F-fluorodeoxyglucose Positron Emission Tomography Scans Research Articles

Defecation after magnesium supplementation enhances cognitive performance in triathletes

Constipation is correlated with diminished cognitive function, revealing a possible rectum-brain connection. In this counter-balanced crossover trial, 13 elite triathletes underwent a Stroop test to assess cognitive function and executive control. The Stroop test was conducted both with and without magnesium oxide intake, with a 1-week washout period between sessions. Oxygenation and blood distribution during the cognitive challenge were measured using Near-Infrared Spectroscopy (NIRS). Measurements were taken in both the prefrontal brain and the sub-navel region, where the highest glucose uptake was detected under the 18F-fluorodeoxyglucose Positron Emission Tomography (PET) scan. A significant reduction in completion time for the Stroop test was observed after defecation compared to the non-defecated condition (non-defecation: [27.1 ​± ​1.1] s; non-magnesium defecation: [24.4 ​± ​0.9] s; magnesium defecation: [23.4 ​± ​0.8] s, p ​< ​0.05). Stroop test performance was improved in all (100%, 13/13) of the participants after magnesium-induced defecation and most (69%, 9/13) of the participants after non-magnesium-induced defecation. While no alterations in oxygenation and blood distribution were observed in the prefrontal brain during the Stroop test, decreased oxygenation levels were observed in the sub-navel region under both defecated conditions, without significant changes in blood distribution (p ​< ​0.05). This data suggests an acute increase in oxygen consumption at this specific region. The result of this study suggests an unexplored causal link between the state of the rectum and cognitive performance. Magnesium supplementation to improved rectal emptying presents a novel application for optimizing cognitive function in athletes navigating intricate racing conditions.

P205: The effect of APOE e4 genotype on cognition, brain volume, glucose metabolism and amyloid deposition in AD

Objective:Many previous studies have shown that the APOE e4 genotype affects cognition, brain volume, glucose metabolism and amyloid deposition. However, these studies were conducted separately, and few studies simultaneously investigated the effects of the APOE e4 genotype on cognition, brain volume, glucose metabolism and amyloid deposition in Alzheimer disease (AD). The purpose of this study is to simultaneously investigate the association of the APOE e4 genotype with cognition, brain volume, glucose metabolism and amyloid deposition in patients with AD.Methods:This is a cross-sectional study of 69 subjects with Alzheimer’s disease (AD). All subjects were divided into carriers and noncarriers of the ε4 allele. Forty APOE ε4 carriers and 29 APOE ε4 non-carriers underwent neuropsychological, structural magnetic resonance imaging, 18F-fluorodeoxyglucose positron emission tomography scans (18F-FDG-PET) and 18F-Florbetaben amyloid positron emission tomography scans (amyloid PET). Analysis of covariance (ANCOVA) was conducted to compare the differences on cognition, brain volume, glucose metabolism and amyloid deposition between APOE ε4 carriers and non-carriers after controlling demographics.Results:APOE ε4 carriers had 50% lower scores of SVLT_delayed recall compared to non-carriers (0.88 ± 1.65 vs 1.76 ± 1.75). However, APOE ε4 carriers performed better on other cognitive tests than non- carriers (K-BNT (11.04 ± 2.55 vs 9.66 ± 2.82), RCFT (25.73 ± 8.56 vs 20.15 ± 10.82), and Stroop test_color response (48.28 ± 26.33 vs 31.56 ± 27.03)). APOE ε4 carriers had slightly smaller hippocampal volume than non-carriers (3.09 ± 0.38 vs 3.32 ± 0.38), but greater total brain cortical thickness (1.45 ± 1.55 vs 1.37 ± 1.24).Conclusions:We found that APOE e4 genotype is associated with cognition, brain volume in AD, suggesting that APOE e4 genotype can play a very important role in the underlying pathogenesis of AD.

The value of FDG combined with PiB PET in the diagnosis of patients with cognitive impairment in a memory clinic.

