Regular arrangement of collecting venules and the Kimura-Takemoto classification for the endoscopic diagnosis of Helicobacter pylori infection: Evaluation in a Western setting

BACKGROUND

The regular arrangement of collecting venules (RAC) and the Kimura-Takemoto classification of atrophic change (KTC) are simple and easy-to-use criteria which have been shown to reliably predict or rule out a Helicobacter pylori infection of the stomach. Although these features have been investigated extensively in Asia, their significance in the West has not been evaluated.

METHODS

In a series of 200 consecutive gastroscopic examinations (single examiner, single center), the presence or absence of RAC and the KTC grade (open type vs closed type) were recorded prospectively. Helicobacter pylori infection was defined as a positive histology or a positive rapid urease test. Furthermore, multivariate analysis of endoscopic predictors of H. pylori infection based on the Kyoto classification of gastritis was performed.

RESULTS

Two hundred patients were examined of which 57 had a H. pylori infection (28%). Both RAC and KTC had excellent negative predictive values of about 90% and sensitivity values of up to 85%. In multivariate analysis, atrophic change and diffuse redness without RAC were significantly associated with H. pylori infection.

CONCLUSION

Regular arrangement of collecting venules and KTC are simple endoscopic features which should be given attention by Western endoscopists and can be easily used to rule out a H. pylori infection of the stomach.

Digital teaching with interactive case presentations of ENT diseases - discussion of utilisation and motivation of students

Introduction: Due to the circumstances of the Covid-19 pandemic, the teaching during the block internship at the Department for Otorhinolaryngology was switched to digital learning. Various online courses were created and the utilisation by the students was analyzed. Material & methods: Examination videos, surgical images and videos were created and live lectures were held. In addition, patient cases of common otorhinolaryngological diseases were reconstructed on an interactive platform. A total of 16 cases were offered in weekly rotation. These cases are provided with gap texts, open and selection questions, links and videos and thematically appropriate digression offers. The time-consuming creation was carried out as a HTML 5 learning package with the authoring program Exelearning 2.5. Each case was to be evaluated separately after being worked on by the students. Results: The direct feedback and the evaluation results of the students on the internship and case presentations were consistently positive. However, on average only 50.72% of the registered students took part in the weekly video meetings. In the course of the semester, the willingness to participate decreased. In addition, the willingness to evaluate the patient cases was low. Discussion: With the case presentation tool, concrete patient examples can be well presented, especially when patient contact is not possible (especially in an ENT clinic due to violation of distance and hygienic rules). Even though the evaluations were positive in terms of content, the frequency of utilisation and also the motivation for feedback seems disappointing. This seems to be associated above all with an increasing return to everyday life after the end of the lockdown.

Pilot study of a newly developed eLearning tool to teach CT and PET/CT in radiology and nuclear medicine

Aim To test the usability and user experience of a newly self-developed eLearning tool to teach PET/CT and CT to undergraduate medical students.

Methods The eLearning tool permits to display PET and CT DICOM images web-based. It contains a healthy subject with anatomical annotations and a clinical case study. The usability and user experience of the eLearning tool was evaluated in undergraduate medical students of the medical faculty of the RWTH Aachen. We applied a survey based on different already existing and validated questionnaires such as System Usability Scale (SUS) and User Experience Questionnaire (UEQ-S) as well as specific questions regarding the eLearning tool.

Results 38 volunteers (9 males) participated in our study. Applying the SUS resulted in a mean of 82.24, and a median of 83.75. This positive evaluation is supported by the results of the UEQ-S that were 2.2 with regard to the pragmatic quality, 2.3 with regard to hedonic quality and 2.3 for overall quality indicating a very positive evaluation. In the free-text answers, students emphasised easy and intuitive use of the eLearning tool that was additionally described as interesting and exciting. The students also positively mentioned the case study and the possibility of practice-based learning. Negative aspects were mainly problems with synchronisation of the PET and CT images.

Conclusion The positive evaluation is encouraging and form a foundation for further development of the eLearning module. It may be the basis for the implementation of a sustainable blended learning concept in the nuclear medicine curriculum.

[The teaching of nuclear medicine in Germany]

AIM

 Molecular imaging and therapy as applied in nuclear medicine represent an important contribution to modern medicine. The university curricula of medical schools permit to convey knowledge of nuclear medicine. In this study, the status quo of nuclear medicine teaching at German medical schools shall be surveyed for the first time.

METHODS

 In cooperation with the chairs and/or lecturers, the topics organizational conditions, scope of teaching, teaching methods, examinations, evaluations, composition of teaching staff, interest of the students in the field of nuclear medicine, as well as suggestions for improvement of teaching were recorded.

RESULTS

 All 36 public German medical schools participated in the survey. In these medical schools a median of 12 hours of nuclear medicine is being taught. 52 % of the teaching consists of teacher-centered learning. 18 medical schools teach additional elective courses in nuclear medicine. Nine 9 persons (median) per department are involved in the teaching. The examinations, in all but one school, follow a multiple choice format. The students' interest in nuclear medicine is perceived by the educators to be predominately medium to high.

CONCLUSIONS

 Potential improvement might be achieved with regard to the quantity of teaching lessons, innovative methods of teaching, design of the exams, the establishment of a nationwide e-learning platform, as well as measures to increase the motivation of teachers.

[Development of a national competency-based learning objective catalogue for undergraduate medical education in Germany]

AIMS

Implementation of the guidelines on the Competency-based Learning Objective Catalogue for Undergraduate Medical Education for a Nuclear Medicine curriculum on behalf of the committee on professional training and continuing education of the German Association of Nuclear Medicine (DGN) METHODS:: In 7 domains 100 learning objectives (LOs) were subject to a prioritization in 3 categories (A, B and C) by means of a questionnaire as part of a Delphi method, in collaboration with all members of the DGN holding a "venia legendi" as experts. Category A defined the essential LOs for each medical practitioner. The prioritization was made by ranking the frequency of the A-classifications. In the 2nd step of the Delphi method, a list of LOs with the ranking positions 1-5 in each domain was presented to the first round's experts as a core curriculum, asking either for acceptance or modifications.

RESULTS

The results of the 1st step of the Delphi method deliver a return rate of 29% of the questionnaires (55 out of 184). The 2nd round shows a return rate of 30.9% (57 out of 184) and full approval of the proposed LOs in all LO domains by in median 72 % of the experts consulted (61%-81%). The present final version contains 37 competency-based LOs in the LO domains "legal basis and radiation protection", "basic science", indications and contra-indications for "PET/CT", "scintigraphy and SPECT", "patient preparation", "image interpretation" as well as "therapy".

