A Rare Case of Polyostotic Fibrous Dysplasia Assessed by Bone Scintigraphy with Tc-99m Methylene Diphosphonate (MDP)

A 66-year-old man affected by polyostotic form of fibrous dysplasia in consequence of worsening of lower extremity bone pain aggravated by walking and concomitant increase of serum alkaline phosphatase and osteocalcin, was subjected first to a radionuclide study. Bone scan demonstrated a pathological uptake of the radiotracer in the craniofacial bones, right scapula, left and right posterior ribs, right hemipelvis and lower extremities confirming the diagnosis but establishing especially the extent of bone involvement, greater than expected on the basis of symptoms and X-ray findings, underlying the importance of nuclear medicine imaging in the assessment and follow-up of this rare disease.

Cardiac and pulmonary calcification in a hemodialysis patient: partial regression 4 years after parathyroidectomy

AIMS

The reversibility of extraskeletal calcifications in dialysis patients is an important and unresolved issue. Although periarticular calcifications have been shown to be reversible, little data are available on vascular or parenchymal calcifications.

CASE HISTORY

A patient on maintenance hemodialysis with severe hyperparathyroidism, hypercalcemia and hyperphosphatemia was admitted to undergo parathyroidectomy. A preoperative total body bone scintigraphy was performed to better evaluate a lytic lesion in the pelvis, the histology of which proved to be a "brown tumor". The scan showed the typical findings of renal osteodystrophy, but also a diffuse extra-skeletal uptake of bone tracer in the lungs, kidneys, femoral arteries and myocardium. After surgery, good control of serum calcium, phosphate (Ca x P product < 50 mg2/dl2) and PTH levels was maintained during 4 years of follow-up. Bone scans were repeated after 2 and 4 years, showing marked improvement of periarticular uptake at the ends of long bones. Extraosseous calcium deposition was still markedly evident, but progressively decreased (at 4 years: heart -36%, lungs -18%).

CONCLUSION

In this dialysis patient, extraskeletal calcification of visceral organs (particularly in the heart and the lungs) due to prolonged hypercalcemia and hyperphosphatemia was partially reversible by parathyroidectomy followed by good long-term control of serum phosphate and calcium.

Peripheral quantitative Computed Tomography (PQCT) in the evaluation of bone geometry, biomechanics and mineral density in postmenopausal women

AIM

Non-invasive assessment of bone geometry, biomechanics, and mineral content in postmenopausal women by peripheral quantitative Computed Tomography (pQCT).

MATERIAL AND METHODS

Total, trabecular and cortical mineral density (totBMD, cortBMD, trabBMD), and the geometrical (total area, trabecular area, cortical area) and biomechanical properties of bone (strength-strain index, cortical thickness) were assessed in 93 consecutive post-menopausal women (mean age: 63+/-7 yrs; age at menopause: 49+/-6 yrs; years since menopause: 14+/-9 yrs) by pQCT at the ultradistal radius of non-dominant forearm.

RESULTS

Compared with 50 healthy women at peak of bone mass, volumetric total, trabecular and cortical bone densities were significantly reduced in postmenopausal subjects (TotBMD: 318+/-106 mg/cm3 vs ctr 442+/-100, -28%, p<0.001; TrabBMD: 117+/-59 mg/cm3 vs ctr: 203+/-47, -42%, p<0.001; CorBMD: 764+/-159 mg/cm3 vs 921+/-111, -17%, p<0.001). The bone loss was greater in trabecular bone. Cortical area (0.7+/-0,1 cm2 vs ctr: 0.8+/-0.1, -12.5%, p<0.001), cortical thickness (0.151+/-0.02 cm vs ctr: 0.169+/-0.03, -11%, p<0.001), and strength-strain index (686+/-207 mm3 vs ctr: 883+/-165, -22%, p<0.001) were significantly lower in post-menopausal women in comparison with the controls. Years since menopause and age showed a significant negative correlation with bone mineral densities and biomechanical parameters.

CONCLUSIONS

In post-menopausal women pQCT showed: 1) osteopoenia in all bone compartments, greater at the trabecular level, related to age and years since menopause; 2) reduced cortical density and cortical thickness, consistent with a reduced ability of bone to absorb loading forces; 3) reduced strength-strain index, indicative of inability to adapt to mechanical use and augmented risk for fracture. We conclude that pQCT is a valuable tool for measuring the true volumetric mineral density and the geometrical and biomechanical indexes of bone, which could be proposed in current clinical practice for the assessment of osteoporosis.

Radio-guided video-assisted parathyroidectomy: a preliminary report

BACKGROUND

The surgical management of primary hyperparathyroidism is changing both in terms of the extent of cervical exploration and in technique. There are many new mini-invasive procedures for neck surgery. We describe our preliminary experience with a technique that combines two mini-invasive procedures--radio-guided and video-assisted parathyroidectomy.

METHODS

Six consecutive patients with no recurrent or persistent primary hyperparathyroidism, no previous cervical operations, and no thyroid pathologies were selected to undergo radio-guided video-assisted parathyroidectomy.

RESULTS

One case was converted. There was no morbidity or mortality in the postoperative period. Six parathyroids were removed; the histological diagnosis was adenoma in all cases. All patients were discharged on the 1st postoperative day. Calcium serum levels normalized in all cases, with only one case of transient postoperative hypocalcemia. All patients were normocalcemic after 6 months.

CONCLUSION

Radio-guided video-assisted parathyroidectomy is feasible in selected patients. However, longer follow-up and more cases are necessary before this procedure can be applied routinely.

The good and evil of HAART in HIV-related progressive multifocal leukoencephalopathy

The use of highly active anti-retroviral therapy in patients with HIV-related progressive multifocal leukoencephalopathy is associated with increased survival and disease stabilization. However, approximately half of the patients receive no benefit from these treatments. In a group of HIV-infected patients with histologically or virologically confirmed PML, we recognized two distinct patterns of response, i.e., long survivors versus nonresponders, but could not identify any factors at baseline predictive of PML outcome. In addition, the use of cidofovir did not substantially affect survival. However, the survival rate was higher during the first years of HAART, i.e., 1996-1997, with better outcomes observed in patients receiving a protease inhibitor-containing regimen either irregularly or after a switch from a 2-nucleoside reverse transcriptase inhibitor combination. In contrast, PML outcome was frequently poor in both HAART-naive and -experienced patients who responded promptly to anti-HIV therapy in terms of CD4 increase and viral load decrease. In addition, in a number of patients, PML onset was temporally associated with immune reconstitution. It may be that, in some patients, rapid immune reconstitution due to HAART paradoxically worsens the course of PML. Gradual reversal of immune deficiency might be associated with better outcome.

