Joseph C. Lee

The segmental distribution and clinical significance of colorectal fluorodeoxyglucose uptake incidentally detected on PET-CT.

BackgroundUnexpected focal colorectal fluorodeoxyglucose (FDG) uptake is becoming a common clinical dilemma with the increasing utilization of positron emission tomography (PET). These findings may subsequently reveal malignant or premalignant pathology. AimIn addition to reporting the prevalence of clinically significant colonic pathology associated with unexpected focal FDG uptake, this study analysed the correlation between pathological colonic segments with those reported on the FDG-PET scan. MethodsThe reports of 2071 consecutive PET-computed tomography (PET-CT) scans performed in a calendar year were reviewed. Information regarding subsequent patient investigation and management was collected from medical records. The segments harbouring foci of unexpected bowel FDG uptake were compared against the eventual outcome(s) of the endoscopic and pathological investigations. ResultsAmong the 62 individual patients represented, 37 (60%) were investigated further. Clinically unsuspected neoplasms were found in 68% of those investigated, including 10 diagnosed with carcinoma. In addition, an unknown bowel lymphoma and 19 colonic adenomas were discovered. The positive predictive value for pathology was higher in the proximal colon than the distal colon. The segments in which the pathological findings were identified correlated well with those reported as abnormal on PET-CT. ConclusionUnexpected bowel FDG uptake on PET-CT is associated with a high incidence of neoplastic pathology. In particular, focal FDG uptake in the proximal colon is associated with a high positive predictive value for neoplasm. The location of pathology is strongly concordant with endoscopic findings.

Positron emission tomography combined with computed tomography as an integral component in evaluation of primary cardiac lymphoma.

We present a case of primary cardiac lymphoma (PCL) that was initially manifest through syncopal episodes. In the diagnostic evaluation, positron emission tomography combined with computed tomography (PET‐CT) made a significant contribution—beyond that which would have been possible if only conventional imaging modalities such as magnetic resonance imaging (MRI) and transthoracic echocardiography (TTE) were utilized—and played a major role in follow‐up. Copyright

A thermodynamic study of the removal of HCl and H2S from syngas

Advanced integrated-gasification combinedcycle (IGCC) and integrated-gasification fuel cell (IFGC) systems require high-temperature sorbents that are capable of removing hydrogen chloride and hydrogen sulfide from coal derived gases to very low levels. HCl and H2S are highly reactive, corrosive, and toxic gases that must be removed to meet stringent environmental regulations, to protect power generation equipment and to control the emissions of contaminants. The thermodynamic behavior of 13 sorbents for the removal of HCl and H2S under various conditions including: initial toxic gas concentration (1–10000 ppm), operating pressure (0.1–11 Mpa), temperature (300 K–1500 K), and the presence of H2O were investigated. The correlation between HCl and H2S was also examined. Thermodynamic calculations were carried out for the reactions of the 13 sorbents using a FactSage 5.2 software package based on free energy minimization. The sorbents, Na2CO3, NaHCO3, K2CO3, and CaO are capable of completely removing chlorine at high temperatures (up to ∼1240 K) and at high pressures. Water vapor did not have any significant effects on the dechlorination capability of the sorbents. Nine of the sorbents namely; Cu2O, Na2CO3, NaHCO3, K2CO3, CaO, ZnO, MnO, FeO, and PbO, were determined to have great potential as desulfurization sorbents. Cu2O and ZnO had the best performance in terms of the optimum operating temperature. The addition of water vapor to the reactant gas produces a slightly detrimental effect on most of the sorbents, but FeO exhibited the worst performance with a reduction in the maximum operating temperature of about 428 K. The dechlorination performance of the alkali sorbents was not affected by the presence of H2S in the reactions. However, the desulfurization capability of some sorbents was greatly affected by the presence of HCl. Particularly, the performance of Cu2O was significantly reduced when HCl was present, but the performance of FeO improved remarkably. The thermodynamic results gathered are valuable for the developments of better sorbents.

Angioembolisation of Pulmonary Artery Pseudoaneurysm Arising in H1N1 Influenza Viral Pneumonia

A 51 year-old Aboriginal woman was diagnosed with H1N1 influenza virus and methicillin-resistant Staphylococcus aureus. Contrasted CT of the pulmonary and bronchial vasculature undertaken for investigation for of haemoptysis revealed an 11 mm left upper lobe pulmonary artery pseudoaneurysm (PAP). The PAP was successfully treated with angioembolisation of the parent artery with two platinum coils. Pulmonary artery pseudoaneurysms are uncommon but potentially life-threatening and have not previously been reported in association with H1N1 influenza viral pneumonia, which has been prominent in recent times in both medical literature and popular press.

