<Superscript>99m</Superscript>Tc-HYNIC octreotide in neuroblastoma

Disease status assessment of neuroblastoma patients requires computed tomography (or magnetic resonance imaging), bone scan, metaiodobenzylguanidine (MIBG) scan, bone marrow tests, and urine catecholamine measurements. There is no clinical experience concerning the evaluation of these patients by means of technetium-99m (^99mTc)-somatostatin analog scintigraphy. Furthermore, these radiopharmaceuticals are promising imaging agents owing to their lower cost, availability, dosimetry, and ease of preparation. An 8-year-old boy already diagnosed with stage-IV neuroblastoma received chemotherapy. In the follow-up, after obtaining the parents’ informed consent, iodin 131 (¹³¹I)-MIBG and ^99mTc-6-hydrazinopyridine-3-carboxylic acid (HYNIC)-octreotide scans were done on separate days to evaluate tumor extension. Even as the ¹³¹I-IBG scan showed mild diffuse uptake in the projection of both lung hili, the ^99mTc-HYNIC-octreotide scan showed multiple axial and appendicular bone uptakes and paravertebral, abdominal, mediastinal, and supraclavicular ganglionar uptakes. The ^99mTc-HYNIC-octreotide showed much more lesion extension than the ¹³¹I-MIBG. Therefore, ^99mTc-HYNIC-octreotide may be a promising radiopharmaceutical for the evaluation of neuroblastoma patients. This finding justifies the pre liminary evaluation of this tracer in the context of a clinical trial.     

Arterio-Ureteric Fistula Following Iliac Angioplasty

Arterio-ureteric fistulae are rare but can be associated with significant morbidity and mortality. We describe a novel case in which an arterio-ureteric fistula occurred as a complication following external iliac artery angioplasty and stenting, in a patient who had undergone previous pelvic surgery, radiotherapy, ureteric stenting, and urinary diversion surgery. Prompt recognition enabled successful endovascular management using a covered stent.     

Incremental prognostic value of <Superscript>99m</Superscript>Tc-tetrofosmin myocardial SPECT after percutaneous coronary intervention

Objective  Percutaneous transluminal coronary angioplasty is a well-established therapeutic method in selected patients with coronary artery disease. The aim of this study was to assess the incremental prognostic value of technetium-99m (^99mTc)-tetrofosmin myocardial gated-single- photon emission computed tomography (SPECT) in asymptomatic patients after coronary artery stenting. Methods  A total of 246 consecutive patients (aged 55.5 ± 8.2 years, 182 men) participated in the study with a median follow-up of 9.5 years (interquartile ra 5.8–10.5 years). All patients underwent exercise gated-SPECT myocardial imaging within 5–7 months. Myocardial scintigrams were performed using 99mTctetrofosmin, and were evaluated calculating the summed stress score (SSS), summed rest score (SRS), and summed difference score (SDS) indexes. Cardiovascular death and non-fatal myocardial infarction were considered as hard cardiac events, and late revascularization (>3 months after myocardial SPECT) procedures as soft events. Receiver-operating characteristic (ROC) analysis was used to test the prognostic ability of SSS and SDS for cardiac events. Cox proportional hazards models were used to evaluate the incremental value of SPECT variables. Results  Cardiac death occurred in 12 (4.9%) patients and non-fatal myocardial infarction in 20 (8.1%) patients. In addition, 60 (24.4%) patients underwent a late revascularization procedure. Using ROC analysis the optimal cut-offs of SSS (AUC = 0.94; 95% CI 0.92–0.97) and SDS (AUC = 0. 76; 95% CI 0.70–0.82) for the prediction of cardiac events were 10 and 1.7, respectively. Multiple Cox regression analyses revealed that SSS > 10 (HR = 24.2; 95% CI 7.44–78.79) and SDS > 1.7 (HR = 2.72; 95% CI 1.23–6.00) provided incremental prognostic value over clinical and exercise test data for the composite end points of any cardiac event. Conclusions   ^99mTc-tetrofosmin myocardial gated- SPECT, performed 6 months post-percutaneous coronary intervention (PCI), provides incremental prognostic information for the prediction of cardiac events in asymptomatic patients after PCI.     

CT-guided percutaneous laser photocoagulation of osteoid osteomas of the hands and feet

Percutaneous local ablation of osteoid osteoma has largely replaced surgery, except in the small bones of the hands and feet. The objective of this study was to describe the technical specificities and results of computed tomography (CT)-guided percutaneous laser photocoagulation in 15 patients with osteoid osteomas of the hands and feet. We retrospectively examined the medical charts of the 15 patients who were treated with CT-guided percutaneous laser photocoagulation therapy at our institution between 1994 and 2004. The 15 patients had a mean age of 24.33 years. None of them had received any prior surgical or percutaneous treatment for the osteoid osteoma. The follow-up period was 24 to 96 months (mean, 49.93). The pain resolved completely within 1 week. Fourteen patients remained symptom-free throughout the follow-up period; the remaining patient experienced a recurrence of pain after 24 months, underwent a second laser photocoagulation procedure, and was symptom-free at last follow-up 45 months later. No adverse events related to the procedure or to the location of the tumor in the hand or the foot were recorded. CT-guided percutaneous laser photocoagulation is an alternative to surgery for the treatment of osteoid osteomas of the hands and feet.     

