Positive 99mTc-MIBI and the subtraction parathyroid scan are related to intact parathyroid hormone but not to total plasma calcium in primary hyperparathyroidism.

OBJECTIVE: Primary hyperparathyroidism (pHPT) is characterised by increased parathyroid hormone (PTH) secretion and consequently increased plasma calcium. During the last few decades parathyroid scintigraphy (PS), is applied in almost all patients with pPHT before surgery and specifically before minimally invasive parathyroidectomy. The aim of this study was to find the best cut-off levels of total plasma calcium and intact PTH (iPTH) that correlate with positive technetium-99m-methoxy isobutyl isonitrile (99mTc-MIBI) PS and with positive subtraction PS (SPS) in patients with pHPT and thus the positive diagnostic value of these PS. SUBJECTS AND METHODS: We studied 50 patients, operated for pHPT, aged from 22-78 years, (median age 60 years), 45 female and 5 male, with a total number of 57 parathyroid glands (PG), (46 adenomas and 11 hyperplasias). All patients underwent SPS before surgery. Static scintigrams of the head, neck and chest were performed 15min after the intravenous (i.v.) injection of 740MBq of 99mTc-MIBI. Late scintigrams of the head, neck and chest were performed 2h and 3h after the injection of 99mTc-MIBI. Four to 24h after the washout of 99mTc-MIBI from the parathyroid and the thyroid glands, we injected i.v. 185MBq of 99mTc-pertechnetate (99mTcP) and after 15min we performed the PS. Normalization and motion correction of the early 99mTc-MIBI scan and the 99mTcP followed. We then subtracted the 99mTcP from the 99mTc-MIBI scan. The areas of increased uptake on the 99mTc-MIBI scan visible at the early and late or at the subtraction images represented the hyperfunctioning tissue of the enlarged and hyperfunctioning parathyroid glands. Scintigraphic findings were graded subjectively, from 1 to 5 depending on the degree of the uptake of the radiopharmaceutical. Normal iPTH levels were between 10.0-65.0pg/mL and normal total plasma calcium between 2.13-2.65mmoL/L. RESULTS: Of all patients 12/50 and 38/50 had both PS positive grade 4 and very positive grade 5 findings respectively. In all patients iPTH levels ranged from 54 to 837pg/mL, median value 187.0±133.8pg/mL, and total plasma calcium ranged from 2.40 to 3.83mmoL/L, median value, 2.87±0.237mmoL/L. In 43 patients, both calcium and the iPTH levels were elevated. Strong positive correlation was found between scintigraphic findings and levels of iPTH: P=0.003. A significant relation between plasma calcium levels and different grades of scintigraphic findings was not found, although significant correlation was found between iPTH and plasma calcium levels (P=0.021). CONCLUSION: In patients with pHPT, the 99mTc-MIBI PS and the subtraction PS showed a strong correlation to iPTH (P=0.003) but not to total plasma calcium levels indicating the importance of both the 99mTc-MIBI and the subtraction parathyroid scans to indicate pHPT.

Technetium-99m-dimercaptosuccinic acid renal scintigraphy can guide clinical management in congenital hydronephrosis.

OBJECTIVE: The purpose of this study was to evaluate damage of the kidney with technetium-99m-dimercaptosuccinic acid (99mTc-DMSA) scintigraphy in children with congenital hydronephrosis (CH) and the influence of other postnatal associated diagnoses on abnormal 99mTc-DMSA findings. SUBJECTS AND METHODS: 99mTc-DMSA scintigraphy in 54 children (17 girls and 37 boys), aged from 2 months to 5 years (median 11 months) with 66 congenital hydronephrotic renal units (RU) (42 unilateral hydronephrosis-29 boys and 13 girls; 12 bilateral hydronephrosis-8 boys and 4 girls) was performed. Male/female ratio was 2,2:1, unilateral/bilateral hydronephrosis ratio was 4:1. Hydronephrosis classified into three groups according to ultrasound measurement of the antero-posterior pelvic diameter APD): mild (APD 5-9.9mm) was present in 13/66RU, moderate (APD 10-14.9mm) in 25/66RU, and severe (APD≥15mm) in 28/66RU. Simple hydronephrosis was present in 15RU, and the postnatal associated clinical diagnosis were vesicoureteric reflux (VUR) in 21, pelviureteric junction (PUJ) obstruction in 7, pyelon et ureter duplex in 11, megaureter in 11 and posterior urethra valves in 1RU, respectively. Static renal scintigraphy was performed 2 to 3 hours after intravenous (iv) injection of 99mTc-DMSA using a dose of 50µCi/kg (1.85MBq/kg; minimal dose: 300µCi). Four views (posterior, left and right posterior oblique and anterior) were obtained with a head gamma camera "Orbiter" filtered with high resolution parallel whole collimator. All images were stored in an Pegasys computer with a matrix size of 256×256. The relative kidney uptake (RKU) between the left and right kidney was calculated as an average number counts from anterior and posterior view. Renal pathology was defined as inhomogenous or focal/multifocal uptake defects of radiopharmaceutical in hydronephrotic kidney or as split renal uptake of <40%, and poor kidney function was defined as split renal uptake <10%. Descriptive and analytical statistics (SPSS version 20.0) was performed. Analytical statistics implied the non-parametric Mann-Whitney test for determination of statistically significant difference between the normal and pathological findings on 99mTc-DMS scan. The default level of significance was P<.05. RESULTS: Our 99mTc-DMSA scintigraphy findings in children with ANH were: decreased or enlarged kidney with inhomogeneous kidney uptake radiopharmaceutical in 22, irregular shape kidney with inhomogeneous accumulation of radiopharmaceutical in 3, connected (fused) kidney in 1 patient, and poorly or nonvisual kidney in 14RU respectively (total 40/66RU with pathological 99mTc-DMSA finding, 60,6%). Relative accumulation in hydronephrotic kidney was less or equal to 40% in 17RU, less than 10% in 14RU and inhomogeneous radiopharmaceutical uptake with relative accumulation over 40% was detected in 9RU. Regular kidney morphology with homogeneous accumulation of radiopharmaceutical (normal DMSA scintigraphy finding) were found in 26/66RU (39,4%). Statistically significant correlation between the degree of the hydronephrosis (APD) and 99mTc-DMSA scan findings (P<0.001) and between the degree of the VUR and DMSA scan finding (P=0.002) was established. In our study, other associated diagnosis were not statistically correlated with pathological findings on 99mTc-DMSA scan due to low number of patients. CONCLUSION: On the basis of these results (60% pathological findings) we recommend DMSA scintigraphy in the evaluation renal pathology in children with congenital hydronephrosis. Greater number of patients is needed for the estimation of the associated diagnosis (other than VUR) influence on the renal parenchymal damage in children with CH.

