C. Colavolpe

Objective To evaluate the usefulness of 2‐[ 18 F]‐fluoro‐2‐deoxy‐ d ‐glucose–positron emission tomography/computed tomography (FDG‐PET/CT) in IgG4‐related disease (IgG4‐RD) for the staging of the disease and the followup under treatment. Methods All patients included in the French IgG4‐RD registry who underwent ≥1 FDG‐PET/CT scan were included in the study. Clinical, biologic, pathologic, radiologic, and FDG‐PET/CT qualitative and quantitative findings were retrospectively collected and analyzed. Results Twenty‐one patients were included in the study and 46 FDG‐PET/CT examinations were evaluated. At either diagnosis or relapse, all evaluated patients presented abnormal 18 F‐FDG uptake in typical IgG4‐RD localizations. In most cases, FDG‐PET/CT was more sensitive than conventional imaging to detect organ involvement, especially in arteries, salivary glands, and lymph nodes. In few cases (small‐sized lesions and brain or kidney contiguous lesions), false‐negative results were noted. Evaluation before and after treatment showed in most cases a good correlation of FDG‐PET/CT results with treatment response and disease activity. Conclusion This large retrospective study shows that FDG‐PET/CT imaging is useful for the staging of IgG4‐RD. Moreover, FDG‐PET/CT is useful to assess the response to treatment during followup.

Satisfaction is considered a valuable measure of outcome of healthcare processes. Only a few anesthesia-related validated questionnaires are reported. Because their scope is restricted to specific clinical contexts, their use remains limited. The objective of the current study was to develop and validate a self-reported questionnaire, Evaluation du Vecu de l'Anesthesie Generale (EVAN-G), assessing the satisfaction of the perioperative period surrounding general anesthesia.Development of the EVAN-G questionnaire comprised a phase of item generation and a phase of psychometric validation. The patient sample was generated to be proportionally matched to the population of patients undergoing general anesthesia in France. The structure of the questionnaire was identified studying interitem, item-dimension, and interdimension correlations and factor analyses. Data were concurrently gathered to assess external validity. The discriminant validity was determined by comparison of scores across well known patient groups. Reliability was assessed by computation of Cronbach alpha coefficients and by test-retest.Eight hundred seventy-four patients were recruited in eight anesthesia departments. The EVAN-G includes 26 items; six specific scores and one global index score are available. Correlations between EVAN-G scores and other concurrent measures supported convergent validity. The EVAN-G correlated poorly with age, American Society of Anesthesiologists physical status, total anesthesia time, and number of previous anesthesias. Significantly higher satisfaction was reported by patients older than 65 yr, belonging to the laryngeal mask group. Reliability and reproducibility were shown.The EVAN-G adds important information oriented toward patients' perceptions. The authors' approach provides a novel, valid, and reliable tool that may be used in anesthesia practice.

Prognosis of recurrent high-grade glioma (HGG) is poor, although bevacizumab has been documented in that context. This study aimed to determine the independent prognostic value of fluorodeoxyglucose (FDG)-PET on progression-free survival (PFS) and overall survival (OS) of recurrent HGG after combined treatment with bevacizumab and irinotecan, compared with other documented prognostic variables. Twenty-five adult patients with histologically proven HGG were included at recurrence. Brain FDG-PET imaging was performed within 6 weeks of starting chemotherapy with bevacizumab and irinotecan. Response based on MRI was assessed every 2 months according to revised assessment in Neuro-Oncology (RANO) criteria. Median PFS and OS were 4 months (range, 0.9-10.4 months) and 7.2 months (range, 1.2-41.7 months), respectively. At 6 months, PFS and OS rate were 16.0% and 72.0%. FDG uptake was the most powerful predictor of both PFS and OS, using either univariate or multivariate analysis, among all variables tested: histological grade, Karnofsky performance status, steroid intake, and number of previous treatments. Moreover, FDG uptake was also prognostic of response to bevacizumab-based therapy. This study provides the first evidence that pretreatment FDG-PET can serve as an imaging biomarker in recurrent HGG for predicting survival following anti-angiogenic therapy with bevacizumab.

Summary Background 18 F‐DOPA has emerged as a promising tool in the localization of chromaffin‐tissue‐derived tumours. Interestingly, phaeochromocytomas (PHEO) are also FDG avid. Aim and methods The aim of this study was to retrospectively evaluate the results of 18 F‐FDOPA and/or 18 F‐FDG–PET in patients with PHEO and paragangliomas (PGLs) and to compare the outcome of this approach with the traditional therapeutic work‐up. Nine patients with non‐MEN2 related PHEO or PGL were evaluated. At the time of the PET studies, the patients were classified into three groups based on their clinical history, conventional and SPECT imaging. The groups were malignant disease ( n = 5, 1 VHL), apparently unique tumour site in patients with previous surgery ( n = 1, SDHB) and multifocal tumours ( n = 3, 1 VHL, 1 SDHD). 18 F‐FDOPA and 18 F‐FDG–PET PET/CT were then performed in all patients. Results PET successfully identified additional tumour sites in five out of five patients with metastatic disease that had not been identified with SPECT + CI. Whilst tumour tracer uptake varied between patients it exhibited a consistently favourable residence time for delayed acquisitions. 18 F‐FDOPA uptake (SUVmax) was superior to 18 F‐FDG uptake in cases of neck PGL (three patients, four tumours). If only metastatic forms and abdominal PGLs were considered, 18 F‐FDG provided additional information in three cases (two metastatic forms, one multifocal disease with SDHD mutation) compared to 18 F‐FDOPA. Conclusions Our results suggest that tumour staging can be improved by combining 18 F‐FDOPA and 18 F‐FDG in the preoperative work‐up of patients with abdominal and malignant PHEOs. 18 F‐FDOPA is also an effective localization tool for neck PGLs. MIBG however, still has a role in these patients as MIBG and FDOPA images did not completely overlap.

