Fréquence des incidentalomes lors d'un examen PET/CT effectué pour une pathologie oncologique

Contexte¦Le PET/CT au 18Fluor (FDG) fait aujourd'hui partie intégrante des moyens diagnostiques¦à disposition pour la stadification des cancers suspectés ou connus. Il n'est pas rare de¦découvrir des lésions fortuites.¦Objectifs¦Notre but était de déterminer la fréquence des lésions tumorales ou non, cliniquement¦silencieuses (incidentalomes), chez des patients consécutifs non sélectionnés examinés¦par PET/CT au FDG pour un cancer connu ou supposé au sein du bassin populationnel¦du CHUV.¦Méthode¦Nous avons rétrospectivement lu les 1226 des rapports d'examens faits d'août 2009 à¦juillet 2010 pour toute indication oncologique et relevé les lésions de découverte¦fortuite et leur localisation, avant de rechercher leur investigation et leur prise en¦charge.¦Résultats¦Nous avons retenu 309 lésions fortuites chez 260 patients (25,2% des rapports lus),¦dont 141 chez 127 patients investiguées. Ont été relevés 31 patients présentant 32¦incidentalomes (2,6%), dont 6 étaient malins, 6 pré-malins et 20 bénins, soit un taux de¦1% pour les malins et pré-malins. Les sites les plus fréquents étaient les mêmes que¦dans la littérature, à savoir la thyroïde, le poumon, la sphère colorectale (lésions prémalignes¦uniquement) et les lymphomes. Pour ces trois derniers, les lésions étaient¦moins fréquentes que ce qui est rapporté. Tous ces foyers sont à investiguer¦soigneusement, afin de différencier une nouvelle atteinte d'une métastase.¦Conclusion¦En tant que première étude suisse sur le sujet, nous obtenons 1% d'incidentalomes¦(pré)malins, soit l'équivalent de la limite inférieure de la littérature, dans des sites¦similaires. Une amélioration serait possible en augmentant l'attention portée aux lésions¦jugées peu significatives. A l'instar de nombreuses autres études, nous sommes aussi¦confrontés au problème lié à l'interprétation des foyers de captation et à la nonspécificité¦du FDG.

Multi-Atlas based Segmentation of Head and Neck CT Images using Active Contour

This paper presents the segmentation of bilateral parotid glands in the Head and Neck (H&N) CT images using an active contour based atlas registration. We compare segmentation results from three atlas selection strategies: (i) selection of "single-most-similar" atlas for each image to be segmented, (ii) fusion of segmentation results from multiple atlases using STAPLE, and (iii) fusion of segmentation results using majority voting. Among these three approaches, fusion using majority voting provided the best results. Finally, we present a detailed evaluation on a dataset of eight images (provided as a part of H&N auto segmentation challenge conducted in conjunction with MICCAI-2010 conference) using majority voting strategy.

Advances in post-mortem CT-angiography.

Performing a post-mortem multidetector CT (MDCT) scan has already become routine in some institutes of forensic medicine. To better visualize the vascular system, different techniques of post-mortem CT-angiography have been explored, which can essentially be divided into partial- and whole-body angiography techniques. Probably the most frequently applied technique today is the so-called multiphase post-mortem CT-angiography (MPMCTA) a standardized method for investigating the vessels of the head, thorax and abdomen. Different studies exist, describing its use for medicolegal investigations, and its advantages as well as its artefacts and pitfalls. With the aim to investigate the performance of PMCTA and to develop and validate techniques, an international working group was created in 2012 called the "Technical Working Group Post-mortem Angiography Methods" (TWGPAM). Beyond its primary perspective, the goals of this group include creating recommendations for the indication of the investigation and for the interpretation of the images and to distribute knowledge about PMCTA. This article provides an overview about the different approaches that have been developed and tested in recent years and an update about ongoing research in this field. It will explain the technique of MPMCTA in detail and give an outline of its indications, application, advantages and limitations.

What factors influence long-term antidepressant use in primary care? Findings from the Australian diamond cohort study.