To analyze the value of 18 F-fluorodeoxyglucose (FDG) positron emission tomography (PET) combined with amyloid PET in cognitive impairment diagnosis. A total of 187 patients with dementia or mild cognitive impairment (MCI) who underwent 11 C-Pittsburgh compound B (PiB) and FDG PET scans in a memory clinic were included in the final analysis. Amyloid-positive and amyloid-negative dementia patient groups showed a significant difference in the proportion of individuals presenting temporoparietal cortex (p < 0.001) and posterior cingulate/precuneus cortex (p < 0.001) hypometabolism. The sensitivity and specificity of this hypometabolic pattern for identifying amyloid pathology were 72.61% and 77.97%, respectively, in patients clinically diagnosed with AD and 60.87% and 76.19%, respectively, in patients with MCI. The initial diagnosis was changed in 32.17% of patients with dementia after considering both PiB and FDG results. There was a significant difference in both the proportion of patients showing the hypometabolic pattern and PiB positivity between dementia conversion patients and patients with a stable diagnosis of MCI (p < 0.05). Temporoparietal and posterior cingulate/precuneus cortex hypometabolism on FDG PET suggested amyloid pathology in patients with cognitive impairment and is helpful in diagnostic decision-making and predicting AD dementia conversion from MCI, particularly when combined with amyloid PET.

Brain Connectome Imaging Markers Research of Glucose Metabolism in the Early Stage of Alzheimer's Disease.

In recent years, increasing evidence had suggested that subjective cognitive decline (SCD) in unimpaired individuals may be the first symptom of Alzheimer's disease (AD). This study investigated the differences in the glucose metabolism network and the influence of the Apolipoprotein E (ApoE) gene between the SCD and normal control (NC) group by using graph theory. In this study, we included 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET) scans from Xuanwu Hospital in Beijing, China. 85 SCD subjects and 74 NC subjects were included. First, we calculated and compared network parameters between the two groups. We then identified the bilateral insula and bilateral parahippocampal gyrus as seed sites and studied the connections to the whole brain. The results showed that both the SCD and the NC showed small-world nature, but the metabolic network of SCD tended to be more regular. The clustering coefficient and local efficiency of SCD were significantly higher than those of NC (P<0.05). In addition, we found that carrying APOE resulted in enhanced metabolic connectivity, but with weaker aggregation and local information exchangeability. Our results suggested that there are differences in the glucose metabolic brain network between SCD and NC, suggesting that the graph-theoretic analysis method may provide evidence for the early pathological mechanism of AD.Clinical relevance- This study suggests that the graph-theoretic analysis method may provide evidence for the early pathological mechanism of AD.

Mirror writing and cortical hypometabolism in Parkinson's disease.

Mirror writing (MW) is the production of individual letters, words, or word strings in the reverse direction. Parkinson's disease (PD) is a progressive neurodegenerative disorder, and high MW rates have been reported in patients with PD. Thus, the present study sought to identify the factors that cause MW in patients with PD. We examined the frequency of MW in patients with PD and investigated the area of the brain where such frequency inversely correlates with reduced regional cerebral metabolic rates of glucose (rCMRglc). We also examined whether this area satisfied the motor and visual monitoring hypotheses of MW that have been presented in previous studies. Thirty-six subjects with idiopathic PD and 23 healthy controls were included in the study. We asked the participants to write down words, numerals, and sentences from left to right using their dominant and non-dominant hands. Patients with PD underwent an 18F-fluorodeoxyglucose positron emission tomography scan to measure the rCMRglc. Neither the patients with PD nor the healthy subjects exhibited MW in the use of the right hand. In the use of the left hand, MW occurred in 15 of the 36 patients with PD, but in none of the healthy controls. The right intraparietal sulcus was identified as the area where rCMRglc was inversely correlated with the number of left-right reversed characters. Previous functional imaging studies have suggested that the right superior parietal cortex and intraparietal sulcus play an important role in recognizing left-right reversed letters. Therefore, dysfunction in the intraparietal sulcus may hinder the recognition of left-right reversed characters, resulting in MW. Consequently, our findings in patients with PD are consistent with the visual-monitoring hypothesis of MW.

Association of 18 F-Fluorodeoxyglucose-Positron Emission Tomography Activity With Angiographic Progression of Disease in Large Vessel Vasculitis.

