Neuroimaging analyses from a randomized, controlled study to evaluate plasma exchange with albumin replacement in mild-to-moderate Alzheimer's disease: additional results from the AMBAR study.

PURPOSE: This study was designed to detect structural and functional brain changes in Alzheimer's disease (AD) patients treated with therapeutic plasma exchange (PE) with albumin replacement, as part of the recent AMBAR phase 2b/3 clinical trial. METHODS: Mild-to-moderate AD patients were randomized into four arms: three arms receiving PE with albumin (one with low-dose albumin, and two with low/high doses of albumin alternated with IVIG), and a placebo (sham PE) arm. All arms underwent 6 weeks of weekly conventional PE followed by 12 months of monthly low-volume PE. Magnetic resonance imaging (MRI) volumetric analyses and regional and statistical parametric mapping (SPM) analysis on 18F-fluorodeoxyglucose positron emission tomography (18FDG-PET) were performed. RESULTS: MRI analyses (n = 198 patients) of selected subcortical structures showed fewer volume changes from baseline to final visit in the high albumin + IVIG treatment group (p < 0.05 in 3 structures vs. 4 to 9 in other groups). The high albumin + IVIG group showed no statistically significant reduction of right hippocampus. SPM 18FDG-PET analyses (n = 213 patients) showed a worsening of metabolic activity in the specific areas affected in AD (posterior cingulate, precuneus, and parieto-temporal regions). The high-albumin + IVIG treatment group showed the greatest metabolic stability over the course of the study, i.e., the smallest percent decline in metabolism (MaskAD), and least progression of defect compared to placebo. CONCLUSIONS: PE with albumin replacement was associated with fewer deleterious changes in subcortical structures and less metabolic decline compared to the typical of the progression of AD. This effect was more marked in the group treated with high albumin + IVIG. TRIAL REGISTRATION: (AMBAR trial registration: EudraCT#: 2011-001,598-25; ClinicalTrials.gov ID: NCT01561053).

Kaposi sarcoma in a child after hematopoietic stem cell transplantation: Should pre-transplant HHV-8 screening be considered in recipients from high prevalence areas?

Kaposi sarcoma (KS) is an angioproliferative disease associated with human herpesvirus 8 (HHV-8). We report the case of a 10-year-old male from a high HHV-8 prevalence area, diagnosed with severe aplastic anemia who underwent an upfront hematopoietic stem cell transplantation (HSCT). Five months after transplant, the patient was diagnosed with KS with skin, mucosae, lymph nodes and lung involvement. After withdrawal of immunosuppression the patient achieved complete remission without requiring further treatments. KS may occur after HSCT in patients from high HHV-8 prevalence areas. Considering that, we propose that screening of HHV-8 by antibody testing could be considered in HSCT donors/recipients from these areas.

Longitudinal Neuroimaging Analysis in Mild-Moderate Alzheimer's Disease Patients Treated with Plasma Exchange with 5% Human Albumin.

BACKGROUND: Recently, modifications of Aß1-42 levels in CSF and plasma associated with improvement in memory and language functions have been observed in patients with mild-moderate Alzheimer's disease (AD) treated with plasma exchange (PE) with albumin replacement. OBJECTIVE: To detect structural and functional brain changes in PE-treated AD patients as part of a Phase II clinical trial. METHODS: Patients received between 3 and 18 PE with albumin (Albutein® 5%, Grifols) or sham-PE (controls) for 21 weeks (divided in one intensive and two maintenance periods) followed by 6-month follow-up. Brain perfusion assessed by SPECT scans using an automated software (NeuroGam®) and brain structural changes assessed by MRI were performed at weeks 0 (baseline), 21, and 44 (with additional SPECT at weeks 9 and 33). Statistical parametric mapping (voxel-based analysis, SPM) and Z-scores calculations were applied to investigate changes to baseline. RESULTS: 42 patients were recruited (39 evaluable; 37 analyzed: 18 PE-treated; 19 controls). There was a trend toward decreasing hippocampi and total intracranial volume for both patient groups during the study (p < 0.05). After six months, PE-treated patients had less cerebral perfusion loss than controls in frontal, temporal, and parietal areas, and perfusion stabilization in Brodmann area BA38-R during the PE-treatment period (p < 0.05). SPM analysis showed stabilization or absence of progression of perfusion loss in PE-treated patients until week 21, not observed in controls. CONCLUSIONS: Mild-moderate AD patients showed decreased brain volume and impairment of brain perfusion as expected for the progression of the disease. PE-treatment with albumin replacement favored the stabilization of perfusion.

