Boris Ajdinovic

Impact of micturating cystourethrography and DMSA renal scintigraphy on the investigation scheme in children with urinary tract infection

ObjectiveThe relationships among urinary tract infection (UTI), vesicoureteral reflux (VUR), and permanent renal damage in children are not fully understood. The aim of this study was to evaluate the incidence of renal scarring in children with a history of UTI and to determine the change in the probability of permanent renal damage owing to the presence of VUR documented on micturating cystourethrography (MCU).MethodsWe analyzed 201 children (400 renal units, two children with solitary kidney). Seventy-four boys and 127 girls (aged 7 months to 7 years, median 2.5 years) with culture verified UTI were referred for technetium-labeled dimercaptosuccinic (DMSA) renal scintigraphy 4-6 months after acute UTI. MCU was also performed mostly 1 month prior to DMSA. Statistical analysis was performed using χ2 test or Fisher’s exact test. Likelihood ratio (LR) positive and negative, diagnostic odds ratio (DOR), and post-test probability of (no) disease were calculated for VUR on MCU versus scarring on DMSA.ResultsVesicoureteral reflux was found in 158 (39.5%) kidneys, and evaluated as grades I, II, III, IV, and V in 3, 70, 43, 25, and 17 refluxing renal units (RRU), respectively. Permanent renal damage according to DMSA was seen in 15.2% (61/400) kidneys. Scarring was shown in 29.7% (47/158) of kidneys with VUR and in 5.8% (14/242) kidneys without VUR (P < 0.0001). LR positive was 2.353 (95% CI 1.889, 2.865), LR negative 0.341 (95% CI 0.209, 0.523), and DOR 6.895 (95% CI 3.533, 14.093). Rate of scarring significantly increased with VUR of grades III, IV, and V. There was no significant difference in the incidence of scarring in kidneys without VUR and RRU with low-grade (I and II) VUR (P = 0.306). The presence of VUR on MCU increased the chance of renal damage on DMSA by about 15%, whereas negative MCU increased the chance of no-renal involvement by 9%.ConclusionsMicturating cystourethrography should not be used as a first-line test to rule out the permanent renal damage owing to UTI. The priority of imaging strategy should be focused on early identification of renal lesions to prevent further deterioration.

90Y-Labeled Tin Fluoride Colloid as a Promising Therapeutic Agent: Preparation, Characterization, and Biological Study in Rats

In this study, tin fluoride colloid (SnF-c) was prepared, labeled with yttrium-90 ((90)Y), and characterized with respect to its physicochemical properties and biological behavior in an animal model. Particle size of SnF-c, at constant concentration of SnF(2), was dependent on pH, concentration of sodium fluoride (NaF), temperature, and time. The particle size of SnF-c decreased with an increase in NaF concentration and a decrease in reaction mixture pH. Radiolabeling yield of (90)Y-SnF-c at higher temperature increased and it was greater than 98% for the preparation at 95 °C. The (90)Y-SnF-c demonstrated high in vitro stability both in human serum and human synovial fluid at 37 °C up to 7 days. In vivo distribution studies in healthy male Wistar rats of (90)Y-SnF-c (particles <1 μm), following intravenous administration, revealed that the localization takes place preferably in the liver. The (90)Y-SnF-c (particles >1 μm) was well retained in the synovial space for 96 h after intra-articular injection, whereas leakage of (90)Y from the joint was 1.96% over this period. Because of high labeling yield and stability, (90)Y-SnF-c might be a promising agent for radiosynovectomy or therapy of liver malignancies.

Five benign myoskeletal diseases in paediatrics and the role of nuclear medicine. Do they differ from those in adults

In this paper we discuss trauma, osteomyelitis, fibrous dysplasia, Legg-Calvé-Perthes disease and osteopetrosis in children. Pathophysiology, incidence, clinical signs, diagnosis and specific trteatment of these diseases are described. We have focused on diagnostic imaging techniques which can be applied in children: X-rays, magnetic resonance imaging bone scintigraphy with technetium- 99m-methylene diphosphonate ((99m)Tc-MDP) and positron emission tomography (PET) with fluorine-18 fluorodesoxyglucose ((18)F-FDG) and fluorine-18 fluoro sodium fluoride ((18)F-NaF). In conclusion, bone scintigraphy with (99m)Tc-MDP and better with PET ((18)F-FDG and (18)F-NaF) can support diagnosis of most of these myoskeletal diseases in children. Radiology is usually applied for local lesions examinations. Magnetic resonance imaging can be used in specific cases in periosteal and bone marrow lesions and CT may be avoided due to its radiation burden, in children.

