The significance of 99mTc-MAA SPECT/CT liver perfusion imaging in treatment planning for 90Y-microsphere selective internal radiation treatment

Selective internal radiation therapy (SIRT), a catheter-based liver-directed modality for treating primary and metastatic liver cancer, requires appropriate planning to maximize its therapeutic response and minimize its side effects. (99m)Tc-macroaggregated albumin (MAA) scanning should precede the therapy to detect any extrahepatic shunting to the lung or gastrointestinal tract. Our aim was to compare the ability of SPECT/CT with that of planar imaging and SPECT in the detection and localization of extrahepatic (99m)Tc-MAA accumulation and to evaluate the impact of SPECT/CT on SIRT treatment planning and its added value to angiography in this setting.

METHODS

Ninety diagnostic hepatic angiograms with (99m)Tc-MAA were obtained for 76 patients with different types of cancer. All images were reviewed retrospectively for extrahepatic MAA deposition in the following order: planar, non-attenuation-corrected SPECT, and SPECT/CT. Review of angiograms and follow-up of patients with abdominal shunting served as reference standards.

RESULTS

Extrahepatic accumulation was detected by planar imaging, SPECT, and SPECT/CT in 12%, 17%, and 42% of examinations, respectively. The sensitivity for detecting extrahepatic shunting with planar imaging, SPECT, and SPECT/CT was 32%, 41%, and 100%, respectively; specificity was 98%, 98%, and 93%, respectively. The respective positive predictive values were 92%, 93%, and 89%, and the respective negative predictive values were 71%, 73%, and 100%. The therapy plan was changed according to the results of planar imaging, SPECT, and SPECT/CT in 7.8%, 8.9%, and 29% of patients, respectively.

CONCLUSION

In pre-SIRT planning, (99m)Tc-MAA SPECT/CT is valuable for identifying extrahepatic visceral sites at risk for postradioembolization complications.

[Uniliteral wheezes as the first clinical sign of a bronchial carcinoid]

HISTORY AND CLINICAL FINDINGS

A 58-years-old non-smoking woman presented at our Thoracic Centre with increasing exertional dyspnea and on examination was found to have wheezing and decreased breath sounds over the left lung.

INVESTIGATIONS

Chest X-ray revealed an atelectasis of the left anterobasal lung segment. Computed tomography revealed a 3.5 cm mass at the left inferior lobe. Bronchioscopy showed a total occlusion of the segmental bronchus because of an endobronchial tumor. Histology of a biopsy showed the tumor to be a carcinoid. Staging by whole-body ocreotide scintigraphy showed no evidence of metastases.

TREATMENT AND COURSE

The patient recovered quickly from resection of the left inferior lobe and radical lymphadenectomy. Two years later, she has remained free of symptoms and without evidence of recurrence.

CONCLUSIONS

Although rare (ca. 1.0 % of all primary lung tumors), the differential diagnosis of dyspnea and uniliteral wheezing should include a bronchial carcinoid. It is a potentially curable tumor, if detected and treated early. An interdisciplinary approach is pivotal to its perioperative management.

Effect of targeting normal fasting glucose levels with basal insulin glargine on glycaemic variability and risk of hypoglycaemia: a randomized, controlled study in patients with early Type 2 diabetes

AIMS

The purpose of this sub-study of the Outcome Reduction with Initial Glargine Intervention (ORIGIN) trial was to determine efficacy and safety of targeting normal fasting plasma glucose (FPG) levels in patients with early Type 2 diabetes treated with insulin glargine in comparison with standard care.

METHODS

Participants were randomly allocated to insulin or standard care. Insulin was titrated to reach FPG <or= 5.3 mmol/l. Two years after randomization in a small subset (43 glargine, 32 standard care), continuous glucose measurement (CGMS System Gold), including a test meal, was performed. Sixteen volunteers with normal oral glucose tolerance test (OGTT) served as control subjects. Objectives were glycaemic variability, standard deviation (sd), mean amplitude of glucose excursion (MAGE) with postprandial glucose excursion after the test meal, time spent < 3.0 mmol/l interstitial glucose.

