RESUMEN
BACKGROUND: Despite the increasing use of fatty meal (FM) as a substitute for cholecystokinin (CCK) in pain reproduction during hepato-imino-diacetic acid (HIDA) scan in functional gallbladder disorder, there are no studies comparing the differences between CCK and FM. The present study was to compare the efficacy of FM in comparison of CCK in FGBD application. METHODS: Patients undergoing HIDA scans from August 2013 to May 2014 were divided into two groups: those undergoing CCK-stimulated HIDA scan versus FM-stimulated HIDA scan. These groups were compared according to demographics and HIDA results. RESULTS: Of 153 patients, 70 received CCK and 83 FM. There was no difference regarding age, gender, gallstones, gallbladder ejection fraction and time to visualization. However, significantly more of the patients receiving CCK than FM experienced pain reproduction (61% vs 30%, P<0.01). CONCLUSIONS: Stimulation of gallbladder contractility with a FM during HIDA is less than half as likely to reproduce biliary symptoms compared to CCK, despite similar ejection fractions and other parameters. It is essential that providers account for this difference when counseling patients regarding cholecystectomy for functional gallbladder disorder.
Asunto(s)
Discinesia Biliar/diagnóstico por imagen , Vesícula Biliar/diagnóstico por imagen , Iminoácidos/administración & dosificación , Radiofármacos/administración & dosificación , Dolor Abdominal/etiología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Discinesia Biliar/fisiopatología , Discinesia Biliar/cirugía , Colecistectomía , Colecistoquinina/administración & dosificación , Colecistoquinina/efectos adversos , Grasas de la Dieta/administración & dosificación , Grasas de la Dieta/efectos adversos , Femenino , Vesícula Biliar/fisiopatología , Vesícula Biliar/cirugía , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Vitamina K/administración & dosificación , Vitamina K/efectos adversos , Adulto JovenRESUMEN
BACKGROUND: Motility disorders of the biliary tree [biliary dyskinesia, including both gallbladder dysfunction (GBD), and sphincter of Oddi dysfunction] are difficult to diagnose and to treat. SUMMARY: There is controversy in the literature in particular regarding the criteria that should be used to select patients for cholecystectomy (CCY) in cases of suspected GBD. The current review covers the history, diagnosis, and treatment of GBD. Key Messages: Only >85% of patients with suspected GBD have relief following CCY, a much lower rate than the nearly 100% success rate following CCY for gallstone disease. Unfortunately, the literature is lacking, and there are no universally agreed-upon criteria for selecting which patients to refer for operation, although cholecystokinin (CCK)-enhanced hepatobiliary iminodiacetic acid scan is often used, with emphasis on an abnormally low gallbladder ejection fraction or pain reproduction at CCK administration. There is a clear need for large, well-designed, more definitive, prospective studies to better identify the indications for and efficacy of CCY in cases of GBD.
Asunto(s)
Discinesia Biliar , Colecistectomía , Discinesia Biliar/diagnóstico , Discinesia Biliar/etiología , Discinesia Biliar/cirugía , Colagogos y Coleréticos , Colecistectomía/tendencias , Colecistoquinina , Enfermedades de la Vesícula Biliar/diagnóstico , Enfermedades de la Vesícula Biliar/etiología , Enfermedades de la Vesícula Biliar/cirugía , Humanos , Disfunción del Esfínter de la Ampolla Hepatopancreática/diagnóstico , Disfunción del Esfínter de la Ampolla Hepatopancreática/etiología , Disfunción del Esfínter de la Ampolla Hepatopancreática/cirugíaRESUMEN
Sentinel lymph node (SLN) mapping has revolutionized the way we stage breast cancer. A blue dye technique (BD) and the use of a radiotracer with the assistance of a gamma-detecting probe (GDP) have been used for the identification of the sentinel nodes. Some groups have suggested that only one technique is necessary. The reported false negative rates have been 0 to 12 per cent and success rates as low as 65 per cent. We have prospectively evaluated these techniques and have used both for the identification of the SLN. Ten surgeons participated in this study. From April 1998 through May 1999, 58 patients underwent SLN mapping followed by an axillary lymph node dissection. After the injection of 0.3 to 1.96 mCi of filtered sulfur colloid diluted to 4 mL all patients had preoperative lymphoscintigraphy. Five minutes before surgery 3 to 5 mL of isosulfan blue was injected around the tumor or tumor bed. Even though preoperative lymphoscintigraphy identified an SLN in 35 patients (63%) successful intraoperative detection of an SLN was possible using both techniques in 53 patients (91%). The SLN was detected by the BD and the GDP in 37 (65%) and 45 (80%) respectively. Nineteen patients (33%) were positive for metastatic disease in the axilla. Twenty-two (19%) of 113 SLNs removed were positive for disease. All cases of metastatic disease in the axilla were detected by the mapping technique. False negative rate was 0 per cent. In 11 patients the only positive node was the sentinel node (58%). Furthermore six (32%) patients were upstaged by the use of immunostains for cytokeratin. Twenty-two positive SLNs were detected in the 19 patients. The positive lymph node was identified only by BD in four patients (21%), only by GDP in six patients (31%), and by both techniques in nine patients (47%). We conclude that if only one technique had been used the false negative rate could have been as high as 32 per cent. Both techniques must be used to obtain a low false negative rate and high yield in the identification of the SLN.
