Fatty acid metabolism in symptomatic patients with mitral valve prolapse but without coronary artery disease--comparison with 201Tl myocardial perfusion scintigraphy

Using 123I-omega-heptadecanoic acid (HDA) and 201Tl, respectively, myocardial fatty acid metabolism and perfusion were studied in 51 symptomatic patients with mitral valve prolapse (MVP) as diagnosed by ventriculography, and no evidence of coronary artery disease. Twelve subjects with normal coronary arteries and normal ventriculogram served as a control group for the evaluation of elimination kinetics of HDA. In the control group, the mean elimination half-life was 26.1 +/- 3.6 min, whereas the patients with MVP had a mean value of 25.0 +/- 6.4 min. In patients with MVP, a high incidence concerning abnormalities of accumulation and/or elimination of HDA occurred, namely accumulation defects in 31% and both prolonged and shortened elimination half-lives in 16% and 29%, respectively. Myocardial perfusion scintigraphy using 201Tl showed abnormalities in 76%. Correlations were found between decreased uptake of HDA and prolonged elimination half-life as well as defects by 201Tl, presumably due to ischemia based on small-vessel disease or abnormalities of cellular metabolism.

Physiological aspects of the thyroid trapping function and its suppression in iodine deficiency using 99mTc pertechnetate

In an area of iodine deficiency, we investigated 190 individuals with and without euthyroid endemic goitre, who had a normal TSH response after TRH and an entirely homogeneous thyroid scintigram before and under suppression. In these subjects, the thyroid uptake of 99mTc pertechnetate, as a measure of the iodide trapping function, was determined before (TcUb) and under suppression (TcUs), using quantitatively evaluated scintigraphy. In this control group of individuals, without evidence of autonomy, the reference ranges of TcUb and TcUs were determined. The upper limit of the reference range for TcUb was 7.4% of the tracer activity injected, and for TcUs 1.6%. The reference range of TcUs is to be used to detect accurately thyroid autonomy in vivo. In addition, factors affecting the thyroid trapping function were investigated. With decreased iodine supply, trapping before suppression was increased, compensating for iodine deficiency. The effect of TSH on the trapping function was secondary, indicating that, to a considerable degree, the follicular cells adapt their iodide trapping to the iodine supply. The trapping before and under suppression increased with the estimated thyroid weight. delta TSH after TRH stimulation measured before suppression correlated inversely with the trapping under suppression. The two latter observations suggest that there is a continuum between low and increased levels of the TSH-independent thyroid function, even among these selected individuals without primary evidence of autonomous tissue. A correlation of the trapping function with sex, oestrogen treatment, and goitre type was not demonstrable. Age was found to have a small influence. Except for iodine contamination, the factors affecting the pertechnetate uptake of the thyroid, can be neglected under routine conditions.

Intensive short-term chemotherapy in patients with advanced breast cancer

Aiming at a high complete remission rate with an intensive induction regimen, 27 patients with advanced breast cancer were given three cycles of VAC chemotherapy consisting of vindesine 3 mg/m2 i.v. on days 1 and 12, adriamycin 40 mg/m2 i.v. on days 1 and 12, and cyclophosphamide 200 mg/m2 p.o. on days 3-6 and 14-17 together with medroxyprogesterone acetate (MPA) 1,500 mg p.o. daily during the induction phase and 1,000 mg p.o. thereafter until relapse. These VAC double cycles were repeated twice with 3-weekly intervals for a total induction period of 15 weeks. In responders, including no change, the chemotherapy was discontinued thereafter, and the patients were observed until relapse with a maintenance therapy of MPA 1,000 mg p.o. daily. A complete remission (CR) was achieved in 8 (29.6%) and a partial remission (PR) in 13 (48.2%) of the 27 patients (CR + PR 77.8%). A no change (NC) status was found in 6 patients (22.2%). There were no nonresponders. The median duration of the CR was 20 (5-42) months with two patients still in CR at 33 and 36 months, of the PR 8.3 (4-13.5) months, and of the NC 6.7 (2-13) months. The treatment was tolerated without life-threatening toxicity or interval prolongation by all patients. No dose-limiting cardiac toxicity was observed in these patients regularly controlled by left ventricular ejection fraction (LVEF). The high response rate of this intensive induction regimen warrants further investigation. Complete remission was achieved only in patients without previous chemotherapy, with marked tumor regression after the first chemotherapy cycle and when there was no extensive bone involvement.