Biopsia selectiva del ganglio centinela en el carcinoma papilar de tiroides en pacientes sin evidencia preoperatoria de metástasis ganglionar / Selective sentinel lymph node biopsy in papillary thyroid carcinoma in patients with no preoperative evidence of lymph node metastasis

Introducción: La linfadenectomía en la cirugía del carcinoma papilar de tiroides se aconseja cuando hay evidencia de metástasis ganglionar cervical (terapéutica) o en pacientes de alto riesgo (profiláctica), como en los tumores T3 y T4 de la clasificación TNM. La técnica de la biopsia selectiva del ganglio centinela puede mejorar el diagnóstico prequirúrgico de las metástasis ganglionares. Objetivo: Analizar el resultado de la biopsia selectiva del ganglio centinela en un grupo de pacientes con carcinoma papilar de tiroides T sin evidencia de afectación ganglionar antes de la cirugía. Pacientes y método: Estudio retrospectivo, unicéntrico en el que se incluyeron los pacientes intervenidos entre los años 2011-2013 que fueran clínicamente N0. La identificación del ganglio centinela se realizó mediante técnica isotópica. En todos los casos, se practicó linfadenectomía del compartimento afecto si el ganglio centinela era positivo, y del compartimento central en caso de ganglio centinela negativo. Resultados: Se incluyeron 43 pacientes, 34 mujeres, con una edad media de 52,3 (±17) años. De los 170 ganglios centinela resecados, 46 (27%) fueron positivos para metástasis, que correspondían a 24 (55,8%) pacientes. En las linfadenectomías se resecaron 612 ganglios. De ellos, 96 (15,6%) fueron positivos para metástasis. Doce de los treinta (40%) pacientes cT1N0 y cT2N0 pasaron a pN1 tras la biopsia selectiva del ganglio centinela, mientras que 12 de los 13 (92%) pacientes cT3N0 y cT4N0, acabaron siendo pN1. Conclusiones: La biopsia selectiva del ganglio centinela recalifica más del 50% de pacientes de cN0 a pN1. Se confirma la necesidad de vaciamiento ganglionar en los tumores T3 y T4, pero pone al descubierto la presencia de metástasis linfáticas en el 40% de los T1-T2 (AU)

Introduction: Lymphadenectomy is recommended during surgery for papillary thyroid carcinoma when there is evidence of cervical lymph node metastasis (therapeutic) or in high-risk patients (prophylactic) such as those with T3 and T4 tumors of the TNM classification. Selective sentinel lymph node biopsy may improve preoperative diagnosis of nodal metastases. Objective: To analyze the results of selective sentinel lymph node biopsy in a group of patients with papillary thyroid carcinoma and no evidence of nodal involvement before surgery. Patients and method: A retrospective, single-center study in patients with papillary thyroid carcinoma and no clinical evidence of lymph node involvement who underwent surgery between 2011 and 2013. The sentinel node was identified by scintigraphy. When the sentinel node was positive, the affected compartment was removed, and when sentinel node was negative, central lymph node dissection was performed. Results: Forty-three patients, 34 females, with a mean age of 52.3 (±17) years, were enrolled. Forty-six (27%) of the 170 SNs resected from 24 (55.8%) patients were positive for metastasis. In addition, 94 (15.6%) out of the 612 lymph nodes removed in the lymphadenectomies were positive for metastases. Twelve of the 30 (40%) low risk patients (cT1N0 and cT2N0) changed their stage to pN1, whereas 12 of 13 (92%) high risk patients (cT3N0 and cT4N0) changed to pN1 stage. Conclusions: Selective sentinel lymph node biopsy changes the stage of more than 50% of patients from cN0 to pN1. This confirms the need for lymph node resection in T3 and T4 tumors, but reveals the presence of lymph node metastases in 40% of T1-T2 tumors (AU)

Selective sentinel lymph node biopsy in papillary thyroid carcinoma in patients with no preoperative evidence of lymph node metastasis. / Biopsia selectiva del ganglio centinela en el carcinoma papilar de tiroides en pacientes sin evidencia preoperatoria de metástasis ganglionar.