To assess whether vascular activity seen on 18 F-fluorodeoxyglucose-positron emission tomography (FDG-PET) scan is associated with angiographic change in large vessel vasculitis (LVV). Patients with LVV were recruited into a prospective cohort. All patients underwent magnetic resonance angiography or computed tomography angiography and FDG-PET imaging. Follow-up imaging using the same imaging modalities was obtained ≥6 months later per a standardized imaging protocol. Arterial damage, defined as stenosis, occlusion, or aneurysm, and corresponding FDG uptake were evaluated in 17 arterial territories. On follow-up, development of new lesions was recorded, and existing lesions were characterized as improved, worsened, or unchanged. A total of 1,091 arterial territories from 70 patients with LVV (38 patients with Takayasu arteritis, 32 patients with giant cell arteritis) were evaluated. Over a median 1.6 years of follow-up, new lesions developed only in 8 arterial territories in 5 patients with Takayasu arteritis. Arterial lesions improved in 16 territories and worsened in 6 territories. Most arterial territories that did not have vascular activity on FDG-PET scan at baseline had no angiographic change over the follow-up period (787 [99%] of 793). Few territories with baseline FDG-PET activity had angiographic change over time (24 [8%] of 298), but of the territories that developed angiographic change, 80% had FDG-PET activity at baseline. Within the same patient, an arterial territory with baseline FDG-PET activity had significantly increased risk for angiographic change compared to a paired arterial territory without FDG-PET activity (odds ratio 19.49 [95% confidence interval 2.44-156.02]; P < 0.01). Concomitant edema and wall thickening further increased risk for angiographic change. Development of angiographic change was infrequent in this cohort of patients with LVV. A lack of baseline FDG-PET activity was strongly associated with stable angiographic disease. In cases of angiographic progression, change was preceded by the presence of FDG-PET activity.

Pulmonary actinomycosis mimicking lung cancer on 18F-fluorodeoxyglucose positron emission tomography: a case report

BackgroundPulmonary actinomycosis is a chronic disease characterized by abscess formation, draining sinuses, fistulae, and tissue fibrosis. It can mimic other conditions, particularly malignant and granulomatous diseases, and is perhaps extremely challenging to diagnose.Case presentationA 64-year-old Japanese man presented with 6-week history of a painful solid lump in the chest wall. Chest computed tomography scan revealed a mass-like consolidation in the left upper lobe, with rib erosion and direct extension into the anterior chest wall. 18F-fluorodeoxyglucose positron emission tomography scan showed increased metabolic activity in the mass, which is indicative of primary lung cancer. The bronchoscopy and computed tomography scan-guided transthoracic biopsy results were considered nondiagnostic. Finally, the patient was diagnosed with pulmonary actinomycosis via surgical resection. He completed an 8-week course of antibiotic therapy and experienced no recurrence.ConclusionsThere is no difference in positron emission tomography/computed tomography scan findings between actinomycosis and malignancy. Therefore, pulmonary actinomycosis should be considered in the differential diagnosis of cases involving intensive activity on 18F-fluorodeoxyglucose positron emission tomography scan.

Effects of Alzheimer and Lewy Body Disease Pathologies on Brain Metabolism.

This study aimed to determine the pattern of 18 F-fluorodeoxyglucose positron emission tomography (FDG-PET) related to postmortem Lewy body disease (LBD) pathology in clinical Alzheimer disease (AD). FDG-PET scans were analyzed in 62 autopsy-confirmed patients and 110 controls in the Alzheimer's Disease Neuroimaging Initiative. Based on neuropathologic evaluations on Braak stage for neurofibrillary tangle, Consortium to Establish a Registry for AD score for neuritic plaque, and Lewy-related pathology, subjects were classified into AD(-)/LBD(-), AD(-)/LBD(+), AD(+)/LBD(-), and AD(+)/LBD(+) groups. The association between postmortem LBD and AD pathologies and antemortem brain metabolism was evaluated. AD and LBD pathologies had significant interaction effects to decrease metabolism in the cerebellar vermis, bilateral caudate, putamen, basal frontal cortex, and anterior cingulate cortex in addition to the left side of the entorhinal cortex and amygdala, and significant interaction effects to increase metabolism in the bilateral parietal and occipital cortices. LBD pathology was associated with hypermetabolism in the cerebellar vermis, bilateral putamen, anterior cingulate cortex, and basal frontal cortex, corresponding to the Lewy body-related hypermetabolic patterns. AD pathology was associated with hypometabolism in the bilateral hippocampus, entorhinal cortex, and posterior cingulate cortex regardless of LBD pathology, whereas LBD pathology was associated with hypermetabolism in the bilateral putamen and anterior cingulate cortex regardless of AD pathology. Postmortem LBD and AD pathologies had significant interaction effects on the antemortem brain metabolism in clinical AD patients. Specific metabolic patterns related to AD and LBD pathologies could be elucidated when simultaneously considering the two pathologies. ANN NEUROL 2022;91:853-863.

