Osseous stress reaction in a rower diagnosed with positron emission tomography (PET): a case report.

Back injury is one of the most frequently encountered injuries in the collegiate rower. The differential diagnosis of back pain in the competitive rower includes muscle strain, ligament/tendon injury, stress reaction, stress fracture, and a tear in the annulus fibrosis. Endurance sports, such as rowing, have an increased frequency of stress injury The diagnosis of stress reaction cannot be made with plain radiographs. Many studies have firmly established the efficacy of single photon emission computed tomography (SPECT) bone scans and magnetic resonance imaging in establishing the diagnosis of a stress reaction We present a case of a collegiate rower with mid back pain secondary to a stress reaction of the endplates of the costotransverse articulation at the T8 level diagnosed by a positive positron emission tomogram study in the setting of a negative SPECT scan.

Analysis of lymphatic drainage in various forms of leg edema using two compartment lymphoscintigraphy.

The anatomical and functional status of the epifascial and subfascial lymphatic compartments was analyzed using two compartment lymphoscintigraphy in five groups of patients (total 55) with various forms of edema of the lower extremities. Digital whole body scintigraphy enabled semiquantitative estimation of radiotracer transport with comparison of lymphatic drainage between those individuals without (normal) and those with leg edema by calculating the uptake of the radiopharmaceutical transported to regional lymph nodes. A visual assessment of the lymphatic drainage pathways of the legs was also performed. In patients with cyclic idiopathic edema, an accelerated rate of lymphatic transport was detected (high lymph volume overload or dynamic insufficiency). In those with venous (phlebo) edemas, high volume lymphatic overload (dynamic insufficiency) of the epifascial compartment was scintigraphically detected by increased tracer uptake in regional nodes. In patients with deep femoral venous occlusion (post-thrombotic syndrome). subfascial lymphatic transport was uniformly markedly reduced (safety valve lymphatic insufficiency). On the other hand, in the epifascial compartment, lymph transport was accelerated. In those patients with recurrent or extensive skin ulceration, lymph transport was reduced. Patients with lipedema (obesity) scintigraphically showed no alteration in lymphatic transport. This study demonstrates that lymphatic drainage is notably affected (except in obesity termed lipedema) in various edemas of the leg. Lymphatic drainage varied depending on the specific compartment and the pathophysiologic mechanism accounting for the edema. Two compartment lymphoscintigraphy is a valuable diagnostic tool for accurate assessment of leg edema of known and unknown origin.

[Involvement of the lymphatic system in primary non-lymphogenic edema of the leg. Studies with 2-compartment lymphoscintigraphy]. / Die Beteiligung des Lymphgefässsystems beim primär nicht-lymphogenen Odem des Beines. Untersuchungen mit der Zwei-Kompartiment-Lymphszintigraphie.

Two-compartment lymphoscintigraphy was developed to examine the sub- and epifascial lymphatics of the leg. Digital images were evaluated visually and semiquantitatively by calculating the uptake of activity within the lymph nodes. The data from patient groups with four different types of leg edema were compared with those of the control group to prove the involvement of the lymphatics in the non-lymphatic edema. The cyclic idiopathic edema demonstrated an accelerated transport of the lymph consistent with a high volume insufficiency. In phlebedema the high volume insufficiency was epifascially so distinct, that it could be detected scintigraphically. In post thrombotic syndrome the transport of the lymph was reduced dramatically corresponding to a safety valve insufficiency. Epifascially however, an accelerated lymph flow was observed due to compensatory mechanisms. The lipedema did not show any scintigraphic abnormalities. These results show that two-compartment lymphoscintigraphy can detect alterations in lymphatic function secondary to non-lymphogenic leg edema. The lymphatic function is changed according to the underlying pathophysiology which may be facilitate the differential diagnosis of such a leg edema.

[Double isotope albumin flux measurement: diagnosis and therapeutic monitoring of acute lung injury]. / Doppelisotopen-Albuminfluxmessung: Diagnose und Therapiemonitoring des Acute Lung Injury.

