Functional stress imaging to predict abnormal coronary fractional flow reserve: the PACIFIC 2 study.

AIMS: The diagnostic performance of non-invasive imaging in patients with prior coronary artery disease (CAD) has not been tested in prospective head-to-head comparative studies. The aim of this study was to compare the diagnostic performance of qualitative single-photon emission computed tomography (SPECT), quantitative positron emission tomography (PET), and qualitative magnetic resonance imaging (MRI) in patients with a prior myocardial infarction (MI) or percutaneous coronary intervention (PCI). METHODS AND RESULTS: In this prospective clinical study, all patients with prior MI and/or PCI and new symptoms of ischaemic CAD underwent 99mTc-tetrofosmin SPECT, [15O]H2O PET, and MRI, followed by invasive coronary angiography with fractional flow reserve (FFR) in all coronary arteries. All modalities were interpreted by core laboratories. Haemodynamically significant CAD was defined by at least one coronary artery with an FFR ≤0.80. Among the 189 enrolled patients, 63% had significant CAD. Sensitivity was 67% (95% confidence interval 58-76%) for SPECT, 81% (72-87%) for PET, and 66% (56-75%) for MRI. Specificity was 61% (48-72%) for SPECT, 65% (53-76%) for PET, and 62% (49-74%) for MRI. Sensitivity of PET was higher than SPECT (P = 0.016) and MRI (P = 0.014), whereas specificity did not differ among the modalities. Diagnostic accuracy for PET (75%, 68-81%) did not statistically differ from SPECT (65%, 58-72%, P = 0.03) and MRI (64%, 57-72%, P = 0.052). Using FFR < 0.75 as a reference, accuracies increased to 69% (SPECT), 79% (PET), and 71% (MRI). CONCLUSION: In this prospective head-to-head comparative study, SPECT, PET, and MRI did not show a significantly different accuracy for diagnosing FFR defined significant CAD in patients with prior PCI and/or MI. Overall diagnostic performances, however, were discouraging and the additive value of non-invasive imaging in this high-risk population is questionable.

Vancomycin-Resistant Enterococci in Patients Attending for Colonoscopy: An Estimate of Community Prevalence.

Aims Ireland has the highest vancomycin-resistant Enterococcus faecium (VRE) bloodstream infection prevalence in Europe. Two patterns of VRE carriage are recognised. European, with widespread community prevalence and North American, where carriage is predominantly nosocomial. It is unclear which pattern is dominant in Ireland. This uncertainty limits infection control measures. This study sought to explore this issue via a cross sectional point prevalence study. Methods Asymptomatic community volunteers, represented by patients undergoing elective outpatient colonoscopy testing, were opportunistically screened for VRE. Demographic and risk factor data were collected via a patient survey. Rectal swabs were collected before colonoscopy and VRE was identified using the VITEK MS system. Results 102 patients were cultured. A single patient tested positive, representing a prevalence rate of 0.98% (95% CI <0.01-5.8%). This patient demonstrated traditional risk factors, suggesting nosocomial rather than community acquisition. 94% (N=94) of patients had no knowledge of VRE, while 83% (N=83) had low levels of concern regarding hospital acquired infections. Conclusion There is a low incidence of VRE in the Irish community setting, in contrast to other European Countries, suggesting asymptomatic community colonization is not responsible for the high rates of VRE seen in Ireland. Wider screening or atypical infection control measures would not be supported by this data.

Hybrid solid-state SPECT/CT left atrial innervation imaging for identification of left atrial ganglionated plexi: Technique and validation in patients with atrial fibrillation.

BACKGROUND: Ablating left atrial (LA) ganglionated plexi (GP), identified invasively by high-frequency stimulation (HFS) during pulmonary vein isolation (PVI), may reduce atrial fibrillation (AF) recurrence. 123I-metaiodobenzylguanidine (123I-mIBG) solid-state SPECT LA innervation imaging (LAII) has the spatial resolution to detect LAGP non-invasively but this has never been demonstrated in clinical practice. METHODS: 20 prospective patients with paroxysmal AF scheduled for PVI underwent 123I-mIBG LAII. High-resolution tomograms, reconstructed where possible using cardiorespiratory gating, were co-registered with pre-PVI cardiac CT. Location and reader confidence (1 [low] to 3 [high]) in discrete 123I-mIBG LA uptake areas (DUAs) were recorded and correlated with HFS. RESULTS: A total of 73 DUAs were identified, of which 59 (81%) were HFS positive (HFS +). HFS + likelihood increased with reader confidence (92% [score 3]). 64% of HFS-negative DUAs occurred over the lateral and inferior LA. Cardiorespiratory gating reduced the number of DUAs per patient (4 vs 7, P = .001) but improved: HFS + predictive value (76% vs 49%); reader confidence (2 vs 1, P = .02); and inter-observer, intra-observer, and inter-study agreement (κ = 0.84 vs 0.68; 0.82 vs 0.74; 0.64 vs 0.53 respectively). CONCLUSIONS: 123I-mIBG SPECT/CT LAII accurately and reproducibly identifies GPs verified by HFS, particularly when reconstructed with cardiorespiratory gating.

