Hepatic artery aneurysm presenting with hemobilia in a patient with Behçet's disease: treatment with percutaneous transcatheteral embolization

We herein report a case of hemobilia caused by a hepatic artery aneurysm. A 40-year-old male patient with a history of Beh?et's disease with a thrombus hanging out of the papilla of Vater had a large hepatic aneurysm in angiography. The hepatic artery feeding the aneurysm was embolized. Endovascular treatment can treat patients with hepatic artery aneurysms caused by Beh?et's disease.     

Multislice CT with single–phase technique in patients with suspected pancreatic cancer

PURPOSE: The purpose of this study was to evaluate the role of multislice computed tomography (MSCT) with a single-phase technique in patients with suspected pancreatic cancer (PC). MATERIALS AND METHODS: Seventy-eight patients underwent MSCT with the following technical parameters: collimation: 4x1 mm; pitch 1; 120 kVp; 260 mAs. The pre-contrast scan was followed by a single acquisition phase in the caudocranial direction from the inferior hepatic margin to the diaphragm with a 60-s delay after IV administration of 150 ml of iodinated contrast material at a rate of 3 ml/s. Two radiologists assessed the single images independently. Receiver operating characteristics (ROC) curves were obtained for each of the two observers. RESULTS: The final diagnosis was pancreatic cancer in 46 cases and chronic pancreatitis in 32 cases. Areas under the curve (AZ) for diagnosis and evaluation of disease resectability were 0.97 and 0.93 for the first observer (p=ns), and 0.97 and 0.90 for the second observer (p=ns). The mean difference in tissue attenuation values between the cancer and normal pancreas was 72 +/- 3 Hounsfield units (HU). No statistically significant differences were observed in the degree of opacification between the peripancreatic arteries and veins. CONCLUSIONS: MSCT with a single-phase technique is an accurate and reproducible method for diagnosis and evaluation of disease resectability in patients with suspected PC, ensuring optimal tumour-to-pancreas contrast and maximal opacification of the main peripancreatic arterial and venous structures.     

Gait asymmetries in children with cerebral palsy: do they deteriorate with running?

In children with cerebral palsy (CP) analysis of gait asymmetry can provide insight into the control of walking and may help in guiding the clinician's treatment decisions. Running is more difficult that walking for the musculoskeletal system, however, in the literature it has been shown that gait deviations associated with CP maybe better tolerated during running. This leads us to the hypothesis that running might increase gait symmetry in patients with CP. Therefore the purpose of this study was to investigate the effect of running on asymmetries in spatio-temporal, kinematic and kinetic gait parameters for children with CP. Twenty-four children with diplegia and 25 with hemiplegia were examined using 3D gait analysis during running and walking. MANOVA on two factors: diagnosis (hemiplegic, diplegic) and movement (walking, running) was conducted on a total of 22 gait parameters. The MANOVA revealed a significant difference in symmetry between walking and running (p<0.001) and between patients groups (p=0.004). The detailed analysis of gait parameters demonstrated a significant decrease of symmetry in 13 of the 22 gait parameters investigated, only symmetry of step time was significantly increased. Therefore the hypothesis that gait symmetry improved with running in children with CP can be rejected. Based on the results of this study, asymmetries masked during walking might appear during running. Therefore, analysis of asymmetry of walking and running gives a more comprehensive assessment of the gait pathology for clinical decision making.     

PCI compared with medical therapy in elderly patients with chronic symptomatic coronary artery disease

PCI compared with medical therapy in elderly patients with chronic symptomatic coronary artery disease!050000$河北医科大学第二医院@刘晓堃 !050000$河北医科大学第二医院@傅向华 !050000$河北医科大学第二医院@马宁     

Concurrent radiotherapy with temozolomide vs. concurrent radiotherapy with a cisplatinum-based polychemotherapy regimen

Purpose

As the efficacy of all pediatric high-grade glioma (HGG) treatments is similar and still disappointing, it is essential to also investigate the toxicity of available treatments.

Methods

Prospectively recorded hematologic and nonhematologic toxicities of children treated with radiochemotherapy in the HIT GBM-C/D and HIT-HGG-2007 trials were compared. Children aged 3–18 years with histologically proven HGG (WHO grade III and IV tumors) or unequivocal radiologic diagnosis of diffuse intrinsic pontine glioma (DIPG) were included in these trials. The HIT-HGG-2007 protocol comprised concomitant radiochemotherapy with temozolomide, while cisplatinum/etoposide (PE) and PE plus ifosfamide (PEI) in combination with weekly vincristine injections were applied during radiochemotherapy in the HIT GBM-C/D protocol.

