POS1397 USEFULNESS OF 18F-FDG PET/CT FOR POLYMYALGIA RHEUMATICA DIAGNOSIS

Background

Polymyalgia rheumatica (PMR) is an inflammatory disorder affecting elderly people. The diagnosis is based on clinical and imaging findings such as ultrasonography. The interest of 18F-fluorodeoxyglucose Positron Emission Tomography/Computed Tomography (18F-FDG PET/CT) in PMR is increasing. However, its exact place in the diagnosis or management of PMR patients remains unclear.

Objectives

We aimed to describe the utility 18F-FDG PET/CT for PMR diagnosis.

Methods

We performed an observational retrospective study of patients with new onset of PMR having a 18F-FDG PET/CT. Diagnosis of PMR was done according to ACR/EULAR 2012 classification criteria. A control group, including patients with sarcoidosis, neoplasia or infection, was also analyzed. The following sites were assessed for the presence of hypermetabolism (SUVmax ≥ 2): shoulders, acromioclavicular and sternoclaviculaire joints, hips, symphysis pubis, ischial tuberosities, great trochanters, cervical and lumbar interspinous process and large vessels. The number of hypermetabolic sites (0-18), the median SUVmax and the highest SUVmax were analyzed.

Results

A total of 85 PMR patients (60% of female, mean age 70.7 years) and 75 controls (51% of female, mean age 65 years) were analyzed. Among PMR patients, hypermetabolism was mostly observed in shoulders (93%), hips (91%), great trochanters (87%), ischial tuberosities (89%) and lumber interspinous process (71%). Large vessel vasculitis was only observed in 7% of PMR patients. In comparison to control patients, PMR had higher number of hypermetabolic sites (11.3 ±3.3 vs. 0.85 ±1.1, p<0.001), and mean SUVmax score (3.9 ±0.8 vs. 2.7 ±0.4, p<0.001). After adjustment to age, the number of hypermetabolic sites (OR 2.57 [1.84; 4.51], p<0.001) and the mean SUVmax were associated with the diagnosis of PMR (OR 1.49 [1.30; 1.78], p<0.001). Among PMR patients, the C-reactive protein (CRP) levels were correlated with the mean SUVmax (r=0.38, p<0.001), the number of hypermetabolic sites (r=0.34, p<0.01) and the highest SUVmax (r=0.38, p<0.001).

Conclusion

18F-FDG PET/CT appears to be a sensitive imaging for PMR. The number of hypermetabolic sites and the man SUVmax are correlated with CRP levels and PMR diagnosis.

Disclosure of Interests

None declared

Comparison of clockwise and counterclockwise right atrial flutter using high-resolution mapping

Background

To the best of our knowledge, few studies have been performed that explore the electrophysiological differences between clockwise (CW) and counterclockwise (CCW) right atrial (RA) cavotricuspid isthmus (CTI)-dependent atrial flutter (AFL) using the high-resolution Rhythmia mapping system. Objectives. Accordingly, our prospective cohort study, sought to compare CW and CCW CTI-dependent AFL in preselected pure right AFL patients (pts) using the ultra-high-definition (ultra-HD) Rhythmia mapping system. The study also aimed to mathematically develop a cartography model based on automatic velocity RA measurements to identify electrophysiological AFL specificities.

Methods and results

Between October 2019 and July 2020, 33 patients were recruited. The mean age was 71±13 years old. No difference was found concerning clinical variables between CCW AFL and CW AFL or regarding left ventricular ejection fraction (LVEF) (55.5±10 vs. 56.6±12; p=0.76). The AFL cycle length was very similar (248±20 vs. 252±28 ms; p=0.6). The sinus venosus (SV) block line was present in 32/33 of cases (97%) and no significant difference was found between CCW and CW CTI AFL (100% vs. 91%; p=0.7). No line was localized in the region of the crista terminalis (CT). A superior gap was present in the posterior line in 14/31 (45.2%) but this was similarly present in CCW AFL, when compared to CW AFL (10/22 [45.5%] vs. (4/10 [40%]); p=0.9). When present, the extension of the posterior line of block was observed in 18/31 pts (58%) without significant differences between CCW and CW CI AFL (12/22 [54.5%] vs. (6/10 [60%]) (p=.9) The Eustachian ridge line of block was similarly present in both groups (82% [18/22] vs. 45.5% [5/11]; p=0.2). The absence of the Eustachian ridge line of block led to significantly slowed velocity in this area (28±10cm/s; n=8),and the velocities were similarly altered between both groups (26±10 [4/22] vs. 29.8±11cm/s [4/11]; p=0.6). We created mathematical, three-dimensional RA reconstruction-velocity model measurements. In each block localization, when the block line was absent, velocity was significantly slowed (≤20cm/s). A systematic slowdown in conduction velocity was observed at the entrance and exit of the CTI in 100% of cases. This alteration to the conduction entrance was localized at the lateral side of the CTI for the CCW AFL and at the septal side of the CTI for CW AFL. The exit-conduction alteration was localized at the CTI septal side for the CCW AFL and at the CTI lateral side for the CW AFL. The only differences between CW and CCW AFL concerned activation patterns.

Conclusions

The ultra-HD Rhythmia mapping system confirmed the absence of significant electrophysiological differences between CCW and CW AFL. The mechanistic posterior SV and Eustachian ridge block lines were confirmed in each arrhythmia. A systematic slowing down at the entrance and exit of the CTI was demonstrated in both CCW and CW AFL, but in reverse positions.

Funding Acknowledgement

Type of funding sources: None.

Is transesophageal echocardiogram mandatory for patients undergoing ablation for right atrial flutter with uninterrupted anticoagulants? A prospective single registry

Funding Acknowledgements

Type of funding sources: None.