Clinical value of dual-isotope fat absorption test system (FATS) using glycerol [125I]trioleate and glycerol [75Se]triether

In order to delineate the clinical value of a dual-isotope fat absorption test system (FATS) using glycerol [75Se]triether as lipid-phase marker and glycerol [125I]trioleate as the test lipid, fecal isotope ratios from single stools (and a 72-hr stool homogenate) were compared to quantitative fecal fat excretion. The study included 11 patients without and 24 patients with steatorrhea. With a figure of 0.8% as the upper limit of normal, the test was a reliable indicator of steatorrhea with 87.5% sensitivity and 81.8% specificity; efficiency was 85.7%. Related to a prevalence of steatorrhea of 45.9% as the mean value of 1269 consecutive 72-hr specimens investigated for steatorrhea during 1978-1982, the positive (negative) predictive value of the FATS is 80.3% (87.2%). With 2% as the upper limit of normal, no false positive results ensued. It is concluded that a two-step interpretation of the FATS (0.8% limit and 2% limit) may be regarded a valid qualitative index for steatorrhea. The FATS isotope ratio using single stools correlated well with FATS ratios in the 72-hr stool homogenates (r = 0.97). FATS therefore allows a convenient estimate of steatorrhea from measuring single stools. As a quantitative measure of fecal fat excretion, the FATS is unreliable.

[Hyperthyroidism in the thyroid hormone treatment of iodine deficiency goiter]

Standardized assessment of 1973 patients with iodine-deficient goitre, treated on average with 100 micrograms thyroxin, revealed clinical signs of thyroid hyperfunction in 2.4%. But an increased hormone concentration alone was not sufficient for the diagnosis. Probable cause of hyperfunction was autonomy of the goitre, as indicated by a negative TRH test before treatment had begun. It was calculated that in this case the risk of hyperthyroidism from thyroid hormone administration was 10%, but only 0.7% in patients with a primarily positive TRH test. Hyperthyroid symptoms disappeared and hormone concentration became normal in 60% of patients after thyroid-hormone administration had been stopped. It is concluded that patients with primarily negative TRH test must be carefully monitored while receiving thyroid-hormone treatment.

[Cementless implantation of Zweymueller-Endler total endoprosthesis of the hip. Clinical, radiologic and scintigraphic follow-up of 2 years]

Sixty-four patients with cementless Zweymueller-Endler total endoprostheses of the hip underwent follow-up postoperatively for 2 years. In 3 patients loosening or infection occurred. In 61 patients no complications were observed. However, in 74% of these patients increasing activity uptake at the tip of the shaft was found by scintigraphy. This was associated with hypertrophy of the corticalis and/or with a marrow cavity reaction, observed radiologically. The results show that scintigraphic evaluation of cementlessly implanted Zweymueller-Endler endoprostheses of the hip must be interpreted differently compared to isoelastic or to cemented prostheses.

Improved quality and information in thyroid scintigraphy

We compared rectilinear scanning, analogous gamma-camera imaging and imaging using a gamma camera interfaced to a computer in order to determine which of these techniques is superior for thyroid scintigraphy. Forty patients with and without goitre and irregular activity distribution were imaged using each of the three techniques. The sets of three scintigrams per patient were rated by seven physicians. These ratings were statistically analysed using a new distribution-free test. Thyroid scintigraphy using a gamma camera interfaced to a computer turned out to be the best method, especially for detecting circumscribed areas of increased uptake. We conclude that this was due to a combination of the following factors: a computer matrix of 128 X 128 pixels in combination with an acquisition zoom of 1.5, the high count density of the scintigrams, computer-controlled documentation after data acquisition and the use of a continuous grey scale for documentation. The improved quality and information content of the scintigrams obtained using a gamma-camera/computer system could improve the diagnostic value of thyroid scintigraphy, especially when the scintigrams are also evaluated quantitatively.

