Inter- and Intraobserver Repeatability of Myocardial Flow Reserve Values Determined with SPECT Study Using a Discovery NM530c Camera and Corridor 4DM Software.

BACKGROUND: Myocardial blood flow (MBF) and flow reserve (MFR) examination, especially useful in the diagnosis of multivessel coronary artery disease (CAD), can be assessed with a cadmium-zinc-telluride (CZT) SPECT gamma camera, as an alternative to the expensive and less available PET. However, study processing is not free from subjective factors. Therefore, this paper aims to evaluate intra- and interobserver repeatability of MBF and MFR values obtained by the same operator and two independent operators. METHODS: This study included 57 adult patients. MBF and MFR were assessed using a Discovery NM530c camera in a two-day, rest/dipyridamople protocol, using 99mTc-MIBI. Data were processed using Corridor4DM software, twice by one operator and once by another operator. RESULTS: The repeatability of the assessed values was quite good in the whole myocardium, LAD and LCX vascular territories, but was poor in the RCA territory. CONCLUSIONS: The poor repeatability of MBF and MFR in RCA vascular territory can be explained by poor automatic orientation of the heart axis during post-processing and a so-called "cardiac creep" phenomenon. Better automatic heart orientation and introduction of automatic motion correction is likely to drastically improve this repeatability. In the present state of the software, PET is better for patients requiring assessment of MFR in the RCA territory.

Mask-Related Motion Artifact on 99mTc-MIBI SPECT: Unexpected Pitfalls of SARS-CoV-2 Countermeasures.

A 61-year-old man was referred for myocardial perfusion scintigraphy (MPS) by an occupational physician to exclude coronary artery disease (CAD). The patient had a complete left bundle branch block (LBBB) that rendered the routine exercise stress test non-diagnostic, but otherwise had no history of heart diseases, good stress tolerance with no symptoms of angina, and no abnormalities in transthoracic echocardiogram, apart from contraction patterns typical for LBBB. Initial MPS, performed using technetium-labeled Sestamibi on a Discovery NM 530c camera equipped with solid-state semiconductor detectors, revealed a significant stress-induced ischemia that did not match the good overall condition of the patient. A motion detection procedure revealed significant heart motion in Z-axis during the stress study. Upon inquiry, the patient reported breathing difficulties caused by the mandatory mask, which slipped into an uncomfortable position during the study. Repeated acquisition, without motion artifacts, revealed no features of ischemia.

Assessment of Renal Function Based on Dynamic Scintigraphy Parameters in the Diagnosis of Obstructive Uro/Nephropathy.

This study evaluates the usefulness of parameters allowing assessment of renal function in absolute values in dynamic renal scintigraphy (DRS) with 99mTc-ethylenedicysteine (99mTc-EC) uptake constant (K), mean transit time (MTT), and parenchymal transit time (PTT) in the diagnosis of obstructive uro/nephropathy. The study included 226 people: 20 healthy volunteers, for whom normative values of assessed parameters were determined, and 206 patients. Reproducibility of results obtained by two independent operators, specificity, correlation with estimated GFR (eGFR), and Cohen's kappa were used to evaluate reliability of assessed parameters. Normative values were as follows: K ≥ 1.6, MTT ≤ 250 s, and PTT ≤ 225 s. Reproducibility of determination of K (rs = 0.99) and MTT (rs = 0.98) was significantly higher than that of PTT (rs = 0.95) (p = 0.001). Specificity was 100% for K, 81% for MTT, and 91% for PTT. Correlation of eGFR with K (rs = 0.89) was significantly higher than with PTT (rs = 0.53) and with split function (SF) (rs = 0.66) (p < 0.0001). Cohen's kappa was κ = 0.89 for K, κ = 0.88 for MTT, and κ = 0.77 for PTT. In a group of patients where standard DRS parameters are unreliable (bilateral obstructive uro/nephropathy or single functioning kidney), the use of K (the most effective among assessed parameters) changed the classification of 23/79 kidneys (29%). K enables reproducible assessment of absolute, individual kidney function without modifying routine DRS protocol. Diagnostic value of MTT and PTT is limited.

