M. M. C. Tiel-Van Buul

The Value of Radiographs and Bone Scintigraphy in Suspected Scaphoid Fracture A Statistical Analysis

The role of radiography and bone scintigraphy in the diagnostic management of suspected scaphoid fracture is controversial. Two strategies were compared for patients with initial negative radiographs: repeated radiography versus selective bone scintigraphy. Using the known positive predictive value of scintigraphy, the sensitivity and specificity of both diagnostic strategies were evaluated in a series of 78 consecutive patients. The kappa value for initial radiographs was 0.76 but decreased to 0.5 for follow-up radiographs. Similarly, sensitivity decreased from 64% to 30% in follow-up radiographs. Specificity of the bone scan was 98%. The best diagnostic strategy in the management of clinically suspected scaphoid fractures consists of initial radiography followed by bone scintigraphy in patients with negative radiographs.

The diagnostic management of suspected scaphoid fracture

The role of radiography and bone scintigraphy in the diagnostic management of patients with clinically suspected scaphoid fracture after carpal injury is reviewed. Evidence is provided that bone scintigraphy is indicated in patients with negative initial scaphoid radiographs. A normal bone scan excludes scaphoid fracture, and a positive bone scan sufficiently confirms the presence of clinically relevant scaphoid fracture. Furthermore, this review assesses the possibility on non-invasive additional radiographs, for the diagnosis or exclusion on scaphoid fracture as a means of avoiding bone scintigraphy in patients with negative first-day X-series.

Radiography and scintigraphy of suspected scaphoid fracture. A long-term study in 160 patients

Radiographs of the scaphoid after injury are difficult to interpret, and bone scintigraphy is widely used to increase the accuracy of diagnosis, though many fractures suspected on scintigraphy cannot be confirmed radiologically. We have reviewed the clinical consequences, after one year, of managing suspected scaphoid fractures according to the bone-scan results. We studied 160 patients, 35 of whom had initially positive radiographs and were treated in a cast for 12 weeks. The other 125 had bone scintigraphy and were managed according to the result. After a minimum of one year 119 patients were reviewed. Scintigraphically suspected scaphoid fracture could not be confirmed radiologically in 25%. There were no cases of nonunion. The long period of immobilisation in patients with positive radiographs or positive bone scans did not influence the frequency or severity of late symptoms compared with those with a normal bone scan.

Magnetic resonance imaging versus bone scintigraphy in suspected scaphoid fracture

Magnetic resonance imaging (MRI) has become increasingly useful in the evaluation of musculoskeletal problems, including those of the wrist. In patients with a wrist injury, MRI is used mainly to assess vascularity of scaphoid non-union. However, the use of MRI in patients in the acute phase following carpal injury is not common. Three-phase bone scintigraphy is routinely performed from at least 72 h after injury in patients with suspected scaphoid fracture and negative initial radiographs. We evaluated MRI in this patient group. The bone scan was used as the reference method. Nineteen patients were included. Bone scintigraphy was performed in all 19 patients, but MRI could be obtained in only 16 (in three patients, MRI was stopped owing to claustrophobia). In five patients, MRI confirmed a scintigraphically suspected scaphoid fracture. In one patient, a perilunar luxation, without a fracture, was seen on MRI, while bone scintigraphy showed a hot spot in the region of the lunate bone, suspected for fracture. This was confirmed by surgery. In two patients, a hot spot in the scaphoid region was suspected for scaphoid fracture, and immobilization and employed for a period of 12 weeks. MRI was negative in both cases; in one of them a scaphoid fracture was retrospectively proven on the initial X-ray series. In another two patients, a hot spot in the region of MCP I was found with a negative MRI. In both, the therapy was adjusted. In the remaining six patients, both modalities were negative. We conclude that in the diagnostic management of patients with suspected scaphoid fracture and negative initial radiographs, the use of MRI may be promising, but is not superior to three-phase bone scintigraphy.

Clinical experience with radiation enhancement by hyperbaric oxygen in children with recurrent neuroblastoma stage IV

The high risk group of patients with neuroblastoma are children over 1 year with stage IV disease. Most series report a maximum of 20% survival at 5 years. For recurrent neuroblastoma stage IV, cure rates are not reported in the literature, but they are nil. Any treatment for recurrent neuroblastoma stage IV remains a therapeutic dilemma. The outcome of radiation therapy is variable. A very important factor in tumour treatment remains tumour hypoxia, and others, such as metabolic factors, also play a role. Combined application of radiation modifiers may influence the final survival rate. In an attempt to improve the survival of recurrent neuroblastoma stage IV, hyperbaric oxygen and radioionated meta-Iodobenzylguanidine (MIBG) was used in a clinical setting. Although survival may not be used as a determinant of the usefulness of a treatment for stage IV neuroblastoma disease, a better one is not available. In this study, at 28 months, a cumulative probability of survival of 32% was recorded for patients treated with [131I]MIBG and hyperbaric oxygen compared to 12% for [131I]MIBG treatment alone. These preliminary results are promising but further studies are needed to reveal substantial therapeutic gain.

