Single-photon emission CT using (99m)Tc-dimercaptosuccinic acid (DMSA) for characterization of suspected renal masses.

OBJECTIVE: A retrospective analysis of the clinical utility of (99m)Tc-dimercaptosuccinic acid (DMSA) single photon emission CT (SPECT) for characterization of suspected renal masses. METHODS: 15 patients who had undergone (99m)Tc-DMSA SPECT were identified, and 13 patients also had SPECT/CT. (99m)Tc-DMSA uptake in the renal lesion was characterized semiquantitatively. Other imaging tests, histology and clinical data were available for correlation. RESULTS: (99m)Tc-DMSA was not taken up in all five renal masses with histological confirmation of malignancy (uptake 7-19% of normal renal tissue); in two further masses, which were clinically likely to be malignant; and in one indeterminate mass (lack of sufficiently long follow-up). No renal malignancy was identified in any of the seven patients whose renal masses had normal (99m)Tc-DMSA uptake (41-130%). CONCLUSION: Although caution with regard to applying those results in clinical practice must be advised, owing to the retrospective nature of this report and the small number of patients included, it seems that (99m)Tc-DMSA SPECT shows a clinically useful diagnostic accuracy for distinguishing true renal masses (which in many cases require surgery) from pseudomasses. ADVANCES IN KNOWLEDGE: (99m)Tc-DMSA SPECT is a clinically useful adjunct test for characterization of suspected renal masses.

[Nuclear medicine in Europe: education]. / Nuklearmedizin in Europa. Die Ausbildungssituation.

The technical developments that have taken place in the preceding years (PET, hybrid imaging) have changed nuclear medicine. The future cooperation with radiologists will be challenging as well as positioning nuclear medicine in an European context. It can also be expected that education in nuclear medicine will undergo a harmonization process in the states of the European Union. In this paper, we describe how nuclear medicine education is organized in several European countries. We aim to stimulate constructive discussions on the future development of the specialization in nuclear medicine in Germany.

TSH receptor antibody (TRAb) assays based on the human monoclonal autoantibody M22 are more sensitive than bovine TSH based assays.

Measurements of TSH receptor autoantibodies (TRAb) using assays based on the human monoclonal TSH receptor autoantibody M22 or bovine TSH have been compared in 136 adult patients. They suffered from Graves' disease (GD, n=62), Hashimoto's thyroiditis (HT, n=26), or non-autoimmune hyperthyroidism (NAH, n=48) and were selected on the basis of undetectable, borderline or low TRAb levels (0.6-3 IU/l) as measured by TSH based TRAb assay (Dynotest TRAKhuman from BRAHMS). The time interval between initial diagnosis of GD and TRAb determination was high and ranged from 1 month to 3.5 years (median: 2.3 years). Using the kit manufacturer's cutoff values, 53/62 (85.5%) of the selected group of GD patients were TRAb positive (>0.4 IU/l) by M22 based TRAb ELISA (Medizym TRAb clone, Medipan) and 45/62 (72.6%) were TRAb positive (>1.5 IU/l) by TSH based TRAb assay. In the HT group, 9/26 (34.6%) sera were positive in the M22 based ELISA and all but one of these 9 were positive or borderline in the TSH based assay. ROC plot analysis of the GD group using the NAH group as reference showed that at 95% specificity, the bovine TSH based TRAb assay had a sensitivity of 62.9% (cutoff for positivity=1.64 IU/l) and the M22 based TRAb ELISA a sensitivity of 90.3% (cutoff for positivity=0.32 IU/l). Overall therefore, the M22 based Medizym TRAb clone assay is more sensitive than the bovine TSH based Dynotest TRAK human assay.

Quality of care of VLBW neonates: relationship between unit volume and outcome is different between metropolitan and rural regions.

BACKGROUND: Recent studies from predominantly rural areas in Germany show that neonatal outcome of very low birth weight (VLBW) neonates is (on average) inferior with lower NICU (neonatal intensive care unit) volume. However, there are no data available which show that study results of one specific region can be transferred to other areas with possibly different medical infrastructure and needs. AIM: It was investigated whether a systematic difference of treatment quality between smaller (1000-2000 births/year; < or =20 neonatal beds) vs. larger neonatal centres in Berlin (>3000 births/year; >20 neonatal beds) exists. Furthermore, the results are compared to data from a rural region in order to discuss transferability between regions. METHODS: Retrospectively, completely, and for the first time, the data of all centres which treat VLBW neonates (< or =1500 g birth weight) in the city-state of Berlin, Germany, from the years 2003/2004 were reviewed. RESULTS: Our study showed no difference in the treatment quality of smaller vs. larger neonatal units in Berlin. This result differs from those of a study in Baden-Württemberg, a predominantly rural state, with different medical infrastructure than Berlin. CONCLUSION: The present study suggests that regional investigations on the infrastructure vs. treatment outcome are not transferable between areas. Patient volume/unit appears inadequate for predicting the future treatment quality of neonatal departments. Direct quality indicators are stable for the assessed departments and should be preferably used to organize medical infrastructure.