Asunto(s)
Neoplasias de la Mama/patología , Radiofármacos , Colorantes de Rosanilina , Biopsia del Ganglio Linfático Centinela/métodos , Azufre Coloidal Tecnecio Tc 99m , Neoplasias de la Mama/diagnóstico por imagen , Femenino , Humanos , Escisión del Ganglio Linfático , Metástasis Linfática/diagnóstico por imagen , Metástasis Linfática/patología , Estudios Prospectivos , CintigrafíaRESUMEN
The authors describe a 42-year-old man with parathyroid hyperplasia secondary to chronic renal failure. Parathyroidectomy was indicated because of persistent hypercalcemia and an increasing parathyroid hormone level despite medical management. A parathyroid sestamibi scan was performed immediately before operation and a gamma-detecting probe was used during operation. Six parathyroid glands weighing nearly 21 g were present. Without the use of the gamma-detecting probe during operation, one of the glands would have been missed. The efficacy of sestamibi scanning with parathyroid hyperplasia is discussed.
Asunto(s)
Hiperparatiroidismo Secundario/diagnóstico por imagen , Hiperparatiroidismo Secundario/cirugía , Glándulas Paratiroides/diagnóstico por imagen , Glándulas Paratiroides/cirugía , Paratiroidectomía/métodos , Cirugía Asistida por Computador/métodos , Tecnecio Tc 99m Sestamibi , Adulto , Cámaras gamma , Humanos , Hiperparatiroidismo Secundario/etiología , Hiperplasia/diagnóstico por imagen , Hiperplasia/etiología , Hiperplasia/patología , Hiperplasia/cirugía , Fallo Renal Crónico/complicaciones , Masculino , Glándulas Paratiroides/patología , Cintigrafía , RadiofármacosRESUMEN
Mammography remains the technique of choice for the detection of early breast cancer. The sensitivity of mammography is 85%, but is decreased in patients with dense breasts. Sestamibi scintimammography (SCM) has been suggested as an adjunctive modality to improve the detection of breast cancer. We conducted a study to determine the impact of SCM in patient management. A prospective study was conducted in 95 patients presenting with palpable masses and/or abnormal mammography scheduled for biopsy. Injection of 20-30 mCi of technetium-99m (Tc-99m) sestamibi into a pedal vein was performed. Ten-minute images of the breast and axilla were obtained in multiple projections. The mammography and SCM were correlated with pathology and clinical findings. The median age was 44 years (range 28-86 years). The total number of lesions was 104, as eight patients had bilateral lesions and one patient had two lesions in the same breast. Fifty-nine patients presented with palpable lesions and 45 patients with nonpalpable lesions (42 with abnormal mammography only and 3 with nipple discharge). A comparison of sensitivity, specificity, positive and negative predictive values, and overall accuracy of SCM and mammography were performed. The sensitivity and specificity for SCM were 83% and 83%, respectively, and for mammography were 65%, and 72%, respectively. The sensitivity and specificity for combined SCM and mammography were 87% and 94%, respectively. The p-value for mammography versus combined SCM and mammography was 0.0003 and that for SCM versus SCM and mammography was 0.0098. There were 80 (77%) benign and 24 (23%) malignant lesions. Of the 24 malignancies, SCM missed six (25%), versus eight (33%) by mammography. In two patients (9%) SCM detected malignancy in the breast that was not visualized by mammography or found on clinical examination. Sestamibi SCM improves the sensitivity of mammography and it detects up to 9% of malignancies not detected by mammography or clinical examination. This testing could impact the management of 16,500 patients in the United States every year. More studies are needed to better define its role in breast cancer detection.
