Esophageal scintigraphy with a semisolid meal to evaluate esophageal dysmotility in systemic sclerosis and Raynaud's phenomenon.

UNLABELLED: Esophageal transit scintigraphy seems to be a valid methodology to assess impaired esophageal motility in early stages of disease. The purpose of this study was to discriminate patients with primary Raynaud's phenomenon (RP) and patients with systemic sclerosis (SSc) from healthy subjects by esophageal scintigraphy with a semisolid meal. METHODS: We studied 32 patients with primary RP, 18 with SSc and 13 healthy subjects. Dysphagia, acid regurgitation and heartburn were scored. After an overnight fast, all subjects underwent esophageal scintigraphy, using a semisolid orally ingested bolus (10 mL apple puree) labeled with 99mTc-sulfur colloid. Esophageal transit and emptying time and integral value were evaluated with the subjects in the upright (sitting) and supine positions. Transit time was defined as the time from the entry of 50% of radioactivity into the upper esophagus until the clearance of 50% of the bolus from the whole esophagus. Emptying time was defined as the time from the entry of 50% of radioactivity into the upper esophagus, until the clearance of 100% of the bolus from the whole esophagus. Integral value was defined as the total counts under the time-activity curve normalized to the maximum. RESULTS: Esophageal transit and emptying time and integral value, evaluated in both positions, were significantly higher in patients with SSc than in healthy subjects and than in patients with RP. Moreover, patients with RP had all three parameters, assessed in supine position, significantly longer compared to healthy subjects. Clinical scores regarding dysphagia, acid regurgitation and heartburn were not significantly different between patients with RP and SSc. CONCLUSION: Esophageal transit and emptying time and integral value appear to be able to discriminate patients with primary RP from patients with SSc and patients with RP from healthy subjects, suggesting an early mild esophageal dysfunction in RP.

99mTc-sulfur colloid gastroesophageal scintigraphy with late lung imaging to evaluate patients with posterior laryngitis.

UNLABELLED: The aim of this study was to use gastroesophageal and pulmonary scintigraphy to evaluate the prevalence of gastroesophageal reflux and airway involvement among patients with posterior laryngitis. METHODS: The study included a total of 201 patients (131 females, 70 males; age range, 15-77 y; mean age +/- SD, 49 +/- 16 y). All patients had posterior laryngitis documented by laryngoscopy and symptoms such as a dry cough, painful swallowing, and hoarseness. A control population of 20 healthy volunteers (13 females, 7 males; age range, 19-74 y; mean age, 53 +/- 13 y) was also evaluated. After a 12-h fast, all subjects underwent gastroesophageal scintigraphy through administration of 300 mL orange juice labeled with 185 MBq 99mTc-sulfur colloid. After 18 h, planar anteroposterior thoracic images were acquired with the subjects supine. RESULTS: Sixty-seven percent of patients (134/201) had scans positive for gastroesophageal reflux; of these, 30 (22%) had distal reflux and 104 (78%) had proximal reflux. In addition, the scans of 31 patients were positive for proximal reflux-associated pulmonary uptake. The frequency, duration, and degree of reflux episodes were significantly greater in patients with proximal reflux than in patients with distal reflux (P < 0.001). The 67 patients in whom reflux was not detected had diseases or reflux-associated cofactors that could account for laryngeal symptoms. No statistically significant difference in symptoms or esophageal motility parameters could be identified among the patient groups, but patients with proximal reflux had significantly prolonged gastric emptying times compared with healthy volunteers. CONCLUSION: Most patients with posterior laryngitis had detectable proximal gastroesophageal reflux. Exposure of the proximal part of the esophagus to acid, by setting the stage for microaspiration of gastric material into the larynx, remains a major cause of damage to the laryngeal mucosa. Slowed gastric emptying may be a predisposing factor. Moreover, symptoms such as a dry cough, painful swallowing, or hoarseness may not be reliable predictors of the presence of gastroesophageal reflux or of associated airway involvement.

A multicenter trial on interobserver and intraobserver reproducibility of segmental scoring of thallium-201 planar myocardial imaging before and after reinjection. Italian Group of Nuclear Cardiology.

