Antecedent interventions in the management of maladaptive behaviours in a child with brain injury.

Typically behaviour management plans attempt to change behaviour by manipulating the environmental consequences of selected behaviour. However, identifying the antecedent events that precede behaviour has also been demonstrated to be an important component of effective behaviour change programmes. The present case presentation attempts to demonstrate how antecedent procedures could be used to effectively manage behaviour problems in individuals with brain injury. Visual inspection of changes in the frequency of physical aggression and self-injurious behaviour of a child with brain injury provides preliminary data supporting the use of an intervention package of antecedent and consequence-based procedures. Clinical implications, limitations and possibilities for future research of antecedent control procedures are discussed.

Tc-99m MAG3 evaluation of recipients with dual adult cadaveric renal allografts. Simultaneous transplantation of both kidneys from marginal donors.

PURPOSE: The application of Tc-99m mercaptoacetyl triglycine (MAG3) renal scintigraphy in patients who had simultaneous unilateral retroperitoneal transplant of both kidneys from marginal adult cadaveric donors is assessed. METHODS: Eighteen patients who had this unusual form of kidney transplant were monitored and evaluated by Tc-99m MAG3 renal scintigraphy. More than 60 of the radioisotopic studies, including immediate postoperative and subsequent follow-up examinations, were performed among these patients. RESULTS: In all the studies, the two transplanted kidneys were not equally well visualized by this scintigraphic procedure because of the inherent difference in their depth from the body surface, a feature of this particular surgical design. Despite this limitation, the efficacy of the scintigraphic procedure for such dual renal allografts appears to be similar to that established for kidney transplants performed in the conventional manner. CONCLUSION: To use the scintigraphic procedure effectively, certain sensible and logical adjustments are needed for the comparative visual and semiquantitative assessments of the two kidneys in this special form of transplantation.

Scintigraphic demonstration of postural induced drainage stasis in an en bloc renal allograft.

Within 6 months after an en bloc transplantation of two kidneys from a cadaveric pediatric donor, the recipient was referred for further scintigraphic evaluation because of clinical suspicion of having a postural related function impairment of the grafted kidneys. Tc-99m MAG3 imaging, modified by varying the position of the patient during the procedure, resulted in detection of drainage stasis only with the patient standing. This drainage stasis had not been appreciated in the preceding routine examinations performed with the patient supine. Although the positional outflow stasis by itself may not be severe enough to cause alarming dysfunction of the grafted kidneys, it could conceivably be a significant contributing factor.

Priapism in children with sickle cell disease.

A review of hospital admissions during 80 months revealed only 8 patients with episodes of priapism of approximately 400 pediatric male patients with sickle cell disease. The patients, who ranged in age from 5 to 19 years, underwent a 99mtechnetium penile scan, and 4 had a low and 4 had a high flow scan. Three cases resolved with hydration alone. Five patients received exchange transfusion of whom 3 subsequently underwent shunt procedures. One patient with a 5-year history of recurrent stuttering episodes was placed on transfusion therapy for 6 months and stuttering episodes have not recurred. One patient had a cerebrovascular accident 1 day after hospital discharge and another had priapism while on chronic transfusion therapy for a cerebrovascular accident. Each postpubertal patient had a severe clinical course; 1 had temporary impotence for 3 months and another had impotence at 2 weeks but was lost to followup. While 99mtechnetium penile scans may help clarify the severity of vascular stagnation, in our small group they were not helpful in predicting clinical course.

Penile scintigraphy for priapism in sickle cell disease.

UNLABELLED: Penile scintigraphy with [99mTc]pertechnetate/99mTc-RBCs was performed in patients with sickle cell disease patients who had priapism to assess the role of this imaging procedure in directing the clinical management of these patients. METHODS: Fifteen studies were performed in 13 patients who were treated according to a protocol not dependent on the imaging results. The scintigraphic findings of penile vascular perfusion (stagnant or nonstagnant patterns) were collated retrospectively with the form of treatment needed for relief of the condition. RESULTS: Four of five patients with the nonstagnant perfusion pattern responded to analgesics and intravenous hydration. Four of eight patients with the stagnant pattern did not require any aggressive interventions such as corporeal aspiration/irrigation, intracorporeal epinephrine or glans-cavernosa shunt. CONCLUSION: Whereas the nonstagnant scintigraphic finding appeared to be a favorable indicator for conservative treatment, the stagnant finding was apparently noncontributory. In addition, no correlation was found between these two types of scintigraphic patterns and the subsequent sexual potency of these patients.

