Efficiency of 123I-ioflupane SPECT as the marker of basal ganglia damage in acute methanol poisoning: 6-year prospective study

CONTEXT

Investigate whether ¹²³I-ioflupane SPECT (DaT SPECT) has the potential as a marker of basal ganglia damage in acute methanol poisoning.

METHODS

Prospective, single-centre, cohort study of patients with confirmed methanol poisoning was conducted. DaT SPECT was performed twice with semi-quantification using DaTQUANT^TM and MRI-based volumetry was calculated. Specific binding ratios (SBR) of striatum, caudate nucleus, and putamen were correlated with laboratory parameters of outcome, volumetric data, and retinal nerve fibres layer (RNFL) thickness measurements.

RESULTS

Forty-two patients (mean age 46.3 ± 4.2 years; 8 females), including 15 with MRI-detected putamen lesions (group I) and 27 patients with intact putamen (group II), underwent DaT SPECT. Volumetry was calculated in 35 of the patients assessed. SBR values for the left putamen correlated with putamen volume (r = 0.665; p < 0.001). Decreased bilateral SBR values were determined for the striatum and the putamen, but not for the nucleus caudate, in group I (p < 0.05). Significant correlation was observed between the SBR of the posterior putamen and arterial blood pH (r = 0.574; p < 0.001) and other toxicological parameters of severity of poisoning/outcome including serum lactate, glucose, and creatinine concentrations (p < 0.05). The SBR of the posterior putamen positively correlated with the global RNFL thickness (p < 0.05). ROC analysis demonstrated a significant discriminatory ability of SBR of the posterior putamen with AUC = 0.753 (95%CI 0.604-0.902; p = 0.007). The multivariate regression model demonstrated that arterial blood pH, age, and gender were the most significant factors associated with SBR of the posterior putamen.

CONCLUSION

DaT SPECT demonstrates significant potential for the diagnosis of methanol-induced basal ganglia damage.

MRI-guided voxel-based automatic semi-quantification of dopamine transporter imaging

PURPOSE

Functional imaging with 123I-FP-CIT SPECT suffers from poor spatial resolution resulting in partial-volume effect, which affects the subsequent semi-quantification. Definition of regions of interest for semi-quantification is further subject to user's experience and inter-observer variability. The aim of this work has been to develop an automatic method for definition of volumes of interest and partial-volume correction using patient-specific MRI and providing complete contrast recovery in striatal region.

METHOD

The method consists of spatial pre-processing (image segmentation and multi-modality registration), partial-volume correction (performed by region-based voxel-wise technique), and calculation of uptake indices in striatal structures. Anthropomorphic striatal phantom was used to optimize the method and to assess linearity, accuracy, and reproducibility. The method was tested on 58 patient datasets and compared with clinical assessment and BasGan software.

RESULTS

The method works automatically. The output is highly linear regarding changing striatal uptake. Complete contrast recovery is achieved using 6.5 mm FWHM. Accuracy is better than 0.15 in terms of RMSE between measured and true uptake indices. Reproducibility is better than 5% for normal uptake ratio. The method outperformed clinical assessment in all measures. With patient data, it provided results closer to BasGan (RMSE 0.9) than to clinical assessment (RMSE 1.9) and fairly correlated with both.

CONCLUSION

The proposed method provides complete recovery of striatal contrast under given acquisition and reconstruction conditions. It reduces intra- and inter-observer variability, accurately defines volumes of interest, and effectively suppresses partial-volume effect. It can be reproduced using publicly available software.

Increased oxidative/nitrosative stress markers measured non- invasively in patients with high 2,3,7,8-tetrachloro-dibenzo-p-dioxin plasma level

OBJECTIVES

2,3,7,8-tetrachloro-dibenzo-p-dioxin (TCDD) is a highly toxic persistent environmental contaminant, classified as a human carcinogen affecting any target organ. The mechanism of carcinogenesis by TCDD is unclear as TCDD shows a lack of direct genotoxicity. Experimental studies also support the role of oxidative stress in TCDD neurotoxicity and vascular dysfunction. The aim was to investigate markers of oxidative/nitrosative stress and inflammation using non-invasive methods in subjects who got ill due to severe occupational exposure to TCDD in the years 1965-1968.