Kidney Efficiency Index - quantitative parameter of a dynamic renal scintigraphy. I. Theory and preliminary verification.

BACKGROUND: One of the basic clinical indications for dynamic renal scintigraphy (DRS) is a diagnosis of obstructive uropathy and/or nephropathy. Currently, a basic quantitative criterion for diagnosing nephropathy is the percentage of individual kidney's contribution in the global uptake of a radiopharmaceutical from the blood (so-called Split Function - SF). From a clinical point of view, a parameter evaluating a radiopharmaceutical uptake and reflecting the efficiency of a specific kidney, determined independently of the total uptake of both kidneys, would be much more useful. Based on a Rutland theory, a kidney uptake constant K proportional to a radiotracer uptake by individual kidney was introduced and applied to DRS with 99mTc-ethylene-1-dicysteine (99mTc-EC). In addition, a kidney efficiency index (KEi) was also worked out as a new parameter obtained by dividing the uptake constant K by the surface of the ROI of a given kidney, which can be interpreted as the average "efficiency" of clearance of a kidney. MATERIAL AND METHODS: K and KEi values were verified in 72 studies selected retrospectively from patients referred routinely for DRS, with available current level of blood creatinine, used for calculation of estimated GFR (eGFR) according to a CKD-EPI formula. After splitting of eGFR values into individual kidneys according to SF, single kidney eGFR values (SKeGFR) were obtained and then used as a verification method for SF, K and KEi values. RESULTS: Correlation between SF and SKeGFR values, rsp = 0.64, was significantly weaker (p < 0.0022) than the correlation of SKeGFR values with K uptake constants and KEi indices: 0.90 and 0.84, respectively. CONCLUSIONS: Uptake constant K and KEi, as quantitative parameters, give the opportunity to analyze a function of each kidney separately and in an absolute way. KEi also allows for a reliable assessment of kidneys of atypical sizes (larger or smaller than average). It also gives the opportunity to create normative values for this parameter and may be useful in a number of clinical situations where the diagnostic effectiveness of such a relative parameter as SF, is severely limited, e.g. in assessing a large kidney with hydronephrosis or while differing a cirrhotic from hypoplastic (i.e. a small but properly functioning) kidney.

Kidney efficiency index quantitative parameter of a dynamic renal scintigraphy. II. usefulness in the diagnosis of obstructive nephropathy.

BACKGROUND: One of the main indications for DRS is a diagnosis of obstructive uro-/nephropathy. In standard practice, this study includes the assessment of sequential scintigraphic images, renographic curves and such quantitative parameters as TMAX, T1/2 and split function of each kidney (SF). Due to the relative nature of SF and limitations of diagnostic capabilities of TMAX and T1/2, DRS was expanded to include new quantitative parameters describing kidney function in absolute values. This study aims to evaluate the usefulness of kidney efficiency index (KEi) - new, in-house developed parameter proportional to the average clearance function of the kidney. MATERIAL AND METHODS: The study included 156 people aged 18-84 (average 51) years. The first group, from which normative values of new parameters were determined, consisted of 20 healthy volunteers. The second group consisted of 136 patients selected retrospectively, based on archived scintigraphic data. "Normalcy rate" (percentage of normal results among selected 62 patients with a low likelihood of obstructive uro-/nephropathy) was used to evaluate the reliability of KEi. A comparative differential analysis of obstructive uro-/nephropathy, based on standard and new DRS parameters, was performed on selected 74 patients (92 kidneys) with single functioning kidney or bilateral obstructive uropathy, where SF is unreliable. RESULTS: Normative values: KEi ≥ 8; Normalcy rate for KEi: 95%. In comparison with standard DRS evaluation, application of KEi changed the diagnosis in 1/3 of assessed kidneys (from uropathy to nephropathy in 27/92 kidneys and vice versa in 4 kidneys). CONCLUSIONS: KEi enables reproducible, quantitative assessment of absolute kidney function without any modifications of the standard DRS protocol. Its values can be compared between independent studies (e.g. follow-up examinations). KEi corrected the diagnosis of obstructive uro-/nephropathy in cases of single functioning kidney or bilateral obstructive uropathy.

