Impact of oral preoperative and perioperative immunonutrition on postoperative infection and mortality in patients undergoing cancer surgery: systematic review and meta-analysis with trial sequential analysis

Background

Infectious complications occur in 4–22 per cent of patients undergoing surgical resection of malignant solid tumours. Improving the patient's immune system in relation to oncological surgery with immunonutrition may play an important role in reducing postoperative infections. A meta‐analysis was undertaken to evaluate the potential clinical benefits of immunonutrition on postoperative infections and 30‐day mortality in patients undergoing oncological surgery.

Methods

PubMed, Embase and Cochrane Library databases were searched to identify eligible studies.

Eligible studies had to include patients undergoing elective curative surgery for a solid malignant tumour and receiving immunonutrition orally before surgery, including patients who continued immunonutrition into the postoperative period. The main outcome was overall infectious complications; secondary outcomes were surgical‐site infection (SSI) and 30‐day mortality, described by relative risk (RR) with trial sequential analysis (TSA). Risk of bias was assessed according to Cochrane methodology.

Results

Some 22 RCTs with 2159 participants were eligible for meta‐analysis. Compared with the control group, immunonutrition reduced overall infectious complications (RR 0·58, 95 per cent c.i. 0·48 to 0·70; I² = 7 per cent; TSA‐adjusted 95 per cent c.i. 0·28 to 1·21) and SSI (RR 0·65, 95 per cent c.i. 0·50 to 0·85; I² = 0 per cent; TSA‐adjusted 95 per cent c.i. 0·21 to 2·04). Thirty‐day mortality was not altered by immunonutrition (RR 0·69, 0·33 to 1·40; I² = 0 per cent).

Conclusion

Immunonutrition reduced overall infectious complications, even after controlling for random error, and also reduced SSI. The quality of evidence was moderate, and mortality was not affected by immunonutrition (low quality). Oral immunonutrition merits consideration as a means of reducing overall infectious complications after cancer surgery.

Multiple diagnostic task performance in CT examination of the chest

Objectives In three experiments, we studied the detection of multiple abnormality types using the satisfaction of search (SOS) paradigm, the provision of a computer-aided detection (CAD) of pulmonary nodules and a focused nodule detection task. Methods 51 chest CT examinations (24 that demonstrated subtle pulmonary nodules and 27 that demonstrated no pulmonary nodules) were read by 15 radiology residents and fellows under two experimental conditions: (1) when there were no other abnormalities present except test abnormalities in the exams (non-SOS condition), and (2) when other abnormalities were present in the exams (SOS condition). Trials from the two conditions were intermixed. Readers were invited to return for two sessions: one in which the SOS condition was repeated with a simulated CAD; another in which only the non-SOS condition was presented. Detection accuracy was measured using receiver operating characteristic (ROC) analysis. Results An SOS effect (reduced detection accuracy for the test nodules in the presence of the diverse added abnormalities) was not found. Average accuracy was much higher when the CAD prompt was provided, without cost in the detection of the added abnormalities. Accuracy for detecting nodules appearing without intermixed SOS trials was also substantially improved. Conclusions CT interpretation was highly task dependent. Nodule detection was poor in the general search task. Therefore, CAD may offer a greater performance improvement than demonstrated in experiments assessing CAD using focused search. The absence of SOS may be due to limited nodule detection even without other abnormalities. Advances in knowledge CAD prompts of nodules increase the detection accuracy of nodules and decrease the time to detection-without impairing the detection accuracy-of non-nodule abnormalities.

Multiple diagnostic task performance in CT examination of the chest

OBJECTIVES

In three experiments, we studied the detection of multiple abnormality types using the satisfaction of search (SOS) paradigm, the provision of a computer-aided detection (CAD) of pulmonary nodules and a focused nodule detection task.

METHODS

51 chest CT examinations (24 that demonstrated subtle pulmonary nodules and 27 that demonstrated no pulmonary nodules) were read by 15 radiology residents and fellows under two experimental conditions: (1) when there were no other abnormalities present except test abnormalities in the exams (non-SOS condition), and (2) when other abnormalities were present in the exams (SOS condition). Trials from the two conditions were intermixed. Readers were invited to return for two sessions: one in which the SOS condition was repeated with a simulated CAD; another in which only the non-SOS condition was presented. Detection accuracy was measured using receiver operating characteristic (ROC) analysis.

RESULTS

An SOS effect (reduced detection accuracy for the test nodules in the presence of the diverse added abnormalities) was not found. Average accuracy was much higher when the CAD prompt was provided, without cost in the detection of the added abnormalities. Accuracy for detecting nodules appearing without intermixed SOS trials was also substantially improved.