Disorders associated with extensive unilateral abnormalities in ventilation/perfusion or perfusion scintigraphy.

Along with the utilization of radionuclides for ventilation (V) and perfusion (Q) functional imaging of the lungs, massive predominantly unilateral scintigraphic abnormalities had been captured and cumulatively recorded in the literature. Such distinctive imaging findings are infrequent and their reported occurrences are reviewed. The precipitating disorders are categorized according to the corresponding V/Q scintigraphic findings that reflect the underlying pathophysiology. This arrangement may facilitate the interpretation of pulmonary scintigraphy with similar unusual imaging characteristics. The perfusion scan of patients with a variety of congenital heart diseases often show imaging abnormalities that are diffusely unilateral. It has been proven quite useful for evaluation of the pulmonary blood flow in those cardiac disorders before and after palliative or corrective surgery.

Pitfalls and limitations of diuretic renography.

We report five pediatric cases that illustrate the methodologic pitfalls and limitations of diuretic renography in suspected ureteropelvic junction obstruction. False-positive studies may be related to such avoidable flaws in methodology as premature diuretic administration, inadequate diuretic dose, and bladder distension, or to recent pyeloplasty. False-negative results may occur despite optimum technique, necessitating a follow-up study for confirmation.

Radioisotopic evaluation of renal transplants.

Owing to the noninvasive nature, ready availability, and efficacy, radionuclide studies remain widely utilized following renal transplantation for monitoring changes in the functional status and detection of detrimental complications of the grafted kidney. Whereas surgical complications, including vascular occlusion, urine extravasation, drainage obstruction, hematoma, or lymphocele formation, can often be detected effectively, specification of other underlying causes of deterioration of parenchymal function, including acute tubular necrosis (ATN), various types of rejection, and cyclosporine A nephrotoxicity (CyA-NT), frequently cannot be derived independently from the findings of a study without clinical correlation. Besides imaging, plotting of renogram or time/activity curves, numerous quantitative methods have been introduced to provide objective measurements of the blood flow, as well as to gauge the capability of concentration and excretion of the transplanted kidneys. However, the findings whether qualitative or quantitative all have overlapping zones. There is no abnormal image, graphic, or numeric index absolutely specific for any of the possible posttransplant renal parenchymal complications. The differentiation of such conditions may best be achieved through chronologic association of the sequential changes, with or without quantification, detected in serial studies with the clinical presentation and findings.

Reversible increased technetium-99m-HMPAO cerebral cortical activity: a scintigraphic reflection of luxuriant hyperperfusion.

A hemiparetic and aphasic patient, 3 days after acute traumatic transection of the left internal carotid artery requiring life-saving total embolic occlusion, revealed ipsilateral increased peripheral hemispheric 99mTc-HMPAO activity. Ten days postocclusion, HMPAO peripheral cortical flow normalized as hemiparesis and aphasia significantly cleared. The initial lateralized HMPAO hyperactivity pattern may reflect reactive hyperemia, a sign previously identified by contrast angiography and often associated with a better prognosis in evolving CVA. Evanescent peripheral cerebral hyperemia may represent beneficial cortical collateralization of the periinfarct area of a deeper lacunar (white matter) CVA.

Testicular scintigraphic findings two to three months after torsion. Correlation with sonography and histopathology.

