Clinical 2017 Flashcards
- Krenning score what is it and describe scale.
Semi-quantitative method of assessing the degree of tracer uptake on octreotide (applicable to SPECT and SPECT/CT)
Commonest application is to assess candidacy for peptide receptor radionuclide therapy (PRRT), such as 177Lu-DOTATATE, usually with a score greater than 2
Relative uptake score: 0 = None 1 = Much lower than liver 2 = Slightly less than or equal to liver 3 = Greater than liver 4 = Greater than spleen
- Causes of increased brown fat and ways to decrease.
Principle sites: Neck; supraclavicular fossa; paravertebral tissue; axilla; mediastinum; abdomen (para-aortic; suprarenal; perinephric; perihepatic)
Known triggers: cold temperature; stimulation of sympathetic nervous system
Keep injection and waiting room at warm temperature +/-
medications to minimize brown fat uptake:
Diazepam 5-10 mg po or 0.1 mg/kg IV prior to FDG
Lorazepam 1 mg po 1h prior to FDG
Fentanyl peds 0.1 μg/kg
Propranolol 20-80 mg two hours prior
- 4 elements of informed consent
CMPA lists 3 key elements of informed consent:
1. It must be voluntary
Free to consent or refuse treatment
Consent should be obtained without duress or coercion
- Patient must have capacity to consent
Understands nature of treatment
Anticipated effects of receiving treatment
Consequences of refusing treatment
3. Patient must be properly informed Explain proposed treatment Indicate chance of success Alternative options Material risks (common and very serious) and special risks applicable to patient
Other sources:
- Patient must have capacity to make decision
- Medical provider must disclose information on test, benefits/risks, likelihood of success
- Patient must comprehend the relevant information
- Patient must voluntarily grant consent without coercion or duress
- Ictal and interictal imaging classic findings in epilepsy and 1 surgical treatable lesion
Interictal SPECT/PET: reflects not only ictal onset site, but areas of ictal spread and postictal depression
Seizure foci exhibiting decreased FDG uptake, suggesting hypometabolism
Area of hypometabolism cannot be used to refine surgical borders
May help with general localization and guiding placement of intracranial electrodes
Ictal SPECT/PET: localize epileptogenic focus during ictal state
Seizure foci appear as hypermetabolic areas
Surgically treatable conditions:
Ipsilateral mesial temporal sclerosis
Focal cortical dysplasia
Lateral temporal tumours (ganglioglioma, DNET, etc)
- 3 f dopa + cancers
1. GI/pancreatic neuroendocrine tumours Insulinoma Gastrinoma VIPoma Glucagonoma Somatostatinoma
- Other neuroendocrine:
Carcinoid
Pheochromocytoma
Paraganglioma
- 4 benign disease with increased Octreoscan (RC)
Paraganglioma Pituitary adenoma Sarcoid Meningioma Accessory spleen/splenosis Thymoma
- Graves with ophthalmopathy, 4 adverse effects and what to do about eyes (RC)
? Adverse effects of I31 treatment was a prior recall. If so: Side effects: Thyroid storm Sialadenitis Exacerbation of ophthalmopathy Hypothyroidism (long term)
Prophylactic treatment for ophthalmopathy:
Prophylactic prednisone 0.5 mg/kg 1 month after I-131 therapy, then taper over 3 months
- 40 years old with Thyroid cancer TNM with 2.5 cm tumour and 1 pretracheal node, what if patients has mets what stage. (RC)
If no distant mets and age < 55 = Stage 1 (Any T Any N)
If distant mets and age < 55 = Stage 2 (Any T, Any N)
3 ways to prep patient for sarcoidosis cardiac pet
Different than viability imaging - want no uptake in myocardium therefore circulating levels of insulin should be low
No carb diet for at least 24 hours
NPO for at least 12 hours
+/- heparin
FDG with 60 min uptake time
- 4 meds that decrease RAIU (RC)
PTU Tapazol Iodinated contrast Perchlorate Lugol’s Synthroid
- 4 enshrined principles of health research (RCish)
Autonomy - autonomy of thought, intention, and action when making decisions
Nonmaleficence - procedure does not harm the patient involved or others in society
Beneficence - intent of doing good for the patient involved
Justice - the burdens and benefits of new or experimental treatments must be distributed equally among all groups in society
- 4 reasons to do first pass study in kids
Calculating left and right ventricular ejection fractions
Assessing wall motion abnormalities
Quantifying left-to-right cardiac shunts
Measuring cardiac output and absolute ventricular chamber volumes
- 4 contraindications to dipyridamole (RC)
Allergy to dipyridamole, adenosine
Severe bronchospasm (severe COPD or asthma)
Systemic hypotension (systolic < 90 mmHg)
Type 2B or 3 AV block
Caffeine / xanthines within last 12 hrs
Acute myocardial infarction within last 48 hrs
- 2 ways indirect radionuclide cystography worse than direct cystography
Indirect RNC vs Direct RNC
Advantages:
Permits evaluation of renal function and urine drainage as well as detection of VUR.
Less traumatic / no risk of urinary infection
More physiologic because of the normal voiding pressure.
Disadvantages :
Less sensitive than direct cystography
Requires complete cooperation from patient (Not for newborn, etc because they need to hold before voiding)
A camera must be ready when they need to void
It cannot be used to see if there is passive (before voiding) VUR.
