Search

Osteomyelitis of the foot is a well-known complication of diabetes mellitus. In this study, the validity of 111In-labeled human nonspecific immunoglobulin G (IgG) scintigraphy was studied in 16 diabetic patients with foot ulcers, gangrene or painful Charcot joints. In all patients, plain radiographs, conventional bone scan images and 111In-IgG images were recorded. The results were verified by histologic examination of surgical specimens in patients who did not respond to antibiotic treatment within 2-3 wk (10 lesions) or long-term clinical follow-up of at least 6-mo (16 lesions). On the bone scans, all seven osteomyelitic foci were detected. However, 19 additional foci not due to osteomyelitis were seen. The absence of true-negative bone scans in this study resulted in a specificity of 0%. On the plain radiographs, four of seven osteomyelitis foci were detected; for 111In-IgG scintigraphy, six of seven (sensitivity 57% and 86%, respectively). Plain radiographs correctly ruled out osteomyelitis in 15 of 19 lesions, 111In-IgG scintigraphy in 16 of 19 (specificity 79% and 84%, respectively). All imaging procedures gave false-positive results in penetrating ulcers over the calcaneus in two patients and in one patient with a Charcot joint, most likely due to recent fractures. A false-negative 111In-IgG study was observed in a patient with severe arterial angiopathy. Accurate estimation of probable osteomyelitis was not possible from the results of soft-tissue cultures, since in only 6 of 12 positive cultures, osteomyelitic foci could be proven. Indium-111-IgG scintigraphy can contribute to adequate evaluation of osteomyelitis in diabetic foot complications because it improves specificity when compared to bone scan and radiographic findings and improves sensitivity in comparison to plain radiographs.

Indium-111-labeled human nonspecific immunoglobulin G (111In-IgG) is a newly developed radiopharmaceutical for imaging infectious and inflammatory foci. This article presents an overview of the literature concerning 111In-IgG scintigraphy. The current theory about the mechanism of accumulation suggests that 111In-IgG accumulates in lesions as a result of enhanced vascular permeability and subsequent entrapment of the radiolabeled protein. Human studies show excellent results in imaging bone and joint, abdominal, and intravascular infection. Of special interest is the ability to depict infectious foci in granulocytopenic patients. The value of 111In-IgG scintigraphy for detection of infection is compared with that of gallium-67, labeled-leukocyte, and technetium-99m (99mTc) nanocolloid scintigraphy. The significance of differences between 111In-IgG scintigraphy and two other new scintigraphic techniques, 99mTc-labeled IgG and 99mTc-labeled murine monoclonal anti-granulocyte antibody BW 250/183, are discussed.

In 35 patients suspected of an infectious focus, the outcome of scintigraphy with 111In-labeled autologous leukocytes (WBC) and 111In-labeled human nonspecific immunoglobulin G (IgG) was evaluated in a prospective comparative study. Clinical, roentgenologic and microbiologic findings were considered to be proof of the presence of infection or inflammation. In this group of patients with mainly subacute infections, 111In-IgG scintigraphy performed significantly better than 111In-WBC scintigraphy, especially in infections of the locomotor system, but also in various soft-tissue infections. Both techniques showed disappointing results in patients with disseminated yersinia infection and in some patients with tuberculosis. Overall sensitivity and specificity was 74% and 100% for 111In-IgG scintigraphy and 52% and 78% for 111In-WBC scintigraphy, respectively.