Development of a more streamlined approach to pregnancy screening before nuclear medicine procedures

It is a self-evident statement that ionizing radiation from a medical imaging procedure is potentially harmful to the foetus. This is enshrined in the most recent relevant guidelines of the Royal Australian and New Zealand College of Radiology (RANZCR). However, in-depth discussion on pre-procedure pregnancy screening would consume too much of this document. It only intends to provide a broad overview of many issues rather than get entrenched in such specific matters. The importance of establishing a uniform standard is highlighted by the wide spectrum of recommendations between institutions. Alternatively, some departments have no structured policy in place at all. Thus, patients are exposed to different standards on different occasions because of the differing preferences of the responsible medical officer on each occasion. In any case, these approaches would be based on anecdote and experience rather than scientific evidence. Radiation protection in pregnancy in Nuclear Medicine (NM) is a particular concern. Needless to say, the radiation dose to the foetus/embryo is minimized within the parameters of the procedure. However, the generalizations stated in guideline documents translate to day-today practice is unstipulated. Inherently, NM requires the administration of a substance to the patient with not only a radiation dose but also associated with systemic circulation (of the administered substance). Pregnancy screening before an NM procedure – or more broadly, for all medical imaging – is therefore a very important clinical problem and it is surprising that a uniform guideline is not already in place. A sensible approach has been previously proposed. It was based on expert consensus, utilizing a Delphi technique. We are in favour of simplifying some aspects. We are also in favour of supervening as much of a sciencebased approach as possible. With these combined factors, we are attempting to generate a more streamlined algorithm that can be followed by NM technologists, physicians and nurses. Questioning a pre-menopausal woman about pregnancy status is not infallible. It has a high negative predictive value – but unfortunately is not 100%. (While it is possible for extra-uterine pregnancies to occur post-hysterectomy, these are generally nonviable.) Hence, except for patients who have had a hysterectomy we would favour pregnancy testing over patient account for all post-menarche/pre-menopausal patients.

The elephant in the room of hypertension treatment

Campbell et al. present a well-designed study that reflects the population we treat. The wide range of variables (encompassing other cardiac conditions, comorbidities, tobacco usage and use of various medications) is thoroughly analysed. However, the study seems oblivious to the major hurdle to adequate blood pressure control in patients with hypertension not adequately treated pharmacologically. The elephant in the room is compliance (and lack thereof). In our experience of the treatment of a range of such patients, poor compliance is the most prevalent reason for inadequate blood pressure control. This is equally true of public and private patients. It occurs just as frequently in cardiology clinics as it can in internal medicine or geriatrics. It is pervasive regardless of all other factors, including how many classes of medications prescribed, the geographical location and the socioeconomic status of patients. Compliance with antihypertensive medications is a common problem in our community and has significant costs. Needless to say, inadequate blood pressure control is strongly linked to concurrent or future cardiovascular and/or cerebrovascular disease. In fact, compliance affects every specialty in the treatment of any chronic condition one can think of. It has been estimated that up to 75% of patients are not taking medications as prescribed. The underlying reasons are many and varied; what a medical practitioner does next is not straightforward. It seems the only thing harder than measuring compliance is improving it. While we are not disputing the findings of this study, we remain mindful that any study in this domain will be significantly distorted by compliance issues. Accounting for this factor adequately is difficult. However, omitting it altogether is ignoring the proverbial elephant.

Anomalous origin of the left internal mammary artery from the aortic arch

A 67-year-old diabetic man with a pacemaker for symptomatic bradycardia underwent cardiac catheterization for unstable angina, 19 years after coronary artery bypass graft surgery. There were bilateral pedicled internal mammary grafts—from the left internal mammary artery (LIMA) to the left

Primary Thoracic Cancers Incidentally Detected on CT Attenuation Correction Images During Myocardial Perfusion Scintigraphy

Low-dose, non-breath-holding computed tomography (CT) images of a significant portion of the thorax can be used to provide CT attenuation correction (CTAC) in myocardial perfusion scintigraphy, enhancing the accuracy of evaluation for myocardial ischaemia.Incidental findings of potential clinical significance, most commonly pulmonary nodules, are seen on the CTAC images in a considerable number of cases and may represent undiagnosed malignancy.Early detection allowed curative surgical treatment to be undertaken in 40% of cases, with no recurrence or metastasis at 1 year in these patients. The nature and location within the thorax of the incidental low-dose CT findings, which represented undiagnosed malignancy, was varied.Review of CTAC images in MPI for incidental lesions and reporting of any suspicious findings should be mandatory given the ability to detect undiagnosed malignancy and potentially improve patient outcomes.Direct communication of suspicious incidental findings between the nuclear medicine physicians and referring doctors at time of reporting may help to reduce the interval between MPI and definitive diagnosis. The position would be further strengthened if reinforced in the guidelines of the major nuclear medicine associations

Patient consent and genuine understanding

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Does cardiac testing before trastuzumab therapy actually make a difference

out, sitaxentan and bosentan were both contraindicated for patients with elevated liver aminotransferases prior to initiation of treatment. Finally, on clinical grounds and according to current recommendations, it is advisable to monitor routinely liver aminotransferase levels for the duration of treatment with ERA. In addition, if patients show liver aminotransferases increased prior to initiation of treatment, alternative therapeutic choices other than ERA should be considered. Received 21 January 2013; accepted 27 January 2013.