Background. Limited data exist regarding the prevalence of left atrial appendage (LAA) thrombi and spontaneous echocardiographic contrast (SEC) in patients with atrial flutter (AFL). Objectives. Our prospective single-center observational study sought to evaluate the prevalence of LAA thrombi in patients referred for AFL ablation, compared to those requiring atrial fibrillation (AFib) ablation during the same time period, as well as to determine the predictive factors of LAA thrombi in terms of arrhythmia etiology. Methods and Results. From July 2019 to August 2020, 321 consecutive patients who were referred for either AFib ablation (n = 229) or AFL ablation (n = 92) were included in the study, with a thrombus detected by transesophageal echocardiography (TEE) in 3.22% (12/321). Prior to ablation under anticoagulants, the percentage of thrombi was similar between patients referred for AFL ablation and those referred for AFib ablation (5.4% [n = 5/92] vs. 3.1% [n = 7/229]; p = 0.3). In the overall population, patients with LAA thrombi had a higher CHA²DS²-VASc score (3 ± 2 vs. 2 ± 1.5; p = 0.048) and a higher presence of valvular prothesis (25% vs. 4.9%; p = 0.003), with relevant left atrial remodeling  more often observed, such as demonstrated by a higher left atrium (LA) volume (57 ± 19 vs. 46 ± 17 ml/m²; p = 0.04), a lower LAA velocity (0.41 ± 0.3 vs. 0.55 ± 0.2; p = 0.04) and a more severe LAA echo contrast (83.3% vs. 3.2%; p &lt;0.0001). In the subset of patients with right AFL, patients with LAA thrombi had a higher CHA²DS²-VASc score (4.4 ± 1 vs. 2.5 ± 1.5; p = 0.008), had more often hypertension (100% vs. 53%; p = 0.04) and more often diabetes mellitus (60% vs. 18.4%; p = 0.03), and a more severe LAA echo contrast (80% vs. 5.7%; p &lt;0.0001). Predictive factors of atrial thrombi evaluated by crude odds ratios were the presence of valvular prosthesis (OR = 6.53; [1.60, 26.65] ; p = 0.009), the CHA²DS²-VASc score (OR = 1.41 [0.99, 2.01] ; p = 0.05), the LAA velocity (cm/s) (OR = 0.03; [0.001, 0.79]; p = 0.04) and presence of severe LAA contrast (OR = 188 ; [35.32, 1002.02] ; &lt;0.0001) rather than the atrial arrhythmia itself. Conclusions. Patients referred for ablation with right AFL have a similar risk of LAA thrombi, compared to those with AFib. The risk of LAA thrombi is better related to the presence of valvular prosthesis, CHA²DS²-VASc score and LA remodelling than the atrial arrhythmia itself. Accordingly, TEE should be recommended before right AFL ablation, especially in case of a valvular prosthesis, high CHA²DS²-VASc score or LA alteration.

Metastatic Renal Cell Carcinoma in a Renal Allograft: A Sustained Complete Remission After Stimulated Rejection

We report the case of a 40-year-old woman who recovered from a diffuse metastatic renal cell carcinoma that developed from a kidney allograft. She was successfully treated by the induction of tumor rejection. Immunosuppression was discontinued, and transplant nephrectomy was deliberately delayed based on the expectation that the tumor mass would trigger the alloimmune response, which was stimulated with pegylated interferon-α-2a. Three years later, the patient remained in complete remission. Despite this severe context, the present case shows that the poor prognosis of allograft metastatic renal cell carcinoma could be dramatically reversed by taking advantage of the donor tumor origin to actively induce a specific alloimmune rejection of the tumor.

[Gastric pneumatosis complicated by a neonatal digestive occlusion]

Gastric pneumatosis is a rare pathology. Its occurrence in the neonatal period requires looking for ulcerative-necrotizing enterocolitis in a context of prematurity or an underlying surgical obstacle. We report a case of gastric pneumatosis at a newborn child born at term, admitted on the third day of life for neonatal occlusion with a flat stomach. The abdomen without preparation showed substantial gastric distension with aspects of gastric pneumatosis and embellishes with images showing a double gastric bubble. The surgical exploration showed gastric pneumatosis, complete duodenal atresia located at the level of the second duodenal portion, and an annular pancreas. Progression was favorable after duodenostomy.

Cognitive patterns in subtypes of schizophrenia

AIM

Because of the heterogeneity of schizophrenia, this study researched different cognitive patterns in distinct subtypes of schizophrenic patients.

METHODS

Thirty-five Diagnostic and Statistical Manual IV (DSM IV) schizophrenic patients and 35 healthy controls were included. Patients were categorized into deficit, disorganized and positive subtypes with the schedule for the deficit syndrome (SDS) and the positive and negative syndrome scale (PANSS). Executive/attentional functions were assessed with the modified card sorting test (MCST), a test of verbal fluency, the trail making test (TMT) and the Stroop color-word test (Stroop test). Episodic memory was explored through the California verbal learning test (CVLT).

RESULTS

The positive subtype had some executive/attentional (fluency and Stroop tests) and mnesic performances in the normal range, suggesting the preservation of good cognitive skills. In contrast, the deficit and disorganized subtypes had major mnesic and executive/attentional dysfunctions compared to healthy subjects. The deficit subtype compared to the control group performed predominantly worse on the MCST and fluency, whereas the disorganized subtype had the lowest scores on the TMT and the Stroop test.

CONCLUSION

This study showed distinct cognitive patterns in deficit, disorganized and positive patients in comparison with the controls, suggesting a heterogeneous cognitive dysfunction in schizophrenia.

[Eye tracking disorders in schizophrenic patients and their parents]

Several studies have confirmed the existence of genetic factors in schizophrenia. However, the genotype predisposing for the disease is not known yet. Nevertheless, those genetic factors in the families of schizophrenic patients urge us to search for genetic vulnerability markers of schizophrenia. Ocular pursuit disorders, in particular, could be one of those vulnerability markers. Eye movements have been often tested in schizophrenia. Most of the schizophrenic patients have eye-tracking disorders and their biological relatives demonstrate an increased prevalence of eye-tracking impairments. The aim of the study was to research if smooth pursuit eye movements could be a vulnerability marker of schizophrenia. In order to have an indication about this hypothesis, impairments of smooth pursuit eye movements were researched in both schizophrenics and their parents.

METHODS

Fifteen DSM IV schizophrenic patients stabilized at the time of the inclusion and not treated with lithium, benzodiazepines, barbiturates, or chloral hydrate; 19 parents without history of schizophrenic spectrum disorders (SADSLA and IPDE), and 2 groups of healthy subjects matched in age and sex with probands and with the parents, were included in the study. Parents only were included (fathers or mothers) in order to have an homogeneous population for the genetic risk and age. The eye-tracking paradigm used was a smooth pursuit task. The stimulus was a sinusoidal wave form moving on a horizontal line, with a frequency of 0.4 Hz and an amplitude of 30 degrees. Different parameters were measured: gain (ratio between the eye velocity and the target velocity) and saccades frequencies (catch-up saccades, back-up saccades, anticipatory saccades and square-wave-jerks). For each parameter, analysis of covariance (ANCOVA) with age as covariable was carried out. For the results reaching the significance of 0.05, the Bonferroni correction was applied (level of significance 0.016). The effect size of the parameter was calculated ((the mean of the subjects minus the mean of the matched controls) divided by standard deviation of the two groups). According to Cohen, 0.20 indicates a small effect size, 0.50 indicates a medium effect size and 0.80 indicates a large effect size.