Calvarial Tumors: A Retrospective Analysis and Clinical Experience.

To elucidate the prognosis, frequency, and diverse nature of pathologies for calvarial tumors among different age groups. Seventy-six patients who underwent surgery for calvarial lesions between January 2007 and March 2021 are included in this study. Clinical data obtained retrospectively from patients? electronic records. Radiological images and surgical notes are reviewed to determine extent of the tumor and resection. Among 76 patients, 33 (43.4%) were male and 43 (56.6%) were female. The mean age was 36.0 years (range: 1?81 years) at the time of initial operation. Children consisted 28.9% (n=22) of the patients. In children, 59.1% (n=13) had tumor-like pathologies, while 27.3% (n=6) had benign pathologies, and 13.6% (n=3) had malignant tumors. In the adult population, 42.6% (n=23) had malignant tumors, 31.5% (n=17) had benign tumors, 16.7% (n=9) had tumor-like pathologies, and 9.2% (n=5) had intermediate-grade tumors. F-fluorodeoxyglucose positron emission tomography (FDG-PET) scan was performed in 16 patients, 10 cases underwent whole-body bone scintigraphy (WBBS), and 4 cases underwent both. Among these examinations, 16 (80%) of the FDG-PET scans and 5 (35.7%) of the WBBS scans revealed an extracranial pathological lesion. A calvarial tumor was diagnosed in 13 of 18 cases of metastatic lesions (72.2%) before the primary tumor detection. Lesions of the calvarium include malignant tumors, intermediate grade tumors, tumor-like lesions, and benign tumors. These masses may be the first presentation in patients with underlying primary tumors. In our study, the malignant tumor rate in the calvaria was 34.2%, and 72.2% of the metastatic tumors were diagnosed with a calvarial resection before the primary tumor was found. Operating a calvarial lesion and making an early diagnosis are crucial for the treatment of the primary lesions.

Effect of Steroid Treatment on the Diagnostic Yield of Baseline PET CT in Aggressive B Cell Lymphoma

Aggressive B cell lymphomas often require prompt steroid treatment prior to baseline 18f-fluorodeoxyglucose positron-emission tomography (PET CT) scan and definitive treatment in order to alleviate symptoms and/or prevent organ damage. Since lymphomas are a steroid sensitive malignancy, there is a concern that steroid prophase might affect PET CT results and diagnostic yield.We conducted a retrospective cohort study to evaluate the effect of steroid treatment prior to baseline PET CT scan on the standardized uptake value (SUV) max and additional PET CT parameters by examining two groups of patients: steroid-naïve and steroid-treated patients. The effect of steroid administration on SUV max was examined across different daily and weekly steroid doses and durations of treatment.Between January of 2017 and May 2020, 187 newly diagnosed patients with aggressive B cell lymphoma who had a pre-treatment PET CT scan were evaluated. 160 patients (85.5%) had Diffuse large B-cell lymphoma (DLBCL)/ High-grade B-cell lymphoma, 13 patients (7%) had primary mediastinal (thymic) large B-cell lymphoma, 9 patients (4.8%) had primary DLBCL of the central nervous system and 5 patients (2.7%) had Burkitt lymphoma.132 patients (70.6%) were included in the steroid-naïve group and 55 patients (29.4%) in the steroid-treated group. In the steroid-treated group, the mean duration of steroid treatment was 10.49 (±9.28) days. Average daily dose of steroid treatment was equivalent to 72.27 (±36) mg of prednisone and the mean cumulative prednisone dose during the week prior to PET CT scan was equivalent to 367.95 (±239.9) mg of prednisone.There was no statistical significant difference between the groups in age, gender or KI67. However, patients in the steroid treated group had a significantly higher stage of disease compared to the steroid-naïve group (mean 3.44 compared to 2.99, respectively, p=0.01). The steroid-treated group also had a trend towards a higher IPI score (mean 2.45 versus 2.08, p=0.08) and a trend towards a higher LDH level (mean 2309.89 U/L, range 250-81374 versus mean 877.65 U/L, range 272-22036, p= 0.07), as depicted in table 1.There was no statistical difference in SUV max between the steroid-naïve and steroid-treated groups (p=0.97). This was consistent across various steroid treatment durations and dosage regimes. Patients in the steroid-treated group had a trend towards a higher tumor burden and a larger tumor volume compared to the steroid-naïve group, however it did not reach statistical significance. Mean tumor volume was 179.04 cm 3 in the steroid naïve group and 337.06 cm 3 in the steroid treated group (p=0.17). Mean tumor burden was 1944.84 in the steroid-naïve group and 3016.94 in the steroid-treated group (p=0.09).There was no difference in additional PET CT parameters including SUV mean, SUV max and SUV mean of liver and mediastinum between the groups as depicted in table 2.In conclusion, in aggressive B cell lymphoma, pre-treatment with steroids prior to initial PET CT scan does not affect SUV max or other PET CT parameters and does not reduce PET CT diagnostic yield. [Display omitted] DisclosuresGurion: Medison: Consultancy; Gilead Sciences: Consultancy; Takeda Pharmaceuticals: Consultancy; JC Health Care: Honoraria; Roche: Honoraria.