Telephone Follow-Up of Mild Traumatic Brain Injury; A Feasibility Study

Background This study investigates the prevalence of Post-Concussion Syndrome (PCS) one-year post-injury in patients that were treated for Mild Traumatic Brain Injury (mTBI) in the Clinical Decision Unit (CDU) of Cork University Hospital's (CUH) Emergency Department. Methods Adults treated for mTBI in 2013 completed a telephone questionnaire comprising the Rivermead Post Concussion Symptoms Questionnaire (RPQ), the Short Form 12 (SF-12), and the EuroQol Health Outcome Assessment Tool (EQ5D5L). Results There were 112 patients identified. Of these, 57 (51%) were successfully contacted. The median age was 40 (IQR 27.5 ­ 57.5) and 58% were male. The most common mechanism of injury was a mechanical fall (28%). PCS of at least mild severity was present in 12 (21%). Overall, females tended to have worse outcomes (mean Physical Function score; males: females, 97.7: 76; p < 0.004). Conclusions mTBI patients continue to suffer from PCS at one-year post-injury and females had a worse physical function outcome.

Automated SPECT analysis compared with expert visual scoring for the detection of FFR-defined coronary artery disease.

PURPOSE: Traditionally, interpretation of myocardial perfusion imaging (MPI) is based on visual assessment. Computer-based automated analysis might be a simple alternative obviating the need for extensive reading experience. Therefore, the aim of the present study was to compare the diagnostic performance of automated analysis with that of expert visual reading for the detection of obstructive coronary artery disease (CAD). METHODS: 206 Patients (64% men, age 58.2 ± 8.7 years) with suspected CAD were included prospectively. All patients underwent 99mTc-tetrofosmin single-photon emission computed tomography (SPECT) and invasive coronary angiography with fractional flow reserve (FFR) measurements. Non-corrected (NC) and attenuation-corrected (AC) SPECT images were analyzed both visually as well as automatically by commercially available SPECT software. Automated analysis comprised a segmental summed stress score (SSS), summed difference score (SDS), stress total perfusion deficit (S-TPD), and ischemic total perfusion deficit (I-TPD), representing the extent and severity of hypoperfused myocardium. Subsequently, software was optimized with an institutional normal database and thresholds. Diagnostic performances of automated and visual analysis were compared taking FFR as a reference. RESULTS: Sensitivity did not differ significantly between visual reading and most automated scoring parameters, except for SDS, which was significantly higher than visual assessment (p < 0.001). Specificity, however, was significantly higher for visual reading than for any of the automated scores (p < 0.001 for all). Diagnostic accuracy was significantly higher for visual scoring (77.2%) than for all NC images scores (p < 0.05), but not compared with SSS AC and S-TPD AC (69.8% and 71.2%, p = 0.063 and p = 0.134). After optimization of the automated software, diagnostic accuracies were similar for visual (73.8%) and automated analysis. Among the automated parameters, S-TPD AC showed the highest accuracy (73.5%). CONCLUSION: Automated analysis of myocardial perfusion SPECT can be as accurate as visual interpretation by an expert reader in detecting significant CAD defined by FFR.

The contribution of dogs and other animals to social inclusion programmes. / Contribución de los perros y otros animales en programas destinados a la inclusión social.

Animal-assisted interventions refer to any intervention that intentionally includes or incorporates animals as part of a therapeutic, palliative, educational, psychoeducational or recreational process or milieu. The Faculty of Veterinary Science of the University of Buenos Aires began work on this issue in 1996 and gradually incorporated outreach, research and teaching projects, undertaking several stages of institutionalisation and reconceptionalisation that led, in 2014, to the creation of an open chair in animal-assisted interventions. This article aims to introduce the discipline, with special emphasis on its potential as a means of promoting inclusion, and to present a specific case of work with dogs, which began in 2009 with the non-profit organisation Senderos del Sembrador (Trails of the Sower) for people with an intellectual disability who are in great need of support. This article describes how the contact with dogs was systematised, along with outcomes, challenges and difficulties, and how leisure came to be used as a means of promoting inclusion and altering the preconceptions of people without disabilities. Finally, in reflecting on practices, the project evolved from a treatment plan for rehabilitating people with disabilities into a space for effective social inclusion that gradually changed the perceptions and practices of all participants.