UNLABELLED: Inter- and intraobserver reproducibility (R) of segmental 201Tl scores after stress (ST), redistribution (RD) and reinjection (RI) planar imaging were evaluated. METHODS: Images were examined from 396 patients with suspected coronary artery disease, demonstrated by means of post-ST imaging of at least one perfusion defect. To eliminate external sources of variability, the same gamma camera, acquisition protocol and computer software were used in this multicenter study. Thallium-201 images of the anterior, left anterior oblique and left lateral projections were obtained immediately, 4 hr after exercise and 30 min after the injection of additional 201Tl either on the same day or on a different day. The left ventricle was divided into 15 segments and evaluated by three independent observers, blinded to clinical data, according to a five-point scale. RESULTS: The R score for ST, RD and RI images, expressed as an intraclass correlation coefficient, was 0.76, 0.74 and 0.72, respectively. After averaging multiple observer scores, R increased to 0.91, 0.90 and 0.89, respectively. Individual observer measurement of the R score was 0.48, 0.51 and 0.32 for ST-RD, ST-RI and RD-RI image pairs, respectively, and multiple observer scores showed R increases to 0.74, 0.76 and 0.58. CONCLUSION: This qualitative scale reliably assesses the severity of 201Tl perfusion defects, particularly when multiple-observer scores are averaged. Individual observer change scores should be taken with great caution, especially in studies involving the visual evaluation of RD-RI image changes.

Cardiac and pulmonary calcification in a hemodialysis patient: partial regression 4 years after parathyroidectomy.

AIMS: The reversibility of extraskeletal calcifications in dialysis patients is an important and unresolved issue. Although periarticular calcifications have been shown to be reversible, little data are available on vascular or parenchymal calcifications. CASE HISTORY: A patient on maintenance hemodialysis with severe hyperparathyroidism, hypercalcemia and hyperphosphatemia was admitted to undergo parathyroidectomy. A preoperative total body bone scintigraphy was performed to better evaluate a lytic lesion in the pelvis, the histology of which proved to be a "brown tumor". The scan showed the typical findings of renal osteodystrophy, but also a diffuse extra-skeletal uptake of bone tracer in the lungs, kidneys, femoral arteries and myocardium. After surgery, good control of serum calcium, phosphate (Ca x P product < 50 mg2/dl2) and PTH levels was maintained during 4 years of follow-up. Bone scans were repeated after 2 and 4 years, showing marked improvement of periarticular uptake at the ends of long bones. Extraosseous calcium deposition was still markedly evident, but progressively decreased (at 4 years: heart -36%, lungs -18%). CONCLUSION: In this dialysis patient, extraskeletal calcification of visceral organs (particularly in the heart and the lungs) due to prolonged hypercalcemia and hyperphosphatemia was partially reversible by parathyroidectomy followed by good long-term control of serum phosphate and calcium.

Accuracy and reproducibility of the assessment of the global ejection fraction using 195mAu and a single-crystal digital gamma camera: influence of collimator design.

A sequence of RAO first-pass studies (first with 99mTc and then twice with 195mAu) was performed in 18 normal volunteers and in 12 CAD patients using two different types of collimator for medium energy: a standard collimator (MEMS) and a special high-sensitivity collimator (MEHS). The following data were compared: the peak count rate, the net LV end-diastolic counts and the LVEF. Using MEMS the end-diastolic counts acquired were so low (12% of 99mTc average value) that EF standard deviation had a mean value of 0.061 (range 0.045-0.081). With MEHS the following results were obtained: 1. the peak count rate and LV net end-diastolic counts with 195mAu were 55% and 50% respectively, of 99mTc values; 2. a good correlation was shown between LVEF values either with 99mTc and 195mAu (r = .97), or with 195mAu sequential studies (r = .98).

Angioscintigraphic assessment of arterial and portal liver blood flow: comparison with splanchnic angiography.

In order to validate an angioscintigraphic method for the evaluation of the components of hepatic blood flow, the results of angioscintigraphy were compared with splanchnic angiography in 25 cirrhotics. Two indices of hepatic portal perfusion and a splenohepatic arterial index were calculated. These were correlated with portal diameter and hepatic artery diameter, respectively. No correlation was found between grades of portal perfusion according Nordlinger's criteria and these indices. The method is very simple and could be applied to evaluate the changes of liver hemodynamics induced by drugs or shunt surgery.

A rare case of polyostotic fibrous dysplasia assessed by bone scintigraphy with Tc-99m methylene diphosphonate (MDP).

A 66-year-old man affected by polyostotic form of fibrous dysplasia in consequence of worsening of lower extremity bone pain aggravated by walking and concomitant increase of serum alkaline phosphatase and osteocalcin, was subjected first to a radionuclide study. Bone scan demonstrated a pathological uptake of the radiotracer in the craniofacial bones, right scapula, left and right posterior ribs, right hemipelvis and lower extremities confirming the diagnosis but establishing especially the extent of bone involvement, greater than expected on the basis of symptoms and X-ray findings, underlying the importance of nuclear medicine imaging in the assessment and follow-up of this rare disease.