Intravascular large B-cell lymphoma (IVLBCL) remains a diagnostic challenge, because of non-specific findings on clinical, laboratory, and imaging studies. We present a case in which 18F-fluorodeoxyglucose (FDG)-positron emission tomography (PET)/computed tomography was particularly useful to suspect the diagnosis, to detect unexpected locations, to guide contributive biopsy, and to assess the response to treatment. In case of initial negative results, FDG-PET should be repeated in the course of clinical evolution. In the presence of neurological or hormonal symptoms without brain magnetic resonance imaging abnormality, FDG-PET brain slices could depict additional pituitary and/or brain hypermetabolisms. We discuss the potential interests of FDG-PET in IVLBCL by a literature review. Copyright © 2014 John Wiley & Sons, Ltd.

Abstract We report on the case of a 10‐month‐old female infant with a metastatic neuroblastoma which became MIBG‐negative at time of relapse. We discuss the different hypothesis associated with this particular outcome, and the potential utility of FDG‐PET as an alternative to follow up the residual disease at this stage. Pediatr Blood Cancer 2008;51:828–831. © 2008 Wiley‐Liss, Inc.

Functional neuroimaging studies have suggested similar mechanisms underlying antidepressant effects of distinct therapeutics.This study aimed to determine and compare functional brain patterns underlying the antidepressant response of 2 distinct protocols of repetitive transcranial magnetic stimulation (rTMS).99mTc-ECD SPECT was performed before and after rTMS of dorsolateral prefrontal cortex in 61 drug-resistant right-handed patients with major depression, using high frequency (10Hz) left-side stimulation in 33 patients, and low frequency (1Hz) right-side stimulation in 28 patients. Efficiency of rTMS response was defined as at least 50% reduction of the baseline Beck Depression Inventory score. We compared the whole-brain voxel-based brain SPECT changes in perfusion after rTMS, between responders and non-responders in the whole sample (p<0.005, uncorrected), and separately in the subgroup of patients with left- and right-stimulation.Before rTMS, the left- and right-prefrontal stimulation groups did not differ from clinical data and brain SPECT perfusion. rTMS efficiency (evaluated on % of responders) was statistically equivalent in the two groups of patients. In the whole-group of responder patients, a perfusion decrease was found after rTMS, in comparison to non-responders, within the left perirhinal cortex (BA35, BA36). This result was secondarily confirmed separately in the two subgroups, i.e. after either left stimulation (p=0.017) or right stimulation (p<0.001), without significant perfusion differences between these two subgroups.These data show that distinct successful rTMS protocols induce equivalent brain functional changes associated to antidepressive efficiency, consisting to a remote brain limbic activity decrease within the left perirhinal cortex. However, these results will have to be confirmed in a double-blind randomized trial using a sham control group.

To evaluate the role of 18-fluoro-deoxy-d-glucose (FDG)-positron emission tomography (PET) scan for detecting distant metastases in the preoperative assessment of patients with recurrent head and neck squamous cell carcinoma (HNSCC). Retrospective study. University Teaching Hospital. Thirty-seven consecutive patients who presented, between April 2008 and April 2010, a local and/or regional recurrence of head and neck squamous cell carcinoma after treatment with radio-chemotherapy were studied. The work-up included thoraco-abdominal computed tomography (CT), fluoro-deoxy-D-glucose-positron emission tomography scan and abdominal ultrasound. The imaging results, when positive, were compared to histology or cytology (conducted during targeted examinations, for example, fiberoptic oesophago-gastro-duodenal search, colonoscopy, bronchoscopy, liver biopsy) or targeted imaging examination (Abdominal MRI, sonography) combined with clinical follow-up. All patients were followed-up for at least 6 months. Positron emission tomography performances were then analysed and compared with those of conventional imaging for detecting distant metastases. Among the 37 patients, 9 (24%) had visceral metastases. The sensitivity, specificity, positive predictive value and negative predictive value for detecting metastasis or second primary were, respectively, 100%, 94%, 86% and 100% for CT and 92%, 87%, 74% and 97% for positron emission tomography. Computed tomography and positron emission tomography were strictly concordant in 32/37 (86%) of cases. No false-negative result was found for CT, while we found one case of false-negative positron emission tomography. The number of false-positive results was two for CT and four for positron emission tomography. From our study, positron emission tomography does not appear to offer a first-choice technique for the detection of metastases before salvage surgery as CT detected all lesions visible on positron emission tomography.

Identification of the embryologic origin of hyperfunctioning parathyroid adenomas in primary hyperparathyroidism (PHPT) could determine the most suitable approach for minimally invasive surgery.The aim of this study was to prospectively evaluate the reliability of a new, combined protocol for the preoperative localization and determination of the embryologic origin of parathyroid adenomas.Methods: Anterior dual-isotope ( 123 I/ 99m Tcsestamibi) static planar imaging followed by tomoscintigraphy (SPECT acquisition) centered over the 140-keV photopeak (combined protocol) was performed on 35 consecutive patients with sporadic PHPT.On the basis of anatomic considerations, adenomas were classified as superior (P4 derived) if they were located above the isthmus or posterior to the thyroid on SPECT images, despite their apparently middle to inferior position, and as inferior (P3 derived) if the foci were located in inferior and anterior positions or along the thyrothymic tract.Parathyroid ultrasonography was performed on all patients.Results: A total of 36 adenomas were removed: 34 solitary adenomas and 1 double adenoma (for totals of 19 P3-derived and 17 P4-derived adenomas).Pinhole subtraction imaging, SPECT, and ultrasonography sensitivities for detecting adenomas were 86%, 78%, and 77%, respectively.False-positive contralateral images were observed only with ultrasonography (3 cases).Positive SPECT results were associated with higher gland weights.Thirteen glands were identified by SPECT as posterior glands, despite their apparently inferior position, and were removed through an appropriate lateral endoscopic approach.Eleven (85%) of these glands had a P4 origin.Only 2 corresponded to large P3-derived adenomas (.2 g).Conclusion: By reclassifying apparently inferior adenomas as P4derived adenomas prolapsed behind the thyroid gland, SPECT provides information about the most suitable surgical approach for avoiding recurrent laryngeal nerve injury.Additional pinhole images should increase the detection of small adenomas.The combined protocol offers both advantages.