RESULTS

Comparison between patients and matched controls: the means of global gain, of gain for the movements to the left and of gain for the movements to the right did not differ significantly between patients and their matched controls. The size effects are 0.31 for the global gain, 0.20 for the movements to the left and 0.41 for the movements to the right. The frequencies of total saccades, catch-up saccades, back-up saccades, anticipatory saccades and square-wave-jerks did not differ significantly between patients and their controls. The size effects for those parameters were 0.09, 0.03, 0.00, 0.39 and 0.63 respectively. Comparison between parents and matched controls: the means of global gain, of gain for the movements to the left and of gain for the movements to the right did not differ significantly between the two groups. The size effects for those parameters were 0.00, 0.05 and 0.17 respectively. The frequency of total saccades did not differ significantly between the groups whereas the size effect was 0.63. The frequency of catch-up saccades was significantly more important in parents than in controls (p = 0.006) and the size effect was 0.80. The other saccadic parameters did not differ significantly between groups, their size effects were 0.24 for the back-up saccades, 0.21 for the anticipatory saccades and 0.00 for the square-wave-jerks. Whereas the gain of the patients had a tendency to be lower than the gain of their controls, no significant difference was observed between patients and their controls. Only a size effect of 0.63 for the frequency of square-wave-jerks was obtained. This large effect size suggests that the difference between patients and controls might be significant in a larger sample. The catch-up saccades frequency between parents and controls was significant. The differences between our study and the previous studies could be due to several factors. The paradigms used were different between the studies and our sample was small (only 15 patients and 19 relatives). Moreover, some patients in the previous studies were treated by lithium, drug well known to modify ocular pursuit and, finally the relatives in the other studies were 10 years older than ours and age is known to alter ocular pursuit. Since an impairment of the smooth pursuit was observed in the relatives of schizophrenic patients but not in the probands, this study does not support the hypothesis that eye-tracking disorders could be considered as a marker of vulnerability of schizophrenia.

Disorders in intentional gestural organization in Alzheimer's disease: combined or selective impairment of the conceptual and production systems?

This study examines disorders which affect the intentional gestural organization in Alzheimer's disease. An original and prospective protocol which assessed both the conceptual and production systems (with reference to the Roy and Square model 1985) was presented to 16 patients with Alzheimer's disease (mild to moderate dementia) and 40 healthy elderly subjects. Our study showed impairment of both systems in the Alzheimer's patients group. Two patients presented reverse performance profiles, which were characterized in one case by preservation of the conceptual system and impairment of the production system and in the other by the reverse dissociation. The findings demonstrated that disorders in the intentional gestural organization in Alzheimer's disease usually affect both the conceptual and production systems. The hypothesis concerning the existence of two functionally distinct systems underlying the organization of intentional body movement was corroborated (1) by a lack of significant correlation between the scores obtained in the assessment of the two systems and (2) by the demonstration of the double dissociation.

Cystic fibrosis-related diabetes mellitus: clinical impact of prediabetes and effects of insulin therapy

In patients with cystic fibrosis (CF), glucose intolerance preceding diabetes (prediabetes) may have adverse effects on nutritional status and respiratory function, which are reversible after the start of insulin therapy. Respiratory function (forced vital capacity and forced expiratory volume in one second) and body mass index (BMI) were compared retrospectively in a French cohort of 14 patients during the 5 y preceding insulin therapy for diabetes and in 14 age- and sex-matched controls with normal oral glucose tolerance tests. In the diabetic group, all three parameters deviated increasingly from the values in the controls; the differences became statistically different during the 6 mo before insulin therapy. The effect was more important in patients for whom diabetes mellitus was diagnosed on the basis of symptoms of hyperglycaemia than in patients for whom it was diagnosed by systematic screening, but still present in the latter. After insulin was started, respiratory function improved and the BMI returned to normal within 1 y. The annual insulin requirement increased from 0.62 during the first year to 1.25 during the fifth year. Glycosylated haemoglobin (HbAIc) values ranged from 6.6 to 7.8%. Only 2 episodes of severe hypoglycaemia were recorded over 42 patient-years of follow-up. The insulin regimen most often used was two daily injections of a mixture of short- and intermediate-acting insulin (n = 10) given with an insulin pen.

CONCLUSION

The clinical status of CF patients who will need insulin therapy deteriorates before the start of insulin. In patients with CF-related diabetes, with or without fasting hyperglycaemia, insulin therapy improves anabolism and provides good glycaemic control with few severe hypoglycaemic episodes.

Cognitive processes involved in delayed non-matching-to-sample performance in Parkinson's disease

Visual recognition memory was assessed in terms of delay duration, memory load and amount of interference(s) in non-demented patients with Parkinson's disease (PD) using an automated delayed non-matching-to-sample (DNMS) task with trial-unique stimuli. Special attention was focused on the different cognitive functions engaged by these patients in solving this recognition memory task. Thirteen patients with PD, carefully selected according to their stable regimen and anticholinergic medication, were compared to 12 controls matched by age and educational level. Besides the DNMS task, a neuropsychological battery that included tasks carefully selected according to processes potentially required to perform the DNMS task (e.g. attention, executive functions, visual discrimination and motor speed) was administered to the subjects. As compared with controls, patients with PD showed a deficit on most DNMS subscores, except those requiring the least cognitive load. The correlative analysis between the DNMS and other neuropsychological tasks suggests involvement of long-term memory mainly in the DNMS performance for the control group, contrasting with a major involvement of executive functions for the patients with PD. These data indicate that visual recognition memory impairment in non-demented patients with PD is largely due to an executive dysfunction, notably in working memory. Several hypotheses are proposed concerning the neuronal substrates underlying the impairment on the visual DNMS task in PD.

Evaluation of air trapping at CT: comparison of continuous-versus suspended-expiration CT techniques

PURPOSE

To compare thin-section computed tomographic (CT) scans obtained during suspended end expiration with helical CT scans obtained during continuous expiration for the assessment of air trapping.

MATERIALS AND METHODS

Forty-nine patients with an airway disease were examined with suspended-end-expiration CT after a 6-8-second expiratory maneuver, which was followed with continuous-expiration CT during a 10-second expiratory maneuver. The extent of expiratory air-trapping areas was calculated by two observers by using a semiquantitative grid score. The relative decrease in attenuation in the areas of air trapping was evaluated with a visual continuous-scale score.

RESULTS

Air trapping was noted in 36 and 35 patients with continuous-expiration CT and with suspended-end-inspiration CT, respectively. The extents of and relative attenuation decreases in air-trapping areas in patients with air-trapping areas on at least one expiratory CT scan increased significantly in scans obtained with continuous-expiration CT compared with those obtained with suspended-end-expiration CT, respectively, with mean extent scores of 0.24 +/- 0.20 (SD) and 0.18 +/- 0.20 (paired t test, P: =.001) respectively, and with mean relative contrast decrease scores of 0.35 +/- 0.23 and 0.27 +/- 0.23 (paired t test, P: =.007), respectively.