CONCLUSIONS

CT interpretation was highly task dependent. Nodule detection was poor in the general search task. Therefore, CAD may offer a greater performance improvement than demonstrated in experiments assessing CAD using focused search. The absence of SOS may be due to limited nodule detection even without other abnormalities. Advances in knowledge CAD prompts of nodules increase the detection accuracy of nodules and decrease the time to detection-without impairing the detection accuracy-of non-nodule abnormalities.

Cell motility, morphology, viability and proliferation in response to nanotopography on silicon black

Knowledge of cells' interactions with nanostructured materials is fundamental for bio-nanotechnology. We present results for how individual mouse fibroblasts from cell line NIH3T3 respond to highly spiked surfaces of silicon black that were fabricated by maskless reactive ion etching (RIE). We did standard measurements of cell viability, proliferation, and morphology on various surfaces. We also analyzed the motility of cells on the same surfaces, as recorded in time lapse movies of sparsely populated cell cultures. We find that motility and morphology vary strongly with nano-patterns, while viability and proliferation show little dependence on substrate type. We conclude that motility analysis can show a wide range of cell responses e.g. over a factor of two in cell speed to different nano-topographies, where standard assays, such as viability or proliferation, in the tested cases show much less variation of the order 10-20%.

Relationship between bone strength and dual-energy X-ray absorptiometry measurements in pigs

Computed tomography and a 3-point bending test were performed on the metacarpal bones of adult production pigs to test the hypothesis that bone strength is strongly correlated with areal bone mineral density (BMD) in this population. The aim of the study was to subject material from adult production pigs grouped by BMD to 3-point bending, to test this hypothesis and determine any correlations. In all, 168 individual computed tomography scans and mechanical tests were performed on the collected material. For evaluation purposes, the material was divided into the categories low, medium, and high BMD (<1, 1 to 1.4, and >1.4 g/cm(2), respectively). The results showed a difference in the maximum load, in the stress at maximum load, and stiffness among each BMD group (P < 0.001) and in elastic modulus between the low BMD group and the 2 other groups (P < 0.001). A correlation between both intrinsic and extrinsic measures of bone strength and BMD was thus demonstrated. The projected change in each of the variables reported, for a 0.1 g/cm(2) alteration in BMD (within the BMD range evaluated in this study), is as follows: maximum load, 708 N; stress at maximum load, 50 N/mm(2); stiffness, 391.6 N/mm; and elastic modulus, 108 N/mm(2) (P < 0.001). The results confirm the relationship between BMD and bone strength and indicate that BMD screening can be used in fracture risk assessments in production pigs.

Factors regulating ovarian function in pigs

The hormonal interactions of the hypothalamic-pituitary-ovarian-uterine axis are accountable for a normal reproduction in female pigs. It is of importance to have knowledge of estrous symptoms and hormonal profiles around ovulation. The introduction of the transrectal ultrasonography in sows has given us the possibility to study ovarian activity in conscious animals and relate the timing of estrus to ovulation. Combining this technique with measuring of several hormones like luteinizing hormone (LH), follicle-stimulating hormone (FSH), inhibin, estradiol, progesterone, insulin-like growth hormone I (IGF-I), prostaglandin F2alpha (PGF2alpha) metabolite, oxytocin, facilitate our knowledge about the sequence of ovarian events. Evidence suggests that activation of the hypothalamic-pituitary-adrenal axis may hamper the normal gonadotropin secretion and in consequence, the ovarian function. The metabolic status during lactation, weaning of piglets and social stress might affect onset of ovarian activity and the related estrous behavior. The role of seminal plasma, artificial insemination and presence of the boar might also be included as factors regulating the temporal kinetics of ovulation, corpus luteum development, uterine function and steroid production in the ovary. Studies using a simulated stress by means of adrenocorticotrophic hormone (ACTH) administration or food deprivation are tools in understanding how the ovary is susceptible to impairment. The intention of this paper is to review current knowledge concerning the endocrine aspects of normal and stress-influenced ovarian function in pigs.

Evaluation of various corrections to the standardized uptake value for diagnosis of pulmonary malignancy

OBJECTIVE

Standard uptake values (SUVs) are widely used for quantifying the uptake of 18F-fluorodeoxyglucose (18F-FDG) in tumours. The objective of this study was to evaluate the accuracy of SUVs for malignancy in lung nodules/masses and to analyse the effects of tumour size, blood glucose levels and different body weight corrections on SUV.

METHODS

One hundred and twenty-seven patients with suspicious lung lesions imaged with 18F-FDG positron emission tomography (PET) were studied retrospectively. Pathology results were used to establish lesion diagnosis in all cases. SUVs based on maximum pixel values were obtained by placing regions of interest around the focus of abnormal 18F-FDG uptake in the lungs. The SUVs were calculated using the following normalizations: body weight (BW), lean body weight (LBW), scaled body surface area (BSA), blood glucose level (Glu) and tumour size (Tsize). Receivers operating characteristic (ROC) curves were generated to compare the accuracy of different methods of SUV calculation.

