The first year after diagnosis: psychological impact on people with multiple sclerosis.

The impact of multiple sclerosis (MS) diagnosis on newly diagnosed individuals remains so far little explored. Our aim is to outline affective, personality and quality of life (QoL) correlates of MS patients shortly after MS diagnosis. Thirty-eight (22 F and 16 M) newly-diagnosed MS patients (mean interval from diagnosis communication 4.7 ± 3.8 months, range 1-12 months) underwent the Montgomery-Åsberg Depression Rating Scale and a comprehensive psychological evaluation: Beck Depression Inventory-II, State-Trait Anxiety Inventory, Psychophysiological Questionnaire-Revised, Fear Survey Schedule, Maudsley Obsessional-Compulsive Questionnaire, Impact of Event Scale-Revised, Personal Meaning Questionnaire, Problem Solving Inventory and Multiple Sclerosis Quality of Life-54. The Expanded Disability Status Scale was assessed during the neurological examination. Depressive symptomatology, only partially related to disability, was observed in approximately 40% of patients. The prevalent approach to MS diagnosis was one of avoidance in 65.8% of cases. QoL reductions in self-perception and psychological well-being emerged, together with a peculiar perception of change in health that was not related to neurological disability. With regard to personality assessment, depressive personal meaning organization correlates inversely with important QoL measures. Newly-diagnosed patients go through a complex network of psychological changes still in the initial phases immediately after diagnosis. A thorough understanding of these adjusting aspects by the neurologist could be crucial in improving patients' QoL, participation in relevant disease decisions and adherence to pharmacological therapy.

Neuropsychological measures in clinical practice.

Cognitive decline in multiple sclerosis can appear early in the course of the disease and may not be evident to the clinician if not investigated formally. Clinical neuropsychological evaluation with these patients has main peculiarities: disabilities, fatigue, relapses, medical treatment, psychological problems, that have to be seriously taken into consideration in choosing the tests and interpreting the profile. The peculiarity of cognitive decline in MS suggests an examination primarily of attentive-executive and memory domains, with Pasat and Symbol Digit Modalities Test, strongly recommended, together with memory test. The utilization of extensive or brief cognitive batteries depends on the different goals of the neuropsychological evaluation. It is important to find a screening procedure to be used by neurologists to identify the patients to be sent to an early formal evaluation, in consideration of the interference of cognitive profile with fundamental aspects of individual functioning, included adherence to rehabilitation and pharmacological treatment.

Use of radioguided surgery with [111In]-pentetreotide in the management of an ACTH-secreting bronchial carcinoid causing ectopic Cushing's syndrome.

Intraoperative [111In]-pentetreotide scintigraphy with a hand-held gamma detector probe has recently been proposed to increase the intraoperative detection rate of small neuroendocrine tumors and their metastases. We report a case of a 28-yr-old woman with ectopic Cushing's syndrome due to an ACTH-secreting bronchial carcinoid, in whom the use of radioguided surgery improved disease management. At presentation, radiolabeled pentetreotide scintigraphy was the only procedure able to detect the ectopic source of ACTH. After radiologic confirmation, the patient underwent removal of a bronchial carcinoid, with disease persistence. After surgery, pentetreotide scintigraphy showed pathologic uptake in the mediastinum not previously detected at surgery and only subsequently confirmed by radiologic studies. Despite a second thoracic exploration, hormonal, scintigraphic, and radiological evidence of residual disease persisted. Radioguided surgery was then performed using a hand-held gamma probe 48 h after iv administration of a tracer dose of radiolabeled [111In-DTPA-D-Phe1]-pentetreotide, which permitted detection and removal of multiple residual mediastinal lymph node metastases. Clinical and radiologic cure, with no evidence of tracer uptake at pentetreotide scintigraphy, was subsequently observed. The use of an intraoperative gamma counter appears a promising procedure in the management of metastatic ACTH-secreting bronchial carcinoids.

[Diagnostic modalities in patients affected by differentiated thyroid carcinoma with high thyroglobulin levels and total body Iodium-131 negative: PET/CT use after recTSH]. / Modalità diagnostiche in pazienti affetti da carcinoma differenwiato della tiroide con elevati livelli di tireoglubulina e total body con Iodio-131 negativo: utilizzo della PET/TC, dopo somministrazione di rec-TSH.

