A European-Japanese study on peach allergy: IgE to Pru p 7 associates with severity

BACKGROUND

Pru p 3 and Pru p 7 have been implicated as risk factors for severe peach allergy. This study aimed to establish sensitization patterns to five peach components across Europe and in Japan, to explore their relation to pollen and foods and to predict symptom severity.

METHODS

In twelve European (EuroPrevall project) and one Japanese outpatient clinic, a standardized clinical evaluation was conducted in 1231 patients who reported symptoms to peach and/or were sensitized to peach. Specific IgE against Pru p 1, 2, 3, 4 and 7 and against Cup s 7 was measured in 474 of them. Univariable and multivariable Lasso regression was applied to identify combinations of parameters predicting severity.

RESULTS

Sensitization to Pru p 3 dominated in Southern Europe but was also quite common in Northern and Central Europe. Sensitization to Pru p 7 was low and variable in the European centers but very dominant in Japan. Severity could be predicted by a model combining age of onset of peach allergy, probable mugwort, Parietaria pollen and latex allergy, and sensitization to Japanese cedar pollen, Pru p 4 and Pru p 7 which resulted in an AUC of 0.73 (95% CI 0.73-0.74). Pru p 3 tended to be a risk factor in South Europe only.

CONCLUSIONS

Pru p 7 was confirmed as a significant risk factor for severe peach allergy in Europe and Japan. Combining outcomes from clinical and demographic background with serology resulted in a model that could better predict severity than CRD alone.

Aromatic border plants in early season berries do not increase parasitism of spotted wing drosophila, Drosophila suzukii

BACKGROUND

The spotted wing drosophila, Drosophila suzukii Matsumura, is a South-East Asian vinegar fly that is a serious worldwide economic threat to the small fruit industry. Typical control consists of weekly pesticide applications, which can have nontarget effects, increase residual pesticides and lead to the development of resistance within pest populations. One potential alternate method of control is the planting of aromatic intercrops to attract the natural enemies of D. suzukii and/or repel the flies directly. We intercropped strawberry rows with flowering sweet alyssum or ryegrass-clover (control) to evaluate their efficacy at mitigating D. suzukii infestation through the attraction of two specialized larval parasitoids, Leptopilina japonica (Novkovic and Kimura) and Ganaspis brasiliensis (Ihering).

RESULTS

Our study did not demonstrate any significant effect of sweet alyssum intercropping on the infestation rate of D. suzukii in strawberries or parasitism level. However, we found that advanced sampling date and recorded numbers of D. suzukii larvae and parasitoids were positively correlated, indicating higher populations at the end of the strawberry-growing season.

CONCLUSIONS

Sweet alyssum intercrops did not reduce D. suzukii infestation rates or increase parasitism levels, likely due to low population numbers in early season berry varieties. Aromatic intercrops may be more effective for increasing pest control in later season crops. © 2022 Society of Chemical Industry.

Adventive Larval Parasitoids Reconstruct Their Close Association with Spotted-Wing Drosophila in the Invaded North American Range

Two species of larval parasitoids of the globally invasive fruit pest, Drosophila suzukii (Diptera: Drosophilidae), Leptopilina japonica, and Ganaspis brasiliensis (both Hymenoptera: Figitidae), were detected in British Columbia, Canada in 2016 and 2019, respectively. Both are presumed to have been unintentionally introduced from Asia; however, the extent of their establishment across different habitats with diverse host plants used by D. suzukii was unclear. In addition, there was no knowledge of the temporal dynamics of parasitism of D. suzukii by these two parasitoids. To address these gaps, we repeatedly sampled the fruits of known host plants of D. suzukii over the entire 2020 growing season in British Columbia. We documented the presence of L. japonica and G. brasiliensis and estimated the apparent percentage of D. suzukii parasitized among host plant species. Across a large region of southwestern British Columbia, both L. japonica and G. brasiliensis were found to be very common across a variety of mostly unmanaged habitats over the entire course of the season (May-October) in the fruits of most host plants known to host D. suzukii larvae. Parasitism of D. suzukii was variable (0-66% percent parasitism) and appeared to be time-structured. Our study demonstrates that the close association between the two larval parasitoids and D. suzukii that exists in Asia has evidently been reconstructed in North America, resulting in the highest parasitism levels of D. suzukii yet recorded outside of its area of origin.

Baseline characteristics of patients with transthyretin amyloid cardiomyopathy enrolled in a tafamidis expanded access programme

Background

Transthyretin amyloid cardiomyopathy (ATTR-CM) is a progressive and ultimately fatal disease caused by the accumulation of amyloid fibrils in the heart muscle. Tafamidis, currently the only approved drug for the treatment of ATTR-CM, demonstrated reduced mortality and cardiovascular-related hospitalisations in the Tafamidis in Transthyretin Cardiomyopathy Clinical Trial (ATTR-ACT). Real-world data in patients with ATTR-CM, including patient characteristics, are scarce. Here we analysed the baseline characteristics of patients enrolled in an expanded access programme (EAP) for tafamidis. Initiated in 2018, this tafamidis EAP allows access to tafamidis for patients who have exhausted all standard-of-care options and are not eligible for a clinical trial.

Purpose

To examine baseline characteristics of patients with ATTR-CM enrolled in a tafamidis EAP.

Methods

All patients enrolled in this tafamidis EAP from the start (May 2018) until November 2020 were included. To be eligible for inclusion, patients had to have documentation of the following: genetic testing for transthyretin amyloidosis (TTR sequencing); ATTR-CM diagnosis, including the criteria used; exclusion of light chain amyloidosis; and current medical/cardiac status, including New York Heart Association (NYHA) functional classification. Patients were grouped for analysis purposes in the following NYHA classes: I–II, >II–III, and >III–IV.

Results

A total of 700 patients (88.7% male) from 20 countries were enrolled over 2.6 years. Mean age was 76.2 years in males and 76.6 years in females. Of 518 patients with a recorded genotype, 87.5% were wild-type (89.6% male) and 12.5% hereditary (73.8% male). In males and females, respectively, mean age was 77.0 and 79.4 years in wild-type patients, and 66.2 and 69.3 years in variant patients. The NYHA class distribution is shown in the Figure. The greatest proportion of patients was considered NYHA class I–II. The proportion of patients considered NYHA class I–II was lower in the first half of the data collection period (Months 0–15, 55.3%) compared with the latter half (Months 15–30, 59.4%). In 254 patients with baseline N-terminal pro-B-type natriuretic peptide (NT-proBNP) data, the median NT-proBNP level was 2784.5 pg/mL (NYHA class I–II, 2408.5 pg/mL; NYHA class >II–III, 3165.0 pg/mL).

Conclusions

These are the first multi-country, real-world data evaluating baseline characteristics of patients with ATTR-CM enrolled in an EAP. It is of interest that, compared with the ATTR-ACT population, this patient group was older and had a greater proportion of wild-type patients. As a higher percentage of patients with less severe disease was enrolled in the latter half of data collection, these data also suggest a potential shift over time to earlier diagnosis of ATTR-CM. This analysis provides insight into the characteristics of real-world patients with ATTR-CM.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Pfizer Figure 1. Baseline NYHA class distribution

P4668Risk of valvular heart disease in bromocriptine-treated women with hyperprolactinaemic disorders

Background

Systematic echocardiographic screening is currently recommended for patients with hyperprolactinemic disorders treated with dopamine agonists, due to a perceived risk of cardiac valve regurgitation as observed in patients with Parkinson's disease. The dopamine agonist bromocriptine is used frequently in hyperprolactinemia patients, but its relation to cardiac valve disease remain uncertain.