Les interventions assistées par des animaux désignent toute intervention intégrant de manière intentionnelle des animaux en tant qu'acteurs au sein d'un processus thérapeutique, palliatif, pédagogique, psycho-éducatif, ludique ou environnemental. La faculté des Sciences vétérinaires de l'université de Buenos Aires a commencé à explorer ce domaine dès 1996, en y ajoutant progressivement des projets d'application locale, de recherche et d'enseignement qui ont connu plusieurs phases successives d'institutionnalisation et de conceptualisation avant d'aboutir en 2014 à la création d'une chaire autonome d'interventions assistées par l'animal. Après avoir introduit cette discipline en mettant un accent particulier sur ses perspectives en tant que facteur d'inclusion, les auteurs décrivent une expérience concrète d'interventions menées depuis 2009 avec des chiens auprès d'une association de la société civile (« Senderos del Sembrador ¼) qui s'occupe de personnes ayant des déficiences intellectuelles et qui ont un grand besoin d'aide. Les auteurs expliquent le recours systématique à ce contact, ainsi que ses résultats, ses enjeux et ses difficultés, et l'utilisation des loisirs comme facteur d'inclusion parallèlement à la lutte contre les préjugés chez les personnes non handicapées. Enfin, à travers les ateliers proposés, ce projet a constitué une authentique proposition thérapeutique qui a donné aux personnes handicapées les outils nécessaires pour constituer un espace d'inclusion sociale efficace, qui a progressivement transformé les conceptions et les pratiques de tous les participants.

Las intervenciones asistidas con animales son cualquier intervención que intencionalmente incluya o incorpore animales como parte de un proceso terapéutico, paliativo, pedagógico, psicoeducativo, lúdico o ambiental. La Facultad de Ciencias Veterinarias de la Universidad de Buenos Aires comenzó a trabajar en este tema en 1996, e incorporó paulatinamente proyectos de extensión, investigación y docencia atravesando diversas etapas de institucionalización y reconceptualización, hasta que en 2014 se creó la Cátedra Libre de Intervenciones Asistidas con Animales. El objetivo de este trabajo es introducir esta disciplina, con especial énfasis en sus posibilidades como factor de inclusión, y presentar una experiencia concreta de trabajo con perros que se realiza desde 2009 con la Asociación Civil Senderos del Sembrador, a la que concurren personas con discapacidad intelectual y una gran necesidad de apoyo. Relatamos cómo hemos sistematizado este contacto, sus resultados, desafíos y dificultades, y cómo hemos podido trabajar el ocio como factor de inclusión además de actuar sobre los prejuicios de las personas sin discapacidad. Finalmente, en cuanto a las prácticas, este proyecto pasó de ser una propuesta terapéutica para rehabilitar a las personas con discapacidad a constituir un espacio de inclusión social efectiva que fue modificando las concepciones y prácticas de todos los participantes.

Prisoner rehabilitation through animal-assisted activities in Argentina: the Huellas de Esperanza Prison Dog Programme. / Resocialización de personas privadas de libertad a través de actividades con animales en Argentina: el programa «Huellas de Esperanza¼.

One of the most traumatic events that a person can ever experience in their lifetime is being detained. The prison dog programmes are the most successful prison rehabilitation programmes in the United States of America and consist of detainees training service dogs for other people to assist with different types of disability. It is a typical win-win system: inmates win as they connect with their deepest feelings of affection and solidarity while acquiring a concrete skill for their future release; people with disabilities win because they receive a dog to support their day-to-day activities; the dogs win (especially adopted street dogs) because their lot in life is improved; institutions win because they are enabled to meet their objective more fully; and society wins because they gain a concrete tool to aid the social rehabilitation of detainees. This article describes the operation and achievements of Huellas de Esperanza (Traces of Hope), the Argentine prison dog programme, which has been implemented by the Federal Penitentiary Service since 2010 using State resources. A total of 85 inmates have participated in the programme, which has delivered more than a dozen assistance dogs to people with disabilities and many more dogs to elderly people to provide them with affection and companionship. The article also describes the programme methodology and the way it has decreased prison unrest and led to a low reoffending rate among programme participants.