Post-stress end-systolic left ventricular dilation: a marker of endocardial post-ischemic stunning

Several studies have shown the accuracy of gated single photon emission computed tomography (SPECT) using thallium-201 and technetium tracers in the assessment of myocardial perfusion and function. Gated SPECT has been successfully utilized to detect post-stress left ventricular ejection fraction (LVEF) reduction resulting from post-ischemic stunning in patients with coronary obstruction. The aim of this study was to evaluate whether the post-stress LVEF impairment could be related to the post-stress end-systolic ventricular dilation resulting from post-ischemic endocardial stunning. Two hundred and eighty-two consecutive patients were studied by conventional diagnostic 2 day stress/rest gated SPECT following injection of 925 MBq of 99mTc-tetrofosmin using a dual-headed SPECT camera. One hundred and forty-seven of these patients (52%) showed reversible perfusion defects, 69 (24%) permanent defects and the remaining 66 (24%) had normal perfusion. One hundred and thirty-eight of these patients had a history of myocardial infarction (MI) and 19% underwent coronary angiography without an intervening cardiac event. Perfusion was analysed on ungated images using 20 segments scored on a five-point scale (0, normal; 4, no uptake), while wall thickening (WT) was assessed visually on stress/rest end-systolic images using a four-point score (0, normal; 3, absence of WT). LVEF and volumes were calculated using an automatic algorithm. The post-stress and rest ratios were determined for both end-diastolic (EDV) and end-systolic (ESV) volume. Normal values for all these parameters were obtained using data from 149 patients with a low likelihood (<5%) of coronary artery disease (CAD). In 50 of the 147 (34%) of patients with reversible perfusion defects, post-stress LVEF was >5% lower than rest values (stunned group), while the remaining 97 patients did not show a significant LVEF change (group 2A). The percentage of patients who developed exercise-induced angina, the percentage of patients who underwent coronary angiography and the segmental summed perfusion and WT scores were significantly higher in the stunned group compared with group 2A. Only ESV increased significantly post-stress, and this increase occurred only in stunned patients. Both EDV and ESV ratios were significantly higher in the stunned group compared with normal controls (P=0.008 and P<0.000001, respectively) and with the subgroup 2A (P=0.011 and P<10(-12), respectively). The ESV stress/rest ratio correlated significantly with the summed WT difference score by univariate analysis in stunned patients. It can be concluded that the post-stress ESV dilation, obtained by stress/rest gated SPECT, seems to be due to endocardial post-ischemic stunning. The stunned patients showed more severe clinical, angiographic, perfusion and function parameters.

Effect of genotypic resistance on the virological response to highly active antiretroviral therapy in cerebrospinal fluid

Paired plasma and cerebrospinal fluid (CSF) specimens drawn from 15 HIV-infected patients with neurological disease before and after a median 6-week duration of highly active antiretroviral therapy (HAART) were studied to assess the short-term virological response of CSF and whether this can be predicted on the basis of baseline resistance mutations. After treatment, the median plasma and CSF viral load (VL) decreased by, respectively, 2.08 log10 (p = 0.0001) and 0.91 log10 copies/ml (p = 0.007) in comparison with baseline. A plasma virological response was observed in all but one patient, whereas the posttreatment CSF VL increased, remained unchanged, or decreased at a substantial lower rate than in plasma of six "CSF non/slow responders" (40%). Direct sequencing of baseline specimens showed that none of these patients had reverse transcriptase (RT) or primary protease resistance mutations in the CSF alone, but two had RT mutations conferring high-level resistance to drugs included in the HAART regimen in both CSF and plasma. The other four patients had no RT or primary protease resistance mutations. There was no significant difference in the nucleotide diversity of the CSF and plasma RT sequences, baseline plasma or CSF VL, the CSF-to-plasma VL ratio, the number of CSF cells, the CD4+ cell counts, or the history of antiretroviral treatment between the CSF non-slow responders and the other patients. During this short-term follow-up and despite a plasma response, a significant proportion of HAART-treated patients with neurological symptoms showed a slow or absent CSF response. Most of these cases were not associated with the presence of resistant HIV strains in the CSF.

Comparison of three nucleic acid amplification assays of cerebrospinal fluid for diagnosis of cytomegalovirus encephalitis

The diagnostic reliabilities of three cytomegalovirus (CMV) nucleic acid amplification assays of cerebrospinal fluid (CSF) were compared by using CSF samples from human immunodeficiency virus-infected patients with a postmortem histopathological diagnosis of CMV encephalitis (n = 15) or other central nervous system conditions (n = 16). By using a nested PCR assay, the quantitative COBAS AMPLICOR CMV MONITOR PCR, and the NucliSens CMV pp67 nucleic acid sequence-based amplification assay, sensitivities were 93.3, 86.6, and 93.3%, respectively, and specificities were 93.7, 93.7, and 87.5%, respectively. The COBAS AMPLICOR assay revealed significantly higher CMV DNA levels in patients with diffuse ventriculoencephalitis than in patients with focal periventricular lesions.

Labelled leukocytes for diagnosis of infectious diseases. Our experience in labelling and clinical usefulness

BACKGROUND

To review our experience in infectious diseases diagnosis, using a simple labelling technique.

METHODS

We made 101 scans in 91 patients with suspected infectious diseases confirmed by clinical, histologic or cultural specimens; a clinical or instrumental follow-up was available for every patient. Patients were divided into four subgroups: A: Inflammatory Bowel Diseases; B: Septic Syndromes; C: Bone diseases; D: Others. We used 99mTc-HMPAO in 80 scans and 111In in 21. In 20/80 frozen and stored HMPAO was used.

RESULTS

99mTc-HMPAO frozen and stored labelling yield was: 60%(SD15%), 99mTcHMPAO: 62(12)(p n.s.), 111In 75%(10%), (p < 0.05). Frozen-stored HMPAO was sterile and apyrogen. 27 had positive scan without leukocytosis or neutrophilia. No correlation between leukocytosis or neutrophilia and yield was observed. Transit lung times ranged between 14-16 min without differences among three radiopharmaceuticals. In each Group and in the sample as a whole True Positive, False Positive, True Negative, False Negative, Sensitivity, Specificity and Accuracy, were calculated. In Group B and in the sample as a whole Predictive Positive Value and Negative Predictive Value were also evaluated.

