Bruno Krug

Role of PET in the Initial Staging of Cutaneous Malignant Melanoma: Systematic Review

PURPOSE To calculate summary estimates of the diagnostic performance of fluorine 18 fluorodeoxyglucose (FDG) positron emission tomographic (PET) imaging in the initial staging of cutaneous malignant melanoma (CMM), following the new American Joint Committee on Cancer (AJCC) staging classification on per-patient and per-lesion bases. MATERIALS AND METHODS MEDLINE, EMBASE, Web of Science, and Cochrane Database of Systematic Reviews databases, and reference lists of reviews and included papers were searched, without any language restrictions, for relevant articles published before March 2007. Two reviewers independently assessed study eligibility and methodologic quality by using the quality assessment of diagnostic accuracy studies checklist. A pooled random effect was estimated and a fixed coefficient regression model was used to explore the existing heterogeneity. RESULTS Twenty-eight studies involving 2905 patients met the inclusion criteria. The pooled estimates of FDG PET for the detection of metastasis in the initial staging of CMM were sensitivity, 83% (95% confidence interval [CI]: 81%, 84%); specificity, 85% (95% CI: 83%, 87%); positive likelihood ratio (LR), 4.56 (95% CI: 3.12, 6.64); negative LR, 0.27 (95% CI: 0.18, 0.40); and diagnostic odds ratio, 19.8 (95% CI: 10.8, 36.4). Results from eight studies suggested that FDG PET was associated with 33% disease management changes (range, 15%-64%). CONCLUSION There is good preliminary evidence that FDG PET is useful for the initial staging of patients with CMM, especially as adjunctive role in AJCC stages III and IV, to help detect deep soft-tissue, lymph node, and visceral metastases. FDG PET-computed tomographic imaging seemed to be more precise than PET alone, as suggested by four eligible studies. Further evaluation by using a well-designed prospective study, with clinical outcome-focused measures and cost effectiveness analysis, is needed to clarify the appropriate role of FDG PET in CMM staging. SUPPLEMENTAL MATERIAL http://radiology.rsnajnls.org/cgi/content/full/249/3/836/DC1.

Is procalcitonin a good marker of renal lesion in febrile urinary tract infection

Four recent prospective studies have suggested that procalcitonin (PCT), a polypeptide produced by the macrophage-monocyte system during severe bacterial infection, might be more specific than leukocyte count or C-reactive protein (CRP) in predicting acute renal involvement during an episode of febrile urinary tract infection (UTI) [1, 2, 3, 5]. The aim of our prospective study was to confirm such findings.

Unsuspected FDG-PET findings in the follow-up of patients with lymphoma

Abstract18F-Fluorodeoxyglucose–positron emission tomography (FDG–PET) plays an increasing role in the management of patients with lymphoma, for which it is successfully used for staging and treatment monitoring. We report seven patients with a history of lymphoma who presented a positive FDG–PET suggestive of lymphoma relapse and for which FDG–PET oriented biopsies revealed alternative diagnoses. Early in lymphoma follow-up, persistence of focal increased FDG activity corresponded to inflammatory or infectious lesions in two patients: one aspergillosis and one sarcoidosis. Later in the follow-up, five cases of secondary malignancies were identified (three lung cancers, one epidermoid carcinoma, and one villous tumor) in this particularly exposed population. The routine use of FDG PET to evaluate lymphoma significantly increases the probability of detecting unexpected diseases. These cases illustrate the potential pitfalls in PET follow-up. Because FDG is not lymphoma-specific, a relapse suspected only on FDG–PET imaging requires biopsy, as alternative diagnoses—infectious or malignant—are possible. Our data draws clinician’s attention to potential false–positive FDG–PET findings, which may lead to therapeutic mistakes. Our data also suggests that FDG–PET might be a new imaging modality for long-term monitoring of late effects, especially second cancer occurrence.

Cost-effectiveness analysis of FDG PET-CT in the management of pulmonary metastases from malignant melanoma.

Abstract Objectives. Most guidelines consider FDG PET-CT to detect occult extra-pulmonary disease prior to lung metastasectomy. A cost-effectiveness analysis, using a Markov model over a 10 year period, was performed to compare two different surveillance programs, either PET-CT or whole-body CT, in patients with suspected pulmonary metastasised melanoma. Methods. Data from published studies provided probabilities for the model. Complication and care costs were obtained from standardised administrative databases from 19 hospitals identified by DRG codes (reported in 2009 Euros). For the cost calculation of PET-CT we performed a microcosting analysis. All costs and benefits were yearly discounted at respectively 3% and 1.5%. Outcomes included life-months gained (LMG) and the number of futile surgeries avoided. Cost-effectiveness ratios were in Euros per LMG. Univariate and probabilistic sensitivity analyses addressed uncertainty in all model parameters. Results. The PET-CT strategy provided 86.29 LMG (95% CI: 81.50–90.88 LMG) at a discounted cost of €3 974 (95% CI: €1 339–12 303), while the conventional strategy provided 86.08 LMG (95% CI: 81.37–90.68 LMG) at a discounted cost of €5 022 (95% CI: €1 378–16 018). This PET-CT strategy resulted in a net saving of €1 048 with a gain of 0.2 LMG. Based on PET-CT findings, 20% of futile surgeries could be avoided. Conclusion. Integrating PET-CT in the management of patients with high risk MM appears to be less costly and more accurate by avoiding futile thoracotomies in one of five patients as well as by providing a small survival benefit at 10 years.

