Acetazolamide-enhanced neuroSPECT scan reveals functional impairment after minimal traumatic brain injury not otherwise discernible

A patient suffering from aggressive personality changes and cognitive impairment following head trauma, without neurological or anatomical imaging findings, underwent neuroSPECT scans with and without acetazolamide injection, both before treatment and during treatment with valproate. Acetazolamide injection induced increased prefrontal perfusion not evident at baseline. Valproate treatment was associated with increased prefrontal perfusion concomitant with clinical improvement and abolished response to acetazolamide challenge.     

Scintigraphic presentation of hip joint synovial chondromatosis

A case of hip joint synovial chondromatosis with an unusual scintigraphic pattern is described. This pattern was suggestive of a hip joint destructive reactive articular process or late manifestations of avascular necrosis of the femoral head. Concurrent radiographs were normal, as were laboratory investigations. Follow-up radiographs six months later showed radiolucencies and erosive bone changes in the diseased joint. Surgical and histopathological findings revealed well developed hip synovial chondromatosis (HSC) with thickened synovium and large, loose, cartilaginous bodies occupying and widening the tightened joint space, with destructive secondary juxta articular pressure and bone erosions. This and other scintigraphic patterns in HSC, and the differential diagnosis of the findings in patients with painful hip presentations are discussed.     

A randomized study comparing yttrium-90 ibritumomab tiuxetan (Zevalin) and high-dose BEAM chemotherapy versus BEAM alone as the conditioning regimen before autologous stem cell transplantation in patients with aggressive lymphoma

BACKGROUND:

High‐dose chemotherapy combined with autologous stem‐cell transplantation (ASCT) is the standard therapy for refractory/relapsed aggressive lymphoma. In the era of rituximab‐containing frontline regimens, it is becoming more challenging to salvage patients in this setting, and novel approaches are required. This is a randomized study evaluating the safety and efficacy of standard‐dose ibritumomab tiuxetan (Zevalin) combined with high‐dose BEAM chemotherapy (Z‐BEAM) and ASCT in refractory/relapsed aggressive lymphoma.

METHODS:

Forty‐three patients with CD20⁺‐aggressive lymphoma were randomized to a treatment arm (Z‐BEAM, n = 22) or control arm (BEAM alone, n = 21). Ibritumomab tiuxetan was given at 0.4 mCi/kg on day ?14 before ASCT.

RESULTS:

Patient characteristics, engraftment kinetics, and toxicity profile were similar between the 2 groups. Two‐year progression‐free survival (PFS) for all patients was 48% (95% confidence interval, 32%‐64%): 59% and 37% after Z‐BEAM and BEAM alone, respectively (P = .2). Multivariate analysis identified advanced age (hazard ratio [HR], 8.3; P = .001), high‐risk disease (relapse within 12 months of diagnosis and/or secondary International Prognostic Index >2; HR, 2.8; P = .04), positive positron emission tomography‐computed tomography pretransplant (HR, 2.4; P = .07), and BEAM alone (HR, 2.8; P = .03) as poor prognostic factors. Intermediate‐risk patients with 1 or 2 risk factors had better PFS with Z‐BEAM compared with BEAM: 69% and 29%, respectively (P = .07). Two‐year overall survival was 91% and 62% after Z‐BEAM and BEAM, respectively (P = .05). Similar prognostic factors determined survival. The HR for BEAM alone in the multivariate analysis was 8.1 (P = .01).

CONCLUSIONS:

Standard‐dose ibritumomab tiuxetan combined with BEAM high‐dose chemotherapy is safe and possibly more effective than BEAM alone as a conditioning regimen for ASCT in the era of rituximab‐containing chemotherapy regimens. Cancer 2012. © 2012 American Cancer Society.     

The diagnosis of delirium among elderly patients presenting to the emergency department of an acute hospital

Delirium is prevalent among elderly people presenting to an emergency department (ED). However, despite the fact that delirium is associated with longer hospital stays, an increased rate of institutionalization and higher mortality (especially in the case of undiagnosed delirium), this condition often goes undiagnosed by ED doctors. We examined the rate of mental status assessment and the prevalence of delirium in the ED among patients older than 65 years in a large teaching hospital in Southern Israel via a retrospective chart review. Surprisingly we found no diagnosis of delirium in the medical charts of representative sample of 319 elderly people. Furthermore, only 12.5% of people received either an adequate or even a partially adequate mental status assessment by the ED doctors. We attribute these negative findings not to a low incidence of delirium but probably to a combination of a heavy workload along with a lack of adequate training of ED physicians. We suggest that part of the solution involves providing appropriate education to ED physicians as well as adding a geriatric consultant to the ED roster.     

