Bacteraemia after leadless pacemaker implantation Garweg, Christophe; Vandenberk, Bert; Jentjens, Sander ...
Journal of cardiovascular electrophysiology,
September 2020, 2020-09-00, 20200901, Letnik:
31, Številka:
9
Journal Article
Recenzirano
Odprti dostop
Background
Transvenous 3 permanent pacemaker‐related infection is a severe condition associated with significant morbidity and mortality. Leadless pacemakers may be more resistant to bacterial ...seeding during bloodstream infection because of its small surface area and encapsulation in the right ventricle. This study reports the incidence and outcomes of bacteraemia in patients implanted with a Micra leadless pacemaker. We present 18F‐fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) findings obtained in a subgroup of patients.
Methods
We report a retrospective cohort study of 155 patients who underwent a Micra TPS implant procedure at the University Hospitals of Leuven between July 2015 and July 2019. We identified the patients who developed an episode of bacteraemia, proved by ≥2 positive blood cultures.
Results
Of the 155 patients, 15 patients presented an episode of bacteraemia at a median of 226 days (range: 3–1129) days after the implant procedure. Gram‐positive species accounted for 73.3% (n = 11) of the bacteraemia including Staphylococcus (n = 5), Enterococcus (n = 3), and Streptococcus (n = 3). The source of infection was identified in nine patients (60%) including endocarditis in four patients, urinary tract in three patients, and skin in two patients. 18F‐FDG PET/CT imaging performed in six patients did not show sign of infection around the leadless pacemaker. Bacteraemia was resolved in all patients after adequate antibiotherapy. Four patients died early during follow up. For all other patients, there were no recurrence of systemic infection during a median follow up of 263 days (range: 15–1134).
Conclusion
In our small cohort, no leadless pacemaker endocarditis was observed among patients with bacteraemia.
Objectives
PSMA-PET has become the PET technique of choice to localise the site of biochemically recurrent prostate cancer (PCa). With hybrid PET/MRI, the advantages of MRI are added to molecular ...characteristic of PET. The aim of this study was to investigate the incremental value of PET/MR versus PET/CT in patients with biochemically recurrent PCa by head-to-head comparison.
Methods
Thirty-four patients with biochemically recurrent PCa were prospectively included. They underwent
68
GaGa-PSMA-11 PET/CT, followed by simultaneous PET/MR. All PET (PET
CT
, PET
MR
), CT and MR images were evaluated for number of lesions and location. The number of lesions at specific sites was compared using Wilcoxon-sign-rank test. For PET, the maximum and mean standardised uptake values (SUVs) were calculated for each lesion compared using a two-sided paired t test.
Results
PET
CT
and PET
MR
scans were positive in 19 and 20 patients, detecting 73 and 79 lesions respectively. All lesions detected on PET
CT
were also detected on PET
MR
. CT and MRI only were positive in 14 and 17 patients, detecting 38 and 50 lesions, respectively, which was significantly lower than PET
CT
and PET
MR
respectively. Combined interpretation showed more lesions on PET/MR than on PET/CT (88 vs 81). No significant difference in detection of presence of local recurrence nor distant metastases was found. SUV
mean
and SUV
max
values were significantly higher on PET
MR
than on PET
CT
in local recurrence and lymph node metastases.
Conclusions
68
GaGa-PSMA-11 PET/MR was able to detect biochemically recurrent PCa at least as accurately as PET/CT for local recurrence, lymph node metastasis and distant metastasis.
Key Points
• PSMA PET/MRI detects the location of biochemical recurrence at least as accurately as PET/CT.
• Substitution of PET/CT by PET/MRI adds sensitivity in PSMA lesion detection also in the setting of distant recurrence due to both the MR and TOF PET components.
Background
Although most guidelines suggest performing a positron emission tomography/computed tomography (PET/CT) with somatostatin receptor (SSTR) ligands for staging of pulmonary carcinoid tumours ...(PC), only a limited number of studies have evaluated the role of this imaging tool in this specific patient population. The preoperative differentiation between typical carcinoid (TC) and atypical carcinoid (AC) and the extent of dissemination (N/M status) are crucial factors for treatment allocation and prognosis of these patients. Therefore, we performed a pathology-based retrospective analysis of the value of SSTR PET/CT in tumour grading and detection of nodal and metastatic involvement of PC and compared this with the previous literature and with
18
FFDG PET/CT in a subgroup of patients.
