity to the measured PET number (cts/pixel). The tissue activity is assumed to be zero at the time of injection. A mathematical simplification, changing the order of integration, enabled the integration with respect to time to be performed analytically before the integration of the arterial input function. As a result of this simplification, only single integrals remain to be calculated numerically; cubic spline integration was used to calculate numerically these remaining integrals. This technique increases the accuracy and speed of evaluating blood flow without making simplifying assumptions. Similar simplifications may be applicable to other physiological models.

Continuous arterial positron monitor for quantitation in PET imaging.

Quantitative measures of physiologic function with PET require continuous monitoring of arterial positron isotope concentration. A device has been developed that automates this process. This device has advantages over manual sampling techniques with syringes since fewer personnel are required, measurements are less error prone, and more continuous measures of arterial positron concentration are available. A constant flow infusion/withdrawal pump withdraws blood from the radial artery through a catheter connected to 0.5 mm inner diameter teflon tubing. This tubing is wrapped around a 50 mm thick by 50 mm diameter NaI(T1) crystal that is interfaced to a photomultiplier tube (PMT) and encased in a cylindrical lead shield. This crystal detects 511 Kev photons that result from positron annihilation. The device sensitivity is greater than 240 (cts/sec)/(microCi/ml) corresponding to a peak activity of approximately 10,000 cts/sec for a 50 mCi bolus injection in an adult. The system dynamic response has been measured and the true arterial input function is recovered by deconvolution. The system has been used clinically for more than 400 human PET studies and has been a reliable continuous monitor of arterial positron concentration.