Occult acetabulum fracture. A case report

Acetabular fractures that are radiographically occult are associated with insufficiency fractures, stress fractures, and fractures secondary to steroid-induced osteoporosis, usually affecting older patients after low-energy trauma. Occult acetabulum fractures in young patients are extremely rare. We discuss herein a case of an occult acetabulum fracture after high-energy trauma, in a young patient. This case illustrates the need for further diagnostic studies such as computed tomography, magnetic resonance imaging, or bone scanning when, despite negative radiographic findings, groin pain is persistent.     

Initial clinical results for breath-hold CT-based processing of respiratory-gated PET acquisitions

Purpose  Respiratory motion causes uptake in positron emission tomography (PET) images of chest structures to spread out and misregister with the CT images. This misregistration can alter the attenuation correction and thus the quantisation of PET images. In this paper, we present the first clinical results for a respiratory-gated PET (RG-PET) processing method based on a single breath-hold CT (BH-CT) acquisition, which seeks to improve diagnostic accuracy via better PET-to-CT co-registration. We refer to this method as “CT-based” RG-PET processing. Methods  Thirteen lesions were studied. Patients underwent a standard clinical PET protocol and then the CT-based protocol, which consists of a 10-min List Mode RG-PET acquisition, followed by a shallow end-expiration BH-CT. The respective performances of the CT-based and clinical PET methods were evaluated by comparing the distances between the lesions’ centroids on PET and CT images. SUV_MAX and volume variations were also investigated. Results  The CT-based method showed significantly lower (p = 0.027) centroid distances (mean change relative to the clinical method = −49%; range = −100% to 0%). This led to higher SUV_MAX (mean change = +33%; range = −4% to 69%). Lesion volumes were significantly lower (p = 0.022) in CT-based PET volumes (mean change = −39%: range = −74% to −1%) compared with clinical ones. Conclusions  A CT-based RG-PET processing method can be implemented in clinical practice with a small increase in radiation exposure. It improves PET-CT co-registration of lung lesions and should lead to more accurate attenuation correction and thus SUV measurement.     

Best evidence in anesthetic practice

Question  

In postoperative non-ventilated patients, what is the efficacy and harm of pharmacological interventions in treating postoperative shivering?     

Innovative Power of Health Care Organisations Affects IT Adoption: A bi-National Health IT Benchmark Comparing Austria and Germany

Multinational health IT benchmarks foster cross-country learning and have been employed at various levels, e.g. OECD and Nordic countries. A bi-national benchmark study conducted in 2007 revealed a significantly higher adoption of health IT in Austria compared to Germany, two countries with comparable healthcare systems. We now investigated whether these differences still persisted. We further studied whether these differences were associated with hospital intrinsic factors, i.e. the innovative power of the organisation and hospital demographics. We thus performed a survey to measure the “perceived IT availability” and the “innovative power of the hospital” of 464 German and 70 Austrian hospitals. The survey was based on a questionnaire with 52 items and was given to the directors of nursing in 2013/2014. Our findings confirmed a significantly greater IT availability in Austria than in Germany. This was visible in the aggregated IT adoption composite score “IT function” as well as in the IT adoption for the individual functions “nursing documentation” (OR?=?5.98), “intensive care unit (ICU) documentation” (OR?=?2.49), “medication administration documentation” (OR?=?2.48), “electronic archive” (OR?=?2.27) and “medication” (OR?=?2.16). “Innovative power” was the strongest factor to explain the variance of the composite score “IT function”. It was effective in hospitals of both countries but significantly more effective in Austria than in Germany. “Hospital size” and “hospital system affiliation” were also significantly associated with the composite score “IT function”, but they did not differ between the countries. These findings can be partly associated with the national characteristics. Indicators point to a more favourable financial situation in Austrian hospitals; we thus argue that Austrian hospitals may possess a larger degree of financial freedom to be innovative and to act accordingly. This study is the first to empirically demonstrate the effect of “innovative power” in hospitals on health IT adoption in a bi-national health IT benchmark. We recommend directly including the financial situation into future regression models. On a political level, measures to stimulate the “innovative power” of hospitals should be considered to increase the digitalisation of healthcare.     

A Belief Rule Based Expert System to Assess Tuberculosis under Uncertainty

The primary diagnosis of Tuberculosis (TB) is usually carried out by looking at the various signs and symptoms of a patient. However, these signs and symptoms cannot be measured with 100 % certainty since they are associated with various types of uncertainties such as vagueness, imprecision, randomness, ignorance and incompleteness. Consequently, traditional primary diagnosis, based on these signs and symptoms, which is carried out by the physicians, cannot deliver reliable results. Therefore, this article presents the design, development and applications of a Belief Rule Based Expert System (BRBES) with the ability to handle various types of uncertainties to diagnose TB. The knowledge base of this system is constructed by taking experts’ suggestions and by analyzing historical data of TB patients. The experiments, carried out, by taking the data of 100 patients demonstrate that the BRBES’s generated results are more reliable than that of human expert as well as fuzzy rule based expert system.