METHODS

In 11 TCDD-exposed patients, and 16 controls, the analysis of following oxidative products of lipids, proteins and nucleic acids in plasma, urine and exhaled breath condensate (EBC) was performed: 8-iso-prostaglandin F2α (8-isoprostane), 4-hydroxy-trans-2-nonenale (HNE), malondialdehyde (MDA), o-tyrosine (o-Tyr), 8-hydroxyguanosine (8-OHG), 8-hydroxy-2´-deoxy-guanosine (8-OHdG), 5-hydroxymethyluracil (5-OHMeU). In addition, nitric-oxide-tyrosine (NO-Tyr) and leukotriene (LT) B4, C4, D4, and E4 were detected by liquid chromatography-mass spectrometry/mass spectrometry (LC-ESI-MS/MS). TCDD was measured by HRGC/HRMS, body lipid content by densitometry. Single-photon emission spectrometry (SPECT) of the brain was performed and compared with the findings of the patients in 2008.

RESULTS

Mean TCDD plasma level in 2010 was 175 ± 162 pg/g lipids (population level about 2 pg/g), total TCDD content in the body 5.16 ± 4.62 mg. Reduction of cerebral blood flow in SPECT progressed in 8 patients, finding was stable in 2 subjects, and improvement occurred in 1 patient. In the EBC, 10 from 12 markers (all except LT D4 and LT E4), were significantly increased in the patients (p<0.05). In the urine, 7 markers were significantly higher than in the controls (p<0.05): 8-isoprostane, MDA, HNE, LT C4, LT E4, o-Tyr and NO-Tyr. In plasma, only NO-Tyr and 8-OHG were elevated (p<0.05).

CONCLUSION

NO-Tyr was increased in all matrices in dioxin-exposed patients. EBC is not limited to lung disorders as the markers of oxidative stress and inflammation were elevated in EBC of patients with normal lung functions. TCDD-induced oxidative stress and inflammation markers can be detected non-invasively in the EBC and urine in the follow-up of the highly-exposed patients. Their prognostic value, however, needs to be elucidated.

Chronic health impairment due to 2,3,7,8-tetrachloro-dibenzo-p-dioxin exposure

OBJECTIVES

The aim of this study, performed in 2008, was to evaluate the consequences of severe occupational intoxication with 2,3,7,8-tetrachloro-dibenzo-p-dioxin (TCDD) that occurred during production of the herbicide trichlorophenoxyacetic acid in the period 1965-1968.

DESIGN

Examination of 11 men, mean age 64.4+/-1.5 years, included: internal and neurological examination, eye fundus examination, TCDD in plasma, thyroid-stimulating hormone (TSH), testosterone and serum lipids, ultrasonography of the carotid artery, nerve conduction study (NCS), electroencephalography (EEG), visual evoked potential (VEP), Lanthony test of acquired visual impairment, single photon emission computer tomography (SPECT) of the brain, neuropsychological examination and carbohydrate-deficient transferrin (CDT), a marker of chronic ethanol intake.

