Opportunities for improvement on current nuclear cardiology practices and radiation exposure in Latin America: Findings from the 65-country IAEA Nuclear Cardiology Protocols cross-sectional Study (INCAPS).

BACKGROUND: Comparison of Latin American (LA) nuclear cardiology (NC) practice with that in the rest of the world (RoW) will identify areas for improvement and lead to educational activities to reduce radiation exposure from NC. METHODS AND RESULTS: INCAPS collected data on all SPECT and PET procedures performed during a single week in March-April 2013 in 36 laboratories in 10 LA countries (n = 1139), and 272 laboratories in 55 countries in RoW (n = 6772). Eight "best practices" were identified a priori and a radiation-related Quality Index (QI) was devised indicating the number used. Mean radiation effective dose (ED) in LA was higher than in RoW (11.8 vs 9.1 mSv, p < 0.001). Within a populous country like Brazil, a wide variation in laboratory mean ED was found, ranging from 8.4 to 17.8 mSv. Only 11% of LA laboratories achieved median ED <9 mSv, compared to 32% in RoW (p < 0.001). QIs ranged from 2 in a laboratory in Mexico to 7 in a laboratory in Cuba. Three major opportunities to reduce ED for LA patients were identified: (1) more laboratories could implement stress-only imaging, (2) camera-based methods of ED reduction, including prone imaging, could be more frequently used, and (3) injected activity of 99mTc could be adjusted reflecting patient weight/habitus. CONCLUSIONS: On average, radiation dose from NC is higher in LA compared to RoW, with median laboratory ED <9 mSv achieved only one third as frequently as in RoW. Opportunities to reduce radiation exposure in LA have been identified and guideline-based recommendations made to optimize protocols and adhere to the "as low as reasonably achievable" (ALARA) principle.

Functional compared to anatomical imaging in the initial evaluation of patients with suspected coronary artery disease: An international, multi-center, randomized controlled trial (IAEA-SPECT/CTA study).

OBJECTIVE: To test the hypothesis that, in the initial evaluation of patients with suspected coronary artery disease (CAD), stress myocardial perfusion imaging (MPI) would result in less downstream testing than coronary computed tomographic angiography (CCTA). METHODS: In this international, randomized trial, mildly symptomatic patients with an intermediate likelihood of having CAD, and asymptomatic patients at intermediate risk of cardiac events, underwent either initial stress-rest MPI or CCTA. The primary outcome was downstream noninvasive or invasive testing at 6 months. Secondary outcomes included cumulative effective radiation dose (ERD) and costs at 12 months. RESULTS: We recruited 303 patients (151 MPI and 152 CTA) from 6 centers in 6 countries. The initial MPI was abnormal in 29% (41/143) and CCTA in 56% (79/141) of patients. Fewer patients undergoing initial stress-rest MPI had further downstream testing at 6 months (adjusted OR 0.51, 95% CI 0.28-0.91, P = 0.023). There was a small increase in the median cumulative ERD with MPI (9.6 vs. 8.8 mSv, P = 0.04), but no difference in costs between the two strategies at 12 months. CONCLUSION: In the management of patients with suspected CAD, a strategy of initial stress MPI is substantially less likely to require further downstream testing than initial testing with CCTA. TRIAL REGISTRATION: clinicaltrials.gov identification number NCT01368770.

Nuclear Cardiology Practice in Asia: Analysis of Radiation Exposure and Best Practice for Myocardial Perfusion Imaging　- Results From the IAEA Nuclear Cardiology Protocols Cross-Sectional Study (INCAPS).