CONCLUSIONS

Labelling yields and "viability" were good using the three radiopharmaceuticals; labelling procedure was simple and safe. Accuracy PPV, NPV, cost-effectiveness were good; 111In is the choice for diagnosis of bone and joint infections. Frozen-stored HMPAO should be introduced as a cost-saving labelling procedure in practice.

Homocysteine concentration in primary and systemic sclerosis associated Raynaud's phenomenon

OBJECTIVE

To investigate whether patients with systemic sclerosis (SSc) have raised homocysteine (Hcy) plasma levels, thought to be an independent risk factor for vascular disease, and to study the relationship between Hcy and endothelial damage, and between Hcy and methylene-tetrahydrofolate reductase (MTHFR) genotypes, and patients' vitamin nutritional status, which are among the more frequent causes of hyperhomocysteinemia.

METHODS

We measured Hcy, von Willebrand factor (vWF), folic acid, and vitamin B12 plasma levels and analyzed the frequencies of MTHFR mutations in 30 patients with SSc and 12 patients with primary Raynaud's phenomenon (RP); 29 healthy subjects served as controls.

RESULTS

Patients with SSc had higher Hcy and vWF concentrations than those with RP (p < 0.01 and p < 0.02, respectively) or controls (p < 0.02 and p < 0.0001, respectively). Folic acid and vitamin B12 were lower in SSc than in RP (p < 0.01 and p < 0.02, respectively) or controls (p < 0.05). MTHFR genotype did not influence Hcy, folate, or vitamin B12 concentrations, but patients homozygous for the mutant gene had higher vWF levels.

CONCLUSION

Patients with SSc, but not those with RP, had significantly higher Hcy and vWF plasma levels. Nutritional rather than inherited factors seem to have a pathogenic role in SSc hyperhomocysteinemia.

99mTc-sulfur colloid gastroesophageal scintigraphy with late lung imaging to evaluate patients with posterior laryngitis

The aim of this study was to use gastroesophageal and pulmonary scintigraphy to evaluate the prevalence of gastroesophageal reflux and airway involvement among patients with posterior laryngitis.

METHODS

The study included a total of 201 patients (131 females, 70 males; age range, 15-77 y; mean age +/- SD, 49 +/- 16 y). All patients had posterior laryngitis documented by laryngoscopy and symptoms such as a dry cough, painful swallowing, and hoarseness. A control population of 20 healthy volunteers (13 females, 7 males; age range, 19-74 y; mean age, 53 +/- 13 y) was also evaluated. After a 12-h fast, all subjects underwent gastroesophageal scintigraphy through administration of 300 mL orange juice labeled with 185 MBq 99mTc-sulfur colloid. After 18 h, planar anteroposterior thoracic images were acquired with the subjects supine.

RESULTS

Sixty-seven percent of patients (134/201) had scans positive for gastroesophageal reflux; of these, 30 (22%) had distal reflux and 104 (78%) had proximal reflux. In addition, the scans of 31 patients were positive for proximal reflux-associated pulmonary uptake. The frequency, duration, and degree of reflux episodes were significantly greater in patients with proximal reflux than in patients with distal reflux (P < 0.001). The 67 patients in whom reflux was not detected had diseases or reflux-associated cofactors that could account for laryngeal symptoms. No statistically significant difference in symptoms or esophageal motility parameters could be identified among the patient groups, but patients with proximal reflux had significantly prolonged gastric emptying times compared with healthy volunteers.

CONCLUSION

Most patients with posterior laryngitis had detectable proximal gastroesophageal reflux. Exposure of the proximal part of the esophagus to acid, by setting the stage for microaspiration of gastric material into the larynx, remains a major cause of damage to the laryngeal mucosa. Slowed gastric emptying may be a predisposing factor. Moreover, symptoms such as a dry cough, painful swallowing, or hoarseness may not be reliable predictors of the presence of gastroesophageal reflux or of associated airway involvement.

[Detection and assessment of myocardial stunning with perfusion tomographic scintigraphy using gated SPECT]

BACKGROUND

Gated-SPECT using 99mTc-labeled flow tracers provides the simultaneous assessment of global and regional myocardial perfusion and function. The aim of this study was to identify patients with stress-induced postischemic stunning, among those with reversible stress perfusion defects, and patients with artifactual defects among those with fixed defects, in order to assess the value of the functional data provided by gated acquisition of perfusion imaging in the characterization of ischemia.

METHODS

We studied 221 consecutive patients who underwent conventional diagnostic dual day stress/rest gated-SPECT following injection of 925 MBq of 99mTc-tetrofosmin using a dual head SPECT camera, 115 of whom (52%) showed reversible perfusion defects, and 66 (30%) fixed defects. Perfusion was analyzed on ungated images using 20 segments scored on a 5-point scale (0 = normal, 4 = no uptake), while wall thickening was assessed visually on stress/rest end-systolic images using a 4-point score (0 = normal, 3 = absence of wall thickening). Left ventricular ejection fraction and volumes were calculated using an automatic algorithm (quantitative gated-SPECT). Fifty-two out of 221 (23.5%) patients underwent coronary angiography.

RESULTS

In 40/115 (35%) patients with reversible perfusion defects, post-stress left ventricular ejection fraction was > 5% lower than that at rest (Group A: stunned), whereas in the remaining 75 patients, post-stress left ventricular ejection fraction was either +/- 5% or greater than that at rest (Group B: non-stunned). Peak exercise angina and ischemic electrocardiographic response to exercise were present in 79 and 58% respectively of Group A patients and in 33 and 39% of Group B patients. The number of patients with multivessel disease was significantly higher in Group A compared to Group B (58 vs 41%, p < 0.05). The total stress and rest perfusion scores were significantly higher in Group A than in Group B (p < 0.01); even the total stress wall thickening score was significantly higher in Group A (p < 0.001). As for global parameters, post-stress end-systolic volume was significantly higher in the stunned group (p < 0.05). In 40 out of 66 (60.5%) patients without reversible ischemia fixed defects were judged to be ischemic (Group C), while in 26/66 (39.5%) they were attributed to attenuation artifacts (Group D). Eighty percent of Group C patients had a previous myocardial infarction against none of Group D. Stress/rest perfusion and wall thickening scores were significantly higher in Group C than in Group D.

CONCLUSIONS

Gated-SPECT myocardial perfusion evaluation allowed us to identify a subgroup of post-stress stunned coronary artery diseased patients. The post-stress left ventricular ejection fraction reduction in this population seems to be due to the increase in end-systolic volume. The stunned patients showed more severe perfusion defects and wall thickening abnormalities.

