Contributions of SPECT/CT imaging to the lymphoscintigraphic investigations of the lower limb lymphedema

Lymphoscintigraphy is a safe and reliable technique for investigating lymphedema. However, interpretation of delayed planar conventional imaging may be questionable due to the superimposition of soft tissues. Therefore, the aim of this retrospective study was to evaluate the contribution of single photon emission computed tomography/computed tomography (SPECT/CT) to lymphoscintigraphic investigation in a selected population with abnormal interstitial activity. Forty one patients with lower limb lymphedema either primary (n=17) or secondary (n=5), or associated with chronic venous insufficiency (n=19) underwent lymphoscintigraphy according to a standard protocol. SPECT/CT imaging that started immediately after planar imaging covered the part of the lower limbs with the most significant interstitial activity. The CT images were also analyzed separately to identify the typical honeycomb pattern of lymphedema. SPECT/CT identified additional abnormalities in vessels and soft tissues in 19 patients (46%). The additional information, primarily related to dermal collateralization of flow, dermal backflow, lymphangioma, and lymphorrhea, aided in understanding the physiopathology of edema and may have influenced management in 35 patients (85%). The honeycomb appearance of the soft tissues was noted on CT in most patients (90%). This study suggests that SPECT/CT is a promising addition to planar imaging in lymphoscintigraphic investigations of lymphedema.

Amyloid-β(1-15/16) as a marker for γ-secretase inhibition in Alzheimer's disease

Amyloid-β (Aβ) producing enzymes are key targets for disease-modifying Alzheimer's disease (AD) therapies since Aβ trafficking is at the core of AD pathogenesis. Development of such drugs might benefit from the identification of markers indicating in vivo drug effects in the central nervous system. We have previously shown that Aβ(1-15) is produced by concerted β-and α-secretase cleavage of amyloid-β protein precursor (AβPP). Here, we test the hypothesis that this pathway is more engaged upon γ-secretase inhibition in humans, and cerebrospinal fluid (CSF) levels of Aβ(1-15/16) represent a biomarker for this effect. Twenty healthy men were treated with placebo (n = 5) or the γ-secretase inhibitor semagacestat (100 mg [n = 5], 140 mg [n = 5], or 280 mg [n = 5]). CSF samples were collected hourly over 36 hours and 10 time points were analyzed by immunoassay for Aβ(1-15/16), Aβ(x-38), Aβ(x-40), Aβ(x-42), sAβPPα, and sAβPPβ. The CSF concentration of Aβ(1-15/16) showed a dose-dependent response over 36 hours. In the 280 mg treatment group, a transient increase was seen with a maximum of 180% relative to baseline at 9 hours post administration of semagacestat. The concentrations of Aβ(x-38), Aβ(x-40), and Aβ(x-42) decreased the first 9 hours followed by increased concentrations after 36 hours relative to baseline. No significant changes were detected for CSF sAβPPα and sAβPPβ. Our data shows that CSF levels of Aβ(1-15/16) increase during treatment with semagacestat supporting its feasibility as a pharmacodynamic biomarker for drug candidates aimed at inhibiting γ-secretase-mediated AβPP-processing.

Determinants of patient satisfaction regarding pain care

BACKGROUND

The management of pain in hospitalized patients remains a major public hospital priority. It has been the object of three French national programs since 1999. The purpose of this study was to reassess pain prevalence, pain intensity and patient perception of its management ten years after the first national program and to determine the factors related to the patient satisfaction with efforts to decrease pain intensity.

METHODS

A 1-day cross-sectional survey in a university hospital.

RESULTS

Pain prevalence was 59%. Pain intensity varied according to the medical department with lower intensity in surgery and obstetrics than medicine departments. Eighty-one percent of patients were satisfied with their pain management. Patient satisfaction was higher when doctors and nurses were heavily involved in the process of pain relief (OR=6.6; 95% CI 3.8, 11.4), and when their pain had decreased (OR=2.9; 1.7, 5.0). The magnitude of decrease in pain were higher when the medical team was involved (OR=1.9; 95% IC 1.1, 3.3) and pain intensity was measured (OR=1.6; 1.0, 2.4). Perceptions of doctor and nurse involvement in the patient's care was higher when pain intensity was measured (OR=6.0; 3.4, 10.5), an immediate treatment offered (OR=3.5; 2.0, 6.2), encouragement to ask for an analgesic was provided (OR=2.0; 1.1, 3.5) and for patients with acute pain (OR=2.2; 1.0, 4.7).