PURPOSE: Acute Lung Injury (ALI) is a clinical condition which is associated with a high lethality. It is characterized by an increased pulmonary capillary permeability and non-cardiogenic pulmonary edema. This study was designed to answer the question whether double isotope albumin-flux measurement is a useful tool both for diagnosis of increased pulmonary capillary permeability and for monitoring therapeutic interventions (nitric oxide (NO) inhalation). METHOD: In 12 patients with clinical signs of ALI, transvascular albumin-flux was measured by a double radioisotope technique before, during and after NO inhalation. 99mTc labeled albumin and 51Cr labeled autologous erythrocytes were used as tracer. The radioactivity of both radiopharmaceuticals was measured externally over the right lung by a radiation probe and simultaneously in arterial blood. For quantification of transvascular albumin-flux Normalized Index (NI) and Normalized Slope Index (NSI) were calculated. Furthermore, pulmonal vascular pressures and other physiological parameters were recorded. RESULTS: All 12 patients showed markedly increased NSI before inhalation of NO. NSI decreased from 0.0074 +/- 0.0046 min-1 without nitric oxide to -0.0051 +/- 0.0041 min-1 during nitric oxide and increased to 0.0046 +/- 0.0111 min-1 after nitric oxide. The decrease of the NSI correlated well with decrease of venous pulmonary resistance during inhalation of NO. CONCLUSION: Inhalation of NO reduces transvascular albumin-flux in patients with ALI. Double isotope albumin-flux measurement enables diagnosis of increased capillary permeability as well as monitoring therapeutic interventions.

Immunoscintigraphy with anti-225.28S for ocular melanoma--a comparison with histology and immunohistochemistry.

AIM: The purpose of this prospective study was to evaluate the value of immunoscintigraphy (ISG) with anti-225.28S in clinically suspected ocular melanoma. METHODS: For this purpose standardized ISG was performed in 36 patients using both planar acquisition and emission computed tomography (ECT). Ocular melanoma was present in 31 patients. In 21 patients therapy was enucleation of the eye. These specimens were evaluated by histology and immunohistochemistry in 11 of 21 patients. RESULTS: Regarding the clinical diagnosis, ISG was positive only in 15 of 31 patients with ocular melanoma, regarding histology in 11 of 21 and regarding immunohistochemistry in 5 of 6 patients with a positive immunoreaction 5 patients showed no immunoreactivity, their ISG was negative. CONCLUSION: Thus a good correlation between ISG and immunohistochemistry was observed. However ISG using the cutaneous melanoma antibody 225.28S cannot be recommended for the diagnostic work-up of an ocular melanoma considering the poor immunoreactivity.

[Cerebral findings following cervical spine distortion caused by acceleration mechanism (whiplash injury). Assessment of current diagnostic methods in nuclear medicine]. / Zerebrale Befunde nach Halswirbelsäulendistorsion durch Beschleunigungsmechanismus (HWS-Schleudertrauma). Standortbestimmung zu neuen diagnostischen Methoden der Nuklearmedizin.

In any grade of distortion of the cervical spine as a result of acceleration forces in addition to cervical symptoms cerebral symptoms like headache, vertigo, auditory disturbances, tinnitus, disturbances in concentration and memory, difficulties in swallowing, impaired vision and temporo-mandibular dysfunctions may appear. These symptoms can persist and become invalidating. Cerebral single-photon emission tomography (SPECT) and positron emission tomography (PET) enable new diagnostic horizons for neurotraumatology. In this article we summarize the actual findings of these nuclear medical methods in neuropsychologically deficient patients with distortion of the cervical spine as a result of acceleration forces. Especially the latest results of the group of Basle (University Hospital Basle, Clinic of Rehabilitation Rheinfelden, Switzerland) are illustrated. This group found parieto-occipital hypoperfusion by relative quantitation using SPECT and bicisate (Neurolite, ECD). A first pilot study using PET and F-18-fluoro-deoxyglucose (FDG) could verify the above observation. The group's working hypothesis is that parieto-occipital hypoperfusion may be caused by activation of nociceptive afferences from the upper cervical spine. A critical approach to interpreting new functional methods and, on the other hand, openness in new scientific findings may contribute to answering the lasting controversial medico-legal discussion with more objectivity.