Activity-based costing evaluation of a [18F]-fludeoxyglucose positron emission tomography study

OBJECTIVE The aim of the study is to use the activity-based costing approach to give a better insight in the actual cost structure of a positron emission tomography procedure (FDG-PET) by defining the constituting components and by simulating the impact of possible resource or practice changes. METHODS The cost data were obtained from the hospital administration, personnel and vendor interviews as well as from structured questionnaires. A process map separates the process in 16 patient- and non-patient-related activities, to which the detailed cost data are related. One-way sensitivity analyses shows to which degree of uncertainty the different parameters affect the individual cost and evaluate the impact of possible resource or practice changes like the acquisition of a hybrid PET/CT device, the patient throughput or the sales price of a 370MBq (18)F-FDG patient dose. RESULTS The PET centre spends 73% of time in clinical activities and the resting time after injection of the tracer (42%) is the single largest departmental cost element. The tracer cost and the operational time have the most influence on cost per procedure. The analysis shows a total cost per FDG-PET ranging from 859 Euro for a BGO PET camera to 1142 Euro for a 16 slices PET-CT system, with a distribution of the resource costs in decreasing order: materials (44%), equipment (24%), wage (16%), space (6%) and hospital overhead (10%). CONCLUSIONS The cost of FDG-PET is mainly influenced by the cost of the radiopharmaceutical. Therefore, the latter rather than the operational time should be reduced in order to improve its cost-effectiveness.

Performance of the Adverse Drug Event Trigger Tool and the Global Trigger Tool for Identifying Adverse Drug Events: Experience in a Belgian Hospital

Background: Medication-related harm can be detected using the adverse drug event (ADE) trigger tool and the medication module of the Global Trigger Tool (GTT) developed by the Institute for Healthcare Improvement (IHI). In recent years, there has been some controversy on the performance of this method. In addition, there are limited data on the performance of the medication module of the GTT as compared with the ADE trigger tool. Objectives: To evaluate the performance of the ADE trigger tool and of the medication module of the GTT for identifying ADEs. Methods: The methodology of the IHI was used. A random sample of 20 adult admissions per month was selected over a 12-month period in a teaching hospital in Belgium. The ADE trigger tool was adapted to the Belgian setting and included 20 triggers. The positive predictive value (PPV) of each trigger was calculated, as well as the proportion of ADEs that would have been identified with the medication module of the GTT as compared with the ADE trigger tool. Results: A total of 200 triggers and 62 ADEs were found, representing 26 ADEs/100 admissions. Nineteen ADEs (31%) were found spontaneously without the presence of a trigger. Three triggers never occurred. The PPVs of other triggers varied from 0 to 0.67, with half of them having PPVs less than 0.20. If we had used the medication triggers included in the GTT (n = 11), we would have identified 77% of total ADEs and 67% of preventable ADEs. Conclusions: Applying the trigger tool method proposed by the IHI to a Belgian hospital led to the identification of one ADE out of 4 admissions. To increase performance, refining the list of triggers in the ADE trigger tool and in the medication module of the GTT would be needed. Recording nontriggered events should be encouraged.

FDG PET utility in paraneoplastic sweet syndrome.

We describe a 43-year-old woman who presented a sudden onset of fever and migratory arthralgias. Physical examination revealed tender, well-demarcated erythematous papules and plaques, consistent with a Sweet syndrome. After developing systemic symptoms with hepatomegaly, a liver biopsy and FDG PET imaging demonstrated the presence of an aggressive and extended non-Hodgkin T-cell lymphoma. This case highlights the usefulness of FDG PET imaging for the screening of this paraneoplastic symdrome.

Comparative study of rest technetium-99m sestamibi SPET and low-dose dobutamine stress echocardiography for the early assessment of myocardial viability after acute myocardial infarction: importance of the severity of the infarct-related stenosis

Rest technetium-99m sestamibi single-photon emission tomography (SPET) has been shown to under-estimate viability in some patients with chronic ischaemic myocardial dysfunction. The present study was designed to appraise the value of99mTc-sestamibi as a viability tracer in patients with a recent myocardial infarction and to determine factors that might influence its accuracy in assessing infarct size. Therefore, rest99mTc-sestamibi SPET, low-dose dobutamines stress echocardiography and quantitative coronary angiography were performed in 51 patients with a recent myocardial infarction. Perfusion activity and regional wall motion were scored semi-quantitatively using the same segmental division of the left ventricle. Assessment of99mTc-sestamibi uptake as a marker of viability was performed by comparing a binary uptake score (viable=>50% vs necrotic =≤50% of the maximal tracer activity) with a binary wall motion classification during low-dose dobutamine infusion (viable=normal/hypokinetic vs necrotic=akinetic/dyskinetic). Infarct size, expressed as the number of segments with evidence of necrotic tissue, was significantly greater in the scintigraphic study than in the echocardiographic study (2.8±1.5 vs 2.2±1.3,P=0.006). This overestimation of infarct size by99mTc-sestamibi was present only in patients with a severe infarct-related stenosis (% diameter stenosis ≽65%–100%) and particularly those with “late” reperfusion therapy (time delay ≽180 min). In patients without a severe infarct-related stenosis,99mTc-sestamibi was able to accurately distinguish viable from necrotic segments. Thus, rest99mTc-sestamibi scintigraphy early after acute myocardial infarction may underestimate residual viability within the infarct region, particularly in patients with low flow state coronary anatomy, as a result of a severe infarct-related stenosis and/or late reperfusion therapy.