BACKGROUND: This paper examines the current status of radiation exposure to patients in myocardial perfusion imaging (MPI) in Asia.Methods and Results:Laboratories voluntarily provided information on MPI performed over a 1-week period. Eight best practice criteria regarding MPI were predefined by an expert panel. Implementation of ≥6 best practices (quality index [QI] ≥6) was pre-specified as a desirable goal for keeping radiation exposure at a low level. Radiation effective dose (ED) in 1,469 patients and QI of 69 laboratories in Asia were compared against data from 239 laboratories in the rest of the world (RoW). Mean ED was significantly higher in Asia (11.4 vs. 9.6 mSv; P<0.0001), with significantly lower doses in South-East vs. East Asia (9.7 vs. 12.7 mSv; P<0.0001). QI in Asia was lower than in RoW. In comparison with RoW, Asian laboratories used thallium more frequently, used weight-based technetium dosing less frequently, and trended towards a lower rate of stress-only imaging. CONCLUSIONS: MPI radiation dose in Asia is higher than that in the RoW and linked to less consistent use of laboratory best practices such as avoidance of thallium, weight-based dosing, and use of stress-only imaging. Given that MPI is performed in Asia within a diverse array of medical contexts, laboratory-specific adoption of best practices offers numerous opportunities to improve quality of care.

Nuclear Cardiology Practices and Radiation Exposure in the Oceania Region: Results From the IAEA Nuclear Cardiology Protocols Study (INCAPS).

BACKGROUND: There is concern about radiation exposure with radionuclide myocardial perfusion imaging (MPI). This sub-study of the International Atomic Energy Agency (IAEA) Nuclear Cardiology Protocols Study reports radiation doses from MPI, and use of dose-optimisation protocols in Australia and New Zealand (ANZ), and compares them with data from the rest of the world. METHODS: Data were collected from 7911 MPI studies performed in 308 laboratories worldwide in one week in 2013, including 439 MPI studies from 34 ANZ laboratories. For each laboratory, effective radiation dose (ED) and a quality index (QI) score (out of 8) based on pre-specified "best practices" was determined. RESULTS: In ANZ patients, ED ranged from 0.9-17.9 milliSievert (mSv). Median ED was similar in ANZ compared with the rest of the world (10.0 (IQR: 6.5-11.7) vs. 10.0 (IQR 6.4-12.6, P=0.15), as were mean QI scores (5.5±0.7 vs. 5.4±1.3, P=0.84). Use of stress-only imaging (17.6% vs. 31.8% of labs, P=0.09) and weight-based dosing of technetium-99m (14.7% vs. 30.3%, P=0.07) was lower in ANZ compared with the rest of the world but this difference was not statistically significant. Median ED was significantly lower in metropolitan versus non-metropolitan laboratories (10.1 mSv vs. 11.6 mSv, P<0.01), although mean QI scores were similar (5.4±0.8 vs. 5.5±0.7, P=0.75). CONCLUSION: Across ANZ, there is variability in ED from MPI, and use of radiation safety practices, particularly between metropolitan and non-metropolitan laboratories. Overall, ANZ laboratories have a similar median ED to laboratories in the rest of the world.

Nuclear cardiology practice and associated radiation doses in Europe: results of the IAEA Nuclear Cardiology Protocols Study (INCAPS) for the 27 European countries.

PURPOSE: Nuclear cardiology is widely used to diagnose coronary artery disease and to guide patient management, but data on current practices, radiation dose-related best practices, and radiation doses are scarce. To address these issues, the IAEA conducted a worldwide study of nuclear cardiology practice. We present the European subanalysis. METHODS: In March 2013, the IAEA invited laboratories across the world to document all SPECT and PET studies performed in one week. The data included age, gender, weight, radiopharmaceuticals, injected activities, camera type, positioning, hardware and software. Radiation effective dose was calculated for each patient. A quality score was defined for each laboratory as the number followed of eight predefined best practices with a bearing on radiation exposure (range of quality score 0 - 8). The participating European countries were assigned to regions (North, East, South, and West). Comparisons were performed between the four European regions and between Europe and the rest-of-the-world (RoW). RESULTS: Data on 2,381 European patients undergoing nuclear cardiology procedures in 102 laboratories in 27 countries were collected. A cardiac SPECT study was performed in 97.9 % of the patients, and a PET study in 2.1 %. The average effective dose of SPECT was 8.0 ± 3.4 mSv (RoW 11.4 ± 4.3 mSv; P < 0.001) and of PET was 2.6 ± 1.5 mSv (RoW 3.8 ± 2.5 mSv; P < 0.001). The mean effective doses of SPECT and PET differed between European regions (P < 0.001 and P = 0.002, respectively). The mean quality score was 6.2 ± 1.2, which was higher than the RoW score (5.0 ± 1.1; P < 0.001). Adherence to best practices did not differ significantly among the European regions (range 6 to 6.4; P = 0.73). Of the best practices, stress-only imaging and weight-adjusted dosing were the least commonly used. CONCLUSION: In Europe, the mean effective dose from nuclear cardiology is lower and the average quality score is higher than in the RoW. There is regional variation in effective dose in relation to the best practice quality score. A possible reason for the differences between Europe and the RoW could be the safety culture fostered by actions under the Euratom directives and the implementation of diagnostic reference levels. Stress-only imaging and weight-adjusted activity might be targets for optimization of European nuclear cardiology practice.