INTRODUCTION: Lymphadenectomy is recommended during surgery for papillary thyroid carcinoma when there is evidence of cervical lymph node metastasis (therapeutic) or in high-risk patients (prophylactic) such as those with T3 and T4 tumors of the TNM classification. Selective sentinel lymph node biopsy may improve preoperative diagnosis of nodal metastases. OBJECTIVE: To analyze the results of selective sentinel lymph node biopsy in a group of patients with papillary thyroid carcinoma and no evidence of nodal involvement before surgery. PATIENTS AND METHOD: A retrospective, single-center study in patients with papillary thyroid carcinoma and no clinical evidence of lymph node involvement who underwent surgery between 2011 and 2013. The sentinel node was identified by scintigraphy. When the sentinel node was positive, the affected compartment was removed, and when sentinel node was negative, central lymph node dissection was performed. RESULTS: Forty-three patients, 34 females, with a mean age of 52.3 (±17) years, were enrolled. Forty-six (27%) of the 170 SNs resected from 24 (55.8%) patients were positive for metastasis. In addition, 94 (15.6%) out of the 612 lymph nodes removed in the lymphadenectomies were positive for metastases. Twelve of the 30 (40%) low risk patients (cT1N0 and cT2N0) changed their stage to pN1, whereas 12 of 13 (92%) high risk patients (cT3N0 and cT4N0) changed to pN1 stage. CONCLUSIONS: Selective sentinel lymph node biopsy changes the stage of more than 50% of patients from cN0 to pN1. This confirms the need for lymph node resection in T3 and T4 tumors, but reveals the presence of lymph node metastases in 40% of T1-T2 tumors.

Chronic Recurrent Multifocal Osteomyelitis and Thalidomide in Chronic Granulomatous Disease.

Chronic granulomatous disease (CGD) is a primary immunodeficiency that leads to severe recurrent infection and inflammatory complications that are usually difficult to diagnose and treat. Several hyperinflammation mechanisms, such as decreased neutrophil apoptosis, toll-like receptor activation imbalance, Th17 cell induction, Nrf2 activity deficiency, and inflammasome activation, have been described in CGD patients However, there have been no reports of chronic recurrent multifocal osteomyelitis as an inflammatory complication in CGD, and the differential diagnosis of this condition with infectious osteomyelitis is challenging. Thalidomide has been used to treat several inflammatory manifestations in CGD patients with good clinical results. Here, we report the case of a previously asymptomatic 11-year-old boy who consulted for difficulty walking and pain at the back of the right thigh, with increased inflammatory markers. Multifocal bone involvement was seen on bone scintigraphy, and acute-phase reactants were elevated. On the basis of a suspected diagnosis of infectious osteomyelitis, broad-spectrum antibiotic therapy was started, with no clinical response. Bone biopsy and microbiological tests yielded negative results; at that point, chronic recurrent multifocal osteomyelitis was suspected. The patient was unresponsive to nonsteroidal antiinflammatory drugs and corticosteroids. Thalidomide was started, and within 6 months, clinical and radiologic resolution of the condition was achieved with no adverse effects. More than 1 year after stopping thalidomide, the patient remained free of symptoms and inflammatory parameters are within normal levels. Thalidomide has a favorable safety profile compared with other alternatives and could be considered a feasible therapeutic option for this type of condition in selected patients.

Femoral head bone viability after free vascularized fibular grafting for osteonecrosis: SPECT/CT study.

PURPOSE: To evaluate femoral head bone viability following free vascularized fibular grafting (FVFG) for osteonecrosis using SPECT/CT imaging. METHODS: Ten hips (9 patients) with osteonecrosis of the femoral head (ONFH) undergoing FVFG were prospectively enrolled. Four cases showed ARCO stage II, while six showed ARCO stage III. The mean age at surgery was 15.7 years (range, 13-22 years). Hip Harris Score (HHS) was measured pre- and post-operative. Bone scintigraphy with SPECT/CT was performed at 2 weeks and 6 months following surgery. RESULTS: Mean follow-up was 4.0 years (range, 2-5.9 years). Mean HHS increased from 37.2 to 92.3. SPECT/CT findings revealed a progressive increase of femoral head uptake in all cases, suggesting subchondral graft bone viability. No progressive deformation of the femoral head was evidenced in radiographic evaluation at final follow-up. CONCLUSIONS: This study demonstrates FVFG's capacity for revitalizing femoral head subchondral bone grafting in patients with ONFH, surgically treated following Urbaniak's technique. © 2015 Wiley Periodicals, Inc. Microsurgery 36:573-577, 2016.