Results

Regular blood counts and information about cellular nadirs were available from 304 patients (leukocytes) and 306 patients (thrombocytes), respectively. Grade 3–4 leukopenia was much more frequent in the HIT GBM-C/D cohort (n = 88, 52%) vs. HIT-HGG-2007 (n = 13, 10%; P <0.001). Grade 3–4 thrombopenia was also more likely in the HIT GBM-C/D cohort (n = 21, 12% vs. n = 3,2%; P <0.001). Grade 3–4 leukopenia appeared more often in children aged 3–7 years (n = 38/85, 45%) than in children aged 8–12 years (n = 39/120, 33%) and 13–18 years (24/100, 24%; P =0.034). In addition, sickness was more frequent in the HIT GBM-C/D cohort (grade 1–2: 44%, grade 3–4: 6% vs. grade 1–2: 28%, grade 3–4: 1%; P <0.001).

Conclusion

Radiochemotherapy involving cisplatinum-based polychemotherapy is more toxic than radiotherapy in combination with temozolomide. Without evidence of differences in therapeutic efficacy, the treatment with lower toxicity, i.?e., radiotherapy with temozolomide should be used.

     

Usefulness of whole PTH assay in patients with renal osteodystrophy —Correlation with bone scintigraphy

OBJECTIVE: Intact parathyroid hormone (PTH) assay has recently been reported to be effective in evaluating both 1-84 PTH (whole PTH) and inactive 7-84 PTH. Inactive 7-84 PTH is considered to be increased in hemodialysis patients and to prevent the effects of 1-84 PTH, and intact PTH is considered to overestimate the PTH activity in these patients. As such, a whole PTH assay has recently been developed. The purpose of this study was to examine the usefulness of a whole PTH assay using the bone to soft tissue (B/ST) ratio on bone scintigraphy. METHOD: Twenty-five hemodialysis patients were included in our study. In all patients, bone scintigraphy and a blood test [whole PTH, intact PTH, alkaline phosphatase (ALP), calcium (Ca), and phosphorus (P)] were performed. Regions of interest (ROIs) were drawn around the cranium, lumbar vertebrae, left femoral neck, and soft tissue of the medial left thigh to obtain the B/ST ratio. RESULTS: The B/ST ratio of the cranium and left femoral neck correlated with whole PTH and intact PTH. In particular, the B/ST ratio of the cranium correlated most significantly with the value of whole PTH. Whole PTH levels correlated with intact PTH levels (r = 0.891, p < 0.0001). CONCLUSION: Our data indicate that a whole PTH assay may be useful in evaluating PTH activity using the B/ST ratio. The B/ST ratio of the cranium may reflect the bone metabolism of hemodialysis patients.     

Diagnostic validity of dynamic salivary gland scintigraphy with ascorbic acid stimulation in patients with Sjögren's syndrome: comparation with unstimulated whole sialometry

BACKGROUND/AIM: Beside many actual groups of classification criteria, uniform classification criteria for Sj?gren's syndrome (SS) are still missing. The ophtalmic component of SS is well defined. Criteria for classifying its oral component remain controversial. The fifth item of the European Union and the United States of America (EU-US) revised diagnostic classification criteria in 2002, is an objective evidence of xerostomia, diagnosed by one of the tests: unstimulated whole sialometry (UWS), parotid sialography, and dynamic salivary gland scintigraphy (DSGS). The aim of this study was to evaluate senstitivity, specificity, positive and negative predictive value and accuracy of DSGS with ascorbic acid stimulation in detecting xerostomia in SS patients and to compare DSGS findings with UWS values. METHODS: Tests DSGS and UWS were done in 20 patients with SS and in 10 of the control subjects. The findings of DSGS were graded from 1 to 4 scintigraphie (SCT) grade 1--normal finding; SCT grade 2--moderate function damage; SCT grade 3--serious function damage, SCT grade 4--very serious function damage. UWS measured 1.5 hour after the breakfast lasted 15 minutes. UWS bellow 2.5 ml/15min min. considered pathological. RESULTS: All SS patients had pathological SCT findings. Comparing SCT grade between the patients and the control group, high statistical significance was found (p < 0.001). The estimated sensitivity of DSGS was 100%, specificity 80%, positive predictive value 91%, negative predictive value 100% and accuracy 93%. The calculated sensitivity of UWS was 75%. Salivary function damage detected by scintigraphy was in positive correlation with UWS findings. CONCLUSION: DSGS is a diagnostic test with high sensitivity, specificity, accuracy and positive and negative predictive values in detecting salivary function damage in SS patients. DSGS and UWS are very sensitive diagnostic tests for objective evidence of xerostomia, and have to be ones of the earliest investigations which shoud be performed in subjects suspected of SS. Test DSGS is more sensitive, and seems to better reflect symptoms of dry mouth than UWS.     