RESULTS

Mean TCDD level in 2008 was still 274.0+/-181.2 pg/g blood lipids (reference level is 2-3 pg/g). All (100%) patients had residues of chloracne/chloracne consequences, atherosclerotic changes on the eye fundus and plaques in the carotid arteries. Progression of intima-media thickness (IMT) from a mean of 0.84+/-0.14 mm in 2003 to 1.09+/-0.18 mm in 2008 was observed. Ninety-one per cents of patients had impairment in SPECT of the brain; and 55% of patients had hyperfixation of the perfusion indicator as a measure of increased neuronal activity. Additionally, 91 % of patients were treated for hyperlipidaemia, 73 % for hypertension, 55 % for diabetes type 2, 45 % for ischemic heart disease, and 36 % for psychological disorders. The Lanthony test demonstrated acquired dyschromatopsia in 80 % of patients. Mean colour confusion index (CCI) was 1.438, which indicates impairment since 2003, when the index was 1.302. CDT was in the normal range and did not correlate with CCI. Neuropsychological status appeared stabilized in all 8 patients examined, with impairment in one or more parameter (memory, attention, verbal fluency, psychomotor speed, motorics) in comparison to the norm.

CONCLUSION

Forty years after intoxication, the blood level of TCDD is still 100 times higher than in the general population. Other PCDD/Fs were not elevated. A high percentage of subjects suffer from neurological and vascular disorders. No association of alcohol consumption with neurological impairment was seen, and the highly significant correlation between CCI and TCDD blood concentration suggests that acquired colour impairment was associated with TCDD but not with alcohol consumption. IMT significantly increased during past 5 years. The patients obviously need complex treatment, including intense hypolipidaemic and antidepressant therapy.

Neurological and neurophysiological examinations on workers with chronic poisoning by 2,3,7,8-TCDD: follow-up 35 years after exposure

Between 1965 and 1968, about 350 workers were accidentally exposed to 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) in a chemical plant, which was producing herbicides based on the trichlorophenoxyacetic acid. About 80 workers developed signs of poisoning. The estimated mean concentration of TCDD at the time of exposure was about 5000 pg/g of plasma fat. Only 15 subjects from the original cohort remained available for the recent follow-up in 2004. All were men, mean age 60 years. The mean current TCDD plasma concentration was 128 pg/g. Neurological examination revealed some CNS impairment in eight subjects. Signs of polyneuropathy were found in nine subjects, confirmed by NCV studies in three cases. Electroencephalography was abnormal in three cases; Visual-evoked potential in five cases. Acquired dyschromatopsia was detected in six patients. SPECT showed focal reduction of perfusion in various brain locations in all but one patient. Two neuropsychological variables and the frequency of abnormal neurophysiological tests in individual patients correlated with TCDD plasma level. The findings support the hypothesis that TCDD can damage the nervous system. In addition to a direct neurotoxic effect of TCDD, changes secondary to vasculopathy should be considered, in the pathophysiology of the damage, because of the high frequency of lipid metabolism disorders and their complications.

The analysis of soil cores polluted with certain metals using the Box-Cox transformation

To define the soil properties for a given area or country including the level of pollution, soil survey and inventory programs are essential tools. Soil data transformations enable the expression of the original data on a new scale, more suitable for data analysis. In the computer-aided interactive analysis of large data files of soil characteristics containing outliers, the diagnostic plots of the exploratory data analysis (EDA) often find that the sample distribution is systematically skewed or reject sample homogeneity. Under such circumstances the original data should be transformed. The Box-Cox transformation improves sample symmetry and stabilizes spread. The logarithmic plot of a profile likelihood function enables the optimum transformation parameter to be found. Here, a proposed procedure for data transformation in univariate data analysis is illustrated on a determination of cadmium content in the plough zone of agricultural soils. A typical soil pollution survey concerns the determination of the elements Be (16 544 values available), Cd (40 317 values), Co (22 176 values), Cr (40 318 values), Hg (32 344 values), Ni (34 989 values), Pb (40 344 values), V (20 373 values) and Zn (36 123 values) in large samples.

Comorbidity of parkinsonism and schizophrenia in a patient treated with clozapine

Clozapine is the least likely anti-psychotic to induce extrapyramidal symptoms (EPS). We present a surprising case of a woman schizophrenic patient treated with clozapine suffering from EPS. Single photon emission computed tomography (SPECT) revealed a low density of presynaptic dopamine transporters in our patient's brain. A comorbid diagnosis of Parkinson's disease in schizophrenia was confirmed in this way. This helped us to find a proper therapeutic strategy for our patient.