Patients receive three study transfusions: (1) One standard of care transfusion, the standard amount for the individual patient-specific transfusion regimen, (2) a standard transfusion with one extra RBC concentrate, and (3) a standard transfusion with two extra RBC concentrates. Secondary outcomes included grade 3-4 bleeding (i.e., requiring major intervention and/or RBC transfusion), transfusion reactions, platelet transfusions within 24 h after CVC placement, and transfusion- and bleeding-related costs. PA12-L05 Prophylactic platelet transfusion prior to central venous catheter placement in patients with... F van Baarle 1, E van de Weerdt 1, W van der Velden 2, B Ruiterkamp 2, P Tuinman 3, P Yp... 1 Intensive Care, Amsterdam UMC location University of Amsterdam, Amsterdam, 2 Haematology, R... B Background: b International transfusion guidelines recommend varying platelet transfusion thresholds (20-50 × 10 SP 9 sp /L) prior to central venous catheter (CVC) placement due to lack of good quality evidence. Parallel Session 5: Technology to improve the donor experience (and blood supply) PA05-L01 Remote monitoring of vital and activity parameters in chronic transfusion dependent patients R Tonino 1,2,3, M Schipperus 4, J Zwaginga 1,3 1 TRIP, Leiden, 2 Internal Medicine, Groene Hart Ziekenhuis, Gouda, 3 Hematology, LUMC, Leide... B Introduction b There are no completed trials investigating the value of transfusion in the outpatient setting for chronic transfusion-dependent patients, and little data in general about this subject. More platelet transfusions per patient were administered within 24 h after CVC placement in the no transfusion group (0.47) than in the transfusion group (0.14); rate ratio (95% CI) = 3.3 (2.2-5.0). [Extracted from the article]

Classification/diagnosis: Diabetic foot infection must be diagnosed clinically, based on the presence of local or systemic signs or symptoms of inflammation (strong; low). Assess the severity of any diabetic foot infection using the Infectious Diseases Society of America/International Working Group on the Diabetic Foot classification scheme (strong; moderate).Osteomyelitis: For an infected open wound, perform a probe-to-bone test; in a patient at low risk for osteomyelitis, a negative test largely rules out the diagnosis, while in a high-risk patient, a positive test is largely diagnostic (strong; high). Markedly elevated serum inflammatory markers, especially erythrocyte sedimentation rate, are suggestive of osteomyelitis in suspected cases (weak; moderate). A definite diagnosis of bone infection usually requires positive results on microbiological (and, optimally, histological) examinations of an aseptically obtained bone sample, but this is usually required only when the diagnosis is in doubt or determining the causative pathogen's antibiotic susceptibility is crucial (strong; moderate). A probable diagnosis of bone infection is reasonable if there are positive results on a combination of diagnostic tests, such as probe-to-bone, serum inflammatory markers, plain X-ray, magnetic resonance imaging (MRI) or radionuclide scanning (strong; weak). Avoid using results of soft tissue or sinus tract specimens for selecting antibiotic therapy for osteomyelitis as they do not accurately reflect bone culture results (strong; moderate). Obtain plain X-rays of the foot in all cases of non-superficial diabetic foot infection (strong; low). Use MRI when an advanced imaging test is needed for diagnosing diabetic foot osteomyelitis (strong; moderate). When MRI is not available or contraindicated, consider a white blood cell-labelled radionuclide scan, or possibly single-photon emission computed tomography (CT) and CT (SPECT/CT) or fluorine-18-fluorodeoxyglucose positron emission tomography/CT scans (weak; moderate).Assessing Severity: At initial evaluation of any infected foot, obtain vital signs and appropriate blood tests, debride the wound and probe and assess the depth and extent of the infection to establish its severity (strong; moderate). At initial evaluation, assess arterial perfusion and decide whether and when further vascular assessment or revascularization is needed (strong; low).Microbiological Considerations: Obtain cultures, preferably of a tissue specimen rather than a swab, of infected wounds to determine the causative microorganisms and their antibiotic sensitivity (strong; high). Do not obtain repeat cultures unless the patient is not clinically responding to treatment, or occasionally for infection control surveillance of resistant pathogens (strong; low). Send collected specimens to the microbiology laboratory promptly, in sterile transport containers, accompanied by clinical information on the type of specimen and location of the wound (strong; low).Surgical Treatment: Consult a surgical specialist in selected cases of moderate, and all cases of severe, diabetic foot infection (weak; low). Perform urgent surgical interventions in cases of deep abscesses, compartment syndrome and virtually all necrotizing soft tissue infections (strong; low). Consider surgical intervention in cases of osteomyelitis accompanied by spreading soft tissue infection, destroyed soft tissue envelope, progressive bone destruction on X-ray or bone protruding through the ulcer (strong; low).Antimicrobial Therapy: While virtually all clinically infected diabetic foot wounds require antimicrobial therapy, do not treat clinically uninfected wounds with antimicrobial therapy (Strong; Low) Select specific antibiotic agents for treatment based on the likely or proven causative pathogens, their antibiotic susceptibilities, the clinical severity of the infection, evidence of efficacy of the agent for diabetic foot infection and costs (strong; moderate). A course of antibiotic therapy of 1-2 weeks is usually adequate for most mild and moderate infections (strong; high). Administer parenteral therapy initially for most severe infections and some moderate infections, with a switch to oral therapy when the infection is responding (strong; low). Do not select a specific type of dressing for a diabetic foot infection with the aim of preventing an infection or improving its outcome (strong; high). For diabetic foot osteomyelitis, we recommend 6 weeks of antibiotic therapy for patients who do not undergo resection of infected bone and no more than a week of antibiotic treatment if all infected bone is resected (strong; moderate). We suggest not using any adjunctive treatments for diabetic foot infection (weak; low). When treating a diabetic foot infection, assess for use of traditional remedies and previous antibiotic use and consider local bacterial pathogens and their susceptibility profile (strong; low). [ABSTRACT FROM AUTHOR]