In the follow-up of differentiated thyroid carcinoma (DTC), after total thyroidectomy and Iodine-131 therapy, thyroglobulin (Tg) levels and Iodine-131 total body have particular importance. The Tg level becomes a specific and very sensitive marker of DTC recurrence: it is usually evaluated after eradication of thyroid residual tissue (by thyroidectomy and radiometabolic therapy), in presence of high level of TSH (>35 microU/ml) obtained with the suspension of therapy or after rec-TSH administration and in absence of anti-Tg antibodies. Usually, to solve diagnostic problems in patients with negative total body Iodine-131 and high levels of thyroglobulin, we consider one or more of the following investigations, on the basis of prognostic factors: radiological examinations (neck US, skeletal X-ray, CT chest and abdomen, MRI) and scintigraphy (bone scintigraphy, Tc-MIBI or Tl-201 scintigraphy, octreoscan, PET/CT). The use of PET is well known in patients in whom carcinoma metastases are strongly suspected and who are unable of concentrating Iodine-131. In order to increase the PET sensitivity, scintigraphy is performed with high TSH levels obtained through a rec-TSH injection on the 1st and 2nd day, PET/CT scan and blood withdrawal (for Tg level evaluation) on the 3rd day. Considering the hypothesis of a recurrence with lesion size below the resolution power of the diagnostic equipment (5 mm), if PET/CT results are negative, the patients are strictly followed-up and Tg is monitored every 4-6 months. An alternative hypothesis might be not to consider the negative-PET patients as sick persons, but to attribute high Tg levels to illegitimate transcription of mRNA for Tg by the non-thyroid cells or to ectopic thyroid tissue (e.g. intrathymus). Positive PET/CT patients are evaluated for a possible surgical removal of the lesions or alternative appropriate therapies.

Management of occult adrenocorticotropin-secreting bronchial carcinoids: limits of endocrine testing and imaging techniques.

The differential diagnosis and the identification of the source of ACTH in occult ectopic Cushing's syndrome due to a bronchial carcinoid still represents a challenge for the endocrinologist. We report our experience in six patients with occult bronchial carcinoid in whom extensive hormonal, imaging, and scintigraphic evaluation was performed. All patients presented with hypercortisolism associated with high plasma ACTH values. The CRH test and high dose dexamethasone suppression test suggested an ectopic source of ACTH in three of six patients. During bilateral inferior petrosal sinus sampling, none of the patients showed a central to peripheral ACTH gradient. At the time of diagnosis, none of the patients had radiological evidence of the ectopic source of ACTH, whereas pentetreotide scintigraphy identified the lesion in two of four patients. Finally, a chest computed tomography scan revealed the presence of a bronchial lesion in all patients, and pentetreotide scintigraphy identified four of six lesions. In all patients a bronchial carcinoid was found and removed. In one patient with scintigraphic evidence of residual disease after two operations, radioguided surgery, using a hand-held gamma probe after iv administration of radiolabeled pentetreotide, was performed; this allowed detection and removal of residual multiple mediastinal lymph node metastases. In conclusion, our data show that there is not a single endocrine test or imaging procedure accurate enough to diagnose and localize occult ectopic ACTH-secreting bronchial carcinoids. Radioguided surgery appears to be promising in the presence of multiple tumor foci and previous incomplete removal of the tumor.

The natural history of incidentally discovered adrenocortical adenomas: a retrospective evaluation.

Adrenal adenoma is the most frequent lesion among adrenal incidentalomas. The present retrospective study was undertaken to investigate medium-term evolution of supposed or ascertained adrenocortical adenomas in a group of 53 subjects (16 males and 37 females, aged 31-83 yr), with bilateral (no.=8) or monolateral (no.=45) incidentally discovered adrenal masses (size 10-50 mm, median 25 mm), who were followed-up for 6-78 months (median 24 months). Diagnosis of adenoma was based on size and morphovolumetric aspect of the lesion at computed tomography (CT), scintigraphic pattern using NP59 as a tracer, and it was histologically confirmed in 7 patients. After an extensive hormonal investigation including morning (no.=53) and midnight (no.=28) serum cortisol, plasma ACTH (no.=50), serum DHEAS (no.=51), daily urinary free cortisol excretion (no.=52), post-dexamethasone (1 mg) cortisol (no.=42) and ACTH stimulation test for 17-hydroxyprogesterone (17-OHP) response (no.=48) at the time of diagnosis, patients were periodically re-evaluated for hormonal function and radiological aspect of the lesion(s) by CT. Seven patients underwent surgery 6-42 months after incidentaloma demonstration, with histological diagnosis of adrenal adenoma. During follow-up an increase in the size of the lesion was demonstrated in 22 patients (41.5%); the increase was greater than 10 mm in 8 cases. In 3 patients with unilateral mass, a contralateral lesion appeared 10-52 months after first demonstration. Six patients (11.3%) showed reduction or disappearance of the lesions. On the basis of the hormonal evaluation 3 patients were considered to have subclinical Cushing's syndrome and 10 patients exhibited 17-OHP hyperresponse to ACTH test consistent with partial 21 -hydroxylase deficiency. A significant difference in the size of the lesions was observed between patients with or without 17-OHP hyperresponse to ACTH test (31.1 1.9 vs 24.1 +/- 1.2 mm; p<0.01). No significant changes in the hormonal parameters were observed in the patients, when retested. In conclusion, although none of the patients of the present series exhibited evolution to hypersecretion or to aberrant growth, in more than 40% of patients an increase in the size of the mass was observed, even after a long period of "quiescence". This suggests that a radiological re-evaluation of lesions should be periodically undertaken.