A 19-year-old man with multiple-system injuries including a serious head injury and two poorly tolerated traumatic ventricular septal defects, was admitted to our hospital. Transcatheter closure of the cardiac defects was attempted instead of surgical repair because the required anticoagulation for cardiopulmonary bypass could precipitate intracranial bleeding. The two ventricular septal defects were successfully closed with Amplatzer devices, but the patient remained in hemodynamically unstable condition and subsequently died. Transcatheter closure of traumatic ventricular septal defect is an alternative to surgical repair, although it remains a hazardous procedure and requires experienced anesthesia management.

Red blood cells (RBC) labeled in vivo with (99m)Tc-pertechnetate are used worldwide in nuclear medicine departments.Here, we present a case of (99m)Tc-RBC labeling failure associated with chocolate intake in a 25-y-old woman, resulting in uninterpretable images. Because of this clinical observation, we performed in vitro RBC labeling on blood samples from volunteers after they consumed chocolate.Chocolate intake inhibited the labeling rate, compared with the control condition, and significantly increased the (99m)Tc free fraction (34.1% +/- 11.3% vs. 14.0% +/- 1.2%).We cannot explain how this interaction could occur, but cacao components are known to modulate red cell and plasma oxidoreductive status and to modify red cell membrane permeability and plasticity. Therefore, for patients who can be considered likely to consume chocolate, such as young patients, we recommend that they limit their consumption of chocolate for 12 h before RBC labeling.

To develop and to validate a scale assessing perioperative patient's satisfaction with anaesthesia (Evan).Descriptive and evaluative study.The study included 742 adults undergoing a surgical or a diagnostic procedure under general anaesthesia. Emergency, ambulatory and obstetrical cases were excluded.A multidisciplinary working party produced 85 questions focusing on various pertinent areas describing satisfaction. After a validation, 25 out of them were selected for the questionnaire. The latter was completed within the 24 hours following anaesthesia by 742 inpatients.Item analysis showed a homogeneous distribution of the answers to each item. Main component analysis allowed to explain 53% of total variance. Six dimensions were isolated by the exploratory analysis: anxiety, embarrassment, fear, pain-discomfort, information and physical needs. Scoring method followed a simple additive model: for each dimension, the scale scored 0-100. The global score represented the sum of the six dimensions also scored 0-100. Acceptability of Evan questionnaire was satisfactory, with a spontaneous non response rate of less than 1% and a completion duration at 11 +/- 8 min.A self-completed questionnaire on patient's satisfaction with anaesthetic period was validated, allowing a global and multidimensional assessment of patient's satisfaction.

Residual masses are an important problem in oncology. The determination of their nature (fibrosis or active tumor) is crucial. The place of 18F-fluorodeoxyglucose -positron emitting tomography (PET) as a new imaging device remains to be determined in this context.To evaluate the place of 18F-fluorodeoxyglucose -PET in the prediction of the nature of residual masses in children with solid tumors.Between January 2004 and January 2006, 238 PETs were performed in children followed up in the pediatric oncology and hematology departments. This was a monocentric retrospective review of the medical files of 18 children, in whom the main objective of the PET was to evaluate a residual mass. The sex ratio was 1/5; the median age 100 months (range, 34 to 180 mo). The underlying diseases were Hodgkin disease (n=5), lymphomas (n=5), osteosarcomas (n=3), rhabdomyosarcomas (n=2), and others (n=3). The final diagnostic (remission or persistent disease) was given by follow-up (median, 18 mo; range, 18 to 40), together with clinical, radiologic, and biopsy (in 6 cases) data.PET was negative in 13 cases and positive in 5, among them 4 patients relapsed. Among the 13 negative PETs, there was 1 relapse and 12 remissions. The respective value of PET sensibility and specificity were 0.8 and 0.92, respectively. Positive and negative predictive values were 0.8 and 0.92, respectively.On the basis of these preliminary results, PET seems to be an interesting tool to assess the nature of posttherapeutic residual masses in children, regardless of the underlying malignancy. Its role needs to be confirmed and further explored by multicentric studies tailored according to the underlying disease.

There are no guidelines regarding the content of information to be delivered in nuclear medicine. This study aimed at describing practices of French nuclear medicine physicians concerning results communication to patients undergoing PETs for oncological indications. A survey was performed among French nuclear medicine physicians using an electronic questionnaire. The study included 250 nuclear medicine physicians. Their practices regarding communication of PET results to patients were heterogeneous: (1) pre- and/or post-PET consultations were systematic for 56%, adapted on a case-to-case basis for 35%, and never performed for 9% of respondents; (2) oral communication of results was systematic for 13%, adapted on a case-to-case basis for 63%, and never performed for 24% of respondents. Working in a private center, presence of post-PET consultations, being older and more years of experience were significantly associated with more oral communication of results. Finally, 80% of physicians admit that current recommendations are not clear enough. The heterogeneity of practices among French nuclear medicine physicians concerning communication of PET results to patients probably results from lack of clear recommendations. An inter-collegial, ethical, and multi-disciplinary reflection is needed to better guide nuclear medicine physicians in relation to the communication of results to patients suffering from serious disease. A ce jour, il n’existe pas de recommandations concernant le contenu de l’information à délivrer en médecine nucléaire. L’objectif de notre étude était de décrire les pratiques des médecins nucléaires français concernant la communication des résultats au patient réalisant une TEP pour une indication oncologique. Une enquête a été réalisée auprès des médecins nucléaires français à l’aide d’un questionnaire éléectronique. L’étude a inclus 250 médecins nucléaires. Leurs pratiques vis-à-vis de la communication des résultats de la TEP aux patients étaient hétérogènes : (1) une consultation avant et/ou après la TEP était réalisée systématiquement pour 56 %, au cas par cas pour 35 % et jamais réalisée pour 9 % des répondants ; (2) la communication orale des résultats était systématique pour 13 %, adaptée au cas par cas pour 63 % et jamais réalisée pour 24 % des répondants. Travailler dans un centre privé, réaliser une consultation après la TEP être plus âgé et avoir un nombre d’années d’exercice plus élevé étaient des facteurs significativement associées à une délivrance orale du résultat plus fréquente. Enfin, il apparaît que les recommandations actuelles ne sont pas assez claires pour 80 % des médecins nucléaires. Cette hétérogénéité des pratiques en médecine nucléaire vis-à-vis de la communication des résultats de la TEP résulte probablement du manque de recommandations. Une réflexion collégiale, pluridisciplinaire et éthique reste à mener pour mieux guider les médecins nucléaires vis-à-vis de la communication des résultats aux patients atteints d’une pathologie grave.

