Sudden death: ectopic pregnancy mortality

OBJECTIVE: To describe the trends in ectopic pregnancy mortality in Michigan from 1985 through 1999 and compare to those of previous time periods. METHODS: We reviewed all cases of maternal mortality from ectopic pregnancy in Michigan from 1985 through 1999. We extracted data from death certificates, hospital inpatient and emergency department records, medical examiner autopsy reports, and reviews by the Michigan Maternal Mortality Study. The Health Data Development Section of the Michigan Department of Community Health provided data on live births and maternal deaths RESULTS: Of the 268 pregnancy-related deaths, 16 (6%) were caused by complications of ectopic pregnancy. Mean age at death was 27 (+/- 6) years. Thirteen deaths were to African-American women and 3 were to white women (P < .01). African-American women had an ectopic mortality ratio 18 times higher than white women (3.25/100,000 live births, compared with 0.18/100,000) Three cases of pregnancy-related death due to complications of ectopic pregnancy were considered preventable, and 2 others were of unknown preventability. CONCLUSION: Ectopic pregnancy treatment has changed in the last 20 years coincident with a decrease in maternal mortality from ectopic pregnancy. Sudden death was the presenting scenario in 75% of nonpreventable ectopic deaths, an increase from previous analyses. A large racial disparity is apparent. Ideally, pregnancy care should start as soon as possible after the first missed menses; however, systemwide changes are needed to create a new norm promoting early access to pregnancy care and promoting education and testing to rule out pregnancy abnormalities. LEVEL OF EVIDENCE: II-2     

The hospital organization of the future

The future of hospital Nuclear Medicine is triggered by the hospital organisation itself. In general, the hospital organisation of the present requires substantial changes in order to be competitive, economical, and abreast of the rapid progresses in medical developments and patient management. It also must be flexible to changes in health politics. In this special report an organisational hospital structure is outlined which may help encounter the challenging hospital future. Some hospitals have already implemented convincing changes, whereas others are far behind.     

Apoptosis-detecting radioligands: current state of the art and future perspectives

This review provides a critical and thorough overview of the radiopharmaceutical development and in vivo evaluation of all apoptosis-detecting radioligands that have emerged so far, along with their possible applications in nuclear medicine. The following SPECT and PET radioligands are discussed: all forms of halogenated Annexin V (i.e. (123)I-labelled, (124)I-labelled, (125)I-labelled, (18)F-labelled), (99m)Tc/(94m)Tc-labelled Annexin V derivatives using different chelators and co-ligands (i.e. BTAP, Hynic, iminothiolane, MAG(3), EDDA, EC, tricarbonyl, SDH) or direct (99m)Tc-labelling, (99m)Tc-labelled Annexin V mutants and (99m)Tc/(18)F-radiopeptide constructs (i.e. AFIM molecules), (111)In-DTPA-PEG-Annexin V, (11)C-Annexin V and (64)Cu-, (67)Ga- and (68)Ga-DOTA-Annexin V. In addition, the potential role and clinical relevance of anti-PS monoclonal antibodies and other alternative apoptosis markers are reviewed, including: anti-Annexin V monoclonal antibodies, radiolabelled caspase inhibitors and substrates and mitochondrial membrane permeability targeting radioligands. Nevertheless, major emphasis is placed on the group of Annexin V-based radioligands, in particular (99m)Tc-Hynic-Annexin V, since this molecule is by far the most extensively investigated and best-characterised apoptosis marker at present. Furthermore, the newly emerging imaging modalities for in vivo detection of programmed cell death, such as MRI, MRS, optical, bioluminescent and ultrasound imaging, are briefly described. Finally, some future perspectives are presented with the aim of promoting the development of potential new strategies in pursuit of the ideal cell death-detecting radioligand.     

Accuracy of commercially available processing algorithms for planar radionuclide ventriculography using data for a dynamic left ventricular phantom

BACKGROUND: Automatic and semi-automatic algorithms to calculate ejection fraction (EF) from planar radionuclide ventriculography (PRV) have been used for many years in nuclear medicine. Validation of these algorithms is scarce and often performed on outdated versions of the software. Nevertheless, clinical trials where PRV is being used as the 'gold standard' for EF are numerous. Because of the importance attributed to the EF calculated by these programs, the accuracy of the resulting EF was assessed with a dynamic left ventricular physical phantom. METHODS: A dynamic left ventricular phantom was used to simulate 21 combinations of various ejection fractions (7-66%) and end diastolic volumes (27-290 ml). For each combination, a planar radionuclide ventriculograph was acquired, converted to an interfile format and transferred into processing stations with 10 different contemporaneously available commercial algorithms. The gold standard was the 'real' EF of the phantom, derived from the exact volume of the ventricle in end diastolic and end systolic position. Correlation and Bland-Altman analysis was performed between the real EF and the calculated EF. RESULTS: The correlation for all data was excellent (r=0.98), the mean difference was very acceptable (0.98%). Nevertheless, Bland-Altman analysis showed a significant trend in the difference between real and calculated EF, with a growing underestimation for higher ranges of EF, due to an overestimation of background in larger volumes compared to smaller ones. CONCLUSION: The determination of EF from PRV, calculated with commercially available algorithms, correlates closely to the real EF of a dynamic left ventricular phantom. This phantom can be used in the development and validation of algorithms for PRV studies, in software audits and in quality assurance procedures.     