Scintigraphic imaging of pituitary adenomas: an in vivo evaluation of somatostatin receptors.

UNLABELLED: We have performed pituitary scintigraphy with the somatostatin (SS) analog pentetreotidean by (111In-P) in patients with GH-secreting adenoma or with "clinically non functioning" adenoma (NFA) to evaluate the presence and the functionality of SS receptors (SS-R). 111In-P pituitary accumulation was expressed as Activity Ratio (AR): the ratio between the uptake of radioactivity by the adenoma and that of the normal brain tissue. In subjects without pituitary disease, AR ranged from 1.6 to 2.2 and a value lower than 2.2 was thus arbitrarily considered as normal. In 15 out of the 17 patients with GH-secreting adenoma, an accumulation of the radioligand was shown. Median AR was 3.8 (range 1-6.9; in 14 AR were greater that 2.2) and ARs were directly correlated (r = 0.54; p < 0.05) with the suppressibility of plasma GH levels by octreotide (OC) acute administration. In two patients who repeated scintigraphy during chronic OC treatment, AR values were reduced. In all the 22 patients with NFA an accumulation of 111In-P at the pituitary level was observed and median AR was 3.0 (range 1.5-20; in 14 greater that 2.2). In vitro autoradiography of surgical specimens in 6 NFA patients revealed SS-R in 4 cases with high scintigraphic AR and negative results in two cases with low AR. Scintiscan was repeated during chronic OC treatment in 5 patients with high score: AR decreased in one patient, increased in three, and did not change in the other patient. No changes in tumor size were shown in any of these patients. A total of 8 patients (3 GH secreting and 5 NFA) had "normal" AR values. CONCLUSIONS: In acromegaly scintigraphy with 111In-P visualizes functioning pituitary SS-R coupled to intracellular events that control hormonal hypersecretion and tumor growth. In contrast, in spite of the positivity of 111In-P imaging in most patients with NFA, their receptors might have a defect in the coupling-transduction process, as they are not inhibited by OC treatment and no tumor shrinkage is observed.

Intensification of 111In-DTPA-octreotide scintigraphy by means of pretreatment with cold octreotide in small cell lung cancer.

Small cell lung cancer (SCLC) expresses somatostatin receptors that can be traced with 111In-DTPA-octreotide scintigraphy. Although this technique is currently employed for staging and follow-up of neuroendocrine tumors of the gastrointestinal tract, its role in the clinical work-up of SCLC is at present under discussion. A better imaging contrast is desirable and recent reports suggest that this aim could be achieved by pretreatment with cold octreotide. Here we report on the results of 111In-DTPA-octreotide scintigraphy in 12 SCLC patients carried out before and after octreotide treatment. The patients were treated for 7 days with octreotide 200 micrograms three times a day s.c. Uptake was studied at 5 h with whole body planar and SPET imagings. In all cases studied, pretreatment with octreotide was followed by enhancement of tumor imaging. In one patient a better contrast of the lesions was found at the parenchymal and mediastinal levels as well as at brain level, allowing a clear definition of otherwise questionable metastases. After octreotide treatment, a decrease in background uptake in the subdiaphragmatic area was observed in most cases, allowing a better imaging of liver metastases. The enhancement effect was confirmed by semiquantitative analysis of scintigraphic uptake. Taken together, our results seem to indicate that cold octreotide enhancement can improve 111In-DTPA-octreotide imaging and optimize its clinical role in SCLC.