Methods
SSTR PET/CT scans performed between January 2007 and May 2020 in the context of PC were included. If available,
18
FFDG PET/CT images were also evaluated. The maximum standardized uptake (SUV
max
) values of the primary tumour, of the pathologically examined hilar and mediastinal lymph node stations, as well as of the distant metastases, were recorded. Tumoural SUV
max
values were related to the tumour type (TC versus AC) for both SSTR and
18
FFDG PET/CT in diagnosing and differentiating both tumour types. Nodal SUV
max
values were compared to the pathological status (N
+
versus N
−
) to evaluate the diagnostic accuracy of SSTR PET/CT in detecting lymph node involvement. Finally, a mixed model analysis of all pathologically proven distant metastatic lesions was performed.
Results
A total of 86 SSTR PET/CT scans performed in 86 patients with PC were retrospectively analysed.
18
FFDG PET/CT was available in 46 patients. Analysis of the SUV
max
values in the primary tumour showed significantly higher SSTR uptake in TC compared with AC (median SUV
max
18.4 vs 3.8;
p
= 0.003) and significantly higher
18
FFDG uptake in AC compared to TC (median SUV
max
5.4 vs 3.5;
p
= 0.038). Receiver operating characteristic (ROC) curve analysis resulted in an area under the curve (AUC) of 0.78 for the detection of TC on SSTR PET/CT and of 0.73 for the detection of AC on
18
FFDG PET/CT. A total of 267 pathologically evaluated hilar and mediastinal lymph node stations were analysed. ROC analysis of paired SSTR/
18
FFDG SUV
max
values for the detection of metastasis of TC in 83 lymph node stations revealed an AUC of 0.91 for SSTR PET/CT and of 0.74 for
18
FFDG PET/CT (difference 0.17; 95% confidence interval − 0.03 to 0.38;
p
= 0.10). In a sub-cohort of 10 patients with 12 distant lesions that were pathologically examined due to a suspicious aspect on SSTR PET/CT, a positive predictive value (PPV) of 100% was observed.
Conclusion
Our findings confirm the higher SSTR ligand uptake in TC compared to AC and vice versa for
18
FFDG uptake. More importantly, we found a good diagnostic performance of SSTR PET/CT for the detection of hilar and mediastinal lymph node metastases of TC. Finally, a PPV of 100% for SSTR PET/CT was found in a small sub-cohort of patients with pathologically investigated distant metastatic lesions. Taken together, SSTR PET/CT has a very high diagnostic value in the TNM assessment of pulmonary carcinoids, particularly in TC, which underscores its position in European guidelines.
Background
Detection of the site of recurrence using PSMA-PET/CT is important to guide treatment in patients with biochemical recurrence of prostate cancer (PCa). The aim of this study was to ...evaluate the positivity rate of
18
FPSMA-1007-PET/CT in patients with biochemically recurrent PCa and identify parameters that predict scan positivity as well as the type and number of detected lesions. This monocentric retrospective study included 137 PCa patients with biochemical recurrence who underwent one or more
18
FPSMA-1007-PET/CT scans between August 2018 and June 2019. PET-positive malignant lesions were classified as local recurrence, lymph node (LN), bone or soft tissue lesions. The association between biochemical/paraclinical parameters, as PSA value, PSA doubling time, PSA velocity, Gleason score (GS) and androgen deprivation therapy (ADT), and scan positivity as well as type and number of detected lesions was evaluated using logistic regression analysis (binary outcomes) and Poisson models (count-type outcomes).
Results
We included 175
18
FPSMA-1007-PET/CT scans after radical prostatectomy (78%), external beam radiation therapy (8.8%), ADT (7.3%), brachytherapy (5.1%) and high intensity focused ultrasound (0.7%) as primary treatment (median PSA value 1.6 ng/ml). Positivity rate was 80%. PSA value and PSA velocity were significant predictors of scan positivity as well as of the presence of bone and soft tissue lesions and number of bone, LN and soft tissue lesions, both in uni- and/or multivariable analysis. Multivariable analysis also showed prior ADT as predictor of bone and soft tissue lesions, GS as predictor of the number of bone lesions and ongoing ADT as predictor of the number of LN lesions.