CARPAL BOX RADIOGRAPHY IN SUSPECTED SCAPHOID FRACTURE

We have assessed the value of using a simple apparatus,the Carpal Box, in patients with suspected scaphoid fracture, to produce elongated and magnified radiographs of the carpus. The interobserver agreement between 60 observers of standard scaphoid radiographs and longitudinal and transverse Carpal Box radiographs (X-CB) was compared in 11 patients. Three-phase bone scanning was used as a comparative standard. If at least 75% of the observers agreed and the result was confirmed by three-phase bone scanning, the outcome was termed reliable. Scaphoid radiographs and the longitudinal X-CB films were reliable in four patients and the transverse X-CB films in six patients. The bone scan suggested a scaphoid fracture in five of the 11 patients. Agreement in the interpretation of the standard scaphoid radiographs was acceptable in only 36% of patients: in interpretation of transverse Carpal Box radiographs this figure increased to 55%.

A rare complication of acute appendicitis: complete bilateral distal ureteral obstruction

Three children treated for appendicitis developed anuria and acute renal insufficiency several days after appendicectomy. Associated hydronephrosis or hydroureters were present in two. At cystoscopy, marked swelling of the trigonum and ureteric orifices was seen. One patient developed unilateral acute tubular necrosis, a complication not reported before. Recognition of this rare complication of acute appendicitis, which need not be accompanied by hydronephrosis, should lead to prompt decompression by the introduction of ureteric stents.

Quantitative analysis of 99tcm-sestamibi myocardial perfusion Spect using a three-dimensional reference heart: a comparison with experienced observers

Background Quantification of myocardial perfusion single photon emission computed tomography (SPECT) may improve scintigraphic analysis. Recently, a fully operator independent technique for the quantification of myocardial perfusion SPECT was described, based on a normal three-dimensional averaged reference heart. The purpose of this study was to compare the automated SPECT quantification technique with experienced observers. Methods A total of 43 patients, 36 with one-vessel coronary artery disease (CAD) and seven with a low likelihood of CAD, underwent 99Tcm-sestamibi SPECT (99Tcm-MIBI SPECT). Three experienced observers and a panel (composed of the three observers), blinded to the clinical and angiographic data, analysed the size and severity of perfusion defects and the relation to the distribution areas of the coronary arteries. Inter-observer agreement was calculated by using kappa (κ) statistics. Results The inter-observer agreement between the human observers and the automated quantitative analysis, for severity and size of perfusion abnormality, was moderate (κ range 0.38-0.68), while this was fair between three individual observers (κ range 0.36-0.87) and good between the individual observers and the panel (κ range 0.63-0.89). There were no differences between the quantitative analysis and the panel in the allocation of perfusion abnormalities to the affected coronary artery. Conclusions The operator independent quantification method showed a moderate agreement with individual observers and a panel analysis for size and severity of perfusion abnormalities. The automatic quantification has a similar ability to assign perfusion abnormalities to the diseased coronary artery as compared to an expert panel.

Reporting of perfusion/ventilation lung scintigraphy using an anatomical lung segment chart: a prospective study.

This study prospectively evaluated the effect of the consistent use of a previously described anatomical lung segment chart on the interpretation of lung scans. Simultaneous perfusion/ventilation lung scintigraphy was performed in 221 consecutive patients with clinically suspected pulmonary embolism. Lung scans were immediately reported as normal, high probability or non-diagnostic with the use of an anatomical lung segment chart. After at least 6 months, blinded lung scans were randomly read by a panel of nuclear medicine physicians. Initial lung scan reports were classified as normal, high probability or non-diagnostic in 64, 63 and 94 patients, respectively. Overall observer disagreement was 5.9% (95% confidence interval (CI) 3.2–9.8%), while this was 7.8, 3.2 and 7.9% for lung scans that were initially reported as normal, non-diagnostic and high probability, respectively. Reclassification consisted of normal to non-diagnostic (5), non-diagnostic to normal (1), non-diagnostic to high probability (2), and high probability to non-diagnostic scan results (5). From the literature, an overall disagreement of 20% was expected if no chart had been used. In conclusion, this study confirms that the consistent use of a lung segment chart reduces observer disagreement in the reporting of lung scans.

Diagnostic imaging in abdominal neuroblastoma: Is there a complementary role of MIBG-scintigraphy and ultrasonography?

Abstract In a retrospective study we evaluated the agreement between the results of meta-iodo benzylguanidine (MIBG) scintigraphy and abdominal ultrasonography (US) in the diagnosis and follow up of neuroblastoma (NBL) with respect to the abdominal region. Data of 28 consecutive paediatric patients with NBL or suspected NBL were included (16 M/12 F, mean age 2.9 years, range 3 weeks – 13.4 years). The results (as judged by the nuclear physician or radiologist, respectively) of 60 MIBG examinations (123I and 131I, including 26 single photon emission computed tomography (SPECT)) and US, respectively, performed within a period of 14 days, could be evaluated. Full agreement was reached in 37 comparisons (62%), while partial and no agreement was found in 17 (28%), and 6 (10%) comparisons, respectively. In 8 out of 37 comparisons with full agreement, 12 diagnosed lesions were histopathologically proven, while 11 comparisons with negative findings were also negative in other clinical modalities. US diagnosed correctly in 68% of the histopathological proven lesions, while this was 54% for MIBG scintigraphy. In approximately 50% of the MIBG scans in which SPECT was available, SPECT provided significant additional information. Conclusion Congruent results of MIBG scintigraphy and ultrasonography in the detection of abdominal lesions in patients with suspected neuroblastoma indicate a high reliability in the diagnosis and localisation. Due to the favourable results of additional SPECT, it is advisable to perform SPECT routinely in this diagnosis.