Nuclear Medicine Imaging for Dementia

Bruno, Michael mbruno at HMC.PSU.EDU
Thu Jul 28 13:57:46 UTC 2016


The old Ceretec™ perfusion SPECT scans we used to routinely perform do indeed have a sensitivity/specificity in the 70-80% range for Alzheimer’s and other types of dementia, and that is probably what you’re thinking of, Peter.

More recently, as Sherri mentioned, new nuclear/radiology hybrid imaging tools such as DaTScan SPECT and Amyvid PET-CT have been introduced (see the website: https://amyvid.myregistrationp.com/amyvid/login.do), and these have improved on those numbers quite a bit.  We’re currently offering those services here in our Nuclear Medicine division at Penn State Hershey as well.  DatScan is a measure of the density of dopamine receptors in the striatum and is very good for detecting parkinsonian syndromes of all types, and Amyvid detects the amyloid deposits in Alzheimer’s disease.

[cid:image004.png at 01D112FF.F77F98B0]
Michael A. Bruno, M.S., M.D., F.A.C.R.
Professor of Radiology & Medicine
Vice Chair for Quality & Patient Safety
Chief, Division of Emergency Radiology
Penn State Milton S. Hershey Medical Center
• (717) 531-8703  |  • mbruno at hmc.psu.edu<mailto:mbruno at hmc.psu.edu>  |  6 (717) 531-5737
[cid:image001.jpg at 01D04A9B.917CDCD0]

*****E-Mail Confidentiality Notice*****
This message (including any attachments) contains information intended for a specific individual(s) and purpose that may be privileged, confidential or otherwise protected from disclosure pursuant to applicable law.  Any inappropriate use, distribution or copying of the message is strictly prohibited and may subject you to criminal or civil penalty.  If you have received this transmission in error, please reply to the sender indicating this error and delete the transmission from your system immediately.




From: Sherri Loeb [mailto:sherriloeb at GMAIL.COM]
Sent: Wednesday, July 27, 2016 10:45 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Mayo Clinic study finds men with Alzheimer's are misdiagnosed more often than women

I find this conversation very interesting as I am an RN and Research Coordinator for an amazing behavioral neurologist. We do not just assign the diagnosis of Alzheimer's to patients. There are several diagnostic tests to help truly define the diagnosis of Alzheimer's vs Lewy Body vs Frontal temporal dementia vs vascular dementia. Through the use of DAT spect scans, amyloid PET scans and csf analysis it is much easier to give a fairly concrete diagnosis to patients and thus better suggest palliative tx as opposed to a cure. In addition with better ability to diagnose the ability to enroll in clinical trials is then available to the patients.

Hope this helps.

Sherri

Sent from my iPhone

On Jul 27, 2016, at 9:26 PM, Elias Peter <pheski69 at GMAIL.COM<mailto:pheski69 at gmail.com>> wrote:
Helene -

Thank you for that added information.  My understanding has been that SPECT has sensitivities in the 70-80% range, making usefulness very dependent on pre-test probability.

I’m curious. What sensitivity/specificity do the NYPresby radiologists have with SPECT for AD, and how have they derived the sensitivity/specificity data? Is it published?

Thanks.

Peter Elias, MD


On 2016.07.27, at 10:01 PM, HM Epstein <hmepstein at GMAIL.COM<mailto:hmepstein at GMAIL.COM>> wrote:

Peter:
I agree with all you wrote but one point. There is a test I'm aware of that can be done on a living patient to identify Alzheimer's. NY Presbyterian's radiologists have been using brain SPECT scans for over a decade with great success and specificity to identify a range of neurological and auto-immune diseases.

Although they aren't the only ones who do SPECT scans, I am unfamiliar with the success rates of other radiology departments.

Best,
Helene

--

hmepstein.com<http://hmepstein.com/>
@hmepstein
Mobile: 914-522-2116

Sent from my iPhone





On Jul 27, 2016, at 3:13 PM, Elias Peter <pheski69 at GMAIL.COM<mailto:pheski69 at gmail.com>> wrote:
Wickedly complex and nuanced response beyond me at the moment, but it is a very good set of questions and deserves at least a start of a reply.

Dementia is a family of diagnoses/conditions. Most are ‘clinical syndromes’ meaning that they are a label applied to a constellation of clinical characteristics that tend to occur in a group. For most of these, a specific diagnosis (which requires knowing the cause and pathologic process) is either not possible at all, or only possible post mortem. The labels serve two purposes:


  *   provide some degree of predictive information (this pattern usually progresses slowly/fast/episodically, or this pattern tends to cause aggression/incontinence/language problems).
  *   help make educated guesses about what interventions might be useful. (E.g., smoking cessation and control of BP in multi-infarct dementia.)

