Luca Tagliabue

Effects of infusion of glucose-insulin-potassium on myocardial function after a recent myocardial infarction.

We studied the effects of glucose, insulin, and KCI infusion (GIK), on regional myocardial perfusion and function by 99m-Tc-tetrofosmin-gated SPECT. Methods - we studied 21 male patients with their first uncomplicated acute myocardial infarction (AMI). All patients underwent a rest and submaximal stress perfusion study before and after 24-hour infusion of GIK-solution (group A) or saline solution (group B). Results - Group A showed better stress tolerance and ischaemic threshold improvement after GIK infusion whilst no statistical differences were found between basal and post-infusion test in group B. At first the stress test in group A, of the 192 segments analysed, 52 (27%) showed reversible perfusion defect. In group B, of 144 segments analysed, 31 (21%) showed reversible perfusion defect. A postinfusion analysis in group A showed a post-GIK end-diastolic significant count improvement in 21 segments, and a post-GIK end-systolic count improvement in 22 segments. In group B, perfusion increase was observed only in 4 segments, whilst systolic thickening increase was observed only in I segment. Conclusion - these data demonstrate the efficacy of GIK infusion to improve regional myocardial perfusion and function mainly in segments adjacent to the recently infarcted area.

Association between peripheral T-Lymphocyte activation and impaired bone mineral density in HIV-infected patients

BackgroundHIV-infected patients display an increased and early incidence of osteopenia/osteoporosis. We investigated whether bone metabolism disorders in HIV-infected patients are related to immune hyperactivation and premature immune senescence.MethodsBone mineral density (BMD) was measured by dual-energy X-ray absorptiometry (DXA): low BMD (LBMD) was defined as T-score or z-score < -1. CD4+/CD8+ phenotype (CD38/HLA-DR, CD127, CD28/CD57), and circulating IL-7, TNF-α, RANKL, OPG were measured. The variables with p < .05 were evaluated by multivariate logistic regression.Results78 patients were enrolled: 55 were LBMD. LBMD patients showed increased activated HDLADR + CD4+ and CD8+ (p = .03 and p = .002, respectively). Interestingly, no differences in senescent CD28-CD57 + CD4+/CD8+ T-cells were observed between groups. However, LBMD patients displayed a decreased CD4 + CD28- phenotype (p = .04) at the advantage of the CD28+ pool (p = .03), possibly reflecting heightened apoptosis of highly differentiated CD28-negative cells.Activated HLADR + CD4+/CD8+ and CD28 + CD4+ cells were independently associated with impaired BMD (AOR = 1.08 for each additional HLADR + CD4+ percentage higher; CI 95%,1.01-1.15; p = .02; AOR = 1.07 for each additional HLADR + CD8+ percentage higher; CI 95%,1.01-1.11; p = .01; AOR = 1.06 for each additional CD28 + CD4+ percentage higher; CI 95%,1.0-1.13; p = .05).ConclusionsHeightened T-cell activation in HIV-infected patients independently predicts BMD disorders, suggesting a critical role of immune activation in the pathogenesis of osteopenia/osteoporosis, even in patients achieving full viral suppression with HAART.

Assessment of radiological vertebral fractures in HIV‐infected patients: clinical implications and predictive factors

The aim of this study was to evaluate the clinical impact of including lateral spine X‐ray in the screening of bone diseases in HIV‐positive patients.

Appropriate use of positron emission tomography with [18F]fluorodeoxyglucose for staging of oncology patients

Positron emission tomography (PET) was developed in the mid-1970, and its initial applications were for heart and brain imaging research. Nowadays, this technology is aimed mainly at staging or restaging tumours as it allows the assessment of biochemical processes that are either specific or associated with tumour biology. The full appreciation of PET potentials and limitations among general practitioners and internists cannot be considered achieved and the appropriate use of PET especially when coupled to X-ray computed tomography (CT) is still suboptimal. The majority of PET studies rely on the use of fluorodeoxyglucose labelled with fluorine-18 (FDG), which is a radiopharmaceutical specific for glucose transport and metabolism. PET with FDG is amenable for studying most type of tumours, including those of the head and neck, lung, oesophagus, colo-rectal, gastrointestinal stromal tumours, pancreas, some types of lymphomas and melanoma, whereas in some tumours, including those of the reproductive system, brain, breast and bones, there is a limited role for PET and there is no substantial role for FDG-PET for the bronchoalveolar, hepatocellular, urinary system, testicular, neuroendocrine, carcinoids and adrenal tumours, differentiated thyroid cancers, and several subtypes of malignant lymphoma. Thus, the limits of FDG have stimulated the use and development of other radiopharmaceuticals. These tracers represent the opportunity for expanding the use of PET to other areas in oncology in the near future.