The 99mTc-HMPAO leukocyte scan: an alternative to radiology and endoscopy in evaluating the extent and the activity of inflammatory bowel disease.

Seventy-eight patients, 47 with Crohn's disease and 31 with ulcerative colitis, were studied using 99mTc-HMPAO-labelled leukocytes, in order to assess the reliability of the scan in evaluating the location and activity of the disease. The granulocyte integrity was assessed by evaluating the lung wash-out and the early liver and spleen uptake using a 20 minute initial dynamic study. The results of the leukocyte scan revealed a high correlation with radiological and endoscopic findings in the diagnosis of the inflamed bowel segments. The disease activity correlated well with uptake in the bowel, graded from 0 to 3. The leukocyte scan exactly documented the activity in the 9 cases of Crohn's disease located in the ileum and in 5 cases in which the endoscopic exploration was hampered by scarring. Four fistulae were correctly visualized. Moreover, the change in activity after therapy in 6 patients was documented. This technique provides images of excellent quality, superior to those obtainable with indium-111.

Biventricular function in Friedreich's ataxia: a radionuclide angiographic study.

The systolic and diastolic function of both ventricles was assessed by radionuclide angiography in 21 patients with Friedreich's ataxia and hypertrophic cardiomyopathy. The indices of systolic function of the two ventricles and those of diastolic function of the right ventricle were generally normal. But in patients with Friedreich's ataxia the time to peak filling rate divided by the diastolic time of the left ventricle was significantly larger than normal. The increase correlated with the heart rate (r = 0.79) and this suggests an alteration in the timing of ventricle filling that is more evident at high heart rates. Movement of the left ventricle was little impaired; however, in 48% of the patients with Friedreich's ataxia the right ventricle showed evidence of hypokinetic segments. Because there is a tendency for congestive heart failure to develop in patients with Friedreich's ataxia, this hypokinesis of the right ventricle should be monitored at follow up.

[Prognostic value of the equivalents of transitory myocardial ischemia evaluated by exercise thallium-201 myocardial scintigraphy in an ambulatory population of 367 patients with a maximum 5-year follow-up]. / Valore prognostico degli equivalenti di ischemia miocardica transitoria rivelabili con la scintigrafia miocardia da sforzo con Tallio-201 in una popolazione ambulatoriale di 367 soggetti con una osservazione massima di 5 anni.

From 1-1-1981 to 3-31-1985, 367 subjects (227 males and 140 females) were examined by means of TL-201 myocardial scintigraphy for diagnostic purpose. A follow-up period, 5 years maximum, was run in order to assess the prognostic value of the three equivalents of transient myocardial ischemia which can be demonstrated by the test (angina, reversible hypoperfusion, and ST-T segment changes). The end points were myocardial infarction and/or sudden death. Three-hundred fifty-four patients complied (96%). During the observation period 9 severe ischemic events (SIE) occurred: 5 myocardial infarctions and 4 sudden deaths. As far as the predictivity of SIE is concerned, the "t" test for independent samples showed a statistically significant difference between the group of patients with no signs of ischemia and the group with positive scintiscan (p less than 0.05) and with the three equivalents of ischemia all together (p less than 0.05). Moreover, in the sub-group of patients with pathological scintigraphic results the probability for SIE to occur was statistically different in the patients with no hypoperfusion in the region supplied by the anterior descending coronary artery and in those with pathological scintigraphic findings in that region (p less than 0.05). In our opinion, the above data demonstrate the pathological signs noticeable with stress myocardial TL-201 scintiscan to have prognostic value.

Tomographic assessment of cerebral perfusion using a single-photon emitter (krypton-81m) and a rotating gamma camera.

Continuous carotid infusion of short-lived krypton-81m (t1/2 13 sec) yields an assessment of regional cerebral perfusion. This assessment can be obtained in three dimensions if activity is recorded with a rotating gamma camera and a computer to reconstruct krypton-81m distribution in tomographic sections. These showed several advantages over conventional views: (a) visualization of blood-flow distribution within brain structures (gray and white matter, basal ganglia); (b) more accurate location and evaluation of areas of relatively reduced or increased perfusion; (c) better definition of patterns of collateral circulation; (d) greater sensitivity and specificity in detecting and defining blood-flow changes during physiological activation studies. A limitation of the krypton-81m technique is its invasiveness. However, this study shows that the combination of new advances in radiochemistry with single-photon emission computed tomography may result in accessible methods for assessing, noninvasively and in three dimensions, the behavior of cerebral function in man.