There are some demented states that have a specific and identifiable cause: b12 deficiency, hypothyroidism. These are relatively uncommon but worth looking for (obviously) and very gratifying when found - if found early enough to prevent permanent damage. (This is in contrast to delirium, where underlying causes are pretty common.)

Alzheimer’s is still a pathologic diagnosis. Technically, it can only be made at autopsy. There is still no accepted accurate test with acceptable sensitivity and specificity. On top of that, the medications used have statistically significant but often clinically meaningless benefits: delaying institutionalization by several months, for example.

The clinical challenge is that because Alzheimer’s (which is increasingly looking like it has more than one sub-type) is a syndrome rather than a disease, is not easily and reliably differentiated from other dementing processes, can occur in parallel with other dementing processes, and because treatment is minimally effective for almost all dementia, no one wants to be honest about it. Clinicians don’t like to be powerless and patients and family desperately want more optimism and certainty than is usually appropriate.

The most important two things I found were:


  *   Honest discussion about what we know and don’t know with patient and caregivers.
  *   Focus on management of the environment and robust support rather than on medication.

Dunno if that helps.

Peter

On 2016.07.27, at 12:07 PM, Peggy Zuckerman <peggyzuckerman at GMAIL.COM<mailto:peggyzuckerman at GMAIL.COM>> wrote:

Having been involved in a small way with a re-design workshop for Alzheimer's patients, I have become very concerned that there is no clear way to diagnosis Alzheimer's patients.  Certainly there was no agreed upon way to analyse the potential patients at an early time, such that interventions can be readily administered and monitored.

My mother-in-law had Alzheimer's, or at least was treated with multiple medications for that, yet there was never any testing or monitoring for that, other than that which was reported by the family, and eventually, the caregivers.  I do remember conversations which were absolutely normal, reflecting a sense of the information, older memories, good judgement, and then the next day she clearly did not remember that her husband had died  10 years earlier.  Since her older sister also had some form of dementia, it was assumed by most that this was a familial form of Alzheimers--those the physician daughter of the sister who is a neurologist said that neither had Alzheimer's, as per her review.

So how is Alzheimer's really recognized, and how is it differentiated from other forms of dementia, and how that that diagnosis challenge handled in clinical settings?
Peggy

Peggy Zuckerman
www.peggyRCC.com<http://www.peggyrcc.com/>

On Wed, Jul 27, 2016 at 6:47 AM, HM Epstein <hmepstein at gmail.com<mailto:hmepstein at gmail.com>> wrote:
Well, Bill, that's a good question that the article didn't address. It does say that men may contract Alzheimer's earlier than women do and that it impacts memory less frequently in men than it does women, hence the diagnostic difficulty. It also says that the disease progresses more rapidly in men than women.

So I'll make an educated (though not medical school educated) guess based on those elements.

When a man in his 60s with rapidly progressive Alzheimer's is not diagnosed it causes great harm to the wife, and other family members. According to the researcher, in addition to memory loss, Alzheimer's is associated with "language impairment, motor disfunction, behavioral issues and apathy". Behavioral issues include being argumentative and the disease often leads to violent tendencies. Being friends with some spouses of Alzheimer's patients, I can't imagine them having survived even the early symptoms without knowing why their husband or wife was acting so erratically. As one girlfriend told me when her husband was diagnosed with early onset Alzheimer's, "At least now I know why he was being such an a-----e."

While there's no cure for Alzheimer's, there are treatments to mitigate some of the symptoms. And promising new clinical trials.

As it is for most Dx errors, not having a diagnosis or having an incorrect diagnosis means a waste of time and money meeting with psychiatrists and neurologists, paying for and suffering through the side effects of the wrong meds. The expense of seeking a diagnosis wastes money desperately needed for care when the patient is no longer able to be alone.

An early Alzheimer's diagnosis means that the family can plan and prepare, mentally, emotionally and financially for the nightmare years ahead.

Will this study help physicians think of Alzheimer's when a male patient presents with the symptoms but without memory loss? Perhaps they might add a brain SPECT scan to the list of tests when the other tests come back negative. That's a proven way to identify Alzheimer's before waiting to autopsy the patient's brain.

Those are my thoughts. What do the experts on this list think? Bill?