RESULTS

The areas under the ROC curves for SUV(BW), SUV(BW+Glu), SUV(LBW), SUV(LBW+Glu), SUV(BSA), SUV(BSA+Glu) and SUV(BW+Tsize) were 0.915, 0.912, 0.911, 0.912, 0.916, 0.909 and 0.864, respectively.

CONCLUSION

The accuracy of SUV analysis for malignancy in lung nodules/masses is not improved by correction for blood glucose or tumour size or by normalizing for body surface area or lean body weight instead of body weight.

A threshold method to improve standardized uptake value reproducibility

Although standardized uptake values (SUV) are widely used to quantify the uptake of 18F-fluorodeoxyglucose (18F-FDG) in tumours, there are systematic differences in the way this index is applied by different investigators. The aims of this study were to compare the effects of using maximum or mean region counts in the calculation of SUV and to investigate an alternative technique based on a fixed fraction of the maximum counts. Simulated PET projections of the thorax were generated together with spherical lesions that varied in diameter from 1.6 to 4.8 cm with uptake values of 2, 4 and 8. The lesion SUVs were determined using either the maximum (SUVmax) or mean count (SUVmean) values found in regions circumscribing the lesion. In addition, average values were calculated that only included region pixels that exceeded a selected fraction of maximum value (SUV0.6max or SUV0.75max). These methods were also applied to six clinical 18F-FDG PET studies with a total of 12 lesions. The SUVs for these lesions were determined independently by four observers. Decreases with respect to SUVmax of 57%, 23% and 14% were found for SUVmean, SUV0.6max and SUV0.75max approaches respectively in the simulation study. The variation in SUVmean with region size was 35%, while the SUV0.6max and SUV0.75max was less than 3%. Similar results were obtained for the clinical data. We conclude that the proposed technique produces SUVs that are essentially independent of lesion region size and shape. It is expected that this will provide a more stable and reliable result than current approaches.

A device for applying static loads to prosthetic limbs of transtibial amputees during spiral CT examination

This paper describes a device that allows the imaging of prosthetic legs under load conditions using spiral computerized tomography (CT). The device consists of a chair and a vertical footplate mounted on a 17.8 x 1.9 cm oak board that is 197 cm long. The load device can be easily positioned onto the CT bed. A subject sits in the chair and applies force by pushing the foot portion of the prosthesis against the footplate. The magnitude of the force is monitored by a digital force gauge coupled to the footplate. Because the load is borne by the hips and lower back of the subject against the chair, substantial forces can be generated and steadily maintained for the 20-45 s duration of the CT study. This device has been used successfully with 19 transtibial amputees, allowing the acquisition of spiral CT studies with half and full body weight loads.

X-ray attenuation coefficients of high-atomic-number, hexanuclear transition metal cluster compounds: a new paradigm for radiographic contrast agents

RATIONALE AND OBJECTIVES

The purpose of this study was to examine the radiologic attenuation properties of the parent cluster compounds, particularly attenuation as a function of discrete photon energy, before investigating ligand substitutions, which are necessary to improve cluster biocompatibility and to impart desirable physicochemical properties.

MATERIALS AND METHODS

The linear attenuation coefficients for solutions of the cluster compounds Ta6Br14, K8Ta6O19, and (H3O)2W6Cl14 were determined at 60, 80, 103, 122, and 140 keV from gamma-ray transmission measurements with americium-241, xenon-133, gadolinium-153, cobalt-57, and technetium-99m radioactive sources. Transmission measurements were obtained for a fixed time interval that ensured a statistically accurate count distribution exceeding 20,000 counts through the sample for each trial.

RESULTS

On a strictly mole per liter basis, a 0.075 mol/L aqueous solution of K8Ta6O19 showed 1.08 times the attenuation of 0.063 mol/L aqueous iohexol at 60 keV and 3.30 times the attenuation at 80 keV. Similarly, a 0.05 mol/L methanolic solution of (H3O)2W6Cl4 showed 0.96 times (96%) the attenuation of 0.063 mol/L aqueous iohexol at 60 keV but 3.09 times the attenuation of the iohexol solution at 80 keV. Attenuations of 0.063 mol/L aqueous iohexol and 0.0125 mol/L Ta6Br14 (ie, at approximately one-fifth the iohexol concentration) were comparable at greater than 60 keV.

CONCLUSION

These results confirm the theoretic potential for use of early transition metal cluster compounds as radiographic contrast agents. At higher x-ray energies, cluster compounds demonstrate multiplied x-ray attenuation relative to iodinated contrast agents.