Dans le cancer pulmonaire non à petites cellules (CPNPC), le stade IIIAN2 constitue un groupe de patients hétérogène en termes de pronostic et de prise en charge thérapeutique, et l’un des enjeux actuels de la recherche clinique, par le développement récent des traitements multimodalités combinant une induction par chimio- ou radiochimiothérapie, suivie d’une chirurgie en cas de bonne réponse ganglionnaire. La tomographie par émission de positons au [18F]-fluorodésoxyglucose (TEP-FDG) est une technique d’imagerie moléculaire et métabolique, actuellement toujours combinée à un scanner, permettant la complémentarité des informations métaboliques et morphologiques. En oncologie pulmonaire, la TEP-FDG tient actuellement une place prépondérante dans la prise en charge des patients, comme le montrent les différentes indications répertoriées dans les standards options recommandations de la FNCLCC. Son intérêt chez les patients de stade IIIAN2 est moins bien établi. L’objectif des auteurs est de faire un état des lieux sur l’intérêt de la TEP-FDG en oncologie pulmonaire, en se focalisant plus précisément sur cette population à l’ère des traitements multimodalités. Chez les patients IIIAN2, la TEP-FDG est plus performante que l’imagerie morphoradiologique seule pour : la stadification ganglionnaire initiale et métastatique à distance, la restadification ganglionnaire après induction, l’évaluation pronostique, l’évaluation de la réponse au traitement. Patients with clinical stage IIIAN2 non-small cell lung cancer (NSCLC) are a heterogeneous subgroup in term of prognosis and therapeutic management. The optimal management of this patient group is a major focus for thoracic oncology research and the concept of multimodality treatment has recently been introduced. This approach combines induction chemotherapy or radiochemotherapy followed by surgery in the case of mediastinal lymph node down-staging. positron emission tomography computed tomography with [18F]-fluorodesoxyglucose (FDG-PET) is a molecular and metabolic imaging modality which combines the metabolic data of PET with morphological data from CT. FDG-PET has become a standard in lung cancer management since the different indications listed in the standards, options and recommendations (SOR) of the FNCLCC. However, the potential specific importance of FDG-PET in IIIAN2 patients needs to be addressed further. In this setting, the authors’ objective is to review the potential role of metabolic imaging in stage IIIAN2 NSCLC, taking into account new multimodality treatments. In stage IIIAN2, FDG-PET has performed better than morphoradiological imaging for baseline and postinduction lymph node staging, the identification of distant metastasis, and determining prognosis, as well as assessing the response to treatment.

EVALUATING PATIENT SATISFACTION: In France, patient satisfaction is a criteria for health care facility accreditation. In this context, the anesthesia community has studied tools available for assessing satisfaction with anesthesia. LIMITATIONS OF AVAILABLE INSTRUMENTS: The construction of a satisfaction assessment instrument can be divided into three phases: design, sorting items, validation. Instruments available in the currently literature (1987-1997) focus mainly on pre, per- or postoperative management but little on overall patient satisfaction. As the concept of satisfaction concerns a variety of elements, many of the available instruments use a multidimensional approach. The areas explored however vary greatly depending on the author or the study. In addition, patient experience is rarely taken into consideration when designing instruments. FOUR INSTRUMENTS: Among the available instruments we retained 4 questionnaires: Patient Satisfaction with General Anaesthesia, Peri-operative Anesthesia Experience Scale, Iowa Satisfaction with Anesthesia Scale, and Amerstadam Preoperative Anxiety and Information Scale. These last 2 scales only assess patient information and anxiety. The Peri-operative Anesthesia Experience Scale alone is available in French (Echelle de Vécu périopératoire de l'Anesthésie). Patient satisfaction is also approached with specialized instruments designed to assess specific items. The most widely used scales assess anxiety and pain. Based on these findings, it is dear that the fundamental concept of patient satisfaction must be revisited. We propose a few points for thought.

2080 Background: The prognostic value of positron emission tomography with [18F]-fluoro-2-deoxy-D-glucose (FDG-PET) has been previously reported in high-grade gliomas (HGG) with inconstant results using different statistical methods in nonhomogeneous population. Indeed, most of these studies are based on univariate or limited multivariate analysis, not including all consensual prognostics factors. The objective of this study was to determine the independent prognostic value of pretherapeutic FDG-PET on overall (OS) and event-free survival (EFS) in HGG. Methods: We retrospectively included 41 histologically-proven HGG: 31 glioblastomas multiforme, WHO grade IV (GBM) and 10 anaplasic gliomas, WHO grade III (AG). Pretherapeutic FDG-PET was performed on hybrid PET/computerized tomography. The uptake of FDG was assessed by a five visual-step metabolic grading (MG), and the ratio between tumour and controlateral maximal standardized uptake value (T/CL). OS and EFS following PET were determined by Kaplan-Meier analysis and correlated with FDG uptake by univariate and multivariate analysis (MVA) using log-rank test and Cox Regression. MVA included FDG uptake, age, Karnofsky performance status (KPS), extend of surgery, histologic grade (HG), and first-line chemotherapy in GBM. A second MVA was performed with FDG uptake and RPA (recursive partitioning analysis) classification of the RTOG. Results: Median OS and EFS of were respectively 18.4 and 9.2 months, significantly higher for AG than GBM (respectively p=0.040 and p=0.027). MG was nearly correlated with OS in the whole group and in the GBM (respectively p=0.077 and 0.059). T/CL ratio was significantly correlated with OS (p=0.003) and nearly significantly with EFS (p=0.052), independently from age, KPS, histological grade, surgery and RPA classification. In GBMs subgroup, T/CL ratio still predicted OS (p=0.018), independently from age, KPS, surgery, RPA classification and 1st-line chemotherapy. Conclusions: On preoperative FDG-PET, the ratio between tumour and controlateral uptake can provide additional prognostic information in the management of HGG, independently from consensual prognostic factors. No significant financial relationships to disclose.

