Mark Tulchinsky

ACR appropriateness Criteria® right lower quadrant pain - Suspected appendicitis

The most common cause of acute right lower quadrant (RLQ) pain requiring surgery is acute appendicitis (AA). This narratives focus is on imaging procedures in the diagnosis of AA, with consideration of other diseases causing RLQ pain. In general, Computed Tomography (CT) is the most accurate imaging study for evaluating suspected AA and alternative etiologies of RLQ pain. Data favor intravenous contrast use for CT, but the need for enteric contrast when intravenous contrast is used is not strongly favored. Radiation exposure concerns from CT have led to increased investigation in minimizing CT radiation dose while maintaining diagnostic accuracy and in using algorithms with ultrasound as a first imaging examination followed by CT in inconclusive cases. In children, ultrasound is the preferred initial examination, as it is nearly as accurate as CT for the diagnosis of AA in this population and without ionizing radiation exposure. In pregnant women, ultrasound is preferred initially with MRI as a second imaging examination in inconclusive cases, which is the majority.The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every three years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Bone mineral density and body composition in lean women with polycystic ovary syndrome

OBJECTIVE To examine bone mineral density (BMD) and fat distribution in lean women with polycystic ovary syndrome (PCOS) compared with matched control women. DESIGN Controlled clinical study. SETTING An academic clinical research center. PATIENT(S) Twelve non-Hispanic white women with PCOS and a body mass index of <26 and 10 healthy control women matched for age, ethnicity, and weight. INTERVENTION(S) Biometric measures, blood sample collection, and total body/regional bone density and fat analysis were performed. MAIN OUTCOME MEASURE(S) Serum levels of androgens, glucose, and insulin were measured. Bone density and fat distribution were measured by total body dual-energy x-ray absorptiometry. RESULT(S) Androgen levels were elevated significantly in the lean women with PCOS compared with the controls. There was no statistically significant difference in total body BMD between the two groups. A significant increase in BMD was noted in the left arm, right arm, and left ribs of the lean PCOS group. Evaluation of upper body BMD showed a significant correlation between testosterone levels and BMD. No statistically significant differences were noted in body fat distribution, although the lean PCOS group tended to have lower mean percentages of body fat. CONCLUSION(S) Lean women with PCOS have regional differences in BMD, with significantly increased BMD in the upper skeleton compared with control women.

Modifiable determinants of bone status in young women

The purpose of this study was to evaluate the contributions of exercise, fitness, body composition, and calcium intake during adolescence to peak bone mineral density and bone structural measurements in young women. University Hospital and 75 healthy, white females in the longitudinal Penn State Young Womens Health Study were included. Body composition, total body, and hip bone mineral density (BMD) were measured by dual-energy X-ray absorptiometry (DXA), exercise scores by sports-exercise questionnaire during ages 12-18 years, and estimated aerobic capacity by bike ergometry. Section modulus values (a measurement of bending strength) cross-sectional area (CSA), subperiosteal width, and cortical thickness were calculated from DXA scan data for the femoral neck and femoral shaft. Calcium intakes were calculated from 39 days of prospective food records collected at 13 timepoints between ages 12 and 20 years; supplemental calcium intakes were included. Section moduli at the femoral neck and shaft were correlated significantly with lean body mass, sports-exercise scores (R(2) = 0.07-0.19, p < 0.05), and aerobic capacity (R(2) = 0.06-0.57, p < 0.05). Sports-exercise scores correlated with BMD at the femoral neck and shaft. Average total daily calcium intake at age 12-20 years ranged from 486 to 1958 mg/day and was not significantly associated with total or regional peak BMD or bone structure measures at 20 years of age. It was shown that achievable levels of exercise and fitness have a favorable effect on BMD and section modulus of the femoral neck and femoral shaft in young adult women, whereas daily calcium intake of >500 mg in female adolescents appears to have little, if any effect.

