Aspiration in the context of upper gastrointestinal endoscopy.

BACKGROUND: Pulmonary aspiration is a life-threatening complication of upper gastrointestinal endoscopy, the incidence of which has not been determined. Endoscopy-related aspiration has not been studied in procedures in which patients swallow a radiolabelled potential aspirate immediately before endoscopy and undergo nuclear scanning postprocedure. METHODS: A pilot study was conducted in which 200 MBq of nonabsorbable technetium-99m phytate in 10 mL of water was administered orally to 50 patients who were about to undergo endoscopy. Gamma camera images were obtained to ensure that there had been no aspiration before endoscopy. After endoscopy, a repeat scan was performed. Fluid aspirated through the endoscope was also collected and analyzed for radioactivity using a hand-held radiation monitor. RESULTS: No evidence of pulmonary aspiration was found in any of the patients studied. The mean estimated percentage of the initially administered radioactivity aspirated through the endoscope was 2.66% (range 0% to 10.3%). CONCLUSION: The present pilot study confirms earlier observations that clinically significant aspiration in the context of upper gastrointestinal endoscopy is uncommon. The incidence of aspiration may, however, be different in acutely bleeding patients undergoing endoscopy. For logistic reasons, this group could not be studied.

Sonography in the diagnosis of carpal tunnel syndrome.

OBJECTIVE: The few papers published on the use of sonography in carpal tunnel syndrome suggest it may be a useful diagnostic test. This study aims to prospectively evaluate the use of sonographic measurements of the median nerve in the diagnosis of carpal tunnel syndrome. SUBJECTS AND METHODS: Patients with documented carpal tunnel syndrome and a group of asymptomatic control subjects were enrolled and underwent high-resolution sonography of the carpal tunnel. A small-footprint linear array transducer was used to scan and measure the median nerve cross-sectional area and the maximum transverse and anteroposterior diameters. Data from the patient group and the control group were compared to establish optimal diagnostic criteria for carpal tunnel syndrome. RESULTS: Sixty-eight carpal tunnel syndrome patients (50 women, 18 men) with 102 affected nerves and 68 nerves in 36 asymptomatic controls (23 women, 13 men) were examined. Qualitative assessment alone was found to be unreliable. All measurements showed significant differences between patients and controls. The most predictive measurement was swelling of the median nerve, which was significantly greater in carpal tunnel syndrome patients compared with controls (mean, 0.13 cm2 versus 0.07 cm2). Thus, quantitative assessment of the median nerve provides an accurate diagnostic test (sensitivity, 82%; specificity, 97%), with an area larger than 0.09 cm2 being highly predictive of carpal tunnel syndrome. CONCLUSION: We confirm that median nerve cross-sectional area measurement correlates well with the presence of carpal tunnel syndrome and is both sensitive and specific for the diagnosis.

VACTERL with hydrocephalus: family with X-linked VACTERL-H.

We describe in a five generation family four affected males with hydrocephalus (4 offspring/4 examined) due to aqueductal stenosis (3/3), symmetrical radial ray abnormalities (4/4), renal anomalies (2/3), anal atresia (3/4), hypoplastic penis/abnormal testes (2/3), and cardiac abnormalities (1/3). X-linked inheritance seems certain in this family. These abnormalities are characteristic of the rare X-linked VACTERL-H syndrome. In addition, one maternal female cousin had a severe tracheo-esophageal fistula. This may represent partial manifestation in a female carrier. Chromosomes were apparently normal (46XY) with no spontaneous or excess induced breakages in one of the affected offspring and his mother. In the absence of a genetic marker, diagnostic ultrasonography is the investigation of choice for early in utero detection of this syndrome. A confident ultrasonographic diagnosis was possible by 20 weeks in the 2 cases examined.

The ultrasonic diagnosis of urachal anomalies.

Seven cases of urachal anomalies are presented. The spectrum of the disorder and the criteria for ultrasound diagnosis are described. Six of seven cases were correctly diagnosed pre-operatively with diagnostic ultrasound, but one case with no cystic component was missed. The appearance of a fixed, midline, cystic, extraperitoneal swelling between the umbilicus and the bladder should suggest the diagnosis.

Thallium-201 myocardial SPECT in myocardial bridging.

