Evaluation of anxiety and depression in patients prior to myocardial perfusion scintigraphy.

OBJECTIVE: In myocardial perfusion scintigraphy (MPS) negative results indicate coronary artery diseases which might cause prominent anxiety and other psychological reactions. The aim of this study was to determine anxiety and depression levels of patients prior to MPS procedures. METHODS: The Hospital Anxiety Depression Scale(HADS) and the State and Trait Anxiety Inventory I and II were used to evaluate the anxiety and depression levels of the patients. Descriptive analyses and independent sample t-test were used for statistical assessment. RESULTS: The mean score of HADS-anxiety score prior to MPS was 8.1 ± 4.2, whereas the mean HADS depression score was 6.1 ± 3.7. The mean state anxiety score prior to MPS was 39.7 ± 10.6 and the mean trait anxiety score was 45.02 ± 9.1. HAD and state and trait anxiety scores were found to be significantly higher in female patients than male patients and non-smoker patients than smoker patients. Other risk factors such as having bypass operation, myocardial infarction, hypercholesterolemia, diabetes and hypertension were not related to depression and anxiety scores. CONCLUSION: The results in this study suggest a role for MPS as a risk factor for higher state anxiety. The MPS procedures might lead to an increase in anxiety levels of patients which is possibly associated with anticipation anxiety felt during waiting period and expectation life-threatening.

Comparison of Planar Imaging Using Dual-phase Tc-99m-sestamibi Scintigraphy and Single Photon Emission Computed Tomography/Computed Tomography in Hyperparathyroidism.

Objectives: The aim of this study was to compare Technetium-99m (Tc-99m)-sestamibi dual-phase planar imaging method and delayed phase single photon emission computed tomography/computed tomography (SPECT/CT) imaging in patients with primary hyperparathyroidism and to evaluate the accuracy of scintigraphy with histopathological results. Methods: Thirty-six patients with a prediagnosis of hyperparathyroidism, who had not been operated on the neck region before, and were not followed up for any other malignancy, and has confirmed histopathologic and biochemical diagnosis after parathyroidectomy, were retrospectively scanned and included in the study. The images of 36 patients who underwent dual-phase Tc-99m-sestamibi planar scintigraphy at the 20th and 120th minutes in the nuclear medicine clinic and delayed phase SPECT/CT imaging immediately after the 120th minute planar imaging were evaluated visually by two nuclear medicine specialists as positive or negative lesion. Dual-phase planar and SPECT/CT images were statistically compared in terms of sensitivity, specificity, positive predictive value, negative predictive value, and accuracy. Results: Thirty-six patients with 41 lesions were evaluated. Comparing dual-phase planar imaging and delayed phase SPECT/CT revealed, sensitivity 84.21%-94.74%, specificity 66.67%-66.67%. Positive predictive value 96.97%-97.30%, negative predictive value 25%-50.0%, accuracy 82.93%-92.68% respectively. There was a statistically significant difference between planar imaging and SPECT/CT; SPECT/CT localized the lesion more accurately (p<0.05). Conclusion: SPECT/CT is superior to planar imaging in determining the anatomical details and localization of the lesion, especially in determining the depth of the lesions in the neck and whether it is ectopic. In patients with hyperparathyroidism, SPECT/CT should be used routinely to detect parathyroid pathologies because it has a lower rate of error and higher accuracy rate.

Urinary MMP-9/NGAL complex in children with acute cystitis.