CONCLUSIONS

This study identifies the factors related to patient satisfaction with pain management and the magnitude of the decrease in pain which should allow further efforts to improve the management of pain and reduce its intensity in hospital inpatients.

[Anterior optic pathways compression by a surgical clip mobilized by delayed chronic hydrocephalus after treatment of a ruptured anterior communicating artery aneurysm]

Chronic hydrocephalus is a classic and recognized complication that affects 6 to 37% of patients with aneurysmal subarachnoid haemorrhage. The diagnosis is often mentioned due to the delayed onset of gait disturbance and slower psychomotor performance. The CT-scan confirms the diagnosis by showing an enlargement of the ventricles. In case of symptomatic hydrocephalus, a ventriculo-peritoneal shunt is often required. The authors report a rare case of chronic hydrocephalus presenting with visual symptoms, due to the delayed mobilisation of a surgical clip with direct mass effect over the anterior optic pathways. The treatment of hydrocephalus led to a rapid and complete regression of symptoms.

Ruptured cerebral oncotic aneurysm from choriocarcinoma: report of two cases and review of the literature

The study design involved case reports and review of the literature. Oncotic aneurysm from choriocarcinoma is an extremely rare event that should be known by all neurosurgeons and suspected in women of childbearing age. The purpose of this article is to report the authors' experience and to provide insight on clinical presentation and radiological signs to aware the reader to this entity and then to prevent misdiagnosis. The authors report two cases of ruptured oncotic aneurysm treated at their institution in 2010. A review of the literature was performed to discuss the pathogenesis and the role of the neurosurgeon. Chemotherapy is the treatment of choice making surgery necessary only for patients with large intracerebral haematoma that represents an immediate threat.

Spinal cord herniation: a misdiagnosed and treatable cause of thoracic myelopathy

This study is a case report and review of the literature. Spinal cord herniation is a rare, although increasingly recognized, cause of spinal cord dysfunction. It is due to an anterior dural defect, through which the spinal cord herniates. The purpose of this article is to report the authors' experience and to provide insight on clinical presentation and radiological signs to make the reader aware of this entity and then to prevent misdiagnosis. The authors conducted a retrospective review of patients who underwent surgery for spinal cord herniation at their institution between 2000 and 2008. Three patients were treated (all women) and the interval between the onset of symptoms and surgery ranged from 24 to 48 months. All patients had progressive signs of thoracic myelopathy, and two of them were initially misdiagnosed. In all cases, the herniation was reduced and the defect repaired using different methods. The results and complications of our cases were compared with that of the reported literature. According to the results in these cases and the review of the literature, the authors believe that spinal cord herniation should be treated by using a dural patch to close the dural defect and to prevent retethering of the spinal cord.

Effect of lateralization and handedness on the function of the lymphatic system of the upper limbs

In the upper limbs (UL), lateralization or handedness coincides with functional (and/or anatomical) asymmetries. Scintigraphic techniques were used to investigate the function of the UL lymphatic system and to determine whether significant differences exist between right and left limbs. With limbs at rest, 99mTc-labeled HSA nanosized colloids were injected intradermally into the forearms in 19 volunteers. Activities in the axillary nodes were recorded 1 minute later, then every 20 minutes up to100 minutes later and reported as per ten thousands of injected activity. When comparing right injections to left injections, no significant difference was found using an unpaired statistical test. However, with paired t-tests, axillary node activity (mean +/- SD) was significantly higher when the right limb was injected than when the left limb was injected, both overall (n = 19) (at 100 minutes: 454 +/- 88 versus 299 +/- 45: p = 0.014) and when the 13 right-handed cases were analyzed separately (501 +/- 116 versus 285 +/- 65: p = 0.004). No difference was found for the six left-handed volunteers. Our results demonstrate, at least in the right handed subjects, the functional asymmetry of the superficial lymphatic system of the right and left upper limbs.