Diuretic 99mTc DTPA renography in assessment of renal function and drainage in infants with antenatally detected hydronephrosis.

BACKGROUND/AIM: The controversy over the postnatal management of infants with antenataly detected hydronephrosis (ANH) still exists. We presented the results of diuretic 99mTc diethylenetriamine pentaacetic acid (DTPA) renography in 30 infants with the antenatal diagnosis of unilateral renal pelvic dilatation. The aim of this study was to assess the renal function determined by the pattern of drainage and split renal function (SRF) on diuretic renography and to correlate these findings with anteroposterior pelvic diameter (APD) estimated by ultrasonography. METHODS: A total of 30 infants with 60 renal units (RU) (25 boys and 5 girls, median age 6.0 months, range 2-24) presented with unilateral hydronephrosis on ultrasound in the newborn period, underwent DTPA diuretic renal scintigraphy (F+15 protocol). The median APD evaluated on perinatal ultrasound was 15 mm (range 5-30). The postnatal associated clinical diagnosis were pelviureteric junction obstruction (PUJ), simple hydronephrosis, megaureter, vesicoureteral reflux (VUR) and posterior urethral valves in 11, 10, 6, 2 and 1 infant, respectively. Images and Tmax/2 after diuretic stimulation on the background subtracted renographic curves were used as the criteria for classifying the drainage as good, partial, and poor or no drainage. The SRF was calculated with the integral method. RESULTS: Good drainage was shown in 36/60, partial drainage in 13/60 and poor or no drainage in 11/60 RU. The SRF > 40% was observed in 55/60 RU, with no RU showing SRF lower than 23.5%. In infants with severe ANH the obstruction was not excluded in 94.1%. CONCLUSION: Diuretic renography in antenatally detected hydronephrosis should be a useful tool in postnatal follow up, especially in differentiating nonobstructive hydronephrosis from obstructive. It is also importanat to assess and monitor the SRF. Our results suggest that even in the presence of partial or no drainage, SRF may not be significantly impaired.

Functional recovery of patients with ischemic cardiomyopathy treated with coronary artery bypass surgery and concomitant intramyocardial bone marrow mononuclear cell implantation--a long-term follow-up study.

BACKGROUND/AIM: Intramyocardial bone marrow mononuclear cells (BMMNC) implantation concomitant to coronary artery bypass grafting (CABG) surgery as an option for regenerative therapy in chronic ischemic heart failure was tested in a very few number of studies, with not consistent conclusions regarding improvement in left ventricular function, and with a follow-up period between 6 months and 1 year. This study was focused on testing of the hypothesis that intramyocardial BMMNC implantation, concomitant to CABG surgery in ischemic cardiomyopathy patients, leads to better postoperative long-term results regarding the primary end-point of conditional status-functional capacity and the secondary endpoint of mortality than CABG surgery alone in a median follow-up period of 5 years. METHODS: A total of 30 patients with ischemic cardiomyopathy and the median left venticular ejection fraction (LVEF) of 35.9 ± 4.7% were prospectively and randomly enrolled in a single center interventional, open labeled clinical trial as two groups: group I of 15 patients designated as the study group to receive CABG surgery and intramyocardial implantation of BMMNC and group II of 15 patients as the control group to receive only the CABG procedure. All the patients in both groups received the average of 3.4 ± 0.7 implanted coronary grafts, and all of them received the left internal mammary artery (LIMA) to the left anterior descending (LAD) and autovenous to other coronaries. RESULTS: The group with BMMNC and CABG had the average of 17.5 ± 3.8 injections of BMMNC suspension with the average number of injected bone marrow mononuclear cells of 70.7 ± 32.4 x 10(6) in the total average volume of 5.7 ± 1.5 mL. In this volume the average count of CD34+ and CD133+ cells was 3.96 ± 2.77 x 10(6) and 2.65 ± 1.71 x 10(6), respectively. All the patients were followed up in 2.5 to 7.5 years (median, 5 years). At the end of the follow-up period, siginificantly more patients from the group that received BMMNC were in the functional class I compared to the CABG only group (14/15 vs 5/15; p = 0.002). After 6 months the results on 6-minute walk test (6-MWT) were significantly different between the groups (435 m in the BMMNC and CABG group and 315 m in the CABG only group; p = 0.001), and continued to be preserved and improved on the final follow-up (520 m in the BMMNC and CABG group vs 343 m in the CABG only group; p < 0.001). Cardiovascular mortality was also significantly reduced in the BMMNC and CABG group (p = 0.049). CONCLUSION: Implanatation of BMMNC concomitant to CABG is a safe and feasible procedure that demonstates not only the improved functional capacity but also a reduced cardiac mortality in a 5-year follow-up in patients with ischemic cardiomyopathy scheduled for CABG surgery.