To analyse current data on use of neuromuscular blocking agents (NBA) in the intensive therapy unit (ITU) patients and to propose practice guidelines.We did a Medline search of French and English language articles on NBA administration in ITU patients from 1960 to 1998. Data were also selected from our own collection of articles and books.Original articles, clinical cases, letters to the editor and review articles were considered.Data on pharmacology of NBA in the ITU patient were extracted, as well as data on administration patterns and cost.The indications for myorelaxation in ITU patients include either short term use, as in anaesthesia, or long term administration for facilitation of mechanical ventilation, control of increased intracranial pressure, status epilepticus, tetanus and oxygen demand in case of muscular hyperactivity, diagnostic and therapeutic procedures facilitation. A beneficial effect of NBA on the prognosis of the disease for which these agents have been used is not yet proven. Suxamethonium, because for its short onset time and duration of action, is the agent of choice for endotracheal intubation if myorelaxation is required. Among the benzylisoquinolines, atracurium and besilate of cisatracurium are convenient agents in ITU patients, whereas mivacurium is of no special interest. Among the aminosteroids, pancuronium and vecuronium are the most often used agents in the ITU. Rocuronium has not yet been extensively assessed. Myorelaxants carry risks for morbidity and mortality. The difficulty to assess the neurological status and the level of sedation is a recognised adverse effect. An accidental disconnection from the circuit and the resulting asphyxia is nowadays recognised without delay by the ventilator. NBAs increase the rate of bronchopulmonary infections. Cardiovascular complications include extreme bradycardia or sinus arrest following vecuronium administration, and cardiac arrest after suxamethonium injection mainly in burned or traumatised patients. Conversely to anaesthesia, NBAs do not carry a significant risk for anaphylactic or anaphylactoid complications in the ITU. Tachyphylaxis occurs mainly in burns and other pathologies modifying acetylcholine receptors. Neuromuscular complications include myopathy from steroids, postparalytic syndrome, deconditioning syndrome and intensive care polyneuropathy. Prolonged curarisation after discontinuation of NBA administration has a multifactorial origin and must be differentiated from neuromuscular complications. For prolonged neuromuscular blockade, pancuronium, vecuronium and atracurium are the agents of choice. The association with an adequate sedation is essential. Assessment of depth of neuromuscular blockade is not based on clinical symptoms but on train-of-four (TOF) twitch monitoring. A convenient basic relaxation is usually obtained with the suppression of the two last responses to TOF.The use of NBA in ITU patient should result from a rational decision making procedure, the blockade titrated with a TOF monitor and maintained as superficially and shortly as possible.

Intrapulmonary occult bleeding is a serious complication of anticoagulants. Diagnostic difficulties are such that this complication is rarely described: 8 cases in the literature. The authors report two new cases. In both of these patients oral anticoagulant therapy resulted in a severe haemorrhagic syndrome on a clinical (melaena and/or epistaxis) and laboratory (haemoglobin less than 9 g/100 ml and prothrombin time less than 10 p. 100) basis. After a period of 24 to 48 hours, an acute respiratory distress syndrome developed. There was dyspnoea without major haemoptysis, a hypoxia/hypercapnia syndrome and, by X-ray, the rapid development of a diffuse micronodular miliary picture. The diagnosis of intrapulmonary occult bleeding was based upon fibroscopy with bronchoalveolar lavage (BAL) showing the pathological presence of large numbers of alveolar siderophages. However, the worsening of hypoxia brought about by bronchoalveolar lavage is such that careful consideration must be taken before the technique is used. Intrapulmonary occult bleeding must therefore be borne in mind in the presence of an imbalance in anticoagulant treatment complicated by respiratory distress and a reticulonodular radiological appearance.

La TEP/TDM au 18F-FDG est un examen largement utilisé dans l’évaluation des pathologies du thorax dans des indications aussi diverses que l’oncologie et, en particulier, l’évaluation du nodule pulmonaire, les affections médiastinales, les lésions mammaires, ou bien encore la pathologie cardiaque et l’étude des valves ainsi que la paroi thoracique. Un certain nombre de précautions sont nécessaires à la bonne réalisation de l’examen et une prudence quant à l’interprétation de l’examen est de mise, étant donné les pièges et artéfacts inhérents à la technique, aux mouvements respiratoires et cardiaques, à la présentation parfois trompeuse des lésions (faux négatifs [FN] ou faux positifs [FP]) ou altérée par le traitement. La connaissance de ces pièges et artéfacts permet de minimiser leur impact sur l’interprétation, d’éviter le recours à des compléments d’investigations parfois invasifs ou l’administration d’un traitement inadapté, voire délétère. Le présent article vise à décrire les pièges et artéfacts rencontrés couramment dans la région thoracique, mais également à exposer les différentes précautions pouvant permettre la réalisation de l’examen, l’interprétation et par la même la prise en charge optimale du patient. PET/CT with 18F-FDG is a test widely used in the evaluation of chest diseases as diverse as oncology indications and in particular the evaluation of pulmonary nodules, mediastinal disorders of the chest wall, breast lesions or even heart diseases including those of infectious valves. Despite the many precautions taken to the successful completion of the examination, a caution of the interpretation of the exam is required, given the pitfalls and artifacts inherent to the technique, respiratory and cardiac movements, the misrepresentation lesions (false positives of false negatives) or altered by the treatment. Their knowledge can minimize their impact on the interpretations and avoid the use of supplements investigations, sometimes invasive, or worse, administering a noxious or inappropriate treatment. The purpose of this paper is to describe the pitfalls and artifacts of PET/CT with 18F-FDG commonly found in the thoracic region but also to expose the various precautions that can help the conduct of the exam, the interpretation and even the optimal patient management.