Pulmonary CT image classification with evolutionary programming

RATIONALE AND OBJECTIVES

It is often difficult to classify information in medical images from derived features. The purpose of this research was to investigate the use of evolutionary programming as a tool for selecting important features and generating algorithms to classify computed tomographic (CT) images of the lung.

MATERIALS AND METHODS

Training and test sets consisting of 11 features derived from multiple lung CT images were generated, along with an indicator of the target area from which features originated. The images included five parameters based on histogram analysis, 11 parameters based on run length and co-occurrence matrix measures, and the fractal dimension. Two classification experiments were performed. In the first, the classification task was to distinguish between the subtle but known differences between anterior and posterior portions of transverse lung CT sections. The second classification task was to distinguish normal lung CT images from emphysematous images. The performance of the evolutionary programming approach was compared with that of three statistical classifiers that used the same training and test sets.

RESULTS

Evolutionary programming produced solutions that compared favorably with those of the statistical classifiers. In separating the anterior from the posterior lung sections, the evolutionary programming results were better than two of the three statistical approaches. The evolutionary programming approach correctly identified all the normal and abnormal lung images and accomplished this by using less features than the best statistical method.

CONCLUSION

The results of this study demonstrate the utility of evolutionary programming as a tool for developing classification algorithms.

The human antibacterial cathelicidin, hCAP-18, is bound to lipoproteins in plasma

Cathelicidins are a family of antibacterial and lipopolysaccharide-binding proteins. hCAP-18, the only human cathelicidin, is a major protein of the specific granules of human neutrophils. The plasma level of hCAP-18 is >20-fold higher than that of other specific granule proteins relative to their levels within circulating neutrophils. The aim of this study was to elucidate the background for this high plasma level of hCAP-18. Plasma was subjected to molecular sieve chromatography, and hCAP-18 was found in distinct high molecular mass fractions that coeluted with apolipoproteins A-I and B, respectively. The association of hCAP-18 with lipoproteins was validated by the cofractionation of hCAP-18 with lipoproteins using two different methods for isolation of lipoproteins from plasma. Furthermore, the level of hCAP-18 in delipidated plasma was <1% of that in normal plasma. Immunoprecipitation of very low, low, and high density lipoprotein particles with anti-apolipoprotein antibodies resulted in coprecipitation of hCAP-18. The binding of hCAP-18 to lipoproteins was mediated by the antibacterial C-terminal part of the protein. The binding of hCAP-18 to lipoproteins suggests that lipoproteins may play an important role as a reservoir of this antimicrobial protein.

Removal of N-terminal polyhistidine tags from recombinant proteins using engineered aminopeptidases

We have developed a specific and efficient method for complete removal of polyhistidine purification tags (HisTags) from the N-termini of target proteins. The method is based on the use of the aminopeptidase dipeptidyl peptidase I (DPPI), either alone or in combination with glutamine cyclotransferase (GCT) and pyroglutamyl aminopeptidase (PGAP). In both cases, the HisTag is cleaved off by DPPI, which catalyzes a stepwise excision of a wide range of dipeptides from the N-terminus of a peptide chain. Some sequences, however, are resistant to DPPI cleavage and a number of mature proteins have nonsubstrate N-termini which protects them against digestion. For such proteins, HisTags composed of an even number of residues can be cleaved off by treatment with DPPI alone. When the target protein is unprotected against DPPI, a blocking group is generated enzymatically from a glutamine residue inserted between the HisTag and the target protein. A protein with a HisTag-Gln extension is incubated with both DPPI and GCT. As above, the polyhistidine sequence is cleaved off by DPPI, but when the glutamine residue appears in the N-terminus, it is immediately converted into a pyroglutamyl residue by an excess of GCT and further DPPI digestion is prevented. The desired sequence is finally obtained by excision of the pyroglutamyl residue with PGAP. All the enzymes employed can bind to immobilized metal affinity chromatography (IMAC) matrices, and in this paper we demonstrate a simple and highly effective process combining IMAC purification of His-tagged proteins, our aminopeptidase-based method for specific excision of HisTags and use of subtractive IMAC for removing processing enzymes. Typical recoveries were 75-90% for the enzymatic processing and subtractive IMAC. The integrated process holds promises for use in large-scale production of pharmaceutical proteins because of a simple overall design, use of robust and inexpensive matrices, and use of enzymes of either recombinant or plant origin.