[The German cigarette industry association--obstructing effective tobacco control in Germany]. / Der Verband der Cigarettenindustrie--Verhinderung wirksamer Tabakkontrollpolitik in Deutschland.

In spite of up to 140,000 tobacco-related deaths each year, Germany still lacks comprehensive tobacco control policies. Through systematic analysis of internal tobacco industry documents we examined how and to what extent the German Cigarette Industry Association (Verband der Cigarettenindustrie, VdC), which is the tobacco industry's trade organisation in Germany, contributed to this lack of more effective tobacco control. The role and strategies of the VdC are illustrated by using selected case studies. The evaluated documents reveal a profound influence of the VdC on political decision-makers in Federal and State Ministries as well as on German governments. The VdC successfully curbed and delayed the national adoption of EU legislation on tobacco advertising and product regulation, public smoking bans, legislation to protect the youth, and rises in tobacco taxation. The VdC's influence has played a key role in obstructing the development and implementation of effective tobacco control policies in Germany.

Renaissance of 224 Ra for the treatment of ankylosing spondylitis: clinical experiences.

Radium (224Ra) is commercially available again for the treatment of ankylosing spondylitis. Twenty patients suffering from ankylosing spondylitis were treated with weekly intravenous (i.v.) injections of 1 MBq 224Ra for 10 weeks. Therapeutic effect was measured by C-reactive protein (CRP), erythrocyte sedimentation rate (ESR) and full blood count, as well as a completion of the Bath ankylosing spondylitis functional index (BASFI) questionnaire. Follow-up was done after three and six months. At the end of the treatment course pain and movement restrictions had improved subjectively in 12 out of 20 patients. These patients were also able to discontinue or reduce their analgesic or anti-inflammatory medications. Subjective improvement was well correlated with a reduction of CRP by 45% and BASFI by 73%. At the six-month follow-up, ten patients reported a lasting improvement, whereas two had suffered a relapse. A late therapeutic response after three months was seen in a single patient only. Patients who did not respond to radium had lower initial levels of acute-phase reactants and peripheral joint involvement. Only mild side-effects, e.g. temporary worsening of pain, were observed. Leukocytes and platelets reversibly decreased by 25%, respectively. It is concluded that 224Ra is an effective and safe treatment for ankylosing spondylitis.

Accuracy of the intra-operative radioguided localization of the sentinel lymph node (SLN) 24 hours after lymphoscintigraphy in patients with malignant melanoma.

AIM: For optimized logistics for the sentinel lymphadenectomy (SL) it might be helpful for the clinics involved if a longer time period between the lymphoscintigraphy (LS) and surgery is possible. Therefore, we investigated if a precise localization of the sentinel lymph node is possible 24 hours after LS. METHODS: 78 patients with primary malignant melanoma (MM; n = 44) or with MM pre-operated by excisional biopsy (n = 34) were investigated. In 40 cases the tumor was localized on the trunk and in 38 cases on the extremities. Mean MM thickness was 2.68 mm (range: 0.29 to 12 mm). In all patients a lymphoscintigraphy (LS) with an average of 85 MBq of Tc-99m nanocolloid was performed one day prior to surgery. Immediately after tracer application dynamic data acquisition was started at a LFOV gamma camera followed by a whole body scan. With a hand-held gamma detector (C-Trak) 2, 4, 6, 8, and 24 hours after tracer administration the SLN was identified and the counts registered. RESULTS: 94 SLNs were identified in 87 lymphatic basins from which 86 could be resected. Nine MM showed two draining channels. After 24 hours 15.5% (as an average) of the initial counts could be measured in the SLN. The uptake in the SLN in pre-operated versus patients with primary tumor was statistically not significant (p = 0.4). In 16 cases (20.5%) the SLN was tumor positive. Four of those patients developed distant metastases and two died within the first year. None of the patients with negative SLN developed distant metastases or died. CONCLUSION: The remaining activity in the SLN up to 24 hours after administration is sufficient for their intra operative localization. The method of lymphoscintigraphy and localization of the SLN by a hand-held gamma detector optimizes the intra operative identification of the SLN in patients with malignant melanoma.

Wound botulism in drug addicts in the United Kingdom.