La privation de liberté est l'une des situations les plus traumatisantes qu'un être humain puisse connaître au cours de son existence. De tous les programmes de réhabilitation appliqués dans les prisons aux États-Unis d'Amérique, Prison Dog Programme est celui qui donne les meilleurs résultats ; il consiste à confier aux détenus la tâche de dresser des chiens en vue d'en faire des chiens aidants qui rendront des services à d'autres personnes atteintes de divers types de handicap. Il s'agit d'un système typiquement « gagnant-gagnant ¼ : le détenu est gagnant, car il renoue avec des sentiments positifs d'affection et de solidarité, tout en recevant un outil concret pour sa vie future une fois libéré ; la personne handicapée est gagnante, car elle reçoit un chien qui l'aidera à vivre au quotidien ; le chien est gagnant, surtout s'il était un chien errant avant d'être adopté, car il accède à une vie meilleure ; enfin, les institutions sont gagnantes car leurs objectifs sont mieux remplis, de même que la société, qui grâce à cet outil concret facilite, la réinsertion sociale des personnes privées de liberté. Les auteurs décrivent le fonctionnement et les réussites de la version argentine de ce programme, intitulée « Traces d'espérance ¼ (Huellas de Esperanza). Le programme a été mis en place par le système pénitentiaire fédéral en 2010 et doté de véritables ressources étatiques; au total, 86 détenus en ont bénéficié et plus d'une douzaine de chiens aidants ont été remis à des personnes handicapées, en plus du grand nombre de chiens dressés et remis à des centres de gériatrie pour apporter un réconfort aux pensionnaires. Les auteurs expliquent la méthodologie suivie, ainsi que la réduction des conflits en milieu carcéral et le faible taux de récidives parmi les ex-détenus ayant participé au programme.

Una de las situaciones más traumáticas que puede atravesar un ser humano a lo largo de su existencia es la privación de su libertad. Los Prison Dog Programmes son los sistemas de rehabilitación carcelaria más exitosos de EE.UU., y consisten en el adiestramiento de perros por parte de personas privadas de la libertad, que los preparan como perros de servicio para apoyo de distintos tipos de discapacidad en otras personas. El sistema es un típico win-win-win: gana el interno conectándose con sus mejores sentimientos de afecto y solidaridad al tiempo que recibe una herramienta concreta para su futuro en libertad; gana la persona con discapacidad que recibe un perro como apoyo para su desempeño cotidiano; gana el perro, sobre todo si se trata de perros vagabundos adoptados que obtienen un destino mejor; ganan las instituciones, que cumplen mejor su objetivo, y gana la sociedad, que facilita, con una herramienta concreta, la reinserción social de las personas privadas de libertad. El presente trabajo describe la operatoria y logros de Huellas de Esperanza, la versión argentina de este Programa, que se desarrolla en el Servicio Penitenciario Federal desde 2010 con recursos estatales genuinos; por este programa han pasado más de 85 internos y ha permitido entregar más de una docena de perros de asistencia a personas con discapacidad y muchos perros a geriátricos para compañía afectiva. Se describe también la metodología y la disminución de la conflictividad intracarcelaria, así como la escasa reiteración de sus participantes.

Effect of Coronary Atherosclerosis and Myocardial Ischemia on Plasma Levels of High-Sensitivity Troponin T and NT-proBNP in Patients With Stable Angina.

OBJECTIVE: Circulating levels of high-sensitivity cardiac troponin T (hs-cTnT) and N terminal pro brain natriuretic peptide (NT-proBNP) are predictors of prognosis in patients with coronary artery disease (CAD). We aimed at evaluating the effect of coronary atherosclerosis and myocardial ischemia on cardiac release of hs-cTnT and NT-proBNP in patients with suspected CAD. APPROACH AND RESULTS: Hs-cTnT and NT-proBNP were measured in 378 patients (60.1±0.5 years, 229 males) with stable angina and unknown CAD enrolled in the Evaluation of Integrated Cardiac Imaging (EVINCI) study. All patients underwent stress imaging to detect myocardial ischemia and coronary computed tomographic angiography to assess the presence and characteristics of CAD. An individual computed tomographic angiography score was calculated combining extent, severity, composition, and location of plaques. In the whole population, the median (25-75 percentiles) value of plasma hs-cTnT was 6.17 (4.2-9.1) ng/L and of NT-proBNP was 61.66 (31.2-132.6) ng/L. In a multivariate model, computed tomographic angiography score was an independent predictor of the plasma hs-cTnT (coefficient 0.06, SE 0.02; P=0.0089), whereas ischemia was a predictor of NT-proBNP (coefficient 0.38, SE 0.12; P=0.0015). Hs-cTnT concentrations were significantly increased in patients with CAD with or without myocardial ischemia (P<0.005), whereas only patients with CAD and ischemia showed significantly higher levels of NT-proBNP (P<0.001). CONCLUSIONS: In patients with stable angina, the presence and extent of coronary atherosclerosis is related with circulating levels of hs-cTnT, also in the absence of ischemia, suggesting an ischemia-independent mechanism of hs-cTnT release. Obstructive CAD causing myocardial ischemia is associated with increased levels of NT-proBNP.