Active recombinant rat dipeptidyl aminopeptidase I (cathepsin C) produced using the baculovirus expression system

An active form of rat dipeptidyl aminopeptidase I (DPPI, cathepsin C) was obtained by heterologous expression in insect cells. Baculoviruses carrying a cDNA sequence encoding the entire rat DPPI precursor was used to infect High Five cells in a serum-free medium. Recombinant DPPI (rDPPI) was secreted into the medium from which it was purified by a combination of ammonium sulfate fractionation, hydrophobic interaction chromatography (HIC), and ion-exchange chromatography. A polyhistidine-tagged form of the enzyme (HT-rDPPI) was purified from the medium by immobilized metal affinity chromatography (IMAC). In vivo activation of native rat DPPI involves at least three chain cleavages per subunit and the ability of the expression system to imitate this processing was investigated. Both rDPPI and HT-rDPPI were secreted into the medium as unprocessed and inactive proenzymes and gradually converted into their active forms in the medium. This process was not completed at the time of harvest but mature enzyme processed similarly to native rat and human DPPI could be obtained by incubating the eluates from the HIC and IMAC columns at pH 4.5 and 5 degrees C for 18-40 h. The yield of purified and matured enzyme was approximately 50 mg/liter, and it was shown that rDPPI and HT-rDPPI were active against both a dipeptide-p-nitroanilide substrate and human growth hormone N-terminally extended with an Ala-Glu dipeptide.

Changing bone marrow micro-environment during development of acute myeloid leukaemia in rats

The Brown Norwegian rat transplanted with promyelocytic leukaemic cells (BNML) has been used as a model for human acute myeloid leukaemia. We have previously shown that both the blood supply to the bone marrow and the metabolic rate decrease in relation to the leukaemic development in these rats. Here we have investigated how the development and progression of this leukaemia affect oxygenation, pH and proliferation of normal and leukaemic cells in vivo. Bone marrow pH was measured by a needle electrode. Nitroimidazol-theophylline (NITP) was used to identify hypoxic cells, and we applied bromodeoxyuridine (BrdUrd) to identify DNA replicating cells. The leukaemia progressed slowly until day 27 after which a rapid deterioration could be observed leading to severe changes over the following 5 d. In whole blood there was evidence of progressing metabolic acidosis. In bone marrow the fraction of leukaemic cells increased to > 90% and the pH dropped to about 6.5. The fraction of NITP+ cells increased to > 80% in bone marrow and to about 40% in blood. The fraction of BrdUrd+ cells was unchanged in blood, but decreased in bone marrow both for normal cells (from about 20% to 5%), and for leukaemic cells (from about 45% to 25%), evidently as a result of the severely changed microenvironment. In this study we have demonstrated in vivo the development of an acidic and hypoxic bone marrow hampering normal haemopoiesis during leukaemic growth. Our data support the notion of BNML as a valuable tool for studying leukaemogenesis.

A method for quantifying SPECT uniformity

Field uniformity is an important parameter for monitoring the performance of SPECT imaging systems. However, it is difficult to apply objective measures of uniformity because of the large variance associated with reconstructed images. In the proposed method, annular sampling of the SPECT uniformity image is used to reduce the noise level without decreasing the magnitude of uniformity artifacts. The reconstructed uniformity image is sectioned into annular rings centered on the center of rotation to match the expected distribution of uniformity artifacts. Statistical fluctuations are reduced by averaging the counts within the annular rings, allowing the use of objective measures of field uniformity such as integral uniformity. Application of the annular sampling technique on simulated and phantom uniformity images showed that the technique could reliably quantify SPECT uniformity artifacts at acceptable count levels. As a result this method can be used to objectively evaluate SPECT field uniformity in systems which utilize parallel collimation and circular orbits.

Emission-based attenuation correction of myocardial perfusion studies

BACKGROUND

Nonuniform attenuation in the thorax can generate artifacts in single-photon emission computed tomographic myocardial perfusion studies that mimic coronary artery disease. In this article we present both phantom and simulation data, as well as clinical data, in support of an emission-based method that provides reliable correction for attenuation effects without the need for a transmission measurement.

METHODS AND RESULTS

The attenuation map is derived from the measured distribution of 99mTc-labeled macroaggregated albumin in the lungs and a radioactive binder wrapped about the thorax. This information is acquired as part of a dual-isotope acquisition during the rest 201Tl study. Segmentation is used to define the interiors of lung and body compartments, which are assigned a single attenuation coefficient for each of the two tissue types. The appropriateness of this approach was investigated by examining the measured attenuation coefficients in a group of 80 individuals (40 male, 40 female) from positron emission tomographic transmission studies. The correction technique was evaluated with computer simulations, a physical phantom, and clinical data acquired from 20 patients. Analysis of the positron emission tomographic data found a small SD in the mean attenuation coefficients for the body (<5%) and lungs (<15%). The application of emission-based attenuation-correction technique produced a substantial reduction in the magnitude of the attenuation artifact in images obtained from both the phantom and the simulation studies. The emission-based attenuation-correction technique was easily applied to myocardial perfusion studies, where it had a significant effect, resulting in changes in interpretation for nine of 20 patients.