Immunoscintigraphy for ocular melanoma: a reliable diagnostic technique?

BACKGROUND: Immunoscintigraphy (IS) has recently been used as a diagnostic tool for ocular melanoma. We wanted to reevaluate published data in our own patients and to correlate immunoscintigraphic results with histologic findings and immunohistochemical characteristics of the tumour tissue. METHODS: During a 4-year period, IS was performed on 35 patients (average age 64 years) with suspected ocular melanoma by i.v. injection of 225.28S, a monoclonal antibody against high-molecular-weight melanoma-associated antigen. Histology was available in 22 cases. Tumour tissue was evaluated for cell type, vascularization, necrosis, pigmentation, and lymphocytic infiltration, and immunohistochemistry was performed with 225.28S and antibodies against HMB-45, S-100 and vimentin. One hundred and two patients with metastasizing cutaneous melanoma served as controls. In these patients the identical immunoscintigraphic technique was applied. RESULTS: IS yielded a positive result in about 50% of our patients with ocular melanoma, while in patients with cutaneous melanoma sensitivity was 89%. In five patients who turned out not to have melanoma, two false-positive results were obtained (one subretinal hemorrhage and one Wegener's granulomatosis). No correlation was found between any of the histological features or the immunoreactivity pattern and the immunoscintigraphic outcome. However, antigenic differences between ocular and cutaneous melanoma were evident. CONCLUSION: We conclude that IS, using the antibody applied in this study, is of only limited value in patients with ocular melanoma. Our results suggest that antigenic differences, rather than histological characteristics or technical problems, are responsible for the low sensitivity in ocular melanoma compared to cutaneous melanoma.

Inhaled nitric oxide reduces pulmonary transvascular albumin flux in patients with acute lung injury.

BACKGROUND: In acute lung injury, when pulmonary microvascular permeability is enhanced, transvascular fluid filtration mainly depends on pulmonary capillary pressure. Inhaled nitric oxide has been shown to decrease pulmonary capillary pressure. Therefore, the effect of inhaled nitric oxide at a concentration of 40 ppm on pulmonary transvascular albumin flux was studied in nine patients with acute lung injury. METHODS: Transvascular albumin flux was measured by a double radioisotope method using 99mTc-labeled albumin and 51Cr-labeled autologous red blood cells. Radioactivity of both isotopes was externally measured over the right lung by a gamma scanner and simultaneously in arterial blood. The normalized ratio of 99mTc/51Cr lung to 99mTc/51Cr blood (normalized index) was calculated. The normalized slope index which is the slope of the regression line of the normalized index versus time represents the accumulation rate of albumin in the interstitial space of the lungs. Normalized slope index and pulmonary capillary pressure were determined before, during, and after inhalation of 40 ppm nitric oxide. Pulmonary capillary pressure was estimated using the visual analysis of the pressure decay curve after pulmonary artery occlusion. RESULTS: Normalized slope index decreased from 0.0077 +/- 0.0054 min-1 (SD) off nitric oxide to -0.0055 +/- 0.0049 min-1 (P < 0.01) during nitric oxide and increased to 0.0041 +/- 0.0135 min-1 after nitric oxide. Pulmonary capillary pressure declined from 24 +/- 4 mmHg off nitric oxide to 21 +/- 4 mmHg during nitric oxide (P < 0.01), whereas pulmonary artery wedge pressure and cardiac output did not change. CONCLUSIONS: It is concluded that 40 ppm inhaled nitric oxide decreases pulmonary transvascular albumin flux in patients with acute lung injury. This effect may be the result of the decrease in pulmonary capillary pressure.