Prolonged fever presents a challenge for the patient and the physician. Fever with a temperature higher than 38.3°C on several occasions that lasts for at least 3 weeks and lacks a clear diagnosis after 1 week of study in the hospital is called a fever of unknown origin (FUO). More than 200 diseases can cause FUO, and the information gathered from history taking, physical examination, laboratory and imaging studies should be evaluated with care. History taking and physical examination may provide some localizing signs and symptoms pointing toward a diagnosis. Infection, cancers, noninfectious inflammatory diseases and some miscellaneous diseases are the main etiologies, and some patients remain undiagnosed despite investigations. Tuberculosis, lymphoma and adult-onset Still's disease are the main diseases. Fluorodeoxyglucose PET is a promising imaging modality in FUO. Establishing a uniform algorithm for FUO management is difficult. Every patient should be carefully evaluated individually considering the previous FUO management experience. [ABSTRACT FROM AUTHOR]

Purpose: The rationale for the present study was to evaluate the predictive role of Tc-infliximab scintigraphy in therapy decision-making in patients with refractory monoarthritis and also candidates for intraarticular (IA) infliximab treatment. Methods: We studied 12 patients (5 with rheumatoid arthritis and 7 with spondyloarthropathy) with active monoarthritis (11 knees and 1 ankle) that had lasted for at least 3 months. Patients were evaluated clinically and ultrasonographically at baseline and 12 weeks after IA administration of infliximab. At the same time-points, Tc-infliximab scintigraphy was performed: planar anterior and posterior images of arthritic joints were acquired at 6 and 20 h after injection and target-to-background (T/B) ratios were calculated. Results: After treatment, a significant improvement in clinical and ultrasonographic parameters was recorded in six patients. Three patients had a partial response and three did not respond. Regarding scintigraphic evaluation, the T/B ratio analysis showed a significantly higher uptake in affected than in nonaffected joints before therapy (1.78 ± 0.46 vs. 1.29 ± 0.27, p = 0.006 at 6 h; 2.05 ± 0.50 vs. 1.41 ± 0.36 at 20 h, p = 0.002), and mean uptake at 20 h was also significantly higher than at 6 h ( p = 0.0004). Scintigraphy showed a significant decrease in posttherapy T/B ratios of the affected joints ( p = 0.0001 at 6 h and p = 0.0001 at 20 h), indicating a reduction in TNF into the affected joints. Most importantly, responders showed a significantly higher percentage increase in pretherapy uptake from 6 h to 20 h in the affected joints than nonresponders ( p = 0.00001). Conclusion: The results of the present investigation suggest that Tc-infliximab scintigraphy could be a useful tool to predict the clinical response to IA infliximab treatment in patients with refractory monoarthritis. [ABSTRACT FROM AUTHOR]

