Calyx to Parenchymal Ratio (CPR): An unexplored tool and its utility in the follow-up of pyeloplasty.

INTRODUCTION: Antero-posterior trans pelvic diameter (APD) and renal scintigraphy play a significant role in the diagnosis of pelvi-ureteric junction (PUJ) obstruction and postoperative follow-up following pyeloplasty. However, the APD varies irrespective of improvement, deterioration, or preserved function in a hydronephrotic kidney and is not a reliable parameter due to various factors (hydration status, compliance, and reduction pyeloplasty). Calyx to Parenchymal Ratio (CPR) is the ratio of the depth of the calyx and parenchymal thickness measured on ultrasound (USG) in coronal image. We assessed the utility of CPR in the follow up of pyeloplasty and compared it with the commonly used APD of the pelvis and renal scintigraphy. MATERIAL AND METHODS: A prospective cohort study was done from July 2016 to October 2017. During this period 73 pyeloplasties were done, and 62 cases meeting the inclusion criteria were enrolled. All the children underwent ultrasound and Technetium-99 m Ethylene dicysteine isotope renogram (EC) scan before and after pyeloplasty. APD and CPR values were measured on USG and compared with isotope renogram outcomes in these children in the preoperative versus postoperative period. Two defined objective variables ΔAPD, percent ΔAPD and ΔCPR, percent ΔCPR were compared with categorical variables that would predict the surgical outcome as - failed, successful or equivocal. Multinomial logistic regression analysis and receiver operating curve (ROC) analysis was used to identify predictive accuracy. RESULTS: The mean (range) APD value recorded in the preoperative period was 3.67 cm (1.40-8.00 cm), which decreased to 1.67 cm (0.40-6.50) postoperatively, which was 54.2% lower (P=<0.001). The mean (range) CPR value decreased from 5.96 (1.20-20.00) in the preoperative period to 2.57 (0.43-10.90) postoperatively, which was 56.8% lower (P=<0.001). On multinomial logistic regression analysis, ΔCPR was found to be a significant predictor of outcome with an overall accuracy of 95.1%, change in CPR was a better predictor of success after pyeloplasty as compared to change in APD, which had an overall accuracy of 85.2% (p = 0.01). Further, on ROC curve analysis, we observed that ΔCPR and %ΔCPR can strongly predict successful pyeloplasty with a sensitivity of each with 96% and 98% respectively and AUC of 0.897 and 0.799 respectively. DISCUSSION: USG (APD) and renogram are the most widely used investigation in follow-up of pyeloplasty; however, APD has its own limitations like operator variability and slower improvement. CPR has the advantages that neither calyceal depth nor parenchymal thickness is directly altered during the surgery, and early resolution of calyceal dilatation and rapid parenchymal growth following pyeloplasty and thus a surgeon independent parameter. Our results have shown that ΔCPR can identify successful pyeloplasty with strong prediction than ΔAPD and thus renal scans can be avoided if there is visible improvement in CPR on follow-up. CONCLUSIONS: Our study identified a change in CPR, i.e., ΔCPR as a strong predictor of surgical outcome, as it is not influenced by extent of pelvis reduction during pyeloplasty and early to change. Using this parameter, we can avoid unnecessary repeated nuclear scans based on persistent high APD values and optimize resource utilization. We recommend the use of CPR in routine practice in the preoperative and postoperative follow-up of PUJ obstruction following pyeloplasty.

Congenital hypothyroidism presenting as menorrhagia in adulthood.

Although hypothyroidism is a common cause of menorrhagia, it is an uncommon presentation of congenital hypothyroidism. We report a case of congenital hypothyroidism presenting in adulthood with severe menorrhagia. Despite the late presentation, she had features to suggest hypothyroidism since birth.

Use of atropine in patients with recent myocardial infarction during exercise myocardial perfusion study. Use of atropine during exercise myocardial perfusion SPECT.

BACKGROUND: Patients with recent myocardial infarction frequently require a myocardial perfusion study for risk stratification. However a conclusive study cannot be accomplished in many due to non-attainment of target heart rate. AIM OF THE STUDY: To evaluate the effect of pre-stress administration of atropine in exercise performance of patients with recent myocardial infarction. MATERIAL AND METHODS: Study included 43 test and 43 control patients and were matched for their age, sex, status of pretest exercise tolerance, area of infarction and for interval between infarction and stress thallium test. Atropine (0.01 mg/kg) was administered intravenously 3 min prior to treadmill stress in all the 43 test patients and no atropine was administered to control patients. RESULTS: Target heart rate was attained in 95.3% patients receiving atropine compared to in 67.4% of control patients. There was no significant difference between mean ages (p>0.33), basal BP (p>0.47), peak BP (p>0.18) of both groups. There was significant difference between the increment in exercise-induced heart rate (p<0.004), peak heart rate (p<0.001) and double product (p<0.001) attained between both groups. No significant adverse effect was noted in patients who received atropine. CONCLUSION: Pre-stress administration of atropine in patients with recent myocardial infarction is safe and results in a significantly better exercise performance, which might be useful in decreasing the number of equivocal myocardial perfusion studies.