Molecular analysis of cerebrospinal fluid: potential for the study of HIV-1 infection of the central nervous system

The molecular analysis of cerebrospinal fluid (CSF) provides an inestimable tool for the study of HIV infection of the central nervous system (CNS). Current nucleic acid amplification techniques enable the measurement of CSF HIV-1 RNA levels which can be predictive of HIV-associated neurological damage. CSF HIV-1 RNA levels do not necessarily correlate with the corresponding plasma levels, thus supporting the possibility of an intrathecal virus production, i.e., from brain macrophages. However, in early stages of HIV infection, as well as during some opportunistic CNS diseases, CNS or CSF infiltrating lymphocytes might be the main source of CSF virus. A drastic decrease in CSF viral load is usually observed along with a decrease in plasma levels in patients receiving highly active antiretroviral therapy (HAART), with durable suppression of CSF viral load over months. However, during the first weeks of therapy, the dynamics of response may differ in the CSF as compared to plasma, again suggesting that virus replication may be compartmentalised in the CSF. A number of mechanisms are likely to be involved in the response to therapy in CSF, including among the others the trafficking of cell populations supporting viral replication between blood, CNS and CSF, and the role of the anatomical brain barriers in limiting the access of antiretroviral drugs into the CSF. A potential risk associated with compartmentalisation of HIV infection is of an incomplete suppression of virus replication in the CSF, thus creating the ground for local development of anti-HIV drug resistance. In order to assess this occurrence, long-term studies of viral load and genotypic analyses on paired CSF and plasma will be necessary and these will also help elucidate the complex interrelationship between viral replication in these compartments.

[Osteoporosis and phytoestrogens: an assessment of bone mineral density via quantitative peripheral computed tomography in milk-egg-vegetarian women in the premenopause]

PURPOSE

Noninvasive assessment of bone mineral density, geometrical and biomechanical properties in premenopausal women with dietary intake of phytoestrogens and comparison of these parameters with those of age-matched female subjects with "Mediterranean" dietary intake lacking in these substances.

MATERIAL AND METHODS

Volumetric cortical, trabecular and total mineral density and bone geometrical properties were evaluated in 15 female subjects with phytoestrogens dietary intake. Peripheral quantitative Computed Tomography (pQCT) was used to make measurements at the distal radius of the nondominant forearm. Fifteen age-matched subjects with "Mediterranean" dietary intake were chosen as a control group. Cross-sectional area (Total A), trabecular area (TA), cortical area (CA), cortical thickness (CThk) and strength strain index (SSI) were assessed as biomechanical parameters.

RESULTS

Daily consumption of phytoestrogens was significatively different in the two groups (phy: 17.45 mg/die vs ctr: 0.35; p < 0.0005), while calcium intake was similar (phy: 652 mg/die vs ctr: 650). Total (0.460 g/cm3 vs ctr: 0.433) and trabecular (phy: 0.209 g/cm3 vs ctr: 0.189) bone mineral densities, such as SSI (phy: 925 mm3 vs ctr: 894) values, were higher in women with dietary intake of phytoestrogens, in comparison with the relative controls, but not significantly (p = ns). Among geometrical parameters, total area and cortical area were tendential in women with a vegetarian diet while cortical thickness was the same in both groups.

CONCLUSIONS

pQCT showed higher bone mineral density (total and trabecular) and SSI values in premenopausal women with dietary intake of phytoestrogens. Despite the lack of statistical significance, these preliminary results, should further support the few literature findings about the potential role of phytoestrogens consumption in preventing trabecular bone loss. However, further studies are warranted to evaluate definitively the efficacy of phytoestrogens in preventing postmenopausal osteoporosis.

Effects of infusion of glucose-insulin-potassium on myocardial function after a recent myocardial infarction

We studied the effects of glucose, insulin, and KCl infusion (GIK), on regional myocardial perfusion and function by 99m-Tc-tetrofosmin-gated SPECT.

METHODS

We studied 21 male patients with their first uncomplicated acute myocardial infarction (AMI). All patients underwent a rest and submaximal stress before and after 24-hour infusion of GIK-solution (group A) or saline solution (group B).

RESULTS

Group A showed better stress tolerance and ischaemic threshold improvement after GIK infusion whilst no statistical differences were found between basal and post-infusion test in group B. At first the stress test in group A, of the 192 segments analysed, 52 (27%) showed reversible perfusion defect. In group B, of 144 segments analysed, 31 (21%) showed reversible perfusion defect. A post-infusion analysis in group A showed a post-GIK end-diastolic significant count improvement in 21 segments, and a post-GIK end-systolic count improvement in 22 segments. In group B, perfusion increase was observed only in 4 segments, whilst systolic thickening increase was observed only in 1 segment.

CONCLUSION

These data demonstrate the efficacy of GIK infusion to improve regional myocardial perfusion and function mainly in segments adjacent to the recently infarcted area.

A rare case of polyostotic fibrous dysplasia assessed by bone scintigraphy with Tc-99m methylene diphosphonate (MDP)

A 66-year-old man affected by polyostotic form of fibrous dysplasia in consequence of worsening of lower extremity bone pain aggravated by walking and concomitant increase of serum alkaline phosphatase and osteocalcin, was subjected first to a radionuclide study. Bone scan demonstrated a pathological uptake of the radiotracer in the craniofacial bones, right scapula, left and right posterior ribs, right hemipelvis and lower extremities confirming the diagnosis but establishing especially the extent of bone involvement, greater than expected on the basis of symptoms and X-ray findings, underlying the importance of nuclear medicine imaging in the assessment and follow-up of this rare disease.

Myocardial viability assessment after acute myocardial infarction: low-dose dobutamine echocardiography versus rest-redistribution thallium-201 SPECT

BACKGROUND

The presence of tissue viability is of great importance in the prognostic work-up of patients recovering from acute myocardial infarction. However, uncertainty still exists concerning the optimal tool for its assessment. The present study was undertaken in order to compare low-dose dobutamine echocardiography and rest-redistribution thallium SPECT for predicting late improvement of regional left ventricular function after acute myocardial infarction.

METHODS

Fifteen patients undergoing coronary angiography, low-dose dobutamine echocardiography and rest-redistribution thallium SPECT after thrombolyzed anterior acute myocardial infarction were studied. A 3 month follow-up echocardiogram was performed in all patients and 9 underwent coronary revascularization.

RESULTS

A significant (> or = 70%) residual stenosis of the infarct-related artery was present in 14 patients, whilst a total occlusion was observed in 1. At 3 month follow-up, 41% of the dyssynergic segments improved. The sensitivity, specificity and accuracy for late wall motion improvement was 61, 89 and 77% for low-dose dobutamine echocardiography and, respectively, 76, 45 and 58% for rest-redistribution thallium SPECT. Tissue viability was detected in 65 and 31% of dyssynergic segments by rest-redistribution thallium SPECT and low-dose dobutamine echocardiography, respectively (p < 0.001). The agreement between the two techniques was 48%.