L’information du patient en France est encadrée par des obligations réglementaires et non réglementaires qui sont toutefois très générales. Aucun consensus n’existe sur le contenu de l’information à délivrer, notamment tenant compte des singularités de chaque spécialité. La relation médecin nucléaire-malade étant très spécifique : comment délivrer alors à un patient d’oncologie (situation fréquente et très délicate), lors d’une consultation unique et rapide, le résultat d’un examen déterminant pour la suite de sa prise en charge, qui peut constituer une mauvaise nouvelle ? L’objectif de notre étude a été d’étudier les pratiques des médecins nucléaires français concernant l’information délivrée au patient réalisant une TEP d’indication oncologique, en particulier sur le résultat de l’examen. Nous avons inclus prospectivement les médecins nucléaires et internes de 3e et 4e année français ayant répondu à notre questionnaire anonyme qui a été adressé par courrier électronique (via les mailing listes de la SFMN et de l’ACOMEN) entre le 25 juin et le 20 juillet 2015. Il est le premier questionnaire français traitant de l’information au patient d’oncologie dans sa globalité. Il comportait 4 parties et 28 questions : description des caractéristiques socio-démographiques du médecin nucléaire répondant, pratiques habituelles des médecins nucléaires français vis-à-vis de la consultation et de la délivrance des résultats avant et/ou après une TEP oncologique, volet éthique (mensonge et dissimulation d’information…) et stratégies proposées pour améliorer les recommandations actuelles. Deux cent cinquante médecins nucléaires et internes ont été inclus (taux de réponse de 31,3 %). Leurs pratiques apparaissent très hétérogènes. Concernant la consultation, si 56 % des médecins voient les patients systématiquement, 35 % adaptent leur attitude au cas par cas et 9 % ne les voient jamais. Concernant la délivrance orale du résultat, 63 % des médecins adaptent leur attitude au cas par cas, 24 % ne le donnent jamais et 13 % le délivrent toujours. Les déterminants influençant l’annonce du résultat (analyse multivariée) sont : un âge (p = 0,002) et un nombre d’années d’exercice plus élevés (p = 0,001) du médecin, l’exercice en centre privé (p = 0,033) et la pratique d’une consultation après la TEP (p > 0,001). Il apparaît que les recommandations actuelles ne sont pas assez claires pour 80 % des médecins. Cette hétérogénéité des pratiques résulte probablement du fait qu’actuellement aucune conduite à tenir claire n’est établie pour les médecins nucléaires qui prendrait en compte les particularités de leur relation avec les malades. Ainsi, une réflexion collégiale, pluridisciplinaire et éthique reste à mener pour clarifier leur rôle dans l’information de patients atteints d’une pathologie grave.

2078 Background: Mutations in the gene encoding isocitrate dehydrogenase enzyme isoforms 1 (IDH1) and 2 (IDH2) have recently been identified in a large proportion of glial tumors of the CNS, but their mechanistic role in tumor development and progression remains unclear. Here, we assessed the actual impact of IDH1 and IDH2 mutations in patients harboring WHO grade 2 and 3 gliomas. Methods: We sequenced IDH1 at codon 132 and IDH2 at codon 172 in 34 patients with WHO grade 2 and 3 gliomas who benefited from a preoperative 18F-FDG positron emission tomography (PET). Immunohistochemical expression of Hypoxia Inducible Factor alpha (HIF-1 a), Carbonic Anhydrase IX (CAIX) and Glucose Transporter 1 (GLUT1) along with the R132HIDH1 mutation was assessed in all cases as well as 1p19q deletion status and p53 expression. Results: HIF-1α expression was found in 15% of IDH-mutated compared to 14.3% of IDH-nonmutated tumors (P=0.954). Also, GLUT-1 positive staining was found in 5.% of IDH-mutated and in 7.1% of IDH-nonmutated tumors (P=0.794). Finally, CA-IX expression was found in 15% of IDH-mutated and in 7.1% of IDH-nonmutated tumors (P=0.484). The combined expression of these three hypoxic markers was found in 2 WHO grade 3 tumors, one of which was IDH-mutated whereas the other was IDH-nonmutated (P=0.794). In IDH-mutated tumors, the median SUVmax ratio was 2.24 vs. 2.15 in IDH-nonmutated tumors (P=0.775). Conclusions: Together, these data suggest the absence of correlation between IDH mutation status and in vivo hypoxic biomarkers expression in WHO grade 2 and 3 gliomas.

to determine whether [18F]2-fluoro-2-deoxyglucose (FDG) positron emission tomography and X-ray computed tomography (PET/CT) findings and metabolic parameters before combined chemo- and radiotherapy (CRT) have a prognostic value in patients with anal carcinoma.45 patients with anal cancer who underwent pre-treatment FDG-PET/CT were included. Metabolic parameters, recurrence and anal carcinoma specific survival were analyzed.SUV max and metabolic volume of the primary tumour were significantly higher in patients with lymph node or distant metastases than in those with locally confined disease (p = 0.020 and p = 0.015, respectively). The extent of disease (local tumour only, lymph node or distant metastases) was highly predictive of both for recurrence free and disease specific survival (p = 0.010 and p < 0.001, respectively). Recurrence free (p = 0.010) and anal carcinoma specific survival (p = 0.006) differed significantly between patients with a metabolic volume ≤45 ml and >45 ml. Multivariate analysis revealed that a metabolic volume >45 ml was the only significant independent determinant (p = 0.19) for recurrence free survival whereas for anal carcinoma specific survival the extent of disease was identified as the only significant independent determinant (p = 0.002).the extent of disease on FDG PET/CT before combined radio-chemotherapy is strongly predictive of prognosis in anal cancer. Furthermore, patients with a large metabolic volume of the primary tumour (>45 ml) are at significantly higher risk of recurrence.