Clostridium novyi has recently been identified as the causative organism responsible for the deaths of 35 heroin addicts who had injected themselves intramuscularly. We present two heroin addicts who developed C. botulinum infection following intramuscular or subcutaneous injection of heroin. Like C. novyi, this grows under anaerobic conditions and clinical presentation may be similar; however, descending motor or autonomic signs are invariably present in botulism. The prognosis is good if the diagnosis is made early and appropriate treatment commenced.

[Prevalence of goiter and iodine deficiency in Saxony is less than previously assumed. A study 6 years after discontinuation of general iodization of table salt]. / Strumaprävalenz und Joddefizit in Sachsen geringer als bisher angenommen. Eine Untersuchung sechs Jahre nach Abschaffung der generellen Speisesalzjodierung.

BACKGROUND: Germany is a known area of goitre endemicity. In East Germany (former German Democratic Republic), iodization of pre-packed table salt was introduced in 1985 and was only abolished after German reunification in 1990. Public awareness campaigns have concentrated on the use of iodized salt in the products of bakers and butchers as well as canned and frozen food since. Reports in the literature give figures of goitre prevalence (13 to 69%) inconsistent with each other and with our own clinical experience (about 30%). METHOD: We undertook a prospective cross-sectional study with a non randomly selected population (craftsmen and -women) covering Saxony in 1996, 1,129 and 1,594 adults were examined in 1996 and 1997, respectively, using a questionnaire, ultrasound, and measurement of urinary iodine excretion (1996 only). RESULTS: We found the following (mean) results in men/women in 1996: thyroid volume 23.0 +/- 1.3/17.1 +/- 1.5 ml, prevalence of goitre 32.1/31.3%, prevalence of thyroid nodules 21.1/23.0%, urinary iodine excretion (per creatinine) 86.4 +/- 1.3/104 +/- 24.1 nmol/mmol (97.1 +/- 1.4/117 +/- 27.1 micrograms/g). In 1997 the results were as follows: thyroid volume 20.9 +/- 1.2/15.7 +/- 2.1 ml, prevalence of goitre 25.6/23.6%, prevalence of thyroid nodules 16.4/19.8%. CONCLUSION: Whilst goitre and iodine deficiency are still endemic in Saxony, both have been improving despite the abolition of general table salt iodization.

Rhenium-188-HEDP in the palliative treatment of bone metastases.

INTRODUCTION: Rhenium-188-HEDP (188Re-HEDP) is a new and attractive radiopharmaceutical for the treatment of bone pain due to metastases. As a product of a 188W/188Re generator it is convenient for clinical use. With a short physical half life of 16.9 hours and a maximal beta-energy of 2.1 MeV, it is suitable for therapy. METHODS: We investigated the influence of 188Re-HEDP on pain relief, analgesic intake and impairment of bone marrow function in 15 patients. All patients were interviewed using standardized questions before, and 1, 2, 3, 4, 8, and 12 weeks after therapy. Blood samples were drawn weekly for 12 weeks, and a blood count was performed. Patients underwent gamma camera imaging to determine the radionuclide accumulation 4, 20, and 28 hours after therapy. The patients were treated with 1600 to 3459 MBq of 188Re-HEDP. RESULTS: Patients showed an improvement of the Karnofsky performance index from 74 +/- 8% to 84 +/- 11% 12 weeks after therapy. This improvement was statistically significant (p = 0.001). Eighty percent of the patients described pain relief and reduction of analgesics. Twenty percent of the patients could discontinue their analgesics. Mean platelet count decreased from (284 +/- 84)*10(3)/microliter to (205 +/- 62)*10(3)/microliter, and mean leukocyte count from (7.5 +/- 1.5)*10(3)/microliter to (5.9 +/- 2.1)*10(3)/microliter after therapy. The maximal differences between the values of platelets and leukocytes before and after therapy were not statistically significant (p = 0.021 and p = 0.094). Prostate specific antigen decreased from 95 +/- 83 ng/ml to 41 +/- 21 ng/ml, the difference was not statistically significant (p = 0.443). The bone accumulation 4, 20, and 28 hours after therapy was 1.3 +/- 0.5%, 0.6 +/- 0.3%, and 0.45 +/- 0.2% of the injected dose of a single metastasis, and 57 +/- 17%, 15.5 +/- 2% and 11 +/- 3% in the whole body, respectively. The effective half-life of 188Re-HEDP was 15.3 +/- 3.0 hours in the bone metastases, and 11.4 +/- 2.8 hours in the whole body. This corresponds to a residence time of 0.22 +/- 0.25 hours in the bone metastases, and of 10.54 +/- 2.59 hours in the whole body. CONCLUSION: In a small patient population, 188Re-HEDP therapy for bone pain palliation was effective and was associated with minimal toxicity.

