Mucosa-associated lymphoid tissue lymphoma with unusual 18F-FDG hypermetabolism arising at the colorectal anastomosis

Mucosa-associated lymphoid tissue (MALT) lymphoma usually originates from the stomach and presents with low ^(18)F-fluorodeoxyglucose (FDG) avidity with average maximum standard uptake value of 3.6. Colorectal MALT lymphoma is a rare entity that contributes to 1.6% of all MALT lymphomas and < 0.2% of large intestinal malignancies. The case reported herein firstly revealed stage Ⅱ MALT lymphoma with unexpected higher ^(18)F-FDG avidity of 18.9 arising at the colorectal anastomosis in a patient with a surgical history for sigmoid adenocarcinoma, which was strongly suspected as local recurrence before histopathological and immunohistochemical examinations. After accurate diagnosis, the patient received four cycles of standard R-CVP regimen (rituximab, cyclophosphamide, vincristine and prednisone), combined target therapy and chemotherapy, instead of radiotherapy recommended by National Comprehensive Cancer Network guidelines. He tolerated the treatment well and reached complete remission.

Unexpected focal fluorodeoxyglucose uptake in main organs;pass through or pass by?

Since the inception of fluorine-18 fluorodeoxyglucose(F-18 FDG),positron emission tomography/computed tomography(PET/CT)utilizing F-18 FDG has become widely accepted as a valuable imaging modality in the field of oncology,with global prevalence in clinical practice.Given that a single Torso PET/CT scan encompasses the anatomical region from the skull base to the upper thigh,the detection of incidental abnormal focal hypermetabolism in areas of limited clinical interest is both feasible and not uncommon.Numerous investigations have been undertaken to delineate the distinctive features of these findings,yet the outcomes have proven inconclusive.The incongruent results of these studies present a challenge for physicians,leaving them uncertain about the appropriate course of action.This article provides a succinct overview of the characteristics of fluorodeoxyglucose,followed by a comprehensive discussion of the imaging findings and clinical significance associated with incidental focal abnormal F-18 FDG activity in several representative organs.In conclusion,while the prevalence of unrecognized malignancy varies across organs,malignancies account for a substantial proportion,ranging from approximately one-third to over half,of incidental focal uptake.In light of these rates,physicians are urged to exercise vigilance in not disregarding unexpected uptake,facilitating more assured clinical decisions,and advocating for further active evaluation.

Focal incidental colorectal fluorodeoxyglucose uptake:Should it be spotlighted?

Fluorine-18 fluorodeoxyglucose(F-18 FDG)positron emission tomography/computed tomography(PET/CT)has emerged as a cornerstone in cancer evaluation imaging,with a well-established history spanning several years.This imaging modality,encompassing the examination of the body from the base of the skull to the upper thighs,comprehensively covers the chest and abdominopelvic regions in a singular scan,allowing for a holistic assessment of nearly the entire body,including areas of marginal interest.The inherent advantage of this expansive scan range lies in its potential to unveil unexpected incidental abnormal hypermetabolic areas.The identification of incidental focal FDG uptake within colorectal regions during PET/CT scans is not an uncommon occurrence,albeit fraught with challenges associated with non-specific FDG uptake.The presence of benign colorectal lesions or physiological uptake poses a particular obstacle,as these may manifest with FDG uptake levels that mimic malignancy.Consequently,physicians are confronted with a diagnostic dilemma when encountering abnormal FDG uptake in unexpected colorectal areas.Existing studies have presented divergent results concerning these uptakes.Standardized uptake value and its derivatives have served as pivotal metrics in quantifying FDG uptake in PET images.In this article,we aim to succinctly explore the distinctive characteristics of FDG,delve into imaging findings,and elucidate the clinical significance of incidental focal colorectal uptake.This discussion aims to contribute valuable insights into the nuanced interpretation of such findings,fostering a comprehensive understanding.