Electronic tools to support medication reconciliation – a systematic review

Objectives: Medication reconciliation (MedRec) is essential for reducing patient harm caused by medication discrepancies across care transitions. Electronic support has been described as a promising approach to moving MedRec forward. We systematically reviewed the evidence about electronic tools that support MedRec, by (a) identifying tools; (b) summarizing their characteristics with regard to context, tool, implementation, and evaluation; and (c) summarizing key messages for successful development and implementation. Materials and Methods: We searched PubMed, the Cumulative Index to Nursing and Allied Health Literature, Embase, PsycINFO, and the Cochrane Library, and identified additional reports from reference lists, reviews, and patent databases. Reports were included if the electronic tool supported medication history taking and the identification and resolution of medication discrepancies. Two researchers independently selected studies, evaluated the quality of reporting, and extracted data. Results: Eighteen reports relative to 11 tools were included. There were eight quality improvement projects, five observational effectiveness studies, three randomized controlled trials (RCTs) or RCT protocols (ie, descriptions of RCTs in progress), and two patents. All tools were developed in academic environments in North America. Most used electronic data from multiple sources and partially implemented functionalities considered to be important. Relevant information on functionalities and implementation features was frequently missing. Evaluations mainly focused on usability, adherence, and user satisfaction. One RCT evaluated the effect on potential adverse drug events. Conclusion: Successful implementation of electronic tools to support MedRec requires favorable context, properly designed tools, and attention to implementation features. Future research is needed to evaluate the effect of these tools on the quality and safety of healthcare.

Is a methodology available that accurately measures the cost of an FDG-PET study?

Health care expenses are escalating in many countries. With more restrictive reimbursement schemes based on case-mix funding systems, increasing complexity and rising costs, the health care sector faces a new challenge in becoming more cost efficient. In nuclear medicine, as in other specialties, the rapid growth and development of medical technology has contributed significantly to the steady increase in the costs of medical care. Hospital administrators and governments are being forced to take difficult decisions regarding which new developments in nuclear medicine should be supported financially, e.g. construction of a cyclotron facility, acquisition of new hybrid devices (SPECT/CT and PET/CT) or building of shielded rooms for metabolic therapies [1, 2]. Cost-effectiveness is now being used by many payers as a criterion for health care coverage, necessitating estimation of the economic effects of incorporating a technological innovation. Implicit in economic analysis is the assignment of some monetary cost to the considered intervention. Cost measurement is a complex matter, however, and there is a lack of clarity both in the terminology and in the cost concepts utilised. Cost is a term that can have several definitions in medical economics [3]. Especially in fee-for-service health systems, “costs” may refer to charges or to actual direct medical costs. A health care charge is synonymous with the administrative price, reflecting the amount requested by an institution or office practice for a given admission, procedure or office visit from third party payers or patients. Most health care organisations have a predetermined charge for each type of service, but the charge may not accurately portray the underlying true cost of providing the service because of historical and political factors, regulatory compliance, budget constraints and market forces. Allocating cost based on revenues may become arbitrary when fees are determined independently of costs [1]. Although the importance of accurate cost data in respect of an FDG-PET study has been recognised, most cost estimates have focussed on average cost per procedure extrapolated from a global cost. Because they are easy to obtain, indirect top-down methods are used to estimate the costs: (a) using hospital charges to estimate hospital costs and physician fees to estimate the cost of professional services, (b) averaging multiple hospital and physician charges, (c) adjusting charges by cost–charge ratios and (d) using third party payments as proxies for resource costs. The differences in methods used, cost components included and health care systems make comparisons unreliable [4–6]. In this era of intense cost containment there is an urgent need for more accurate data on the precise costs of a health care procedure. Unfortunately, we currently lack well-accepted metrics for the accurate determination of costs. Current hospital accounting systems do not provide the information needed to determine the cost of a medical service or to make decisions. Traditional accounting systems break down costs into direct and indirect costs. Direct costs comprise expenditure on resources, in the form of specific products (e.g. the price of radiopharmaceuticals or other consumables, the acquisition or repair cost of a PET scanner). Slightly murkier are indirect costs, which are defined by default. These indirect costs Eur J Nucl Med Mol Imaging (2007) 34:625–627 DOI 10.1007/s00259-006-0308-y