Application of normalized values of kidney clearance function in the diagnosis of bilateral obstructive nephropathy - a preliminary report.

BACKGROUND: Dynamic renal scintigraphy provides effective diagnosis of obstructive uropathy and nephropathy. However, in case of a bilateral outflow impairment, relative differential renal function (DRF), which is a primary quantitative criterion for diagnosis of unilateral obstructive nephropathy (when its value is below 45%, according to EANM guidelines from 2011), becomes unreliable. In case of bilateral nephropathy with similar severity, this parameter may even be within the normal range (45-55%) for both kidneys. The aim of this study was therefore to assess diagnostic usefulness of the original, normalized, absolute parameter proportional to the value of renal clearance function (K) in the evaluation of obstructive nephropathy in a group of patients with bilateral uropathy. MATERIAL AND METHODS: 16 healthy volunteers (32 kidneys) without history of kidney diseases were examined to determine normative value of K index. Then, 8 patients (16 kidneys) with bilateral obstructive uropathy found in standard dynamic renal scintigraphy performed using 111 MBq of 99mTc-EC (cumulative renographic curve that continued rising or dropped by less than 50% after i.v. administration of Furosemide) were examined. For each of the subjects 60 sequential 20s images were obtained, which were then assessed using an original method of post-processing scintigraphic data. It included normalization of renographic curves to the area under the heart curve. Subsequently, these normalized values from the uptake phase (between 2nd and 3rd minute) were inserted into the linear regression equation, from which K index was obtained. RESULTS: In healthy volunteers the average value of K index was 0.23 ± 0.05. The value of 0.13 (mean -2 SD) was taken as the lower limit of the norm. Values below that limit suggest obstructive nephropathy. In patients with bilateral obstructive uropathy, 5 kidneys met the conventional criteria of nephropathy (DRF < 45%), while 11 kidneys had DRF within normal range. K index was below the norm in 9 kidneys (including 4 kidneys with low and 5 with normal DRF), while its value was normal in 7, including one kidney with reduced DRF (37%). K index changed the diagnosis in 6 kidneys out of 16 (38%). CONCLUSIONS: Preliminary results indicate usefulness of K index in diagnosis of obstructive nephropathy in patients with bilateral obstructive uropathy. For further evaluation of clinical value of this method, it is planned to examine a larger group of patients with varying degrees of renal parenchymal function impairments.

Assessment of the relation between pelvicalyceal dilatation in ultrasound and features of obstructive uropathy in dynamic renal scintigraphy.

BACKGROUND: Ultrasound is the first-line imaging in the diagnostics of the urinary system. It provides valuable morphological information, but its usefulness in assessment of the function of renal parenchyma is limited. Dynamic renal scintigraphy provides much more accurate information about parenchymal function of kidneys and urinary outflow. The aim of the study was to establish morphological ultrasound criteria for high likelihood of obstructive uropathy. MATERIAL AND METHODS: 59 patients (38 women, 21 men, between 18 and 82 years old, average age 50) with the pelvis dilatation > 10 mm in one or both kidneys newly diagnosed in ultrasound, without earlier history of kidney and urinary tract diseases or renal surgery. A total of 79 kidneys were included in the study. Ultrasound and dynamic renal scintigraphy were performed on the same day. In ultrasound, maximum anteroposterior diameter of the renal pelvis (mAPD) and anteroposterior pelvic diameter at hilum (hAPD) were obtained. The ratio of total pelvicalyceal area to the whole kidney area (%PCS) was also calculated. Uropathy was determined by the positive diuretic test in renal scintigraphy performed using 111 MBq of 99mTc-EC. RESULTS: In dynamic renal scintigraphy, features of uropathy were found in 18 out of 79 kidneys (23%). Optimal thresholds for detection of obstructive uropathy for measured ultrasound parameters were determined based on the ROC curves: mAPD ≥ 23 mm (sensitivity 94%, specificity 76%, accuracy 80%, AUROC 0.91) hAPD ≥ 20 mm (sensitivity 78%, specificity 87%, accuracy 85%, AUROC 0.82) PCA/WKA ≥ 22% (sensitivity 83%, specificity 74%, accuracy 76%, AUROC 0.85). CONCLUSIONS: Determined thresholds of parameters measuring pelvicalyceal dilatation in ultrasound, including the easiest one to obtain in routine diagnostics - mADP, provide satisfactory effectiveness in isolating kidneys with high likelihood of obstructive uropathy. Their application can optimize the selection of patients for further kidney diagnostic imaging (dynamic renal scintigrapy or urography).