Conclusion
18
FPSMA-1007-PET/CT showed a high positivity rate in patients with biochemically recurrent PCa. PSA value and PSA velocity were significant predictors of scan positivity as well as of the presence and number of bone and soft tissue lesions and the number of LN lesions. Our findings can guide clinicians in optimal patient selection for
18
FPSMA-1007-PET/CT and support further research leading to the development of a prediction nomogram.
Background and purpose
Enterovirus infections pose a serious threat for patients with humoral deficiencies and may be lethal, whilst the efficacy of proposed treatment options such as ...corticosteroids, intravenous immunoglobulins and fluoxetine remains debated.
Methods
Viral clearance was investigated in a patient with rituximab‐induced B‐cell depletion and chronic echovirus 13 (E13) meningoencephalitis/myofasciitis in response to intravenous immunoglobulins and fluoxetine using sequential semi‐quantitative E13 viral load measurements by real‐time reverse transcription polymerase chain reaction. Fluoxetine concentrations in plasma and cerebrospinal fluid were determined by liquid chromatography mass spectrometry.
Results
Intravenous immunoglobulins appeared ineffective in this case of E13 infection, whereas virus clearance in cerebrospinal fluid was obtained after 167 days of oral fluoxetine. Since treatment with corticosteroids resulted in a flare of symptoms, rechallenge with viral load measurements was not attempted.
Conclusion
In this report of a patient with rituximab‐associated chronic echovirus 13 meningoencephalitis, viral clearance in response to single treatment options is assessed for the first time. Our observations further support the in vivo efficacy of fluoxetine against enteroviral infections. More research is needed to establish its efficacy in different enterovirus strains.
In this report of a patient with rituximab‐associated chronic echovirus 13 (E13) meningoencephalitis, viral clearance in response to single treatment options is assessed for the first time. Our observations further support the in vivo efficacy of fluoxetine against enteroviral infections. Oral fluoxetine treatment was associated with clinical improvement and molecularly confirmed E13 clearance from cerebrospinal fluid after 167 days.
Background
Salvage radiotherapy (RT) (± androgen deprivation therapy (ADT)) is often used as a treatment in patients with biochemical recurrence (BCR) following radical prostatectomy (RP). ...Unfortunately, even after RT ± ADT, a significant number of patients will develop ‘second’ BCR. The aim of this study was to investigate the impact of postoperative treatments (adjuvant/salvage radiotherapy (RT) ± androgen deprivation therapy) on the recurrence pattern in patients with BCR following RP assessed by 11C-Choline PET/CT or 68 Ga-PSMA PET/CT.
Methods
Patients who developed BCR following RP and who had at least one positive lesion on PET/CT were retrospectively assessed. Positive spots were mapped as local, lymph node (LN), skeletal or visceral recurrence. A distinction was made between locoregional (prostate bed and pelvic LN) and extrapelvic recurrence (skeletal, visceral and/or extrapelvic LN). Patients were categorized according to postoperative treatment received in three subgroups (RT, ADT and RT + ADT) and compared with the reference group (RP only). The impact of the radiation field was also investigated.
Results
We identified 200 patients assessed by
68
Ga-PSMA-11 (80%) or
11
C-Choline PET/CT (20%). Patients who received postoperative RT + ADT had less LN recurrence distal to the common iliac bifurcation (26.7% vs 66.6%;
p
= 0.0004), but more recurrence to retroperitoneal LN than the reference group (38% vs. 14.4%,
p
= 0.02). Moreover, the RT + ADT subgroup had more extrapelvic recurrence compared to the reference group (66.2% vs 40.8%,
p
= 0.02). Patients who received RT to the prostate bed had more recurrence distal to the common iliac bifurcation compared to those who received RT to the prostate bed + pelvic LN (51.6% vs 26.1%,
p
= 0.0069).
Conclusion
Post-prostatectomy treatments (ADT and/or RT) and the postoperative radiation field (prostate bed vs. prostate bed + pelvis) have a significant impact on the recurrence pattern. This knowledge can help clinicians to counsel their patients on their chances of being eligible for (locoregional) metastasis-directed therapies.
Purpose
The aim of this study was to develop a convolutional neural network (CNN) for the automatic detection and segmentation of gliomas using
18
Ffluoroethyl-L-tyrosine (
18
FFET) PET.