Renal Scintigraphy in Children with Vesicoureteral Reflux

ObjectiveTo determine the incidence and pattern of abnormal scintigraphy findings in children with UTI and VUR.MethodsData of 118 children who underwent micturating cystourethrography (MCU) and late Tc-99m dimercaptosuccinic acid (DMSA) scan were evaluated. Findings were categorized under the image appearance and relative kidney uptake (RKU) and related to the grade of VUR, sex and child’s age.ResultsMCU revealed VUR (78 unilateral and 40 bilateral) of grades I, II, III, IV and V in 2, 47, 35, 19 and 15 patients respectively. There were 52 children with normal and 66 with abnormal DMSA finding. Scarring rate was significantly associated with high grade VUR (p=0.0023) and male gender ( p=0.0412). Bilateral scarring was seen exclusively in children with bilateral VUR. No significant difference was found between renal scarring and child’s age in the same gender group. Poor kidney function was shown in 5 patients.ConclusionRenal scarring highly correlated with grade of VUR. A strategy to perform MCU only on patients with abnormal DMSA finding is proposed.

99mTc-MDP bone scintigraphy in the diagnosis of stress fracture of the metatarsal bones mimicking oligoarthritis.

BACKGROUND Stress fractures are the injuries of soft tissues and bones caused by intensive and repeated stress on a bone. Repeated submaximal stress disturbs the balance between the processes of bone production and resorption that results in fracture. CASE REPORT We presented a case of a patient with stress fracture of metatarsal bone. The patient was diagnosed and treated as having reactive oligoarthritis caused by Chlamydia trachomatis and administered antibiotics. Initial plain radiography was negative for bone fracture. Tc-99m bone scintigraphy suggested stress fracture of the second metatarsal. Plain radiography was became positive three weeks later, showing callus formation in the proximal part of the second metatarsal. CONCLUSION Bone scintigraphy is a diagnostic test of choice in early diagnosis of stress fracture, and it is important to apply it timely in order to include the entire therapy and prevent complications, as well as to let a patient return to previous daily activities.

Angiotensin II type 1 receptor gene polymorphism could influence renoprotective response to losartan treatment in type 1 diabetic patients with high urinary albumin excretion rate

BACKGROUND/AIM Diabetic nephropathy (DN) is a clinical syndrome characterized by persistent albuminuria, increasing arterial blood pressure and progressive decline in glomerular filtration rate (GFR). When persistent albuminuria is established, antihypertensive treatment becomes most important factor in slowing the progression of diabetic glomerulopathy. The aim of this study was to examine if renoprotective response to a short-term losartan therapy depends on 1166 A/C gene polymorphism for its target receptor. METHOD The study included 35 patients with diabetes mellitus type 1 and persistently high urinary albumin excretion rate (UAE: > 30 mg/24 h), genotyped for the 1166 A/C gene polymorphism for the angiotensin II type 1 receptor (AT1R). The participants were segregated into 3 genotype groups according to combinations of A or C allele: AA (16%), AC (15%) and CC (11%). The patients received losartan 50 mg daily for 4 weeks, following 100 mg daily for another 8 weeks. At baseline and after 12 weeks of the treatment period UAE, blood pressure, GFR and filtration fraction (FF) were determined. RESULTS After 12 weeks of the treatment with losartan, albuminuria was reduced from baseline by 9% [95% confidence interval (CI): 1-17, p = 0.039] in the AA genotype, and by 11% (95% CI: 6-17, p = 0.0001) in the AC genotype. Losartan treatment reduced albuminuria in the CC group by 5% (95% CI: -13-22, p = 0.47). Glomerular filtration rate remained unchanged in all genotype groups. Filtration fraction was significantly reduced from baseline by 0.018 +/- 0.024 (p = 0.012) only in the AC genotype. In the AA genotype, FF was reduced from baseline by 0.017 +/- 0.03 (p = 0.052), and in the CC genotype by 0.01 +/- 0.008 (p = 0.092). In the AA group, systolic blood pressure declined from 136 +/- 24 mmHg at baseline, to an average of 121 +/- 18 mmHg at the end of the study (p = 0.001). The AC group achived reduction from 131 +/- 10 mmHg at baseline to 115 +/- 7 mmHg (p = 0.001) during the investigation period. In the AA genotype group losartan reduced diastolic blood pressure from 86 +/- 13 mmHg at baseline to 78 +/- 8 mmHg (p = 0.004), and in the AC genotype from 88 +/- 5 mmHg at baseline to 11.7 +/- 5.6 mmHg during the investigation period (p = 0.001). In the CC genotype diastolic blood pressure reduction remained nonsignificant (p = 0.066). CONCLUSION The results of our small sample size study provide the evidence that 1166 A/C AT1R polymorphism could be associated with the renoprotective response to losartan therapy.