Lung uptake of 201Tl in myocardial stress imaging: correlation with echocardiographic and scintigraphic variables of myocardial ischaemia.

The lung uptake of thallium-201 (201Tl) in planar imaging was evaluated in 384 patients enrolled in the SIRT study (Italian Multicentre Study on Thallium Reinjection). All patients underwent treadmill exercise, and at peak exercise 74 MBq of 201TI were injected. The patients were then evaluated after reinjection of 201Tl under baseline conditions. The left ventricle was subdivided into 16 echocardiographic and 15 scintigraphic segments. The best correlates of visually scored 201Tl lung uptake, of the lung heart ratio and lung wash-out were checked. The independent variables entered in the stepwise multiple-regression analysis were: the echocardiographic wall motion index, the scintigraphic perfusion score index, and the number of segments that improved by at least 1 and 2 grades after redistribution and after reinjection. We concluded that the lung:heart ratio and, in particular, lung wash-out do not correlate more closely than the visual score with the variables taken into consideration. This suggests that visually scored lung uptake of 201Tl is still of value in nuclear cardiology practice. The scintigraphic variables associated with reinjection do not seem to offer any additional information with respect to redistribution variables. We also analysed the impact on 201Tl lung uptake of several other index variables. Student's t-test revealed that no single variable significantly alters lung uptake after stress testing.

Post-stress end-systolic left ventricular dilation: a marker of endocardial post-ischemic stunning.

Several studies have shown the accuracy of gated single photon emission computed tomography (SPECT) using thallium-201 and technetium tracers in the assessment of myocardial perfusion and function. Gated SPECT has been successfully utilized to detect post-stress left ventricular ejection fraction (LVEF) reduction resulting from post-ischemic stunning in patients with coronary obstruction. The aim of this study was to evaluate whether the post-stress LVEF impairment could be related to the post-stress end-systolic ventricular dilation resulting from post-ischemic endocardial stunning. Two hundred and eighty-two consecutive patients were studied by conventional diagnostic 2 day stress/rest gated SPECT following injection of 925 MBq of 99mTc-tetrofosmin using a dual-headed SPECT camera. One hundred and forty-seven of these patients (52%) showed reversible perfusion defects, 69 (24%) permanent defects and the remaining 66 (24%) had normal perfusion. One hundred and thirty-eight of these patients had a history of myocardial infarction (MI) and 19% underwent coronary angiography without an intervening cardiac event. Perfusion was analysed on ungated images using 20 segments scored on a five-point scale (0, normal; 4, no uptake), while wall thickening (WT) was assessed visually on stress/rest end-systolic images using a four-point score (0, normal; 3, absence of WT). LVEF and volumes were calculated using an automatic algorithm. The post-stress and rest ratios were determined for both end-diastolic (EDV) and end-systolic (ESV) volume. Normal values for all these parameters were obtained using data from 149 patients with a low likelihood (<5%) of coronary artery disease (CAD). In 50 of the 147 (34%) of patients with reversible perfusion defects, post-stress LVEF was >5% lower than rest values (stunned group), while the remaining 97 patients did not show a significant LVEF change (group 2A). The percentage of patients who developed exercise-induced angina, the percentage of patients who underwent coronary angiography and the segmental summed perfusion and WT scores were significantly higher in the stunned group compared with group 2A. Only ESV increased significantly post-stress, and this increase occurred only in stunned patients. Both EDV and ESV ratios were significantly higher in the stunned group compared with normal controls (P=0.008 and P<0.000001, respectively) and with the subgroup 2A (P=0.011 and P<10(-12), respectively). The ESV stress/rest ratio correlated significantly with the summed WT difference score by univariate analysis in stunned patients. It can be concluded that the post-stress ESV dilation, obtained by stress/rest gated SPECT, seems to be due to endocardial post-ischemic stunning. The stunned patients showed more severe clinical, angiographic, perfusion and function parameters.

Value of hepatobiliary scintigraphy and ultrasonography in the differential diagnosis of jaundice.