Assessment of the mean-value of 17-hydroxypregnenolone in the umbilical blood of newborns by the exploratory analysis of biochemical data

The main aim of data analysis in biochemical metrology is the extraction of relevant information from biochemical data measurements. A system of extended exploratory data analysis (EDA) based on the concept of graphical tools for sample data summarization and exploration is proposed and the original EDA algorithm in S-Plus is available on the Internet at http://www.trilobyte.cz/EDA. To check basic assumptions about biochemical and medical data is to examine the independence of sample elements, sample normality and homogeneity. The exact assessment of the mean-value and the variance of steroid levels in controls is necessary for the correct assessment of the samples from patients. Data examination procedures are illustrated by a determination of the mean-value of 17-hydroxypregnenolone in the umbilical blood of newborns. For an asymmetric, strongly skewed sample distribution corrupted with outliers the best estimate of location seems to be the median. The Box-Cox transformation improves a sample symmetry. The proposed procedure gives reliable estimates of a mean-value for an asymmetric distribution of 17-hydroxypregnenolone when the arithmetic mean can not be used.

Analysis of large and small samples of biochemical and clinical data

Statistical software often offers a list of various descriptive statistics of location and scale, but rarely selects an efficient estimate that is statistically adequate for an actual univariate sample. The sample interval estimate for a specified degree of uncertainty seems to be more meaningful if it covers an unknown value of the population parameter. The concept of an interval estimate in medicine is then used for medical decision-making. The proposed methodology, which uses the S-Plus algorithm for biochemical, biological and clinical data analysis contains the following steps: (i) Exploratory data analysis identifies basic statistical features and patterns of the data, the distributions of which are mostly non-normal, non-homogeneous and often corrupted by outliers. (ii) Sample assumptions about data, independence of sample elements, normality and homogeneity are examined. (iii) Power transformation and the Box-Cox transformation to improve sample symmetry and stabilize the spread. (iv) Classical and robust statistics for both large (n>30) and medium-sized samples (15<n<30), point and interval estimates for the parameters of location, scale and shape. For an analysis of small samples (4<n<20) the Horn procedure of pivot measures is recommended. The proposed methodology is demonstrated in two case studies, a large sample analysis of mean pregnenolone concentrations in the umbilical blood of newborns, and a small sample analysis of mean haptoglobin concentrations in human serum.

Transformation in the PC-aided biochemical data analysis

Data transformations enable expression of original data in a new scale, more suitable for data analysis. In computer-aided interactive analysis of biochemical and clinical data an exploratory data analysis often finds that the sample distribution is systematically skewed or does not accept a sample homogeneity. Under such circumstances the original data should be transformed. The power transformation and the Box-Cox transformation improve sample symmetry and also stabilize variance. Both the Hines-Hines selection graph and the plot of logarithm of a maximum likelihood function allow selection of an optimum transformation parameter. The proposed procedure of data transformation in univariate data analysis is illustrated on a determination of 17-hydroxypregnenolone in umbilical blood of a population of newborns. Lower levels of free 5-ene steroids in umbilical blood and elevated levels of 5-ene steroid sulfates indicate a congenital sex-specific placental sulfatase insufficiency. After examination of statistical assumptions by diagnostic plots of an exploratory data analysis the best estimate of a mean value of 17-hydroxypregnenolone is derived.

Comparison of clinical, laboratory, radiographic, and scintigraphic findings in erosive and nonerosive hand osteoarthritis. Results of a two-year study

OBJECTIVES

The primary objective was to compare the clinical, radiologic, laboratory, and scintigraphic features in 28 patients with erosive hand osteoarthritis and in 24 with non-erosive hand osteoarthritis. Other objectives were to evaluate clinical, radiographic, and scintigraphic progression in the two groups over a two-year period and to estimate the value of bone scintigraphy for predicting clinical and radiographic progression.