CONCLUSION

The Competency-based Learning Objective Catalogue for Nuclear Medicine describes the knowledge and competencies, every physician should have at the end of his medical studies. The LO catalogue is a living document, which needs to be adapted continuously to the progress of the medical and technological development.

Follow-up Findings in Regional Cerebral Blood Flow (r-CBF)-SPECT in a Case of idiopathic Childhood Hemidystonia

A 9½-year-old girl suffered from intermitting tremor and jitteriness of her left hand and oral muscles every 4 to 6 weeks with long lasting episodes. Clinically myoclonias and dystonic positioning of the left arm, hand and facial muscles were seen. No evidence of trauma, infection or inborn errors of metabolism was found. Successful therapy with carbamazepine was initiated while L-DOPA failed. An ictal 99m-Tc-HMPAO-SPECT showed severe asymmetry with focal hyperperfusion of the contralateral right thalamus and basal ganglia as well as of the bifrontal cortex, whereas no anatomical lesions were found by MRI. In contrast, an interictally performed 99m-Tc-HMPAO SPECT showed hypoperfusion of the right thalamus and normalisation of the frontal perfusion under medical treatment. These 99m-Tc-HMPAO-SPECT findings may provide new insights into the localisation and pathophysiological pathways of idiopathic childhood dystonia.

Hirn-SPECT mit Tc-99m-Bicisat (ECD) bei rasch progredientem dementiellen Syndrom

Wir berichten über einen 61jährigen Patienten mit progredientem dementieilen Syndrom, der unter der Verdachtsdiagnose einer Demenz vom Alzheimer-Typ (DAT) zur Hirn-SPECT-Untersuchung mit Tc-99m-Bicisat (ECD) vorgestellt wurde. Zum Untersuchungszeitpunkt bestanden neben dem Vollbild einer Demenz eine ausgeprägte Apraxie und Aphasie bei unspezifischen Veränderungen im EEG sowie der neuroradiologischen Bildgebung. In der Hirn-SPECT-Untersuchung fanden sich für eine DAT untypische ausgedehnte, vorwiegend rechtshemisphärische Perfusionsstörungen. Im weiteren Verlauf rasche Progredienz des Krankheitsbildes mit Entwicklung eines akinetischen Mutismus sowie Nachweis erhöhter Werte der neuronspezifischen Enolase und des 14-3-3-Proteins im Liquor. Der Patient verstarb schließlich unter dem Bild einer Decortication. Aufgrund des klinischen Verlaufs sowie der Liquorbefunde wurde, da eine autoptische Befundsicherung nicht vorliegt, die Diagnose einer wahrscheinlichen Creutzfeldt-Jakob-Erkrankung gestellt. Die vorgestellte Kasuistik unterstreicht aus unserer Sicht den Wert der Hirn-SPECT in der differentialdiagnostischen Abgrenzung dementieller Zustandsbilder.

Implantation of Stimulation Electrodes in the Subretinal Space to Demonstrate Cortical Responses in Yucatan Minipig in the Course of Visual Prosthesis Development

Purpose

During the course of the development of visual prostheses, subretinal stimulation films were implanted in micropigs in order to prove the feasibility of subretinal electrical stimulation with subsequent cortical response. One aim was to demonstrate that epidural recording of visual evoked potentials is possible in the micropig.

Methods

Film-bound stimulation electrode arrays were placed in the subretinal space of micropigs. This enabled the retina to be stimulated subretinally. Since conventional visual evoked potential (VEP) measuring is virtually impossible in the pig from the neurosurgical point of view, epidural recording electrode arrays were positioned over the visual cortex as permanent electrodes.

Results

The feasibility of temporary implantation of film-bound stimulation electrode arrays was successfully demonstrated in the micropig model. On stimulation with monopolar voltage pulses (1000 to 3000 mV), reproducible epidural VEP measurements (5 to 10 μV) were detected.

Conclusions

The feasibility of subretinal stimulation of the retina was demonstrated in a retinal model that is similar to the human retina. This animal model therefore offers a suitable means of studying the tolerability of stimulation situations in the course of visual prosthesis development.

The therapeutic impact of 18F-FDG whole body PET

Aims: An explorative analysis of the diagnostic as well as therapeutic impact of 18F-FDG whole body PET on patients with various tumours in the setting of an university hospital radiation therapy was performed. Patients and methods: 222 FDG PET investigations (148 initial stagings, 74 restagings) in 176 patients with diverse tumour entities (37 lung carcinoma, 15 gastrointestinal tumours, 38 head and neck cancer, 30 lymphoma, 37 breast cancer, 19 sarcoma and 16 other carcinomas) were done. All PET scans were evaluated in an interdisciplinary approach and consecutively confirmed by other imaging modalities or biopsy. Unconfirmed PET findings were ignored. Proportions of verified PET findings, additional diagnostic information (diagnostic impact) and changes of the therapeutic concept intended and documented before PET with special emphasis on radiooncological decisions (therapeutic impact) were analysed. Results: 195/222 (88%) FDG-PET findings were verified, 104/222 (47%) FDG-PET scans yielded additional diagnostic information (38 distant, 30 additional metastasis, 11 local recurrencies, 10 primary tumours and 15 residual tumours after chemoptherapy). The results of 75/222 (34%) scans induced changes in cancer therapy and those of 58/222 (26%) scans induced modifications of radiotherapeutic treatment plan (esp. target volumes). Conclusion: 18F-FDG whole body PET is a valuable diagnostic tool for therapy planning in radiooncology with a high impact on therapeutic decisions in initial staging as well as in restaging. Especially in a curative setting it should be used for definition of target volumes.

Papillary microcarcinoma and papillary cancer of the thyroid ≤1cm

Aims: Major controversies exist regarding the treatment of papillary microcarcinoma of the thyroid (PMC). Prior to 2003 PMC was defined by the WHO as a papillary carcinoma of 1cm or less in diameter. In 2004 that definition changed, with the new classification requiring that the tumour also must be found incidentally. Patients, methods: In this study we reviewed the clinical records of 67 patients with papillary tumours of the thyroid ≤1 cm, taking into account the new WHO definition (54 pts. with incidentally found PMC, median age: 53 years, 13 pts. with suspicion of thyroid neoplasm before resection, median age: 38 years). Clinical presentation, surgical treatment, further therapy and follow-up are presented. Results: Median tumour size was 7 mm in both groups (1.10 mm). Multicentric tumours were found in 15 pts. (22%), 8 had more than one PMC on the same side, and 7 displayed PMC bilaterally. Eleven (16%) of the primary tumors had metastatic involvement of regional lymph nodes at the time of initial surgery or during follow-up. Two patients showed distant metastases. No correlation between tumour size and multifocality or the presence of lymph node metastases could be seen. The gender of patients was the only significant independent variable for all patients; age and lymph node involvement was significantly different between incidentally and non-incidentally found PMC. Conclusions: Despite the majority of patients with PMC having an excellent outcome, there are also cases showing an unfavorable course. Currently no predictive parameter exists to anticipate the course and long-term outcome for an individual patient. Until this problem is solved, each patient should have the option to decide for him or herself whether to be treated similarly or differently than for conventional thyroid cancer.