[Antigen pattern in choroid melanoma in correlation with immunoscintigraphy]. / Antigenmuster beim Aderhautmelanom in Korrelation zur Immunszintigraphie.

We have reported that the sensitivity of immunoscintigraphy in ocular melanoma is fairly low in comparison with (metastasizing) cutaneous melanoma. No significant correlation was found between the histological data for ocular melanoma and the immunoscintigraphic results. We therefore wanted to see whether we could demonstrate an antigen pattern that was different from that of cutaneous melanoma, which might explain our previous results. Our study comprised tumor tissue from 20 patients with ocular melanoma who had undergone previous immunoscintigraphic examination. Using immunohistochemical techniques, tumor immunoreactivity was investigated against 225.28S, the antibody used for immunoscintigraphy, on cryosections in 12 cases, and against anti-HMB-45, and anti-S-100 and anti-vimentin on paraffin sections in all 20 patients. In summary, there was marked immunohistochemical heterogeneity, and none of the antibodies examined showed a significant correlation with immunoscintigraphy. Even 225.28S that was used for the immunoscintigraphic examination did not retrospectively allow a predictable immunoscintigraphic outcome. When comparing our results with the literature on cutaneous melanoma we were also able to confirm differences in immunoreactivity with regard to the other antibodies. We conclude that the comparatively poor results in ocular immunoscintigraphy obtained with 225.28S are due to antigenic differences between ocular and cutaneous melanoma.

Subretinal tumour in a patient with a limited form of Wegener's granulomatosis.

In 1939 F. Wegener published a report concerning a peculiar febrile syndrome with necrotizing inflammation of the upper respiratory tract, focal glomerulonephritis and systemic angiitis (Wegener 1939). Clinically Wegener's granulomatosis can be divided into a limited and a generalized form. We describe a patient presenting with unilateral ocular symptoms suspicious of a neoplasm, one episode of angina pectoris and general malaise without any clinical signs of upper respiratory tract involvement. Before Wegener's granulomatosis was diagnosed by a positive titre of antineutrophil cytoplasmic antibodies and open lung biopsy, immunoscintigraphy for malignant melanoma showed a false positive result. Systemic treatment with corticosteroids and cyclophosphamide resulted in an improvement of the ocular symptoms within weeks.

Improved dose concept for radioiodine therapy of multifocal and disseminated functional thyroid autonomy.

The present study analyzes the improvement of the outcome of radioidine therapy in non-immunogenic hyperthyroidism by adapting the target dose to the 99mTc-pertechnetate thyroid uptake under suppression (TcTUs) prior to radioiodine therapy. The TcTUs is a substitute for the non-suppressible iodine turnover. The 89 patients presented with a basal thyrotropin level of < 0.1 mU/l, normal values for free triiodothyronine and thyroxine and with multifocal or disseminated thyroid autonomy. These terms describe the scintigraphic distribution pattern of autonomous iodine turnover. Thirty-two patients had a TcTUs between 1.6 and 3.2% (group A) and 57 had a TcTUs > 3.2% (group B). Fifty-five patients (three of group A and 52 of group B) were treated previously for overt hyperthyroidism with antithyroid drugs. Target doses of 150 and 200 Gy were used in both groups and 300 Gy in group B only. Six months after radioiodine therapy, a basal TSH level of > or = 0.5 mU/l as criterion of therapy success was observed in 94% of group A and in 54% of group B. Further differentiation of group B shows an increasing success rate with the target dose used: 45% after 150 Gy, 50% after 200 Gy and 90% after 300 Gy. In patients with a basal TSH level of < 0.5 mU/l after radioiodine therapy, the TcTUs was evaluated again.(ABSTRACT TRUNCATED AT 250 WORDS)

[Immunoscintigraphy results in the comparison of ocular with cutaneous melanoma]. / Immunszintigraphische Ergebnisse beim okulären im Vergleich zum kutanen Melanom.