Variability of radiation doses of cardiac diagnostic imaging tests: the RADIO-EVINCI study (RADIationdOse subproject of the EVINCI study).

BACKGROUND: Patients with coronary artery disease can accumulate significant radiation dose through repeated exposures to coronary computed tomographic angiography, myocardial perfusion imaging with single photon emission computed tomography or positron emission tomography, and to invasive coronary angiography. Aim of the study was to audit radiation doses of coronary computed tomographic angiography, single photon emission computed tomography, positron emission tomography and invasive coronary angiography in patients enrolled in the prospective, randomized, multi-centre European study-EVINCI (Evaluation of Integrated Cardiac Imaging for the Detection and Characterization of Ischemic Heart Disease). METHODS: We reviewed 1070 tests (476 coronary computed tomographic angiographies, 85 positron emission tomographies, 310 single photon emission computed tomographies, 199 invasive coronary angiographies) performed in 476 patients (mean age 60 ± 9 years, 60% males) enrolled in 12 centers of the EVINCI. The effective doses were calculated in milli-Sievert (mSv) as median, interquartile range (IQR) and coefficient of variation of the mean. RESULTS: Coronary computed tomographic angiography (476 exams in 12 centers) median effective dose was 9.6 mSv (IQR = 13.2 mSv); single photon emission computed tomography (310 exams in 9 centers) effective dose was 9.3 (IQR = 2.8); positron emission tomography (85 in 3 centers) effective dose 1.8 (IQR = 1.6) and invasive coronary angiography (199 in 9 centers) effective dose 7.4 (IQR = 7.3). Inter-institutional variability was highest for invasive coronary angiography (100%) and coronary computed tomographic angiography (54%) and lowest for single photon emission computed tomography (20%). Intra-institutional variability was highest for invasive coronary angiography (121%) and coronary computed tomographic angiography (115%) and lowest for single photon emission computed tomography (14%). CONCLUSION: Coronary computed tomographic angiography and invasive coronary angiography doses vary substantially between and within centers. The variability in nuclear medicine procedures is substantially lower. The findings highlight the need to audit doses, to track cumulative exposures and to standardize doses for imaging techniques. TRIAL REGISTRATION: The study protocol is available at https://www.clinicaltrials.gov/ (ClinicalTrials.gov Identifier: NCT00979199 ). Information provided on September 16, 2009.

Interleukin (IL) 31 induces in cynomolgus monkeys a rapid and intense itch response that can be inhibited by an IL-31 neutralizing antibody.

BACKGROUND: Overexpression or administration of interleukin 31 (IL-31) has been shown to induce a profound itch response in mice and dogs. The chronic pruritus observed in mouse IL-31 transgenic mice results in the development of skin lesions and alopecia through excoriation from excessive scratching, a condition similar to that observed in patients with atopic dermatitis (AD). OBJECTIVE: To test whether IL-31 induces pruritus in non-human primates and, if so, whether treatment with an anti-IL-31 neutralizing monoclonal antibody (mAb) can block the response. METHODS: A series of studies was conducted in cynomolgus monkeys to evaluate the itch response to recombinant cynomolgus IL-31 (cIL-31) administration. Three routes of cIL-31 administration (intravenous, intradermal, and subcutaneous) were evaluated. Subcutaneous treatment with a humanized anti-human IL-31 mAb cross-reactive to cIL-31 was subsequently tested for its ability to block the response to intradermal cIL-31 administration. RESULTS: Each route of cIL-31 delivery elicited a scratching response immediately after cIL-31 administration and lasted at least 3 h. Treatment with the IL-31 mAb inhibited the cIL-31-mediated scratching response in a dose-dependent manner. CONCLUSION: These results demonstrate that an IL-31 mAb can inhibit IL-31-mediated pruritus in vivo, and could be an effective therapy for pruritic skin conditions like AD where IL-31 upregulation may play a role.

Nuclear Cardiology Practices and Radiation Exposure in the Oceania Region: Results From the IAEA Nuclear Cardiology Protocols Study (INCAPS).

