A challenging road to diagnosing transthyretin cardiac amyloidosis and using technetium-99m pyrophosphate bone scintigraphy in nuclear cardiology - A case report.

Cardiac amyloidosis (CA) is a rare form of protein deposition disease, leading to restrictive cardiomyopathy that often presents with signs and symptoms of unexplained heart failure with preserved ejection fraction (HFpEF). There are two main subtypes of CA, namely light chain amyloidosis (AL) and transthyretin amyloidosis (ATTR), which are conventionally confirmed by endomyocardial biopsy (EMB). The prognosis and treatment of the subtypes differ extensively, making it crucial to distinguish between the two. Although echocardiography (ECHO) and cardiac magnetic resonance imaging (CMR) are useful to aid in the diagnosis, they are unable to differentiate between the subtypes. Advantageously, the transthyretin cardiac amyloidosis (ATTR-CA) subtype can be diagnosed based on nuclear medicine bone scintigraphy imaging using Technetiumlabelled bone-seeking radiotracers. We report a case of a previously well, elderly gentleman who presented with acute heart failure symptoms, whereby ECHO findings were suspicious for CA. Technetium-99m pyrophosphate (99mTc- PYP) bone scintigraphy performed with complementary single photon emission computed tomography/computed tomography (SPECT/CT) at three hours post-injection revealed radiotracer uptake in the myocardium that was higher than the skeletal bone uptake. This corresponded to Perugini score of 3 along with an increased heart to contralateral lung ratio (H:CL) of 1.69. The bone scintigraphy findings together with his symptoms, ECHO, CMR, and laboratory results enabled the diagnosis of ATTR-CA to be made. In summary, bone scintigraphy offers a reliable and non-invasive method for the diagnosis of ATTR-CA. We also highlight the diagnostic pitfalls and recommendations in reporting bone scintigraphy for the indication of typing cardiac amyloidosis.

18F-FDG PET/CT for the pre-surgical localization of epileptogenic focus among paediatric patients with drug resistant epilepsy in Malaysia: perspective of a nuclear medicine physician.

BACKGROUND: Scalp video electroencephalography monitoring (VEM) and brain MRI sometime fail to identify the epileptogenic focus (EF) in patients with drug resistant epilepsy (DRE). 18F-FDG PET/CT has been shown to improve the detection of EF in patients but is not widely used in Malaysia. Thus, the objective of this study was to identify whether 18F-FDG PET/CT conferred an added benefit in the pre-surgical evaluation of DRE. METHODS: Retrospective review of 119 consecutive paediatric patients referred for 18F-FDG-PET/CT at the Department of Nuclear Medicine of the National Cancer Institute, Putrajaya. All had DRE and underwent evaluation at the Paediatric Institute, Hospital Kuala Lumpur. Visually detected areas of 18F-FDG-PET/CT hypometabolism were correlated with clinical, MRI and VEM findings. RESULTS: Hypometabolism was detected in 102/119 (86%) 18FFDG- PET/CT scans. The pattern of hypometabolism in 73 patients with normal MRI was focal unilobar in 16/73 (22%), multilobar unilateral in 8/73 (11%), bilateral in 27/73 (37%) and global in 5/73 (7%) of patients; whilst 17/73 (23%) showed normal metabolism. In 46 patients with lesions on MRI, 18F-FDG-PET/CT showed concordant localisation and lateralization of the EF in 30/46 (65%) patients, and bilateral or widespread hypometabolism in the rest. Addition of 18FFDG PET/CT impacted decision making in 66/119 (55%) of patients; 24/73 with non-lesional and 30/46 patients with lesional epilepsies were recommended for surgery or further surgical work up, whilst surgery was not recommended in 11/46 patients with lesional epilepsy due to bilateral or widespread hypometabolism. 25 patients subsequently underwent epilepsy surgery, with 16/25 becoming seizure free following surgery. CONCLUSION: 18F-FDG-PET/CT has an added benefit for the localization and lateralization of EF, particularly in patients with normal or inconclusive MRI.

Functionality among stroke survivors with upper limb impairment attending community-based rehabilitation.

INTRODUCTION: There is scarcity of research information on upper limb (UL) functionality among Malaysian post-stroke population despite the increasing number of stroke survivors. This study intends to evaluate functionality among stroke survivors residing in the community, with a specific focus on the UL. METHODS: This cross-sectional study involved 65 stroke survivors with UL dysfunction (mean (SD) age = 64.83 (8.05) years, mean (SD) post-stroke duration 41.62 (35.24) months) who attended community-based rehabilitation program. Upper limb functionality was assessed using the UL items of Stroke Specific Quality of Life Scale (SSQOL), the Lawton Instrumental Activities of Daily Living (IADL) Scale and the Jebsen-Taylor Hand Function Test (JTHFT). The stroke survivors' performance in completing JTHFT using their affected dominant hand was compared with standard norms. RESULTS: The three most affected UL daily living tasks were writing (64.7%, n=42), opening a jar (63.1%, n=41) and putting on socks (58.5%, n=38). As for IADL, the mean (SD) score of Lawton scale was 3.26 (2.41), with more than 50% unable to handle finance, do the laundry and prepare meals for themselves. Performances of stroke survivors were much slower than normal population in all tasks of JTHFT (p<0.05), with largest speed difference demonstrated for 'stacking objects' task (mean difference 43.24 secs (p=0.003) and 24.57 (p<0.001) in males and females, respectively. CONCLUSION: UL functions are significantly impaired among stroke survivors despite undergoing rehabilitation. Rehabilitation professionals should prioritize highly problematic tasks when retraining UL for greater post-stroke functionality.

Usage of Traditional and Complementary Medicine (T & CM): Prevalence, Practice and Perception among Post Stroke Patients Attending Conventional Stroke Rehabilitation in A Teaching Hospital in Malaysia.

INTRODUCTION: The lack of evidence that proves the benefit of traditional and complementary medicines (T & CM) in treating chronic medical conditions does not deter its usage among patients worldwide. Prevalence of usage among post-stroke patients in Malaysia especially is unknown. This study aims to determine the prevalence, practice and perception of T & CM use among stroke survivors attending an outpatient rehabilitation program in a teaching hospital. METHODS: A cross-sectional study was conducted among 104 post stroke patients attending an outpatient rehabilitation program. A structured self-administered questionnaire was used to collect data on sociodemographic and clinical profile of patients, as well as types of therapy used and perception on T & CM usage. Descriptive analysis was done, and bivariate analysis was used to determine associations between categorical data. RESULTS: Mean age of patients was 62 years (SD 12.2), 54% were Chinese and 75% of the patients had ischaemic stroke. Mean age of T & CM users was younger compared to non- T & CM users (61 years vs. 66 years, p=0.04). Two-thirds (66%) of patients admitted to concurrent T & CM usage while attending conventional post stroke rehabilitation. Acupuncture (40.4%), massage (40.4%) and traditional Chinese medicine (11.5%) were the most common T & CM used. Positive perception was recorded in terms of ability of T & CM usage to relieve post stroke symptoms (68%), and it was safe to use because it was made from 'natural sources'. Negative perception recorded: T & CM caused significant adverse effects (57.6%) and was not safe to be used in combination with other conventional medicines (62.5%). CONCLUSIONS: Concurrent T & CM usage among post-stroke patients attending structured outpatient rehabilitation program is widely practised especially acupuncture, massage and traditional Chinese medicines. Overall the perception towards its use is favourable.