Clinical utility of technetium-99m methoxisobutylisonitrile imaging in differentiated thyroid carcinoma : comparison with thallium-201 and iodine-131 Na scintigraphy, and serum thyroglobulin quantitation

Recently, technetium-99m methoxyisobutylisonitrile (99mTc-MIBI) has been used to image thyroid carcinoma. A prospective study was performed to compare the efficacy of99mTc-MIBI to thallium-201 (201T1) scintigraphy in patients with differentiated thyroid carcinoma. The clinical utility of all radionuclide imaging modalities, i.e.,99mTc-MIBI,201Tl, and iodine-131 Na (131I-Na), as well as serum thyroglobulin estimation, was evaluated. Thirty-four post-thyroidectomy patients (age range: 26–76 years) underwent 45 studies. Histopathologies studied included fourteen papillary, eight papillaryfollicular, ten follicular, one Hürthle cell, and one medullary carcinoma of the thyroid. Following optimal stimulation of endogenous thyroid stimulating hormone (i.e, TSH >-50 mU/ml), the patients underwent201Tl and99mTc-MIBI scintigraphy. Concomitant131I-Na scintigraphy was performed and serum thyroglobulin levels were measured. Sixteen scan sets were performed prior to131I-Na ablation therapy. Twenty-nine scan sets were performed following131I-Na ablation therapy. The presence or absence of thyroid cancer was established by clinical, biochemical, radiologic, and/or biopsy findings. There was no significant difference in sensitivity and specificity of201Tl scintigraphy versus99mTc-MIBI scintigraphy in pre- and postablation studies.131I-Na scintigraphy with determination of thyroglobulin level was sufficient in preablation studies. Among postablation patients, the addition of99mTc-MIBI or201Tl offered a higher diagnostic yield. Between the201Tl and99mTc-MIBI studies, there was a concordance of 69% in preablation and 97% among postablation patients (P=0.027). It is concluded that99mTc-MIBI is a suitable alternative to201Tl scintigraphy in thyroid carcinoma, especially following thyroidectomy and131I-Na therapy.131I-Na scintigraphy with serum thyroglobulin is adequate in both pre- and postablation patients. Among the post-131I-Na ablation patients,99mTc-MIBI or201Tl is extremely valuable for tumor localization, especially when the131I-Na whole-body scan is negative. The combination of99mTc-MIBI or201Tl scintigraphy with131I-Na and serum thyroglobulin offers the highest diagnostic yield.

Scintigraphic evaluation of pediatric urinary tract infection

Scintigraphic evaluation of urinary tract infection, pyelonephritis, and renal scarring represents a significant portion of a clinical pediatric nuclear medicine practice. Renal scarring from recurring infection remains an important cause of end-stage renal disease and hypertension in the pediatric population. However, the clinical presentation in infants and young children is often elusive, and clinical diagnosis of upper tract involvement is frequently unreliable. As a result, diagnostic imaging has a critical role to play in the localization of infection to the lower or upper urinary tract. Radionuclide cystography and renal cortical imaging have become mainstays of this evaluation. Direct radionuclide cystography is the preferred cystographic screening technique, because it has lower radiation exposure and greater sensitivity for the detection of vesicoureteral reflux than either indirect radionuclide cystography or fluoroscopic contrast cystography. Renal cortical scintigraphy has become the standard for the detection of pyelonephritis and renal scarring. Correlation with histopathology has demonstrated a high degree of diagnostic accuracy. Acute pyelonephritis has been shown to be the necessary etiologic factor for the development of subsequent renal scarring, and the mechanism of renal injury in pyelonephritis has been extensively studied in experimental models. The ability of prompt and appropriate antibiotic therapy to dramatically reduce the incidence of subsequent scarring also has been conclusively demonstrated both clinically and in the experimental model. Vesicoureteral reflux was once thought to be a necessary prerequisite for the development of renal scarring. Although it is clear that the intrarenal reflux of infected urine will create pyelonephritis in the experimental model, the high incidence of pyelonephritis and subsequent scarring in the absence of demonstrable vesicoureteral reflux leaves the role of reflux in question. Although the role of vesicoureteral reflux is incompletely understood, its detection nevertheless remains a standard part of the patients evaluation.

123I-mIBG scintigraphy in patients with known or suspected neuroblastoma: Results from a prospective multicenter trial

A prospective trial was conducted to confirm the diagnostic performance of 123I‐mIBG scintigraphy in patients with known or suspected neuroblastoma.