Purpose

To determine the incidence of valvular heart disease in bromocriptine-treated women with hyperprolactinaemic disorders compared with matched controls from background population.

Methods

In nationwide Danish registries, we identified patients with hyperprolactinaemic disorders treated with bromocriptine between 1995–2017. Patients were matched 1:5 with population controls based on age and sex using incidence density sampling. We estimated the risk of valvular heart disease defined as admission and/or outpatient clinic visits. Incidence rates, cumulative incidence curve and adjusted cox-proportional hazard models were used to assess outcomes.

Results

A total of 23883 female bromocriptine users and 119415 controls were included. Median age was 29.9 years (Q1-Q3 26.4–33.8). Both groups had few comorbidities, 218 (0.9%) patients and 787 (0.7%) controls with hypertension, 160 (0.7%) patients and 629 (0.5%) controls with diabetes, 408 (1.7%) patients and 1305 (1.1%) controls were beta-blocker users. During a mean follow-up of 19 years 106 (0.44%) patients and 416 (0.35%) controls were diagnosed with valvular heart disease. Incidence rates were 0.254 per 1000 patient years (PY) in bromocriptine users (95% CI 0.21–0.31) and 0.198 per 1000 PY in the control cohort (95% CI 0.18–0.22). Overall, the cumulative incidence of valvular heart disease was 0.6% (95% CI 0.48–0.73) among patients and 0.5% (95% CI 0.4–0.51) among controls; P=0.03 (figure 1a). In adjusted analysis bromocriptine users still had a significant higher risk of valvular heart disease (hazard ratio=1.32, 95% CI 1.06–1.64, P=0.01).

Incidence of valvular heart disease

Conclusion

The use of bromocriptine in younger and otherwise healthy women with hyperprolactinaemic disorders, were associated with a low absolute risk of cardiac valve disease. Still risk was approximately 30% higher compared with age- and sex matched controls. Our study suggests a low clinical yield of echocardiographic screening in this patient population.

Acknowledgement/Funding

Internal grant, Copenhagen University Hospital Rigshospitalet

Fish oil in infancy protects against food allergy in Iceland-Results from a birth cohort study

BACKGROUND

Consumption of oily fish or fish oil during pregnancy, lactation and infancy has been linked to a reduction in the development of allergic diseases in childhood.

METHODS

In an observational study, Icelandic children (n = 1304) were prospectively followed from birth to 2.5 years with detailed questionnaires administered at birth and at 1 and 2 years of age, including questions about fish oil supplementation. Children with suspected food allergy were invited for physical examinations, allergic sensitization tests, and a double-blind, placebo-controlled food challenge if the allergy testing or clinical history indicated food allergy. The study investigated the development of sensitization to food and confirmed food allergy according to age and frequency of postnatal fish oil supplementation using proportional hazards modelling.

RESULTS

The incidence of diagnosed food sensitization was significantly lower in children who received regular fish oil supplementation (relative risk: 0.51, 95% confidence interval: 0.32-0.82). The incidence of challenge-confirmed food allergy was also reduced, although not statistically significant (0.57, 0.30-1.12). Children who began to receive fish oil in their first half year of life were significantly more protected than those who began later (P = .045 for sensitization, P = .018 for allergy). Indicators of allergy severity decreased with increased fish oil consumption (P = .013). Adjusting for parent education and allergic family history did not change the results.

CONCLUSION

Postnatal fish oil consumption is associated with decreased food sensitization and food allergies in infants and may provide an intervention strategy for allergy prevention.

Component-resolved diagnosis and beyond: Multivariable regression models to predict severity of hazelnut allergy

BACKGROUND

Component-resolved diagnosis (CRD) has revealed significant associations between IgE against individual allergens and severity of hazelnut allergy. Less attention has been given to combining them with clinical factors in predicting severity.

AIM

To analyze associations between severity and sensitization patterns, patient characteristics and clinical history, and to develop models to improve predictive accuracy.

METHODS

Patients reporting hazelnut allergy (n = 423) from 12 European cities were tested for IgE against individual hazelnut allergens. Symptoms (reported and during Double-blind placebo-controlled food challenge [DBPCFC]) were categorized in mild, moderate, and severe. Multiple regression models to predict severity were generated from clinical factors and sensitization patterns (CRD- and extract-based). Odds ratios (ORs) and areas under receiver-operating characteristic (ROC) curves (AUCs) were used to evaluate their predictive value.

RESULTS

Cor a 9 and 14 were positively (OR 10.5 and 10.1, respectively), and Cor a 1 negatively (OR 0.14) associated with severe symptoms during DBPCFC, with AUCs of 0.70-073. Combining Cor a 1 and 9 improved this to 0.76. A model using a combination of atopic dermatitis (risk), pollen allergy (protection), IgE against Cor a 14 (risk) and walnut (risk) increased the AUC to 0.91. At 92% sensitivity, the specificity was 76.3%, and the positive and negative predictive values 62.2% and 95.7%, respectively. For reported symptoms, associations and generated models proved to be almost identical but weaker.

CONCLUSION

A model combining CRD with clinical background and extract-based serology is superior to CRD alone in assessing the risk of severe reactions to hazelnut, particular in ruling out severe reactions.

Introduction of a quality management system compliant with DIN EN ISO 9001:2000 into a university department of nuclear medicine

In 1995, the management of the University Clinic Hamburg-Eppendorf proposed to establish a total quality assurance (QA) system. A revised QA-system has been introduced stepwise in the department of nuclear medicine since 1997, and certification was achieved in accordance with DIN EN ISO 9001:2000 on February 14,2001.

The QA-handbook is devided into two parts. The first part contains operational (diagnostic and therapeutic) procedures in so-called standard operating procedures (SOP). They describe the indication of procedures as well as the competences and time necessary in a standardized manner. Up to now, more than 70 SOPs have been written as a collaborative approach between technicians and physicians during daily clinical routine after analysing and discussing the procedures. Thus, the results were more clearly defined processes and more satisfied employees.

The second part consists of general rules and directions concerning the security of work and equipment as well as radialion protection tasks, hygiene etc. as it is required by the law. This part was written predominantly by the management of the department of nuclear-medicine and the QA-coordinator. Detailed information for the patients, documentation of the work-flows as well as the medical report was adapted to the QM-system. Although in the introduction phase of a QA-system a vast amount of time is necessary, some months later a surplus for the clinical workday will become available. The well defined relations of competences and procedures will result in a gain of time, a reduction of costs and a help to ensure the legal demands. Last but not least, the QA-system simply helps to build up confidence and acceptance both by the patients and the referring physicians.

Der Röntgenthorax: Routineindikation in der Nachsorge des differenzierten Schilddrüsenkarzinoms?