CONCLUSION

When suspended-end-expiration CT images are ambiguous, complementary continuous-expiration CT can be used to improve the conspicuity and apparent extent of air trapping.

Non-invasive grading of oligodendrogliomas: correlation between in vivo metabolic pattern and histopathology

Several studies have shown that the prognosis of oligodendrogliomas is dependent on their histological grade. In order to identify a non-invasive method for the primary diagnosis and follow-up of these tumours, we investigated the relationship between their in vivo metabolism, assessed by positron emission tomography (PET), and their histological grade assessed at the same time. Forty-seven patients with histologically confirmed oligodendrogliomas were investigated. Conventional neuroradiological assessment by computed tomography and magnetic resonance imaging (MRI) was performed in all the patients. All the histology slices were reviewed by the same pathologist after referral from various pathology laboratories. The PET investigation included a carbon-1 methionine (11C-MET) uptake study and, in the majority of cases, a fluorine-18 fluorodeoxyglucose (18F-FDG) uptake study, in order to investigate at the same time both amino acid metabolism and glycolysis. The sampled tumour region of interest (ROI) was defined from the T1-weighted 3D MR scan matched with the PET scan. Tracer concentration in each voxel of the tumour ROI was divided by the mean concentration in an ROI of the same size located in the healthy brain tissue. For each tumour and each tracer, we characterized the metabolic pattern on the basis of the mean and the maximum tumour to healthy tissue concentration ratio, and also the standard deviation and range of the ratios, which indicate the degree of metabolic heterogeneity of the tumour. The histological criteria for differentiating between high- and low-grade tumours were those of the WHO and, partially, of the Sainte-Anne-Daumas-Duport classification. Highly significant differences between high- and low-grade oligodendrogliomas (Mann-Whitney test: P<0.0001) were observed for all the assessed parameters of 11C-MET uptake. On the other hand, the pattern of 18F-FDG uptake showed only moderate differences between the two tumour groups.

Type 1 diabetic children have abnormal lipid profiles during pubertal years

AIM/HYPOTHESIS

To study the prevalence of hypercholesterolemia, hypertriglyceridemia and the relationship between metabolic control, pubertal status and plasma lipoprotein levels in children with diabetes mellitus.

SUBJECTS AND METHODS

A cross-sectional study was conducted on 126 subjects with type I diabetes followed at our institution. There were 57 boys and 69 girls (mean age: 13.4+/-3.4 yr; mean duration of diabetes: 7.3+/-2.1 yr), on whom fasting lipoprotein levels and pubertal status were determined. Mean glycated hemoglobin (HbA1c) of the preceding year was used in the analysis. Cholesterol (CT) and triglyceride (TG) levels were transformed into standard deviations (SD) using age dependent normal values.

RESULTS

1) CT levels of DM children (mean level: +0.9+/-1.2 SD) are higher for both sexes and at each age. Sixteen percent of the cases had CT level > or =2 SD. Within the range of the HbA1c observed (9.1+/-1.2%), CT levels are not correlated with the degree of metabolic control. In contrast to non-diabetic children, CT levels of the diabetic children did not vary throughout pubertal stages. CT levels correlated highly with apolipoprotein B (r=0.79; p<0.00001 and r(2)=82%, in univariate and multivariate analysis, respectively. 2) Plasma TG levels are comparable in the diabetic children (mean level: -0.11+/-0.9 SD) and non-diabetic children. Only 5% of the diabetic children have a TG level > or =2 SD. The TG levels are significantly, but weakly, positively correlated with duration of diabetes and the degree of metabolic control (r(2)=12% and 16%, respectively, p<0.0001 for both).

CONCLUSIONS

Plasma CT levels of type I diabetic children are increased in comparison to non-diabetic children and do not follow the usual decreasing pattern during puberty.

Proton magnetic resonance spectroscopy of the medial prefrontal cortex in patients with deficit schizophrenia: preliminary report

OBJECTIVE

Proton magnetic resonance spectroscopy (1H-MRS) was used to study medial prefrontal metabolic impairments in schizophrenic patients with the deficit syndrome.

METHOD

The subjects were 22 schizophrenic patients categorized as deficit (N=5) or nondeficit (N=17) and 21 healthy subjects. (1)H-MRS was performed for the right and the left medial prefrontal cortex.

RESULTS

The patients with the deficit syndrome had significantly lower ratios of N-acetylaspartate to creatine plus phosphocreatine than did the healthy subjects or nondeficit patients.

CONCLUSIONS

As N-acetylaspartate levels could reflect neuronal density and/or viability, this finding suggests a neuronal loss in the medial prefrontal cortex of deficit patients.

Picture naming without Broca's and Wernicke's area

Lexical and semantic retrieval was investigated in normal volunteers with PET by comparing picture confrontation naming and verb generation related to the same pictures. Conjunction analysis of the naming and verb generation uncovered a common network including the occipito-temporal ventral pathway for object recognition, and the bilateral anterior insula, SMA and precentral gyrus for coordination, planning and overt word production. Naming and verb generation highlighted two different patterns: verb generation showed specific implication of Broca and Wernicke's areas, whereas naming specifically relied on the primary visual areas, the right fusiform and parahippocampal gyri and the left anterior temporal region. These results indicate that speech does not necessarily involve the Wernicke-Broca's language network and testify that naming relies on an early developmental language network.

Predictive value of (99m)Tc-HMPAO-SPECT for neurological Outcome/Recovery at the acute stage of stroke

BACKGROUND AND PURPOSE

Combined perfusion and oxygen metabolism PET imaging is highly predictive of spontaneous outcome after middle cerebral artery (MCA) stroke, independent of clinical scores, but whether the assessment of perfusion alone by SPECT provides similar information remains unclear. We have assessed the prognostic value of (99m)Tc-HMPAO-SPECT at the acute stage of stroke.

METHODS

Twenty-seven first-ever nonhemorrhagic MCA territory stroke patients were prospectively studied 4-20 h (mean: 12 h) after onset with (99m)Tc-HMPAO-SPECT. None was part of a therapeutic trial or received thrombolysis. Neurological deficits were quantified at admission and 2 months later with Orgogozo's MCA scale. SPECT images were visually classified by 3 independent observers into one of three patterns, as follows: pattern I = marked and extensive tracer hypofixation; pattern II = moderate and/or focal hypofixation with or without combined hyperfixation, and pattern III = normal or increased uptake without hypofixation. In addition to this visual analysis, we also calculated a voxel-based 'hypoperfusion score', an index of severity x extent of hypofixation according to Mountz's method.