[Nuclear Medicine in Germany. Updated key data and trends from official statistics]

AIM

Updated presentation of the spectrum of nuclear medicine in-vivo examinations and therapies from officially available statistics on out-patient and in-patient care as well as trends of structural data on nuclear medicine in Germany.

METHODS

Data from the German Federal Health Monitoring, from the frequency statistics of the statutory health insurance for out-patients and from the German Medical Association were used and supplemented by data from selective literature searches.

RESULTS

In descending order, thyroid, bone and cardiac scans continue to be the most frequent nuclear medicine procedures. With a marked increase of PET/CT and SPECT/CT, the number of basic scintigraphies is declining. Cardiac, lung and brain scans as well as lymph scintigraphies are increasingly requested, bone and thyroid scan decrease. The consultation of nuclear medicine physicians in private practices is increasing by 4 % per year (2009: 2 164 664; 2015: 2 687 359). The number of nuclear medicine physicians in the out-patient sector rose significantly (2009: 756, 2015: 939, growth 24 %) and has remained constant due to restrictions since 2013. The specialist recognitions of women in nuclear medicine increased (proportion currently 46 %). In hospitals, more PET(/CT) scanners (2009: 97; 2015: 125) and fewer gamma cameras (2009: 594; 2015: 550) are operated. The number of non-thyroid (and also out-patient) radionuclide therapies continued to increase.

CONCLUSION

With increased use of hybrid technologies, the nuclear medicine spectrum shows positive trends especially in nuclear cardiology and extra-thyroid therapy. These developments must be taken into account when amending regulations of specialist training and medical student teaching.

Octreotide LAR and Prednisone as Neoadjuvant Treatment in Patients with Primary or Locally Recurrent Unresectable Thymic Tumors: A Phase II Study

Therapeutic options to cure advanced, recurrent, and unresectable thymomas are limited. The most important factor for long-term survival of thymoma patients is complete resection (R0) of the tumor. We therefore evaluated the response to and the induction of resectability of primarily or locally recurrent unresectable thymomas and thymic carcinomas by octreotide Long-Acting Release (LAR) plus prednisone therapy in patients with positive octreotide scans. In this open label, single-arm phase II study, 17 patients with thymomas considered unresectable or locally recurrent thymoma (n = 15) and thymic carcinoma (n = 2) at Masaoka stage III were enrolled. Octreotide LAR (30 mg once every 2 weeks) was administered in combination with prednisone (0.6 mg/kg per day) for a maximum of 24 weeks (study design according to Fleming´s one sample multiple testing procedure for phase II clinical trials). Tumor size was evaluated by volumetric CT measurements, and a decrease in tumor volume of at least 20% at week 12 compared to baseline was considered as a response. We found that octreotide LAR plus prednisone elicited response in 15 of 17 patients (88%). Median reduction of tumor volume after 12 weeks of treatment was 51% (range 20%-86%). Subsequently, complete surgical resection was achieved in five (29%) and four patients (23%) after 12 and 24 weeks, respectively. Octreotide LAR plus prednisone treatment was discontinued in two patients before week 12 due to unsatisfactory therapeutic effects or adverse events. The most frequent adverse events were gastrointestinal (71%), infectious (65%), and hematological (41%) complications. In conclusion, octreotide LAR plus prednisone is efficacious in patients with primary or recurrent unresectable thymoma with respect to tumor regression. Octreotide LAR plus prednisone was well tolerated and adverse events were in line with the known safety profile of both agents.

Quality management of eLearning for medical education: current situation and outlook

Introduction: In 2008, the German Council of Science had advised universities to establish a quality management system (QMS) that conforms to international standards. The system was to be implemented within 5 years, i.e., until 2014 at the latest. The aim of the present study was to determine whether a QMS suitable for electronic learning (eLearning) domain of medical education to be used across Germany has meanwhile been identified.

Methods: We approached all medical universities in Germany (n=35), using an anonymous questionnaire (8 domains, 50 items).

Results: Our results (response rate 46.3%) indicated very reluctant application of QMS in eLearning and a major information deficit at the various institutions.

Conclusions: Authors conclude that under the limitations of this study there seems to be a considerable need to improve the current knowledge on QMS for eLearning, and that clear guidelines and standards for their implementation should be further defined.

Fluorodeoxyglucose positron emission tomography in anti-N-methyl-D-aspartate receptor encephalitis: distinct pattern of disease

BACKGROUND

Patients with encephalitis associated with antibodies against N-methyl-D-aspartate-receptor antibody (NMDAR-ab) encephalitis frequently show psychotic symptoms, amnesia, seizures and movement disorders. While brain MRI in NMDAR-ab encephalitis is often normal, abnormalities of cerebral glucose metabolism have been demonstrated by positron emission tomography (PET) with 18F-fluorodeoxyglucose(FDG) in a few usually isolated case reports. However, a common pattern of FDG-PET abnormalities has not been reported.

METHODS

The authors retrospectively identified six patients with NMDAR-ab encephalitis in two large German centres who underwent at least one whole-body FDG-PET for tumour screening between January 2007 and July 2010. They analysed the pattern of cerebral uptake derived from whole-body PET data for characteristic changes of glucose metabolism compared with controls, and the changes of this pattern during the course of the disease.

RESULTS

Groupwise analysis revealed that patients with NMDAR-ab encephalitis showed relative frontal and temporal glucose hypermetabolism associated with occipital hypometabolism. Cross-sectional analysis of the group demonstrated that the extent of these changes is positively associated with clinical disease severity. Longitudinal analysis of two cases showed normalisation of the pattern of cerebral glucose metabolism with recovery.

CONCLUSIONS

A characteristic change in cerebral glucose metabolism during NMDAR-ab encephalitis is an increased frontotemporal-to-occipital gradient. This pattern correlates with disease severity. Similar changes have been observed in psychosis induced by NMDAR antagonists. Thus, this pattern might be a consequence of impaired NMDAR function.