Hyperthyroidism due to Graves' disease and due to autonomous goiter

An attempt was made to classify 326 patients with hyperthyroidism due to Graves' disease and due to autonomous goiter in an area of endemic iodine deficient goiter using the following two sets of criteria: Primary criteria: the presence of endocrine ophthalmopathy (Graves' disease) and the absence of endocrine ophthalmopathy and the absence of microsomal antibodies greater than or equal to 1:1600 (autonomous goiter). Sixty-nine percent of the patients could be divided in the two groups with the aid of these criteria. Secondary criteria: age greater than 50 years, presence of a goiter, presence of thyroid nodules, activity distribution in the scan, iodine intake determined by iodine excretion in the urine. These criteria had to be applied in the 31% of the patients who could not be divided into one of the two groups using the primary criteria. The secondary criteria were accumulative. Using these criteria 55% of the 326 patients were classified as having Graves' disease and 45% as having autonomous goiter. The probability of correct grouping when both primary and secondary criteria were applied was estimated to be 90% compared to 54% when we used only the classical terms, i.e. endocrine ophthalmopathy and diffuse goiter on the one hand and multinodular goiter without endocrine ophthalmopathy on the other hand. In a second group of 120 hyperthyroid patients classified in this way, thyrotropin displacing activity was determined independently. Its prevalence was 79% in patients classified as having Graves' disease but only 3% in those classified as having autonomous goiter. The prevalence of TDA observed in patients who presumably had autonomous goiter was in the same range as in the following groups: 45 normal individuals; 126 patients with euthyroid goiter; and in 112 patients with euthyroid and hyperthyroid autonomous adenoma.(ABSTRACT TRUNCATED AT 250 WORDS)

Detection of occult and intermittent rhinorrhea using 111In-DTPA

In an attempt to detect occult or intermittent rhinorrhea, 10 patients without and 9 cases with rhinorrhea were investigated after a lumbal injection of 1.3 mCi 111In-DTPA. Significant count rates were detectable in the nasal pledgets of all individuals, so that it was not possible to distinguish those with and those without rhinorrhea. Therefore, the ratio of activity in nasal pledgets and blood normalized for weight recommended by McKusick et al. was used. In the patients without evidence of rhinorrhea, the ratio did not exceed 2.0, whereas in 8 of the 9 cases with rhinorrhea, it was considerably increased. The detectability of rhinorrhea was increased by using more than one measurement and by provocation manoeuvres.

Therapy of endemic goitre: controlled study on the effect of iodine and thyroxine

Two kinds of medical treatment of endemic goitre (400 microgram of iodine, n=11, and 150 microgram of L-thyroxine, n=12) were compared in a double blind study with a placebo group (n=12) during a period of 12 months and an observation time of three months after cessation of therapy. The means of the neck circumference and of the estimated thyroid volume decreased significantly during treatment in both groups, whereas no significant difference was observed in the placebo group. The results in both therapy groups did not differ significantly from each other. No side effects or symptoms of hyperthyroidism were observed. During treatment the index of free thyroxine (FT4I) increased significantly in both the iodine and the thyroxine group and delta TSH after TRH decreased significantly. Total triiodothyronine (TT3) did not show significant alterations. Three months after cessation of therapy in the thyroxine treated group the mean FT4I dropped into the range before treatment, whereas it remained slightly elevated in the iodine group. In the thyroxine treated group the mean delta TSH was higher than its value before therapy. After withdrawal of iodine, however, the mean delta TSH remained decreased for three months. The study indicates that 400 micrograms of iodine per day may be at least as effective as a standard dose of 150 micrograms of thyroxine to treat endemic goitre in an iodine deficient area.