RESULTS

There was a good intra- and interobserver agreement. After consensus, 9, 14 and 4 patients were classified in patterns I, II and III, respectively. These patterns had a significant predictive value for raw outcome but not for percentage recovery (p = 0.008 and p = 0.127, respectively). Thus, all patients in pattern III had a good outcome, while most (but not all) patients in pattern I had a poor or intermediate outcome; pattern II patients were more evenly distributed among outcomes. Hypoperfusion scores were highly significantly positively correlated with both 2-month outcomes and percentage recoveries, even after controlling the predictive value of day 0 MCA scores by partial correlations.

COMMENTS

We found that SPECT had a significant added predictive value even when compared to admission neurological scores. Although less accurate than PET, (99m)Tc-HMPAO-SPECT may help to predict spontaneous individual neurological evolution, especially whenever perfusion images are normal or show an increased tracer uptake without associated hypofixation.

Voxel-based mapping of irreversible ischaemic damage with PET in acute stroke

Objective mapping of irreversible tissue damage in the acute stage of ischaemic stroke would be useful for prognosis and in assessing the efficacy of therapeutic manoeuvres in impeding extension of infarction. From our database of 30 patients studied with 15O-PET within 5-18 h after onset of first-ever middle cerebral artery territory stroke, we extracted a subgroup of 19 survivors (age 74.6 +/- 8.5 years) in whom late CT coregistered with PET was available to determine final infarct topography. By means of a voxel-based analysis of the PET data, we determined putative thresholds for irreversible tissue damage as the lower limit of the 95% confidence interval calculated from all voxels within the ultimately non-infarcted brain parenchyma ipsilateral to the insult. The following values were found: 8.43 ml/100 ml/min, 0.87 ml/100 ml/min, 1.64 ml/100 ml, 0.27 and 2.21/min, for cerebral blood flow (CBF), oxygen consumption (CMRO2), blood volume (CBV), oxygen extraction fraction and the ratio CBF : CBV, respectively. Voxels below these thresholds occurred significantly more frequently in the final infarct region than in the non-infarcted parenchyma for CBF and CMRO2 (P = 0.016 and P = 0.0045, respectively, Wilcoxon test), but not for the other PET variables. Furthermore, with both CBF and CMRO2, the percentage of irreversible tissue damage voxels in the affected hemisphere relative to the opposite hemisphere was significantly positively correlated to both the volume of final infarct and the neurological outcome at 2 months (all P < 0.005, Spearman ranked test). These findings validate our voxel-based CBF and CMRO2 thresholds for probabilistic mapping of irreversible tissue damage within the 5-18 h interval after stroke onset; however, whether they would be applicable to earlier intervals remains to be determined. Transfer of our procedure for determination of irreversible tissue damage thresholds to other imaging modalities such as single proton emission computed tomography and diffusion-weighted MRI should be straightforward.

SAPHO syndrome: a long-term follow-up study of 120 cases

OBJECTIVE

To assess the long-term outcome of the synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) syndrome.

METHODS

All patients with the SAPHO syndrome seen at our unit between 1974 and 1997 were identified. Follow-up was prospective from 1992 to 1997. Data before 1992 were analyzed retrospectively. Clinical symptoms, treatments and biological data, including erythrocyte sedimentation rate and C-reactive protein, were recorded at least yearly. When available, radiological data, HLA B27 status, and findings from bone or skin biopsy specimens were recorded. For each drug, an efficacy index (El) was determined as follows: "0" for less than 30% improvement, as judged by the patient, on horizontal visual analog scale, "0.5" for partial efficacy, and "1" for more than 60% improvement.

RESULTS

We identified 120 patients with the SAPHO syndrome (50 men, 70 women), of whom 102 patients were followed-up prospectively after 1992; 3 of these 102 patients were lost to follow-up. Six patients also had Crohn's disease, and three had ulcerative colitis. Except for a significant association of palmoplantar pustulosis (PPP) or psoriasis vulgaris (PV) with axial osteitis (P = .007), the dermatologic presentation had no significant influence on rheumatic symptoms (ie, osteitis or arthritis, peripheral or axial). The HLA B27 antigen was not significantly associated with a particular pattern of distribution of arthritis or osteitis. No severe or disabling complications were noted. In the 47 patients followed-up for more than 5 years (mean, 9.5; range, 5 to 23), the mean number of osteitis or arthritis foci increased during follow-up from 1.57 to 1.91 and from 2.68 to 3.11, respectively. Nonsteroidal antiinflammatory drugs (NSAIDs) were prescribed in 113 of 120 (94%) patients, with a mean El of 0.67 (+/-0.39). Corticosteroid (CS) therapy was used in 23 patients, with a mean El of 0.67 (+/-0.42). Colchicine and sulfasalazine had a mean El of 0.36 (+/-0.44) and 0.16 (+/-0.30), in 28 and 18 patients, respectively. Methotrexate was given to 10 patients (6 with peripheral arthritis), with a mean El of 0.64 (+/-0.48). Doxycyclin (100 mg twice daily) was used in 20 patients, usually to treat osteitis, with a mean El of 0.26 (+/-0.42). Intraarticular injections of a CS or osmic acid were used in 27 patients, with a mean El of 0.77 (+/-0.35).

CONCLUSIONS

SAPHO syndrome is a relevant and stable entity, with a good long-term prognosis. NSAIDs and intraarticular injections (CS or osmic acid) most often alleviate rheumatic symptoms, but prednisone or methotrexate are sometimes necessary and appear globally helpful.

Cardiorespiratory exercise tolerance in asymptomatic children with Ebstein's anomaly

The aim of the study was to evaluate cardiorespiratory exercise tolerance in asymptomatic children with Ebstein's anomaly. Eleven children with a mean age of 9.6 years were prospectively studied by spirometry, cardiopulmonary exercise testing (bicycle ergometer n = 8, treadmill test n = 3), and contrast echocardiography. A right-to-left atrial shunt was detected by contrast echocardiography in 7 children (group 1), whereas no shunt was found in 4 (group 2). VO2 max was decreased [84.5 (SD = 16.8)] and was strongly correlated to oxygen saturation in group 1 (p < 0.0001). Oxygen saturation at peak uptake was significantly decreased compared to baseline [97.4 (SD = 2.0) vs 90% (SD = 9.5%), p = 0.02] and was significantly lower in group 1 than in group 2 [85.7 (2.2) vs 98.2% (SD = 1.2%), p = 0. 03]. Oxygen desaturation was related to a right-to-left atrial shunt (p = 0.01). Decreased VO2 max was also correlated to the small size of the left ventricle (p = 0.05). We concluded that decreased exercise tolerance in children with asymptomatic Ebstein's anomaly is related to a right-to-left atrial shunt and to a small left ventricle. In case of poor exercise tolerance, a contrast echocardiography should be performed to detect an atrial septal defect.