The matrix metalloproteinase-9 (MMP-9) and neutrophil gelatinase associated lipocalin (NGAL) are shown to increase in an inflammatory situation. Based on our previous reports that NGAL can be detected in the urine of children with urinary tract infection (UTI), we also asked whether MMP-9/NGAL complex could be detected in the urine of children with UTI. This multicenter, prospective study was conducted between October 2009 and October 2010. Seventy-one patients with symptomatic culture proven UTI, 37 asymptomatic children with contaminated urine and 37 healthy children were recruited. Mean uMMP-9/NGAL/Cr levels were significantly higher in the UTI group than in the control group (p < 0.0001). According to ROC analysis, the optimal cut-off level was 0.08 ng/mg to predict UTI. Using a cut-off value, sensitivity and specificity were 98.6 and 97.3%, respectively. The mean levels of uMMP-9/NGAL/cr in the UTI group were also significantly higher than those in the contamination group (p < 0.0001). There was no statistically significant difference between contamination group and the control group (p = 0.21). The mean uMMP-9/NGAL/Cr in the UTI group were significantly higher before treatment than after treatment (p < 0.0001). The area under the curve was 0.997 (SE: 0.002, 95% CI: 0.993 to 1.001) for uMMP-9/NGAL/Cr. Urinary MMP-9/NGAL/Cr level was also correlated with positive urine nitrite test, positive urine leukocyte esterase reaction and renal scarring (p = 0.0001, p = 0.0001, p = 0.04, respectively) whereas was not correlated to leukocytosis and positive CRP level in serum. Urine MMP-9/NGAL/cr can be used as a diagnostic biomarker for UTI in children. Identification of NGAL-MMP-9/cr levels in the urine of suspected UTI patients may also be useful to differentiate between contamination and infection and for monitoring of treatment response in children.

Urinary macrophage migration inhibitory factor in children with urinary tract infection.

Macrophage migration inhibitory factor (MIF) plays an essential pathophysiological role in inflammatory reactions. The aim of this study was to investigate the clinical utility of urine MIF (uMIF) level in predicting urinary tract infections (UTI). This multicenter, prospective study was conducted over a 1-year period between March 2008 and March 2009. Sixty patients with symptomatic culture-proven UTI and 29 healthy children were recruited. Urine MIF was measured by enzyme-linked immunosorbent assay. The mean MIF level was found to be significantly higher in the UTI group than in the control group (1082.82 vs. 211.45 pg/ml, p = 0.0001). Receiver operating characteristic (ROC) analysis revealed that the optimal cut-off uMIF level was 295 pg/ml for uMIF to predict UTI. The sensitivity and specificity of this cut-off level were 91.7% and 69%, respectively. Mean uMIF/creatinine (Cr) was also significantly higher in the UTI group than in the control group (2400.69 vs. 267.56 pg/mgCr, p = 0.0001). At a cut-off of 815 pg/mgCr for uMIF/Cr, the sensitivity and specificity were 95 and 79%, respectively. The area under curve (AUC) was 0.848 (standard error 0.040, 95% confidence interval 0.756-0.915) for uMIF and 0.889 (0.034, 0.805-0.946) for uMIF/Cr. Urine MIF/Cr was significantly higher in the patients with a positive leukocyte esterase reaction in the urine (p = 0.047), leukocytosis (p = 0.0001) and positive C-reactive protein level in serum (p = 0.003). The uMIF level was not related to leukocytosis, positive CRP level in serum and leukocyte esterase reaction in the urine. Neither uMIF nor uMIF/Cr were correlated to the positive urine nitrite test, pyuria, urine pH and specific gravity (p > 0.05). These results suggest that urine MIF and uMIF/Cr can be used for the early prediction of UTI in children.

Differentiated thyroid carcinoma in children: Clinical characteristics and long-term follow-up.

Differentiated thyroid cancer (DTC) is rare in children, but it still remains the most common endocrine malignancy in children. The aim of this study was to analyze treatment response to radioactive iodine (RAI) therapy, clinical outcomes, recurrences, survival analysis, and long-term follow-up. We retrospectively reviewed the medical records of 43 pediatric patients (≤17 years of age) with DTC diagnosis after thyroidectomy who were treated with RAI. The follow-up protocol consisted of detailed clinical examination, testing of thyroid function, determination of serum thyroglobulin (Tg), and anti-Tg antibodies, and neck ultrasonography application. Forty-three pediatric patients (34 females and 9 males) treated with RAI for DTC in our institute. The median follow-up period was 54 months. The histologic classification was papillary thyroid cancer in 41 patients and the remaining 2 patients had follicular thyroid cancer. After the long-term follow-up, complete remission, partial remission, and recurrent-persistent disease were observed in 37 patients, 3 patients, and 3 patients, respectively. Among the series, 1 death occurred due to multiple metastases. The mortality rate is 2.56%. Total thyroidectomy followed by RAI appears to be the most effective treatment for patients with pediatric DTC in terms of reducing the rate of relapse and improving surveillance for recurrent disease.