Mitral valve prolapse in the ventriculogram: scintigraphic, electrocardiographic, and hemodynamic abnormalities

Patients with mitral valve prolapse (MVP) frequently have chest pain, which may be difficult to differentiate from angina pectoris in coronary artery disease (CAD). We performed resting and exercise ECGs, pulmonary arterial pressure measurements, radionuclide ventriculography (99mtechnetium), and perfusion scintigrams (201thallium) in 56 patients with angiographically proven MVP and no CAD. Pathological results were obtained in 31% of exercise ECGs, 33% of pulmonary arterial pressure measurements during exercise, 22% of radionuclide ventriculographies, and in 75% of thallium perfusion scintigrams. A significant correlation in pathological results was found only between exercise ECG and both radionuclide ventriculography and pulmonary arterial pressure measurements. Because of the high prevalence of false-positive perfusion scintigrams in patients with typical or atypical chest pain, the use of exercise 201Tl imaging as a screening method to separate patients with MVP from those with CAD will not be appropriate. The variability of cardiac abnormalities in our patients with MVP and angiographically normal coronary arteries suggests that the MVP syndrome may represent a variable combination of metabolic, ischemic, or myopathic disorders.

[Megestrol acetate in various doses in the treatment of metastatic breast carcinoma--clinical and endocrinologic studies]

Both medroxyprogesterone acetate (MPA) and megestrol acetate (MA) are effective in the treatment of metastatic breast cancer. Although the dose-dependent mode of actions of MPA have been extensively clarified, there is still some uncertainty regarding the mode of actions and dosage of MA. Thirty-three patients with metastatic breast cancer were treated with various dosages of MA under a phase-II study. Eight patients were given 200 mg, 9 X 400 mg, 10 X 600 mg and 6 X 800 mg MA daily per os. The LH, FSH, TBI, T3, T4, TSH, ACTH, aldosterone, testosterone, prolactin and cortisol levels were determined regularly during treatment to enable the investigation of the pharmacodynamics of MA. A complete remission was achieved in two patients, a partial remission in seven patients and there was no change in eight patients (total responder rate 51.5%). The clinical and endocrine changes therefore suggest that the dose-dependent mode of actions of MPA and MA are identical. Equivalent dosages of MPA are 1000-1500 mg per os and of MA 160-200 mg. Furthermore, similar relationships between the endocrine changes and remission behaviour of MA and MPA have been observed. Persisting tumour remissions are inevitable under cortisol suppression and normal prolactin, aldosterone and ACTH levels.

Underestimation of left-ventricular ejection fraction by radionuclide ventriculography in patients with aneurysm

The left-ventricular ejection fraction (LVEF) of 72 patients with aneurysm of the anterior wall was measured by multiple gated blood pool acquisition (MUGA) in the anterior and left anterior oblique (LAO) positions, and by cineangiography (CA) in right anterior oblique (RAO) and LAO projections of 30 degrees and 60 degrees, respectively. The LVEF was overestimated by CA in the LAO projection and by MUGA in the anterior position, but underestimated by CA in the RAO projection (6.1 percentage points) and by MUGA in the LAO position (6.2 percentage points). In 50 patients without aneurysm, no systematical error occurred using MUGA. The underestimation of the LVEF in patients with aneurysm by MUGA in the LAO position is due to differences of photon attenuation in various parts of the cardiac blood pool. This systematical error can be overcome by biplane MUGA.