Incidence and imaging characteristics of skeletal metastases detected by bone scintigraphy in lung cancer patients

BACKGROUND/AIM Detection of metastatic bone disease by skeletal scintigraphy is a classical application of nuclear medicine in cancer patients. Detection of bone metastases in patients with lung cancer is necessary for an appropriate treatment modality. The aim of this study was to report the frequency and imaging characteristics of bone metastases detected by bone scintigraphy (BS) using technetium-99m phosphonates in patients with lung cancer. METHODS We retrospectively analyzed a total of one hundred patients (78 males and 22 females), mean age of 63.3 years, with the diagnosis of lung cancer, who underwent BS during a three-year-period (2003-2005). Scintiscans were classified as positive, negative and suspicious with regard to the presence of bone metastases. RESULTS The incidence of positive, negative and suspicious findings were 57%. 32% and 11%, respectively. Out of 57 patients with bone metastases, 51 had multiple asymmetric foci of increased tracer activity localized in the ribs, spine, extremities, pelvis, sternum, scapula and skull in 72%, 54%, 49%, 37%, 12%, 9% and 5% of scans, respectively. BS revealed solitary metastases in 6 of the patients. The lesions were located in the lower limbs in three patients and in the upper limbs, pelvis and sternum in the remaining three patients. CONCLUSION Bone scintigraphy plays a significant role in staging and selecting of patients for curative lung surgery. Due to the fact that metastatic involvment of the extremities was frequently shown, our study suggests that systematic inclusion of the limbs in BS acquisition should be obligatory.

Significance of the determination of Doppler sonography haemodynamic indices for the assessment of distal perfusion in patients with critical ischemia of lower limbs

BACKGROUND/AIM The perfusion of tissue, especially the muscles of the lower limbs (LL), implies the blood flow that carries enough nutrition, energy materials and oxygen. The aim of this study was to determine whether the decreased Doppler sonography parameters, resistence index (RI), and pulsatility index (PI) were significant as indicatiors of irreversible ischemia of LL. METHODS In 40 patients (mean age 66 +/- 14.9 years, 21% women and 79% men) with the signs of critical ischemia of LL, Lariche-Fontaine class III and IV, we performed contrast angiography of the LL arteries, and perfusion scintigraphy of LL using, thallium-201, while we performed Doppler sonography to determine resistance index (RI), as well as pulsatility index (PI). After that, all the patients were treated with vasodilatation using Bergmanns solution within a 10-day period. Following that, all the patients underwent the determination of haemodynamic indices RI and PI applying the methods of Doppler sonography. The obtained values of RI and PI indices revealed no clinical recovery which suggested the irreversibility of critical ischemia (unsuccessful therapy in 100% of the patients), and clinical recovery which suggested the reversibility of the disease (unsuccessful therapy in 80% of the patients). RESULTS The obtained values of PI = 0-0.3 and RI = 0-0.25 for the examined LL arteries were the indicators of irreversible ischemia. A significant correlation between the values of RI in the distal parts of a. tibialis anterior and posterior was proved, as well as between the decreased perfusion of LL determined by tallium-201 (p < 0.05, r = 0.43), and a tibialis anterior (p = 0.05, r= 0.38). There was, however, no statistically significant correlation between the angiographic values and perfusion scintigraphy of LL. CONCLUSION The obtained values of haemodynamic RI and PI indices should be a novel approach for introducing a new criteria for the assessment of reversible and irreversible critical ischemia of LL using the method od Doppler.