Multi-field-of-view SPECT is superior to whole-body scanning for assessing metastatic bone disease in patients with prostate cancer.

AIM The aim of this study was to compare the diagnostic performance of whole-body bone scintigraphy (WBS) and multi-field-of-view single photon emission tomography (multi-FOV SPECT) with 99mTc-oxidronate (99mTc-HDP) in patients with prostate cancer (PCa). METHODS In a prospective study, WBS and SPECT acquisitions were performed in 194 patients with histologically confirmed PCa and serum prostate-specific antigen (PSA) levels above 10 ng/mL. Scans obtained using the two modalities were interpreted separately. Clinical and biochemical follow-up, radiological studies and biopsies served as benchmarks for the assessments. The impact of PSA level on WBS and SPECT results was also evaluated. RESULTS The patient-based sensitivity, specificity, accuracy, PPV and NPV values of SPECT examinations were higher than those of WBS, especially in patients with serum PSA levels <40 ng/mL. CONCLUSION Multi-FOV SPECT proved to be more sensitive and specific than WBS in detecting bone metastases in PCa patients.

Evaluation of renal function in elderly patients: performance of creatinine-based formulae versus the isotopic method using 99mTc-diethylene triamine pentaacetic acid.

IntroductionMeasurement of the glomerular filtration rate (GFR) is recognized worldwide as the most accurate way of assessing kidney function. The prevalence of impaired renal function increases with advancing age. In this study we compared the clinical formulae Cockcroft–Gault (CG), isotope dilution mass spectrometry-modification of diet in renal disease (IMDS-MDRD) and chronic kidney disease epidemiology collaboration (CKD-EPI) with 99mTc-diethylene triamine pentaacetic acid (99mTc-DTPA) in elderly patients over and under the age of 70 years in an attempt to establish which formula produces the best measurement of renal function in this population. Materials and methodsPatients were randomly selected from two age groups [<70 years (n=37) and ≥70 years (n=39)]. Two plasma samples were collected at 60 and 180 min after injection of 99mTc-DTPA, and the GFR was calculated applying Charles D. Russell’s two-sample method. ResultsIn patients younger than 70 years, no statistically significant difference was found between GFR evaluated with 99mTc-DTPA and GFR obtained using the other methods.In patients aged at least 70 years, no statistically significant difference was found between GFR evaluated with 99mTc-DTPA and GFR evaluated using the CG real weight formula. Conversely, statistically significant differences were found between GFR evaluated with 99mTc-DTPA and GFR obtained using the CG normalized weight (P=0.002), IMDS-MDRD (P=0.024) and CKD-EPI (P=0.028) formulae. Discussion and conclusionIn patients older than 70 years, the use of the two ‘classical’ formulae (IMDS-MDRD and CKD-EPI) overestimated GFR in stage III CKD (GFR 30–59 ml/min) when compared with the gold standard 99mTc-DTPA method. Thus, in patients aged 70 years and above only the CG real weight formula provided unbiased results comparable to 99mTc-DTPA. In conclusion, in elderly patients, GFR measured using CKD-EPI and IMDS-MDRD serum creatinine-based formulae may be overestimated compared with that measured using 99mTc-DTPA GFR.

Enhanced prognostic stratification of CAD patients with low ejection fraction by stress-rest Tc99m tetrofosmin gated-spect.