CONCLUSIONS

Low-dose dobutamine echocardiography is more accurate than rest-redistribution thallium SPECT for predicting 3 month wall motion improvement in patients with acute anterior myocardial infarction, mainly due to its significantly better specificity.

[Esophageal motility in systemic sclerosis and primary Raynaud' phenomenon by esophageal scintigraphy with semisolid meal]

BACKGROUND

Esophageal transit scintigraphy seems to be a valid methodology to assess impaired esophageal motility, also in the early stages of disease.

AIM

To discriminate patients with primary Raynaud's phenomenon (RPh and patients with systemic sclerosis (SSc) from healthy subjects, by esophageal scintigraphy with a semisolid meal.

METHODS

Thirty-two patients with primary RPh, 18 patients with SSc and 13 healthy subjects have been studied. Symptoms as dysphagia, acid regurgitation and heartburn, were scored. After an overnight fast, all subjects underwent esophageal scintigraphy, using a semisolid orally ingested bolus (10 ml apple purèe) labelled with 99mTc-sulfur colloid. Esophageal transit and emptying time and integral value were evaluated with the subjects in the upright (sitting) and in the supine position. Transit time was defined as the time from entry of 50% of radioactivity into the upper esophagus, up to the clearance of 50% of the bolus from the whole esophagus. Emptying time was defined as the time from the entry of 50% of radioactivity into the upper esophagus, up to the clearance of 100% of the bolus from the whole esophagus. Integral value was defined as the total count under the time/activity curve normalized to the maximum.

RESULTS

Esophageal transit and emptying time, and integral value, evaluated in both positions, were significantly higher in patients with SSc than in healthy subjects and than in patients with RPh. Moreover, patients with RPh had all three parameters, assessed in supine position, significantly longer compared to healthy subjects. Clinical scores regarding dysphagia, acid regurgitation and heartburn were not significantly different between patients with RPh and SSc.

CONCLUSIONS

Esophageal transit and emptying time and integral value seem to be able to discriminate well patients with primary RPh from patients with SSc and patients wih RPh from healthy subjects, suggesting an early mild esophageal dysfunction in RPh.

[A comparison between attenuation-corrected and -uncorrected transmission-emission SPECT images obtained with Tl-201 in CAD patients]

BACKGROUND

The aim of this study was to evaluate the impact of attenuation correction (AC) on the diagnostic accuracy of conventional stress/red thallium SPECT studies.

METHODS

We studied 60 consecutive patients (36 males) who underwent conventional diagnostic stress/red study with and without AC (NAC) using a dual-head SPECT camera (Vertex ADAC) with a 153Gd source. The mean age of these patients was 60 years (30-80) and 29 of the subjects had a history of MI. Reconstructed images were visually analyzed using 20 segments scored on a 5-point scale (0 = normal, 4 = no uptake). Diagnostic accuracy was evaluated in 24 consecutive patients who underwent coronary angiography. Polar plots from each of the four reconstructed data sets per patient were normalized on the maximum and quantified using a nine segment model.

RESULTS

The comparison between the segmental stress score obtained with and without AC showed agreement in 1057 out of 1200 (88%) segments analyzed, K statistic value = 0.67. The number of fixed defects was significantly lower after AC. The diagnostic accuracy, evaluated in 24 patients (480 segs), was not significantly different between AC and NAC analysis (80 vs 84% respectively).

CONCLUSIONS

AC seems to reduce the number of fixed defects due to attenuation artefacts without improving diagnostic accuracy, probably because of the low number of subjects submitted to angiography and of the interpreting bias due to the expertise of the operators. In fact, in the rather small group of patients evaluated, no improvement in diagnostic accuracy was observed, probably because several attenuation defects were not considered pathological due to operator expertise.

[Assessment of geometric, biomechanical, and osteodensitometric properties of the ultradistal radius with peripheral quantitative computerized tomography in uremic patients with severe hyperparathyroidism]

INTRODUCTION

Bone integrity and mineral status were studied with a noninvasive method in uremic patients with severe secondary hyperparathyroidism undergoing maintenance hemodialysis.

MATERIAL AND METHODS

Volumetric cortical and trabecular mineral density (cBMD, tBMD) and bone geometrical properties were evaluated in 16 patients (11 women and 5 men) candidate to parathyroidectomy. Peripheral quantitative Computed Tomography (pQCT) was used to make measurements at the distal radius of the nondominant forearm. Thirty-two age-matched healthy subjects were chosen as a control group. Cortical area (CA), cross-sectional area (Total A), cortical thickness (CThk) and stress strain index (SSI) were assessed as biomechanical parameters. Serum intact PTH levels were assessed with a radioimmunoassay method (IRMA).

RESULTS

Both cBMD and tBMD were decreased in all patients and the difference was more significant in women (p < .0004 and p < .009) than in the smaller group of men (p < .01 and p < .01). Serum PTH levels correlated negatively with cBMD (r = .52; p < .01), CThk (r = .51; p < .04), CA (r = .52; p < .03) and SSI (r = .54; p < .02), as well as tBMD (r = .34), though not significantly. Dialysis duration did not significantly correlate with cBMD (r = .33), tBMD (r = .20), CA (r = .31), CThk (r = .40) and SSI (r = .35). As for geometrical and biomechanical parameters, CA, CThk and SSI were significantly different in both male and female uremic patients in comparison with the relative controls. Bone quantitative analysis and three-dimensional (3D) representation with the paraboloid revolution model also demonstrated osteopenia.

CONCLUSIONS

pQCT shows significant cortical and trabecular osteopenia in uremic patients with severe secondary hyperparathyroidism. Osteopenia is associated with geometrical and mechanical impairment with consequently increased bone fragility and thus a higher risk of fracture. Prolonged PTH hyperexpression seems to be mainly associated with intracortical porosity and cortical-endosteal resorption. Bone quantitative analysis and 3D representation provide rapid automated information on the cortex mineral status.

[Myocardial scintigraphy by the gated SPECT method in coronary disease patients with postischemic stunning]

Gated SPECT using Tc-99m-labeled flow tracers provides simultaneous assessment of global and regional myocardial perfusion and function. The aim of this study was to evaluate whether regional wall thickening (WT) obtained after stress and at rest makes it possible to identify and analyze a subgroup of post-ischemic stunned patients.