Current worldwide nuclear cardiology practices and radiation exposure: results from the 65 country IAEA Nuclear Cardiology Protocols Cross-Sectional Study (INCAPS).

AIMS: To characterize patient radiation doses from nuclear myocardial perfusion imaging (MPI) and the use of radiation-optimizing 'best practices' worldwide, and to evaluate the relationship between laboratory use of best practices and patient radiation dose. METHODS AND RESULTS: We conducted an observational cross-sectional study of protocols used for all 7911 MPI studies performed in 308 nuclear cardiology laboratories in 65 countries for a single week in March-April 2013. Eight 'best practices' relating to radiation exposure were identified a priori by an expert committee, and a radiation-related quality index (QI) devised indicating the number of best practices used by a laboratory. Patient radiation effective dose (ED) ranged between 0.8 and 35.6 mSv (median 10.0 mSv). Average laboratory ED ranged from 2.2 to 24.4 mSv (median 10.4 mSv); only 91 (30%) laboratories achieved the median ED ≤ 9 mSv recommended by guidelines. Laboratory QIs ranged from 2 to 8 (median 5). Both ED and QI differed significantly between laboratories, countries, and world regions. The lowest median ED (8.0 mSv), in Europe, coincided with high best-practice adherence (mean laboratory QI 6.2). The highest doses (median 12.1 mSv) and low QI (4.9) occurred in Latin America. In hierarchical regression modelling, patients undergoing MPI at laboratories following more 'best practices' had lower EDs. CONCLUSION: Marked worldwide variation exists in radiation safety practices pertaining to MPI, with targeted EDs currently achieved in a minority of laboratories. The significant relationship between best-practice implementation and lower doses indicates numerous opportunities to reduce radiation exposure from MPI globally.

Evaluation of a novel decorporation approach to prevent radioactivity uptake by using acidosis in experimental animals.

With an aim to devise a prophylactic and/or therapeutic approach for preventing internalization of radiothallium (201Tl), and more importantly by implication, its chemical analogue radiocesium (137Cs) during any nuclear emergency, different ex vivo and in vivo animal models were created to determine the role ofpH in absorption of 201Tl across jejunum/muscle tissue and whole body retention of 201Tl respectively. Movement of Tl+ under simulated pH conditions proved that pH had direct influence on its absorption. Oral intake of acidified water or parenteral administration of lactic acid was able to reduce the body burden of 201Tl by up to 12 and 50% respectively. The results indicate that acidification of gut, within physiological range may be used as an option for decorporation/inhibition of incorporation of radiothallium and radiocesium, particularly in cases of mass casualty.

Use of technetium(99m)-ciprofloxacin scan in Pott's spine to assess the disease activity.

PURPOSE: The World Health Organisation has declared tuberculosis (TB) a global emergency and spinal tuberculosis is one of the most common forms. There is still controversy regarding optimum duration of treatment in osteoarticular tuberculosis due to the lack of well-defined criteria for the end point of treatment. Emergence of multi drug resistant tuberculosis, primarily due to use of poor drug regimens, further illustrates the need of newer and more effective diagnostic methods, particularly in developing countries. METHODS: This prospective clinical study to evaluate the role of technetium ((99m)Tc)-ciprofloxacin scan as a tool to assess disease activity involved in 15 cases of TB spine with a mean age of 32.2 years (range 21-72). Following a clinico-radiological diagnosis, all patients were treated with standard anti tubercular treatment and a scan was done at zero, three and six months of treatment with tracer activity being recorded and compared in sequential scans along with a parallel evaluation of clinical and radiological profile at regular intervals. RESULTS: Out of 15 cases, nine had an initially positive bone scan. Two patients (22%) converted to negative scans at three months, whereas the remaining seven (78%) turned negative at six months. The end of six months treatment was also accompanied by clinico-radiological resolution in all cases. CONCLUSION: In conclusion, technetium ((99m)Tc)-ciprofloxacin scan could be a promising tool for monitoring disease activity in selected cases of tuberculosis spine as an alternative for therapeutic drug monitoring; however, due to the small sample size, studies with a large number of patients might be of help in defining these cases in a better way.