Right prefrontal rTMS treatment for refractory auditory command hallucinations - a neuroSPECT assisted case study

Auditory command hallucinations probably arise from the patient's failure to monitor his/her own 'inner speech', which is connected to activation of speech perception areas of the left cerebral cortex and to various degrees of dysfunction of cortical circuits involved in schizophrenia as supported by functional brain imaging. We hypothesized that rapid transcranial magnetic stimulation (rTMS), by increasing cortical activation of the right prefrontal brain region, would bring about a reduction of the hallucinations. We report our first schizophrenic patient affected with refractory command hallucinations treated with 10 Hz rTMS. Treatment was performed over the right dorsolateral prefrontal cortex, with 1200 magnetic stimulations administered daily for 20 days at 90% motor threshold. Regional cerebral blood flow changes were monitored with neuroSPECT. Clinical evaluation and scores on the Positive and Negative Symptoms Scale and the Brief Psychiatric Rating Scale demonstrated a global improvement in the patient's condition, with no change in the intensity and frequency of the hallucinations. NeuroSPECT performed at intervals during and after treatment indicated a general improvement in cerebral perfusion. We conclude that right prefrontal rTMS may induce a general clinical improvement of schizophrenic brain function, without directly influencing the mechanism involved in auditory command hallucinations.     

Brain reactivity to specific symptom provocation indicates prospective therapeutic outcome in OCD

A pertinent question in biological psychiatry is what differentiates responders and non-responders to pharmacological treatment. One possibility is that individual differences in the symptomatic spectrum as well as in the underlying biology of the disorder lead to the known 40% failure in pharmacological treatment. Our study aimed to maximize individual brain markers of obsessive-compulsive disorder (OCD) by applying single photon emission computed tomography (SPECT) during a provoked symptomatic state prior to and following treatment. Four brain SPECT scans were obtained from 26 OCD patients prior to and at 6 months of sertraline treatment. At each time point, two SPECT scans were performed in a counterbalanced order of two specific states; one a symptom-provoking condition and the other a relaxed condition. At 6 months of treatment, patients were divided into responders and non-responders according to a predetermined clinical criterion. Prospective responders showed significantly lower brain perfusion in the dorsal-caudal anterior cingulum and higher brain perfusion in the right caudate, when compared to non-responders, only during symptom provocation. When pre- and post-treatment scans during symptom provocation were compared, only responders showed significant change in brain response: increased perfusion in the left anterior temporal cortex and prefrontal cortex at 6 months' treatment. These findings suggest that obtaining functional brain imaging during specific symptom provocation emphasizes individual differences in brain reactivity. Thus can indicate prospective responders to symptom-related treatment in OCD and mark the relevant brain regions for effective response to treatment.     

Malignant Bronchial Carcinoid Tumor Metastatic to the Pituitary in a Thyroid Carcinoma Patient: Successful Treatment with Surgery,Radiotherapy and Somatostatin Analog

A carcinoid pituitary metastasis is very rare, and is reported scarcely in a few patients. We describe an unusual case of metastatic atypical bronchial carcinoid to the anterior pituitary gland in a 47-year-old male who presented with bitemporal hemianopsia and hypopituitarism. His primary bronchial carcinoid was resected two years previously. Foci of metastatic papillary thyroid carcinoma were also identified in the lung resected for the bronchial carcinoid. He thereby underwent total thyroidectomy followed by radioiodine ablative treatment. Transsphenoidal partial removal of the suprasellar mass was performed, and atypical carcinoid metastasis was identified. He received conventional fractionated sellar radiotherapy, which was supplemented with octreotide (Sandostatin LAR) injections following a positive pituitary uptake on octreotide scan. This treatment suppressed his elevated 5-HIAA urinary excretion to a normal level. His vision has returned to normal and the pituitary mass diminished in size.     

Isolated ectopic lung uptake of technetium 99m methylene diphosphonate on bone scintigraphy in primary amyloidosis

Pulmonary deposition of technetium 99m methylene diphosphonate was found on a bone scan of a patient with undiagnosed primary AL amyloidosis. Unusual clinical manifestations during the course of the disease led to a post-mortem diagnosis. The mechanisms for pulmonary and other ectopic soft tissue bone scan tracer depositions, as well as their significance in the diagnosis of amyloidosis, are discussed.