Bernese Periacetabular Osteotomy in a Hip Extra-Articular Resection Followed by Reconstruction Using an Extracorporeal Irradiated Acetabulum Autograft with Megaprosthesis, for Proximal Femur Osteosarcoma in a Pediatric Patient.

Osteosarcoma is the most common primary malignant tumour of bone. The oncologic surgery of a proximal femur osteosarcoma affecting the hip joint can be very challenging. We present an 8-year-old boy with a 5-month history of right hip pain. Radiographs and magnetic resonance imaging (MRI) showed a lytic lesion of the proximal femur extending 13 cm to the diaphysis. Histological evaluation was consistent with high-grade osteoblastic osteosarcoma. After completing chemotherapy we performed an extra-articular resection of the hip. Reconstruction was accomplished by reimplanting the acetabulum after irradiation and modular proximal femur megaprosthesis. Endoprosthetic reconstruction following proximal femur resection is a good treatment alternative achieving good postoperative function. Extra-articular resection of the hip using a periacetabular osteotomy technique enabled us to achieve wide margins and leave an intact posterior column to optimize acetabular reconstruction stability. Extracorporeal irradiation and reimplantation is a valuable treatment option in a situation such as this where allograft geometric fit is a priority. We conclude that an extra-articular resection of the hip, followed by reconstruction with an extracorporeally irradiated acetabulum and a proximal femur modular megaprosthesis, is a useful combined treatment option for malignant lesions involving the hip joint, especially in paediatric patients.

Escolar amb osteomielitis multifocal crònica recurrent / Escolar con osteomielitis multifocal cronica recurrente / Child with chronic recurrent multifocal osteomyelitis

Introducció: l'osteomielitis multifocal crònica recurrent(OMCR) és una rara entitat d'etiologia desconeguda, quesol presentar-se en la infància primerenca, caracteritzadaper afectació òssia multifocal d'evolució clínica subagudao crònica amb remissions. Es presenta com una entitat in-dependent o com una síndrome combinada amb lesions ala pell (síndrome SAPHO). Les lesions òssies imiten unaosteomielitis aguda, però els estudis microbiològics són ne-gatius. El tractament d'elecció són els antiinflamatoris noesteroïdals, encara que no hi ha un tractament específic. Cas clínic: es presenta un pacient de sexe masculí de 7anys amb dolor, pruïja i edema al segon dit de la mà dretade 13 dies d'evolució. La radiografia del dit va mostrar lesions osteolítiques a les falanges mitjana i proximal senseafectació articular. En l'analítica sanguínia destacava unaVSG augmentada. La gammagrafia òssia amb Tc-99 descrivia diverses lesions òssies amb intensa reacció osteogènicaen diferents localitzacions. La nul•la resposta al tractamentantibiòtic, la negativitat dels cultius i la biòpsia òssia inespecífica feta en més d'un focus ossi van orientar eldiagnòstic d'OMCR. S'inicià tractament amb ibuprofèn,amb millora del dolor, l'eritema i l'edema del dit fins a laresolució total. Comentaris: el diagnòstic d'OMCR es fa davant unes troballes clíniques i radiològiques compatibles, i descartant lacausa microbiològica o tumoral mitjançant l'estudi micro-biològic i histològic de la biòpsia òssia. La gammagrafia òssia és una exploració indispensable, ja que revela lesionsòssies asimptomàtiques i les que no s'aprecien amb la radiologia simple

Introducción. La osteomielitis multifocal crónica recurrente (OMCR) es una rara entidad de etiología desconocida, que suele presentarse en la infancia temprana, caracterizada por afectación ósea multifocal de evolución clínica subaguda o crónica con remisiones. Se presenta como una entidad independiente o como un síndrome combinado con lesiones en la piel (síndrome SAPHO). Las lesiones óseas imitan una osteomielitis aguda, pero los estudios microbiológicos son negativos. El tratamiento de elección son los antiinflamatorios no esteroideos, aunque no hay un tratamiento específico. Caso clínico. Se presenta un paciente de sexo masculino de 7 años con dolor, prurito y edema en segundo dedo de la mano derecha de 13 días de evolución. La radiografía del dedo mostró lesiones osteolíticas en falanges media y proximal sin afectación articular. En la analítica sanguínea destacaba una VSG aumentada. La gammagrafía ósea con Tc-99 describía varias lesiones óseas con intensa reacción osteogénica en distintas localizaciones. La nula respuesta al tratamiento antibiótico, la negatividad de los cultivos y la biopsia ósea inespecífica orientaron al diagnóstico de OMCR. Se inició tratamiento con ibuprofeno con mejoría del dolor, el eritema y el edema del dedo hasta su total resolución. Comentarios. El diagnóstico de OMCR se realiza ante unos hallazgos clínicos y radiológicos compatibles, y descartando la causa microbiológica o tumoral mediante el estudio microbiológico e histológico de la biopsia ósea. La gammagrafía ósea es una exploración indispensable, ya que revela lesiones óseas asintomáticas y aquéllas que no se aprecian con la radiología simple (AU)