Myocardial bridging is an uncommon condition where a major coronary artery is bridged by a band of muscle and narrows during systole, particularly during rapid heart rates. We present a patient with typical angina and angiographically proven 60% systolic bridging of the left anterior descending artery distal to the first perforator. Postexercise SPECT 201TI scanning demonstrated a severe reduction of perfusion to the septum and a moderate reduction of perfusion to the anterior wall of the left ventricle. Redistribution images demonstrated good reversibility of the perfusion defects indicating reversible myocardial ischemia. This case provides additional supportive evidence that myocardial bridging may cause myocardial ischemia.

The role of gallium-67 scanning in febrile patients.

The source of sepsis in febrile patients can be a difficult diagnostic problem. Gallium-67 has been utilized as a diagnostic tool in the evaluation of these patients. A retrospective review was done of 47 patients who presented with pyrexia of unknown origin (27 patients), postoperative fever (11 patients), septicaemia (4 patients) and miscellaneous sepsis (5 patients). Whole body imaging with Gallium-67 gave an overall sensitivity and specificity of 86 and 77%, respectively, which compares favourably with previous studies. The sensitivity and specificity was similar in all patient subgroups. Gallium-67 allowed for more effective and directed use of organ-specific imaging modalities, such as computed tomography, ultrasound and guided intervention, in localizing and defining the source of sepsis. Where more than one possible source of fever was present. Gallium-67 scanning correctly identified the activity of the different foci. Gallium-67 scanning should be used early in the evaluation of patients presenting with fever of uncertain origin.

[Usefulness of exercise echocardiography for the diagnosis of ischemic heart disease]. / Utilidad de la ecocardiografía de esfuerzo en el diagnóstico de la cardiopatía isquémica.

INTRODUCTION AND PURPOSE: The purpose was assessing the usefulness of exercise digitalized echocardiography for the diagnosis of ischemic heart disease. PATIENTS AND METHODS: Eighty-eight patients, with suspected artery coronary disease, underwent both a exercise echocardiography with treadmill Bruce protocol and a coronary arteriography, within a period less than 2 months, without changes in their clinical evolution. Fifty-eight patients shown significant coronary lesions (> or = 50%). RESULTS: The exercise echocardiography showed a high sensitivity (74%), significantly greater (p < 0.01) than exercise electrocardiography alone. The sensitivity was fixed by the level of exercise done, reaching 91% when submaximal exercise was achieved, and by the severity and extension of coronary disease, being of 68.5% for a single-vessel, 80% for two-vessel and 100% for three-vessel. The specificity was 87%, considering the lesions lesser than 50% as not significant, and it was 100% when the coronary arteries without disease were taken into account. CONCLUSIONS: Exercise echocardiography can be a rutinary method for the diagnosis of ischemic heart disease, and it shows a high sensitivity and specificity, greater than exercise electrocardiography alone.

Gallium-67 scintigraphy in borderline lepromatous leprosy.

A middle aged woman with a pyrexia of unknown origin was shown to have borderline lepromatous leprosy. Early gallium-67 scintigraphy demonstrated increased uptake in the subcutaneous tissues of the face and thighs. As a result of these findings skin biopsy was obtained from the right thigh which gave a diagnosis of borderline lepromatous leprosy. The authors have been unable to find other reports of gallium-67 scintigraphy in leprosy but the pattern of gallium-67 distribution should suggest the diagnosis.

[Coronary ostial stenosis after an aortic valve replacement diagnosed by transesophageal echocardiography]. / Estenosis de ostium coronario tras recambio valvular aórtico diagnosticado mediante ecocardiografía transesofágica.

We submit the case of a 75-year-old man that underwent aortic valve replacement whose preoperative coronary angiography showed lesion-free coronaries. Two months after surgery he began to feel rapidly progressing effort angina pectoris. Transesophageal echocardiography showed prosthetic normal function while allowing the study of the great coronary trunks. We observed the presence of a 50% stenosis at the ostium of the left coronary artery trunk due to the use of selective coronary cannulation to supply cardioplegia solution during valve replacement. A second coronary angiography confirmed this finding. Transesophageal echocardiography may be used as an initial diagnostic method when coronary ostial stenosis is suspected after aortic valve replacement.

[Intrapericardial pheochromocytoma]. / Feocromocitoma intrapericárdico.