MAGIC OF ADVANCED IMAGING AND IMMUNOTHERAPY IN CARDIAC SARCOIDOSIS

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: This case report emphasizes the role of advanced imaging and immunotherapy in the diagnosis and management of cardiac sarcoidosis (CS). CASE PRESENTATION: A 52-year-old healthy male presented with near-syncope for 5 days. He had a blood pressure of 164/67 mmHg and a heart rate of 43 bpm. Electrocardiogram revealed complete-heart-block (CHB) with a ventricular rate of 38/min. Troponin T and electrolytes were normal, and Lyme's serology was negative. Echocardiogram was normal. Cardiac magnetic resonance imaging (CMR) revealed late gadolinium enhancement (LGE) affecting the mid inferior segment at the right ventricle (RV) insertion site (Figure 1). A cardiac and whole-body 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) scan showed focal areas of increased FDG uptake in the LV involving mid and basal anteroseptal segments, mid inferoseptal segment, basal inferolateral, and basal inferior segments with normal perfusion (Figure 2). The scan also revealed hypermetabolic bilateral hilar and mediastinal lymphadenopathy. A diagnosis of CS was made. An Implantable-Cardioverter-defibrillator (ICD) was placed and the patient was discharged on 40mg of prednisone and 20mg of leflunomide. Within 4 months, he went from 100% RV pacing to 0%. Eventually, the corticosteroid was tapered off. At follow-up after 1.5 years, RV pacing remained 0% on Leflunomide 20mg. DISCUSSION: One should always suspect CS in young patients with high-grade AV block. During the workup of CHB (Figure 3), the 2017 Japanese Circulation Society Working Group Criteria for diagnosing CS was followed (1). The patient had 2 characteristic findings strongly suggestive of sarcoidosis: (a) hilar lymphadenopathy and (b) significant tracer accumulation in the myocardium and hilar lymph nodes on FDG-PET scan. He also met 2 major criteria strongly suggestive of CS: (a) LGE on CMR and (b) abnormal myocardial FDG uptake. These findings, per the criteria, establish the clinical diagnosis of CS. The mainstay of treatment for CS is corticosteroids +/- steroid-sparing agents to decrease intra-cardiac inflammation (1). CHB patients with CS have a high risk of ventricular arrhythmias, hence should receive ICD (2). The addition of antimetabolite adjuvants is more effective than corticosteroids alone (3). They may reduce the total time of glucocorticoid therapy and keep patients in remission. CONCLUSIONS: Clinical diagnosis of CS can be established with FDG-PET imaging and CMR. CS patients with advanced heart block should receive ICD. Corticosteroids are the mainstay of treatment. Immunotherapy is an effective adjunct that can help taper the glucocorticoids and keep patients in remission. Early introduction of these agents should be considered in these patients. REFERENCE #1: 1. Trivieri MG et al. Challenges in Cardiac and Pulmonary Sarcoidosis: JACC State-of-the-Art Review. J Am Coll Cardiol 2020;76:1878-1901 REFERENCE #2: 2. Nordenswan H-K et al. Outcome of Cardiac Sarcoidosis Presenting With High-Grade Atrioventricular Block. Circulation: Arrhythmia and Electrophysiology 2018;11:e006145 REFERENCE #3: 3. Nagai S, Yokomatsu et al. Treatment with methotrexate and low-dose corticosteroids in sarcoidosis patients with cardiac lesions. Intern Med 2014;53:427-33. DISCLOSURES: No relevant relationships by Roy Chung, source=Web Response No relevant relationships by Sachin Kumar, source=Web Response No relevant relationships by Raunak Nair, source=Web Response

Clinical and surgical approaches for malignant pulmonary lesions after a previous extrapulmonary malignancy.