Perfusion lung scintigraphy for the prediction of postoperative residual pulmonary function in patients with lung cancer.

BACKGROUND: Accurate prediction of postoperative pulmonary function in patients with non-small cell lung cancer is crucial for proper qualification for surgery, the only effective therapeutic method. The aim of the study was to select the most accurate method for acquisition and processing of lung perfusion scintigraphy (LPS) combined with spirometry for prediction of postoperative pulmonary function in patients qualified for surgery. MATERIAL AND METHODS: LPS was performed in 70 patients (40 males, 30 females), with preoperative spirometry (mean FEV1preop = 2.26 ± 0.72 L), after administration of 185 MBq of 99mTc-microalbumin/macroaggregate, using planar (appa) and SPECT/CT methods. Predicted postoperative lung function (FEV1pred) was calculated as a part of active lung parenchyma to remain after surgery. A non-imaging segment counting method was also applied. FEV1pred(appa, SPECT, SPECT/CT, segm.) were further compared with actual FEV1postop values obtained from postoperative spirometry. RESULTS: In the whole studied group (47 lobectomies, 23 pneumonectomies) mean value of FEV1postop was equal to 1.76 (± 0.56) L. FEV1pred(appa, SPECT, SPECT/CT, segm.) were equal to 1.75 (± 0.58) L, 1.71 (± 0.57) L, 1.72 (± 0.57) L and 1.57 (± 0.58) L, respectively. A segment counting method systematically lowered predicted FEV1 values (p < 10-5). Moreover, in 31 patients with FEV1preop < 2 L error of predicted values was assessed with Bland-Altman method. Mean absolute differences FEV1postop - FEV1pred amounted to: appa - (0.04 ± 0.13) L, SPECT - (0.07 ± 0.14) L, SPECT/CT - (0.06 ± 0.14) L and segm. - (0.21 ± 0.19) L, respectively. Lower limit of 95% confidence interval calculated for planar - optimal method, was equal to -220 mL (also determined separately in subgroups after lobectomy and pneumonectomy). CONCLUSIONS: This study shows that planar LPS may be applied for prediction of postoperative pulmonary function in patients qualified for pneumonectomy and lobectomy. If actual FEV1postop value is to be ≥ 800 mL, predicted value should exceed 1000 mL.

Preliminary assessment of interand intraobserver reproducibility, and normative values of renal mean transit time (MTT) and parenchymal transit time (PTT) for 99mTc-etylenodicysteine.