[Role of right-to-left atrial shunt in exercise tolerance of patients with Ebstein anomaly]

The aim of this study was to assess cardiorespiratory tolerance to exercise in children with non-operated, paucisymptomatic and untreated froms of Ebstein's anomaly. The authors undertook a prospective study in 11 children, mean age 9.6 years, who had lung function tests, cardiorespiratory exercise stress tests (bicycle ergometry N = 8, treadmill N = 3) and contrast echocardiography. All parameters of spirometry were normal. Contrast echocardiography showed a right-to-left interatrial shunt in 7 children (group 1) whereas the remaining 4 children had no shunt (group 2). The resting oxygen saturation was 97.4 +/- 2%, with no difference between the two groups. On the other hand, oxygen saturation at peak VO2 (VO2 max) was 90 +/- 9.5%, significantly lower in group 1 than in group 2 (85.7 +/- 2.2% vs 98.2 +/- 1.2%; p = 0.03). In group 1, the VO2 max was correlated to oxygen saturation (r = 0.98; p < 0.001, N = 6). The oxygen desaturation was correlated with presence of a right-to-left interatrial shunt (p = 0.01). The reduced exercise tolerance of non-operated, paucisymptomatic children with Ebstein's anomaly is due to a right-to-left interatrial shunt. In patients with poor exercise tolerance, contrast echocardiography is advised for the detection of these atrial shunts.

Relationships between trait and state anxiety and the central benzodiazepine receptor: a PET study

The central benzodiazepine receptor (cBZr) has long been implicated in anxiety disorders on the basis of: (i) the well-known anxiolytic and anxiogenic properties of cBZr agonists and inverse agonists, respectively; (ii) a possibly reduced sensitivity to benzodiazepines in anxious subjects; and (iii) a putative endogenous ligand. Thus, two main hypothesis have been advanced, namely changes in the concentration or properties of the latter, and changes in the GABAA complex conformation, which contains the cBZr. Neither postmortem studies nor appropriate animal models are available to investigate these ideas. We have used positron emission tomography (PET) to measure both the density and affinity of the cBZr in multiple brain regions in unmedicated patients and age- and sex-matched healthy volunteers, and have looked for differences between groups as well as correlations between cBZr parameters and state and trait anxiety scores. We studied 10 unmedicated patients (sex ratio 1 : 1; mean age: 39 years), prospectively recruited using DSM III-R criteria, and 10 age- and gender-matched healthy unmedicated volunteers. Thanks to a PET procedure using two successive administrations of 11C-flumazenil (at high and low specific radioactivity) and previously validated by us, we estimated the Bmax, Kd and bound : free (B/F) ratios in 11 neocortical areas and in the cerebellum. Before and after the PET session, anxiety scores from Spielberger's and Covi's scales were obtained. There was no statistically significant difference in Bmax, Kd or B/F-values between the two groups for any region. Across the two groups, there were only a few marginally significant anxiety-score-PET correlations, suggesting chance findings. This is the first fully quantitative study to report on the relationships between cBZr parameters and anxiety. Using two independent approaches (i.e. group comparison and across-group correlations), we found no evidence for a link between anxiety trait or state and the cBZr in neocortex or cerebellum in this sample. These findings, if confirmed by studies on larger samples, have implications for the pharmacotherapy of anxiety disorders, and will need to be considered when designing new neurobiological models of anxiety.

Longitudinal determination of antiphospholipid antibodies in lupus patients without previous manifestations of antiphospholipid syndrome. A prospective study

OBJECTIVE

To investigate whether serial anticardiolipin determination contributes to the clinical management of patients with systemic lupus erythematosus (SLE) with no previous sign of the antiphospholipid syndrome (APS).

METHODS

In 90 patients with SLE with no previous clinical manifestations of the APS, repeated clinical evaluations were performed, and serial blood samples (obtained over a 30 month period, range 13-53 mo) were screened for antiphospholipid antibodies (aPL). Anticardiolipin antibodies (aCL) were detected using an ELISA and considered positive if the result was >25 GPL on 2 separate occasions. Patients were not required to be on a specific treatment regimen during the study.

RESULTS

Thirty-four patients (37%) had at least one positive ELISA and 11 (11/90, 12%) 2 positive ELISA for IgG aCL during the study. Lupus anticoagulant (LAC) was found in 16 patients, and a false positive VDRL in 5. At study completion, the total number of clinical or laboratory events associated with APS was 30. In univariate analysis, aCL was significantly associated only with LAC (p<0.012). Presence of aCL also correlated with hemoglobin level, anti-DNA antibody, leukocyte count, and the SLE Disease Activity Index (SLEDAI). LAC and aCL were significantly associated with each other (OR 5.17; 95% CI 1.5-17.7), but LAC had a better positive predictive value than aCL for arterial thrombosis and neurological events.

CONCLUSION

Among our patients with SLE without previous clinical manifestations of APS, positive aCL did not predict the occurrence of APS within the next 3 years, but was statistically related to the clinical disease activity (SLEDAI).

Anti-Sa antibody is an accurate diagnostic and prognostic marker in adult rheumatoid arthritis

OBJECTIVES

To evaluate in various groups of patients with chronic joint disease the sensitivity and specificity of anti-Sa antibody, recently described in sera from adults with rheumatoid arthritis (RA); and to determine the prognostic significance of anti-Sa in initial sera from patients with long standing RA with or without severe joint destruction.

METHODS

Serum samples from 489 patients were included. Of these, 154 were collected from patients with RA attending 2 rheumatology units. Controls were 335 patients with a variety of inflammatory joint diseases other than RA. IgG anti-Sa was detected using an immunoblotting method with purified Sa antigen from human placenta extracts. All patients were tested for the following antibodies: rheumatoid factor (RF), anti-keratin antibody (AKA), antiperinuclear factor (APF), and anti-RA 33. HLA class II DRB alleles were also determined.

RESULTS

Anti-Sa was detected in 39.8% of RA sera overall, 46.7% of sera from the long standing RA group, and 23.5% of sera from the recent onset RA group (p<0.01). In patients with long standing RA, statistically significant associations were found between the presence of anti-Sa and the following variables: RF (p<0.0001), AKA (p<0.0001), APF (p<0.00001), and HLA DRB1*04 or 01 (p<0.01). In contrast, no association was found with anti-RA33. Anti-Sa was positive in 11 adult controls (7.8%) and in 26 pediatric patients with juvenile chronic arthritis (22%). The specificity of anti-Sa for RA was 92.1% in adults with well characterized rheumatic diseases and 85.9% in adults and children together. Among patients with long standing RA, those with destructive disease were more likely to test positive for anti-Sa (66.6%) than those with nondestructive disease (22.2%) (p<0.0001). Comparisons with other serologic markers for RA demonstrated that anti-Sa was sensitive (68.4%) and was also the test with the highest specificity (79%), positive predictive value (75%), and negative predictive value (71%) for discriminating between patients who do and those that do not develop late severe radiographic damage.