Early prediction of urinary tract infection with urinary neutrophil gelatinase associated lipocalin.

Neutrophil gelatinase associated lipocalin (NGAL) is a protein identified in human neutrophil granules. The aim of the study was to assess whether urine level of NGAL (uNGAL) could represent a novel, reliable marker of urinary tract infection (UTI) and to determine the optimal cutoff level for uNGAL to predict UTI in children. Sixty patients with symptomatic UTI and 29 healthy controls were enrolled the study. Urine NGAL was measured by enzyme-linked immunosorbent assay. A dimercaptosuccinic acid (DMSA) radionuclide scan was performed within 7 days in the patients with UTI in an attempt to distinguish pyelonephritis from cystitis. Mean uNGAL level was significantly higher in the UTI group than in the controls (91.02 ng/ml vs 14.29 ng/ml, p = 0.0001) and using a cutoff 20 ng/ml for uNGAL for diagnosis of UTI, sensitivity, and specificity were 97% and 76%, respectively [area under the curve (AUC): 0.979]. Mean uNGAL/creatinine ratio (uNGAL/Cr) was also significantly higher in the UTI group [201.81 ng/mg creatinine (Cr) vs 18.08 ng/mg Cr; p = 0.0001], and using a cutoff 30 ng/mg Cr for uNGAL/Cr for diagnosis of UTI, sensitivity and specificity were 98% and 76%, respectively (AUC: 0.992). In conclusion, both uNGAL and uNGAL/Cr can be used as a novel, sensitive marker for early prediction of UTI in the absence of acute kidney injury and chronic kidney disease, and the optimal cutoff value for prediction of UTI is lower than the values determined for acute kidney injury. Further investigations with larger patient groups are required to confirm our results.

Gamma probe (99m)Tc-pertechnetate assisted completion thyroidectomy vs conventional thyroidectomy in differentiated thyroid carcinoma.

Patients undergoing partial thyroidectomy for benign diseases may need re-operation if differentiated thyroid carcinoma (DTC) is detected on histopathology. The aim of this study was to determine if using gamma probe during the above surgery in a procedure called: gamma probe completion thyroidectomy (GPCT) could support the diagnosis of DTC tissue and offer an advantage in the surgical treatment of DTC patients. We have studied 100 patients who after bilateral subtotal thyroidectomy for benign disease in several hospitals, were found to have DTC histopathologically and referred to our clinic for subsequent re-operation. Of these, 50 underwent conventional completion thyroidectomy (Group I) and 50 underwent GPCT (Group II). We compared retrospectively Group I and Group II in terms of volume of residual thyroid tissue, thyroid stimulating hormone (TSH) values, complication rates and incidence of tumor found in the residual thyroid. Our results showed that one month postoperatively, TSH was significantly higher in Group II (P<0.001). Volumes of residual thyroid were also significantly less in Group II (P<0.000). Complications and the incidence of tumor cells found in the residual thyroid tissue between the groups were not statistically different (P>0.05). In conclusion, GPCT in patients with DTC significantly increased the success of this operation in localizing and removing residual thyroid tissue.

Abdominal Splenosis Mimicking Peritoneal Metastasis in Prostate-Specific Membrane Antigen PET/CT, Confirmed With Selective Spleen SPECT/CT.

Ga-prostate-specific membrane antigen (PSMA) PET/CT is a rapidly evolving diagnostic technique to image prostate cancer. In contrast to the name PSMA, various tissues show Ga-PSMA uptake in PET/CT imaging. We present a case of a 68-year-old man with prostate cancer who underwent Ga-PSMA PET/CT. Along with metastatic lymph nodes, multiple nodular lesions within the peritoneal spaces of all 4 quadrants of the abdomen showed high PSMA expression. Because of a history of splenic rupture, a Tc-labeled heat-denatured erythrocyte scintigraphy and SPECT were performed. Peritoneal lesions showed high uptake, confirming widespread peritoneal splenosis.

The Accuracy of 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography in the Evaluation of Bone Lesions of Undetermined Origin.