BACKGROUND: Antidepressants are one of the most commonly prescribed drugs in primary care. The rise in use is mostly due to an increasing number of long-term users of antidepressants (LTU AD). Little is known about the factors driving increased long-term use. We examined the socio-demographic, clinical factors and health service use characteristics associated with LTU AD to extend our understanding of the factors that may be driving the increase in antidepressant use. METHODS: Cross-sectional analysis of 789 participants with probable depression (CES-D≥16) recruited from 30 randomly selected Australian general practices to take part in a ten-year cohort study about depression were surveyed about their antidepressant use. RESULTS: 165 (21.0%) participants reported <2 years of antidepressant use and 145 (18.4%) reported ≥2 years of antidepressant use. After adjusting for depression severity, LTU AD was associated with: single (OR 1.56, 95%CI 1.05-2.32) or recurrent episode of depression (3.44, 2.06-5.74); using SSRIs (3.85, 2.03-7.33), sedatives (2.04, 1.29-3.22), or antipsychotics (4.51, 1.67-12.17); functional limitations due to long-term illness (2.81, 1.55-5.08), poor/fair self-rated health (1.57, 1.14-2.15), inability to work (2.49, 1.37-4.53), benefits as main source of income (2.15, 1.33-3.49), GP visits longer than 20min (1.79, 1.17-2.73); rating GP visits as moderately to extremely helpful (2.71, 1.79-4.11), and more self-help practices (1.16, 1.09-1.23). LIMITATIONS: All measures were self-report. Sample may not be representative of culturally different or adolescent populations. Cross-sectional design raises possibility of "confounding by indication". CONCLUSIONS: Long-term antidepressant use is relatively common in primary care. It occurs within the context of complex mental, physical and social morbidities. Whilst most long-term use is associated with a history of recurrent depression there remains a significant opportunity for treatment re-evaluation and timely discontinuation.

Fatal tolperisone poisoning: Autopsy and toxicology findings in three suicide cases.

Tolperisone (Mydocalm(®)) is a centrally acting muscle relaxant with few sedative side effects that is used for the treatment of chronic pain conditions. We describe three cases of suicidal tolperisone poisoning in three healthy young subjects in the years 2006, 2008 and 2009. In all cases, macroscopic and microscopic autopsy findings did not reveal the cause of death. Systematic toxicological analysis (STA) including immunological tests, screening for volatile substances and blood, urine and gastric content screening by GC-MS and HPLC-DAD demonstrated the presence of tolperisone in all cases. In addition to tolperisone, only the analgesics paracetamol (acetaminophen), ibuprofen and naproxen could be detected. The blood ethanol concentrations were all lower than 0.10g/kg. Tolperisone was extracted by liquid-liquid extraction using n-chlorobutane as the extraction solvent. The quantification was performed by GC-NPD analysis of blood, urine and gastric content. Tolperisone concentrations of 7.0mg/l, 14mg/l and 19mg/l were found in the blood of the deceased. In the absence of other autopsy findings, the deaths in these three cases were finally explained as a result of lethal tolperisone ingestion. To the best of our knowledge, these three cases are the first reported cases of suicidal tolperisone poisonings.

Evaluation Findings: Rural Reentry Program Works, Data Download, Iowa Department of Corrections, April 2010

Iowa’s Division of Criminal and Juvenile Justice Planning (CJJP) recently completed an evaluation of the 2nd Judicial District’s Rural Prisoner Reentry Initiative (PRI), which provided reentry services to offenders both while in prison and after release.