Inflammatory bowel diseases are represented by ulcerative colitis and Crohn's disease, both consisting of a chronic, uncontrolled inflammation of the intestinal mucosa of any part of the gastrointestinal tract with patchy or continuous inflammation. Ileo-colonoscopy is considered the current gold standard imaging technique for the diagnosis. However, as the majority of patients need a long-term follow-up it would be ideal to rely on a non-invasive technique with good compliance. This review focuses on nuclear medicine imaging techniques in Crohn's disease. Different scintigraphic methods of imaging cells involved in the pathogenesis are described. The radiopharmaceuticals can be divided into non-specific radiopharmaceuticals for inflammation and specific radiopharmaceuticals that directly image lymphocytes involved in the process. This non-invasive molecular imaging approach can be useful also because it images the small bowel or other areas––where colonoscopy is not useful—and that it may play a role for constant follow-up, because relapses are frequent. Finally, an update on other imaging modalities, and particularly MRI, in the evaluation of Crohn's disease activity, is provided. Although MRI cannot directly detect inflammatory cells, it has shown a high sensitivity in detecting the macroscopic signs of inflammation at the level of the intestinal wall affected by Crohn's disease and Ulcerative colitis. The current diagnostic value of MRI in the detection of inflamed bowel segment and in the assessment of CD activity, as well the potentials MR spectroscopy, MR diffusion imaging and MR molecular imaging, is briefly discussed. J. Cell. Physiol. 223:562–571, 2010. © 2010 Wiley-Liss, Inc. [ABSTRACT FROM AUTHOR]

The article presents abstracts on diagnostic technology which include the therapeutic use of Ioflupane I123 brain single photon emission computed tomography (SPECT) in Movement Disorder patients, a software tool to trace epileptogenic foci in intractable partial epilepsy, and the automated injection system for ictal SPECT in epilepsia.

The objectives of this study were to evaluate the diagnostic value of 99mTc-HMPAO labelled white blood cell scintigraphy (WBCS) in patients with suspected osteomyelitis using late images and to study interobserver reproducibility. This study prospectively included 120 patients, and after a follow-up of one year, only 70 patients ( n = 49 with implants, n = 21 without implants) were selected. The final diagnosis of infection was based either on microbiological data ( n = 54) or follow-up ( n = 16). We performed WBCS with 4 h and 24 h scans. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 77%, 72%, 83%, 64%, and 75% at 4 h, and 74%, 87%, 91%, 59%, and 79% at 24 h, respectively. The interobserver reproducibility shows a 63% prevalence of agreement between results ( κ = 0.5) at 4 h and 80% ( κ = 0.74) at 24 h, respectively. WBCS with 24-h images improves specificity and interobserver reproducibility in patients with suspected osteoarticular sepsis. [ABSTRACT FROM AUTHOR]

The article focuses on research which was done to determine the accuracy of historical features, physical examination, and laboratory testing which is done on diabetic patients who have symptoms of osteomyelitis of the lower extremity. Researchers examined English language articles published between 1966 and 2007 which were related to osteomyelitis in patients with diabetes and were found on MEDLINE. They found that the best diagnostic tool is bone biopsy and that an ulcer area of a certain size, a positive probe to bone test result, an erythrocyte sedimentation rate of more than 70 mm/h, and an abnormal plain radiograph result are helpful in diagnosing osteomyelitis.