What's wrong with this picture?

According to Mr. Hage, when the government tries to measure economic output, "the 1930's mentality sticks like bubble gum to the sole of a shoe." He is alarmed that the current debate about healthcare reform is based on economic data derived from antiquated methods of analysis and that we are "rocketing into the 21st century with our eyes firmly fixed on the rear-view mirror."     

Dynamic MR urography in children with uropathic disease with a combined 2D and 3D acquisition protocol—comparison with MAG3 scintigraphy

Objective:

The aim of this study was to evaluate combined two-dimensional (2D) and three-dimensional (3D) dynamic MR urography with respiratory compensation in children with anomalies of the genitourinary tract, allowing for computation of split renal function and assessment of urinary tract obstruction.

Methods:

Dynamic MR urography was performed in 53 children (3 months–16 years of age) with anomalies of the urinary tract. A protocol for dynamic MR urography and nephrography was implemented at 1.5 T using a navigator-triggered 2D TurboFLASH sequence. Split renal function and contrast-medium excretion were assessed after the bolus injection of 0.05 mmol kg⁻¹ body weight of gadolinium dimeglumine. In the excretory phase, a 3D gradient-echo data set with high spatial resolution was acquired. In all patients, mercaptoacetyltriglycine (MAG3) scintigraphy was obtained as a reference standard.

Results:

In all children, dynamic MR nephrography and urography could be performed with excellent compensation of breathing artefacts providing region of interest analysis in nearly identical kidney positions. The assessment of contrast-medium excretion into the ureter allowed for discrimination of functional from non-functional stenosis. Split renal function assessed by MRI showed an excellent agreement with the MAG3 reference standard with a correlation coefficient r = 0.95. Additionally recorded 3D data sets offered good depiction of anatomical anomalies in all patients.

Conclusion:

The proposed protocol provides a robust technique for assessment of ureteral obstruction and split renal function with compensation of breathing artefacts, short post-processing time and excellent 3D spatial resolution.

Advances in knowledge:

The combined protocol of 2D and 3D MR urography is an efficient technique for assessment of renal morphology and function.Obstructive uropathy is a congenital disease caused by faulty embryological development of the kidneys and ureters.^1,2 Patients show a dilatation of the renal pelvis combined with stenosis of the ureteropelvic junction, the ureterovesical junction or the subvesical urinary tract. This disease pattern is often referred to as CAKUT (“congenital anomalies of the kidney and the urinary tract”). In the majority of cases, histological alterations of the ipsilateral renal parenchyma as well as reduced renal function can be found, which are based on malformation of the renal parenchyma during embryonic development, and further aggravated dependent on the degree of obstruction. Owing to the varying contribution of these two effects, it is difficult to anticipate the individual future development regarding kidney function. It is often challenging to decide which patient may benefit from surgical treatment.In this context, dilatation of the renal collecting system and the ureter is not necessarily paralleled by persistent renal obstruction. Dysplastic embryological development or vesicoureteral reflux can be a cause for widening of the renal collecting system or the ureter as well. Approximately 1 out of 500 children is affected by CAKUT. Stenosis of the ureteropelvic junction is the most common cause of a dilation of the renal pelvis in newborns; less frequently, the stenosis is located at the ureterovesical junction.In past years, MR urography (MRU) has emerged as a powerful modality for the assessment of paediatric obstructive nephropathy offering highly resolved morphological as well as functional information of the kidneys and the urinary tract. Advantages of MRI over CT are, amongst others, the intrinsically high soft-tissue contrast, the multiplanar imaging capabilities and the complete lack of radiation exposure. Moreover, dynamic MR urography^3–7 offers the possibility to assess urinary transport as well as the computation of split renal function, similar to established techniques applying radionuclide scintigraphy.The currently published studies applied conventional gradient-echo sequences with two-dimensional (2D) or three-dimensional (3D) phase-encoding schemes and standard or reduced dosage of gadolinium-based contrast media.^3–7 One disadvantage of these conventional gradient-echo sequences regarding applications in young children is, however, the relatively long acquisition time of approximately 5–15 s resulting in breathing artefacts. In this study, we evaluate a protocol applying a single-shot TurboFLASH sequence with an acquisition time of only 0.5 s, which can be combined with a navigator-triggering technique providing images at virtually identical diaphragm positions.The aim of our study was to evaluate combined 2D and 3D dynamic MR urography with respiratory compensation in children with anomalies of the genitourinary tract, allowing for computation of split renal function and assessment of urinary tract obstruction in comparison with a MAG3 reference standard, to demonstrate that the proposed protocol provides functional information comparable with mercaptoacetyltriglycine (MAG3) scintigraphy with additional anatomical 3D information, and to report our experiences in 53 included patients.     