Evaluation of transmyocardial laser revascularization (TMLR) by gated myocardial perfusion scintigraphy.

TMLR is a novel treatment for patients with coronary artery disease. It comprises the creation of transmyocardial channels thought to improve myocardial perfusion. Gated Tc-99m sestamibi scintigraphy was used to evaluate changes in myocardial perfusion after TMLR. Twelve patients underwent TMLR using a carbon dioxide laser. Sestamibi scans were carried out following a standard protocol prior to and 1, 3, 6, and 12 months after TMLR. Both visual and semi-quantitative assessment showed improvement in 4 patients, deterioration in 2 patients, and no change in the remaining 6 patients each. However, visual and semi-quantitative assessment were concordant in 6 patients and discordant in 6 patients. In 3 of these, semi-quantitative assessment suggested a better outcome, and in 3 patients visual assessment gave better results. Our findings in a small group of patients suggest that about a third benefited from TMLR. Gated myocardial perfusion scintigraphy using technetium-99m sestamibi is suitable for visual evaluation of changes in the lased area over time, but does not allow semi-quantitative evaluation in the patient population typically treated with TMLR. Further investigations using optimized imaging protocols, including positron emission tomography and three dimensional image presentation, are warranted.

[Can immunoradiometric measurement of thyrotropin (TSH) in human serum compete with a luminometric assay?]. / Ist die immunradiometrische Bestimmung von Thyreotropin (TSH) im Humanserum einem Lumineszenzassay unterlegen?

UNLABELLED: The development of highly sensitive, nonradioimmunometric assays for the measurement of thyrotropin (TSH) during the last few years have improved the measurement of low TSH values and thus benefit the diagnosis of thyroid function disorders. These third or fourth generation assays are especially popular in laboratories not accustomed to the use of radioactive tracers and can be easily automatized. AIM: This study investigates whether these new assays provide an advantage in routine diagnosis of thyroid disorders. METHODS: TSH was measured in 150 patients with various thyroid pathology using an immunoradiometric assay (IRMA) as well as a highly sensitive luminometric assay (LUMI), both by B.R.A.H.M.S. Diagnostica. We used the current modern IRMA (available since 1997) TSH was below 0.4 mU/l, between 0.4 and 4.0 mU/l, and above 4.0 mU/l in a third of the patients in each group, respectively. RESULTS: As expected the results obtained with LUMI and IRMA correlated well for TSH values above 0.1 mU/l and less well between 0.1 and 0.01 mU/l. There was no correlation between the two types of assay at TSH concentrations below 0.01 mU/l. This shows that measurements using both types of assay become increasingly less precise below 0.1 mU/l. CONCLUSION: Both types of assay gave an identical estimate of thyroid function in every single patient. Use of the LUMI did not give additional information leading to a change in patient management. Therefore, TSH measurement using IRMA does still meet today's routine clinical requirements.

Clinical value of a bispecific antibody binding to thyroglobulin and thyroperoxidase (TGPO-aAb) in various thyroid diseases.

TGPO-aAb is a bispecific antibody which binds to thyroglobulin as well as thyroid peroxidase. It is supposed to be raised in some patients with autoimmune thyroid disease. We investigated 205 patients suffering from Graves' disease (n = 81), Hashimoto's thyroiditis (n = 36), toxic nodular goitre (n = 50), differentiated carcinoma of the thyroid (n = 10), and autoimmune thyropathy of unknown origin (n = 28). An immunoradiometric assay was used to measure serum TGPO-aAb. Eighty-nine of 205 patients had elevated titres of TGPO-aAb. If TGPO-aAb were raised then autoantibodies against thyroglobulin and thyroid peroxidase were always raised, too. This was, however, not true vice versa. We found TGPO-aAb in 61% of patients with Hashimoto's, 49% of patients with Graves', 64% of patients with autoimmune thyropathy, but only in 12% of patients with toxic nodular goitre. In patients with thyroid carcinoma TGPO-aAb was found only if there was evidence of paraneoplastic autoimmune thyroiditis. We re-examined 16 of 36 patients with Hashimoto's thyroiditis after 1 year: 8 patients had retained their raised TGPO-aAb, 4 patients showed no TGPO-aAb on both occasions, and 4 patients had 'lost' their previously raised TGPO-aAb on follow-up. We conclude that TGPO-aAb may provide additional information in Hashimoto's thyroiditis. Determination of TGPO-aAb does not allow to distinguish between various forms of autoimmune thyroid disease. Nevertheless, the presence of TGPO-aAb and its variation during the natural course of autoimmune thyroid disease remains to be understood which would give a better insight into its clinical significance.