BACKGROUND: There is concern about radiation exposure with radionuclide myocardial perfusion imaging (MPI). This sub-study of the International Atomic Energy Agency (IAEA) Nuclear Cardiology Protocols Study reports radiation doses from MPI, and use of dose-optimisation protocols in Australia and New Zealand (ANZ), and compares them with data from the rest of the world. METHODS: Data were collected from 7911 MPI studies performed in 308 laboratories worldwide in one week in 2013, including 439 MPI studies from 34 ANZ laboratories. For each laboratory, effective radiation dose (ED) and a quality index (QI) score (out of 8) based on pre-specified "best practices" was determined. RESULTS: In ANZ patients, ED ranged from 0.9-17.9 milliSievert (mSv). Median ED was similar in ANZ compared with the rest of the world (10.0 (IQR: 6.5-11.7) vs. 10.0 (IQR 6.4-12.6, P=0.15), as were mean QI scores (5.5±0.7 vs. 5.4±1.3, P=0.84). Use of stress-only imaging (17.6% vs. 31.8% of labs, P=0.09) and weight-based dosing of technetium-99m (14.7% vs. 30.3%, P=0.07) was lower in ANZ compared with the rest of the world but this difference was not statistically significant. Median ED was significantly lower in metropolitan versus non-metropolitan laboratories (10.1 mSv vs. 11.6 mSv, P<0.01), although mean QI scores were similar (5.4±0.8 vs. 5.5±0.7, P=0.75). CONCLUSION: Across ANZ, there is variability in ED from MPI, and use of radiation safety practices, particularly between metropolitan and non-metropolitan laboratories. Overall, ANZ laboratories have a similar median ED to laboratories in the rest of the world.

Nuclear cardiology practice and associated radiation doses in Europe: results of the IAEA Nuclear Cardiology Protocols Study (INCAPS) for the 27 European countries.

PURPOSE: Nuclear cardiology is widely used to diagnose coronary artery disease and to guide patient management, but data on current practices, radiation dose-related best practices, and radiation doses are scarce. To address these issues, the IAEA conducted a worldwide study of nuclear cardiology practice. We present the European subanalysis. METHODS: In March 2013, the IAEA invited laboratories across the world to document all SPECT and PET studies performed in one week. The data included age, gender, weight, radiopharmaceuticals, injected activities, camera type, positioning, hardware and software. Radiation effective dose was calculated for each patient. A quality score was defined for each laboratory as the number followed of eight predefined best practices with a bearing on radiation exposure (range of quality score 0 - 8). The participating European countries were assigned to regions (North, East, South, and West). Comparisons were performed between the four European regions and between Europe and the rest-of-the-world (RoW). RESULTS: Data on 2,381 European patients undergoing nuclear cardiology procedures in 102 laboratories in 27 countries were collected. A cardiac SPECT study was performed in 97.9 % of the patients, and a PET study in 2.1 %. The average effective dose of SPECT was 8.0 ± 3.4 mSv (RoW 11.4 ± 4.3 mSv; P < 0.001) and of PET was 2.6 ± 1.5 mSv (RoW 3.8 ± 2.5 mSv; P < 0.001). The mean effective doses of SPECT and PET differed between European regions (P < 0.001 and P = 0.002, respectively). The mean quality score was 6.2 ± 1.2, which was higher than the RoW score (5.0 ± 1.1; P < 0.001). Adherence to best practices did not differ significantly among the European regions (range 6 to 6.4; P = 0.73). Of the best practices, stress-only imaging and weight-adjusted dosing were the least commonly used. CONCLUSION: In Europe, the mean effective dose from nuclear cardiology is lower and the average quality score is higher than in the RoW. There is regional variation in effective dose in relation to the best practice quality score. A possible reason for the differences between Europe and the RoW could be the safety culture fostered by actions under the Euratom directives and the implementation of diagnostic reference levels. Stress-only imaging and weight-adjusted activity might be targets for optimization of European nuclear cardiology practice.

Current worldwide nuclear cardiology practices and radiation exposure: results from the 65 country IAEA Nuclear Cardiology Protocols Cross-Sectional Study (INCAPS).