Asunto(s)
Neoplasias de la Mama/diagnóstico por imagen , Cintigrafía/normas , Radiofármacos , Tecnecio Tc 99m Sestamibi , Adulto , Anciano , Anciano de 80 o más Años , Carcinoma Ductal de Mama/diagnóstico por imagen , Carcinoma Lobular/diagnóstico por imagen , Femenino , Humanos , Mamografía/métodos , Mamografía/normas , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Prospectivos , Cintigrafía/métodos , Sensibilidad y EspecificidadRESUMEN
BACKGROUND: Resting myocardial perfusion imaging (MPI) improves the triage of patients presenting to the emergency department (ED) with symptoms suggestive of acute cardiac ischemia (ACI). In the ED setting the presence of diabetes mellitus (DM) is a predictor of ACI and hospitalization, but the role of resting MPI in patients with DM is unknown. METHODS AND RESULTS: A secondary data analysis of a prospective, multicenter, randomized, controlled trial of ED evaluation strategies in patients with symptoms suggestive of ACI and normal or nondiagnostic electrocardiograms was performed. In the main trial 2475 patients were randomized to receive either the usual ED evaluation strategy (n = 1260) or the usual strategy supplemented by results from resting MPI by use of single photon emission computed tomography (SPECT) technetium 99m sestamibi (n = 1215). Patients with diabetes (n = 341) were evaluated separately. Imaging results, final diagnoses, effect on triage, and prognostic value of the SPECT imaging were compared between diabetic and nondiabetic patients. Of the 341 patients with diabetes, 153 (45%) were randomized to the imaging strategy. Patients with DM had higher rates of hospitalization (66% vs 49.6%, P = .0001) and ACI (21.1% vs 12.0%, P < .001) than patients without DM. Among diabetic patients without ACI, the admission rate was 63% in the usual strategy group versus 54% in the imaging strategy group (relative risk [RR] = 0.91 [95% CI, 0.76-1.06]; P = .24). There was no difference in the magnitude of this reduced risk of admission compared with patients without DM (RR = 0.84 [95% CI, 0.77-0.92]; P = .0002 for patients without DM and P = .35 for interaction of diabetes and RR reduction). CONCLUSIONS: Acute resting MPI with Tc-99m sestamibi is associated with improved triage decision making in symptomatic ED patients with diabetes.
Asunto(s)
Dolor en el Pecho/epidemiología , Diabetes Mellitus/epidemiología , Isquemia Miocárdica/diagnóstico por imagen , Isquemia Miocárdica/epidemiología , Medición de Riesgo/métodos , Tecnecio Tc 99m Sestamibi , Triaje/métodos , Enfermedad Aguda , Dolor en el Pecho/diagnóstico por imagen , Comorbilidad , Diabetes Mellitus/diagnóstico por imagen , Servicios Médicos de Urgencia/estadística & datos numéricos , Humanos , Incidencia , Pronóstico , Radiofármacos , Reproducibilidad de los Resultados , Descanso , Medición de Riesgo/estadística & datos numéricos , Factores de Riesgo , Sensibilidad y Especificidad , Tomografía Computarizada de Emisión de Fotón Único/estadística & datos numéricos , Triaje/estadística & datos numéricos , Estados Unidos/epidemiologíaRESUMEN
CONTEXT: Observational studies of acute myocardial perfusion imaging in emergency department (ED) patients with chest pain have suggested high sensitivity and negative predictive value for acute cardiac ischemia, but use of this method has not been prospectively tested. OBJECTIVE: To assess whether incorporating acute resting perfusion imaging into an ED evaluation strategy for patients with suspected acute ischemia but no initial electrocardiogram (ECG) changes diagnostic of acute ischemia improves clinical decision making for initial ED triage. DESIGN, SETTING, AND PATIENTS: Prospective, randomized controlled trial conducted at 7 academic medical centers and community hospitals between July 1997 and May 1999 among 2475 adult ED patients with chest pain or other symptoms suggestive of acute cardiac ischemia and with normal or nondiagnostic initial ECG results. INTERVENTION: Patients were randomly assigned to receive either the usual ED evaluation strategy (n = 1260) or the usual strategy supplemented with results from acute resting myocardial perfusion imaging using single-photon emission computed tomography with injection of 20 to 30 mCi of Tc-99m sestamibi (n = 1215), interpreted in real time by local staff physicians and with results provided to the ED physician for incorporation into clinical decision making. MAIN OUTCOME MEASURE: Appropriateness of triage decision either to admit to hospital/observation or to discharge directly home from the ED. RESULTS: Among patients with acute cardiac ischemia (ie, acute myocardial infarction [MI] or unstable angina; n = 329), there were no differences in ED triage decisions between those receiving standard evaluation and those whose evaluation was supplemented by a sestamibi scan. Among patients with acute MI (n = 56), 97% vs 96% were hospitalized (relative risk [RR], 1.00; 95% confidence interval [CI], 0.89-1.12), and among those with unstable angina (n = 273), 83% vs 81% were hospitalized (RR, 0.98; 95% CI, 0.87-1.10). However, among patients without acute cardiac ischemia (n = 2146), hospitalization was 52% with usual care vs 42% with sestamibi imaging (RR, 0.84; 95% CI, 0.77-0.92). CONCLUSIONS: Sestamibi perfusion imaging improves ED triage decision making for patients with symptoms suggestive of acute cardiac ischemia without obvious abnormalities on initial ECG. In this study, unnecessary hospitalizations were reduced among patients without acute ischemia, without reducing appropriate admission for patients with acute ischemia.