[Follow-up of patients with anterior wall aneurysms using radionuclide ventriculography]

32 patients with a large anterolateral aneurysm were studied by using biplane ventricular angiography and rest and exercise radionuclide ventriculography (gated-blood-pool method). The correlation coefficient of biplane ejection fraction by angiography and radionuclide ventriculography was poor (r = 0.65), but repeated investigations and interobserver comparison showed nearly identical values, therefore we used the gated-blood-pool method (GBP) for follow-up investigations in patients with an aneurysm of the anterolateral wall. 11 patients were studied before and 17 +/- 6 months after left ventricular aneurysmectomy. Resting ejection fraction (LVEF) increased significantly from 28 +/- 8 to 38 +/- 8% (p less than 0.005), but exercise LVEF did not. In 21 patients with medical therapy the second GBP measurement after 16 +/- 6 months showed so significant changes in biplane LVEF (33 +/- 9 and 31 +/- 7%, respectively). During exercise LVEF remained unchanged after aneurysmectomy but increased slightly by 5% (p less than 0.05) in the medically treated group. The regional wall motion was unchanged in patients with medical therapy, but after aneurysmectomy there was a significant increase in local ejection fractions in the anterolateral, apical and posterolateral region. The gated-blood-pool methods is suitable for the determination of left ventricular function in patients with anterolateral aneurysm and may be used for follow-up studies. Left ventricular aneurysmectomy is effective in improving resting ventricular function, whereas in patients with medical therapy LV function remains unchanged.

[Scintigraphy with 99mTc-methylene diphosphonate for the detection and localization of rhabdomyolysis]

In 24 patients with biochemically proven rhabdomyolysis 34 scans with 99mTc-MDP were performed to detect regional as well as generalized myolysis. When performing the scan within 10 days after the maximum of myolysis, scintigraphic detection was possible in 95% of the patients, but after 20 days in none. Regional tracer accumulation in muscles was more frequent (89%) than generalized diffuse accumulation (31%). Predominantly muscles of the thigh, the buttocks and the upper arm were involved. Diffuse tracer accumulation in both kidneys occurred in 75% of patients with significant renal dysfunction. The results show that in addition to regional muscle damage generalized myolysis may be detected by scintigraphy with 99mTc-MDP. In cases of regional muscle damage scintigraphy proved to be more sensitive than clinical signs.

Role of gastrointestinal transit in the delay of absorption by viscous fibre (guar)

The influence of guar gum on gastric emptying of liquids in healthy volunteers and on mouth-to-caecum transit time in controls and partially gastrectomized patients has been studied. Together with a flattening effect on blood glucose profiles after a liquid glucose load, guar significantly delays mouth-to-caecum transit time both in healthy controls and partially gastrectomized patients. The retardation of transit is not explicable by a delay in gastric emptying, as can be shown by means of an isotope technique. Only in "quick starters' was a delay in initial gastric emptying observed. The exponential phase of gastric emptying remained unaffected. Moreover, it is shown that the prolongation of mouth-to-caecum transit time is not mediated by factors operating at the level of the pyloricantral region. Delayed small-bowel passage by guar might modulate absorption of glucose by increasing the unstirred layer resistance and, in the non-steady state, by limiting the absorptive area initially covered by a bolus.

Analysis of left ventricular regional motility: a comparison of different methods

Multiple gated blood pool (MUGA) and contrast ventriculographic studies were performed within 24 h in 80 patients, 20 with 120 normokinetic wall segments and 60 with wall motion abnormalities in 239 of 360 wall segments. Three methods of evaluation of the radionuclide ventriculograms were compared with the results of the biplane contrast ventriculography which served as a standard: (1) qualitative analysis of the cine mode, (2) analysis of parametric scans (amplitude and phase images) and the phase histogram obtained by Fourier analysis, (3) quantitative determination of regional ejection fraction. Normal values were obtained from 20 patients with normal wall motion in the contrast angiogram. The overall sensitivity for the detection of wall motion abnormalities of high degree was 96% for method 1, 95% for method 2, and 90% for method 3, for those of low degree 72% for method 1, 63% for method 2, and 75% for method 3. Combining methods 2 and 3 the sensitivity was increased to 99% for high grade and to 81% for low grade wall motion abnormalities. The two methods showed a complementary effect because of different sensitivities in dependence of the localization of the wall motion abnormality. Although a high efficiency for the evaluation of left ventricular function was provided by the qualitative analysis of the cine mode the combination of Fourier analysis and the determination of regional ejection fraction should be preferred. It increases the sensitivity for the detection of wall motion abnormalities. Moreover, it offers quantitative data which improve the reproducibility and decrease the observer variability.

