Leonard Rosenthall

Observations on the sequential use of 99mTc-phosphate complex and 67Ga imaging in osteomyelitis, cellulitis, and septic arthritis.

Sequential studies with 99mTc-methylene diphosphonate (99mTc-MDP) and 67Ga were performed in 40 patients to determine the role of each agent in evaluating osteomyelitis, cellulitis, and spetic arthritis. Apart from the value of 67Ga in distinguishing cellulitis from osteomyelitis, it is a good adjuvant to 99mTc-MDP imaging in chronic osteomyelitis to identify continuing or recurrent sepsis and localize the focus of infection more precisely.

Observation on the Use of 99mTc-Phosphate Imaging in Peripheral Bone Trauma1

The utility of 99mTc-phosphate imaging of fractured bones adjacent to joints soon after injury is examined. Joints usually respond to trauma by a generalized increased regional concentration of the radiopharmaceutical; but with careful attention to technique, a superimposed focal deposition due to the fractured bone can be seen. Fractures which were initially indefinite or which seemed normal at radiography were revealed as early as 7 hours after injury. In our experience, failure to show a focal concentration beyond 3 days excludes a fracture. However, a focal concentration need not necessarily represent a gross fracture; a ligamentous avulsion of a bone chip and/or periosteum could yield the same picture and not be disclosed by radiography. Radionuclide imaging of joint fractures is a useful adjunct to clinical assessment.

Renal transplant evaluation

Radionuclide scintigraphy of the renal transplant has assumed an important role in disclosing the complications that beset this life-prolonging procedure. Renal ischemia, whether caused by mechanical obstruction of the blood vessels or ureter or immunological rejection, can be detected by qualitative and quantitative perfusion studies using 99mTc-complexes such as pertechnetate, glucoheptonate and DTPA. Similarly, parenchymal agents such as radiohippurate and 99mTc-DTPA can be quantitated for uptake and their drainage patterns monitored to reveal possible underlying obstructive uropathy and urine extravasation. The literature is replete with mathematical strategems for quantitating perfusion and parenchymal transit of the tracers, but none are truly specific enough to be diagnostic of a given cause of renal ischemia. Serial quantitative radionuclide studies should be obtained during the first 2-3 wk after transplantation with the view of noting an improvement or deterioration of the quantitation parameters as a guage of progress. A deterioration may anticipate biochemical manifestations by 24-48 hr, but it is not specific and must be interpreted in light of the clinical circumstances or necessitate invasive procedures for a definitive diagnosis.

Observations on Radionuclide Imaging in Hypertrophic Pulmonary Osteoarthropathy

99mTc pyrophosphate was employed in the study of patients with hypertrophic pulmonary osteoarthropathy. Several facts emerge when comparing the radionuclide, radiographic and clinical findings. Radionuclide imaging reveals the presence and extent of subperiosteal activity with greater clarity than does radiography. Synovitis associated with the syndrome is readily disclosed, and the regression of the skeletal manifestions following excision of the pulmonary lesion can be documented.

Temporal changes of periprosthetic bone density in patients with a modular noncemented femoral prosthesis

Bone mineral density changes surrounding a porous-coated proximal modular sleeved hip prosthesis were determined as a function of time over a 24-month period. The periprosthetic bone regions were defined by the 7 Gruen zones. Measurements were obtained with a dual-energy x-ray densitometer using a dedicated software program. Inclusion criteria required that the patients had primary implants, were asymptomatic with Harris hip scores of > or =95 for the duration of the study, and showed no radiographic evidence of loosening. The protocol specified that bone measurements be obtained within 1 week after surgery as a baseline reference and at 3, 6, 9, 12, 18, and 24 months thereafter. A total of 111 consecutive patients were enrolled in this ongoing prospective study, of whom 52 had 4 or more measurements after the initial baseline determination for statistical analysis. At 3 months, all zones showed a significant decrease in bone mineral density relative to the baseline measurements, and their mean loss ranged from 6.5% to 11.2%. By 24 months, mineral losses relative to baseline varied from 0 to 11% for Gruen zones 1 to 6. Relative to the 3-month levels, there was no significant change in zones 1, 4, and 6; a significant improvement in zones 3 and 5; and a small but significant loss in zone 2 at 24 months. Gruen zone 7, the medial femoral neck cortex, differed in that it was the site of greatest bone mineral loss, attaining a mean of 20.2% at 24 months. It was found that the amount of periprosthetic mineral loss at 12 months was independent of the initial baseline reference bone mineral levels. Results of this study show the normal temporal bone mineral changes surrounding a proximally modular porouscoated femoral implant. The pattern of change demonstrated may be peculiar to the prosthesis used in this study because it might differ in implants of different design and material composition.