METHODS

We studied 20 patients (18 males) who underwent conventional diagnostic dual-day stress/rest Gated SPECT following injection of 925 MBq of 99mTc-tetrofosmin using a dual-head SPECT camera (Vertex ADAC). The mean age of these patients was 59 years (38-71) and 10 of them had a history of previous acute myocardial infarction (AMI). Perfusion was analyzed on ungated images using 20 segments scored on a 5-point scale (0 = normal, 4 = no uptake), while WT and motion were assessed visually on stress/rest end-systolic images using a 4-point score (0 = normal, 3 = absence of WT/motion). Left ventricular ejection fraction (LVEF) and volumes were calculated. All patients underwent coronary angiography.

RESULTS

All patients showed at least one reversible defect with post-stress WT reduction and normal rest WT. The stunned group showed a significant post-stress reduction of LVEF and a statistically non-significant increase of end systolic volume (ESV). A good correlation was observed between global perfusion and WT score both at stress and rest conditions; LVEF showed a significant inverse correlation with global post-stress and rest perfusion and WT score. ESV and the global perfusion stress/rest score showed a good correlation, while end-diastolic volume did not correlate. In 44% of the segments with fixed defects, there was a normal WT and normal coronary-related vessel (false positives); 28% of reversible segments showed a post-stress pathological WT and five of them a rest pathological WT.

CONCLUSIONS

The gated SPECT myocardial perfusion evaluation allowed us to analyze a subgroup of post-stress stunned coronary artery disease patients. The post-stress LVEF reduction in this population seems to be due to the increase of end-systolic volume caused by endocardial ischemia. The stunned segments showed severe perfusion defects.

Esophageal scintigraphy with a semisolid meal to evaluate esophageal dysmotility in systemic sclerosis and Raynaud's phenomenon

Esophageal transit scintigraphy seems to be a valid methodology to assess impaired esophageal motility in early stages of disease. The purpose of this study was to discriminate patients with primary Raynaud's phenomenon (RP) and patients with systemic sclerosis (SSc) from healthy subjects by esophageal scintigraphy with a semisolid meal.

METHODS

We studied 32 patients with primary RP, 18 with SSc and 13 healthy subjects. Dysphagia, acid regurgitation and heartburn were scored. After an overnight fast, all subjects underwent esophageal scintigraphy, using a semisolid orally ingested bolus (10 mL apple puree) labeled with 99mTc-sulfur colloid. Esophageal transit and emptying time and integral value were evaluated with the subjects in the upright (sitting) and supine positions. Transit time was defined as the time from the entry of 50% of radioactivity into the upper esophagus until the clearance of 50% of the bolus from the whole esophagus. Emptying time was defined as the time from the entry of 50% of radioactivity into the upper esophagus, until the clearance of 100% of the bolus from the whole esophagus. Integral value was defined as the total counts under the time-activity curve normalized to the maximum.

RESULTS

Esophageal transit and emptying time and integral value, evaluated in both positions, were significantly higher in patients with SSc than in healthy subjects and than in patients with RP. Moreover, patients with RP had all three parameters, assessed in supine position, significantly longer compared to healthy subjects. Clinical scores regarding dysphagia, acid regurgitation and heartburn were not significantly different between patients with RP and SSc.

CONCLUSION

Esophageal transit and emptying time and integral value appear to be able to discriminate patients with primary RP from patients with SSc and patients with RP from healthy subjects, suggesting an early mild esophageal dysfunction in RP.

[Improvement of the diagnostic value of synchronous myocardial tomoscintigraphy in the assessment of regional myocardial perfusion]

INTRODUCTION

Gated SPECT using 99mTc-labeled flow tracers provides simultaneous assessment of global and regional myocardial function.

PURPOSE

To investigate whether studying regional wall thickening after stress and at rest provides additional diagnostic information in coronary artery disease patients.

METHODS

We examined 61 consecutive patients (40 men) who underwent conventional diagnostic dual day stress/rest Gated SPECT using a dual head SPECT camera, following injection of 925 MBq of 99mTc-Tetrofosmin. The mean age of these patients was 61 years (range: 23-73); 28 patients had a history of myocardial infarction. Perfusion was analyzed on both ungated and end-diastolic images using 20 segments scored on a 5-point scale (0 = normal, 4 = no uptake), while wall thickening and motion were assessed visually on stress/rest end-systolic images using a 4-point score (0 = normal, 3 = no wall thickening/motion). Twenty eight patients underwent coronary angiography.

RESULTS AND DISCUSSION

14/61 (23%) patients showed no segmental defects, while fixed equivocal defects, with preserved wall thickening, in 10/61 (16%) patients were considered artifactual. 11/61 (18%) showed true fixed defects. The remaining 26 patients showed al least one reversible defect. 14/61 (23%) patients with post-stress wall thinning and normal rest wall thickness, were considered stunned. The stunned subgroup showed a significant post-stress reduction in left ventricular ejection fraction. Finally, analyzing 1220 segments, we found an excellent agreement (k = .697) between the segmental score obtained by end-diastolic and ungated post-stress images: in fact, comparing the two sets of images, diagnostic accuracy was not significantly different. However the number of segments with fixed defects and normal wall thickening was lower with end-diastolic perfusion images than with ungated images, probably due to attenuation artifacts. This suggests a better accuracy of the former in the evaluation of regional myocardial perfusion.

CONCLUSIONS

Although stress end-diastolic images do not seem to significantly improve diagnostic perfusion accuracy compared to ungated acquisitions, the simultaneous assessment of stress-rest wall thickening permits better characterization of a coronary artery disease population.

[Incidence and functional role of antithyroid antibodies in hyperthyroidism]

INTRODUCTION

We report our personal experience in patients with biochemical hyperthyroidism and no nodules, studying the correlations between antithyroid autoantibodies titers, thyroid function and clinical symptoms.

MATERIAL AND METHODS

We examined 93 patients (13 men and 80 women, mean age: 44.6 years, range: 25-68 years) referred for suspected hyperthyroidism. Thyroid 99mTc scintigraphy was performed and the 20 minutes' uptake index (UI) calculated: all these patients had a scintigraphic pattern of normal or enlarged thyroid with homogeneous radiotracer uptake. The presence and titer of antiperoxidase (TPO) and anti-TSH receptor antibodies (TRAB), FT3, FT4, TSH were assayed. Based on the results, the patients were divided into 4 subgroups: A (high TRAB/high TPO, no. 17), B (low TRAB/high TPO, no. 15), C (high TRAB/low TPO, no. 35), D (low TRAB/low TPO, no. 26). The incidence of hyperthyroidism symptoms was 94% in Group A, 40% in Group B, 89% in Group C, 50% in group D.