Ziel: Anhand einer retrospektiven Untersuchung wurde überprüft, inwieweit der routinemäßige Einsatz des Röntgenthorax auch bei Low-risk-Patienten trotz der hohen Sensitivität des Tumormarkers Thyreoglobulin sinnvoll ist. Methode: Es wurden die Krankengeschichten von 609 Patienten mit einem differenzierten Schilddrüsenkarzinom ausgewertet. Bei 50 Patienten wurde eine pulmonale Metastasierung diagnostiziert. Der Thyreoglobulinwert zum Zeitpunkt der Diagnosestellung der pulmonalen Metastasierung wurde mit dem Befund des Röntgenthorax und der vorhandenen weiteren Diagnostik, wie der lod-131-Ganzkörperszintigraphie und CT des Thorax, soweit vorhanden, verglichen. Ergebnisse: Die gefundene Sensitivität des Röntgenthorax im Nachweis von Lungenmetastasen lag mit 52% unterhalb der Sensitivität der 131 -lod-Ganzkörperszintigraphie (64%), der Thorax-CT (82%) und der Sensitivität des Thyreoglobulins unter Suppressionsbedingungen (86%). Bei Patienten mit papillärem Schilddrüsenkarzinom der Tumorstadien I und II entwickelte nur ein Patient im Verlauf eine Lungenmetastasierung. Der Nachweis von Lungenfiliae nur mit Hilfe des Röntgenthorax bei einem Thyreoglobulinwert unter der Nachweisgrenze ist in einer solchen Low-risk-Gruppe sehr selten (berechnete Wahrscheinlichkeit: 1:4000) und mit erheblichen Kosten verbunden. Schlußfolgerung: Der routinemäßige, lebenslange Einsatz des Röntgenthorax ohne Rezidivverdacht (z. B. Thyreoglobulin positiv) ist für Low-risk-Patienten zu überdenken.

Die quantitative Sialoszintigraphie -eine sinnvolle Untersuchung im Vorfeld und in der Nachsorge der Radiojodtherapie

Ziel: Mit einer standardisierten, quantitativen Sialoszintigraphie (qSZ) sollte geprüft werden, ob auch durch relativ niedrige, im Rahmen gutartiger Schilddrüsenerkrankungen applizierte Aktivitäten von Radiojod subtile Speicheldrüsenschäden meßbar sind. Zusätzlich wurde die Prävalenz von Sialopathien bei Schilddrüsenpatienten ermittelt. Methoden: Im Rahmen der Schilddrüsenszintigraphie wurde eine qSZ nach i.v Injektion von 36-126 MBq 99mTc-Pertechnetat durchgeführt. Referenzbereiche für den 99mTc-Uptake und die Exkretionsfraktion nach Stimulation wurden an 312 Speicheldrüsengesunden ermittelt. 144 Patienten wurden vor und 3 Monate nach einer Radiojodtherapie untersucht. Bei weiteren 674 Schilddrüsenpatienten wurden die Ergebnisse der qSZ zur Erfassung der Prävalenz von Speicheldrüsenschäden ausgewertet. Ergebnisse: Im Referenzkollektiv betrug der Uptake 0,45 ± 0,14% bzw. 0,39 ± 0,12% und die Exkretionsfraktion 49,5 ± 10,6% bzw. 39,1 ± 9,2% in den GH. parotides bzw. submandibulares. Trotz intratherapeutischer Gabe von Sialogoga war eine signifikante und mit der Aktivität korrelierende Einschränkung der Parenchymfunktion von 14-90% nach Applikation von 0,4 bis 24 GBq 1-131 meßbar. Die Prävalenz prätherapeutischer Sialopathien betrug an singulären Speicheldrüsen 77/674 = 11,4%, die der globalen Speicheldrüseninsuffizienzen lag bei 52/674 = 7,7%. Schlußfolgerung: Die im Rahmen der Schilddrüsenszintigraphie durchführbare qSZ ist ein einfach durchzuführendes Verfahren ohne zusätzliche Strahlenbelastung. Sie sollte zur Dokumentation der Speicheldrüsenfunktion vor jeder Radiojodtherapie durchgeführt und zum Ausschluß bzw. zur Quantifizierung einer schon bei niedrigen 131I-Aktivitäten nachweisbaren Parenchymschädigung nach

Onko-PET: Bildanalyse mittels Monitor versus standardisierter Filmdokumentation

Ziel: Die Wertigkeit einer standardisierten Filmdokumentation in der Beurteilung von 2-[18F]Fluor-2-deoxy-D-Glukose (F-18-FDG) Onko-PET-Untersuchungen sollte untersucht werden. Methoden: 100 Onko-PET-Untersuchungen (ohne Schwächungskorrektur) wurden in Hinblick auf Zahl und Lokalisation malignitätsverdächtiger Läsionen ausgewertet: zum einen mittels standardisierter Filmvorlagen und zum anderen unter zusätzlicher Analyse am Monitor. Die Filmdokumentation beinhaltet erstens transversale Schnitte des Gehirns, zweitens koronale Schnitte und Maximum-intensity-projections (MIPs) sowohl des Kopf-/Halsbereiches als auch drittens des Körperstammes und viertens MIPs der Beine. Bei der Monitorauswertung wurden sämtliche Körperabschnitte in koronaler, transversaler und sagittaler Schnittführung analysiert. Ergebnisse: Insgesamt wurden 315 Läsionen bei 100 Patienten detektiert. Bei 96/100 Untersuchungen fand sich eine Übereinstimmung beider Auswertemethoden in Anzahl und Lokalisation der Läsionen. In der Filmauswertung wurden bei drei Patienten insgesamt sieben Herde in den Beinen übersehen. 9/315 Läsionen in 2/100 Patienten erfuhren durch die zusätzliche Monitorauswertung eine Lokalisationsänderung. Hiervon befanden sich acht der neun Läsionen in den Beinen. Erst nach zusätzlicher Dokumentation der Beine in koronaler Schnittführung wurden sämtliche, in den MIPs übersehene Läsionen detektiert und die topographisch falsch zugeordneten Läsionen konnten konkordant zur Monitorauswertung lokalisiert werden. Bei dieser so ergänzten Filmdokumentation führte die zusätzliche Monitorauswertung zu keiner Detektion weiterer Herde und zu einer klinisch nicht relevanten Lokalisationsänderung von lediglich 1/322 Läsionen. Schlußfolgerung: Die beschriebene, standardisierte Filmdokumentation erlaubt eine Befundung unter nur noch gezieltem Einsatz der Analyse am Monitor. Darüber hinaus entspricht der hier vorgestellte Ansatz den Intentionen der nuklearmedizinischen Arbeitsgemeinschaft Standardisierung, daß auswärtige Voruntersuchungen problemlos in eine Verlaufsbeurteilung einbezogen werden können.

Szintigraphischer Nachweis einer stillen Aspiration nach beidseitiger Lungentransplantation

Vorgestellt wird der Fall einer 25jährigen Patientin nach beidseitiger Lungentransplantation und rezidivierenden Pneumonien. Klinisch bestand der Verdacht auf eine stille Aspiration. Szintigraphisch gelang sowohl der Aspirationsnachweis als auch eine Differenzierung hinsichtlich der Genese: direkte oro-pulmonale Aspiration versus Aspiration nach gastro-öspohagealem Reflux.