Pratique du scanner en Suisse: fréquence et évolution temporelle [CT utilisation in Switzerland: frequency and secular trends]

PURPOSE: This study analyzes CT examinations in Switzerland. MATERIALS AND METHODS: Using different sources (administrative data on the equipment, a 1998 nationwide inquiry into practices, and data provided by the Swiss University Hospitals of Basel, Zurich, and Lausanne), we determined the frequency of CT examinations (hospitals and private radiologists) in 1998 according to different descriptive variables and studied the progression in CT use over time. RESULTS: CT scanners increased by 7% between 1998 and 2004. The average annual number of CT examinations in 1998 was 46.3/1000 population, 3.4% of all radiological examinations in Switzerland in 1997-1998. The most frequent examination was CT of the skull (24%), while private radiology institutes perform more CTs of the spine. More CT examinations were performed for men than for women (sex ratio M/F=1.17). The average annual increase in CT in Swiss hospitals varied from 8% for Basel to 18% for Lausanne. Finally, the proportion of pediatric examinations was 5%; their numbers appear to be stabilizing. CONCLUSION: There is a significant increase in CT examinations. It is hoped that our study will heighten awareness among doctors of CT examinations in order to optimize their use.

Procalcitonin and C-reactive protein in pericardial fluid for postmortem diagnosis of sepsis.

The aim of this study was to investigate the presence and concentrations of procalcitonin and C-reactive protein in pericardial fluid and compare these levels to those found in the postmortem serum obtained from the femoral blood. Two groups were formed, a sepsis-related fatalities group and a control group. Postmortem native CT scans, autopsies, histology, neuropathology and toxicology as well as other postmortem biochemistry investigations were performed in all cases. Pericardial fluid procalcitonin levels were significantly different between the cases of sepsis-related fatalities and those of the control group. Postmortem serum procalcitonin levels below the detection limit were also reflected in undetectable pericardial fluid levels. Similarly, a large increase in postmortem serum procalcitonin levels was reflected in a large increase of procalcitonin pericardial fluid levels. Based on these findings, pericardial fluid could be an alternative to postmortem serum for the determination of procalcitonin levels in cases where postmortem serum is not available and measurements of procalcitonin are required to circumstantiate the pathogenesis of death.

A CT-based study investigating the relationship between pedicle screw placement and stimulation threshold of compound muscle action potentials measured by intraoperative neurophysiological monitoring.

PURPOSE: Neurophysiological monitoring aims to improve the safety of pedicle screw placement, but few quantitative studies assess specificity and sensitivity. In this study, screw placement within the pedicle is measured (post-op CT scan, horizontal and vertical distance from the screw edge to the surface of the pedicle) and correlated with intraoperative neurophysiological stimulation thresholds. METHODS: A single surgeon placed 68 thoracic and 136 lumbar screws in 30 consecutive patients during instrumented fusion under EMG control. The female to male ratio was 1.6 and the average age was 61.3 years (SD 17.7). Radiological measurements, blinded to stimulation threshold, were done on reformatted CT reconstructions using OsiriX software. A standard deviation of the screw position of 2.8 mm was determined from pilot measurements, and a 1 mm of screw-pedicle edge distance was considered as a difference of interest (standardised difference of 0.35) leading to a power of the study of 75 % (significance level 0.05). RESULTS: Correct placement and stimulation thresholds above 10 mA were found in 71 % of screws. Twenty-two percent of screws caused cortical breach, 80 % of these had stimulation thresholds above 10 mA (sensitivity 20 %, specificity 90 %). True prediction of correct position of the screw was more frequent for lumbar than for thoracic screws. CONCLUSION: A screw stimulation threshold of >10 mA does not indicate correct pedicle screw placement. A hypothesised gradual decrease of screw stimulation thresholds was not observed as screw placement approaches the nerve root. Aside from a robust threshold of 2 mA indicating direct contact with nervous tissue, a secondary threshold appears to depend on patients' pathology and surgical conditions.