Diagnostic applications of radiopertechnetate and radiohippurate imaging in post-renal transplant complications

Radiopertechnetate and radiohippurate imaging offer a noninvasive method of distinguishing between various complications of renal transplantation. They are especially useful in patients on dialysis, may anticipate biochemical changes by as much as 48 hours, and also provide a useful independent means of confirming the biochemical and clinical parameters. The potential hazards of angiography and retrograde ureteral catheterization are eliminated.

A Nucleography and Radioangiographic Study of a Patient with Torsion of the Spleen

A rare case of torsion of the spleen is described in which the radio-colloid image disclosed absent spleen function in association with a mobile left upper quadrant mass. Celiac angiography showed looping of the splenic artery with stenosis at the point of twisting and a prolonged splenogram; there was failure to visualize the splenic vein.

Tc-99m-IDA gallbladder kinetics and response to CCK in chronic cholecystitis

The cholecystographic pattern and the contractile response of the gallbladder (GB) to cholecystokinin (CCK) were studied in 101 consecutive patients with uncomplicated chronic cholecystitis confirmed by pathology. Sequential GB images were obtained after administration of 5 mCi 99mTc-Disofenin and the ejection fraction was determined following a 15 min infusion of CCK. Sixteen of 101 (16%) GB failed to visualize upto 4 h; of the remaining patients, 3/85 (4%) showed delayed visualization beyond 1 h, and 82/85 visualized within 1 h. The mean ejection fraction (EF) in 67 patients was 56.9%±27.5% compared to 74.8%±19.8% in a normal control group of 27 subjects (P0.005). However, there was a large overlap as 76% of chronic cholecystitis patients had EF values falling within the full normal range. GB disease could be identified with confidence when the EF was less than 35%, i.e. below the 2 standard deviation range of normal. On the basis of radionuclide kinetic studies alone, the majority of patients with chronic cholecystitis cannot be distinguished from normal.

Assessment of bone viability by scintiscanning in frostbite injuries.

Radionuclide bone imaging with a radiotechnetium-labeled phosphate (99mTc-methylene diphosphonate) has been employed to study the extremities injured by frostbite. The degree of accretion of the radiopharmaceutical in bone is dependent on the integrity of the vascular supply. This property has been used successfully to distinguish viable and nonviable bone.

Relationship between gallbladder contraction and progesterone receptors in patients will gallstones

Stasis of bile within the gallbladder has long been suspected of having an important role in the pathogenesis of gallstone disease. We postulated that the female preponderance of gallstone disease might partly be related to the effects of progesterone, a known smooth muscle relaxant, on specific receptors in the gallbladder wall, leading to stasis of bile. A total of 42 patients with gallstone disease and 28 control subjects underwent radionuclide scan imaging and their gallbladder ejection fractions were calculated in response to intravenous infusion of cholecystokinin octapeptide. Patients then underwent cholecystectomy and a piece of gallbladder fundus was assayed for the presence of progesterone receptors. Receptors were present in 60 percent of patients. As a group, gallstone patients had a decreased ejection fraction compared with control subjects. The presence of progesterone receptors in the gallbladder wall was associated with a decreased percentage of ejection compared with both healthy control subjects and patients whose gallbladders were receptor-negative. We conclude that progesterone receptors are present in the gallbladder wall of gallstone patients and that their presence correlates with impaired gallbladder emptying.