In our study, since the operative histopathological distinction of new malignant pulmonary lesions as either a primary lung cancer or a pulmonary metastasis is difficult, we aimed to identify the clinical variables which might allow distinction between a new lung cancer and a pulmonary metastasis, and the appropriate surgical management. We divided 55 cases into two groups: patients with new lung cancer (NLC, n=32) and patients with pulmonary metastases (PM, n=23). Based on the primary organ, the previous malignancy was classified into four categories: head and neck, colorectal, genitourinary, and breast cancer. The parameters included in the study were age, sex, smoking history, a family history of cancer, disease-free interval, primary organ, treatments for previous malignancies, size, and SUV max of the lung lesion on 18F-fluorodeoxyglucose positron emission tomography scan and high-resolution computed tomography findings of the lung lesion. A predisposition for larger lesions was found in the NLC group. In addition, in the NLC group, disease-free interval was noted to be longer, patients were significantly older and SUV-max values of solitary pulmonary lesions were significantly higher than in the PM group. Pulmonary lesions in patients with prior head and neck cancers were more likely to develop NLC. No significant difference in statistical analysis was observed between the groups in terms of sex, smoking, a family history of cancer, a history of adjuvant therapy, radiological pulmonary lesions signs, and localization. PL monitoring on CT surveillance is essential, particularly in patients with previous head and neck cancers, who appear to have a higher risk for NLC. If pathological MLN accompanies PL in a patient with previous extrapulmonary malignancy, cervical mediastinoscopy may help acquire a possible PL diagnosis besides mediastinal staging. Intraoperative frozen section may have difficulty in distinguishing between PM and NLC when the lesion is of the same histological type as the previous malignancy. When precise distinction cannot be achieved by frozen section, we speculate that DFI, age, and radiological findings of the PL may help thoracic surgeons take initiative peroperatively while designating the subsequent surgical intervention. Lastly, pulmonary segmentectomy is also better be considered along with lobectomy in NLC cases.

Management of Cardiac Sarcoidosis Using Mycophenolate Mofetil as a Steroid-Sparing Agent

BackgroundCardiac sarcoidosis (CS) is a major cause of morbidity and mortality in patients with systemic sarcoidosis. Steroid-sparing agents are increasingly used, despite a lack of randomized trials or published guidelines to direct treatment. Methods and ResultsThis retrospective study included 77 patients with CS treated with prednisone monotherapy (n = 32) or a combination with mycophenolate mofetil (n = 45) between 2003 and 2018. Baseline characteristics and clinical outcomes were evaluated. The mean patient age was 53 ± 11 years at CS diagnosis, 66.2% were male, and 35.1% were Black. The total exposure to maximum prednisone dose (initial prednisone dose × days at dose) was lower in the combination therapy group (1440 mg [interquartile range (IQR), 1200–2760 mg] vs 2710 mg [IQR, 1200–5080 mg]; P = .06). On 18F-fluorodeoxyglucose positron emission tomography scans, both groups demonstrated a significant decrease in the cardiac maximum standardized uptake value after treatment: a median decrease of 3.9 (IQR 2.7–9.0, P = .002) and 2.9 (IQR 0–5.0, P = .001) for prednisone monotherapy and combination therapy, respectively. Most patients experienced improvement or complete resolution in qualitative cardiac 18F-fluorodeoxyglucose uptake (92.3% and 70.4% for the prednisone and combination therapy groups, respectively). Mycophenolate mofetil was well tolerated. ConclusionsMycophenolate mofetil in combination with prednisone for the treatment of CS may minimize corticosteroid exposure and decrease cardiac inflammation without significant adverse effects.

Hidden under the Surface: A Rare Cause of Repeated Syncope in a Patient with Recent Pacemaker Implantation

A 66-year-old woman received a pacemaker implantation because of syncope with documented sinus arrest and junctional bradycardia. Three weeks later the pacemaker analysis revealed episodes of nonsustained ventricular tachycardia. Coronary angiography and invasive coronary assessment showed diffuse moderate stenosis but no significant ischemia. Three months later she experienced a new syncope and the pacemaker analysis showed runs of nonsustained ventricular tachycardia at the time of syncope. The combination of brady- and tachyarrhythmias raised concern for cardiac sarcoidosis. 18F-fluorodeoxyglucose positron emission tomography (PET) scan showed increased FDG uptake in the basal segments compatible with inflammatory disease. Cardiac magnetic resonance imaging showed late gadolinium enhancement in the same region of the PET-avid lesions. Diagnostic electrophysiologic study could induce VT. The diagnosis of cardiac sarcoidosis was made, for which high dose corticosteroids were prescribed and an upgrade to a dual chamber implantable cardioverter defibrillator was performed. Because of the localization of the lesions, an endomyocardial biopsy was not performed. All the lesions regressed completely on PET-scan after treatment with high dose corticosteroids.