Evaluation of Tc99m-glucoheptonate for SPECT functional imaging of medulloblastoma.

OBJECTIVES: Functional imaging of medulloblastoma using SPECT has been a difficult problem as this tumour does not concentrate conventional brain tumour imaging radiopharmaceuticals. This study aimed to evaluate Tc99m-glucoheptonate as a "brain tumour-seeking" radiopharmaceutical for functional imaging of medulloblastoma. METHODS: Tc99m-glucoheptonate brain SPECT was performed in 27 patients with medulloblastoma after radiation therapy and with clinical suspicion of tumour recurrence. Histological verification was obtained within 7 days in patients with a SPECT diagnosis of tumour recurrence. Patients with a SPECT diagnosis of post-radiation gliosis were clinically observed for a minimum period of one year after the SPECT study. RESULTS: Fourteen patients had increased radiotracer uptake in the primary tumour bed, suggesting tumour recurrence. Histopathology confirmed viable medulloblastoma in all cases. Thirteen patients had no increased tracer uptake in the primary tumour bed, suggesting post-radiation gliosis. They all had a clinical course consistent with post-radiation gliosis. CONCLUSION: Tc99m-glucoheptonate is an ideal SPECT tracer for functional evaluation of medulloblastoma. SPECT utilising Tc99m-glucoheptonate is a reliable diagnostic modality to differentiate tumour recurrence from post-radiation gliosis in patients with medulloblastoma.

Does I-131-MIBG underestimate skeletal disease burden in neuroblastoma?

BACKGROUND: Controversy persists as to the need for both MIBG and bone scanning in routine evaluation of neuroblastoma. AIM: To compare the efficacy of I-131- metaiodobenzylguanidine (MIBG) scan against that of conventional Tc99m- methylene diphosphonate (MDP) bone scan for the detection of skeletal deposition of neuroblastoma. METHODS AND MATERIAL: The study included 57 patients (36 boys, 21 girls: age range 1-14 years) of neuroblastoma who underwent both bone scan with Tc99m-MDP and I-131-MIBG scan within 15 days of each other at presentation and during follow-up. RESULTS: At presentation 11(19.2%) patients had evidence of skeletal metastases on MDP scan against 7 patients who showed bony secondaries on MIBG scan. Of the 7 patients, with positive MIBG and MDP scans, MDP scan detected 11 sites whereas MIBG scan detected 7 sites. On follow-up study, 3 patients with initial abnormal MDP scan but normal MIBG scan, developed skeletal metastases detectable on MIBG scan, whereas 3 of the 46 patients who had normal MDP and MIBG scan at presentation; developed skeletal metastases detectable on MDP scan. MIBG scan was concordant in 2 of them but was normal in the third patient. CONCLUSION: I-131-MIBG underestimates skeletal disease burden in neuroblastoma. Therefore, Tc99m-MDP bone scan should remain a part of routine assessment of patients with neuroblastoma.

Cerebellar medulloblastoma presenting with skeletal metastasis.

Medulloblastomas are highly malignant brain tumours, but only rarely produce skeletal metastases. No case of medulloblastoma has been documented to have produced skeletal metastases prior to craniotomy or shunt surgery. A 21-year-old male presented with pain in the hip and lower back with difficulty in walking of 3 months' duration. Signs of cerebellar dysfunction were present hence a diagnosis of cerebellar neoplasm or skeletal tuberculosis with cerebellar abscess formation was considered. MRI of brain revealed a lesion in the cerebellum suggestive of medulloblastoma. Bone scan revealed multiple sites of skeletal metastases excluding the lumbar vertebrae. MRI of lumbar spine and hip revealed metastases to all lumbar vertebrae and both hips. Computed tomography-guided biopsy was obtained from the L3 vertebra, which revealed metastatic deposits from medulloblastoma. Cerebrospinal fluid cytology showed the presence of medulloblastoma cells. A final diagnosis of cerebellar medulloblastoma with skeletal metastases was made. He underwent craniotomy and histopathology confirmed medulloblastoma.