Introduction. Chronic recurrent multifocal osteomyelitis (CRMO) is a rare disease of unknown etiology that usually occurs in early childhood and is characterized by multifocal bone involvement with subacute or chronic clinical course and remission periods. It comes as a separate entity or as part of a syndrome with skin lesions (SAPHO syndrome). The bone lesions mimic an acute osteomyelitis, but microbiological studies are negative. The treatment of choice is with non-steroidal anti-inflammatory drugs. Case report. We report the case of a 7-year-old male who presented with pain, itching, and swelling of the second finger of the right hand for 13 days. A plain X-ray showed osteolytic changes in the middle and proximal phalanges without joint involvement. Blood tests were significant for an elevated ESR, and Tc-99 bone scintigraphy showed multiple bone lesions with intense osteogenic response. The lack of response to antibiotics, the negative cultures, and the nonspecific findings in the multiple bone biopsies suggested the diagnosis of CRMO. Treatment with ibuprofen was started, with improvement in pain, erythema, and edema of the finger, leading to complete resolution. Comments. The diagnosis of CRMO is made based on the compatible clinical and radiological findings, once neoplastic and infectious etiologies have been ruled out by histological and microbiological examination of bone biopsy. Bone scintigraphy is the most sensitive radiological method for diagnosis, as it may reveal asymptomatic lesions and also lesions not seen on plain X-ray (AU)

Continuous endotracheal tube cuff pressure control system protects against ventilator-associated pneumonia.

INTRODUCTION: The use of a system for continuous control of endotracheal tube cuff pressure reduced the incidence of ventilator-associated pneumonia (VAP) in one randomized controlled trial (RCT) with 112 patients but not in another RCT with 142 patients. In several guidelines on the prevention of VAP, the use of a system for continuous or intermittent control of endotracheal cuff pressure is not reviewed. The objective of this study was to compare the incidence of VAP in a large sample of patients (n = 284) treated with either continuous or intermittent control of endotracheal tube cuff pressure. METHODS: We performed a prospective observational study of patients undergoing mechanical ventilation during more than 48 hours in an intensive care unit (ICU) using either continuous or intermittent endotracheal tube cuff pressure control. Multivariate logistic regression analysis (MLRA) and Cox proportional hazard regression analysis were used to predict VAP. The magnitude of the effect was expressed as odds ratio (OR) or hazard ratio (HR), respectively, and 95% confidence interval (CI). RESULTS: We found a lower incidence of VAP with the continuous (n = 150) than with the intermittent (n = 134) pressure control system (22.0% versus 11.2%; p = 0.02). MLRA showed that the continuous pressure control system (OR = 0.45; 95% CI = 0.22-0.89; p = 0.02) and the use of an endotracheal tube incorporating a lumen for subglottic secretion drainage (SSD) (OR = 0.39; 95% CI = 0.19-0.84; p = 0.02) were protective factors against VAP. Cox regression analysis showed that the continuous pressure control system (HR = 0.45; 95% CI = 0.24-0.84; p = 0.01) and the use of an endotracheal tube incorporating a lumen for SSD (HR = 0.29; 95% CI = 0.15-0.56; p < 0.001) were protective factors against VAP. However, the interaction between type of endotracheal cuff pressure control system (continuous or intermittent) and endotracheal tube (with or without SSD) was not statistically significant in MLRA (OR = 0.41; 95% CI = 0.07-2.37; p = 0.32) or in Cox analysis (HR = 0.35; 95% CI = 0.06-1.84; p = 0.21). CONCLUSIONS: The use of a continuous endotracheal cuff pressure control system and/or an endotracheal tube with a lumen for SSD could help to prevent VAP in patients requiring more than 48 hours of mechanical ventilation.