A patient with a nontender testicular mass had sonographic abnormalities compatible with but not entirely typical of a chronic torsion. His scintigraphic studies, done on the same day as ultrasonography and 1 month later, revealed only findings consistent with a very mild subsiding scrotal inflammatory process. On surgical exploration and pathologic examination, it was found that he had an organizing infarct of the testicle secondary to torsion. The clinical history, diagnostic studies, and microscopic slides of the surgical specimen were reviewed. It appeared that tissue granulation and lipogranulomatous changes in the epididymis, known histologic sequelae to the unusually prolonged testicular torsion of 2-3 months, produced scintigraphic findings different from those which have been described for a late or an atrophic torsion.

Hypertrophic osteoarthropathy associated with Pneumocystis carinii pneumonia in AIDS.

Hypertrophic osteoarthropathy (HOA) is a systemic disorder primarily affecting the bones, joints, and soft tissues and developing in association with another disease process. Acute pyogenic pulmonary processes (empyema, lung abscess) are occasionally accompanied by transient HOA, but reversible HOA has not previously been reported in the setting of PCP in AIDS.

Attempts at clarification of splenic visualization on reticuloendothelial images: Tc-99m DISIDA compared with heat- denatured Tc-99m RBC imaging.

Four patients with enlarged left hepatic lobes and questionable or difficult splenic visualization on Tc-99m sulphur colloid (SC) images were further examined with additional radionuclide procedures. All four patients had Tc-99m DISIDA imaging, and three of them also had heat-denatured Tc-99m RBC imaging. The hepatobiliary images appear very effective in confirming postsplenectomy expanded enlargement of the left lobe of the liver and in refuting the presence of spleen in such cases. However, distinct visualization of the spleen in these patients can be achieved only through selective spleen imaging with heat-damaged red cells.

Reversible pulmonary uptake and hypertrophic pulmonary osteoarthropathic distribution of technetium-99m methylene diphosphonate in a case of Pneumocystis carinii pneumonia.

Diffuse pulmonary deposition of [99mTc]methylene diphosphonate (MDP) as well as abnormalities characteristic of hypertrophic pulmonary osteoarthropathy have been observed in a patient with Pneumocystis carinii pneumonia (PCP). The findings of the bone scan together with those in the corresponding scintigraphy, and roentgenograms of the chest and skeletal structures are presented. Parallel reversal of [67Ga]citrate and [99mTc]MDP pulmonary uptake with specific treatment for and clinical resolution of PCP implies a causal relationship.

Paget's disease: a cause of photopenic skeletal defect in indium-111 WBC scintigraphy.

As an incidental finding in an [111In]WBC scan performed in search of an infectious focus, photon deficient areas were found in several skeletal locations, characterized by bone and gallium scintigraphy and confirmed radiographically as sites of active Paget's disease. The literature concerning cold bone defects in the [111In]WBC scintiscan is reviewed. Loss of marrow component in the bone appears to be the underlying mechanism for such an abnormality.

Ileal leiomyosarcoma and leiomyoma. False-positive scintiscans for Meckel's diverticulum.

Two cases of ileal leiomyomatous neoplasms with positive scintigraphic findings for Meckel's diverticulum are presented. The precise mechanism for the abnormal concentration of the Tc-99m pertechnetate is uncertain. Illustrations of the collating barium and computerized tomographic studies are included and the scanning technique utilized is reviewed.

Scintiscan for acute intrascrotal conditions.

The efficacy and merit of testicular imaging, utilizing Tc-99m pertechnetate, were studied prospectively in a group of patients who presented with acute onset of scrotal pain. Consecutive admissions were studied. All were managed according to the likelihood of the problem being testicular torsion, which was determined from the clinical history, physical examination and the routine laboratory data. The final diagnostic outcome, whether by surgical exploration or clinical progress with conservative treatment, is collated with the preoperative scintigraphic interpretations, made with respect to predefined criteria. Analysis of the pretreatment images obtained in 57 patients shows that the radionuclide study is highly reliable in cases of testicular torsion and epididymo-orchitis. It appears to be much less dependable, however, in the other acute scrotal conditions. Torsions that are intermittent in nature or corrected manually apparently can have variable presentations. Certain difficulties and potential pitfalls encountered in interpreting the scintigraphic studies are discussed.