The aim of the current study was to determine the diagnostic accuracy of whole-body fluorine-18-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) in detecting carcinoma of unknown primary (CUP) with bone metastases. We evaluated 87 patients who were referred to FDG-PET/CT imaging and reported to have skeletal lesions with suspicion of malignancy. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated. The median survival rate was measured to evaluate the prognostic value of the FDG-PET/CT findings. In the search for a primary, FDG-PET/CT findings correctly diagnosed lesions as the site of the primary true positive (TP) in 64 (73%) cases, 4 (5%) findings diagnosed no site of a primary, and none were subsequently proven to be true negative (TN); 14 (16%) diagnoses were false positive (FP) and 5 (6%) diagnoses were false negative (FN). Life expectancy was between 2 months and 25 months. Whole-body FDG-PET/CT imaging may be a useful method in assessing the bone lesions with suspicion of bone metastases.

The Value of Attenuation Correction in Hybrid Cardiac SPECT/CT on Inferior Wall According to Body Mass Index.

The purpose of this study was to evaluate the diagnostic value of attenuation-corrected single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) on the inferior wall compared to uncorrected (NC) SPECT MPI between obese and nonobese patients. A total of 157 consecutive patients (122 males and 35 females, with median age: 57.4 ± 11 years) who underwent AC technetium 99m-methoxyisobutylisonitrile (AC Tc99m-sestamibi) SPECT MPI were included to the study. A hybrid SPECT and transmission computed tomography (CT) system was used for the diagnosis with 1-day protocol, and stress imaging was performed first. During attenuation correction (AC) processing on a Xeleris Workstation using Myovation cardiac software with ordered subset expectation maximization (OSEM), iterative reconstruction with attenuation correction (IRAC) and NC images filtered back projection (FBP) were used. For statistical purposes, P < 0.05 was considered significant. This study included 73 patients with body mass index (BMI) <30 and 84 patients with BMI ≥ 30. In patients with higher BMI, increased amount of both visual and semiquantitative attenuation of the inferior wall was detected. IRAC reconstruction corrects the diaphragm attenuation of the inferior wall better than FBP. AC with OSEM iterative reconstruction significantly improves the diagnostic value of stress-only SPECT MPI in patients with normal weight and those who are obese, but the improvements are significantly greater in obese patients. Stress-only SPECT imaging with AC provides shorter and lower radiation exposure.

Diagnostic value of single-photon emission computed tomography combined with computed tomography in relation to MRI on osteochondral lesions of the talus.

BACKGROUND: Osteochondral lesion of the talus (OLT) involves the separation of a fragment of articular cartilage, as defined by Kappis in 1922. MRI is the current standard for noninvasive diagnosis of OLT. Single-photon emission computed tomography combined with computed tomography (SPECT/CT) provides both morphologic and functional information. The purpose of the study was to compare SPECT/CT with MRI for image interpretation and treatment decision making in talar osteochondral lesions. MATERIALS AND METHODS: A total of 21 patients (four bilateral) were evaluated with MRI and SPECT/CT. Diagnostic arthroscopy was performed to validate the indication by identifying unstable cartilage areas. Activation was assessed in nine regions of interest, as described by Elias and colleagues. SPECT/CT findings were assessed by the modified scoring system of Hart and colleagues, and MRI findings with the modified classification system of Hepple and colleagues. Sensitivity, specificity, positive and negative predictive values, and accuracy were calculated for SPECT/CT and MRI. RESULTS: A total of 25 lesions were identified. Seventeen lesions were located on the medial third of the talar dome, eight on the lateral third, and seven on the central third. Four patients revealed diffuse uptake on more than one zone on SPECT/CT. SPECT/CT identified two subchondral lesions, which were not visualized on MRI. CONCLUSION: MRI is the current standard for OLT diagnosis. SPECT/CT allows a three-dimensional localization of scintigraphic osteoblastic activity in the area of interest, providing additional information about the involvement of the subchondral bone and the vitality of the osteochondral lesion and the location of multiple lesions. We recommend the use of SPECT/CT and MRI together for comprehensive diagnostic assessment of OLT.

The effect of high dose radioiodine therapy on formation of radiation retinopathy during thyroid cancer treatment.