Current understanding of thermo(dys)regulation in severe burn injury and the pathophysiological influence of hypermetabolism,adrenergic stress and hypothalamic regulation-a systematic review

Background:In this systematic review,we summarize the aetiology as well as the current knowl-edge regarding thermo(dys)regulation and hypothermia after severe burn trauma and aim to present key concepts of pathophysiology and treatment options.Severe burn injuries with>20%total body surface area(TBSA)affected commonly leave the patient requiring several surgical procedures,prolonged hospital stays and cause substantial changes to body composition and metabolism in the acute and long-term phase.Particularly in severely burned patients,the loss of intact skin and the dysregulation of peripheral and central thermoregulatory processes may lead to substantial complications.Methods:A systematic and protocol-based search for suitable publications was conducted fol-lowing the PRISMA guidelines.Articles were screened and included if deemed eligible.This encompasses animal-based in vivo studies as well as clinical studies examining the control-loops of thermoregulation and metabolic stability within burn patients Results:Both experimental animal studies and clinical studies examining thermoregulation and metabolic functions within burn patients have produced a general understanding of core concepts which are,nonetheless,lacking in detail.We describe the wide range of pathophysiological alterations observed after severe burn trauma and highlight the association between thermoregulation and hypermetabolism as well as the interactions between nearly all organ systems.Lastly,the current clinical standards of mitigating the negative effects of thermodysregulation and hypothermia are summarized,as a comprehensive understanding and implementation of the key concepts is critical for patient survival and long-term well-being.Conclusions:The available in vivo animal models have provided many insights into the interwoven pathophysiology of severe burn injury,especially concerning thermoregulation.We offer an outlook on concepts of altered central thermoregulation from non-burn research as potential areas of future research interest and aim to provide an overview of the clinical implications of temperature management in burn patients.

Metabolic theory of septic shock

Septic shock is a life threatening condition that can develop subsequent to infection. Mortality can reach as high as 80% with over 150000 deaths yearly in the United States alone. Septic shock causes progressive failure of vital homeostatic mechanisms culminating in immunosuppression, coagulopathy and microvascular dysfunction which can lead to refractory hypotension, organ failure and death. The hypermetabolic response that accompanies a systemic inflammatory reaction places high demands upon stored nutritional resources. A crucial element that can become depleted early during the progression to septic shock is glutathione. Glutathione is chiefly responsible for supplying reducing equivalents to neutralize hydrogen peroxide, a toxic oxidizing agent that is produced during normal metabolism. Without glutathione, hydrogen peroxide can rise to toxic levels in tissues and blood where it can cause severe oxidative injury to organs and to the microvasculature. Continued exposure can result in microvascular dysfunction, capillary leakage and septic shock. It is the aim of this paper to present evidence that elevated systemic levels of hydrogen peroxide are present inseptic shock victims and that it significantly contributes to the development and progression of this frequently lethal condition.

The pathogenesis and diagnosis of sepsis post burn injury

Burn is an under-appreciated trauma that is associated with unacceptably high morbidity and mortality.Although the survival rate after devastating burn injuries has continued to increase in previous decades due to medical advances in burn wound care,nutritional and fluid resuscitation and improved infection control practices,there are still large numbers of patients at a high risk of death.One of the most common complications of burn is sepsis,which is defined as“severe organ dysfunction attributed to host’s disordered response to infection”and is the primary cause of death in burn patients.Indeed,burn injuries are accompanied by a series of events that lead to sepsis and multiple organ dysfunction syndrome,such as a hypovolaemic state,immune and inflammatory responses and metabolic changes.Therefore,clear diagnostic criteria and predictive biomarkers are especially important in the prevention and treatment of sepsis and septic shock.In this review,we focus on the pathogenesis of burn wound infection and the post-burn events leading to sepsis.Moreover,the clinical and promising biomarkers of burn sepsis will also be summarized.

Status of adult inpatient burn rehabilitation in Europe: are we neglecting metabolic outcomes?