Best,
Helene

--

hmepstein.com<http://hmepstein.com/>
@hmepstein
Mobile: 914-522-2116<tel:914-522-2116>

Sent from my iPhone



On Jul 27, 2016, at 6:03 AM, DR WILLIAM CORCORAN <williamcorcoran at sbcglobal.net<mailto:williamcorcoran at sbcglobal.net>> wrote:
Helene,

What harm resulted from the inaccurate diagnosis?

What should we get out of this article?

Take care,

Bill Corcoran


William  R. Corcoran, Ph.D., P.E.
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779<tel:860-285-8779>
William.R.Corcoran at 1959.USNA.com<mailto:William.R.Corcoran at 1959.usna.com>
http://www.linkedin.com/in/williamcorcoranphdpe
https://www.box.com/shared/kfxg1lt9dh

On Tuesday, July 26, 2016 8:45 PM, HM Epstein <hmepstein at GMAIL.COM<mailto:hmepstein at gmail.com>> wrote:

"Thirty-four percent of the men with Alzheimer’s who donated their brains to the State of Florida brain bank were inaccurately diagnosed, researchers found. Only 22 percent of women with Alzheimer’s were misdiagnosed. Researchers were able to identify the donated brains as having come from people Alzheimer’s because of the presence of the tau and amyloid proteins found in the brain of someone with Alzheimer’s."
http://jacksonville.com/news/health-and-fitness/2016-07-26/story/mayo-study-finds-men-alzheimers-are-misdiagnosed-more-often

Best,
Helene
hmepstein.com<http://hmepstein.com/>
@hmepstein<https://twitter.com/hmepstein>
Mobile: 914-522-2116

________________________________

Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at list.improvediagnosis.org>

To unsubscribe from IMPROVEDX: click the following link:
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1 or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX-SIGNOFF-REQUEST at list.improvediagnosis.org>

Visit the searchable archives or adjust your subscription at: http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX
Moderator:David Meyers, Board Member, Society for Improving Diagnosis in Medicine

To learn more about SIDM visit:
http://www.improvediagnosis.org/


________________________________

Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>

To unsubscribe from IMPROVEDX: click the following link:
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1 or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG>

Visit the searchable archives or adjust your subscription at: http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX
Moderator:David Meyers, Board Member, Society for Improving Diagnosis in Medicine

To learn more about SIDM visit:
http://www.improvediagnosis.org/


________________________________

Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>

To unsubscribe from IMPROVEDX: click the following link:
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1

or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG>

Visit the searchable archives or adjust your subscription at: http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX


Moderator:David Meyers, Board Member, Society for Improving Diagnosis in Medicine

To learn more about SIDM visit:
http://www.improvediagnosis.org/



________________________________

Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at list.improvediagnosis.org>

To unsubscribe from IMPROVEDX: click the following link:
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1

or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX-SIGNOFF-REQUEST at list.improvediagnosis.org>

Visit the searchable archives or adjust your subscription at: http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX


Moderator:David Meyers, Board Member, Society for Improving Diagnosis in Medicine

To learn more about SIDM visit:
http://www.improvediagnosis.org/



________________________________

Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at list.improvediagnosis.org>

To unsubscribe from IMPROVEDX: click the following link:
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX-SIGNOFF-REQUEST at list.improvediagnosis.org>

Visit the searchable archives or adjust your subscription at: http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX

Moderator:David Meyers, Board Member, Society for Improving Diagnosis in Medicine

To learn more about SIDM visit:
http://www.improvediagnosis.org/

________________________________

Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>

To unsubscribe from IMPROVEDX: click the following link:
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG>

Visit the searchable archives or adjust your subscription at: http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX

Moderator:David Meyers, Board Member, Society for Improving Diagnosis in Medicine

To learn more about SIDM visit:
http://www.improvediagnosis.org/

To unsubscribe from the IMPROVEDX:
mail to:IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
or click the following link: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG

Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG

For additional information and subscription commands, visit:
http://www.lsoft.com/resources/faq.asp#4A

http://LIST.IMPROVEDIAGNOSIS.ORG/ (with your password)

Visit the searchable archives or adjust your subscription at:
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX

Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine

To unsubscribe from the IMPROVEDX list, click the following link:<br>
<a href="http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1" target="_blank">http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1</a>
</p>

HTML Version:
URL: <../attachments/20160728/f5ff0ad7/attachment.html> ATTACHMENT:
Name: image001.png Type: image/png Size: 2281 bytes Desc: image001.png URL: <../attachments/20160728/f5ff0ad7/attachment.png> ATTACHMENT:
Name: image002.jpg Type: image/jpeg Size: 3077 bytes Desc: image002.jpg URL: <../attachments/20160728/f5ff0ad7/attachment.jpg>


More information about the Test mailing list