99mTc depreotide scan compared with 99mTc-MDP bone scintigraphy for the detection of bone metastases and prediction of response to hormonal treatment in patients with breast cancer

BACKGROUND: The purpose of this study was to determine the potential role of Tc depreotide scintigraphy for the evaluation of bone metastases compared with Tc methylenediphosphonate (MDP) bone scintigraphy and for the prediction of treatment response in breast cancer patients in whom first- or second-line hormonal therapy was to be initiated. METHODS: Twelve patients with a diagnosis of advanced breast cancer were included. All patients underwent both a bone scan and a depreotide scan and at least one other conventional imaging procedure, including plain film radiography (n=11), computed tomography (n=6) or magnetic resonance imaging (n=5), for confirmation of metastatic disease. The mean time interval between the bone scan and the depreotide scan was 30.6 days. Follow-up data were retrieved from routine clinical evaluation by means of physical examination, imaging and blood analysis. RESULTS: On a patient basis we found a sensitivity, specificity and accuracy of, respectively 100%, 50% and 83.3% for the bone scan and 62.5%, 100% and 75% for the depreotide scan in the diagnosis of bone metastasis. In eight patients with available follow-up data two with a positive depreotide scan remained stable and five of six patients with a negative depreotide scan had progressive disease. CONCLUSION: In this small series of breast cancer patients Tc depreotide scintigraphy proves less sensitive but more specific as compared to Tc-MDP bone scintigraphy in measuring the extent of bone metastasis. On the other hand Tc depreotide scintigraphy elucidates, non-invasively, tumour characteristics and may be indicative for prognosis and response to hormonal treatment.     

99mTc ciprofloxacin imaging for the diagnosis of infection in the postoperative spine

BACKGROUND: The non-invasive assessment of postoperative spinal infections can pose a substantial diagnostic challenge, especially in the presence of orthopaedic devices. In contrast to white blood cell scanning, which is of limited use in the spine, the low uptake of 99mTc ciprofloxacin into normal bone marrow, combined with its claimed bacterial specificity, makes it, theoretically, an ideal candidate for evaluating postoperative spinal infections. AIM: This study aimed to evaluate 99mTc ciprofloxacin planar and single photon emission tomography (SPET) imaging in relation to microbiological diagnosis in the postoperative spine. METHODS: Only patients with a microbiologically confirmed diagnosis were included in this analysis. Planar imaging was performed at 1, 3 and 24 h, and SPET was performed at 3 h post-injection of 370 MBq 99mTc ciprofloxacin. Images were scored by two independent, certified, nuclear medicine physicians, blinded for the final diagnosis. RESULTS: Within the first 22 consecutive patients with microbiological diagnosis, there were nine deep infections. Sensitivity, specificity and accuracy at visual scoring were, respectively, 67%, 77%, 73% (1 h), 78%, 69%, 73% (3 h), and 56%, 92%, 77% (24 h) for planar imaging, and 100%, 54%, and 73% for SPET. CONCLUSION: In contrast to white blood cell scanning, SPET with Tc ciprofloxacin is sensitive in evaluating infections in the postoperative spine. Sensitivity is higher for SPET than for planar imaging. However, the results presented prove that its specificity is limited, especially in patients who have recently (< 6 months) undergone surgery. Taken this limitation into account, we advise planar and SPET imaging at 3 h post-injection and at an interval of at least 6 months after surgery to minimize the chance for false positives.     

Lesional expression of RhoA and RhoB following traumatic brain injury in humans

Inhibition of the small GTPase Rho or of its downstream target Rho-associated kinase (ROCK) has been shown to promote axon regeneration and to improve functional recovery following traumatic CNS lesions in the adult rat. In order to determine the expression pattern of RhoA and RhoB following human traumatic brain injury (TBI) and to assess whether Rho is a possible target for pharmacological intervention in humans, we investigated expression patterns of RhoA and RhoB in brain specimens from 25 patients who died after closed TBI in comparison to brain tissue derived from four neuropathologically unaffected control patients by immunohistochemistry. A highly significant lesional upregulation of both RhoA and RhoB was observed beginning several hours after the traumatic event and continuing for months after TBI. The cellular sources of both molecules included polymorphonuclear granulocytes, monocytes/macrophages, and reactive astrocytes. Additionally, expression of RhoA was also detected in neuronal cells in some of the cases. From our data, we conclude that inhibition of Rho is a promising mechanism for the development of new pharmacological interventions in human TBI. As the observed upregulation of RhoA and RhoB was still detectable months after TBI, we speculate that even delayed treatment with Rho inhibitors might be a therapeutic option.