Background:Hypermetabolism,muscle wasting and insulin resistance are challenging yet important rehabilitation targets in the management of burns.In the absence of concrete practice guidelines,however,it remains unclear how these metabolic targets are currently managed.This study aimed to describe the current practice of inpatient rehabilitation across Europe.Methods:An electronic survey was distributed by the European Burn Association to burn centres throughout Europe,comprising generic and profession-specific questions directed at therapists,medical doctors and dieticians.Questions concerned exercise prescription,metabolic management and treatment priorities,motivation and knowledge of burn-induced metabolic sequelae.Odds ratios were computed to analyse associations between data derived from the responses of treatment priorities and knowledge of burn-induced metabolic sequelae.Results:Fifty-nine clinicians with 12.3±9 years of professional experience in burns,representing 18 out of 91 burn centres(response rate,19.8%)across eight European countries responded.Resistance and aerobic exercises were only provided by 42%and 38%of therapists to intubated patients,87%and 65%once out-of-bed mobility was possible and 97%and 83%once patients were able to leave their hospital room,respectively.The assessment of resting energy expenditure by indirect calorimetry,muscle wasting and insulin resistance was carried out by only 40.7%,15.3%and 7.4%respondents,respectively,with large variability in employed frequency and methods.Not all clinicians changed their care in cases of hypermetabolism(59.3%),muscle wasting(70.4%)or insulin resistance(44.4%),and large variations in management strategies were reported.Significant interdisciplinary variation was present in treatment goal importance ratings,motivation and knowledge of burn-induced metabolic sequelae.The prevention of metabolic sequelae was regarded as the least important treatment goal,while the restoration of functional status was rated as the most important.Knowledge of burn-induced metabolic sequelae was linked to higher importance ratings of metabolic sequelae as a therapy goal(odds ratio,4.63;95%CI,1.50–14.25;p<0.01).Conclusion:This survey reveals considerable non-uniformity around multiple aspects of inpatient rehabilitation across European burn care,including,most notably,a potential neglect of metabolic outcomes.The results contribute to the necessary groundwork to formulate practice guidelines for inpatient burn rehabilitation.

Disruption of orbitofrontal-hypothalamic projections in a murine ALS model and in human patients

Background:Increased catabolism has recently been recognized as a clinical manifestation of amyotrophic lateral sclerosis(ALS).The hypothalamic systems have been shown to be involved in the metabolic dysfunction in ALS,but the exact extent of hypothalamic circuit alterations in ALS is yet to be determined.Here we explored the integrity of large-scale cortico-hypothalamic circuits involved in energy homeostasis in murine models and in ALS patients.Methods:The rAAV2-based large-scale projection mapping and image analysis pipeline based on Wholebrain and Ilastik software suites were used to identify and quantify projections from the forebrain to the lateral hypothalamus in the SOD1(G93A)ALS mouse model(hypermetabolic)and the FusΔNLS ALS mouse model(normo-metabolic).3 T diffusion tensor imaging(DTI)-magnetic resonance imaging(MRI)was performed on 83 ALS and 65 control cases to investigate cortical projections to the lateral hypothalamus(LHA)in ALS.Results:Symptomatic SOD1(G93A)mice displayed an expansion of projections from agranular insula,ventrolateral orbitofrontal and secondary motor cortex to the LHA.These findings were reproduced in an independent cohort by using a different analytic approach.In contrast,in the FusΔNLS ALS mouse model hypothalamic inputs from insula and orbitofrontal cortex were maintained while the projections from motor cortex were lost.The DTI-MRI data confirmed the disruption of the orbitofrontal-hypothalamic tract in ALS patients.Conclusion:This study provides converging murine and human data demonstrating the selective structural disruption of hypothalamic inputs in ALS as a promising factor contributing to the origin of the hypermetabolic phenotype.

Effects of enteral nutrition with different energy supplies on metabolic changes and organ damage in burned rats

Background:Enteral nutrition(EN)is an important treatment for burn patients.However,severe gastrointestinal damage caused by major burns often leads to EN intolerance.Trophic EN solves this problem basically,but how to transition from trophic EN to standard EN smoothly is still a challenge in burn clinical nutrition.The aim of this study is to investigate the effects of EN with different energy supplies on metabolic changes,organ damage and prognosis in burned rats.Methods:Different feeding regimens were designed based on the continuous monitoring of resting energy expenditure in rats.Thirty-two Sprague-Dawley rats were randomly divided into a normal control group,burn+50%REE group,burn+75%REE group and burn+100%REE group.At the end of a nutritional treatment cycle(14th day),nuclear magnetic resonance spectroscopy,blood biochemistry analysis and quantification of subscab bacteria were performed to explore the differences in metabolic changes,degrees of organ damage and prognoses between the groups.Results:Sixteen metabolites involving seven metabolic pathways were identified from the different energy supply groups.After burn injury,resting energy consumption and body weight loss increased obviously.Meanwhile,weight loss was inversely related to energy supply.The greatest changes in the degree of organ damage,the level of plasma proteins,lipids and endotoxins,as well as the quantification of subscab bacteria were observed in the 50%REE group,followed by the 75 and 100%groups.Conclusions:Achieving an early balance between energy supply and expenditure is conducive to mitigating metabolic disorders and improving prognosis after burn injury.