RESULTS

Participants allocated to insulin and standard care had FPG levels of 5.3 and 6.1 mmol/l (P = 0.019) and glycated haemoglobin (HbA(1c)) 5.7% and 5.9%, respectively (P < 0.025). Time (min/24 h) spent at low glucose levels was not significantly different between groups (30.6 +/- 83.8 min control subjects, 33.7 +/- 75.1 min insulin, 10.6 +/- 50.6 min standard care). Standard deviation and MAGE were similar for glargine and standard care, but significantly higher than in control subjects. If FPG was < 5.3 mmol/l, the postprandial glucose excursion was in the range seen in control subjects.

CONCLUSIONS

Treatment to target of FPG < 5.3 mmol/l with insulin glargine was not associated with significantly increased risk of hypoglycaemia. Strict control of FPG with insulin glargine was effective to control postprandial glucose excursion, but had no significant effect on sd and MAGE.

Secrets to psychological success: why older doctors might have lower psychological distress and burnout than younger doctors

BACKGROUND

Doctors have long been exposed to situations that can induce psychological distress. Long hours, little acknowledgement, poor sleep and high-stress work environments all contribute to making doctors prone to psychological distress and burnout, which have been much studied in younger doctors, but less so in older doctors. Little is known about whether there are differences in psychological distress among different age groups of doctors.

METHODS

Doctors (n = 158) were recruited from in and around the St George Hospital, a major teaching hospital in Sydney, Australia. Participants completed a self-report questionnaire, comprising the Maslach Burnout Inventory (MBI), and Kessler 10 Psychological Distress Scale. Demographic details were collected. A subsample (n = 51) completed a semi-structured interview about issues related to burnout. These data were subjected to qualitative analysis.

RESULTS

Older doctors and doctors with more years of experience had significantly lower scores on MBI subscales of Depersonalization and Emotional exhaustion, and K-10 measured psychological distress. Aspects of working conditions such as being in private practice were associated with increased scores on MBI subscales of Personal accomplishment, and lower scores on MBI subscales of Emotional exhaustion and Depersonalization, and K-10 measured psychological distress. Older doctors more frequently worked in private practice. These quantitative findings were supported by the qualitative data that suggested that older doctors perceived that they experienced less psychological distress compared with earlier in their careers, which they attributed to the development of protective defences in their relationship with patients and the liberation afforded by accumulation of experience and changed work conditions.

CONCLUSIONS

Findings from this study suggest that older, more experienced doctors report lower psychological distress and burnout than younger doctors which the older doctors attributed to lessons learned over their years of training and practice. It may be of considerable value to find ways to more efficiently pass on these lessons to younger doctors to aid them in dealing with this challenging profession. By soliciting older doctors to aid in this transfer of knowledge, this approach may also have the added benefit of assisting older doctors in transitioning from an active clinical practice to a role of mentoring the new physician cohort.

Tobacco in prisons: a focus group study

OBJECTIVE

To examine the role of tobacco use in prison and possible influences of the prison environment on smoking among inmates in the context of developing inmate smoking cessation programmes.

METHOD

Qualitative study based on seven focus groups with prisoners and ex-prisoners.

SETTINGS

A maximum security prison in rural New South Wales (NSW), Australia, and a community justice restorative centre and accommodation service for ex-prisoners in Sydney, NSW, Australia.

PARTICIPANTS

40 participants (28 men and 12 women) comprising nine prisoners (including four Indigenous inmates) and 31 ex-prisoners.