Wirksamkeit der Radiosynoviorthese bei degenerativ-entzündlichen und chronisch-entzündlichen Gelenkerkrankungen

Ziel: Der Therapieerfolg der Radiosynoviorthese (RSO) sollte bei aktivierter Arthrose und anderen chronisch-entzündlichen Gelenkerkrankungen anhand der subjektiven Befindlichkeit und objektiver Parameter evaluiert werden. Methoden: Es wurden insgesamt 98 Gelenke bei 61 Patienten behandelt. Entsprechend der Grunderkrankung umfaßte die erste Gruppe 35 Patienten mit einer therapieresistenten, aktivierten Arthrose (46 Gelenke). Die zweite Patientengruppe beinhaltete 26 Patienten (52 Gelenke) mit peripherem Gelenkbefall bei Morbus Bechterew, reaktiver Arthritis, undifferenzierter Kollagenose mit Gelenkbeteiligung, Psoriasis-assoziierter Arthritis, pigmentierter villo-nodulärer Synoviales und chronisch-entzündliche Reizzustände nach vorangegangener Operation. Die Veränderung der Beschwerdesymptomatik wurde anhand eines standardisierten Fragebogens entsprechend den ARA-Kriterien subjektiv erfaßt und mit T/B-Quotienten in der Blutpoolphase der Skelettszintigraphie vor und nach der RSO quantifiziert. Ergebnisse: In der ersten Gruppe berichteten die Patienten über eine deutliche Besserung der Beschwerdesymptomatik in 40% der Fälle. In 51 % fand sich eine Beschwerdekonstanz, in 9% eine Verschlechterung des Beschwerdebildes. Analoge Verhältnisse fanden sich in der zweiten Patientengruppe. Die Mehrzahl der als unverändert beschriebenen Gelenke waren kleine Fingergelenke. Hingegen zeigten Hand- und Kniegelenke bessere Ergebnisse. Eine Übereinstimmung zwischen szintigraphischem Befund und subjektiver Einschätzung fand sich in der ersten Gruppe bei 38% und in der zweiten Gruppe bei 67%. Schlußfolgerung: Die Radiosynoviorthese stellt auch bei der aktivierten Arthrose und den nicht durch eine rheumatoide Arthritis verursachten Synovialitiden eine nebenwirkungsarme, gut nutzbare lokal anwendbare Therapieoption dar.

Computer simulations suggest that acute correction of hyperglycaemia with an insulin bolus protocol might be useful in brain FDG PET

Aim: FDG PET in hyperglycaemic subjects often suffers from limited statistical image quality, which may hamper visual and quantitative evaluation. In our study the following insulin bolus protocol is proposed for acute correction of hyperglycaemia (> 7.0 mmol/l) in brain FDG PET. (i) Intravenous bolus injection of short-acting insulin, one I.E. for each 0.6 mmol/l blood glucose above 7.0. (ii) If 20 min after insulin administration plasma glucose is ≤ 7.0 mmol/l, proceed to (iii). If insulin has not taken sufficient effect step back to (i). Compute insulin dose with the updated blood glucose level. (iii) Wait further 20 min before injection of FDG. (iv) Continuous supervision of the patient during the whole scanning procedure. Methods: The potential of this protocol for improvement of image quality in brain FDG PET in hyperglycaemic subjects was evaluated by computer simulations within the Sokoloff model. A plausibility check of the prediction of the computer simulations on the magnitude of the effect that might be achieved by correction of hyperglycaemia was performed by retrospective evaluation of the relation between blood glucose level and brain FDG uptake in 89 subjects in whom FDG PET had been performed for diagnosis of Alzheimer's disease. Results: The computer simulations suggested that acute correction of hyperglycaemia according to the proposed bolus insulin protocol might increase the FDG uptake of the brain by up to 80%. The magnitude of this effect was confirmed by the patient data. Conclusion: The proposed management protocol for acute correction of hyper glycaemia with insulin has the potential to significantly improve the statistical quality of brain FDG PET images. This should be confirmed in a prospective study in patients.

Prevalence of iodine- and thyroglobulin negative findings in differentiated thyroid cancer

Aim: The prevalence of iodine- and thyroglobulin-nega-tive findings was evaluated in all patients with differentiated thyroid cancer (DTC) treated from 1961 until 1998 at the Department of Nuclear Medicine, University Hospital Hamburg-Eppendorf. Methods: A total of 490 patients with papillary thyroid cancer (PCA) and 242 patients with follicular thyroid cancer (FCA) were analyzed retrospectively. Patients were divided into four groups: 1: no recurrence, 2: recurrent disease, 3: primary metas-tatic/progressive disease and 4: inconclusive follow-up. Results of iodine scan, serum-TG, and additional imaging modalities as well as histology were compared in all patients. Results: 21/490 (4,3%) of patients with PCA and 16/242 (6,6%) with FCA suffered from recurrent disease. 62/490 (12,7%) of patients with PCA and 59/242 (24,4%) with FCA had primary metastatic/progressive disease. 12/21 patients with PCA and 12/16 with FCA showing up with recurrent disease had a negative iodinescan. 11/21 of patients with PCA and 4/16 with FCA and tumor recurrence had negative serum-TG levels. 14/62 patients with PCA and 14/59 with FCA presenting with primary metastatic/ progressive disease had negative iodinescan. 14/62 patients with PCA and 6/59 with FCA had negative serum-TG. Conclusion: The prevalence of iodine-negative recurrent"/metastatic disease is in accordance to the literature, whereas the prevalence of TG-negative recurrent/metastatic was noted higher than reported previously. Thus, the commonly used follow-up scheme of DTC is confirmed. However, iodine scan should be regularly performed in patients with high risk of recurrence.

Incidence and natural history of hen's egg allergy in the first 2 years of life-the EuroPrevall birth cohort study

BACKGROUND

Parents and health staff perceive hen's egg allergy (HEA) as a common food allergy in early childhood, but the true incidence is unclear because population-based studies with gold-standard diagnostic criteria are lacking.

OBJECTIVE

To establish the incidence and course of challenge-confirmed HEA in children, from birth until the age of 24 months, in different European regions.

METHODS

In the EuroPrevall birth cohort study, children with a suspected HEA and their age-matched controls were evaluated in 9 countries, using a standardized protocol including measurement of HE-specific immunoglobulin E-antibodies in serum, skin prick tests, and double-blind, placebo-controlled food challenges (DBPCFC).

RESULTS

Across Europe, 12 049 newborns were enrolled, and 9336 (77.5%) were followed up to 2 years of age. In 298 children, HEA was suspected and DBPCFC was offered. HEA by age two was confirmed in 86 of 172 challenged children (mean raw incidence 0.84%, 95% confidence interval (95% CI) 0.67-1.03). Adjusted mean incidence of HEA was 1.23% (95% CI 0.98-1.51) considering possible cases among eligible children who were not challenged. Centre-specific incidence ranged from United Kingdom (2.18%, 95% CI 1.27-3.47) to Greece (0.07%). Half of the HE-allergic children became tolerant to HE within 1 year after the initial diagnosis.

CONCLUSIONS

The largest multinational European birth cohort study on food allergy with gold-standard diagnostic methods showed that the mean adjusted incidence of HEA was considerably lower than previously documented, although differences in incidence rates among countries were noted. Half of the children with documented HEA gained tolerance within 1 year postdiagnosis.

Incidence and natural history of challenge-proven cow's milk allergy in European children--EuroPrevall birth cohort

BACKGROUND

Cow's milk allergy (CMA) is one of the most commonly reported childhood food problems. Community-based incidence and prevalence estimates vary widely, due to possible misinterpretations of presumed reactions to milk and differences in study design, particularly diagnostic criteria.

METHODS

Children from the EuroPrevall birth cohort in 9 European countries with symptoms possibly related to CMA were invited for clinical evaluation including cows' milk-specific IgE antibodies (IgE), skin prick test (SPT) reactivity and double-blind, placebo-controlled food challenge.

RESULTS

Across Europe, 12 049 children were enrolled, and 9336 (77.5%) were followed up to 2 years of age. CMA was suspected in 358 children and confirmed in 55 resulting in an overall incidence of challenge-proven CMA of 0.54% (95% CI 0.41-0.70). National incidences ranged from 1% (in the Netherlands and UK) to <0.3% (in Lithuania, Germany and Greece). Of all children with CMA, 23.6% had no cow's milk-specific IgE in serum, especially those from UK, the Netherlands, Poland and Italy. Of children with CMA who were re-evaluated one year after diagnosis, 69% (22/32) tolerated cow's milk, including all children with non-IgE-associated CMA and 57% of those children with IgE-associated CMA.