Evaluation of adequacy of short-course chemotherapy for extraspinal osteoarticular tuberculosis using 99mTc ciprofloxacin scan.

In the evidence-based medicine era, objective treatment guidelines have been laid down for pulmonary tuberculosis, but the same is not true for osteoarticular tuberculosis. This has led to demands for standardising the treatment protocol and to a lack of consensus between doctors regarding the composition and duration of treatment. Twenty-five patients with extraspinal osteoarticular tuberculosis were evaluated prospectively. Following the diagnosis, patients were given standard directly observed treatment short course (DOTS) regimen and were monitored for disease activity at zero, three and six months with the help of technetium-99m-labelled ciprofloxacin ((99m)Tc) scan. Tracer activity at the site was recorded and compared on sequential scans. Clinical and radiological profile of all the patients were also recorded at regular intervals and compared. All 25 cases had a positive (99m)Tc bone scan initially. Four patients (16%) converted to negative scans at three months, whereas the remaining 21 patients (84%) showed negative scans at six months. The end of six months therapy also coincided with resolution of clinical and radiological parameters in all cases. In conclusion, (99m)Tc scan is a promising tool for monitoring drug response in osteoarticular tuberculosis; however, due to the small sample size, studies with a large number of patients might be of help.

A randomised controlled trial to assess the feasibility of utilising virtual reality to facilitate analgesia during external cephalic version.

External cephalic version (ECV) is associated with a moderate degree of pain. Virtual reality (VR) is a technology that has shown promise in offering procedural analgesia. We undertook a clinical pilot to assess the viability of VR to reduce pain during ECV. In an open randomised controlled trial (RCT), we randomised 50 women to either VR or standard care each (25 per group). Women receiving VR were administered VR content (Skylights) via a headset. Pre- and post-procedural measures of pain, anxiety, device experience and vital signs were measured. There were no significant differences between groups (VR/no VR) in pain scores (60.68 vs 49.76; p = 0.2), ECV success rates (80% vs 76%; p = 0.7) or anxiety levels. The women receiving VR had a significantly higher anticipation of pain pre-procedurally (70.0 vs 50.0; p = 0.03). 20 (80%) of the VR women indicated that they would use VR again and 22 (88%) indicated they would recommend it to a friend having ECV. There were no significant differences between groups for side effects encountered or changes in vital signs. We have shown that using VR during ECV is feasible and appears safe. Our results inform the design of future RCTs.

Development of atropine sulphate nasal drops and its pharmacokinetic and safety evaluation in healthy human volunteers.

INTRODUCTION: The increased use of organophosphate (OP) insecticides and the ever increasing possibility of terror groups using nerve agents underscore the need to develop effective and safe antidotes against OP poisoning. While intramuscular administration of nerve gas antidotes like atropine sulphate has certain lacunae, intravenous route is neither practical nor feasible in the field conditions for mass casualties. The objective was to develop a novel atropine sulphate nasal drop formulation, evaluate and characterize it using scintigraphy and to carry out safety-efficacy study in human volunteers with a view to obtain early pharmacological effects in comparison to the existing options, particularly the conventional intramuscular route. METHODS: Permeability studies were done using atropine sulphate solution containing variable amount of chitosan. Radiometric method was developed for scintigraphy studies while standard spectroscopy was used for the quantification of atropine sulphate in fluids. Concentration of atropine sulphate in nasal drops to produce therapeutic concentration in blood was calculated. Six volunteers (age range 18-53 years) were administered the formulation delivering 6mg of atropine sulphate each. Bioavailability and atropinization were noted serially. RESULTS: Based on the results of in vitro, human scintigraphy and analytical data, 1% atropine sulphate-0.5% chitosan was chosen as the final nasal formulation. Human bioavailability curve was created which showed that the therapeutic concentration of the drug in blood was reached within 5min with nasal drops suggesting that drug delivery through the nasal route is significantly better than the intramuscular route. Unpaired t-test between the means of baseline value of heart rate and that of each time interval showed that increase in heart rate of all the volunteers became significant at 15min (P<0.01) and extremely significant at 30min (P<0.001). Correlation was evident from 5min (c>0.7). Pupil diameter showed maximal increase at 30min (P<0.01). CONCLUSIONS: This novel product, 1% atropine sulphate-0.5% chitosan nasal drops might be a safe and efficacious emergency treatment of organophosphorous poisoning with several advantages over the present management, including early atropinization and capability of mass treatment in least amount of time.