Renal scintigraphy in infants with antenatally diagnosed renal pelvis dilatation

BACKGROUND/AIM Ureteropelvic junction obstruction and vesicoureteral reflux are the most frequent entities identified on the basis of antenatal hydronephrosis. The aim of this study was to determine the incidence and pattern of abnormal renal scintigraphy findings in postnatal investigation of children with antenatal hydronephrosis. METHODS Twenty-four infants (19 boys and five girls) presented with antenatal hydronephrosis and mild to moderate hydronephrosis on ultrasound in newborn period were referred for renal scintigraphy. Ten patients with vesicoureteral reflux documented on micturating cystoureterography underwent 99mTc-DMSA renal scintigraphy and 14 patients were subjected to 99mTc-DTPA scintigraphy. RESULTS Anteroposterior pelvic diameter on ultrasound ranged from 11 to 24 mm. Renal DMSA scans identified congenital scars in two boys with bilateral reflux of grade V and unilateral reflux of grade III. Relative kidney uptake (RKU) less than 40% was found in three, and poor kidney function (RKU less than 10%) in two patients. Significant obstruction was shown on DTPA diuretic renal scintigraphy in 6/14 patients. Some slowing in dranaige (T1/2 greater than 10 minutes) with no reduction in differential renal function was identified in three patients. Differential renal function less than 10% was obtained in one case. CONCLUSION A high percent of abnormal renal scintigraphy findings was obtained. Renal scintigraphy was useful in determination of underlying cause of antenatally detected hydronephrosis.

[Coexistence of Hashimoto's thyroiditis and papillary thyroidal carcinoma with papillary carcinoma of thyreoglossal duct].

BACKGROUND Simultaneous presence of Hashimotos thyroiditis and papillary thyroidal carcinoma in thyroidal gland with papillary carcinoma association in thyroglossal duct is quite rare. The questions like where the original site of primary process, is where metastasis is, what the cause of coexisting of these diseasesis present a diagnostic dilemma. CASE REPORT We presented a case of a 53-year old female patient, with the diagnosis of Hashimotos thyroiditis and symptoms of subclinical hypothyreosis and nodal changes in the right lobe of thyroidal gland, according to clinical investigation. Morphological examination of thyroidal gland, ultrasound examination and scintigraphy with technetium (Tc) confirmed the existence of nonhomogenic tissue with parenchyma nodular changes in the right lobe of thyroidal gland that weakly bonded Tc. Fine needle biopsy in nodal changes, with cytological analyses showed no evidence of atypical thyreocites. Hashimotos thyroiditis was confirmed on the basis of the increased values of anti-microsomal antibodies, the high levels of thyreogobulin 117 ng/ml and TSH 6.29 microIU/ml. The operation near by the nodular change in the right lobe of thyroidal gland revealed pyramidal lobe spread in the thyroglossal duct. Total thyroidectomia was done with the elimination of thyroglossal duct. Final patohystological findings showed papillary carcinoma in the nodal changes pT2, N0 and in the thyroglossal duct with the presence of Hashimotos thyroiditis in the residual parenchyme of the thyroid gland. After the surgery the whole body scintigraphy with iodine 131 (131I) did not reveal accumulation of 131I in the body, while the fixation in the neck was 1%. After that, the patient was treated with thyroxin with suppression-substitution doses. CONCLUSION Abnormality in embrional development of thyroidal tissue might be the source of thyroidal carcinoma or the way of spreading of metastasis of primary thyroidal carcinoma from thyroid gland. The cause of this process is most probably a hereditary mutation in RET oncogenes.