Cognitive, genetic, and brain perfusion factors associated with four year incidence of Alzheimer's disease from mild cognitive impairment.

BACKGROUND: There is a range of factors that predict the development of Alzheimer's disease (AD) dementia among patients with amnestic mild cognitive impairment (MCI). OBJECTIVES: To identify the neuropsychological, genetic, and functional brain imaging data that best predict conversion to AD dementia in patients with amnestic MCI. METHODS: From an initial group of 42 amnestic MCI patients assessed with neurological, neuropsychological, and brain SPECT, 39 (25 converters, 14 non-converters) were followed for 4 years, and 36 had APOE ε4 genotyping. Baseline neuropsychological data and brain SPECT data were used to predict which of the MCI patients would develop dementia by the end of the 4 years of observation. RESULTS: The MCI patients who had converted to AD dementia had poorer performance on long-term visual memory and Semantic Fluency tests. The MCI subjects who developed dementia were more likely to carry at least one copy of the APOE ε4 allele (Hazard Risk = 4.22). There was lower brain perfusion in converters than non-converters, mainly in postcentral gyrus. An additional analysis of the SPECT data found differences between the MCI subjects and controls in the posterior cingulate gyrus and the basal forebrain. When the brain imaging and neuropsychological test data were combined in the same Cox regression model, only the neuropsychological test data were significantly associated with time to dementia. CONCLUSION: Although the presence of reduced brain perfusion in postcentral gyrus and basal forebrain indicated an at-risk condition, it was the extent of memory impairment that was linked to the speed of decline from MCI to AD.

Evaluation of bone viability.

Bone scintigraphy is an excellent tool to assess bone viability. The functional information provided is crucial in several clinical settings, like the detection of avascular necrosis, septic embolism, frostbite lesions and osteonecrosis, and to evaluate the results of surgical treatment in cases of avascular necrosis. Mechanisms to obtain molecular images, as well as different kind of techniques, are detailed. Comparative and multimodality imaging to focus on any clinical problem and a review of the clinical indications reflect the multidisciplinary approach with close collaboration between orthopaedists, radiologists and nuclear medicine physicians. Finally, an effort has been made to list the most important points of imaging of bone viability in children.

A two-year follow-up of cognitive deficits and brain perfusion in mild cognitive impairment and mild Alzheimer's disease.

The 15-Objects Test (15-OT) provides useful gradation of visuoperceptual impairment from normal aging through Alzheimer's disease (AD) and correlates with temporo-parietal perfusion. The objectives of this study were to analyze progression of 15-OT performance in mild cognitive impairment (MCI) and AD, and its correlates with cognition and single photon emission computerized tomography (SPECT), as well as to examine neuropsychological and SPECT differences between the MCI patients who developed AD and those who did not. From the initial 126 participants (42/group), 38 AD, 39 MCI, and 38 elderly controls (EC) were reassessed (SPECT: 35 AD, 33 MCI, 35 EC) after two years. The progression of cognitive and SPECT scores during this period was compared between groups, and baseline data between converters and non-converters. The 15-OT was the only measure of progression that differed between the three groups; worsening scores on 15-OT were associated with worsening in verbal and visual retention, and decreased perfusion on left postsubicular area. In the MCI patients, cerebral perfusion fell over the two years in medial-posterior cingulate and fronto-temporo-parietal regions; AD showed extensive changes involving almost all cerebral regions. No SPECT changes were detected in controls. At baseline, the MCI patients who developed AD differed from non-converters in verbal recognition memory, but not in SPECT perfusion. In conclusion, SPECT and 15-OT appear to provide a potential measure to differentiate between normal aging, MCI, and AD. Worsening on 15-OT was related to decreased perfusion in postsubicular area; but further longitudinal studies are needed to determine the contribution of 15-OT as a predictor of AD from MCI.

Change in clinical management of sentinel lymph node location in early stage cervical cancer: the role of SPECT/CT.