CONCLUSIONS

This unique pan-European birth cohort study using the gold standard diagnostic procedure for food allergies confirmed challenge-proven CMA in <1% of children up to age 2. Affected infants without detectable specific antibodies to cow's milk were very likely to tolerate cow's milk one year after diagnosis, whereas only half of those with specific antibodies in serum 'outgrew' their disease so soon.

Predictors of health-related quality of life of European food-allergic patients

BACKGROUND

Although food allergy has universally been found to impair HRQL, studies have found significant differences in HRQL between countries, even when corrected for differences in perceived disease severity. However, little is known about factors other than disease severity which may contribute to HRQL in food-allergic patients. Therefore, the aim of this study was to identify factors which may predict HRQL of food-allergic patients and also to investigate the specific impact of having experienced anaphylaxis and being prescribed an EAI on HRQL.

METHODS

A total of 648 European food-allergic patients (404 adults, 244 children) completed an age-specific questionnaire package including descriptive questions. Multivariable regression analyses were performed to develop models for predicting HRQL of these patients.

RESULTS

For adults, the prediction model accounted for 62% of the variance in HRQL and included perceived disease severity, type of symptoms, having a fish or milk allergy, and gender. For children, the prediction model accounted for 28% of the variance in HRQL and included perceived disease severity, having a peanut or soy allergy, and country of origin. For both adults and children, neither experiencing anaphylaxis nor being prescribed an epinephrine auto-injector (EAI) contributed to impairment of HRQL.

CONCLUSIONS

In this study, food allergy-related HRQL may be predicted to a greater extent in adults than in children. Allergy to certain foods may cause greater HRQL impairment than others. Country of origin may affect HRQL, at least in children. Experiencing anaphylaxis or being prescribed an EAI has no impact on HRQL in either adults or children.

The EuroPrevall outpatient clinic study on food allergy: background and methodology

BACKGROUND

The EuroPrevall project aimed to develop effective management strategies in food allergy through a suite of interconnected studies and a multidisciplinary integrated approach. To address some of the gaps in food allergy diagnosis, allergen risk management and socio-economic impact and to complement the EuroPrevall population-based surveys, a cross-sectional study in 12 outpatient clinics across Europe was conducted. We describe the study protocol.

METHODS

Patients referred for immediate food adverse reactions underwent a consistent and standardized allergy work-up that comprised collection of medical history; assessment of sensitization to 24 foods, 14 inhalant allergens and 55 allergenic molecules; and confirmation of clinical reactivity and food thresholds by standardized double-blind placebo-controlled food challenges (DBPCFCs) to milk, egg, fish, shrimp, peanut, hazelnut, celeriac, apple and peach.

RESULTS

A standardized methodology for a comprehensive evaluation of food allergy was developed and implemented in 12 outpatient clinics across Europe. A total of 2121 patients (22.6% <14 years) reporting 8257 reactions to foods were studied, and 516 DBPCFCs were performed.

CONCLUSIONS

This is the largest multicentre European case series in food allergy, in which subjects underwent a comprehensive, uniform and standardized evaluation including DBPCFC, by a methodology which is made available for further studies in food allergy. The analysis of this population will provide information on the different phenotypes of food allergy across Europe, will allow to validate novel in vitro diagnostic tests, to establish threshold values for major allergenic foods and to analyse the socio-economic impact of food allergy.

IgE recognition patterns in peanut allergy are age dependent: perspectives of the EuroPrevall study

BACKGROUND

We tested the hypothesis that specific molecular sensitization patterns correlate with the clinical data/manifestation in a European peanut-allergic population characterized under a common protocol.

METHODS

Sixty-eight peanut-allergic subjects and 82 tolerant controls from 11 European countries were included. Allergy to peanut and lowest symptom-eliciting dose was established by double-blind placebo-controlled food challenge in all but anaphylactic subjects. Information of early or late (before or after 14 years of age) onset of peanut allergy was obtained from standardized questionnaires. IgE to peanut allergens rAra h 1-3, 6, 8-9, profilin and CCD was determined using ImmunoCAP.

RESULTS

Seventy-eight percent of peanut allergics were sensitized to peanut extract and 90% to at least one peanut component. rAra h 2 was the sole major allergen for the peanut-allergic population. Geographical differences were observed for rAra h 8 and rAra h 9, which were major allergens for central/western and southern Europeans, respectively. Sensitization to rAra h 1 and 2 was exclusively observed in early-onset peanut allergy. Peanut-tolerant subjects were frequently sensitized to rAra h 8 or 9 but not to storage proteins. Sensitization to Ara h 2 ≥ 1.0 kUA /l conferred a 97% probability for a systemic reaction (P = 0.0002). Logistic regression revealed a significant influence of peanut extract sensitization and region on the occurrence of systemic reactions (P = 0.0185 and P = 0.0436, respectively).

CONCLUSION

Sensitization to Ara h 1, 2 and 3 is usually acquired in childhood. IgE to Ara h 2 ≥ 1.0 kUA /l is significantly associated with the development of systemic reactions to peanut.

Historical epidemiology of hepatitis C virus (HCV) in selected countries

Chronic infection with hepatitis C virus (HCV) is a leading indicator for liver disease. New treatment options are becoming available, and there is a need to characterize the epidemiology and disease burden of HCV. Data for prevalence, viremia, genotype, diagnosis and treatment were obtained through literature searches and expert consensus for 16 countries. For some countries, data from centralized registries were used to estimate diagnosis and treatment rates. Data for the number of liver transplants and the proportion attributable to HCV were obtained from centralized databases. Viremic prevalence estimates varied widely between countries, ranging from 0.3% in Austria, England and Germany to 8.5% in Egypt. The largest viremic populations were in Egypt, with 6,358,000 cases in 2008 and Brazil with 2,106,000 cases in 2007. The age distribution of cases differed between countries. In most countries, prevalence rates were higher among males, reflecting higher rates of injection drug use. Diagnosis, treatment and transplant levels also differed considerably between countries. Reliable estimates characterizing HCV-infected populations are critical for addressing HCV-related morbidity and mortality. There is a need to quantify the burden of chronic HCV infection at the national level.

The present and future disease burden of hepatitis C virus (HCV) infection with today's treatment paradigm

The disease burden of hepatitis C virus (HCV) is expected to increase as the infected population ages. A modelling approach was used to estimate the total number of viremic infections, diagnosed, treated and new infections in 2013. In addition, the model was used to estimate the change in the total number of HCV infections, the disease progression and mortality in 2013-2030. Finally, expert panel consensus was used to capture current treatment practices in each country. Using today's treatment paradigm, the total number of HCV infections is projected to decline or remain flat in all countries studied. However, in the same time period, the number of individuals with late-stage liver disease is projected to increase. This study concluded that the current treatment rate and efficacy are not sufficient to manage the disease burden of HCV. Thus, alternative strategies are required to keep the number of HCV individuals with advanced liver disease and liver-related deaths from increasing.