Neural correlates of tinnitus duration and distress: a positron emission tomography study

Cerebral (18)F-deoxyglucose positron emission tomography (FDG-PET) has shown altered auditory pathway activity in tinnitus. However, the corresponding studies involved only small samples and analyses were restricted to the auditory cortex in most studies. Evidence is growing that also limbic, frontal, and parietal areas are involved in the pathophysiology of chronic tinnitus. These regions are considered to mediate perceptual, attentional, and emotional processes. Thus, the aim of the present study was the systematic evaluation of metabolic brain activity in a large sample of tinnitus patients. Ninety one patients with chronic tinnitus underwent FDG-PET. The effects of tinnitus severity (assessed by a tinnitus questionnaire score), duration and laterality were evaluated with statistical parametric mapping (SPM) in whole brain analyses. In addition, region of interest analyses were performed for primary auditory areas. Tinnitus duration correlated positively with brain metabolism in right inferior frontal, right ventro-medial prefrontal, and right posterior cingulate cortex. Tinnitus distress correlated positively with activation of left and right posterior inferior temporal gyrus as well as left and right posterior parahippocampal-hippocampal interface. Region of interest analysis demonstrated an overactivation of left in contrast to right Heschl's gyrus independently from tinnitus laterality and anatomical hemispheric differences. Tinnitus duration and distress were associated with areas involved in attentional and emotional processing. This is in line with recent findings indicating the relevance of higher order areas in the pathophysiology of tinnitus. Earlier results of asymmetric activation of the auditory cortices in tinnitus were confirmed, i.e., left-sided overactivation was found independently from tinnitus laterality.

GLUT1 expression is increased in hepatocellular carcinoma and promotes tumorigenesis

Accelerated glycolysis is one of the biochemical characteristics of cancer cells. The glucose transporter isoform 1 (GLUT1) gene encodes a key rate-limiting factor in glucose transport into cancer cells. However, its expression level and functional significance in hepatocellular cancer (HCC) are still disputed. Therefore, we aimed to analyze the expression and function of the GLUT1 gene in cases of HCC. We found significantly higher GLUT1 mRNA expression levels in HCC tissues and cell lines compared with primary human hepatocytes and matched nontumor tissue. Immunohistochemical analysis of a tissue microarray of 152 HCC cases revealed a significant correlation between Glut1 protein expression levels and a higher Ki-67 labeling index, advanced tumor stages, and poor differentiation. Accordingly, suppression of GLUT1 expression by siRNA significantly impaired both the growth and migratory potential of HCC cells. Furthermore, inhibition of GLUT1 expression reduced both glucose uptake and lactate secretion. Hypoxic conditions further increased GLUT1 expression levels in HCC cells, and this induction was dependent on the activation of the transcription factor hypoxia-inducible factor-1alpha. In summary, our findings suggest that increased GLUT1 expression levels in HCC cells functionally affect tumorigenicity, and thus, we propose GLUT1 as an innovative therapeutic target for this highly aggressive tumor.

The role of genetic variants of NOD2/CARD15, a receptor of the innate immune system, in GvHD and complications following related and unrelated donor haematopoietic stem cell transplantation

Previous studies from our group indicated a role of SNPs within the innate immunity receptor NOD2/CARD15 as a risk factor for GvHD and treatment-related mortality allogeneic stem cell transplantation from HLA-identical siblings. We now extended these studies to assess the role of NOD2/CARD15 SNPs in 342 unrelated donor transplants. Overall, presence of any SNPs in patients or donor resulted in an increased risk of severe GvHD (25% in wildtype versus 38% in recipients and donors with variants, P= 0.01), which did not translate in increased mortality. When the analysis was broken down to individual SNPs, the presence of a SNP13 in the donor turned out to be the only highly significant risk factor (GvHD III/IV 22% wt, 42% SNP13 donor, P < 0.004; TRM 33% wt versus 59% SNP13 donor, P= 0.01; overall survival 49% wt versus 26% SNP13 donor, P= 0.007). This association was confirmed in multivariate analysis. Analysis of clinical risk factors suggested that this effect was most prominent in patients receiving any form of T cell depletion. Thus our observation indicates that the presence of a defect in innate immunity signalling in donor monocytes and possibly antigen presenting cells is most prominent in patients having additional T cell deficiency.

Poster exhibitions at national conferences: education or farce?

INTRODUCTION

The so-called poster exhibition is an established element of medical meetings which often receives little attention. The aim of this study was to analyze the organization, acceptance and value of poster exhibitions.

METHODS

Interview based study conducted during the annual meeting of a German specialist medical conference. A total of 247 attendees, poster authors and "poster chairpersons" were interviewed. Attendance at poster exhibitions was documented, the poster review and award process analyzed, and abstracts assessed for redundancy of presentation.

RESULTS

Participation in poster exhibitions was very low. Despite this, their scientific value was esteemed high by young authors and the poster chairpersons. Almost a third (29.4%) of posters had been displayed at other meetings. Several attendees (55.4%) and poster presenters (49.1%) say they would welcome the opportunity for personal one-on-one discussion at the poster in addition to poster viewing.

DISCUSSION

The option of additional personal discussion with the poster presenter may lead to an increase of the rather modest participation of attendees at poster exhibitions. Poster exhibitions are of value in particular for young scientists and poster chairpersons.

Positron emission tomography findings in obstructive sleep apnea patients with residual sleepiness treated with continuous positive airway pressure

Despite sufficient continuous positive airway pressure (CPAP) therapy, some patients with the obstructive sleep apnea syndrome (OSAS) still suffer from excessive daytime sleepiness (EDS). In some of them, no cause of the persistence of EDS can be found. Brain damage due to nocturnal hypoxemia is a potential cause for this unclear persistent sleepiness (UPS). This study was done to evaluate this hypothesis. Patients with UPS were identified among the OSAS patients, who came for a CPAP therapy checkup to our sleep laboratory. UPS was recognized when no explanation for persistent EDS could be yielded by standard diagnostic procedures. Out of 167 patients under CPAP therapy 13 had UPS. To investigate the brain morphology, positron emission tomography (PET) scanning with the tracer fluorine-18 fluorodeoxyglucose (FDG), called FDG-PET, were performed in 7 of the UPS patients. Abnormal PET findings were concentrated in frontal area (found in 4 patients). The frontal abnormality seems to distinguish the OSAS patients with UPS from the whole OSAS population, examined in previous studies.

[Frequency and distribution pattern of distant metastases in patients with ENT tumors and their consequences for pretherapeutic staging]

PURPOSE

To address the following questions: which parameters influenced the frequency of distant metastases in patients with locally advanced ear-nose-throat (ENT) tumors, which was the distribution pattern of metastases, and what were the diagnostic consequences for pretherapeutic staging?