Pediatric CT: how to compare the Present DRL Values? : 12.10

Purpose: To determine dose thresholds, in term of CTDIvol, where subtle anatomical structures of pediatric CT images becomes no more detectable and compare them to the most recent Reference Dose Levels (DRL) proposed in the UK, Germany and Switzerland. Materials and methods: A GE LightSpeed-Ultra scanner (MSCT 8 slices) was used to perform chest and abdomen acquisitions on 8 patients (age range 2 to 16 years old) to provide a set of gold standard images. Dose reductions were then simulated by introducing image noise on raw data to provide simulated CT images with CTDIvol ranging from 2 to 22 mGy. All images were reviewed and scored independently by four experienced radiologists using the VGA methodology (Visual Grading Analysis) to determine the dose threshold where a significant loss of normal anatomy conspicuity appeared. Data were analyzed with ANOVA and Tukey HSD tests, a p >0.05 was considered to be significant. Results: No significant difference in VGA scoring appeared for CTDIvol leading to image noise levels lower than 10 and 25 HU for respectively abdominal and chest acquisitions. These data can thus be used to set the AEC (automatic exposure control) system of units having similar noise properties than the GE LightSpeed-Ultra used in this study. The present DRLs proposed for pediatric CT acquisitions are compatible with an excellent image quality level. Conclusion: The differences of DRL values proposed in Europe for pediatric acquisitions are marginal and assure a very good image quality level. The results of this study allow to further optimize the acquisition protocol by giving Noise Index value to set the AEC device.

Clinical characteristics and outcome of inpatients versus outpatients with venous thromboembolism: findings from the RIETE Registry.

BACKGROUND: Patients with venous thromboembolism (VTE) treated with anticoagulants are at risk of death from pulmonary embolism (PE) and/or bleeding. However, whether patients who develop VTE in hospital have a higher complication rate than those who develop VTE in an outpatient setting is unclear. PATIENTS AND METHODS: RIETE is an ongoing, prospective registry of consecutive patients with acute, objectively confirmed, symptomatic VTE. We compared the 3-month incidence of fatal PE and fatal bleeding in patients in whom the VTE had developed while in hospital for another medical condition (inpatients) with those who presented to the emergency ward because of VTE (outpatients). RESULTS: Up to April 2008, 22,133 patients with acute VTE were enrolled: 10,461 (47%) presented with PE, 11,672 with deep vein thrombosis. Overall, 6445 (29%) were inpatients. During the study period, those who developed VTE as inpatients had a significantly higher incidence of fatal PE (2.1% vs. 1.5%; odds ratio: 1.4; 95% CI: 1.1-1.7), overall death (7.0% vs. 5.4%; odds ratio: 1.3; 95% CI: 1.2-1.5), and major bleeding (2.9% vs. 2.1%; odds ratio: 1.4; 95% CI: 1.1-1.6) than outpatients. The incidence of fatal bleeding was not significantly increased (0.7% vs. 0.5%; odds ratio: 1.2; 95% CI: 0.9-1.8). In multivariable analysis, inpatient status was significantly associated with a higher risk for fatal PE (odds ratio: 1.3; 95% CI: 1.1-1.7). CONCLUSIONS: VTE occurring in hospitalized patients carries a significantly higher risk for death of PE than in outpatients, underscoring the importance of VTE prevention strategies in the hospital setting.

Postmortem dynamic CT-angiography : P30

Purpose: Forensic imaging and especially forensic radiology is a new trend in forensic medicine. More and more forensic institutes set up their own CT-scanner in order to perform postmortem cross-sectional imaging. Due to this trend, a new subspecialty was born: the forensic radiology. To image the vascular system after death, a postmortem CT- angiography can be performed. Methods and materials: In the Institute of Forensic Medicine in Lausanne, a science group has been created with specialists of different medical fields that has set up a new technique of forensic CT-angiography. The method consists in the creation of a postmortem circulation by the use of a modified heart lung machine. As circulating liquid Angiofil, an oily contrast agent, is injected. Results: With the aid of this technique, the whole vascular system of a deceased person can be imaged in detail without autopsy. The circulating contrast allows demonstrating the vascular system when it is under pressure, similarly to living patients. First experiences showed, that vascular pathologies such as cardiac tamponade and aortic dissection can be well demonstrated. Since the oily Angiofil strictly remains in the intravascular space, no artifacts had been observed during the CT-examination and the later performed autopsy. Conclusion: Post-mortem dynamic CT angiography is of great advantage in forensic pathology, because the detailed mapping of the entire vascular system is almost impossible with conventional autopsy tools.