In order to compare the reliability of hepatobiliary scintigraphy using DISIDA (DHS) and ultrasonography (US) in the diagnosis of obstructive jaundice, 36 consecutive patients clinically suspected for obstruction were examined with both methods. Sixteen patients who were definitively shown to have obstruction, were all correctly detected with DHS; US was positive in 15 cases, revealing the cause of the obstruction in four cases. The site of obstruction was predicted in eight cases by DHS and in 11 cases by US. Associated gallbladder diseases were evaluated better by US than by DHS, but a perforation was only demonstrated clearly by DHS. In the 20 patients with nonobstructive disease the false positive results were found in one case using DHS and in two cases using US. In this series of patients DHS and US showed high sensitivity and specificity, which were further increased when the two techniques were combined.

Two-dimensional echocardiographic evaluation of right ventricular ejection fraction: comparison between three different methods.

Twelve patients with chronic cor pulmonale due to chronic obstructive pulmonary disease have been examined with 2D echocardiography, performing four-chamber view by apical and subcostal approaches, and the right ventricular outflow tract view by the subcostal approach. These views have permitted evaluation of right ventricular volumes, and hence right ventricular ejection fraction, by the use of three different geometrical formulae: the biplane area-length method, Simpson's rule and the pyramidal method. The ejection fraction values obtained from each method have been compared to those obtained by equilibrium radionuclide angiocardiography. Four-chamber apical and subcostal views were satisfactorily recorded in 10 of the 12 patients (83.3%), and right ventricular outflow tract view in 8 patients (66.6%). No significant statistical differences have been found between measurements obtained from the three different echocardiographic examinations performed on each subject by the same operator, so demonstrating a satisfactory reproducibility of the technique. The highest correlation coefficient for ejection fraction was shown by Simpson's rule (r = 0.96, p less than 0.001), with a very narrow confidence intervals, while the r values for the biplane area-length method was 0.63 (p less than 0.05) and for the pyramidal method 0.50 (not statistically significant), with increasingly wider confidence intervals. The statistically significant difference between the three correlation coefficients demonstrates the higher accuracy of Simpson's rule for the determination of right ventricular ejection fraction.

Effects of infusion of glucose-insulin-potassium on myocardial function after a recent myocardial infarction.

UNLABELLED: We studied the effects of glucose, insulin, and KCl infusion (GIK), on regional myocardial perfusion and function by 99m-Tc-tetrofosmin-gated SPECT. METHODS: We studied 21 male patients with their first uncomplicated acute myocardial infarction (AMI). All patients underwent a rest and submaximal stress before and after 24-hour infusion of GIK-solution (group A) or saline solution (group B). RESULTS: Group A showed better stress tolerance and ischaemic threshold improvement after GIK infusion whilst no statistical differences were found between basal and post-infusion test in group B. At first the stress test in group A, of the 192 segments analysed, 52 (27%) showed reversible perfusion defect. In group B, of 144 segments analysed, 31 (21%) showed reversible perfusion defect. A post-infusion analysis in group A showed a post-GIK end-diastolic significant count improvement in 21 segments, and a post-GIK end-systolic count improvement in 22 segments. In group B, perfusion increase was observed only in 4 segments, whilst systolic thickening increase was observed only in 1 segment. CONCLUSION: These data demonstrate the efficacy of GIK infusion to improve regional myocardial perfusion and function mainly in segments adjacent to the recently infarcted area.

Diagnosis of coronary artery disease by radionuclide ventriculography during stress: handgrip and cold pressor.

Radionuclide ventriculography during stress has been shown a useful and non invasive technique for detecting left ventricular dysfunction induced by ischemia in association with coronary artery disease. The aim of this study was to assess the usefulness of handgrip and cold pressor test as alternative stresses because of the limits that bicycle exercise presents when it is combined with multigated radionuclide ventriculography. A resting cardiac imaging was performed in 8 healthy volunteers and in 21 patients with coronary artery disease. All of them repeated the examination during handgrip; 6 controls and 11 patients also underwent cold pressor test. Abnormal regional wall motion was observed in 17 of the 21 patients with coronary artery disease who underwent handgrip, while all the controls maintained a normal motility. The test elicited no significant difference in average ejection fraction in both patients and normal subjects. All but one the patients who performed the cold pressor test showed an abnormal motility during the stress. Mean ejection fraction decreased significantly (p less than 0.05). All the controls had a normal response to cold pressor. Our results confirm that these two tests can be alternative to stress testing for detecting coronary artery disease by means of radionuclide ventriculography.

[Esophageal motility in systemic sclerosis and primary Raynaud' phenomenon by esophageal scintigraphy with semisolid meal]. / Valutazione della motilità esofagea nella sclerosi sistemica e nel fenomeno di Raynaud primario mediante scintigrafia esofagea con pasto semisolido.

