Practical recommendations for radium-223 treatment of metastatic castration-resistant prostate cancer

Purpose

Radium Ra 223 dichloride (radium-223, Xofigo®) is the first targeted alpha therapy for patients with castration-resistant prostate cancer and symptomatic bone metastases. Radium-223 provides a new treatment option for this setting, but also necessitates a new treatment management approach. We provide straightforward and practical recommendations for European nuclear medicine centres to optimize radium-223 service provision.

Methods

An independent research consultancy agency observed radium-223 procedures and conducted interviews with all key staff members involved in radium-223 treatment delivery in 11 nuclear medicine centres across six countries (Germany, Italy, the Netherlands, Spain, Switzerland and the UK) experienced in administering radium-223. The findings were collated and discussed at a meeting of experts from these centres, during which key consensus recommendations were defined.

Results

The recommendations cover centre organization and preparation; patient referral; radium-223 ordering, preparation and disposal; radium-223 treatment delivery/administration; and patient experience. Guidance includes structured coordination and communication within centres and multidisciplinary teams, focusing on sharing best practice to provide high-quality, patient-centred care throughout the treatment pathway.

Conclusions

These expert recommendations are intended to complement existing management guidelines. Sharing best practice and experience will help nuclear medicine centres to optimize radium-223 service provision and improve patient care.

     

Intravenous immunoglobulin in the treatment of severe methotrexate-induced acral erythema

Chemotherapy-induced acral erythema is an uncommon and dramatic reaction to high-dose chemotherapy. It is characterized by painful erythema of both palms and soles with symmetrically well-defined borders, which may progress to bullae formation and desquamation. The bullous variant of this reaction has been reported with methotrexate and more frequently cytosine arabinoside. Rapid differential diagnosis and discrimination from more serious conditions such as graft versus host disease or toxic epidermal necrolysis is essential. In this case report, we present a 13-year-old boy who developed severe and prolonged chemotherapy-induced acral erythema after high-dose methotrexate treatment and successfully responded to intravenous immunoglobulin.     

Retinal nitric oxide and malonyldialdehyde levels following photodynamic therapy

Background:

To determine the retinal nitric oxide (NO) and malonyldialdehyde (MDA) levels following photodynamic therapy (PDT).

Materials and Methods:

Seven Dutch-belted rabbits received dextrose, while seven others received 2 mg/kg verteporfin infusion over a period of 15 minutes in a dim-lit room. Irradiation to a 1.5 mm diameter intact chorioretinal area in the right eye of verteporfin-infused rabbits, was started 5 minutes after the end of infusion. Three groups were control (dextrose infusion), infusion with verteporfin (left eyes were not irradiated), and irradiation after verteporfin injection (right eyes were irradiated). On the fifth day of the experiment, the eyes were enucleated. The retinas were subsequently frozen and homogenized. Nitrite, a stable end-product of NO and MDA, was measured using the spectrophotometer. Protein concentrations were measured by the Lowry method. Tissue NO and MDA levels were expressed as μmol/gprt and nmol/mgprt, respectively.

Results:

The mean retinal NO and MDA levels of the control, infusion, and irradiation groups were 24.67 ± 6.66, 0.11 ± 0.02; 45.90 ± 15.52, 0.21 ± 0.09; and 84.43 ± 14.96 μmol/gprt, 0.58 ± 0.14 nmol/mgprt, respectively. The mean retinal NO levels were significantly elevated in the infusion and irradiation groups compared with the control group (P:0.004; P:0.001). The mean retinal MDA levels were significantly elevated in the infusion and irradiation groups compared to the control one (P:0.026; P:0.001). Also the mean retinal NO and MDA levels in the irradiation group were found to be significantly higher than the infusion group (P:0.018; P:0.018).

Conclusion:

Not only PDT, but also verteporfin infusion alone resulted in NO and MDA level increments in the retina, which might be toxic.     

Linezolid-induced reversible bicytopenia in a 4-year-old boy with methicillin-resistant Staphylococcus aureus bacteremia

The authors report on a 4-year-old child with the diagnosis of tetralogy of Fallot (TOF) and infective endocarditis. Methicillin-resistant Staphylococcus aureus (MRSA) was isolated from the blood culture of the patient. While receiving imipenem, amikacin, and linezolid therapies, the boy's general condition improved, acute phase reactants decreased, and his blood culture became negative for MRSA. On his follow-up echocardiography, the vegetation had also disappeared. However, he developed progressive bicytopenia following linezolid therapy for 5 weeks. During linezolid therapy, his hemoglobin level decreased from 12.1 to 5.3 g/dL and his platelet count from 242 × 10⁹ to 14 × 10⁹/L. His white blood cell count (WBC) did not decrease during linezolid therapy. Six days following termination of linezolid therapy, his hemoglobin had increased to 8.2 g/dL and platelet count to 192 × 10⁹/L. Thus, it should be kept in mind that linezolid may induce cytopenias in children. If these side effects of linezolid are known, unnecessary laboratory investigations may be prevented and cessation of the drug may be sufficient for reversal of the cytopenias.     