PATIENTS AND METHODS

600 patients (526 men, 76 women, median age 56 years) with ENT tumors (squamous cell carcinoma histology) were studied retrospectively. The distribution of primary tumor site and stage (AJCC) was as follows: oropharynx: n = 161 (26.8%), hypopharynx: n = 187 (31.2%), oral cavity: n = 89 (14.8%), larynx: n = 118 (19.7%), cancer of unknown origin: n = 13 (2.2%), others: n = 32(5.3%), I: n = 24 (4%), II: n = 49 (8.2%), III: n = 89 (14.8%), IV: n = 438 (73%). 270 patients (45%) received radiochemotherapy, 330 (55%) postoperative radiotherapy. The following parameters were analyzed in association with distant metastases: tumor localization, T- and N-category, primary treatment, local tumor control, and second neoplasms.

RESULTS

114/600 patients (19%) developed distant metastases, 29/600 (4.9%) at presentation, 50% within 9.3 months after diagnosis of the primary tumor. Distant metastases were most frequent in stage IV (24.2%), carcinoma of the hypopharynx (25.7%), local recurrence (24.3%), and second neoplasm (31.7%) with the following distribution pattern: pulmonary 61/114 (53.5%), pleural 15/114 (13.1%), osseous 45/114 (39.5%), hepatic 14/114 (12.3%), cerebral 8/114 (7%), cutaneous 14/114 (12.3%). 34/114 patients (29.8%) presented monotopic, 80/114 (70.2%) polytopic metastases. 82/600 (13.6%) patients additionally had second neoplasms, 20 corresponding with synchronous or metachronous bronchial tumors.

CONCLUSION

With locally advanced ENT tumor stage IVa/b, carcinoma of the hypopharynx, local recurrence or second neoplasms, at least a pretherapeutic CT of the thorax should be performed because every seventh patient (88/600) developed metastases or second primary tumors within the thoracic space during the course of disease. Regarding the side effects and costs of curative therapy, the definition of generally accepted guidelines for the systemic staging of locally advanced ENT tumors should be undertaken.

[FDG-PET-CT based imaging of retropharyngeal lymph nodes with its impact on radiotherapy]

BACKGROUND

In about 20% there is an involvement of the retropharyngeal lymph nodes in patients with locally advanced carcinoma of the hypopharynx and cervical esophagus. A case report should demonstrate the diagnostic and therapeutic impact of FDG-PET/CT in the radiotherapeutic management of a locally advanced carcinoma of the hypopharynx in special consideration of the RPLN.

PATIENT AND METHOD

A pretherapeutic FDG-PET/CT was performed with the patient fixed in the radiotherapy mask in order to integrate the anatomic and metabolic information into the radiotherapy planning system by an exact matching of the data.

RESULTS

Only the FDG-PET could detect a retropharyngeal lymph node involvement (RPLN) by an intensive glucose utilisation with a consecutive modification of the target volume and dose increase in this region.

CONCLUSION

This case report demonstrates that FDG-PET/CT facilitates the imaging of metabolic active and otherwise hardly detectable lymph nodes in locally advanced head and neck cancer with consequences on target volume definition and dose application in radiotherapy.

The prognostic value of anaemia at different treatment times in patients with locally advanced head and neck cancer treated with surgery and postoperative radiotherapy

AIMS

We report a retrospective mono-institutional analysis of anaemia (< 12 g/dl) at different treatment times (preoperative, postoperative, before radiotherapy and nadir levels during radiotherapy) in head and neck cancer patients treated with surgery and postoperative radiotherapy. The study objective was to determine whether, and at which time points, anaemia had a significant effect on the end points overall survival and local recurrence-free survival (LRFS).

MATERIALS AND METHODS

The end points for the statistical analysis in 130 patients were LRFS and overall survival. A univariate analysis (Log-rank test) was carried out on the following variables with potential end point-related impact: gender, T, N, G, American Joint Committee on Cancer (AJCC) stage, tumour site, resection status, overall treatment time (OTT), radiotherapy treatment time (RTT) and preoperative, postoperative, pre-radiotherapy and nadir levels of haemoglobin during radiotherapy. Individual variables with a significant effect (P=0.05) were then subjected to multivariate Cox regression analysis.

RESULTS

The median overall survival was 59 months. The univariate analysis showed that AJCC stage (P=0.0268), resection status (P=0.0407), preoperative haemoglobin level (P=0.0087), postoperative haemoglobin level (P=0.0035), RTT (P=0.0042) and OTT (P=0.0343) significantly influenced overall survival. OTT (P=0.0130) and postoperative haemoglobin (P=0.0243) had a significant effect on LRFS. The multivariate Cox regression analysis showed postoperative haemoglobin < 12 g/dl and OTT>100 days to be independent negative prognostic factors for both end points.

CONCLUSIONS

Postoperative acute anaemia < 12 g/dl and an OTT>100 days were independent negative prognostic factors for LRFS and overall survival in patients with head and neck cancer treated with surgery and postoperative radiotherapy.

Überleben mit hämatogen metastasierten HNO-Tumoren

QUESTIONS

The objective of this retrospective analysis was to investigate parameters with a potential impact on survival in a collective of 114 patients with distant metastatic disease after head and neck cancer.

PATIENTS AND METHODS

The primary endpoint was the survival with distant metastatic disease, the secondary endpoint was overall survival. Primary therapy, local recurrence, second neoplasms, palliative chemotherapy (CHT) and radiotherapy (RT), as well as Karnofsky performance status (KPS) at the time of diagnosis of the metastases were analyzed as potential impact parameters using the log-rank test with subsequent Cox regression analysis.

RESULTS

Palliative CHT (P=0.0020) and KPS (P=0.0011) had a significant positive impact on the median survival probability with metastases (8.2 months) using the log-rank test, KPS at the time of diagnosis of metastases remained as an independent prognostic parameter in the Cox regression (P=0.0013). Primary therapy, local tumor control and KPS had a significant positive influence on the median overall survival probability (18.5 months) univariately (P=0.0139, P=0.0106, P= 0.0096) and multivariately (P=0.0123, and P=0.0063, P=0.0197, respectively).

CONCLUSIONS

KPS at the time of diagnosis of metastases is an independent prognostic parameter for both endpoints. Lacking evidence for life prolongation, palliative therapies should therefore first and foremost focus on the stabilization of the KPS.

Papillary microcarcinoma and papillary cancer of the thyroid <or=1 cm: modified definition of the WHO and the therapeutic dilemma

AIMS

Major controversies exist regarding the treatment of papillary microcarcinoma of the thyroid (PMC). Prior to 2003 PMC was defined by the WHO as a papillary carcinoma of 1 cm or less in diameter. In 2004 that definition changed, with the new classification requiring that the tumour also must be found incidentally.

PATIENTS, METHODS

In this study we reviewed the clinical records of 67 patients with papillary tumours of the thyroid <or=1 cm, taking into account the new WHO definition (54 pts. with incidentally found PMC, median age: 53 years, 13 pts. with suspicion of thyroid neoplasm before resection, median age: 38 years). Clinical presentation, surgical treatment, further therapy and follow-up are presented.