CONCLUSION

Immunoblot-detected IgG anti-Sa is a sensitive serologic marker for RA patients with severe radiographic damage.

The neural substrates of memory systems impairment in Alzheimer's disease. A PET study of resting brain glucose utilization

The aim of this study was to determine the neuronal basis for memory impairment in Alzheimer's disease by taking advantage of the clinical and metabolic heterogeneity of this pathology. To this end, 19 patients satisfying the NINCDSADRDA criteria for probably Alzheimer's disease of mild-to-moderate severity underwent a detailed examination of the five memory systems according to Tulving's model, together with a PET measurement of resting regional cerebral glucose utilization (CMRGlc). Compared with controls, the patients as a group showed the expected memory and metabolic profiles of impairment. Correlations (corrected for the effects of ageing) were calculated between memory scores and CMRGlc (normalized by the vermis CMRGlc) using two methods: (i) the classic regions-of-interest method, based on a priori hypotheses and individual coregistered structural MRI; and (ii) the statistical parametric mapping method which allows a systematic voxel-by-voxel analysis, in a more descriptive and exploratory way. Significant correlations were above chance levels and largely consistent between the two methods. They were almost exclusively positive (i.e. in the neurobiologically expected direction) and their distribution showed striking differences according to each memory system. Thus, verbal episodic memory impairment was related to changes in a large neuronal network including not only the limbic structures (mesial temporal cortex, thalamus and cingulate gyrus, with left side predominance) but also the parietotemporal and frontal association cortices of the right hemisphere, possibly on a compensatory basis. Regardless of modality, short-term memory tests were mainly correlated with bilateral activity in posterior association cortex, and also with activity in left prefrontal cortex for the visuospatial span, possibly indicating essentially uniform strategies for the performance of the different tasks. As predicted, semantic memory scores correlated with activity in temporoparietal and frontal association cortices of the left hemisphere, and also with activity in left cingulate cortex. Thus, for episodic, short-term and semantic memory, many findings fit classical neuropsychology, while most of the less expected ones were consistent with recent results from functional neuro-imaging in healthy subjects, notably with the hemispheric encoding/ retrieval asymmetry (HERA) model; only few findings suggested possible reorganization processes and/or recourse to unexpected cognitive strategy. Finally, only negative correlations were found for perceptual priming and procedural memory; although they could arise by chance, some of these unexpected findings give rise to interesting hypotheses about the cognitive relationships between the most and least affected memory systems. This study documents the validity and usefulness of our approach in unravelling the neural substrates of cognitive impairment in brain pathology without focal tissue loss such as that seen in neurodegenerative diseases.

Comparative in vitro killing activities of meropenem, imipenem, ceftriaxone, and ceftriaxone plus vancomycin at clinically achievable cerebrospinal fluid concentrations against penicillin-resistant Streptococcus pneumoniae isolates from children with meningitis

The activities of meropenem, imipenem, ceftriaxone, and vancomycin were evaluated against 80 penicillin-susceptible and -resistant Streptococcus pneumoniae strains. Meropenem, imipenem, ceftriaxone, and vancomycin MICs at which 90% of the isolates are inhibited were 0.5, 0.25, 1, and 0.25 microg/ml, respectively. Against penicillin-resistant strains, the best killing activity at cerebrospinal fluid concentrations was obtained with imipenem and ceftriaxone-vancomycin. However, while the killing activity of imipenem was significantly greater than that of meropenem, no significant difference was observed between the activities of meropenem and ceftriaxone-vancomycin.

Heterozygous mutation in the pore of potassium channel gene KvLQT1 causes an apparently normal phenotype in long QT syndrome

Mutations in KvLQT1, a gene encoding a potassium channel, cause both the recessive Jervell and Lange-Nielsen (JLN) syndrome and the dominant Romano-Ward (RW) syndrome. These diseases are characterised by a prolonged QT interval on the ECG, syncopes and sudden death due to cardiac arrhythmias. The JLN syndrome is also associated with a congenital bilateral deafness. We report here a novel missense mutation, W305S, in the pore region of KvLQT1 identified by PCR-SSCP analysis in two consanguineous JLN families. In contrast to several missense mutations found in the same region of KvLQT1 in RW patients which are associated with severe cardiac phenotypes, the W305S mutation is responsible for an apparently normal phenotype in heterozygous JLN carriers.

In utero eyeball development study by magnetic resonance imaging

The aim of this study was to measure fetal ocular development and to determine a growth curve by means of measurements in utero. Fetal ocular development was recorded by analysis of the results of magnetic resonance imaging (MRI). An anatomic study allowed definition of the best contrasted MRI sequences for calculation of the ocular surface. Biometric analysis of the values of the ocular surface in the neuro-ocular plane in 35 fetuses allowed establishment of a linear model of ocular growth curve in utero. Evaluation of ocular development may allow the detection and confirmation of malformational ocular anomalies such as microphthalmia.

Autoantibodies predicting the outcome of rheumatoid arthritis: evaluation in two subsets of patients according to severity of radiographic damage

OBJECTIVE

Autoantibodies such as rheumatoid factor (RF), antikeratin antibodies (AKA), antiperinuclear factor (APF), and anti-RA 33 antibodies are considered of value for the diagnosis of RA. The purpose of this study was to evaluate these autoantibodies as predictors of severe radiographic damage in rheumatoid arthritis (RA).

PATIENTS AND METHODS

Eighty six patients with RA (70 women, 16 men) fulfilling 1987 ACR criteria were selected from a cohort of 469 patients followed up since the first year of RA onset because they could be divided in two groups according to the severity of the radiographic damage. These 86 patients had a mean (SD) disease duration of eight (four) years: 43 patients had severe radiographic damage (Larsen score > or = 2) and 43 had limited radiographic damage (Larsen score < 2). The two groups were matched by disease duration and sex. The following autoantibodies were looked for: RF, ANA, AKA, APF, and anti-RA 33 antibodies. In addition, HLA class II DR beta alleles and standard inflammatory parameters (erythrocyte sedimentation rate, C reactive protein) were determined.

RESULTS

Patients with severe radiographic damage differed from those with limited radiographic damage in that they had higher RF (p = 0.01), APF (p < 0.02), and AKA (p = 0.001) titres. Stepwise regression analysis was done to calculate the odds ratios (OR) for each clinical and laboratory variable; only presence of cutaneous nodules (OR: 14.9; 95% CI: 7, 128), HLA DRB1*04 or DRB1*01 (OR: 7.53; 95% CI: 1.32, 42.9), AKA (OR: 3.11; 95%, CI: 0.58, 16.8), a high erythrocyte sedimentation rate (OR: 2.66; 95% CI: 0.60, 11.9), and a high C reactive protein value (OR: 7.4; 95% CI: 1.43, 38.1) were predictive of severe radiographic damage.