Strategies to manage hepatitis C virus (HCV) disease burden

The number of hepatitis C virus (HCV) infections is projected to decline while those with advanced liver disease will increase. A modeling approach was used to forecast two treatment scenarios: (i) the impact of increased treatment efficacy while keeping the number of treated patients constant and (ii) increasing efficacy and treatment rate. This analysis suggests that successful diagnosis and treatment of a small proportion of patients can contribute significantly to the reduction of disease burden in the countries studied. The largest reduction in HCV-related morbidity and mortality occurs when increased treatment is combined with higher efficacy therapies, generally in combination with increased diagnosis. With a treatment rate of approximately 10%, this analysis suggests it is possible to achieve elimination of HCV (defined as a >90% decline in total infections by 2030). However, for most countries presented, this will require a 3-5 fold increase in diagnosis and/or treatment. Thus, building the public health and clinical provider capacity for improved diagnosis and treatment will be critical.

The prevalence and distribution of food sensitization in European adults

BACKGROUND

Complaints of 'food allergy' are increasing. Standardized surveys of IgE sensitization to foods are still uncommon and multicountry surveys are rare. We have assessed IgE sensitization to food-associated allergens in different regions of Europe using a common protocol.

METHODS

Participants from general populations aged 20-54 years in eight European centres (Zurich, Madrid, Utrecht, Lodz, Sophia, Athens, Reykjavik and Vilnius) were asked whether they had allergic symptoms associated with specific foods. Weighted samples of those with and without allergic symptoms then completed a longer questionnaire and donated serum for IgE analysis by ImmunoCAP for 24 foods, 6 aeroallergens and, by allergen microarray, for 48 individual food proteins.

RESULTS

The prevalence of IgE sensitization to foods ranged from 23.6% to 6.6%. The least common IgE sensitizations were to fish (0.2%), milk (0.8%) and egg (0.9%), and the most common were to hazelnut (9.3%), peach (7.9%) and apple (6.5%). The order of prevalence of IgE sensitization against different foods was similar in each centre and correlated with the prevalence of the pollen-associated allergens Bet v 1 and Bet v 2 (r = 0.86). IgE sensitization to plant allergen components unrelated to pollen allergens was more evenly distributed and independent of pollen IgE sensitization (r = -0.10). The most common foods containing allergens not cross-reacting with pollens were sesame, shrimp and hazelnut.

DISCUSSION

IgE sensitization to foods is common, but varies widely and is predominantly related to IgE sensitization to pollen allergens. IgE sensitization to food allergens not cross-reacting with pollens is rare and more evenly distributed.

The EuroPrevall birth cohort study on food allergy: baseline characteristics of 12,000 newborns and their families from nine European countries

It is unclear why some children develop food allergy. The EuroPrevall birth cohort was established to examine regional differences in the prevalence and risk factors of food allergy in European children using gold-standard diagnostic criteria. The aim of this report was to describe pre-, post-natal and environmental characteristics among the participating countries. In nine countries across four major European climatic regions, mothers and their newborns were enrolled from October 2005 through February 2010. Using standardized questionnaires, we assessed allergic diseases and self-reported food hypersensitivity of parents and siblings, nutrition during pregnancy, nutritional supplements, medications, mode of delivery, socio-demographic data and home environmental exposures. A total of 12,049 babies and their families were recruited. Self-reported adverse reactions to food ever were considerably more common in mothers from Germany (30%), Iceland, United Kingdom, and the Netherlands (all 20-22%) compared with those from Italy (11%), Lithuania, Greece, Poland, and Spain (all 5-8%). Prevalence estimates of parental asthma, allergic rhinitis and eczema were highest in north-west (Iceland, UK), followed by west (Germany, the Netherlands), south (Greece, Italy, Spain) and lowest in central and east Europe (Poland, Lithuania). Over 17% of Spanish and Greek children were exposed to tobacco smoke in utero compared with only 8-11% in other countries. Caesarean section rate was highest in Greece (44%) and lowest in Spain (<3%). We found country-specific differences in antibiotic use, pet ownership, type of flooring and baby's mattress. In the EuroPrevall birth cohort study, the largest study using gold-standard diagnostic criteria for food allergy in children worldwide, we found considerable country-specific baseline differences regarding a wide range of factors that are hypothesized to play a role in the development of food allergy including allergic family history, obstetrical practices, pre- and post-natal environmental exposures.

The multinational birth cohort of EuroPrevall: background, aims and methods

BACKGROUND/AIM

The true prevalence and risk factors of food allergies in children are not known because estimates were based predominantly on subjective assessments and skin or serum tests of allergic sensitization to food. The diagnostic gold standard, a double-blind placebo-controlled food provocation test, was not performed consistently to confirm suspected allergic reactions in previous population studies in children. This protocol describes the specific aims and diagnostic protocol of a birth cohort study examining prevalence patterns and influential factors of confirmed food allergies in European children from different regions.

METHODS

Within the collaborative translational research project EuroPrevall, we started a multi-center birth cohort study, recruiting a total of over 12 000 newborns in nine countries across Europe in 2005-2009. In addition to three telephone interviews during the first 30 months, parents were asked to immediately inform the centers about possible allergic reactions to food at any time during the follow-up period.

RESULTS

All children with suspected food allergy symptoms were clinically evaluated including double-blind placebo-controlled food challenge tests. We assessed sensitization to different food allergens by measurements of specific serum immunoglobulin E and skin prick tests, collect blood, saliva or buccal swabs for genetic tests, breast milk for measurement of food proteins/cytokines, and evaluate quality-of-life and economic burden of families with food allergic children.

CONCLUSIONS

This birth cohort provides unique data on prevalence, risk factors, quality-of-life, and costs of food allergies in Europe, leading to the development of more informed and integrated preventative and treatment strategies for children with food allergies.

The EuroPrevall surveys on the prevalence of food allergies in children and adults: background and study methodology

BACKGROUND

The epidemiological surveys in children and adults of the EU-funded multidisciplinary Integrated Project EuroPrevall, launched in June 2005, were designed to estimate the currently unknown prevalence of food allergy and exposure to known or suspected risk factors for food allergy across Europe. We describe the protocol for the epidemiological surveys in children and adults. This protocol provides specific instructions on the sampling strategy, the use of questionnaires, and collection of blood samples for immunological analyses.

METHODS

The surveys were performed as multi-centre, cross-sectional studies in general populations. Case-control studies were nested within these surveys. The studies in children aged 7-10 years and adults aged 20-54 years were undertaken in eight centres representing different social and climatic regions in Europe.

RESULTS

After a community-based survey collecting basic information on adverse reactions to foods, all those stating they had experienced such reactions, as well as of a random sample of those stating 'no reactions' to foods, completed a detailed questionnaire on potential risks and exposures. Also a blood sample was taken to allow serological analysis to establish patterns of food and aeroallergen sensitization. We also included a questionnaire to schools on their preparedness for dealing with food allergy amongst pupils. Subjects reporting adverse reactions to foods and sensitized to the same food(s) were called in for a full clinical evaluation that included a double blind placebo controlled food challenge (DBPCFC), following a protocol which is described in detail elsewhere.

CONCLUSIONS

The outcome of these studies will help to improve our understanding of several important aspects of food allergies in the European Community, providing for more well-informed policies and effective measures of disease prevention, diagnosis and management.

Infant feeding and allergy prevention: a review of current knowledge and recommendations. A EuroPrevall state of the art paper

The relationship between infant feeding patterns and the later development of food allergies has been the focus of much debate and research over the last decade. National recommendations have been made by many countries on how to feed infants to reduce the risk of food allergy but due to the lack of firm evidence the recommendations differ widely. This review has been developed as part of EuroPrevall, a European multicentre research project funded by the European Union, to document the differing feeding recommendations made across Europe, to investigate the current evidence base for any allergy prevention feeding recommendations and to identify areas where further research is needed. This review will also provide information which, when combined with the infant feeding data collected as part of EuroPrevall, will give an indication of compliance to national feeding guidelines which can be utilised to assess the effectiveness of current dissemination and implementation strategies.