RESULTS

Median tumour size was 7 mm in both groups (1-10 mm). Multicentric tumours were found in 15 pts. (22%), 8 had more than one PMC on the same side, and 7 displayed PMC bilaterally. Eleven (16%) of the primary tumors had metastatic involvement of regional lymph nodes at the time of initial surgery or during follow-up. Two patients showed distant metastases. No correlation between tumour size and multifocality or the presence of lymph node metastases could be seen. The gender of patients was the only significant independent variable for all patients; age and lymph node involvement was significantly different between incidentally and non-incidentally found PMC.

CONCLUSIONS

Despite the majority of patients with PMC having an excellent outcome, there are also cases showing an unfavorable course. Currently no predictive parameter exists to anticipate the course and long-term outcome for an individual patient. Until this problem is solved, each patient should have the option to decide for him or herself whether to be treated similarly or differently than for conventional thyroid cancer.

Cerebellar and thalamic metabolic changes visualized by [18]-FDG-PET in olanzapine-induced acute akathisia

OBJECTIVES

Akathisia is a clinical important symptom, frequently induced by neuroleptic treatment. Despite its clinical importance, less is known about its pathophysiology.

METHODS

Using [18]-FDG-PET, imaging patterns of cortical metabolic activity were obtained in a patient during olanzapine-induced akathisia and after recovery.

RESULTS

Akathisia was characterized by a reduced metabolic activity in thalamus and cerebellum. After discontinuing medication akathisia disappeared, reflected by a recovery of metabolic activity in these brain areas.

CONCLUSION

[18]-FDG-PET may be useful to identify cortical regions mediating clinical aspects of drug-induced akathisia, thereby offering a deeper insight into the pathophysiology of this serious side effect.

Thin corpus callosum and amyotrophy in spastic paraplegia—Case report and review of literature

We report the clinical, structural, functional and genetic characterization of a 37-year-old Caucasian female, presenting as a sporadic case of complicated spastic paraplegia with thin corpus callosum (CC), cognitive impairment, amyotrophy of the hand muscles and a sensorimotor neuropathy and review the literature for spastic paraplegia with thin CC. Magnetic resonance imaging (MRI) examination revealed a thin CC with fronto-parietal cortical atrophy. 18Fluordesoxyglucose positron emission tomography (FDG-PET) showed reduced cortical and thalamic metabolism. By transcranial magnetic stimulation, we delineated a severe impairment of transcallosal inhibition. Sequence analysis did not reveal disease causing mutations in the genes SLC12A6 (Andermann), Spastin (SPG 4), BSCL2 (SPG 17) and Spartin (SPG 20). We reviewed the literature for HSP with thin CC and found 113 HSP patients with thin CC previously described (35 with linkage to chromosome 15q13-15). Thin CC and peripheral neuropathy often appear together in spastic paraplegia and might be indicative for combined degeneration mechanism of central and peripheral axons.

Mechanisms of regional wall motion abnormalities in contrast-enhanced Dobutamine Stress Echocardiography

BACKGROUND

In the diagnosis of coronary artery disease (CAD) with Dobutamine Stress Echocardiography (DSE), regional wall motion abnormalities (RWMA) are assumed to indicate a perfusion deficit.

METHODS AND RESULTS

For a more particular examination of RWMAs, we compared simultaneous echo-contrast (Optisone)-enhanced DSE (0-40 microg/kg Dobutamine, 16-segment- model) and MiBi-SPECT in a prospective double-blinded study design in 69 non-selected consecutive patients (44 male, 25 female, age 64+/-12 years). Additionally, all patients were examined by coronary-angiography. The prevalence of significant CAD (stenosis >50% lumen diameter) was 52%. DSE had a sensitivity of 78% and a specificity of 66% for the detection of significant CAD with a positive and negative predictive value of 72 and 73%, respectively. Among 28 patients with significant CAD and positive DSE study (true positive), 78% displayed a corresponding perfusion deficit in MiBi-SPECT. Among 11 patients with a positive DSE study but no current significant coronary stenosis (false positive), 82% showed stress-induced RWMAs in the inferior/posterior region, 73% displayed left ventricular hypertrophy, 54% resting-ECG abnormalities and 45% resting-RWMA (3 previous MI, 2 previous CABG surgery). Among 8 patients with negative DSE study but significant coronary stenosis (false negative), 75% had a stenosis of the LCX, 63% displayed resting- WMA, 63% displayed left bundle branch block or ST-segment depression, 50% displayed only peripheral coronary stenosis, and DSE visualization was suboptimal in 38%.

CONCLUSION

This prospective study in non-selected patients shows that the majority of RWMAs in DSE are matched to a perfusion deficit detectable by nuclear imaging. Nevertheless, pre-existing cardiac abnormalities may also lead to stress-induced RWMA not associated with a perfusion deficit or mask a perfusion deficit upon DSE. Particularly in patients with LV hypertrophy, resting-RWMA, bundle branch block or ST segment depression, the predictive value of DSE may, therefore, be limited.

FDG-PET in radiotherapy treatment planning of advanced head and neck cancer—A prospective clinical analysis

BACKGROUND

A prospective clinical analysis was carried out to assess the diagnostic and therapeutic impact of fluorodeoxyglucose positron emission tomography (FDG-PET) on planning radiotherapy in patients with advanced head and neck cancer in AJCC Stages III/IV.

METHODS

From July 1999 to May 2004 FDG-PET was performed in 49 patients prior to radiotherapy for exclusion of systemic disease, synchronous second or unknown primary tumors.

RESULTS

45/49 (91.9%) FDG-PET findings could be confirmed in comparison with conventional imaging and the clinical follow up of 9.5 months. 21/49 FDG-PET (42.8%) yielded new diagnostic information with therapeutic implications in 20/49 (40.8%) cases. The therapy strategy was changed in 14/49 patients, minor modifications in the portal design occurred in 6/49 patients. 9/49 (18.3%) FDG-PET supported a curative strategy, 11/49 (22.4%) a palliative one.

CONCLUSIONS

FDG-PET is a useful and important diagnostic tool mainly for exclusion of systemic disease in advanced head and neck cancer, thus influencing radiotherapy in 20/49 (40.8%) of patients investigated in our study.

Neuronavigierte repetitive transkranielle Magnetstimulation (rTMS)

BACKGROUND AND OBJECTIVE

Idiopathic tinnitus is a frequent and debilitating disorder of largely unknown pathophysiology. Focal brain activation in the auditory cortex has recently been demonstrated in chronic tinnitus. Low-frequency rTMS can reduce cortical hyperexcitability.