Transparent exo-polymeric particles (TEP) have been associated with the aggregation of diatoms. Comparisons of TEP concentrations to those of conventionally-determined particles during a mesocosm experiment show that particles larger than about 30 μm had concentrations very similar to, if not the same as, those of conventionally-determined particles. Smaller TEP were present mostly at concentrations less than those of non-TEP. Furthermore, their relative concentrations decreased over the course of the experiment. These comparisons suggest that the dominant interaction of TEP with algae in marine snow formation is to affect general particle stickiness rather than to aggregate by themselves.

Les récidives des cancers des voies aérodigestives supérieures (VADS) sont fréquentes, précoces et de mauvais pronostic. La surveillance post-thérapeutique a pour but de détecter une récidive le plus précocement possible pour pouvoir réaliser un traitement de rattrapage à visée curative. Les patients les plus à risque sont les cancers localement avancés. L’imagerie morphologique – scanner et imagerie par résonance magnétique (IRM) – peut parfois être limitée par les remaniements liés à la chirurgie et à la radiothérapie et ne permet pas toujours un diagnostic précoce. L’histologie pose le problème de sa morbidité en tissu irradié et du biais d’échantillonnage. La tomographie d’émission de positons (TEP) au 18F-fluoro-déoxy-glucose (FDG) a des performances supérieures aux techniques conventionnelles pour la recherche et la stadification d’une récidive, d’autant plus qu’elle est réalisée à trois mois de la fin des traitements. Sa sensibilité et sa valeur prédictive négative sont excellentes et permettent d’éviter des explorations multiples et invasives en cas de TEP-FDG négative. Au contraire, sa spécificité et sa valeur prédictive positive relativement limitées nécessitent de poursuivre les investigations en cas d’examen positif, pour éliminer les faux positifs. Dans le diagnostic de récidive, la TEP-FDG a un maximum d’impact sur la prise en charge et constitue un « standard ». En revanche, la réalisation d’une TEP-FDG systématique de surveillance n’est pas encore validée. Elle est recommandée dans les cas difficiles et dans le cadre de protocoles d’évaluation. Recurrence of head and neck squamous cell carcinomas occurs early and currently, with poor prognosis. Post-therapeutic surveillance aims to diagnose a recurrence as early as possible in order to perform curative salvage therapy. The risk of recurrence is highest in locally advanced cancers. Morphological imaging, including Computed Tomography (CT Scan) and magnetic resonance imaging, can be limited by the anatomic changes following surgery and radiotherapy, and sometimes cannot provide early diagnosis of recurrence. Histology presents some risk of morbidity, especially in irradiated tissues, and sampling error. Positron Emission Tomography (PET) with 18F-fluorodeoxyglucose (FDG) is superior to conventional imaging for the diagnosis and staging of recurrence, especially when it is performed three months after the end of treatments. FDG-PET has high sensitivity and negative predictive value for recurrence, so that further morphological and invasive investigations should not be performed in case of negative examination. On the other hand, because of its limited specificity and positive predictive value, any positive PET finding should be documented, in order to avoid false positives findings. The diagnosis of recurrence is the field of application in which FDP-PET has the greatest impact on head and neck cancer management: it is considered as a standard. However, the interest of FDG-PET during systematic follow-up has not yet been confirmed. PET should only be performed in difficult cases and within evaluation protocols.

The pulmonary venous admixture, Pa02, and pulmonary and systemic haemodynamics were studied in six mongrel dogs during infusion of dobutamine (infusion rate 7.5 μg · kg−1 · min−1) dopamine (7.5 μg · kg−1 ⇒ min−1) and isoproterenol (0.1 μg · kg−1 · min−1. Anaesthesia was performed by a single injection of Fentanyl (0.35 mg/kg). The carbon dioxide tension and produced a significant change in pulmonary arterial pressure from an average of 1.2 ± 0.4 kPa to 1.6 ± 0.2 kPa (P < 0.05). There was no significant change in pulmonary venous admixture or in Pa02. There was no significant change in systemic haemodynamics with any of the three drugs. The use of catecholamines in dogs with healthy lungs does not induce any development in pulmonary venous admixture when haemodynamics are unchanged. Changes in these variables are dependent upon changes in pulmonary blood flow rather than being direct effects of the catecholamine.

Cimetidine and theophylline were given together to a 67 year old chronic bronchitic post-operatively: the patient became very confused, shook of all his limbs, vomited, and presented a tachycardia. The greater than normal blood levels of theophylline (27.8 mg . 1(-1) confirmed its involvement in this clinical state. But, as there was no real overdose, the simultaneous administration of cimetidine was probably responsible for inducing this state. Three days after stopping this treatment, the disorder had completely disappeared.

Pulmonary complications remain the most frequent of postoperative complications (32-60), especially after upper abdominal surgery (14-41). Chronic respiratory insufficiency (80) also continues to be a major risk factor, in spite of the progress made in both anesthesiology and postoperative care. In the immediate postoperative period, weaning from mechanical ventilation is one of the most dangerous phases of anesthesia (84). We discuss the importance of weaning procedures, in particular, in patients with a high risk of pulmonary complications.

Branched chain amino acid enriched solutions have been proposed in several situations. The fate of the nitrogen contained in those amino acids, particularly the immediate urinary excretion, has not been established yet. In the present study, the rates of urea and total urinary nitrogen loss from 15N leucine were measured in a patient receiving a branched chain amino acid enriched solution. The results showed that: 1) the urinary excretion of leucine represented less than 1% of the amount of injected leucine; 2) 15N excreted from leucine was 5.37% of the 15N injected during the 24 h of the infusion and 7.66% during the following day; 3) the excretion of 15N urea represented 62% of the total 15N excreted during the first 24 h and 72% for the following day. Finally, in this patient, the amount of nitrogen from leucine immediately excreted in the urine was moderate.