Direct RNC vs VCUG Advantages At least and probably more sensitive than VCUG Allows for continuous monitoring Overlying bowel contents not a factor Gonadal dose is about 1/100 of VCUG
Disadvantages:
Can’t evaluate male urethra
Minor bladder abnormality such as diverticula can’t be detected
Reflux can’t be graded based on the 5 grade international system
Findings on bone scan in medial meniscus injury (RC)
Peripheral increased uptake in crescentic pattern in the tibial plateau as well as focal posterior femoral condylar uptake
Other elements:
Medial collateral ligament, ACL
Tibial plateau fracture
- 4 causes of neonatal hyperbilirubinemia (RC)
Surgical:
Biliary atresia
Choledochal cyst
Stricture
Medical:
Infectious hepatitis (TORCH, syphilis, viral, sepsis)
Metabolic (galactosemia, alpha-1 antitrypsin)
Endocrine: hypothyroidism, hypopituitarism
Cystic fibrosis
- Flare phenomena and why does it occur? (RC)
Paradoxical increase in abnormal tracer uptake on bone scan (#/intensity) after therapy.
Between 2 weeks and 3 months post therapy and it should subsequently decrease on repeat exam at 2-3 months but may last up to 6 months.
Due to increased osteoblastic activity caused by skeletal healing in response to therapy, a favorable response
- 3 of classic Meckel’s rule of 2s
Rule of 2’s: 2% population 2% become symptomatic 2 feet from the ileocecal valve 2 main complications: bleeding/obstruction 2 inches in length 2:1 male:female < 2 years old are most symptomatic
- 2 cell types of thyroid and biochemical indices of associated cancers (RC)
Two cell types:
Follicular cells - secrete thyroid hormone
Parafollicular/C cells - secrete calcitonin
Follicular cells
Associated cancers = papillary and follicular
Biochemical marker = thyroglobulin
Parafollicular cells
Associated cancer = medullary
Biochemical marker = CEA and calcitonin
- 2 early and 1 late complication of radiosynovectomy (RC)
Early:
Erythema, skin necrosis
Temporary increase in synovitis and pain is common before improvement at 1 mos.
Other complications of any puncture including infection, haemorrhage, etc.
Risk of DVT since immobilization for 48 hours is required
Late:
Hyaline cartilage breakdown
“Hematologic malignancy, following knee injection of 90Y colloid, regional lymph node dose is estimated at 100 Gy, although no definite evidence for malignancy, only theoretic”. (old recall)
List categories of Deauville classification? How do you denote a lesion that is not related to lymphoma? (RC)
Deauville:
5-point scoring system
Internationally accepted for FDG avidity of a
Hodgkin’s lymphoma or Non-Hodgkin’s lymphoma mass as seen on FDG PET
Deauville 1 – No FDG activity
Deauville 2 – FDG activity <= mediastinal blood pool
Deauville 3 – FDG activity > mediastinal blood pool and <= Liver
Deauville 4 – FDG activity greater than liver
Deauville 5 - FDG activity markedly greater than liver (2-3x) and/or new lesions
: list 4 techniques or reading methods to deal with breast attenuation artifact
Breast binding (Practical nuclear medicine, pg.164)
Attenuation correction, assess the rotating raw planar projection images to confirm
NH3 PET, less likely to suffer from attenuation artefact (works for obese people)
Ensure that breasts are in the same position on both sets of images
Assess for normal regional wall motion.
Prone imaging?
- 5 causes of lung uptake on sulfur colloid (expanded RC)
Excess aluminum in radiopharmaceutical (floccular precipitant)
Medications containing aluminum (i.e. antacids)
Overheating/overboiling radiopharmaceutical (results in larger particles)
———–
Diffuse hepatic parenchymal disease
Amyloidosis
Elevated magnesium levels
Mucopolysaccharidosis
- 5 conditions/substances - do they accelerate or delay gastric emptying? (hyperthyroid, nicotine, Anorexia, Diabetic neuropathy, scleroderma, pyloroplasty)
Accelerate: Gastrin Erythromycin Thyroxine Metoclopramide Domperidone Cisapride Tegaserod Thyroxine ------------------ Gastritis Duodenal ulcer Zollinger Ellison syndrome Carb rich meal Hyperthyroidism Pyloroplasty
Delay: Nicotine CCK Secretin Progesterone Glucagon Somatostatin Opiates Atropine Nifedipine Progesterone Octreotide --------------------- Anorexia Hypothyroidism Fatty meal Protein meal Diabetic gastroparesis Scleroderma Amyloid
- What/why early post-op complication more common in cadaveric transplants than living donors
ATN significantly more frequent in cadaveric vs living donor transplants (25% vs 5%) Longer cold ischemic time Donor hypotension Excess lactate Increased vascular resistance
35 year old female Graves for radioiodine treatment. Has husband, two young kids, 1 hamster. List 8 radiation safety issues or adverse effects to discuss.
Side effects:
- Thyroid storm
- Sialadenitis
- Exacerbation of ophthalmopathy
- Hypothyroidism (long term)
- Neck tenderness
Safety Issues
- Separate bathroom
- Flush immediately
- Not primary child caregiver
- Drive home separate from children if possible
- Teratogenic (no pregnancy)
- No breastfeeding
- Urease products, 3 drugs that mess up and 2 false P (RC)
Urease products:
Ammonia + 14CO2
False positives:
Chewing capsule
Achlorhydria (overgrowth of non H-pylori bacteria)
Chemiluminescence
Interfering medications:
Antibiotics
PPI
Bismuth
- 6 high risk myocardial pet study findings (RCish if same as SPECT??)
Stress defect size and severity ≥ 10% Rest defect size and severity ≥ 10% Reversibility size and severity ≥ 10% Transient cavity dilation >1.13 Increased lung uptake - Visual estimate Rest LVEF - <40% Stress LVEF - <40% Increased RV tracer uptake - Visual estimate