AIMS: To characterize patient radiation doses from nuclear myocardial perfusion imaging (MPI) and the use of radiation-optimizing 'best practices' worldwide, and to evaluate the relationship between laboratory use of best practices and patient radiation dose. METHODS AND RESULTS: We conducted an observational cross-sectional study of protocols used for all 7911 MPI studies performed in 308 nuclear cardiology laboratories in 65 countries for a single week in March-April 2013. Eight 'best practices' relating to radiation exposure were identified a priori by an expert committee, and a radiation-related quality index (QI) devised indicating the number of best practices used by a laboratory. Patient radiation effective dose (ED) ranged between 0.8 and 35.6 mSv (median 10.0 mSv). Average laboratory ED ranged from 2.2 to 24.4 mSv (median 10.4 mSv); only 91 (30%) laboratories achieved the median ED ≤ 9 mSv recommended by guidelines. Laboratory QIs ranged from 2 to 8 (median 5). Both ED and QI differed significantly between laboratories, countries, and world regions. The lowest median ED (8.0 mSv), in Europe, coincided with high best-practice adherence (mean laboratory QI 6.2). The highest doses (median 12.1 mSv) and low QI (4.9) occurred in Latin America. In hierarchical regression modelling, patients undergoing MPI at laboratories following more 'best practices' had lower EDs. CONCLUSION: Marked worldwide variation exists in radiation safety practices pertaining to MPI, with targeted EDs currently achieved in a minority of laboratories. The significant relationship between best-practice implementation and lower doses indicates numerous opportunities to reduce radiation exposure from MPI globally.

Advances in radionuclide imaging of cardiac sarcoidosis.

INTRODUCTION: Radionuclide imaging for the diagnosis and monitoring of cardiac involvement in sarcoidosis has advanced significantly in recent years. SOURCES OF DATA: This article is based on published clinical guidelines, literature review and our collective clinical experience. AREAS OF AGREEMENT: Gallium-67 scintigraphy is among the diagnostic criteria for cardiac involvement in systemic sarcoidosis, and it is strongly associated with response to treatment. However, fluorine-18, 2-fluoro-deoxyglucose (FDG) positron emission tomography (PET) is now preferred both for diagnosis and for assessing prognosis. AREAS OF CONTROVERSY: Most data are from small observational studies that are potentially biased. GROWING POINTS: Quantitative imaging to assess changes in disease activity in response to treatment may lead to FDG-PET having an important routine role in managing cardiac sarcoidosis. AREAS TIMELY FOR DEVELOPING RESEARCH: Larger prospective studies are required, particularly to assess the effectiveness of radionuclide imaging in improving clinical management and outcome.

Regadenoson in Europe: first-year experience of regadenoson stress combined with submaximal exercise in patients undergoing myocardial perfusion scintigraphy.

PURPOSE: Regadenoson was approved for clinical use in Europe in 2011. Since then, it has become the default form of stress at our institution. We have assessed the side-effect profile and tolerability of regadenoson in patients undergoing clinically indicated myocardial perfusion scintigraphy between July 2011 and July 2012. METHODS: Clinical, stress and imaging data were recorded prospectively. Symptoms during stress were recorded and defined as mild, moderate or severe. An adverse event was defined as any symptom that persisted for more than 30 min or that required investigation or treatment. RESULTS: Of 1,764 consecutive patients, 1,581 (90%) received regadenoson combined with submaximal exercise unless contraindicated. Symptoms were common (63%) but transient and well-tolerated. The severity of symptoms was recorded in most patients as mild (84%). Dyspnoea (36%) and chest discomfort (12%) were the commonest side effects. Adverse events were reported in eight patients (0.5%), thought to be vasovagal in seven of these. All patients recovered fully without sequelae. There were no deaths, myocardial infarction or hospital admissions. Regadenoson stress was performed in 206 patients (12%) with asthma or chronic obstructive pulmonary disease (COPD) without bronchospasm or any other major side effect. CONCLUSION: We studied the symptom profile of regadenoson in the largest European cohort to date. Regadenoson combined with submaximal exercise was well tolerated, notably also in patients with asthma or COPD. The majority of regadenoson-related adverse events were vasovagal episodes without sequelae.

The diagnostic performance of quantitative flow ratio and perfusion imaging in patients with prior coronary artery disease.