PATIENTS AND METHODS

In 12 patients with chronic tinnitus, fusion of [18F]deoxyglucose-PET and structural MRI (T1, MPRAGE) scans allowed the area of increased metabolic activity in the auditory cortex to be exactly identified; this area was selected as the target for rTMS. A neuronavigational system adapted for TMS positioning enabled the relative positions of the figure-8 coil and the target area to be monitored. Repetitive TMS (110% motor threshold; 1 Hz; 2000 stimuli per day over 5 days) was performed using a placebo-controlled crossover design. A sham coil system was used for the placebo stimulation. Treatment outcome was assessed with a specific tinnitus questionnaire (Goebel and Hiller).

RESULTS

In all 12 patients an asymmetrically increased metabolic activation of the gyrus of Heschl was detected. The tinnitus score was significantly improved after 5 days of active rTMS, an effect not seen after placebo stimulation.

CONCLUSION

These preliminary results show that neuronavigated rTMS may improve our understanding and treatment of chronic tinnitus.

Integration von PACS und KIS in den Workflow einer nuklearmedizinischen Abteilung

Ziel: Die Entwicklung neuer Diagnoseverfahren und Implementierung eines modernen Qualitätsmanagements bedingen die permanente Anpassung vorhandener EDVStrukturen an den Arbeitsablauf in einer nuklearmedizinischen Abteilung. Die gesetzliche Pflicht zur Patientendatensicherung und ein schneller Datenzugriff mittels Vernetzung, wird durch ein PACS mit Anschluss an das KIS ermöglicht bzw. wesentlich erleichtert. Ziel dieser Arbeit ist deshalb den Aufbau, die Struktur und Ergebnisse eines derartigen Systems darzustellen und zu bewerten. Methode: Initial wurde der Workflow der Nuklearmedizin analysiert und den einzelnen Systemkomponenten der Abteilung zugeordnet. Die im Klinikum eingesetzte, auf den Standardverfahren SAP R/3 und IS-H bzw. IS-H*med basierende Software zur Patientenverwaltung, wurde entsprechend den Bedürfnissen der Nuklearmedizin angepasst. Die Vernetzung der bildgebenden Systeme erfolgte durch die Integration eines PACS. Im letzten Schritt erfolgte die Anbindung des PACS an das KIS mit der Möglichkeit dem schriftlichen Befund die entsprechenden Bildbefunde anzuhängen. Ergebnisse, Schlussfolgerung: Durch Vernetzung des KIS mit dem nuklearmedizinischen PACS konnte der Workflow wesentlich verbessert werden. Der Datenfluss kann von der Anmeldung, über die Akquisition, bis zum Abruf von schriftlichem und bildlichem Befund transparent nachvollzogen werden. Eine wesentliche Kostenreduktion, sowie ein schnellerer Zugang zu schriftlichem Befund und Bilddaten von Seiten der anfordernden Abteilungen ist festzuhalten. Die Integration von PACS und KIS in den Workflow der Nuklearmedizin dient auch unter Berücksichtigung der kritischen Aspekte, wie permanenter Systempflege oder regelmäßiger Aktualisierung, trotzdem der Effizienzsteigerung und Kostenersparnis. Das Patientenmanagement und die Nachvollziehbarkeit des Datenflusses werden erheblich verbessert.

[Integration of PACS and HIS into the workflow of a nuclear medicine department. Experience in Regensburg]

AIM

The development of new diagnostic techniques and the implementation of a modern quality control management system requires the continuous adaptation of existing data processing tools to the nuclear medicine diagnostic workflow. Furthermore, PACS connected to HIS facilitates and enhances the transfer of data and pictures, and satisfies the legal requirements for data retention as regulated by law. Therefore, the aim of this work is to present the architecture, structure and results of such a system newly installed in a department of nuclear medicine.

METHODS

Initially, the nuclear medicine workflow was carefully analyzed and each step was correlated to the corresponding module. The standard SAP R/3 and IS-H/IS-H(*)med based software used for patient administration at the University of Regensburg Hospital was adapted to the needs of the Nuclear Medicine Department. The networking of the imaging systems was done by integration of a PACS. Finally, the PACS was connected to the HIS to allow the attachment of images to the medical report.

RESULTS, CONCLUSION

By connecting the HIS to the nuclear medicine PACS, the workflow was significantly improved. The data management sequence starting at the reception desk, continuing through the nuclear medical examination, to the physician's final written and image report is clearly structured. Although high demands exist on technical support and administration the integration of PACS and HIS into the nuclear medicine workflow leads to enhanced efficiency and reduction in hospital costs. Patient and data management are considerably improved in this way.

Dual function of membrane-bound heat shock protein 70 (Hsp70), Bag-4, and Hsp40: protection against radiation-induced effects and target structure for natural killer cells

CX+/CX- and Colo+/Colo- tumor sublines with stable heat shock protein 70 (Hsp70) high and low membrane expression were generated by fluorescence activated cell sorting of the parental human colon (CX2) and pancreas (Colo357) carcinoma cell lines, using an Hsp70-specific antibody. Two-parameter flow cytometry revealed that Hsp70 colocalizes with Bag-4, also termed silencer of death domain, not only in the cytosol but also on the plasma membrane. After nonlethal gamma-irradiation, the percentage of membrane-positive cells and the protein density of Hsp70 and Bag-4 were found to be strongly upregulated in carcinoma sublines with initially low expression levels (CX-, Colo-). Membrane expression of Hsp70 was also elevated in Bag-4 overexpressing HeLa cervix carcinoma cells when compared to neo-transfected cells. In response to gamma-irradiation, neo-transfected HeLa cells behaved like Hsp70/Bag-4 low-expressing CX- and Colo-, and Bag-4-transfected HeLa cells like Hsp70/Bag-4 high-expressing carcinoma sublines CX+ and Colo+. Immunoprecipitation studies further confirmed colocalization of Hsp70 and Bag-4 but also point to an association of Hsp70 and Hsp40 on the plasma membrane of CX+ and Colo+ cells; on CX- and Colo- tumor sublines, Hsp40 was detectable in the absence of Hsp70 and Bag-4. Other co-chaperones including Hsp60 and Hsp90 were neither found on the cell surface of CX+/CX-, Colo+/Colo- nor on HeLa neo-/HeLa Bag-4-transfected tumor cells. Functionally, Hsp70/Bag-4 and Hsp70/Hsp40 membrane-positive tumor cells appeared to be better protected against radiation-induced effects, including G2/M arrest and growth inhibition, on the one hand. On the other hand, membrane-bound Hsp70, but neither Bag-4 nor Hsp40, served as a recognition site for the cytolytic attack mediated by natural killer cells.