ACR appropriateness criteria® pretreatment staging of colorectal cancer

Because virtually all patients with colonic cancer will undergo some form of surgical therapy, the role of preoperative imaging is directed at determining the presence or absence of synchronous carcinomas or adenomas and local or distant metastases. In contrast, preoperative staging for rectal carcinoma has significant therapeutic implications and will direct the use of radiation therapy, surgical excision, or chemotherapy. CT of the chest, abdomen, and pelvis is recommended for the initial evaluation for the preoperative assessment of patients with colorectal carcinoma. Although the overall accuracy of CT varies directly with the stage of colorectal carcinoma, CT can accurately assess the presence of metastatic disease. MRI using endorectal coils can accurately assess the depth of bowel wall penetration of rectal carcinomas. Phased-array coils provide additional information about lymph node involvement. Adding diffusion-weighted imaging to conventional MRI yields better diagnostic accuracy than conventional MRI alone. Transrectal ultrasound can distinguish layers within the rectal wall and provides accurate assessment of the depth of tumor penetration and perirectal spread, and PET and PET/CT have been shown to alter therapy in almost one-third of patients with advanced primary rectal cancer. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Sincalide-Stimulated Cholescintigraphy: A Multicenter Investigation to Determine Optimal Infusion Methodology and Gallbladder Ejection Fraction Normal Values

Sincalide-stimulated cholescintigraphy is performed to quantify gallbladder contraction and emptying. However, different infusion methods are used for this study. Our purpose was to determine the infusion method with the least variability (smallest coefficient of variation [CV]) for calculation of the gallbladder ejection fraction (GBEF) in healthy subjects and to establish normal values. Methods: Sixty healthy volunteers at 4 medical centers were injected intravenously with 99mTc-mebrofenin. After gallbladder visualization had been confirmed at 60 min, 0.02 μg of sincalide per kilogram was administered using 3 different infusion durations, 15, 30, and 60 min, each performed on separate days. The CV, mean, SD, first to 99th percentile, and fifth to 95th percentile were calculated. GBEF normal values were determined for the different infusion durations. Results: The CV was smallest for the 60-min infusion at 60 min (19%; 95% confidence interval [CI], 16%−23%), compared with the 30-min infusion at 30 min (35%; 95% CI, 29.2%−42.1%) and the 15-min infusion at 15 min (52%; 95% CI, 44%−63%). These were all significantly different (P < 0.0007). For the 60-min infusion at 60 min, the lower limit of normal for the GBEF was 38% defined at the 1% CI. Conclusion: The GBEF at 60 min has the lowest CV in healthy subjects, compared with shorter infusions of 15 or 30 min. This multicenter trial establishes a GBEF lower limit of normal of 38% (first percentile) for a 60-min infusion of 0.02 μg of sincalide per kilogram, quantified at 60 min. Using this infusion method minimizes the variability in measured GBEFs. This sincalide infusion method should become the standard for routine clinical use.

SNM Practice Guideline for Parathyroid Scintigraphy 4.0

1St. Louis, Missouri; 2Northwestern University, Chicago, Illinois; 3Thomas Jefferson University, Philadelphia, Pennsylvania; 4Southern Molecular Imaging, Savannah, Georgia; 5St. Thomas’ Hospital, London, United Kingdom; 6North Shore–Long Island Jewish Health System, New Hyde Park, New York; 7Barnes–Jewish Hospital, St. Louis, Missouri; 8Vanderbilt University, Nashville, Tennessee; and 9Milton S. Hershey Medical Center, Hershey, Pennsylvania

ACR appropriateness criteria right upper quadrant pain

Acute right upper quadrant pain is a common presenting symptom in patients with acute cholecystitis. When acute cholecystitis is suspected in patients with right upper quadrant pain, in most clinical scenarios, the initial imaging modality of choice is ultrasound. Although cholescintigraphy has been shown to have slightly higher sensitivity and specificity for diagnosis, ultrasound is preferred as the initial study for a variety of reasons, including greater availability, shorter examination time, lack of ionizing radiation, morphologic evaluation, confirmation of the presence or absence of gallstones, evaluation of bile ducts, and identification or exclusion of alternative diagnoses. CT or MRI may be helpful in equivocal cases and may identify complications of acute cholecystitis. When ultrasound findings are inconclusive, MRI is the preferred imaging test in pregnant patients who present with right upper quadrant pain. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.