Afin de valider un bilan préopératoire minimum, 30 patients ont bénéficié d'explorations ventilatoires réalisées selon une double modalité : d'une part en laboratoire au cours d'épreuves fonctionnelles respiratoires classiques, d'autre part au lit grâce à un spiromètre portable, permettant les mesures de la capacité vitale (VC), du volume expiré maximum-seconde (FEV1) du rapport FEV1/VC et du débit de pointe (PEF). La corrélation entre les deux séries de mesure de VC et FEV1 est étroite et hautement significative (p <0,001), permettant de considérer comme fiables ces deux paramètres lorsqu'ils sont recueillis au lit. En revanche, la sensibilité du rapport FEV1/VC est moindre, puisque chez 3 des 30 patients la signification accordée à ce paramètre (normale >70 %) est différente selon qu'il a été déterminé au lit ou au laboratoire et sans que l'analyse ultérieure permette de conclure à la supériorité de l'une ou l'autre des deux méthodes. Les valeurs de PEF n'ont été recueillies qu'au lit, et il n'a pas été établi de comparaison statistique. Cependant la prise en compte de ce dernier paramètre s'avère utile pour diagnostiquer à partir du bilan simplifié un syndrome obstructif. Le spiromètre portable semble donc un moyen simple et fiable de premier diagnostic d'une anomalie ventilatoire, de son type (obstructif ou restrictif) et de sa gravité. A simplified preoperative respiratory assessment was carried out in order to assess the reliability of a pocket-sized spirometer. 30 patients were each tested using two methods : 1) the traditional extensive laboratory lung function tests and 2) a bedside test using a pocket-sized spirometer, which measured the vital capacity (VC), the forced expiratory volume in 1 second (FEV1), the peakflow (PEF) and the ratio of FEV1 to VC. The correlation between the two series of VC and FEV1 meeasurements was highly significant (p<0.001). Therefore, these two parameters could be considered as reliable when testing was performed at the bedside. However, the sensitivity of the FEV1/VC ratio was decreased; in three of the patients, the significance of this third parameter was not the same with the two methods. Measurements of peakflow were only collected at the bedside, and a statistical comparison was not established. Analysis of this last parameter always allowed us to confirm or not an obstructive syndrome when the values of FEV1 or FEV1/VC were in disagreement. The pocket-sized spirometer would seem to be a simple and reliable means of diagnosing respiratory insufficiency, its type (obstructive or restrictive) and its seriousness.

Blinatumomab, a new bispecific CD19/CD3 T-cell engager antibody, has been shown to improve the outcome in patients with relapsed and/or refractory B-cell acute lymphoblastic leukemia (R/R ALL) comp...

Diagnostic d’une masse tissulaire du rein : donner les principaux groupes anatomo-pathologiques et leur fréquence. Donner une approche diagnostique d’une masse tissulaire rénale en échographie, TDM et IRM. Préciser la stratégie pré-thérapeutique en imagerie en fonction du terrain et du type de lésion rénale.

Si l'importance de la formation médicale continue est reconnue, ses modalités restent l'objet de discussions. Afin de pouvoir disposer d'informations sur les souhaits et les difficultés rencontrés par les médecins anesthésistes-réanimateurs, le Comité Education de la Société Française d'Anesthésie et de Réanimation a réalisé une enquête à l'aide d'un questionnaire adressé à 7 000 médecins anesthésistes-réanimateurs. Le taux de réponse a été d'environ 10 %. En termes d'âge, de sexe, de mode d'exercice et d'ancienneté dans la spécialité, la population des répondeurs est représentative de celle des anesthésistes-réanimateurs exerçant en France. Cette enquête paraît exprimer une forte motivation vis-à-vis de la formation médicale continue, des souhaits de stages pratiques, de séances regroupées sur deux jours ou plus, et d'autoévaluation. Le financement et les difficultés de remplacement, qui représentent les principaux obstacles rencontrés par les anesthésistes-réanimateurs, limitent l'accès à la formation médicale continue. Although the importance of continuing medical education (CME) is a recognized fact, its modalities are still a controversial matter. In order to obtain informations on the demands and the difficulties to which French anaesthetist (AN) are faced with, the Committee for Education of the French Society of Anaesthesia (SFAR) carried out an inquiry with a questionnaire circulated to 7000 AN. The rate of answers was about 10 %. With regard to age, gender, mode of activity and length of service in the speciality, the group of responders was representative of the French population of AN. The inquiry seems to demonstrate a strong motivation for CME, as well as demands for training courses, courses extending over two days or more, and a self-assessment. The funding of the expenses as well as the difficulties to obtain a locum tenens were the two main obstacles which limited the access to CME.

A protocol of repeated I. V. injections of flunitrazepam was constructed by mathematical simulation on the basis of pharmacokinetic data obtained from single intravenous injections given to healthy subjects. This protocol would given serum blood levels equal to 15 ng . ml-1, rapidly and compatible with long term artificial ventilation, thanks to the pharmacological action of flunitrazepam. Four patients in the ICU benefited from this protocol. The levels desired were not reached but in two cases out of four it was possible to continue artificial ventilation without the addition of any other drug. Furthermore it was possible to show that the three compartment model developed from healthy subjects remains valid in pathological circumstances. A second protocol based on pharmacokinetic data from four patients should allow us to obtain the objective aimed at.

In order to determine the impact of intraoperative autotransfusion on vascular surgical care, data related to 200 abdominal aortic surgical operations performed over a 20 months period were prospectively analysed. Volumes of blood salvaged and transfused during and after each operation were considered. One hundred and twenty one patients had an intraoperative autologous transfusion at a mean volume of 616 +/- 410 ml. Among them, 36 patients (43%) had only their own autotransfused blood and no other homologous blood components were required. Rapid autotransfusion was associated neither with significant haemolysis, nor with coagulopathy. Neither mortality nor morbidity was related to intraoperative autotransfusion. These data suggest that intraoperative autotransfusion is a safe replacement method in major vascular surgery. The procedure should be used in conjunction with preoperative donations when feasible.