Factors influencing the incidence and prevalence of food allergy

Food allergy is an increasing problem in Europe and elsewhere and severe reactions to food are also becoming more common. As food allergy is usually associated with other forms of allergic sensitisation it is likely that many risk factors are common to all forms of allergy. However the potential severity of the disease and the specific public heath measures required for food allergy make it important to identify the specific risk factors for this condition. Food allergy is unusual in that it often manifests itself very early in life and commonly remits with the development of tolerance. Hypotheses that explain the distribution of food allergy include specific genetic polymorphisms, the nature of the allergens involved and the unique exposure to large quantities of allergen through the gut. Progress has been made in developing more specific and testable hypotheses but the evidence for any of these is still only preliminary. Further collaborative research is required to develop an appropriate public health response to this growing problem.

How well do questionnaires perform compared with physical examination in detecting flexural eczema? Findings from the International Study of Asthma and Allergies in Childhood (ISAAC) Phase Two

BACKGROUND

Questionnaires are widely used in epidemiological studies to measure eczema symptom prevalence, but there are concerns regarding their accuracy if used as a diagnostic tool.

OBJECTIVES

To compare the performance of a validated eczema symptom questionnaire and a standardized skin examination protocol employed in the second phase of the International Study of Asthma and Allergies in Childhood (ISAAC).

METHODS

A total of 30,358 schoolchildren aged 8-12 years from 18 countries were examined for flexural eczema. Parents also completed an eczema symptom questionnaire. We compared prevalence estimates at the population level based on the questionnaire vs. physical examination. We also compared the skin examination and the ISAAC questionnaire in making a diagnosis of flexural eczema.

RESULTS

The point prevalences for flexural eczema at centre level based on a single examination were lower than the questionnaire-based 12-month period prevalences (mean centre prevalence 3.9% vs. 9.4%). Correlation between prevalences of both outcome measures was high (r = 0.77, P < 0.001). At the individual level, questionnaire-derived symptoms of 'persistent flexural eczema in the past 12 months' missed < 10% of cases of flexural eczema detected on physical examination. However, between 33% and 100% of questionnaire-based symptoms of 'persistent flexural eczema in the past 12 months' were not confirmed on examination.

CONCLUSIONS

ISAAC questionnaire-derived symptom prevalences are sufficiently precise for comparisons between populations. Where diagnostic precision at the individual level is important, questionnaires should be validated and potentially modified in those populations beforehand, or a standardized skin examination protocol should be used.

Computer simulations suggest that acute correction of hyperglycaemia with an insulin bolus protocol might be useful in brain FDG PET

AIM

FDG PET in hyperglycaemic subjects often suffers from limited statistical image quality, which may hamper visual and quantitative evaluation. In our study the following insulin bolus protocol is proposed for acute correction of hyperglycaemia (>7.0 mmol/l) in brain FDG PET. (i) Intravenous bolus injection of short-acting insulin, one I.E. for each 0.6 mmol/l blood glucose above 7.0. (ii) If 20 min after insulin administration plasma glucose is <or=7.0 mmol/l, proceed to (iii). If insulin has not taken sufficient effect step back to (i). Compute insulin dose with the updated blood glucose level. (iii) Wait further 20 min before injection of FDG. (iv) Continuous supervision of the patient during the whole scanning procedure.

METHODS

The potential of this protocol for improvement of image quality in brain FDG PET in hyperglycaemic subjects was evaluated by computer simulations within the Sokoloff model. A plausibility check of the prediction of the computer simulations on the magnitude of the effect that might be achieved by correction of hyperglycaemia was performed by retrospective evaluation of the relation between blood glucose level and brain FDG uptake in 89 subjects in whom FDG PET had been performed for diagnosis of Alzheimer's disease.

RESULTS

The computer simulations suggested that acute correction of hyperglycaemia according to the proposed bolus insulin protocol might increase the FDG uptake of the brain by up to 80%. The magnitude of this effect was confirmed by the patient data.

CONCLUSION

The proposed management protocol for acute correction of hyper glycaemia with insulin has the potential to significantly improve the statistical quality of brain FDG PET images. This should be confirmed in a prospective study in patients.

A precise method to determine the angular distribution of backscattered light to high angles

We present an approach to measure the angular dependence of the diffusely scattered intensity of a multiple scattering sample in backscattering geometry. Increasing scattering strength give rise to an increased width of the coherent backscattering and sets higher demands on the angular detection range. This is of particular interest in the search for the transition to Anderson localization of light. To cover a range of -60 degrees to +85 degrees from direct back-reflection, we introduced a new parallel intensity recording technique. This allows one-shot measurements, with fast alignment and short measuring time, which prevents the influence of illumination variations. Configurational average is achieved by rotating the sample and singly scattered light is suppressed with the use of circularly polarized light up to 97%. This implies that backscattering enhancements of almost two can be achieved. In combination with a standard setup for measuring small angles up to +/-3 degrees , a full characterization of the coherent backscattering cone can be achieved. With this setup we are able to accurately determine transport mean free paths as low as 235 nm.

The role of nuclear medicine in the diagnosis of cancer of unknown origin

Cancer of unknown origin (CUO) is defined by the absence of any primary tumour in biopsy-proved metastatic cancer. CUO accounts for a 5-10% of all malignancies. These tumors have a specific biology with clinical characteristics of rapid progression and atypical metastases. Diagnostic evaluation is directed at the identification of treatable subset. Accurate diagnostic workup is crucial because both prognosis and survival rates depend mainly on detection of the primary tumor site. Although these patients undergo extensive imaging procedures, nuclear medicine techniques are under-utilized despite their ability of providing molecular information. Positron emission tomography has an emerging role in this clinical challenge along with other nuclear medicine methods including, bone scan, thyroid scintigraphy.

Evaluation of a cefoxitin 30 microg disc on Iso-Sensitest agar for detection of methicillin-resistant Staphylococcus aureus

OBJECTIVES

To evaluate the performance of a cefoxitin 30 microg disc on Iso-Sensitest agar, using a semi-confluent inoculum and overnight incubation at 35-36 degrees C, for detection of methicillin-resistant Staphylococcus aureus (MRSA).

METHODS

A total of 457 S. aureus, including 190 MRSA of several defined PFGE types and a number of low-level resistant isolates, were tested with a cefoxitin 30 microg disc on Iso-Sensitest agar, using a semi-confluent inoculum and overnight incubation at 35-36 degrees C. This method was compared with the standard SRGA (Swedish Reference Group for Antibiotics) method (oxacillin 1 microg disc on Iso-Sensitest agar supplemented with 5% defibrinated horse blood, confluent growth and 24 h incubation in ambient air at 30 degrees C).

RESULTS

The cefoxitin method was excellent, with a sensitivity of 100% and a specificity of 99% using an interpretative zone diameter of S > or = 29 mm and R < 29 mm. Its performance was much better than the SRGA method, which with this collection of difficult strains had a sensitivity of only 78% using the current breakpoint of S > or = 12 mm.

CONCLUSION

We suggest that the cefoxitin method should replace that currently recommended by the SRGA for the detection of MRSA, and that it would fit well into BSAC methodology.