RESULTS

UI significantly correlated with FT3 (p < .001), FT4 (p < .01) and TRAB (p < .01) titers. FT3 and UI average values were significantly higher in Group A and Group C patients (high TRAB) than in Group B and Group D patients (low TRAB) (p < .01); these parameters were significantly higher also in Group A than in Group B patients (p < .05 for FT3 and p < .03 for UI, respectively). Mean intergroup TSH values did not differ (p = ns) and anti-TPO antibodies did not correlate with FT3, FT4 and TSH titers.

CONCLUSIONS

UI behaved as a good marker of hyperthyroidism in all patients and TRAB correlated well with organ function and the clinical picture; however, about 18% of patients exhibited no antibody production. No correlation was found between TPO and thyroid function. The lack of antithyroid antibodies seems to indicate a better clinical course for hyperthyroidism. The patients without TRAB and/or with high anti-TPO titers may follow different clinical courses and need a regular follow-up.

[Clinical significance of the role of left ventricular cavitation ratio in the assessment of coronary artery disease with 99mTc-tetrofosmin]

This study was aimed at assessing the increase in left ventricular cavity volume in patients with induced stress ischemia, by the quantitative analysis of myocardial SPECT perfusion images obtained 30-45 min after 99mTc-Tetrofosmin injection.

PATIENTS AND METHODS

31 consecutive patients with suspected CAD (group A) and 16 low risk CAD subjects (group B) underwent the study. Global (GMPR) and regional myocardial perfusion reserve indices were assessed superimposing a 17 ROI mask on stress and rest bull's eye images. Ventricular cavitation index (VCI) was calculated manually, outlining the left ventricular cavity on stress and rest midventricular SPECT slices. L/H ratio was determined on anterior SPECT images.

RESULTS

On the basis of perfusion patterns, group A was divided into two subgroups: subgroup 1 included the patients with reversible perfusion defects (n = 20) and subgroup B those with irreversible perfusion defects (n = 11). Average stress CI was significantly higher in group A than in group B (p < 0.01) and in subgroup 1 than in group B (p < 0.005). Rest CVI, GMPR and L/H ratio showed no significant intergroup differences. The stress VCI to rest VCI ratio (VCI ratio) was higher in subgroup 1 than group B (p < 0.0001) and in subgroup 1 than in subgroup 2 (p < 0.01). Moreover, VCI ratio was higher in group A than in group B.

CONCLUSION

These preliminary data show that, in ischemic patients, left ventricular cavity volume increases after stress also in 99mTc-Tetrofosmin images. Since our images were acquired 30-45 min after stress, when the dilatation due to ventricular dysfunction is usually resolved, the volume increase may be caused by a cavitation effect due to reduced intracardiac blood flow.

Nuclear cardiology and echocardiography for the assessment of myocardial viability

The review aims to make a comparative analysis of the nuclear cardiology and echocardiographic approaches for the assessment of myocardial viability on the basis of the most recent literature. Preliminarily the most extensively used methods are described: 1) metabolic tracers, especially as regards FDG-F18 (quantitative uptake; mismatch FDG uptake/perfusion); 2) sarcolemmal integrity tracers (201Tl- with stress-redistribution-reinjection or with rest-redistribution protocols; rest MIBI 99mTc); 3) low dose dobutamine stress echocardiography (LDDSE) for the detection of residual contractility reserve. Global sensitivity values of thallium studies are reported to be similar to those of LDDSE, but in selected patients populations with akinetic or severely hypokinetic segments the LDDSE sensitivity seems to be significantly lower, when metabolic viability assessed by FDG studies is assumed as gold standard. According to the Authors' opinion thallium study with a protocol including a rest injestion can be considered at the moment the first choice for myocardial viability assessment because of its convenience, reproducibility, possibility of technical and interpretative standardization, amount of clinical and experimental validations. Anyway further clinical trials with adequate follow-up are necessary in order to define the scintigraphic and echocardiographic patterns that provide the best accuracy in the prediction of the post-revascularization clinical outcome.

Effects of a new foam formulation of ketoprofen lysine salt in experimental models of inflammation and hyperalgesia

The anti-inflammatory and analgesic profile of a new topical foam formulation of ketoprofen lysine salt (CAS 57469-78-0, Artrosilene Schiuma, KLS-foam) was characterized in comparison with marketed gel formulations containing KLS (KLS-gel) or diclofenac diethylammonium salt (DCF-gel). KLS-foam dose-dependently inhibited oedema formation and hyperalgesia induced by subplantar injection of carrageenan or substance P, being more potent than KLS-gel. At equieffective anti-inflammatory doses, KLS-foam provided a more pronounced analgesic effect than DCF-gel. KLS-foam also markedly inhibited exudate formation and prostaglandin production induced by subcutaneous implantation of carrageenan soaked sponges. In carrageenan induced paw inflammation, KLS-foam provided the same anti-inflammatory effect as orally administered KLS, but induced significantly less gastric damages. Oral administration of KLS resulted in sustained systemic absorption of ketoprofen, whereas after topical application of KLS-foam no appreciable ketoprofen plasma levels were detected. These data support the anti-inflammatory and particularly the analgesic effectiveness of the new foam formulation of KLS, a finding that, together with the high gastric tolerability, further emphasizes the usefulness of KLS-foam in the treatment of localized flogistic diseases and associated pain.

[Kinetics of hepatic enzymes in anorexia nervosa]

Nervous anorexia in advanced stage causes a generalized deterioration of organs' and apparatuses' functions. In particular, well-known are disorders of both CNS and PNS, changes of the haematic crasis and worsening of the metabolic-endocrine axis. Less well-known, however, is the compromission of function. Analysis of the data obtained in this trial points out a statistically significant correlation between the loss of weight and the variation of level of some liver enzymes (SGPT, SGOT, LDH). These indexes of hepatic necrosis in our opinion, can therefore, be regarded as sound markers not only for a more careful evaluation of the clinical evolution of the anorexic patient, but also for a better monitoring of the effectiveness of diet therapy.