OBJECTIVE: The aim of this study was to investigate the feasibility of the sentinel lymph node (SLN) identification with SPECT/CT lymphoscintigraphy imaging in the early stage invasive cervical cancer in patients undergoing radical hysterectomy and pelvic lymphadenectomy. METHODS: Between March 2007 and June 2009, a prospective consecutive study was designed for SLN mapping. Twenty-two patients with cervical cancer FIGO stage IB1 (n=20) or stage IIA1 (n=2) underwent SLN identification with preoperative SPECT/CT and planar images (technetium-99m colloid albumin injection around the tumor) and posterior intraoperative detection with both blue dye and a handheld or laparoscopic gamma probe. Complete pelvic lymphadenectomy was performed in all cases by open (n=2) or laparoscopic (n=20) surgery. RESULTS: In the present series, a total of 35 SLN were detected with planar images and 40 SLN were identified and well located by SPECT/CT lymphoscintigraphy (median 2.0 nodes per patient). In 5/22 patients (22.7%) SPECT/CT procedure improves the number of localized SLN. Intraoperatively, 57 SLNs were identified, with a median of 3 SLNs per patient by gamma probe (a total of 53 hot nodes) and a median of 2 nodes per patient after blue dye injection (a total of 42 blue nodes). Microscopic nodal metastases (eight nodes, corresponding to four patients) were confirmed in 18.18% of cases; all these lymph nodes were previously detected as SLN. The remaining 450 nodes, including SLNs, following complete pelvic lymphadenectomy, were histologically negative. CONCLUSIONS: Sentinel lymph node detection is improved by SPECT/CT imaging because of the increased number of SLN detected and the better tridimensional anatomic location, allowing easier intra-operative detection with gamma probe and showing, in this series, a 100% negative predictive value.

The International Atomic Energy Agency software package for the analysis of scintigraphic renal dynamic studies: a tool for the clinician, teacher, and researcher.

Under the auspices of the International Atomic Energy Agency, a new-generation, platform-independent, and x86-compatible software package was developed for the analysis of scintigraphic renal dynamic imaging studies. It provides nuclear medicine professionals cost-free access to the most recent developments in the field. The software package is a step forward towards harmonization and standardization. Embedded functionalities render it a suitable tool for education, research, and for receiving distant expert's opinions. Another objective of this effort is to allow introducing clinically useful parameters of drainage, including normalized residual activity and outflow efficiency. Furthermore, it provides an effective teaching tool for young professionals who are being introduced to dynamic kidney studies by selected teaching case studies. The software facilitates a better understanding through practically approaching different variables and settings and their effect on the numerical results. An effort was made to introduce instruments of quality assurance at the various levels of the program's execution, including visual inspection and automatic detection and correction of patient's motion, automatic placement of regions of interest around the kidneys, cortical regions, and placement of reproducible background region on both primary dynamic and on postmicturition studies. The user can calculate the differential renal function through 2 independent methods, the integral or the Rutland-Patlak approaches. Standardized digital reports, storage and retrieval of regions of interest, and built-in database operations allow the generation and tracing of full image reports and of numerical outputs. The software package is undergoing quality assurance procedures to verify the accuracy and the interuser reproducibility with the final aim of launching the program for use by professionals and teaching institutions worldwide.

[Neuroimaging in Alzheimer's disease: findings in plasmapheresis with albumin]. / Neuroimagen en la enfermedad de Alzheimer: resultados en plasmaféresis con albúmina.

INTRODUCTION AND AIM: Changes in cerebral function were evaluated in patients with Alzheimer disease treated or not with plasmapheresis with Human Albumin Grifols 5%. Sequential brain single photon emission computerized tomography (SPECT) and magnetic resonance imaging techniques were used. MATERIALS AND METHODS: Brain SPECT (99mTc-ECD) studies were obtained at baseline (double headed gammacamera Siemens Ecam, LE-HR, 30 sec/image/3 degrees, 128 x 128). Studies were quantified by means of SPM (Statistical Parametric Mapping) and Neurogam. Changes between baseline and after a follow-up period of up to 12 months were evaluated in patients undergoing or not the plasma exchange treatment program. All the studies were double blinded and referenced to a normal age-matched database. Comparisons were performed individually and between groups: treated (plasma exchange) versus non treated group, and baseline versus post follow-up analysis. RESULTS AND CONCLUSIONS: Significant differences in the areas of Brodmann were observed between the treated and the control groups and after the follow-up period. Regarding the hippocampal uptake, significant differences were observed between the treated and the control groups. Together with the clinical findings, these preliminary results provide biological evidence to the hypothesis that plasmapheresis with Human Albumin Grifols 5% can play a role in the treatment of Alzheimer's disease.

Brain perfusion correlates of visuoperceptual deficits in mild cognitive impairment and mild Alzheimer's disease.