SPECT study with I-123-Ioflupane (DaTSCAN) in patients with essential tremor. Is there any correlation with Parkinson’s disease?

Objectives

The differential diagnosis between essential tremor (ET) and Parkinson??s disease (PD) may be, in some cases, very difficult on clinical grounds alone. In addition, it is accepted that a small percentage of ET patients presenting symptoms and signs of possible PD may progress finally to a typical pattern of parkinsonism. Ioflupane, N-u-fluoropropyl-2a-carbomethoxy-3a-(4-iodophenyl) nortropane, also called FP-CIT, labelled with ¹²³I (commercially known as DaTSCAN) has been proven to be useful in the differential diagnosis between PD and ET and to confirm dopaminergic degeneration in patients with parkinsonism. The aim of this study is to identify dopaminergic degeneration in patients with PD and distinguish them from others with ET using semi-quantitative SPECT ¹²³I-Ioflupane (DaTSCAN) data in comparison with normal volunteers (NV), in addition with the respective ones of patients referred as suffering from ET, as well as, of patients with a PD diagnosis at an initial stage with a unilateral presentation of motor signs.

Methods

Twenty-eight patients suffering from ET (10 males plus 18 females) and 28 NV (12 males and 16 females) were enroled in this study. In addition, 33 patients (11 males and 22 females) with an established diagnosis of PD with unilateral limb involvement (12 left hemi-body and 21 right hemi-body) were included for comparison with ET. We used DaTSCAN to obtain SPECT images and measure the radiopharmaceutical uptake in the striatum (S), as well as the caudate nucleus (CN) and putamen (P) in all individuals.

Results

Qualitative (Visual) interpretation of the SPECT data did not find any difference in the uptake of the radiopharmaceutical at the level of the S, CN and P between NV and ET patients. Reduced accumulation of the radiopharmaceutical uptake was found in the P of all PD patients. Semiquantitative analysis revealed significant differences between NV and ET patients in the striatum, reduced in the latter. There was also a significant reduction in the tracer accumulation in the left putamen of patients with right hemi-parkinsonism compared to ET and NV. Patients with left hemi-parkinsonism, demonstrated reduced radioligand uptake in the right putamen in comparison with ET and NV. Clinical follow-up of 20 patients with ET at (so many months afterwards) revealed no significant change in clinical presentation, particularly no signs of PD. Follow-up DaTSCAN performed in 10 of them (so many months afterwards) was negative in all but one. This one had an equivocal baseline study which deteriorated 12?months later.

Conclusions

Our results do not support the hypothesis of a link between essential tremor and Parkinson??s disease. However, it appears that ET patients have a small degree of striatal dopaminergic degeneration. If this is due to alterations in the nigrostriatl pathway or of other origin it is not clear. Follow-up studies of essential tremor patients are warranted to assess progression of disease and to understand better the possible cause for striatal dopaminergic degeneration.     

Gallium-67 scintigraphic findings in a patient with breast lymphoma complicated with Sjögren syndrome

We report here a patient with mucosa associated lymphoid tissue (MALT)-lymphoma of the breast complicated with Sjögren syndrome. It is speculated that Ga-67 could accumulate not only in lymphoma lesions but also in benign lymphoproliferative locations of Sjögren syndrome. Gallium-67 scintigraphy might be useful for the diagnosis and therapeutic monitoring of MALT-lymphoma complicated with Sjögren syndrome.     