OBJECTIVE: Non-thyroidal complication of high-dose radioiodine therapy for thyroid carcinoma might cause salivary and lacrimal gland dysfunction, which may be transient or permanent in a dose-dependent manner. However, radiation retinopathy complicating 131I therapy, has not been previously well characterized. The aim of this study was to evaluate the extent of retinal damage among patients who had received high doses of radioiodine treatment. METHODS: Forty eyes of 20 patients (3 male, 17 female) who received 250-1000 mCi during 131I therapy and on ophthalmological follow up for a year after the last treatment were included in the study. Mean age of the study group was 50 years (range 25-70 years). In ophthalmologic examination, visual acuity was measured in order to determine visual loss. Intraocular pressure was measured in all the patients. Then lens examination was carried out with slit lamp biomicroscopy in order to investigate cataract or partial lens opacities. Fundus observation was carried out through the dilated pupil with slit lamp biomicroscopy using 90 D noncontact lens. RESULT: The best corrected visual aquity with Snellen chart was found as 1.0 in 36 eyes (90%) and between 0.6 and 0.9 (10%) in 4 eyes (10%). At the biomicroscopic fundus examination, retinal hemorrhage consistent with radiation retinopathy, microaneurysm, microinfarction, edema or exudation, vitreus hemorrhage, partial or total optical disc pallor indicating papillopathy in the optic disc were not observed in any of the eyes. CONCLUSION: This result indicates that there is not any significant correlation between repeated high-dose radioiodine therapy and radiation retinopathy in differentiated thyroid carcinomas. Even though there is not a significant restriction in use of higher doses of radioiodine therapy in differentiated thyroid carcinoma, more extensive studies are needed in order to obtain more accurate data on possible occurrence of retinopathy.

Gamma Probe Guided Minimally Invasive Parathyroidectomy without Quick Parathyroid Hormone Measurement in the Cases of Solitary Parathyroid Adenomas.

OBJECTIVE: In this study, our aim was to study the efficiency of gamma probe guided minimally invasive parathyroidectomy (GP-MIP), conducted without the intra-operative quick parathyroid hormone (QPTH) measurement in the cases of solitary parathyroid adenomas (SPA) detected with USG and dual phase 99mTc-MIBI parathyroid scintigraphy (PS) in the preoperative period. MATERIAL AND METHODS: This clinical study was performed in 31 SPA patients (27 female, 4 male; mean age 51±11years) between February 2006 and January 2009. All patients were operated within 30 days after the detection of the SPA with dual phase 99mTc-MIBI PS and USG. The GP-MIP was done 90-120 min after the iv injection of 740 MBq 99mTc-MIBI. In all cases, except 1 patient, the GP-MIP was performed under local anesthesia; due to the enormity of size of SPA, then general anesthesia is chosen. RESULTS: The operation time was 30-60 min, mean 38,2±7 min. In the first postoperative day, there was a more than 50% decrease in PTH levels in all patients and all but one had normal serum calcium levels. Transient hypocalcemia was detected in one patient. CONCLUSION: GP-MIP without intra-operative QPTH measurement is a suitable method in the surgical treatment of SPA detected by dual phase 99mTc-MIBI PS and USG. CONFLICT OF INTEREST: None declared.

Intraocular and orbital metastasis as a rare form of clinical presentation of insular thyroid cancer.

Insular carcinoma of thyroid is a rare tumor, which accounts for 4 to 6% of thyroid malignancies. Clinically and morphologically it is considered to be in an intermediate position between well-differentiated carcinoma of the thyroid (papillary or follicular) and undifferentiated or anaplastic carcinoma of the thyroid. Capsular and blood vessel invasion is seen frequently, and metastases to regional lymph nodes, lungs and bones are common. The initial presentation of distant metastasis in patients with thyroid cancer is rare. Thus metastatic thyroid carcinoma rarely involves the orbit. We report a rare case of choroidal metastasis from insular thyroid carcinoma.

Bilateral Achilles tendon ossification: diagnosis with ultrasonography and Single Photon Emission Computed Tomography/Computed Tomography. Case report.

Ossification of the Achilles tendon is a rare clinical condition characterized by the presence of one or more segments of variable sized ossified mass within the tendon. The cause of the condition is obscure. We present the case of a 41 year-old male patient with pain in the Achilles tendon due to bilateral ossification of the tendon near the calcaneus insertion. The case was evaluated by ultrasonography, single photon emission computed tomography, and transmission computed tomography. In this case, we regarded repetitive microtrauma as the cause of the ossification based on the bilateral occurrence.