Visuoperceptual processing is impaired early in the clinical course of Alzheimer's disease (AD). The 15-Objects Test (15-OT) detects such subtle performance deficits in mild cognitive impairment (MCI) and mild AD. Reduced brain perfusion in the temporal, parietal, and prefrontal regions have been found in early AD and MCI patients. The objectives of this study were to confirm the role of the 15-OT in the diagnosis of MCI and AD and to investigate the brain perfusion correlates of visuoperceptual dysfunction (15-OT) in subjects with MCI, AD, and normal aging. Forty-two AD, 42 MCI, and 42 healthy elderly control subjects underwent a brain Single Photon Emission Tomography (SPECT) and separately completed the 15-OT. An analysis of variance compared 15-OT scores between groups. SPM5 was used to analyse the SPECT data. 15-OT performance was impaired in the MCI and AD patients. In terms of the SPECT scans, AD patients showed reduced perfusion in temporal-parietal regions, while the MCI subjects had decreased perfusion in the middle and posterior cingulate. When MCI and AD groups were compared, a significant brain perfusion reduction was found in temporo-parietal regions. In the whole sample, 15-OT performance was significantly correlated with the clinical dementia rating scores, and with the perfusion in the bilateral posterior cingulate and the right temporal pole, with no significant correlation in each separate group. Our findings suggest that the 15-OT performance provides a useful gradation of impairment from normal aging to AD, and it seems to be related to perfusion in the bilateral posterior cingulate and the right temporal pole.

Neuroimagen en la enfermedad de Alzheimer: resultados en plasmaféresis con albúmina / Neuroimaging in Alzheimer’s disease: findings in plasmapheresis with albumin

Introducción. Con el objetivo de estudiar los cambios funcionales cerebrales en pacientes con enfermedad de Alzheimer sometidos a plasmaféresis con recambio plasmático con Albúmina Humana Grifols® 5%, se han realizado prospectivamente y a doble ciego estudios secuenciales de tomografía computarizada por emisión de fotón único (SPECT) y resonancia magnética cerebrales a pacientes sometidos o no a esta terapia. Materiales y métodos. Los SPECT cerebrales (99mTc-ECD) se obtuvieron en condiciones basales (gamma-cámara doble detector Ecam, LE-HR, 30 sec/image/3º, 128 × 128). Estos estudios se cuantificaron mediante SPM (Statistical Parametric Mapping) y Neurogam para valorar los cambios entre el estudio basal y el seguimiento tras la plasmaféresis. Todos los estudios, referenciados con una base de datos normal para la edad, se han comparado de forma individual y por grupos: tratados/no tratados con plasmaféresis y estudios pretratamiento/postratamiento en diferentes tiempos. Resultados y conclusiones. Se presentan los resultados de las áreas de Brodmann en las que se han detectado diferencias significativas entre los grupos tratado y control y entre los controles evolutivos, y las variaciones evolutivas en la captación del hipocampo en los grupos control y tratados. Junto con los hallazgos clínicos, estos resultados preliminares aportan evidencia biológica a la hipótesis de que el recambio plasmático con Albúmina Humana Grifols® 5% puede desempeñar un papel en el tratamiento de la enfermedad de Alzheimer (AU)

Introduction and aim. Changes in cerebral function were evaluated in patients with Alzheimer disease treated or not with plasmapheresis with Human Albumin Grifols® 5%. Sequential brain single photon emission computerized tomography (SPECT) and magnetic resonance imaging techniques were used. Materials and methods. Brain SPECT (99mTc-ECD) studies were obtained at baseline (double headed gammacamera Siemens Ecam, LE-HR, 30 sec/image/3°, 128 x 128). Studies were quantified by means of SPM (Statistical Parametric Mapping) and Neurogam. Changes between baseline and after a follow-up period of up to 12 months were evaluated in patients undergoing or not the plasma exchange treatment program. All the studies were double blinded and referenced to a normal age-matched database. Comparisons were performed individually and between groups: treated (plasma exchange) versus non treated group, and baseline versus post follow-up analysis. Results and conclusions. Significant differences in the areas of Brodmann were observed between the treated and the control groups and after the follow-up period. Regarding the hippocampal uptake, significant differences were observed between the treated and the control groups. Together with the clinical findings, these preliminary results provide biological evidence to the hypothesis that plasmapheresis with Human Albumin Grifols® 5% can play a role in the treatment of Alzheimer’s disease (AU)