BACKGROUND: Esophageal transit scintigraphy seems to be a valid methodology to assess impaired esophageal motility, also in the early stages of disease. AIM: To discriminate patients with primary Raynaud's phenomenon (RPh and patients with systemic sclerosis (SSc) from healthy subjects, by esophageal scintigraphy with a semisolid meal. METHODS: Thirty-two patients with primary RPh, 18 patients with SSc and 13 healthy subjects have been studied. Symptoms as dysphagia, acid regurgitation and heartburn, were scored. After an overnight fast, all subjects underwent esophageal scintigraphy, using a semisolid orally ingested bolus (10 ml apple purèe) labelled with 99mTc-sulfur colloid. Esophageal transit and emptying time and integral value were evaluated with the subjects in the upright (sitting) and in the supine position. Transit time was defined as the time from entry of 50% of radioactivity into the upper esophagus, up to the clearance of 50% of the bolus from the whole esophagus. Emptying time was defined as the time from the entry of 50% of radioactivity into the upper esophagus, up to the clearance of 100% of the bolus from the whole esophagus. Integral value was defined as the total count under the time/activity curve normalized to the maximum. RESULTS: Esophageal transit and emptying time, and integral value, evaluated in both positions, were significantly higher in patients with SSc than in healthy subjects and than in patients with RPh. Moreover, patients with RPh had all three parameters, assessed in supine position, significantly longer compared to healthy subjects. Clinical scores regarding dysphagia, acid regurgitation and heartburn were not significantly different between patients with RPh and SSc. CONCLUSIONS: Esophageal transit and emptying time and integral value seem to be able to discriminate well patients with primary RPh from patients with SSc and patients wih RPh from healthy subjects, suggesting an early mild esophageal dysfunction in RPh.

[Decisive scintigraphic diagnosis in a case of Borrelia infective sacro-iliitis]. / Diagnosi scintigrafica decisiva in un caso di sacro-ileite infettiva da Borrelia.

The authors describe one case of infections sacro-iliitis caused by Borrelia, where the diagnostic procedures by conventional radiology, computerized tomography and nuclear magnetic resonance imaging have not permitted the localization and the assessment of joint inflammatory disease. The bone "theree phases" scintiscan by 99m Technectium-methylene diphosphonate (99mTC-MDP) has made it possible to localize on left sacro-iliac synchondrosis a modification of radioactivity, due to inflammations. Next microbiological studies gave a positive result for borrelia. The authors finish by underlying the importance of the nuclear medicine methods in the screening of infective osteo-arthritis.

Labelled leukocytes for diagnosis of infectious diseases. Our experience in labelling and clinical usefulness.

BACKGROUND: To review our experience in infectious diseases diagnosis, using a simple labelling technique. METHODS: We made 101 scans in 91 patients with suspected infectious diseases confirmed by clinical, histologic or cultural specimens; a clinical or instrumental follow-up was available for every patient. Patients were divided into four subgroups: A: Inflammatory Bowel Diseases; B: Septic Syndromes; C: Bone diseases; D: Others. We used 99mTc-HMPAO in 80 scans and 111In in 21. In 20/80 frozen and stored HMPAO was used. RESULTS: 99mTc-HMPAO frozen and stored labelling yield was: 60%(SD15%), 99mTcHMPAO: 62(12)(p n.s.), 111In 75%(10%), (p < 0.05). Frozen-stored HMPAO was sterile and apyrogen. 27 had positive scan without leukocytosis or neutrophilia. No correlation between leukocytosis or neutrophilia and yield was observed. Transit lung times ranged between 14-16 min without differences among three radiopharmaceuticals. In each Group and in the sample as a whole True Positive, False Positive, True Negative, False Negative, Sensitivity, Specificity and Accuracy, were calculated. In Group B and in the sample as a whole Predictive Positive Value and Negative Predictive Value were also evaluated. CONCLUSIONS: Labelling yields and "viability" were good using the three radiopharmaceuticals; labelling procedure was simple and safe. Accuracy PPV, NPV, cost-effectiveness were good; 111In is the choice for diagnosis of bone and joint infections. Frozen-stored HMPAO should be introduced as a cost-saving labelling procedure in practice.

Biomarkers and IL-2R in lung cancer.

A study of TPA, CEA and IL-2R serum levels was conducted in patients untreated with various histological types of bronchial carcinoma. A total of 43 subjects were evaluated. We have observed a significant correlation between serum levels and stage of the disease for both CEA and TPA markers, whereas for IL-2R an increase was shown for the all patients not correlated with stage.