Value of preoperative diagnostic modalities in patients with recurrent thyroid carcinoma

Background

The prognosis of differentiated thyroid carcinoma is usually excellent, but the majority of patients who develop a recurrence have a higher risk of death from the disease. Beside clinical examination, several diagnostic tools, such as ultrasonography, 131I scanning, [18F]fluorodeoxyglucose positron emission tomography (FDG-PET) and thyroglobulin (TG) measurement under raised thyroid-stimulating hormone in serum can detect tumour recurrences. This prospective study compared the value of different diagnostic modalities in the detection of recurrent differentiated thyroid cancer.

Methods

From April 1992 to October 1999, 181 patients with thyroid carcinoma, of whom 150 had a well differentiated tumour, subjected to surgical treatment were identified prospectively. Some 107 patients (71 per cent) presented with primary tumour and 43 patients (29 per cent) with recurrent disease. The patients with tumour recurrence were evaluated regarding the mode of detection of recurrent disease, including clinical examination, ultrasonography, fine-needle biopsy (FNB), TG measurement and FDG-PET, the surgical treatment and outcome.

Results

Some 63 per cent of patients presented with regional lymph node metastases and 37 per cent with local recurrence. None of the patients with local recurrence was operated on for primary tumour in this department. In 87 per cent the recurrence was detected by clinical examination. Ultrasonography and 131I scan revealed suspicious findings in 97 and 69 per cent respectively. FNB disclosed abnormal cytological findings in 95 per cent. There were pathological TG levels in 86 per cent of patients. Among patients with a raised level of TG and negative scan results, 13 underwent FDG-PET, with pathological findings in 82 per cent.

Conclusion

In patients with well differentiated thyroid carcinoma, ultrasonography and FNB are the most sensitive methods for the detection of local recurrence or regional lymph node metastases. FDG-PET is a useful diagnostic tool in patients with a negative 131I scan and a raised level of TG.

Experience with 123I-iomazenil SPECT in acute cerebral infarction

Neuronal cells are susceptible to cerebral ischaemia. As gamma-aminobutyric acid(A) (GABA(A)) receptors are specific for neurones, functional receptor imaging using I-iomazenil (IMZ), a ligand to the GABA benzodiazepine receptor, has been proposed as an imaging modality for the assessment of neuronal integrity. However, there is only limited experience with IMZ in patients with acute cerebral infarction. Therefore, the aim of this study was to evaluate IMZ single photon emission computed tomography (SPECT) in patients with acute cerebral ischaemia. IMZ SPECT was performed in 21 patients with acute cerebral infarction 7-10 days after stroke onset. Eleven patients underwent systemic thrombolysis within 6 h after symptom onset (group 1), whereas 10 patients were treated conservatively (group 2). IMZ (150-200 MBq) was injected intravenously and imaging was performed using a dedicated four-head SPECT camera at 5 min (perfusion) and 90 min (receptor distribution) post-injection, with an acquisition time of 50 min each. Images were analysed by visual inspection. Four patients showed normal IMZ distribution, and 17 patients showed abnormalities of IMZ uptake on both early and late images. In six patients with regional uptake deficits, a crossed cerebellar diaschisis was observed on early images. Cerebellar inhomogeneity of tracer uptake was absent at the time of late images in all six patients. In eight patients, areas of hypoperfusion corresponded exactly to the regions of receptor deficiency (match). In five patients, preserved neuronal integrity was present in hypoperfused areas (mismatch). In four patients, normally or even hyperperfused areas exhibited regional receptor deficiency (inverse mismatch). In conclusion, IMZ SPECT demonstrated differences between regional perfusion and receptor distribution in about one-half of patients 7-10 days after acute cerebral ischaemia. Interesting patterns between the early phase (perfusion) and the late phase (receptor distribution) were found. These patterns are indicative of the heterogeneous development of cerebral ischaemia where, even days after stroke onset, areas of hypoperfusion but preserved neuronal integrity may be present. However, the evaluation of the potential clinical and therapeutic impact of individual IMZ distribution patterns requires further investigation.

Preoperative diagnostic value of [(18)F] fluorodeoxyglucose positron emission tomography in patients with radioiodine-negative recurrent well-differentiated thyroid carcinoma

OBJECTIVE

To assess the utility of 2-[(18)F] fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET) to detect recurrent disease in the follow-up of patients with well-differentiated thyroid cancer (WDTC) who have negative diagnostic (131)I scans and abnormal thyroglobulin levels.

SUMMARY BACKGROUND DATA

In general, patients with WDTC have an excellent long-term prognosis when appropriate surgical treatment and follow-up are carried out. After total thyroid ablation, whole-body (131)I scintigraphy and measurement of serum thyroglobulin are useful diagnostic tools to detect persistent or recurrent malignancy. In case of tumor dedifferentiation, decreased or lost iodine-accumulating ability may lead to false-negative (131)I scanning results. The diagnostic and therapeutic delay is responsible for a poor prognosis in this subgroup of patients. Efforts have been made in the search for suitable imaging modalities capable of early detection of recurrent thyroid carcinoma.

METHODS

The authors prospectively analyzed 24 patients with WDTC, negative results of whole-body (131)I scintigraphy, and elevated serum thyroglobulin concentrations. Attenuation-corrected whole-body FDG-PET scans from the neck to the upper legs were performed. In addition, all patients underwent cervical ultrasonography. The results of the imaging studies were compared with histopathologic findings. If no resection of the suspicious lesion was carried out, computed tomography data were used as control criteria.

RESULTS

Overall, FDG-PET disclosed 38 hot spots. The sensitivity of the method was 94.6%, but the specificity was lower (25.0%). The diagnostic accuracy was 87.8%. There were three false-positive results in two patients with benign cervical lymph nodes. In one patient with regional lymph node metastases in the neck, two false-negative results were obtained. Ultrasound classified both findings as malignant, however. Because of unexpected findings, FDG-PET suggested potential modification of the surgical management in nine patients. Distant metastases could be disclosed using FDG-PET in only three patients.

CONCLUSIONS

FDG-PET is a useful diagnostic tool in the follow-up of thyroidectomized patients with WDTC, negative (131)I scanning results, and abnormal serum thyroglobulin concentrations. The method detects metastatic disease in 94.6% of cases. PET results changed surgical tactics in a significant number of patients. Accurate staging of locoregional cancer recurrence in the neck may be consummately obtained by concomitant analysis of PET and ultrasound results.

[Introduction of a quality management system compliant with DIN EN 9001:2000 in a university department of nuclear medicine]

In 1995, the management of the University Clinic Hamburg-Eppendorf proposed to establish a total quality assurance (QA) system. A revised QA-system has been introduced stepwise in the department of nuclear medicine since 1997, and certification was achieved in accordance with DIN EN ISO 9001:2000 on February 14, 2001. The QA-handbook is divided into two parts. The first part contains operational (diagnostic and therapeutic) procedures in so-called standard operating procedures (SOP). They describe the indication of procedures as well as the competences and time necessary in a standardized manner. Up to now, more than 70 SOPs have been written as a collaborative approach between technicians and physicians during daily clinical routine after analysing and discussing the procedures. Thus, the results were more clearly defined processes and more satisfied employees. The second part consists of general rules and directions concerning the security of work and equipment as well as radiation protection tasks, hygiene etc. as it is required by the law. This part was written predominantly by the management of the department of nuclear-medicine and the QA-coordinator. Detailed information for the patients, documentation of the work-flows as well as the medical report was adopted to the QM-system. Although in the introduction phase of a QA-system a vast amount of time is necessary, some months later a surplus for the clinical workday will become available. The well defined relations of competences and procedures will result in a gain of time, a reduction of costs and a help to ensure the legal demands. Last but not least, the QA-system simply helps to build up confidence and acceptance both by the patients and the referring physicians.