AIMS: In chronic coronary syndrome (CCS) patients with documented coronary artery disease (CAD), ischaemia detection by myocardial perfusion imaging (MPI) and an invasive approach are viable diagnostic strategies. We compared the diagnostic performance of quantitative flow ratio (QFR) with single-photon emission computed tomography (SPECT), positron emission tomography (PET), and cardiac magnetic resonance imaging (CMR) in patients with prior CAD [previous percutaneous coronary intervention (PCI) and/or myocardial infarction (MI)]. METHODS AND RESULTS: This PACIFIC-2 sub-study evaluated 189 CCS patients with prior CAD for inclusion. Patients underwent SPECT, PET, and CMR followed by invasive coronary angiography with fractional flow reserve (FFR) measurements of all major coronary arteries (N = 567), except for vessels with a sub-total or chronic total occlusion. Quantitative flow ratio computation was attempted in 488 (86%) vessels with measured FFR available (FFR ≤0.80 defined haemodynamically significant CAD). Quantitative flow ratio analysis was successful in 334 (68%) vessels among 166 patients and demonstrated a higher accuracy (84%) and sensitivity (72%) compared with SPECT (66%, P < 0.001 and 46%, P = 0.001), PET (65%, P < 0.001 and 58%, P = 0.032), and CMR (72%, P < 0.001 and 33%, P < 0.001). The specificity of QFR (87%) was similar to that of CMR (83%, P = 0.123) but higher than that of SPECT (71%, P < 0.001) and PET (67%, P < 0.001). Lastly, QFR exhibited a higher area under the receiver operating characteristic curve (0.89) than SPECT (0.57, P < 0.001), PET (0.66, P < 0.001), and CMR (0.60, P < 0.001). CONCLUSION: QFR correlated better with FFR in patients with prior CAD than MPI, as reflected in the higher diagnostic performance measures for detecting FFR-defined, vessel-specific, significant CAD.

Myocardial perfusion scintigraphy in Europe 2007: a survey of the European Council of Nuclear Cardiology.

PURPOSE: This is the second of a series of surveys designed to assess myocardial perfusion scintigraphy (MPS) practice in Europe. METHODS: Data were collected from 258 centres in 18 countries. The number of MPS studies per million population (pmp) was estimated assuming that the nonresponding centres performed either no studies (lower estimate) or the same number as the responding centres (upper estimate). RESULTS: The responding centres served 24% of the population of their countries. The total number of noncardiac nuclear medicine studies was between 2,160 and 8,000 studies pmp. The total number of MPS studies was between 529 and 2,293 pmp. The median number of MPS studies per centre was 571 per year with 57% performing fewer than 500 studies per year and 23% of centres performing fewer than 250 studies per year. There was significant variation between countries, with higher numbers of MPS studies (lower limit of estimate above the mid-range of all countries combined) in Austria, Denmark, Hungary, Portugal and Slovenia, and lower numbers (upper limit of estimate below the mid-range of all countries) in Finland, Norway, Spain and Switzerland. The ratio of MPS to coronary angiography to revascularization procedures was 0.9 to 2.2 to 1. Pharmacological stress was used in 57% and technetium-99m-labelled tracers in 88% of studies. ECG gating was performed in 74% of studies and attenuation correction in 22%. CONCLUSION: MPS utilization in Europe remains low compared with coronary angiography although there has been a 21% increase in the number of studies pmp in centres that reported in both 2005 and 2007. Pharmacological agents continue to be the predominant form of stress. Despite the widespread use of technetium-99m-labelled tracers, ECG gating is not universally performed. As in the 2005 survey, imaging aids such as attenuation and motion correction and prone imaging are not commonly used.

Effect of body mass index on the efficacy, side effect profile, and plasma concentration of fixed-dose regadenoson for myocardial perfusion imaging.

BACKGROUND: There are limited data on the effect of body mass index (BMI) on the actions of fixed-dose regadenoson. The purpose of this study was to determine the effect of BMI on the efficacy, side effects, and plasma concentration of regadenoson for Myocardial Perfusion Imaging (MPI). METHODS AND RESULTS: The study included 2,015 subjects from the ADVANCE MPI trials. Initial adenosine MPI was followed by randomization to regadenoson (400-µg bolus injection) or adenosine (6-minute infusion) MPI. Subjects were classified according to BMI into six categories from underweight (<20 kg/m(2)) to extremely obese (≥40 kg/m(2)). PK modeling was used to predict the effect of BMI on plasma regadenoson concentration (PRC). Adenosine-regadenoson agreement rates for the presence and extent of reversibility were similar across BMI categories (P > .05). The incidence of side effects was also similar across BMIs (P ≥ .06). Subjects were less likely to feel very or extremely uncomfortable after regadenoson vs adenosine in all groups with BMI ≥ 25 kg/m(2), but this trend was not statistically significant in subjects with BMI 20-24 kg/m(2) (P > .05). PRC was inversely related to BMI with 19% higher PRC in the underweight and 36% lower PRC in the extremely obese compared with a normal weight subject. CONCLUSIONS: BMI does not alter the efficacy of regadenoson MPI despite lower PRC in high BMI subjects, or its side effect profile despite higher PRC in low BMI subjects. Regadenoson is better tolerated than adenosine but this benefit seems to lose statistical significance in subjects with BMI < 25 kg/m(2).