Role of 99mTc-Tetrofosmin delayed scintigraphy and color Doppler sonography in characterization of solitary thyroid nodules.

OBJECTIVES: A study was undertaken to evaluate the diagnostic efficiency of Tc-Tetrofosmin scan and color Doppler in the characterization of benign and malignant solitary thyroid nodules. METHODS: Fifty-two patients found to have a cold solitary thyroid nodule on Tc-pertechnetate scintigraphy were included in this study. All patients underwent a single-injection dual-phase (30 min and 120 min) Tc-Tetrofosmin scan. The intranodular vascularity was measured using color Doppler sonography. Fine-needle aspiration cytology was performed on all the patients. In the following days and weeks all patients underwent surgery. RESULTS: Thirteen out of 15 patients with thyroid cancer showed delayed retention of radiotracer (on 120 min images as compared to the initial 30 min image). Thirty-six out of 37 patients harboring benign solitary nodules showed significant washout of tracer on delayed images. Sensitivity, specificity, positive predictive value and negative predictive value of delayed Tc-Tetrofosmin scintigraphy were found to be 86.6, 97.2, 92.8 and 94.7%, respectively. The Doppler study was able to demonstrate increased vascularity in the center of 8 of the 15 malignant nodules. Thirty-two patients harboring a benign solitary nodule showed normal or increased peripheral vascularity on Doppler study. Sensitivity, specificity, positive predictive value and negative predictive value of color Doppler were found to be 53.5, 86.4, 61.5 and 82%, respectively. CONCLUSION: Delayed Tc-Tetrofosmin scintigraphy is a highly sensitive and specific method for characterizing solitary thyroid nodules, while color Doppler has a low sensitivity but relatively high specificity in differentiating benign from malignant thyroid lesions.

Tc-99m ciprofloxacin scans for detection of tubercular bone infection.

Tc-99m MDP and Tc-99m ciprofloxacin scans were performed in 14 patients with suspected tubercular bone disease and in 2 cases of nontubercular bone infection. In 5 patients the findings were true negative. There were no false positives and 1 was false negative. The sensitivity, specificity, and positive predictive value were found to be 93, 71, and 87.5%, respectively, for detection of bone tubercular lesions. However, the test does not distinguish TB osteomyelitis from other types of osteomyelitis. Delayed 24 hour scans were found useful to differentiate between inflammatory and infective lesions. The aim of this study was to evaluate the usefulness of the Tc-99m ciprofloxacin scan as a means to detect tubercular bone disease.

Nuclear cardiology practices and radiation exposure in Africa: results from the IAEA Nuclear Cardiology Protocols Study (INCAPS).