CONCLUSIONS

The results of this study provide strong support for the concept that an attenuation map can be generated with fixed attenuation values in place of those that are directly measured. Thus the emission-based attenuation-correction technique can be considered an inexpensive alternative to transmission-based correction methods. Because the emission-based correction technique does not require any additional hardware, it has the major advantage of being applicable to all single-photon emission computed tomographic systems.

The primary structure and enzymic properties of porcine prochymosin and chymosin

Preliminary investigations by N-terminal sequence analysis showed that pig and calf chymosin possessed 80% amino acid sequence identity but showed considerable differences in their enzymatic properties. A comparison of their structures may therefore contribute to an understanding of the significance of the amino acid residues responsible for the differences in these properties. Pig chymosis was extracted from the stomachs of pigs of less than 3 weeks of age, and was purified by ion exchange chromatography. Half of the primary structure was determined by amino acid sequencing and the complete structure was deduced from a cloned chymosin cDNA. Results showed that the zymogen showed 81% sequence identity with calf prochymosin and 57% identity with pig pepsinogen A. The size of the propart and location of the residue which becomes the N-terminus in the active molecule were the same in the prochymosins. The maximum general proteolytic activity at pH 3.5 of pig chymosin was 2-3% of that of the activity of pig pepsin A at pH 2, whereas the milk clotting activity relative to the general proteolytic activity of pig chymosin was much higher than that of calf chymosin. Agar gel electrophoresis at pH 5.3 of stomach extracts of individual pigs showed the existence of two predominant genetic variants of zymogen and enzyme. The two variants could not be distinguished by amino acid composition or N-terminal sequencing, and no differences in the enzymatic properties of the genetic variants were observed. It was concluded that of the residues that participate in the substrate binding, calf and pig chymosin differ in the following positions (pig pepsin numbering, subsites in parentheses): Ser 12 Thr (S4), Leu 30 Val (S1/S3), His 74 Gln (S'2), Val 111 Ile (S1/S3), Lys 220 Met (S4). With regard to the low general proteolytic activity of pig chymosin, the substitution Asp 303 Val relative to calf chymosin may contribute to an explanation of this.

Cranial osteomyelitis: diagnosis and follow-up with In-111 white blood cell and Tc-99m methylene diphosphonate bone SPECT, CT, and MR imaging

PURPOSE

To assess the usefulness of indium-111 white blood cell and technetium-99m methylene diphosphonate bone single photon emission computed tomography (SPECT), computed tomography (CT), and magnetic resonance (MR) imaging in cranial osteomyelitis.

MATERIALS AND METHODS

Twenty-six cases (25 patients: 13 male, 12 female; mean age, 55 years) of suspected osteomyelitis were evaluated. Sixteen were postoperative. Final diagnosis was established by means of bone culture in 18 cases and clinical follow-up in eight.

RESULTS

Of 35 CT scans, 10 were true-positive (TP); three false-negative (FN); 13, true-negative (TN); one, false-positive (FP); and eight, equivocal. Of 36 SPECT scans, 19 were TP; 13, TN; one, FP; one, FN; and two, equivocal. Of 11 MR images four were TP; five, TN; and two, FN.

CONCLUSION

CT is best for differentiation between soft-tissue and bone infection. MR imaging is best for assessment of the calvaria and skull base. SPECT is best for assessment of altered bone and may be the best technique for follow-up.

Blocking of tissue factor pathway inhibitor (TFPI) shortens the bleeding time in rabbits with antibody induced haemophilia A

Tissue factor (TF)/FVIIa initiates coagulation by activating factor IX (FIX) and factor X (FX). Tissue factor pathway inhibitor (TFPI)-FXa complexes form and inhibit TF/FVIIa. Blocking of TFPI may facilitate haemostasis initiated by FVIIa/TF thereby compensating for impaired FIX/FVIII-dependent coagulation. This hypothesis was tested in a study using rabbits made temporarily haemophilic by the injection of antibodies against FVIII. These rabbits were given i.v. injections of anti-TFPI IgG antibodies and 40 min later bleeding was initiated by cutting the nail including the apex of the cuticle. Injection of anti-TFPI IgG shortened the bleeding time significantly from 26 min to 11 min (normal mean bleeding time in non-haemophilia rabbits: 5 min). Treatment with anti-TFPI IgG also resulted in a shortening of the haemophilic aPTT to a level slightly longer than the normal aPTT. In addition, the prolonged dilute TF clotting time was shortened by the anti-TFPI IgG treatment. Thus, both bleeding and coagulation parameters indicated that blocking of TFPI may be potentially haemostatic in haemophilia.