Sarcoid Heart Disease: Review of Current Knowledge.

Sarcoidosis is a granulomatous disease with the potential of multiple organ system involvement and its etiology remains unknown. Cardiac involvement is associated with worse clinical outcome, and has been reported to be 20-30% in white and as high as 58% in Japanese populations with sarcoidosis. Clinical manifestations of cardiac sarcoidosis highly depend on the extent and location of granulomatous inflammation. The most frequent presentations include heart block, tachyarrhythmia, or heart failure. Endomyocardial biopsy is the most specific diagnostic test, but has poor sensitivity due to often patchy involvement. The diagnosis of cardiac sarcoidosis remains challenging due to nonspecific imaging findings. Both 18 F-fluorodeoxyglucose-positron emission tomography (FDG-PET) and cardiac magnetic resonance imaging can be used to evaluate cardiac sarcoidosis, but evaluate different stages of the disease process. FDG-PET detects metabolically active inflammatory cells while cardiac magnetic resonance imaging with late gadolinium enhancement reveals areas of myocardial necrosis and fibrosis. Aggressive therapy of symptomatic cardiac sarcoidosis is often sought due to the high risk of sudden death and/or progression to heart failure. Prednisone 20-40 mg a day is the recommended initial treatment. In refractory or severe cases, higher doses of prednisone, 1-1.5 mg/kg/d (or its equivalent) and addition of a steroid-sparing agent have been utilized. Methotrexate is added most commonly. Long-term improvement has been reported with the use of a combination of weekly methotrexate and prednisone versus prednisone alone. After initiation of treatment, a cardiac FDG-PET scan may be performed 2-3 months later to assess treatment response.

Functional Neural Correlates of the WAIS-IV Block Design Test in Older Adult with Mild Cognitive Impairment and Alzheimer’s Disease

The Wechsler Adult intelligence scale-Revised (WAIS-R) Block design test (BDT) is a neuropsychological test widely used to assess cognitive declines in aging population. Previous studies suggest parietal lobe is the key region to influence the performance on the BDT; yet, it has not been clearly identified. The aim of the current study, therefore, is to identify the functional neural correlates of the BDT in older adults with mild cognitive impairment (MCI) and Alzheimer’s disease (AD) dementia patients. The current study includes 213 cognitively impaired mid to old-aged community dwelling Korean. All participants underwent comprehensive clinical and neuropsychological assessments and 18F-fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) scans. Performance on the BDT was assessed using the WAIS-IV Korean version. Voxel-wise analyses were used to investigate the correlation between regional cerebral glucose metabolism and BDT performance. The same analyses were conducted on the subgroups categorized by clinical severity based on the Clinical Dementia Rating (CDR). Significant positive correlations between performance on the BDT and regional cerebral glucose metabolism were found bilaterally in the inferior parietal lobules, right thalamus and right middle frontal gyrus. Our results suggest that performance on the BDT in MCI and AD patients functionally relies on the brain regions known to be associated with motor and executive functions in addition to visuospatial function.

Arrhythmogenic cardiomyopathy presenting as an inflammatory cardiomyopathy: the role of 18F-fluorodeoxyglucose positron emission tomography scan.

Arrhythmogenic cardiomyopathy presenting as an inflammatory cardiomyopathy: the role of 18F-fluorodeoxyglucose positron emission tomography scan.

Longitudinal Changes in Isolated Rapid Eye Movement Sleep Behavior Disorder-Related Metabolic Pattern Expression.