For several years, immunoscintigraphy (IS) using a 99mTc-labeled monoclonal antibody for tumor localization has been used as an additional tool in the diagnosis of malignant melanoma. The aim of our study was to verify previously published data with respect to our own patients and to correlate immunoscintigraphic results with histological findings. In particular, we wanted to compare the outcome of IS in ocular melanoma with that in cutaneous melanoma. We examined 28 patients (15 females, 13 males, average age 64 years) with clinically suspected ocular melanoma. IS was performed using the monoclonal antibody 225.28S (Tecnemab-K-1, Fa. Sorin/Solco), and images were obtained in a standard fashion (planar) as well as with the SPECT technique. In 16 patients, the tumor was examined afterwards histologically. The control group consisted of 102 patients with histologically proven metastasizing cutaneous melanoma who were investigated by IS in an identical fashion. In contrast to the literature published so far, we demonstrated a positive IS reaction in only 42% (and 56% in histologically proven cases, respectively) in our patients with ocular melanoma, while in patients with cutaneous melanoma, we found a sensitivity of more than 80%. In the 3 patients who turned out not to have ocular melanoma, we found one false-positive reaction (subretinal hemorrhage). No correlation was found between the various histological features of ocular melanoma and the immunoscintigraphic results. We conclude that IS using the antibody 25.28S is of limited value in patients with ocular melanoma and should only be recommended in selected cases.(ABSTRACT TRUNCATED AT 250 WORDS)

[The value of CEA immunoscintigraphy for diagnosis of colorectal cancer and its metastases: results of a prospective study]. / Die Bedeutung der CEA-Immunszintigraphie für die Diagnostik kolorektaler Karzinome und ihrer Metastasen: Ergebnisse einer prospektiven Studie.

The importance of the CEA-immunoscintigraphy (IS; BW 431/26 Fa Behring) for the diagnosis of colorectal carcinoma and its metastases was determined in a prospective trial including 60 patients. The results were compared with results of the ultrasound, the CT-Scan and the Angio-CT. Patients suffered from a colorectal carcinoma (15), from a local tumor recurrence after bowel resection (10), from hepatic (39) and/or extrahepatic metastases (16). In 40 patients the diagnosis was confirmed by laparotomy. Regarding the detection of hepatic metastases the sensitivity and specificity of the Angio-CT were superior to the IS (0.86 and 0.63 vs. 0.78 and 0.45). Ultrasound and Angio-CT together revealed true positive results in 89.2%. The IS did not improve this rate. Regarding the detection of extrahepatic metastases the sensitivity and the specificity of the CT were slightly superior to the IS (0.59 and 0.87 vs. 0.47 and 0.28). However, the IS increased the rate of true positive results by 18.8% (US + CT 43.7%; +IS 62.5% true positive results). Due to these results the IS is not recommended as the method of choice to detect liver metastases. But in patients unfit for diagnostic laparotomy the IS may give additional information of the extrahepatic tumor stage.

The importance of the subfascial lymphatics in the diagnosis of lower limb edema: investigations with semiquantitative lymphoscintigraphy.

A new method of semiquantitative lymphoscintigraphy for the evaluation of lower limb edema is characterized by (1) the evaluation of both the epifascial and subfascial system in order to assess type and stage of the edema, (2) the use of high-resolution digital whole-body imaging to facilitate the calculation of functional parameters, and (3) the use of active, standardized ergometry for reproducibility. The appearance time of 99mTc-labeled human albumin nanocolloid in inguinal lymph nodes after injection and the percent uptake of colloid into lymph nodes at 40 and 120 min after injection served as functional parameters. Patients with edema of the lower limb were compared with normal subjects. In patients with primary lymphedema the two lymphatic compartments are functionally compromised. Early and advanced stages of postthrombotic syndromes can be distinguished by characteristic lymphoscintigraphic patterns in epifascial and subfascial lymphatic compartments. These results indicate that only the separate evaluation of both the epifascial and subfascial compartments allows an accurate functional assessment of the lymphatics in lower limb edema.