Do electrocardiographic changes with adenosine myocardial perfusion imaging predict ischaemia in patients with left ventricular hypertrophy?

BACKGROUND: Electrocardiographic (ECG) changes during adenosine myocardial perfusion imaging (MPI) correlate with severe coronary artery disease and the presence of collaterals. However, the significance of these changes during adenosine MPI in patients with left ventricular hypertrophy (LVH) on baseline electrocardiogram is less well understood. OBJECTIVE: To evaluate whether ECG changes on adenosine MPI predict ischaemia in patients with LVH. METHODS: We reviewed retrospectively 454 consecutive patients who had undergone adenosine MPI at our institution. The baseline electrocardiogram was reviewed to determine whether or not LVH was present. All patients were administered adenosine at 140 microg x kg x min for a total of 6 min and Tc-sestamibi was injected at 3 min into the protocol. None of the patients underwent any form of exercise during the stress test. RESULTS: Of the 146 patients with LVH, 10 had stress ECG changes suggestive of ischaemia and 40 had evidence of ischaemia on MPI. Similarly, of the 308 patients without LVH, 43 had stress ECG changes suggestive of ischaemia and 68 had ischaemia on MPI. The sensitivity and specificity of stress ECG changes in predicting ischaemia on perfusion in patients with LVH were 12.5% and 95.3%, respectively, with a positive predictive value of 50% and a negative predictive value of 74.3%. CONCLUSION: ECG changes suggestive of ischaemia in patients with LVH are very specific for ischaemia on MPI, and their significance is similar to that in patients without LVH.     

Is abnormal iodine-123-MIBG kinetics associated with left ventricular dysfunction in patients with diabetes mellitus?

BACKGROUND: Although autonomic neuropathy is frequently recognized in patients with diabetes mellitus, it is uncertain whether cardiac sympathetic neuropathy may play a role in the development of diabetic cardiomyopathy. METHODS AND RESULTS: In 10 control subjects and 61 patients with diabetes mellitus who did not have coronary artery disease, cardiac sympathetic function and left ventricular ejection fraction (LVEF) were evaluated by using iodine-123-metaiodobenzylguanidine (MIBG) imaging and echocardiography, respectively. Dynamic acquisitions and planar images obtained 15 and 150 minutes after injection were used as a means of measuring early and late myocardial uptake and clearance rates of MIBG from the heart. Eight patients with an LVEF less than 50% demonstrated a lower late myocardial MIBG uptake (0.0043% +/- 0.0017% vs. 0.0024% +/- 0.0009%/pixel, P = .002) and a higher clearance rate (22.9% +/- 17.7% vs. 49.3% +/- 12.2%, P<.0001) than the 53 patients with an LVEF of 50% or greater, although the age, sex, type of diabetes mellitus, and frequency of neuropathy, retinopathy, and nephropathy were not significantly different between the 2 subgroups. The LVEF correlated weakly but significantly with early and late myocardial uptake and clearance rate (r = 0.277, P = .03; r = 0.421, P = .001; r = 0.382, P = .002; respectively) in patients with diabetes mellitus. CONCLUSION: Marked MIBG abnormalities are associated with left ventricular dysfunction in patients with diabetes mellitus. However, long-term follow-up of patients with diabetes mellitus who have marked MIBG abnormalities and normal LVEF will be required to determine whether these patients would demonstrate systolic dysfunction earlier than patients without an MIBG abnormality.     

Can patients with McArdle's disease run?

Patients with McArdle's disease commonly adopt a sedentary lifestyle. This sedentary behaviour, however, usually worsens the limited exercise capacity of these patients. Although eccentric muscle work can be associated with rhabdomyolysis, supervised eccentric training with gradually increasing loads has important advantages compared with conventional concentric work, particularly for patients with a poor cardiorespiratory system. We report the beneficial effects (particularly, increased VO(2peak) (from 14.6 to 30.8 ml/kg/min) and increased gross muscle efficiency (from 13.8% to 17.2%)) induced by a supervised aerobic training programme of 7 months duration including 3-4 running sessions (< or =60 min/session) per week in a 38-year-old patient. These preliminary data suggest the potential therapeutic value of this type of exercise in these patients.