Beitrag der Szintigraphie mit 99mTc-Methylendiphosphonat zum Nachweis und zur Lokalisation von Rhabdomyolysen

Zum Nachweis regionaler und generalisierter Rhabdomyolysen wurden bei 24 Patienten mit einer laborchemisch gesicherten Rhabdomyolyse insgesamt 34 Szintigramme mit 99mTcMDP angefertigt. Ein szintigraphischer Nachweis war bei Untersuchung innerhalb von 10 Tagen nach dem Maximum der Myolyse in 95% möglich, nach 20 Tagen jedoch in keinem Fall mehr. Mit 89% waren regional betonte Anreicherungen häufiger als generalisierte mit 31%. Am häufigsten waren Oberschenkel-, Gesäß- und Oberarmmuskulatur betroffen. Eine diffuse Anreicherung in den Nieren wurde in 75% der Patienten mit einer Niereninsuffizienz beobachtet. Die Ergebnisse weisen darauf hin, daß neben regionalen auch generalisierte Muskelschädigungen bei Rhabdomyolyse Vorkommen und szintigraphisch erfaßt werden können. Die Lokalisation regionaler Myolysen mit Hilfe des Szintigrammes war empfindlicher als der klinische Nachweis.

[The prognostic value of the determination of thyroid hormones]

For recognition and exclusion of hyper- and hypothyroidism total thyroxine, index of free thyroxine, free thyroxine and total triiodothyronine were evaluated. Among 532 strictly selected patients, corresponding to the five main thyroid out-patient groups, the four parameters were estimated simultaneously. Their sensitivity and specificity including two combinations of free thyroxine and total triiodothyronine were calculated. On the basis of an average prevalence of the five above-mentioned groups among our patients and the two most frequent interfering factors (administration of oestrogens and additional iodine intake) predictive values were assessed. The following results were obtained. 1. Differences among the various in-vitro parameters are less than generally assumed. For free thyroxine and the combination of increased free thyroxine or total triiodothyronine, sensitivity and specificity were slightly higher than for other parameters. 2. There is insufficiently substantiated probability of positive evidence of hyperthyroid and hypothyroid states being supplied by all the examined parameters if these are the only criteria relied upon. The probability of positive evidence of hyperthyroid states is only acceptable if, prior to use of in-vitro tests, the prevalence has been considerably increased by history and clinical findings. 3. The probability of exclusion of hyperthyroid states supplied by the examined parameters is high. However, despite their high negative predictive value they are insufficient for the definite exclusion of hypothyroid states if the latent types are included.

[Prognostic value of thallium scintigraphy in diagnostic problem cases]

Quantitative myocardial scintigraphy was performed in 40 patients with a medium prevalence of coronary artery disease (CAD), i.e. in cases with diagnostic difficulties. The results were compared with those of coronary angiography and ventriculography performed within 6 months thereafter. Sensitivity of scintigraphy in 16 patients with CAD was 88% and specificity in 14 individuals without heart disease was 93%. But in 10 patients with non-coronary heart disease specificity decreased to 30%. Scintigraphic evidence of ischemia increased specificity to nearly 100% including patients with non-coronary heart disease but sensitivity was reduced to 69%. The results demonstrate that myocardial scintigraphy with 201Tl is useful in cases with suspected CAD if diagnostic difficulties arise during the early phase of investigation. But there are limitations due to a rather high prevalence of non-coronary heart disease in such groups.