The AAPM/RSNA physics tutorial for residents. Introduction to emission CT

The article explores the fundamentals of emission computed tomography (CT) from a nonmathematical approach. Tomographic images reveal the internal distributions of radioactivity in three-dimensional objects, and thus allows anatomic localization and improves contrast. Tomography requires a stable distribution of radionuclides, uniform detector response, an accurate center of rotation, and a complete set of projections. In emission CT, a large number of measurements, called projections, are collected at various angles about the patient during the examination. This information is organized by the angles of acquisition into a stack, called a sinogram. Each projection is modified by applying a reconstruction filter (eg, ramp or windowed reconstruction filters). These modified projections are backprojected to form the transverse tomographic images. The quality of tomographic images generated from filtered backprojection depends on the underlying assumptions about the projections. Typical artifacts that result from violations of these assumptions include motion, uniformity, and attenuation artifacts. In addition, an inaccurate center of rotation, insufficient angular sampling, and errors in selection of pixel size can result in poor-quality reconstructed images.

Scintigraphic evaluation of small bowel transit in healthy subjects: inter- and intrasubject variability

OBJECTIVES

This study was performed to evaluate inter- and intrasubject variability of small bowel transit time and the effect of age and sex on transit in the small bowel.

METHODS

Ten young subjects (five females) and nine elderly subjects (four females) were studied. Small bowel transit time was assessed by scintigraphic method using 99mtechnetium-sulfur colloid-labeled eggs. To evaluate intrasubject variability, 10 subjects underwent a second study on a later occasion.

RESULTS

Mean small bowel transit time was 220.9 +/- 49 min with a range of 131 to 322 min, with no significant difference between the young and elderly groups or between sexes. There was a good intraobserver and interobserver reproducibility within the same test (r = 0.92 and r = 0.85, respectively). There was a significant biological variability between the first and the second studies, which was true whether the studies were processed independently (r = 0.43) or whether identical regions of interest were applied (r = 0.50).

CONCLUSION

The normal range of small bowel transit time is wide in normal subjects; and there is a significant intrasubject biological variability for small bowel transit time. These findings should be kept in mind when using scintigraphic techniques for assessment of patients with motility disorders or when using the test repeatedly in the same subject in the evaluation of therapeutic measures. The results do not seem to be affected by age or sex.

Quantitation of SPECT performance: Report of Task Group 4, Nuclear Medicine Committee

A comprehensive performance testing program is an essential ingredient of high-quality single-photon emission computed tomography (SPECT). Many of the procedures previously published are complicated, time consuming, or require a special testing environment. This Task Group developed a protocol for evaluating SPECT imaging systems that was simple, practical, required minimal test equipment, and could be performed in a few hours using processing software available on all nuclear medicine computers. It was designed to test rotational stability of uniformity and sensitivity, tomographic spatial resolution, uniformity and contrast, and the accuracy of attenuation correction. It can be performed in less than three hours and requires only a Co-57 flood source, a line source, and a tomographic cylindrical phantom. The protocol was used 51 times on 42 different cameras (seven vendors) by four different individuals. The results were used to establish acceptable ranges for the measured parameters. The variation between vendors was relatively small and appeared to reflect slight differences in basic camera performance, collimation, and reconstruction software. Individuals can use the tabulated values to evaluate the performance of individual systems.

Captopril-enhanced 99Tcm-MAG3 renal scintigraphy in subjects with suspected renovascular hypertension

This pilot study was undertaken to generate preliminary data on the accuracy of captopril-enhanced renal scintigraphy with a relatively new radiopharmaceutical, 99Tcm-mercaptoacetyltriglycine (99Tcm-MAG3) for detecting significant renal artery stenosis. Truth data was based either on arteriographic or outcome criteria (blood pressure response to therapy). Twenty-seven subjects with suspected renovascular hypertension were studied with baseline and captopril-enhanced 99Tcm-MAG3 renal scintigraphy and renal arteriography. Scan interpretations were expressed as a probability of a significant renal artery stenosis. Scan interpretations were compared with renal arteriographic results, renal vein renin levels, blood pressure values after renal artery repair, and blood pressure control after 4-26 months of clinical follow-up. Using > or = 50% luminal obstruction on arteriography as the reference standard for renal artery stenosis and a high probability scan representing a positive test, the test sensitivity and specificity were 33 and 97%, respectively (using high or indeterminate probability to represent a positive scan, the test sensitivity and specificity were 67 and 83%, respectively). The negative predictive value of a low probability scan for renal artery stenosis was 80%. However, including a measure of renovascular hypertension (blood pressure response to renal artery repair) as the reference standard, the accuracy of the scan improves, with the negative predictive value of a low probability scan for renovascular hypertension increasing to 97%. Scintigraphic results were also positively correlated with renal vein renin values in a statistically significant fashion (two-tailed Fisher exact test statistic = 6.43, P = 0.0219). Captopril-enhanced 99Tcm-MAG3 renal scintigraphy is a moderately accurate technique for detecting renal artery stenosis. More importantly, our preliminary findings suggest that the scintigraphic technique using 99Tcm-MAG3 appears to predict the blood pressure response to renal artery repair in subjects with suspected renovascular hypertension, thereby separating subjects with haemodynamically insignificant renal artery stenosis from those with renovascular hypertension.