Methods
...Ninety-three patients (84 in-house/7 external) who underwent a 20–40-min static
18
FFET PET scan were retrospectively included. Lesions and background regions were defined by two nuclear medicine physicians using the MIM software, such that delineations by one expert reader served as ground truth for training and testing the CNN model, while delineations by the second expert reader were used to evaluate inter-reader agreement. A multi-label CNN was developed to segment the lesion and background region while a single-label CNN was implemented for a lesion-only segmentation. Lesion detectability was evaluated by classifying
18
FFET PET scans as negative when no tumor was segmented and vice versa, while segmentation performance was assessed using the dice similarity coefficient (DSC) and segmented tumor volume. The quantitative accuracy was evaluated using the maximal and mean tumor to mean background uptake ratio (TBR
max
/TBR
mean
). CNN models were trained and tested by a threefold cross-validation (CV) using the in-house data, while the external data was used for an independent evaluation to assess the generalizability of the two CNN models.
Results
Based on the threefold CV, the multi-label CNN model achieved 88.9% sensitivity and 96.5% precision for discriminating between positive and negative
18
FFET PET scans compared to a 35.3% sensitivity and 83.1% precision obtained with the single-label CNN model. In addition, the multi-label CNN allowed an accurate estimation of the maximal/mean lesion and mean background uptake, resulting in an accurate TBR
max
/TBR
mean
estimation compared to a semi-automatic approach. In terms of lesion segmentation, the multi-label CNN model (DSC = 74.6 ± 23.1%) demonstrated equal performance as the single-label CNN model (DSC = 73.7 ± 23.2%) with tumor volumes estimated by the single-label and multi-label model (22.9 ± 23.6 ml and 23.1 ± 24.3 ml, respectively) closely approximating the tumor volumes estimated by the expert reader (24.1 ± 24.4 ml). DSCs of both CNN models were in line with the DSCs by the second expert reader compared with the lesion segmentations by the first expert reader, while detection and segmentation performance of both CNN models as determined with the in-house data were confirmed by the independent evaluation using external data.
Conclusion
The proposed multi-label CNN model detected positive
18
FFET PET scans with high sensitivity and precision. Once detected, an accurate tumor segmentation and estimation of background activity was achieved resulting in an automatic and accurate TBR
max
/TBR
mean
estimation, such that user interaction and potential inter-reader variability can be minimized.
Although concomitant coronary artery disease (CAD) is frequent in patients with severe aortic stenosis (AS), hemodynamic assessment of CAD severity in patients undergoing valve replacement for severe ...AS is challenging. Myocardial hypertrophic remodeling interferes with coronary blood flow and may influence the values of fractional flow reserve (FFR) and nonhyperemic pressure ratios (NHPRs). The aim of the current study is to investigate the effect of the AS and its treatment on current indices used for evaluation of CAD. We will compare intracoronary hemodynamics before, immediately after, and 6 mo after aortic valve replacement (AVR) when it is expected that microvascular function has improved. Furthermore, we will compare FFR and resting full-cycle ratio (RFR) with myocardial perfusion single-photon emission-computed tomography (SPECT) as indicators of myocardial ischemia in patients with AS and CAD. One-hundred consecutive patients with AS and intermediate CAD will be prospectively included. Patients will undergo pre-AVR SPECT and intracoronary hemodynamic assessment at baseline, immediately after valve replacement if transcatheter AVR (TAVR) is chosen, and 6 mo after AVR. The primary end point is the change in FFR 6 mo after AVR. Secondary end points include the acute change of FFR after TAVR, the diagnostic accuracy of FFR versus RFR compared with SPECT for the assessment of ischemia, changes in microvascular function as assessed by the index of microcirculatory resistance (IMR), and the effect of these changes on FFR. The present study will evaluate intracoronary hemodynamic parameters before, immediately after, and 6 mo after AVR in patients with AS and intermediate coronary stenosis. The understanding of the impact of AVR on the assessment of FFR, NHPR, and microvascular function may help guide the need for revascularization in patients with AS and CAD planned for AVR.
A 76-y-old man with hypoosmolar hyponatremia of unknown origin was referred to the nuclear medicine department for
F-FDG PET/CT to exclude a malignant cause. Increased
F-FDG uptake in both adrenal ...glands was observed and investigated.
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