Abstract. We report here the results of a validation study of the avidin/indium-111 biotin approach in patients with skeletal lesions. This study involved 54 patients with orthopaedic conditions: 20 patients with intermediate suspected osteomyelitis of the trunk, 19 patients with infection/inflammation of prosthetic joint replacements, and 15 patients with suspected osteomyelitis of appendicular bones. Avidin (3 mg) was injected as an i.v. bolus, followed 4 h later by Illin-biotin; imaging was acquired 30 min and 16-18 h after administration of [sup 111]In-biotin. Technetium-99m hexamethylpropylene amine oxime ([sup 99m]Tc-HMPAO)-labelled leucocyte scintigraphy was performed in 39/54 patients. The overall sensitivity of the avidin/[sup 111]In-biotin scan was 97.7% (versus 88.9% for [sup 99m]Tc-HMPAO leucocyte scintigraphy). While the diagnostic performance of avidin/[sup 111]Inbiotin scintigraphy was similar to that of [sup 99m]Tc-HMPAO leucocyte scintigraphy in patients with prosthetic joint replacements or osteomyelitis of appendicular bones, the avidin/[sup 111]In-biotin approach clearly performed better than 99mTc-HMPAO leucocyte scintigraphy in patients with suspected osteomyelitis of the trunk (100% sensitivity, specificity and accuracy versus 50% sensitivity, 100% specificity and 66.7% accuracy for 99mTcHMPAO-leucocyte scintigraphy). These results demonstrate the feasibility of the avidin/[sup 111]In-biotin approach for imaging sites of infection/inflammation in the clinical setting. Although no systematic advantages of avidin/[sup 111]In-biotin scintigraphy were found versus [sup 99m]TcHMPAO leucocyte scintigraphy, the newer scintigraphic method is more practicable and involves lower biological risk for the operators. [ABSTRACT FROM AUTHOR]

Discusses the importance of endothelium and interstitial fluid in nuclear medicine. Three types of endothelium; Factors that influence endothelial permeability; Model for the distribution of interstitial fluid.

Abstract. We conducted a prospective study in order to evaluate the contribution of technetium-99m hexamethylpropylene amine oxime (HMPAO) labelled leucocyte scintigraphy to the diagnosis and follow-up of osteomyelitis in the diabetic foot. The study was conducted between October 1992 and November 1996 and included 42 patients (30 men and 12 women; mean age 63 years) with diabetes mellitus (type 1, n = 22, type 2, n = 20) who had a total of 56 diabetic foot ulcers. The initial exploration included standard radiography, three-phase bone scintigraphy and [sup 99m]Tc-HMPAO labelled leucocyte scintigraphy (HMPAO-LS), performed within a 3-day interval. For the 56 ulceration sites, 26 cases of osteomyelitis were diagnosed: ten on the basis of radiographic and histological/bacteriological criteria after bone biopsy, 11 after radiographic follow-up and five on the basis of biopsy results alone. No osteomyelitis was present at 30 sites, there were seven cases of cellulitis. The sensitivity and specificity of [sup 99m]Tc-HMPAO-LS were 88.4% and 96.6% respectively (23 true-positives, 29 true-negatives, one false-positive, three false-negatives). The accuracy of radiography, [sup 99m]Tc-methylene diphosphonate and HMPAO-LS was 69.6%, 62.5%, and 92.9%, respectively. Follow-up scintigraphy (n = 14) 4 months after initial diagnosis and 1 month after antibiotic withdrawal confirmed cure of osteomyelitis despite the absence of complete clinical regression of the ulcers. In conclusion, [sup 99m]Tc-HMPAO labelled leucocyte scintigraphy was found to be an excellent method for the diagnosis of osteomyelitis in the diabetic foot. It can... [ABSTRACT FROM AUTHOR]

Discusses the use of scintigraphy to determine the location of a lesion rather than to specifically identify the pathologic process. Nuclear medicine imaging techniques as an important adjunct to other used modalities in the evaluation of patients with fever of unknown origin (FUO); Diseases responsible for FUO.