CONCLUSION

These data suggest that the risk of severe radiographic damage in RA patients is higher when cutaneous nodules, HLA DRB1*04 or DRB1*01, and/or AKA are present. The other autoantibodies of diagnostic significance are of little help for predicting joint destruction.

Congenital diaphragmatic hernia: antenatal prognostic factors. Does cardiac ventricular disproportion in utero predict outcome and pulmonary hypoplasia?

Despite regular progress in neonatal intensive care, congenital diaphragmatic hernia (CDH) diagnosed antenatally is still associated with up to 80% mortality. It is impossible to predict which fetus with CDH will survive or not.

OBJECTIVE

To identify reliable antenatal predictors of outcome and of pulmonary hypoplasia (PH) in fetuses with CDH.

DESIGN

Retrospective study.

SETTING

Paediatric intensive care unit of a university children's hospital.

PATIENTS AND METHODS

Antenatal parameters and presence of left ventricular hypoplasia in utero were compared retrospectively to outcome and to presence of PH in 32 consecutive newborn infants with antenatally diagnosed CDH. Antenatal parameters included: gestational age at diagnosis, herniated organs, associated malformations and presence of polyhydramnios. Size of the cardiac ventricles, the aorta (Ao) and the pulmonary artery (PA) were obtained by fetal echocardiography, from which we calculated a cardioventricular index (left ventricle/right ventricle, LV/RV) and a cardiovascular index (Ao/PA). Delivery was planned in order to provide ventilatory and hemodynamic management. In case of death, PH was assessed according to the following criteria: the lung weight/body weight index and the radial alveolar count. For statistical comparisons, patients were separated into two groups: the hypoplasia group (H) and the non-hypoplasia group (NH).

RESULTS

Thirty-two pregnancies were delivered. Twenty-six newborns died (81%), 6 survived (19%). When comparing non-survivors to survivors, predictors of poor outcome were: mean gestational age at diagnosis (23 vs 28 weeks, p = 0.002), intrathoracic stomach (20 vs 1 s, p = 0.01) and associated malformations (6 vs 0). Cardiac ventricular disproportion, expressed by the LV/RV ratio, appeared to correlate well with a poor outcome (0.63 in non-survivors vs 0.93 in survivors, p = 0.03) and with PH (0.63 in the H group vs 0.95 in the NH group, p = 0.03).

CONCLUSIONS

Our study confirmed the factors for a poor prognosis associated with CDH previously described in the literature, but none with a consistent demonstration of accuracy. LV hypoplasia may be a more accurate predictor of outcome and of PH but it has to be assessed by prospective studies with larger samples. Further basic science and Doppler-flow studies may be helpful to understand the natural history and pathophysiology of LV hypoplasia in CDH.

Computerized microscope morphometry of umbilical vessels from pregnancies with intrauterine growth retardation and abnormal umbilical artery Doppler

Computerized microscope morphometry was used to study cross sections from the vessels of the umbilical cord in placentas of patients with intrauterine growth retardation (IUGR) that displayed either normal or abnormal umbilical arteries (UA) Doppler flow velocity waveforms (FVW). Cords from 63 eutrophic fetuses with normal Doppler (controls), 47 IUGR fetuses with normal Doppler and 32 IUGR fetuses with abnormal Doppler underwent morphometric analysis using a highly optimized microscope environment (HOME) and "CordHOME" software. IUGR with an accompanying normal Doppler versus control showed a reduction of Wharton jelly and both the total and lumen vein areas. IUGR with an accompanying pathological Doppler showed a comparable reduction in wall thickness and areas of every vessel. These findings indicate that the hypoplastic umbilical vessels are associated with an increase in placental vascular resistance that may be the consequence of underdevelopment in response to a chronic reduction in placental blood flow.

Nocturnal hypoglycemia in children and adolescents with insulin-dependent diabetes mellitus: prevalence and risk factors

OBJECTIVES

To evaluate the prevalence and risk factors of nocturnal hypoglycemia (NH) in children and adolescents with insulin-dependent diabetes mellitus.

STUDY DESIGN

A total of 150 patients, 87% of whom were receiving conventional therapy, were admitted to the hospital for one night. Blood glucose (BG) levels were measured hourly from 10 PM to 8 AM.

RESULTS

The prevalence of NH was 47%; NH was asymptomatic in 49% of the cases. Risk factors were as follows: at least two episodes of severe hypoglycemia from onset of insulin-dependent diabetes mellitus (p = 0.0004), insulin dosage > 0.85 IU/kg per day (p = 0.02), more than 5% of BG measurements < or = 3.3 mmol/L during the last month of monitoring (p = 0.04). The risk decreased significantly with age (p = 0.0001). Both high predictive values and significant relative risk were found for BG thresholds < or = 5.2 mmol/L at dinner time (p < 0.0001) and < or = 6.7 mmol/L at 7 AM (p < 0.0001). When BG values at 10 PM were used, prediction of NH was weak.

CONCLUSIONS

Nocturnal hypoglycemia occurred frequently in children and adolescents with insulin-dependent diabetes mellitus. Our study found risk factors that will help pediatricians to identify those children with a high risk of NH. Especially in these patients, counseling based on the BG values before dinner and early in the morning is indicated to reduce the prevalence of NH.

Subcutaneous or intramuscular injections of insulin in children. Are we injecting where we think we are?

OBJECTIVE

This study was designed to assess the insulin injection location in a group of children who had their injection according to their daily practice, thought to lead to subcutaneous injections.

RESEARCH DESIGN AND METHODS

The location of the insulin deposit at the injection site was visualized using an ultrasound device.

RESULTS

The exact insulin injection location could be localized, and 18 of 59 injections (30.5%) (one injection for each child) were in the intramuscular tissue. Of the children who had intramuscular injection, 15 of 18 were boys. The children who had an intramuscular injection had a significantly lower percentile of BMI (mean +/- SE: 47 +/- 8 vs. 72 +/- 4, P = 0.004), lower distance from skin surface to muscle fascia without a skinfold (5.6 +/- 0.6 vs. 11 +/- 0.7 mm, P < 0.0001), and a lower distance from skin surface to muscle fascia with a skinfold (8.1 +/- 0.9 vs. 15.9 +/- 0.8 mm, P < 0.0001) than children who had a subcutaneous insulin injection.

CONCLUSIONS

We identified a group of children at risk for intramuscular insulin injections and that may deserve specific injection technique and advice.