[Tumor scintigraphy using 123I-labeled estradiol in breast cancer--receptor scintigraphy]. / Tumor-Szintigraphie mit 123J-markiertem Ostradiol beim Mammakarzinom--Rezeptorszintigraphie.

The estrogen receptor (ER) status is an important factor for prognosis and endocrine therapy of breast cancer. Therefore 16-alpha-123I-iodoestradiol-17-beta (123I-E2) as a receptor-specific radiopharmacon was used for scintigraphic tumor detection in 62 patients suspected of breast cancer. The studies were performed as a multicenter trial (5 university hospitals) to validate the method and to overcome methodical problems. A fast tracer elimination from the blood pool into the liver was seen, followed by biliary excretion allowing early imaging of the thorax due to low background activity but resulting in difficult imaging conditions of the abdomen. In 42 patients (30 carcinomas, 12 benign lesions) the overall sensitivity was 66% (ER status cut-off: 10 fmol/mg). Some patients with breast cancer showed focal or diffuse uptake in the area of primary lymph drainage (parasternal, axillary) without any clinical correlation, demanding follow-up investigations. There was only one false-positive result in a receptor-negative primary carcinoma; thus, the non-invasive determination of the ER status seems to be feasible. The sensitivity of 123I-E2 in the detection of primary breast cancer or metastases and recurrences is low compared to mammography and other methods; therefore, 123I-E2 scintigraphy cannot be used as a screening method. Differentiation of malignant and benign tissue is even more difficult as both may have a positive ER status, for example in mastopathy. Nevertheless, 123I-E2 scintigraphy is an in vivo imaging technique for the detection of breast cancer depending on the ER status and provides information about tumor localisation. It may become a specific method for the non-invasive diagnosis of the ER status and may be helpful in follow-up studies. As a receptor-specific agent 123I-E2 may give answers to questions of tumor heterogeneity and changes of the ER status during therapy.

Treatment with diltiazem preoperatively in open heart surgery for myocardial protection: experimental studies in dogs with chronic healed myocardial infarction.

Calcium antagonists have become important in open heart surgery because of their effects on myocardial protection and cardioplegia. We evaluated the effect of pretreatment with the calcium antagonist diltiazem for myocardial protection in dogs with experimentally induced, chronic, healed myocardial infarction in a double-blind randomized study. One group consisted of 5 dogs treated with diltiazem (10 mg/kg bodyweight) for 7 days preoperatively, while a second group of 4 dogs were treated with placebo. All animals then underwent hypothermic, ischemic cardiac arrest (90 min) with extracorporeal circulation (ECC), followed by 30 min of reperfusion. Hemodynamic parameters were measured before and after ECC. An EKG was recorded during the entire procedure. The myocardium was studied by light microscopy for fresh necroses. The old, experimentally induced infarction scars were quantified by a new method that was developed for planimetry of the histological specimens. The diltiazem group compared with the placebo group showed myocardial cell necroses to a smaller extent. The hemodynamic studies supported the contention that diltiazem given preoperatively has a myocardial protective effect. These results encourage further studies on the use of diltiazem preoperatively for myocardial protection.

[Communication for patients with severe motor handicaps--clinical experience with a new electronic communication aid]. / Kommunikation für motorisch Schwerstbehinderte--Klinische Erfahrungen mit einer neuen elektronischen Kommunikationshilfe.

The use of "Komhilf", a newly developed communication aid for persons with severe physical handicap, is described on the example of two patients with amyotrophic lateral sclerosis. Aside individual letter input, it provides input of complete phrases signifying basic needs or common request, without a need for letter-by-letter spelling. After a short familiarization period, both patients were able to communicate up to two to three hours daily via "Komhilf". Psychic stabilization and increased levels of activity were observed in the patients, which subsequently also entailed increased compliance with other therapeutic measures. Additional features include good transportability, use in lying and sitting (wheelchair) patients alike, easy-to-learn operation, and, not least, a competitive price.