METHOD

Prospective two-year study of 52 patients with hand osteoarthritis, of whom 28 had at least three subchondral erosions and 24 patients had no erosions.

RESULTS

The group with erosive disease had higher serum immunoglobulin G levels (14.53 +/- 3.79 mg/L vs. 12.03 +/- 4.01 mg/L; P < 0.05) and a higher radiographic index (91.81 +/- 3.67 vs. 25.88 +/- 12.81; P < 0.001), whereas the group with non-erosive disease had a higher rate of paresthesia (66.7% vs. 39.3%; P < 0.05) and higher values for the erythrocyte sedimentation rate (25.21 +/- 20.86 vs. 13.21 +/- 12.85; P < 0.05) and serum C-reactive protein level (8.82 +/- 6.08 vs. 3.25 +/- 6.92; P < 0.01). None of the other study parameters showed any significant differences, and both age and sex distribution were also similar in the two groups. At completion of the two-year follow-up, no changes versus baseline were found in any of the study parameters in the overall study population or in either of the two groups. The baseline scintigraphic index was significantly correlated with the radiographic index at baseline (r = 0.497; P < 0.01) and at study completion (r = 0.550; P < 0.001). Joints with a positive baseline scintigram were significantly more likely to show radiographic progression (21.09%, vs 6.68% in negative joints; P < 0.001) and joint tenderness exacerbation (21.22% vs. 13.73%; P < 0.001).

CONCLUSION

These data suggest that bone scintigraphy may be useful for predicting clinical and radiographic progression of hand osteoarthritis with or without erosions.

Hepatic copper concentrations in purebred and mixed-breed dogs

Histomorphologic, histochemical, and atomic absorption analysis studies were performed on liver tissue from 623 clinically normal purebred and mixed-breed dogs to assess the range of hepatic copper concentrations, the histologic distribution of copper, and the histomorphologic changes associated with the various copper concentrations that were found. Atomic absorption analysis revealed a continuous numerical spectrum ranging from less than 100 parts per million on a dry weight basis (ppm dw) to more than 2,000. No decisive numerical criterion was found that could be used to separate normal from abnormal copper concentrations because of this continuous array. The threshold for histochemical demonstration of copper-containing granules using rhodanine or rubeanic acid staining was 400 ppm dw. At this concentration the copper-containing granules were located in the centrilobular hepatocytes (zone 3 of Rappaport). Copper-containing granules were found in the midzonal and periportal hepatocytes (zones 2 and 1 of Rappaport) in livers with 1,000 ppm dw and higher copper concentrations. The majority of the 623 livers were normal histomorphologically. Multifocal hepatitis characterized by mixed inflammatory cell accumulation and centrilobular distribution was found to be associated with copper concentrations in the range of 2,000 ppm dw or higher. An appropriate upper limit for normal hepatic copper concentration in the dog was not determined based on the present study.

Erdheim-Chester disease

A new case of Erdheim-Chester lipoid granulomatosis is described in a 40-year-old man. In this lipid storage disease, characteristic symmetrical osteosclerotic areas are observed mainly in metadiaphyses of long tubular bones. Bone biopsy is mandatory for definite diagnosis, although characteristic radiographic pictures often provide an important clue to the correct diagnosis.

[The role scalene node biopsy in the treatment in carcinoma of the cervix (author's transl)]

Of 75 scalene node biopsies 18 (24%) were positive. In 56 metastasizing carcinomas of the cervix 11 (20%) scalene node biopsies were positive. In primary inoperable cases (57%) or in recurrent spreading cases (54%) of carcinoma of the cervix the scalene node biopsy is valuable for the treatment plan. Irrespective of treatment the patients with metastases to the scalene node survived a mean of 10--11 months. The scalene node biopsy has few complications (6.7%). In the less than 3% carcinomas of the cervix confined to metastases in the lesser pelvis, the scalene node biopsy is not necessary. 2/3 of the prescalene lymph node metastases can be palpated by an experienced examinar.