Th1 polarization of the immune response in uveitis in Behçet's disease

BACKGROUND: It has been reported that abnormalities in the balance of T-helper cells type 1/2 (Th1/Th2) may account for the pathophysiology of human autoimmune diseases. The purpose of this study was to define the role of the Th1/Th2 balance in the pathogenesis of uveitis in Beh?et's disease (BD). METHODS: From February 2003 to August 2005, we studied 31 patients with active BD. Of these patients, 21 (12 female, 9 male; mean age 35.5 [SD 10] years) presented with acute uveitis, and 10 (7 female, 3 male; mean age 34 [SD 11] years) presented with inflammatory arthritis but no prior uveitis attack. The control group consisted of 10 (7 female, 3 male; mean age 34.7 [SD 8] years) age-matched, healthy individuals. CD4+ CD26+ and CD4+ CD30+ cell surface expression of the peripheral blood CD4+ T lymphocytes was evaluated by analytic flow cytometry in order to determine percentages of Th1 and Th2 lymphocyte subsets. RESULTS: The mean percentage of CD4+ CD26+ and CD4+ CD30+ cells was 26.27 (SD 6.18) % and 2.56 (SD 0.82) %, 17.42 (SD 5.90) % and 2.86 (SD 0.72) %, and 14.99 (SD 3.96) % and 3.11 (SD 1.25) % in BD with active uveitis, BD with inflammatory arthritis but no prior uveitis attack, and control groups, respectively. T-helper 1 (Th1) cell percentage was significantly higher in the BD with active uveitis group than the BD with arthritis and no prior uveitis attack group (p = 0.001). With respect to the percentage of CD30+ Th2 cells, there was no statistical difference between the 2 BD groups (p = 0.529) or among the 3 groups (p = 0.375). INTERPRETATION: Th1 lymphocyte dominance in peripheral circulating blood may play a role in the pathogenesis of BD uveitis.     

Periorbital necrobiosis lipoidica diabeticorum: case report

Necrobiosis lipoidica diabeticorum (NLD) is a relatively common manifestation of diabetes mellitus that is thought to be related to immune-complex vasculitis. The legs are the most common site for NLD, but other locations, such as the forearms or hands, have been reported. We describe a case of periorbital NLD that was diagnosed on the basis of histopathology.     

Osteotomy assisted maxillary posterior impaction with miniplate anchorage

This case report presents orthodontic treatment with miniplate anchorage accelerated by osteotomy-assisted maxillary posterior impaction in a severe open bite case. A 14-year-old girl with a severe anterior open bite was treated by intrusion of the maxillary posterior teeth. A segmental osteotomy was applied, and the miniplates were fixed to the zygomatic buttress area. The intrusive force was applied with nickel-titanium closed coil springs using a force of 250 g between the miniplates and the upper first and second molar buccal tubes. The intrusion was completed 2.5 months after osteotomy. The treatment was continued with the fixed orthodontic appliances and completed after 12 months. At the end of treatment, optimal occlusion and the correction of the anterior open bite were achieved. The maxillary molars were impacted 4.0 mm, and the mandibular plane showed a counterclockwise autorotation of 3.0 degrees . The results showed that osteotomy-facilitated orthodontic treatment clearly reduced the treatment time and had no adverse effects. In conclusion, this one-stage osteotomy technique can be an effective option to help molar intrusion in severe open bite cases.     

Colorimetric analysis of opaque porcelain fired to different base metal alloys used in metal ceramic restorations

STATEMENT OF PROBLEM: The popularity of base metal alloys has considerably increased in recent years because of their superior mechanical properties as well as the high cost of noble alloys. However, there is disagreement about their effect on the opaque porcelain color and the color differences among base metal alloys. PURPOSE: The purpose of this in vitro study was to determine and compare the influence of various commercially available base metal alloys (excluding titanium-based systems) on the resulting color of opaque porcelain with the use of a colorimetric device. MATERIAL AND METHODS: Fourteen different types of Ni-Cr and 3 different types of Co-Cr porcelain bonding alloys were selected with a Au-Pd alloy (V-Delta SF) as the control group for colorimetric measurements and determination of color shift after opaque application. Shade B1 of an opaque porcelain (IPS d.SIGN Opaquer) was applied (0.1 mm) to all specimens (16 mm x 1 mm). The color coordinates of each specimen were measured with a chromameter. The data were displayed in L*, a*, and b* values according to the CIELAB system, and the color differences (DeltaE) between base metal alloys and the control group were calculated. Data were statistically analyzed with 1-way ANOVA (alpha=.05). The ANOVA was followed by Dunnett's multiple comparison test for comparisons with the control group to determine specifically which groups were significantly different from the control group. RESULTS: The L* value of only 1 base metal alloy was significantly different from the control group (P<.001). All base metal alloy groups except 3 had a* values which were significantly different from the control group a* value (P=.001 for Rexillium III, P=.008 for Heracles N, and P<.001 for the remaining 12 alloys), whereas only 3 base metal alloys were not statistically significantly different from the control group in the means of b* values (P<.001). All base metal alloys to which opaque porcelain was applied had significantly different DeltaE values in comparison with the control group (P<.001). CONCLUSIONS: The data of the study indicated that a 0.1-mm-thick layer of opaque porcelain applied on the Ni-Cr and Co-Cr alloys did not reliably reproduce the color of opaque porcelain. However, within the limitations of this study, the color differences of base metal alloys measured according to the control group are within clinically acceptable limits (DeltaE<3.5).