ABSTRACTBackgroundIt remains unclear whether and how the isolated rapid eye movement (REM) sleep behavior disorder (iRBD)‐related metabolic pattern (RBDRP) changes with disease progression in iRBD.ObjectiveTo examine longitudinal changes in RBDRP expression in iRBD patients and to explore trajectories of relative metabolic activities of individual brain regions constituting RBDRP.MethodsIn this cohort study, 25 iRBD patients (mean age [±standard deviation], 69.2 ± 5.3 years; 12 [48%] patients were men) and 24 age‐matched healthy controls were included. The patients underwent at least two 18F‐fluorodeoxyglucose positron emission tomography scans at baseline and at the 2‐year and/or 4‐year follow‐ups. We measured the RBDRP expression of the patients and controls which was validated by reproduction in a separate iRBD cohort (n = 13).ResultsAt baseline, the RBDRP expression discriminated iRBD patients from healthy controls. However, the RBDRP expression z scores tended to decrease over time in the patients, especially with longer follow‐ups, and this tendency was observed even in patients with high‐risk of phenoconversion. Furthermore, the degree of RBDRP expression at baseline did not predict the disease conversion. The RBDRP breakdown was mainly provoked by the attenuation of relative hypermetabolism in the frontal cortex including premotor areas and relative hypometabolism in the occipital cortex. The putaminal metabolic activity increased steadily with the disease progression.ConclusionsThe RBDRP expression in iRBD patients was altered significantly over time. Some of the brain metabolic changes seem to represent attempted functional compensation against ongoing neurodegeneration. The RBDRP expression measurement at one time point may not be a reliable biomarker for predicting disease conversion. © 2021 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society

Outcome of primary mediastinal large B-cell lymphoma using R-CHOP: impact of a PET-adapted approach

AbstractCure rates for primary mediastinal large B-cell lymphoma (PMBCL) have improved with the integration of rituximab. However, the type of primary therapy and role of radiotherapy (RT) remains ill-defined. Herein, we evaluated the outcome of PMBCL primarily treated with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) and the impact of an end-of-treatment (EOT) 18F-fluorodeoxyglucose positron emission tomography (PET) scan to guide consolidative RT. Patients ≥18 years of age with PMBCL treated with curative intent rituximab-chemotherapy were identified. Prior to 2005, patients were recommended to receive R-CHOP + RT (RT era). Beginning in 2005, EOT PET was used to guide RT and only those with a PET-positive scan received RT (PET era). In total, 159 patients were identified, 94% were treated with R-CHOP and 44% received RT (78% in RT era, 28% in PET era). The 5-year time to progression (TTP) and overall survival (OS) for the entire cohort were 80% and 89%, respectively, similar across treatment eras. Overall, 10% had refractory disease. In total, 113 patients had an EOT PET scan: 63% negative and 37% positive with a 5-year TTP of 90% vs 71% and 5-year OS of 97% vs 88%, respectively. For those with Deauville (D)-scored PET scans (n = 103), the 5-year TTP for PET-negative cases by Deauville criteria (D1-D3, DX) was 91%, with inferior outcomes for D5 vs D4 (5-year TTP 33% vs 87%, P = .0002). Outcomes for PMBCL treated with RCHOP are favorable and use of a PET-adapted approach reduces RT in the majority of patients. A small proportion have refractory disease and may benefit from an alternate treatment.

Sequential 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET) scan findings in patients with extrapulmonary tuberculosis during the course of treatment—a prospective observational study

Initial studies of tuberculosis (TB) in macaques and humans using 18F-FDG positron emission tomography (PET) imaging as a research tool suggest its usefulness in localising disease sites and as a clinical biomarker. Sequential serial scans in patients with extrapulmonary TB (EPTB) could inform on the value of PET-CT for monitoring response to treatment and defining cure. HIV-negative adults with EPTB from eight sites across six countries had three 18F-FDG PET/CT scans: (i) within 2weeks of enrolment, (ii) at 2months into TB treatment and (iii) at end of ATT treatment. Scanning was performed according to the EANM guidelines. 18F-FDG PET/CT scans were performed 60 ± 10min after intravenous injection of 2.5-5.0MBq/kg of 18F-FDG. One hundred and forty-seven patients with EPTB underwent 3 sequential scans. A progressive reduction over time of both the number of active sites and the uptake level (SUVmax) at these sites was seen. At the end of WHO recommended treatment, 53/147 (36.0%) patients had negative PET/CT scans, and 94/147 (63.9%) patients remained PET/CT positive, of which 12 patients had developed MDR TB. One died of brain tuberculoma. Current 18F-FDG PET/CT imaging technology cannot be used clinically as a biomarker of treatment response, cure or for decision-making on when to stop EPTB treatment. PET/CT remains a research tool for TB and further development of PET/CT is required using new Mycobacterium tuberculosis-specific radiopharmaceuticals targeting high-density surface epitopes, gene targets or metabolic pathways.