[Experience with the Marshall-Marchetti operation for stress incontinence (author's transl)]

From 1962 to 1975 severe stress incontinence or recurrent stress incontinence was operated according to Marshall-Marchetti In 64 cases. Sixty patients were followed up. More than 2/3 of the patients were satisified with the result. Objective follow-up with urethrocystotonometry showed that only slightly more than 50% of the patients were cured. It was possible to divide the cases in 4 groups to elucidate the discrepancy between subjective and objective cure. The operative and postoperative complications were minor. The recurrence rate was the same with follow-up from 3 to 14 years. The results can probably be improved by precise pre-operative diagnosis regarding intrinsic urinary tract disease and by an extension of the indication for this operation or risk cases. The patients must be warned that the result also depends on their cooperation.

[The needle biopsy in suspected pelvic recurrence]

The Silverman needle biopsy for the diagnosis of suspicious palpatory findings in the pelvis in cancer patients is recommended. Occasional trauma cannot be avoided but is of secondary importance in the light of the diagnostic value of the procedure. The risk of treatment of a recurrence is much higher. Only 1 trauma necessitated long term antibiotic treatment because of a parametritis. Perforation or biopsy of the bladder or the rectum usually remained asymptomatic. The needle biopsy confirmed the diagnosis of recurrent tumor in 47 out of 74 patients with the first try. In 6 out of 10 patients the tumor diagnosis was confirmed by a second needle biopsy 2 to 3 months later. Two patients had a third negative biopsy. A total of 11 patients were saved from the fate of treatment of a clinically suspected cancer recurrence as confirmed by the subsequent clinical course over the next 1 to 6 years.

Studies in the epidemiology and control of seasonal conjunctivitis and trachoma in southern Morocco

It has been noted in many parts of the world that bacterial conjunctivitis is a major cause of total or partial loss of vision. In addition, trachoma is aggravated if there are associated bacterial infections and these lead to more frequent corneal complications.In the trials described the seasonal variation of bacterial infections was studied in addition to trachoma in 3 pilot sectors in southern Morocco. The frequency of complications and late sequelae from these infections in the whole population of these sectors was also studied.In one of the sectors 3 different methods of limiting the regular seasonal increase in bacterial infections and of curing trachoma were evaluated separately or in combination. These included the effect of fly-suppression on the transmission of infection, a possible method of chemoprophylaxis, and intermittent treatment with chlortetracycline ointment.The effect of the latter, when applied to a whole population group by auxiliary personnel, was compared with the long-term effect of self-treatment, in this and the two other sectors.The total observation period covered 12 years.

Sampling studies on the epidemiology and control of trachoma in southern Morocco

Mass-treatment campaigns against trachoma and seasonal conjunctivitis, using chlortetracycline ointment, were started in 1952 in parts of southern Morocco. This paper reports the results of a survey carried out between 1962 and 1965, under the auspices of the Moroccan Government, WHO and UNICEF, to evaluate the effects of the mass-campaign.The survey assessed the prevalence, gravity and frequency of complications of trachoma by ophthalmological examinations, conducted in the home, and the results are compared with data published elsewhere which were obtained before treatment started in the 1950s in parts of the study area. Additional studies were made of the relation between trachoma and the availability and use of water, and between the prevalence of trachoma in females and their exposure to infection.The over-all prevalence of trachoma was unaffected by the mass-treatment campaign but a larger proportion of the cases were at stage IV of the disease (healed). In one region, however, the prevalence of active cases (stages I-III) in the younger age-groups had decreased considerably. The occurrence of pannus decreased and while trichiasis decreased in children under 15 years of age, its prevalence increased in adults. This result may be important in planning future mass-campaigns.