Fourier amplitude image circumferential profile analysis in the evaluation of the dipyridamole test

The aim of this study was to evaluate a circumferential profile method of analysis (CPA) of the Fourier image of amplitude (FA), obtained by equilibrium gated radionuclide angiocardiography (EGRA) in the assessment of the response to the dipyridamole (DIP) test in patients with previous myocardial infarction. The changes in regional wall motion (RWM) induced by DIP in a group of 29 patients with previous MI were compared with those of a ten-patient control group. On the basis of SPECT thallium-201 standard stress-rest scintigraphy the infarcted patients were divided into 9 patients with fixed perfusion defects at four hours and 20 patients with both fixed and reversible perfusion defects. The quantitative CPA was carried out on the FA image normalized by the mean amplitude calculated for the left ventricle (LV) area. A circular ROI was drawn around the FA left ventricle image and two curves (basal and post-DIP) with 60 points were obtained. We compared this method with a five-sector method of analysis applied to the same FA images. An increase of 2 or more SD in the basal post-DIP ratio curve, compared with the average of the ratios in the control group, was found in 16 of 20 patients with reversible perfusion defects (sensitivity: 80%) and an increase in the same ratio was found in 2 of 9 MI patients with fixed perfusion defects (specificity: 78%). A sensitivity and specificity of 60% and 78% respectively were found using sectorial analysis.

Thallium-201 lung uptake: comparison of an automatic and a manual method of ROI drawing

An automatic method for ROI drawing to measure 201TI lung uptake after stress testing in planar and tomographic myocardial perfusion imaging, was compared with the more commonly used manual method. A linear correlation in the lung/heart ratio (LHR) and lung washout (LWO) data, obtained in planar and SPECT images with the two methods, was found. Pearson's correlation coefficient between the automatic and manual methods was highly significant both for LHR and for LWO. For LHR we found a high linear correlation between the two methods in the planar anterior (r = 0.71, p < 0.001), SPECT anterior (r = 0.84, p < 0.001), and SPECT LAO (r = 0.96, p < 0.001) views. The analysis of LWO data showed a good linear correlation for the planar anterior (r = 0.84, p < 0.001), SPECT anterior (r = 0.66, p < 0.005) and SPECT LAO (r = 0.79, p < 0.001) views. Furthermore, comparison by the student's t test of the averages of the LHR and LWO values obtained in the same views but with different methods was performed. The advantages and the critical issues associated with the automatic method are discussed; it appears to be quick and easy to perform and to be equivalent to the more time-consuming method based on a manual definition of left lung ROI.

[Decisive scintigraphic diagnosis in a case of Borrelia infective sacro-iliitis]

The authors describe one case of infections sacro-iliitis caused by Borrelia, where the diagnostic procedures by conventional radiology, computerized tomography and nuclear magnetic resonance imaging have not permitted the localization and the assessment of joint inflammatory disease. The bone "theree phases" scintiscan by 99m Technectium-methylene diphosphonate (99mTC-MDP) has made it possible to localize on left sacro-iliac synchondrosis a modification of radioactivity, due to inflammations. Next microbiological studies gave a positive result for borrelia. The authors finish by underlying the importance of the nuclear medicine methods in the screening of infective osteo-arthritis.

Delayed effect of streptokinase on left ventricular function after acute myocardial infarction assessed by equilibrium gated radionuclide angiocardiography

A blind comparative study was conducted on 80 consecutive patients who were given Streptokinase (SK) or placebo between 3 and 6 hours after the onset of acute myocardial infarction (AMI). Left ventricular ejection fraction (LVEF), peak ejection rate (PER), peak filling rate (PFR) and regional wall motion (RWM) were evaluated by equilibrium gated radionuclide angiocardiography (EGRA) at 3-5 weeks and 6 months after the onset of AMI. In the anterior AMI SK-group, the mean LVEF values rose from 0.37 at one month to 0.43 at six months, PER (end-diastolic volumes per second) from 1.76 to 2.00, and PFR (end-diastolic volumes per second) from 1.46 to 1.75 (p = 0.01, p < 0.05, and p < 0.05, respectively). In the anterior non-SK group no improvement was seen in any of the LV function parameters. Only a slight improvement was observed in the inferior AMI group, with no significant difference between the treated and non-treated patients. The regional wall motion analysis was in agreement with the global function data. In conclusion, SK treatment given between three and six hours after the onset of anterior AMI may result in some improvement in LV function, which becomes fully appreciable only after the complete resolution of stunning, i.e. after more than one month.

Radionuclide assessment of left ventricular function in patients with myocardial infarction and diabetes mellitus

The aim of this study was to compare left ventricular function, assessed by radionuclide angiocardiography, in 54 diabetics and 194 non-diabetics with acute myocardial infarction (AMI). The most meaningful results concern the inferior AMI group, whose left ventricular ejection fraction (LVEF) and regional wall motion were significantly lower in diabetics than in non-diabetics (LVEF was 44.2 +/- 11 vs. 51.6 +/- 9%, P less than 0.005; the regional wall motion score was 0.46 +/- 1 vs. 1.56 +/- 1, P less than 0.01, respectively), while no significant difference was observed in the anterior AMI group. However, in the group as a whole, the LVEF was 41 +/- 13% in diabetics and 47 +/- 13% in non-diabetics (P less than 0.01), the number of abnormally contracting segments was 2.0 +/- 0.9 and 1.5 +/- 1, respectively, and the wall motion score was 0.2 +/- 1.1 and 1.0 +/- 1.4, respectively (P less than 0.01). These data could be explained by an underlying cardiac dysfunction in diabetes, in addition to AMI. The more marked difference between diabetics and non-diabetics in inferior AMI might be related to the smaller infarct size in this group.

[The noninvasive assessment of the effects of penbutolol on liver hemodynamics in cirrhotic patients using angioscintigraphy. A randomized controlled double-blind study]

This randomized double-blind controlled study analyzed the hemodynamic effects of penbutolol, a new levo-rotatory betablocker, using radionuclide angiography. Twenty cirrhotics with esophageal varices were randomized: 10 received 40 mg/day of penbutolol orally and the others a placebo. Angioscintigraphy was performed before and after an 8-day treatment period. Three cases in the penbutolol group were lost due to software damage, hence the data of 17 patients were analyzed. The two groups were similar for age, sex, etiology of cirrhosis and hepatic function. The index of portal perfusion decreased significantly (-29%; p = 0.018), and the hepatic artery index increased significantly (+23%; p = 0.018), whereas no changes were observed after placebo. The heart rate decreased significantly after penbutolol (-9%; p = 0.021); while neither penbutolol nor placebo modified the ejection fraction. In conclusion, penbutolol decreased portal perfusion index (the compensatory increase of hepatic artery index confirmed this change) without significant modification of total hepatic blood flow and systemic hemodynamics. Angioscintigraphy is reasonably accurate, reproducible, safe and can be considered suitable for routine use in the assessment of liver hemodynamics.