16-OR: Investigation of Sharp Trauma and Gunshot Cases Using Post-mortem CT-Angiography

Investigation of violent death, especially cases of sharp trauma and gunshot, is an important part of medico-legal investigations. Beside the execution of a conventional autopsy, the performance of a post-mortem Multi-Detector Computed Tomography (MDCT)-scan has become a highly appreciated tool. In order to investigate also the vascular system, post-mortem CT-angiography has been introduced. The most studied and widespread technique is the Multi-phase post-mortem CT-angiography (MPMCTA). Its sensitivity to detect vascular lesions is even superior to conventional autopsy. The application of MPMCTA for cases of gunshot and sharp-trauma is therefore an obvious choice, as vascular lesions are common in such victims. In most cases of sharp trauma and in several cases of gunshots, death can be attributed to exsanguinations. MPMCTA is able to detect the exact source of bleeding and also to visualize trajectories, which are of most importance in these cases. The reconstructed images allow to clearly visualizing the trajectory in a way that is easily comprehensible for not medically trained legal professionals. The sensitivity of MPMCTA for soft tissue and organ lesions approximately matches the sensitivity of conventional autopsy. However, special care, experience and effective use of the imaging software is necessary for performing the reconstructions of the trajectory. Large volume consuming haemorrhages and shift of inner organs are sources of errors and misinterpretations. This presentation shall give an overview about the advantages and limitations of the use of MPMCTA for investigating cases of gunshot and sharp-trauma.

Screening of illegal intracorporeal containers ("body packing"): is abdominal radiography sufficiently accurate? A comparative study with low-dose CT.

PURPOSE: To evaluate the diagnostic performance of abdominal radiography in the detection of illegal intracorporeal containers (hereafter, packets), with low-dose computed tomography (CT) as the reference standard. MATERIALS AND METHODS: This study was approved by the institutional ethical review board, with written informed consent. From July 2007 to July 2010, 330 people (296 men, 34 women; mean age, 32 years [range, 18-55 years]) suspected of having ingested drug packets underwent supine abdominal radiography and low-dose CT. The presence or absence of packets at abdominal radiography was reported, with low-dose CT as the reference standard. The density and number of packets (≤ 12 or >12) at low-dose CT were recorded and analyzed to determine whether those variables influence interpretation of results at abdominal radiography. RESULTS: Packets were detected at low-dose CT in 53 (16%) suspects. Sensitivity of abdominal radiography for depiction of packets was 0.77 (41 of 53), and specificity was 0.96 (267 of 277). The packets appeared isoattenuated to the bowel contents at low-dose CT in 16 (30%) of the 53 suspects with positive results. Nineteen (36%) of the 53 suspects with positive low-dose CT results had fewer than 12 packets. Packets that were isoattenuated at low-dose CT and a low number of packets (≤12) were both significantly associated with false-negative results at abdominal radiography (P = .004 and P = .016, respectively). CONCLUSION: Abdominal radiography is mainly limited by low sensitivity when compared with low-dose CT in the screening of people suspected of carrying drug packets. Low-dose CT is an effective imaging alternative to abdominal radiography.

Pure sensory neuropathy in patients with primary Sjogren's syndrome: clinical, immunological and electromyographic findings

A pure sensory neuropathy caused by lymphocytic infiltration of the dorsal root ganglia has been reported in a few patients with Sjögren's syndrome. The clinical, immunological, and electromyographic findings of five patients with this type of neuropathy and primary Sjögren's syndrome were reviewed. Typical clinical indications were the presence of a chronic asymmetrical sensory deficit, initial disease in the hands with a predominant loss of the vibratory and joint position senses, and an association with Adie's pupil syndrome or trigeminal sensory neuropathy. The simultaneous impairment of the central and peripheral evoked cortical potentials suggested that there was a lesion of the neuronal cell body. The neuropathy preceded the diagnosis of Sjögren's syndrome in four patients. Four patients were positive for Ro antibodies, but systemic vasculitis or malignancy was not found after a mean follow up of six years. These findings indicate that in patients with a sensory neuropathy the diagnosis of Sjögren's syndrome has to be considered, even if the patient denies the presence of sicca symptoms, and that appropriate tests must be carried out.