Objective — This study was performed to assess whether post-stress and rest functional parameters, as measured by gated-SPECT, provide additional predictive value for long-term prognosis, over clinical and perfusion data in patients (pts.) with low left ventricular ejection fraction (LVEF). Methods — 647 consecutive pts. underwent stress/rest gated-SPECT, and 497 were followed for a mean period of 516 ± 264 days. Segmental perfusion and motion/thickening (post-stress and rest) were analysed visually, while EF and LV volumes were calculated using an automatic algorithm (QGS).The post-stress and rest ratio were determined for both end-diastolic (EDV) and end-systolic volume (ESV), while the post-stress LVEF change was calculated subtracting rest-EF from stress-EF. Results — 84/497 pts. showed rest EF < 40%, and 15/84 (18%) experienced a cardiac event (3 cardiac deaths, 1 infarction, 3 hospitalized angina and 9 late revascularizations).The perfusion and functional parameters were not significantly more compromised in pts. with cardiac events compared with pts. without events. Post-stress ESV was the only index significantly higher in pts. with low EF and events compared with pts. with low EF without events (150 ± 72 ml vs. 123 ± 53 ml, P = 0.02). Univariate Cox analysis of clinical, perfusion and functional data showed that the best predictor of cardiac events was stress-ESV (score 6.5, P = 0.01), followed by rest-ESV, rest-EDV, stress-EDV and stress-LVEF. Multivariate analysis demonstrated that the addition of stress-ESV to stress-EF, yielded a significant increase in the global χ2 in the prediction of hard events (cardiac death/infarction) (score 4.634, P = 0.03). Conclusion — In patients with depressed LVEF, stress-ESV was the only independent predictor of long-term outcome.

Severe Cortical and Trabecular Osteopenia in Secondary Hyperparathyroidism

Background:  Peripheral quantitative computed tomography (pQCT) provides real volumetric bone density values, not only of the total, but also of trabecular and cortical bone, separately. In addition, it provides data on bone geometry that can be related to the risk of fracture.

A rare case of hepatic carcinoid.

A 49-year-old woman was thought to have an echino-coccus cyst of the liver based on borderline antibody titers and findings of magnetic resonance imaging (MRI). Increased activity consistent with tumor was seen on In-111 octreotide imaging, and a biopsy indicated carcinoid tumor of the liver.

Quality control on radiochemical purity in Technetium-99m radiopharmaceuticals labelling: three years of experience on 2280 procedures

Objective: the purpose of this study was to offer an example of evaluations of the ISO9001 certified internal quality assurance (QA) system of 99mTc-radiopharmaceutical preparations and quality control in vivo use, using industrial kits and generators in order to identify possible sources of errors in the procedures labeling and quality control procedures. Methods: The study was performed at a single institution over a period of three years (July 1st, 2011 - July 1st, 2014), and included a total of 2280 radiopharmaceutical preparations prepared by four different technologists. All the radiopharmaceutical preparations and quality controls were performed according to each SPC provided by the manufacturer. The radiopharmaceutical preparations were the following (trade names are reported in brackets): 99mTc-albumin colloid [Nanocoll] (n=349), 99mTc-oxidronate [Technescan®hdp] (n=701), 99mTc-exametazime [Ceretec] (n=169), 99mTc-sestamibi [Cardiolite] (n=92), 99mTc-albumin aggregated [Technescan®lyomaa] (n=140), 99mTc-tetrofosmin [Myoview]) (n=567), 99mTc-diethylene triamine pentacetic acid [Technescan®dtpa] (n=254), and 99mTc-dimercapto succinic acid [Renocis®] (n=8). Data were analyzed to determine the number and type of radiopharmaceutical labelling failure and to derive the sources of these failures to define corrective actions and optimize the quality assurance program. Results: A total of 2280 procedures were performed and recorded. Following the quality control procedure six out of the 2280 preparations (0.26%) were non-conforming for clinical use with the RCP limits indicated in the SPC. Five of these were due to gross technical errors in measurements and manual procedures and were immediately repeated, returning within the limits of acceptability. The sixth failure was due to short incubation time, though compliant with the manufacturer’s instructions. Conclusions: We concluded that the quality of the final product depends on a controlled production system based on the implementation of specific standard operating procedures (ISO9001, SOP) for each radiopharmaceutical production, according to strict adherence to the SPC of each radiopharmaceutical. Based on these conclusions, in our opinion every quality control suggesting a possible error in the synthesis procedure recommended in the SPC should be immediately reported to the manufacturer, for a revision of the SPC, as well as to the regulatory agencies for an alert. This strategy may in fact allow the continuous improvement of the labelling procedures and therefore the optimization of the quality control procedures frequency to ensure both patients safety and a more rational management of resources for economic sustainability. (www.actabiomedica.it)