Intrapericardial pheochromocytomas are extremely rare tumors. Diagnosing and localizing them are very difficult tasks when using conventional methods used for adrenal pheochromocytoma. We present the case of a patient with a pheochromocytoma who had a CT scan of the thorax and abdomen performed, as well as 131I methaiodinebencilguanidin (131 I-MIBG) gammagraphy, with completely normal results. The tumor was localized in the mediastinal area using 123 I-MIBG and NMR. The tumor was found intrapericardial during the operation; it was fixed to the pulmonary artery and in close contact with the left atrial, as well as with the circumflex and aorta arteries. It was possible to carry out the resection without causing any damage to these structures.

A clinical comparison of Technegas and xenon-133 in 50 patients with suspected pulmonary embolus.

A comparison of "Technegas" and xenon-133 was performed in 50 patients presenting with a clinical diagnosis of pulmonary embolus. All patients underwent studies with xenon inhalation, Technegas inhalation, and macroaggregated albumin perfusion. Technegas is a new ultrafine ventilatory agent with a particle size of 50 to 200A produced from technetium pertechnetate and graphite in an argon environment. Although particulate in nature, Technegas is transported and diffuses like a gaseous agent. Its production results in a high specific activity yield with high efficiency. There is no significant deposition in the central airways, and good peripheral visualization of the lung is obtained. The study was designed to assess whether Technegas could be used as a ventilatory agent to obtain high-quality diagnostic images. All studies were reported as in normal clinical practice, and no statistical analysis was performed. The aim of the study was simply to see what role Technegas had in a busy clinical department and how well it reflected ventilation by comparison with xenon. Patient compliance with Technegas was 100 percent and for xenon was 94 percent. Technegas enables one to obtain high-quality ventilatory images and has an important role to play in the assessment of pulmonary ventilation.

Technetium-99m autologous phagocyte scanning: a new imaging technique for inflammatory bowel disease.

A method to determine the extent of active inflammatory bowel disease using selective labelling of autologous neutrophils and monocytes by phagocytosis of a technetium-99m (99mTc) stannous oxide colloid is described. Unlike leucocyte scanning techniques using Indium-III (IIIIn), the 99mTc colloid scan uses a cheap, readily available isotope, which specifically labels phagocytes. Scan results in 20 patients with inflammatory bowel disease were compared with barium examinations and colonoscopic appearances. There was close agreement in 15 of 20 patients as to the extent of mucosal disease. In four cases the scan showed more extensive disease than was suggested by barium examination. The scan showed terminal ileal Crohn's disease in three patients in whom the barium studies of the ileum had been reported as normal. In four patients with inactive disease and normal barium examinations no activity was seen on the scans. The 99mTc phagocyte scan is a sensitive, reliable means of determining the extent of active inflammatory bowel disease and can be used to quantify disease activity.

Lung ventilation studies with technetium-99m Pseudogas.

Technetium-99m Pseudogas is an ultrafine near monodisperse aerosol of 0.12-microgram diam particle size. This report describes initial clinical experiences with 27 patients referred for investigation of suspected pulmonary embolism, and in whom Pseudogas ventilation images were compared with a high quality commercial aerosol. An additional group of ten patients with severe COPD was examined in a comparative trial of Pseudogas with 81mKr. Pseudogas was better than a conventional aerosol in reaching a diagnosis of pulmonary embolism using a simple blinded comparison with coded images. In addition, bronchial deposition was minimal unless COPD was severe. Moderately well patients had no difficulty inhaling the necessary activity in one or two breaths, and even severely ill and frail aged persons could accomplish the passive breathing maneuver in less than a minute. Clearance of Pseudogas was directly to the systemic circulation with a half-time of 10 min in normal subjects extending up to 100 min in patients with airways disease.

Identification of factors affecting technetium 99m leucocyte labelling by phagocytic engulfment and development of an optimal technique.

Human autologous leucocytes can be simply and reproducibly labelled by phagocytic engulfment of technetium 99m stannous colloid with high leucocyte-labelling efficiency (LLE), similar human biodistribution to indium-111-oxine labelled leucocytes and good cell viability. A mean particle size of 2.1 microns is optimal for phagocytosis and the most important parameter in maintaining reproducibly high neutrophil uptake. It is more critical than hitherto appreciated. When such variables as type of colloid, purity of starting materials, speed of mixer rotation when preparing colloid and labelling leucocytes, heparin concentration, freshness of colloid preparation, type of sterilising membrane filter used and incubation time of cells with colloid are rigidly controlled, consistent labelling efficiencies in excess of 90% can be obtained with neutrophil predominance. The lyophilised kit tested produced suboptimal results.