OBJECTIVE: While nuclear myocardial perfusion imaging (MPI) offers many benefits to patients with known or suspected cardiovascular disease, concerns exist regarding radiation-associated health effects. Little is known regarding MPI practice in Africa. We sought to characterise radiation doses and the use of MPI best practices that could minimise radiation in African nuclear cardiology laboratories, and compare these to practice worldwide. METHODS: Demographics and clinical characteristics were collected for a consecutive sample of 348 patients from 12 laboratories in six African countries over a one-week period from March to April 2013. Radiation effective dose (ED) was estimated for each patient. A quality index (QI) enumerating adherence to eight best practices, identified a priori by an IAEA expert panel, was calculated for each laboratory. We compared these metrics with those from 7 563 patients from 296 laboratories outside Africa. RESULTS: Median (interquartile range) patient ED in Africa was similar to that of the rest of the world [9.1 (5.1-15.6) vs 10.3 mSv (6.8-12.6), p = 0.14], although a larger proportion of African patients received a low ED, ≤ 9 mSv targeted in societal recommendations (49.7 vs 38.2%, p < 0.001). Bestpractice adherence was higher among African laboratories (QI score: 6.3 ± 1.2 vs 5.4 ± 1.3, p = 0.013). However, median ED varied significantly among African laboratories (range: 2.0-16.3 mSv; p < 0.0001) and QI range was 4-8. CONCLUSION: Patient radiation dose from MPI in Africa was similar to that in the rest of the world, and adherence to best practices was relatively high in African laboratories. Nevertheless there remain opportunities to further reduce radiation exposure to African patients from MPI.

Gender Differences in Radiation Dose From Nuclear Cardiology Studies Across the World: Findings From the INCAPS Registry.

OBJECTIVES: The aim of this study was to investigate gender-based differences in nuclear cardiology practice globally, with a particular focus on laboratory volume, radiation dose, protocols, and best practices. BACKGROUND: It is unclear whether gender-based differences exist in radiation exposure for nuclear cardiology procedures. METHODS: In a large, multicenter, observational, cross-sectional study encompassing 7,911 patients in 65 countries, radiation effective dose was estimated for each examination. Patient-level best practices relating to radiation exposure were compared between genders. Analysis of covariance was used to determine any difference in radiation exposure according to gender, region, and the interaction between gender and region. Linear, logistic, and hierarchical regression models were developed to evaluate gender-based differences in radiation exposure and laboratory adherence to best practices. The study also included the United Nations Gender Inequality Index and Human Development Index as covariates in multivariable models. RESULTS: The proportion of myocardial perfusion imaging studies performed in women varied among countries; however, there was no significant correlation with the Gender Inequality Index. Globally, mean effective dose for nuclear cardiology procedures was only slightly lower in women (9.6 ± 4.5 mSv) than in men (10.3 ± 4.5 mSv; p < 0.001), with a difference of only 0.3 mSv in a multivariable model adjusting for patients' age and weight. Stress-only imaging was performed more frequently in women (12.5% vs. 8.4%; p < 0.001); however, camera-based dose reduction strategies were used less frequently in women (58.6% vs. 65.5%; p < 0.001). CONCLUSIONS: Despite significant worldwide variation in best practice use and radiation doses from nuclear cardiology procedures, only small differences were observed between genders worldwide. Regional variations noted in myocardial perfusion imaging use and radiation dose offer potential opportunities to address gender-related differences in delivery of nuclear cardiology care.

Anti-inflammatory activity of Seabuckthorn (Hippophae rhamnoides) leaves.

Immunomodulatory activity of Seabuckthorn (SBT) leaf extract was evaluated in adjuvant induced arthritis (AIA) rat model. Inflammation was induced by injecting Complete Freund's Adjuvant (CFA) in the right hind paw of rats. SBT extract was administered intraperitoneally to treat the inflammation. The extent of inflammation and treatment response was evaluated by clinical analysis, scintigraphic visualization using technitium-99m-glutathione (Tc99m-GSH) and lymphocyte proliferation. Serial evaluation was carried out on days 1, 7, 14, 21 and 28 after creation of inflammation. The Tc99m-GSH uptake in the inflamed leg was compared with the normal contralateral leg of the same animal. The measurements were done by obtaining scintigraphic images using gamma camera and an online computer. Both qualitative and quantitative evaluation of radiotracer accumulation was considered to evaluate the anti-inflammatory response. The lymphocyte proliferation study revealed cellular immunosuppression during the early phase of the disease. Administration of SBT extract on the same day or 5 days prior to inflammatory insult into the joint, significantly reduced the inflammation as compared to the untreated animals in a dose dependent manner. These observations suggest that the SBT leaf extract has a significant anti-inflammatory activity and has the potential for the treatment of arthritis.

Etiology and clinical predictors of intractable epilepsy.