RESULTS

Prisoners reported that tobacco serves as a de facto currency in correctional settings and can be exchanged for goods, used to pay debts and for gambling. Smoking helps manage the stressful situations such as transfers, court appearances and prison visits. Inmate smoking cessation programmes need to address the enmeshment of tobacco in prison life, improve availability of pharmacotherapies (for example, nicotine patches, bupropion) and the quitline (a free telephone helpline providing information on stopping smoking), provide non-smoking cells and areas within prisons, encourage physical activity for inmates and maintain monitoring of smoking cessation status after release.

CONCLUSIONS

Tobacco is integrally bound up in the prison "culture". Our findings are relevant to inform prison health authorities concerned with improving the health of prisoners, and for support organisations attempting to facilitate smoking cessation both in prison and after release. Smoking cessation programmes in prisons should be tailored to the unique stresses of the prison environment. Programmes need to acknowledge the difficulties of quitting smoking in prison arising from the stresses posed by this setting.

Peripheral MR angiography with blood pool contrast agent: prospective intraindividual comparative study of high-spatial-resolution steady-state MR angiography versus standard-resolution first-pass MR angiography and DSA

PURPOSE

To prospectively compare the accuracy of high-spatial-resolution steady-state magnetic resonance (MR) angiography with standard-resolution first-pass MR angiography in the lower extremities, with digital subtraction angiography (DSA) as the reference standard.

MATERIALS AND METHODS

Institutional ethics committee approval and written informed consent were obtained. Twenty-seven patients (16 men, 11 women; mean age, 64.4 years +/- 14.8 [standard deviation]; range, 26-87 years) suspected of having or known to have peripheral arterial disease underwent first-pass and steady-state MR angiography and DSA. First-pass and steady-state MR angiography were performed in the same patient in the same session and with the same dose of blood pool contrast agent. The most severe stenosis grade of each evaluated segment was measured; sensitivity, specificity, and positive and negative predictive values were calculated at first-pass and steady-state MR angiography, with DSA as the reference standard. The kappa coefficient was used to measure the agreement between first-pass MR angiography, steady-state MR angiography, and DSA.

RESULTS

A total of 334 arterial segments were available for intraindividual comparison of first-pass MR angiography, steady-state MR angiography, and DSA in 27 patients. In 20 (74%) of 27 patients, the stenosis grade of at least one of the evaluated vessels differed at steady-state MR angiography from that at first-pass MR angiography. In total, stenosis grade was judged as higher at first-pass MR angiography than at DSA (overestimation) in 28 of 334 segments and as lower (underestimation) in 15 of 334 segments. The stenosis grade as judged at steady-state MR angiography matched with that at DSA in 334 of 334 vessel segments.

CONCLUSION

High-spatial-resolution steady-state MR angiography allowed for better agreement with DSA regarding stenosis grade in patients with arterial disease compared with standard-resolution arterial-phase first-pass MR angiography.

Effectiveness of psychoeducation for relapse, symptoms, knowledge, adherence and functioning in psychotic disorders: a meta-analysis

Psychoeducation (PE) for schizophrenia and other psychotic disorders is widely adopted but insufficiently evaluated. So far, meta-analytic data has demonstrated efficacy for PE when interventions include family members. Whether PE directed solely at patients is also effective remains unclear. The current meta-analysis evaluates short- and long-term efficacy of PE with and without inclusion of families with regard to relapse, symptom-reduction, knowledge, medication adherence, and functioning. Randomized controlled trials comparing PE to standard care or non-specific interventions were included. A literature search in the Cochrane Library, PsycINFO and Medline retrieved 199 studies for closer examination, of which 18 studies, reporting on 19 comparisons, met the inclusion criteria. These studies were coded with regard to methodology, participants, interventions and validity. Effect sizes were integrated using the fixed effects model for homogeneous effects and the random effects model for heterogeneous effects. Independent of treatment modality, PE produced a medium effect at post-treatment for relapse and a small effect size for knowledge. PE had no effect on symptoms, functioning and medication adherence. Effect sizes for relapse and rehospitalization remained significant for 12 months after treatment but failed significance for longer follow-up periods. Interventions that included families were more effective in reducing symptoms by the end of treatment and preventing relapse at 7-12 month follow-up. Effects achieved for PE directed at patients alone were not significant. It is concluded that the additional effort of integrating families in PE is worthwhile, while patient-focused interventions alone need further improvement and research.