[The influence of ionizing radiation on the development of posterior capsule opacification in vitro]

BACKGROUND AND PURPOSE

Histologically, the posterior capsule opacification (PCO) corresponds to regenerative tissue of transformed lens epithelial cells (LECs) with extracellular matrix production. In this study, the influence of ionizing radiation on proliferating LECs and the development of PCO was investigated in vitro.

MATERIAL AND METHODS

Each four and 14 pork lenses, respectively, were irradiated with 6 MeV electrons with single doses of 8, 10, 12, and 20 Gy. 1-2 h after irradiation the lens was removed by capsulorrhexis and hydrodissection. After fixation of the capsular bag in a special device the proliferation of residual LECs was examined daily. The experiment was considered to be finished when the capsular bag was completely opacified by confluent cell proliferates.

RESULTS

Single dose irradiation with electrons in a dose range from 8 to 12 Gy significantly protracted the development of PCO with complete inhibition of PCO after application of 20 Gy.

CONCLUSION

To inhibit PCO in vitro, a single dose of 20 Gy is necessary. The actual in vitro model allows an optimal investigation of PCO formation under different external influences and is therefore very suitable for radiobiological questions.

Implantation of stimulation electrodes in the subretinal space to demonstrate cortical responses in Yucatan minipig in the course of visual prosthesis development

PURPOSE

During the course of the development of visual prostheses, subretinal stimulation films were implanted in micropigs in order to prove the feasibility of subretinal electrical stimulation with subsequent cortical response. One aim was to demonstrate that epidural recording of visual evoked potentials is possible in the micropig.

METHODS

Film-bound stimulation electrode arrays were placed in the subretinal space of micropigs. This enabled the retina to be stimulated subretinally. Since conventional visual evoked potential (VEP) measuring is virtually impossible in the pig from the neurosurgical point of view, epidural recording electrode arrays were positioned over the visual cortex as permanent electrodes.

RESULTS

The feasibility of temporary implantation of film-bound stimulation electrode arrays was successfully demonstrated in the micropig model. On stimulation with monopolar voltage pulses (1000 to 3000 mV), reproducible epidural VEP measurements (5 to 10 micronV) were detected.

CONCLUSIONS

The feasibility of subretinal stimulation of the retina was demonstrated in a retinal model that is similar to the human retina. This animal model therefore offers a suitable means of studying the tolerability of stimulation situations in the course of visual prosthesis development.

Clioquinol Treatment in Familiar Early Onset of Alzheimer’s Disease

Recently the metal chelator clioquinol (CQ) has been suggested as a possible option for treatment of Alzheimer's disease (AD). We report two patients with early onset of AD [one with a mutant amyloid-precursor-protein (APP) gene] who received long-term treatment with CQ. In both cases focally augmented cerebral glucose metabolism and stabilization but no amelioration of the clinical impression were observed without signs of neurotoxicity. In one case CSF-tau and beta-Amyloid (42/40) concentrations changed during CQ treatment.

The genetic causes of basal ganglia calcification, dementia, and bone cysts: DAP12 and TREM2

BACKGROUND

Polycystic lipomembranous osteodysplasia with sclerosing leukoencephalopathy (PLOSL), or Nasu-Hakola disease, is a presenile dementia associated with loss of myelin, basal ganglia calcification, and bone cysts. It is caused by recessively inherited mutations in two genes encoding subunits of a cell membrane-associated receptor complex: TREM2 and DAP12. The clinical course of PLOSL has not been characterized in a series of patients with TREM2 mutations.

METHODS

The authors compare neurologic and neuroradiologic follow-up data of six patients carrying TREM2 mutations with PLOSL due to defective DAP12 genes. The authors review the known mutations in these two genes.

RESULTS

Mutations in DAP12 and TREM2 result in a uniform disease phenotype. In Finnish and Japanese patients with PLOSL, DAP12 mutations predominate, whereas TREM2 is mutated more frequently elsewhere.

CONCLUSIONS

Polycystic lipomembranous osteodysplasia with sclerosing leukoencephalopathy should be considered in adult patients under age 50 years with dementia and basal ganglia calcification. Radiographs of ankles and wrists, and DNA test in uncertain cases, confirm the diagnosis.

Cardiovascular Risk Estimates and Risk Factors in Renal Transplant Recipients

Cardiovascular morbidity, including coronary artery disease and left ventricular hypertrophy, and mortality are high in patients following renal transplantation. Cardiovascular disease is thought to be due to traditional (hypertension, hyperlipidemia, diabetes mellitus and smoking) as well as nontraditional cardiovascular risk factors (microinflammation). Furthermore, immunosuppressive drugs, namely, calcineurin inhibitors, sirolimus, and steroids, have been reported to adversely affect cardiovascular risk factors (e.g., hypertension, hyperlipidemia, hyperglycemia). Evidence from comparative trials and from conversion studies suggest that blood pressure, hyperlipidemia, and hyperglycemia after renal transplantation may be differentially affected by the calcineurin inhibitors cyclosporine and tacrolimus. In the European Tacrolimus versus Cyclosporin A Microemulsion Renal Transplantation Study, 557 patients were randomly allocated to therapy with tacrolimus (n = 286) versus cyclosporine (n = 271). In addition, to blood pressure, serum cholesterol, HDL cholesterol, triglycerides, and blood glucose, we estimated the 10-year risk of coronary heart disease (Framingham risk score). Tacrolimus resulted in a significantly lower time-weighted average of serum cholesterol (P < .001), and mean arterial blood pressure (P < .05), but a higher time-weighted average of blood glucose (P < .01) than cyclosporine. Mean 10-year coronary artery disease risk estimate was significantly lower in men treated with tacrolimus, (10.0% versus 13.2%; P < .01) but was unchanged in women (4.7% versus 7.0%). Tacrolimus and cyclosporine microemulsion have compound-specific effects on cardiovascular risk factors that differentially affect the predicted rate of coronary artery disease.

[Differences in cerebral glucose metabolism between frontotemporal lobar degeneration and Alzheimer's disease]

OBJECTIVE

To describe differences in cerebral glucose metabolism between frontotemporal lobar degeneration (FTLD) and Alzheimer's disease (AD).

METHODS

14 patients with FTLD (7 f/7 m, mean age 60.1 years) and 14 patients with AD (7 f/7 m, mean age 59.5 years) were examined. [18F]FDG positron emission tomography (PET) scans were analysed with statistical nonparametric mapping (SnPM) and statistical parametric mapping (SPM99).

RESULTS

Significant decreases in glucose metabolism in FTLD compared to AD were detected in the left insula/left inferior frontal gyrus (Brodman area [BA]13, 45 and 47) and in the medial frontal gyrus bilaterally (BA10). A significant decrease in AD compared to FTLD was identified in the right middle temporal gyrus (BA39).

CONCLUSION

Cerebral PET could be a promising tool to discriminate FTLD from AD.