To determine the etiology and clinical predictors of intractable epilepsy, a case-control study comprising 50 patients and 50 control subjects was performed. Patients included children who had more than one seizure per month over at least 6 months. Control subjects included children with epilepsy who had been seizure-free for more than 6 months. Patients were evaluated with special reference to birth history and development. Clinical examination and neurodevelopmental assessment were performed in all the patients. Drug monitoring was performed to exclude pseudointractability. Epilepsy in the study group was caused by perinatal problems (48%) and sequelae of central nervous system infection (24%) and was idiopathic in 20%. In the control group, epilepsy was idiopathic in 72%, a result of calcified granuloma in 22%, and perinatal problems comprised 6% of the subjects. On univariate analysis, strong association was evident between intractable epilepsy and several factors, including age at onset of seizure, remote symptomatic epilepsy, initial seizure type, history of neonatal seizure, high initial seizure frequency, microcephaly, and neurologic impairment. On multivariate analysis, neurologic impairment (odds ratio [OR] 12.25; 95% confidence interval [CI] 3.58-41.89), age at onset of seizure less than 1 year (OR 11.70; 95% CI 2.95-46.43), myoclonic seizure/infantile spasm (OR 10.36; 95% CI 2.39-44.93), and remote symptomatic epilepsy (OR 2.9; 95% CI 1.13-7.43), were independent predictors of intractability.

Unusual widespread metastatic presentation of mixed medullary-follicular thyroid carcinoma.

Mixed medullary-follicular thyroid carcinoma (MMFTC) is a rare tumor with a metastatic behavior that has not been fully appreciated. Scintigraphy and radioiodine entrapment propensity of its metastases remains largely undescribed. The authors present a case of MMFTC with widespread bone and soft-tissue metastases, where every known site of metastases concentrated radioiodine intensely. The patient responded well to radioiodine therapy. The report suggests that the tumor may have a propensity to metastasize to the skeleton, and the metastases retain the ability to accumulate radioiodine.

Differentiation of malignant and benign solitary thyroid nodules using 30- and 120-minute tc-99m MIBI scans.

Technetium-99m methoxy isobutylisonitrate (MIBI) has been found to be taken up by various tumors, including thyroid cancer. We prospectively evaluated 77 patients with cold thyroid solitary nodules on Tc-99m pertechnetate scintigraphy to evaluate the diagnostic value of Tc-99m MIBI scintigraphy. The aim of this study was to find out if thyroid nodules can be characterized on the basis of retention of MIBI and whether preoperative evaluation of malignancy is possible using this method. Single injection, dual-phase (30 and 120 minutes) thyroid scintigraphy using Tc-99m MIBI was performed in all these patients. In the following days and weeks, all patients underwent surgery. Using the 120/30-minute thyroid lesion to background radiouptake ratio (RUR), malignant and benign thyroid nodules could be separated with a sensitivity, specificity, and positive predictive value of 84.4%, 95.45%, and 93.33%, respectively. The mean RUR for malignant thyroid lesions was found to be 1.57+/-0.32, whereas for benign lesions, the ratio was significantly lower, 0.32+/-0.19. In conclusion, fine needle aspiration cytology along with the 120/30 minutes Tc-99m MIBI scintigraphy ratio appears to be useful in the preoperative assessment of solitary thyroid nodules.

Detecting protein losing enteropathy by Tc-99m dextran scintigraphy: a novel experience.

OBJECTIVE: To evaluate protien using enteropathy by Tc-99m dextran scintigraphy. METHODS: Methods for detecting protein loss from the intestine revolve around fecal nitrogen excretion, the clearance of alpha-1 antitrypsin in stools and by endoscopic biopsy. RESULT: The diagnosis of protein-losing enteropathy (PLE) can also be established by a scintigraphic method that is noninvasive, simple and requires no patient preparation or motivation. This diagnostic modality can also delineate the site of protein loss, thereby offering a targeted approach, and if need be, surgery. Radiolabelling of a non-protein, noncolloidal, nonparticulate and biofriendly molecule like dextran with Technetium-99m for imaging enteric protein loss was utilized in imaging eight children with PLE. CONCLUSION: The results were encouraging. The authors advocate the use of this diagnostic tool in identifying patients with PLE, particularly in the pediatric age group.