Physician don't heal thyself: a descriptive study of impaired older doctors

BACKGROUND

The growing and welcome interest in the issues leading to distress and impairment in younger doctors has not been mirrored by a focus on the similar issues in older doctors which is surprising given the aging medical workforce.

OBJECTIVES

To improve understanding of impairment in older doctors and to facilitate the planning of primary prevention strategies.

METHOD

Consecutive case records of notifications to the Impaired Registrants Program of the New South Wales Medical Board, Australia, of doctors over 60 years from January 2000 to January 2006 (N = 41) were examined. Details of demographics, type of practice, nature of referral, medical morbidity, cognitive examination, psychiatric diagnosis and outcome of assessment were recorded.

RESULTS

Impaired older doctors suffered cognitive impairment (54%), substance abuse (29%) and depression (22%) and 17% had two comorbid psychiatric conditions. Twelve percent had frank dementia. Two work patterns--the "workhorse" and the "dabbler"--were observed, as was a culture of postponed retirement due to a sense of obligation and working "until you drop." Impaired older doctors were found to have higher chronic illness burden compared with community norms. Almost half were the subject of patient complaints or of poor performance within ten years of presentation.

CONCLUSION

To our knowledge there has been no other comprehensive examination of patterns of impairment in older doctors. Older doctors are prone to suffer "the four Ds": dementia, drugs, drink and depression. We need to encourage mature doctors to adapt to age-related changes and illness and validate their right to timely and appropriate retirement.

Molekulare Bildgebung der Apoptose bei kardiovaskulären Erkrankungen

Molecular imaging of functional parameters such as apoptosis (programmed cell death) in vivo opens new possibilities in clinical diagnostic and scientific research. Especially in the case of cardiovascular diseases that are mainly responsible for both morbidity and mortality in Western industrial nations, innovative non-invasive examination strategies are necessary for early diagnosis of these diseases. Since apoptosis unlike necrosis is present even after minor alterations of the microenvironment of cells and has been shown to be involved in a large number of cardiovascular diseases, there are currently several experimental studies underway with the goal of imaging apoptosis in vivo. The review discusses the basics of apoptosis in myocardial infarction, myocarditis, atherosclerosis, restenosis after angioplasty and stent implantation, currently used imaging techniques, achieved results, and future possibilities for molecular imaging of apoptosis.

Female mate-choice drives the evolution of male-biased dispersal in a social mammal

Dispersal has a significant impact on lifetime reproductive success, and is often more prevalent in one sex than the other. In group-living mammals, dispersal is normally male-biased and in theory this sexual bias could be a response by males to female mate preferences, competition for access to females or resources, or the result of males avoiding inbreeding. There is a lack of studies on social mammals that simultaneously assess these factors and measure the fitness consequences of male dispersal decisions. Here we show that male-biased dispersal in the spotted hyaena (Crocuta crocuta) most probably results from an adaptive response by males to simple female mate-choice rules that have evolved to avoid inbreeding. Microsatellite profiling revealed that females preferred sires that were born into or immigrated into the female's group after the female was born. Furthermore, young females preferred short-tenured sires and older females preferred longer-tenured sires. Males responded to these female mate preferences by initiating their reproductive careers in groups containing the highest number of young females. As a consequence, 11% of males started their reproductive career in their natal group and 89% of males dispersed. Males that started reproduction in groups containing the highest number of young females had a higher long-term reproductive success than males that did not. The female mate-choice rules ensured that females effectively avoided inbreeding without the need to discriminate directly against close kin or males born in their own group, or to favour immigrant males. The extent of male dispersal as a response to such female mate preferences depends on the demographic structure of breeding groups, rather than the genetic relatedness between females and males.