BACKGROUND: The clinical significance of MTT and PTT, determined by deconvolution of renographic curves, is arguable. Their usefulness in diagnosis of obstructive uro- and nephropathy, renovascular hypertension and monitoring of transplanted kidneys is pointed out, but susceptibility of deconvolution methods to errors resulting from "statistical noise" is also stressed. So far there are no reports on normative MTT values for 99mTc-EC, although such values were already determined for ¹³¹I-OIH, 99mTc-DTPA and 99mTc-MAG3. The aim of this study is an assessment of inter- and intraobserver reproducibility of MTT and PTT for 99mTc-EC, and determination of normative values for these parameters. MATERIALS AND METHODS: 31 patients (17 women and 14 men aged 19-75, average 44 years) referred for dynamic renal scintigraphy with: unilateral flow impairment (11), unilateral nephrolithiasis (2), control after unilateral lithotripsy (4), moderate hypertension (demographically with > 99% probability of primary hypertension) (4), suspected cirrhosis of one kidney (3), future kidney donors (3), control after abdominal injuries (3), incontinence (1). 42 functionally efficient kidneys were included in the study. Criteria for recognition of a kidney as functionally efficient were: - no earlier history of renal disease, signs of renal damage in basic blood and urine tests, or abnormalities in ultrasonography; - normal result of dynamic renal scintigraphy (in terms of sequential images and renographic curve). MTT and PTT values were determined independently by two operators, using a matrix method for deconvolution of renographic curves. RESULTS: Differences between mean MTT and PTT from two studies by one operator were insignificant and those values were closely correlated (r = 0.99 and r = 0.97, respectively). Differences of values obtained by both operators were practically insignificant for MTT (r = 0.93), and significant for PTT (r = 0.81 and p < 0.001). These differences do not disqualify that processing method. The upper limits of normative values of MTT and PTT were based on the results from first study performed by more experienced operator - 200 s and 170 s, respectively. CONCLUSIONS: The procedure of processing dynamic renal scintigraphy used in this study is reproducible. Normative values of MTT and PTT for 99mTc-EC were established as 200 s and 170 s, respectively. An attempt to optimize and standardize the technique of determining parenchymal ROI in a matrix deconvolution method, followed by an evaluation of clinical usefulness of these parameters in the diagnosis of chosen renal function impairments would be a logical continuation of this initial research.

[Strategy of physiotherapy in dysphagia associated with spinal muscular atrophy type Ib: Case study]. / Strategia fizjoterapii u chorych z dysfagia z powodu rdzeniowego zaniku miesni typu Ib. Studium przypadku.

INTRODUCTION: Neuromuscular diseases progress to pathologic conditions which reveal structural or functional lesions of the elements forming the motor unit of the body. Typical clinical symptoms include muscle weakness, muscle flaccidity, pareses, and partial or total loss of reflexes. Excessive intensity of these symptoms leads i.a. to motor dysfunctions and ultimately to problems with physical development of children and youth. Treatment of such conditions is based on physiotherapy. The aim of this article is to expose the growing problem of dysphagia in patients with neuromuscular diseases and to systematize therapeutic activities during the process of rehabilitation. MATERIAL AND METHODS: We present the case of a 25-year-old male with SMA Ib diagnosed at birth, with full-blown symptoms of mechanical and oropharyngeal dysphagia. The patient complained of jaw rigidity, reduced oral aperture, difficulties in moving food in the oral cavity, loss of masticatory force, weakness and quickly progressing fatigue of jaw muscles during chewing, and problems with swallowing. Prior to the physiotherapeutic test, we performed a qualitative and quantitative assessment of temporomandibular joint (TMJ) mobility. Quantitative assessment of movement range was done in accordance with principles for functional examination of the masticatory organ in dentistry with the use of a millimeter ruler. We also recorded the subjective assessment by the patient of eating and swallowing. Assessment was done at the start and end of therapy (after 8 weeks). The patient underwent an 8-week course of therapy which consisted of stretching of cervical muscles according to Anderson, massage of soft tissues in the TMJ region, acupressure of the attachment of the masseter muscle (on the zygomatic bone), postisometric relaxation ofmasseter muscles (in the direction of abduction), active TMJ movements, active tongue exercises, and swallowing maneuvers. Rehabilitation was performed according to the sequence above during 20-minute sessions three times per week. RESULTS: We observed objective and subjective improvement after our physiotherapy of the patient. TMJ mobility increased and the patient reported subjective improvement in the quality of life manifested with greater comfort during eating, moving, chewing, and swallowing food. CONCLUSIONS: Therapy ofdysphagia in SMA Ib patients should be included as early as possible in the rehabilitation program in anticipation of problems with food ingestion. Therapy of dysphagia should be comprehensive, i.e. should not be limited to exercises stimulating TMJ mobility but should also address tongue movements and therapy of soft tissues. Therapy needs to be continuous and systematic regardless of the severity of dysphagia. It is particularly important to start dysphagia prevention measures in children with neuromuscular disorders by including exercises of the masticatory organ in the rehabilitation program.

[Physiotherapy and biological regeneration: for everyone?]. / Fizjoterapia i odnowa biologiczna--czy dla wszystkich?

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