Positron emission tomographic measurement of bone marrow blood flow to the pelvis and lumbar vertebrae in young normal adults

Ten young normal adults had pelvic and lumbar vertebral body bone marrow blood flow examined using [15O]water and positron emission tomography (PET) in a study designed to assess the feasibility and reproducibility of the PET technique for measuring marrow blood flow to various marrow regions. The procedure was well tolerated. Repeated blood flow measurements obtained from two consecutive [15O]water exams on each individual subject were highly reproducible. In addition, there was minimal variation in marrow blood flow from individual to individual and no gender differences were noted. In contrast, mean +/- SD bone marrow blood flows (expressed as milliliters per minute per 100 g) at selected anatomical sites were significantly different and were as follows: lower lumbar vertebral bodies, 17.6 +/- 3.1; most posterior and superior pelvis (conventional site of percutaneous bone marrow biopsy), 14.3 +/- 3.1; and total superior pelvis, 11.1 +/- 2.0. We conclude that PET is a relatively noninvasive, simple, and reproducible technique for measuring bone marrow blood flow. Marrow blood flow is consistent between normal young subjects, but varies significantly between different anatomic regions of the marrow.

The safety and pharmacokinetics in adult subjects of an intravenously administered 99mTc-labeled 17 amino acid peptide (CYT-379)

A phase I study was designed to evaluate the safety and pharmacokinetics of a novel platelet reactive peptide, peptide acetyl-SYGRGDVRGDFKCTCCA-amide (CYT-379), which binds to the fibrinogen receptor of activated platelets and also binds to 99mTc. Eleven subjects with suspected deep venous thrombosis had 0.1, 0.5 or 1.0 mg of the peptide infused intravenously. Pharmacokinetics were determined by assaying blood samples in 6 of the 11 subjects and by urine sampling in 5 of these 6 subjects. Plasma and whole blood time-activity curves demonstrated an initial fast component with half-time clearance of 0.2 +/- 0.01 and 0.2 +/- 0.02 h and a slow component with half-time clearance of 2.8 +/- 0.3 and 2.7 +/- 0.2 h (mean +/- SEM for plasma and whole blood, respectively). Urine clearance was 22.6 +/- 3.3 and 10.8 +/- 1.6 mL/min when normalized to body surface area. The cumulative excretion of 99mTc-CYT-379 in the urine was 16.6 +/- 3.6, 45.6 +/- 16.9 and 45.6 +/- 1.8% of the administered dose over 0-2, 0-12 and 0-24 h after radiopharmaceutical injection, respectively. Images obtained in 11 subjects immediately, at 1-2, and 4-6 h after injection were evaluated for abnormalities and were compared with duplex Doppler ultrasonography. 99mTc-CYT-379 images were positive in only 3 of 7 subjects who had a positive duplex Doppler examination in at least one lower extremity. One subject with negative duplex Doppler had also negative 99mTc-CYT-379 scintigraphy. One subject with negative scintigraphy and two other subjects with positive scintigraphy had no other imaging studies of the deep venous system performed. No adverse reactions were observed during or after the infusion of 99mTc-CYT-379. 99mTc-CYT-379 appears to be a safe radiopharmaceutical and demonstrates rapid clearance from plasma in human subjects.

An emission-based technique for obtaining attenuation correction data for myocardial SPECT studies

In this paper, a technique is described for obtaining the information needed to perform attenuation correction in the thorax entirely from an emission study. This technique is based on the observation that the variation in soft tissue and lung attenuation coefficients is small among individuals. Thus only the outer contours of the body and lungs need be determined for obtaining the attenuation map. The contours are determined by using 99Tcm-macroaggregated albumin (MAA) to locate the lungs and an external source wrapped about the chest to locate the body boundary. Simulation studies were performed to investigate how errors in the presumed tissue attenuation coefficients affect the accuracy of the correction. Body and lung attenuation coefficients were varied from 20% less to 20% more than the coefficients used in the corrections. Over this range, there was less than a 15% alteration in the relative distribution of counts in the left ventricle. To test clinical feasibility, seven patients referred for clinical myocardial perfusion studies were scanned before and after the placement of the body source and the administration of 99Tcm-MAA. Reconstructed images from these studies showed clear demarcation of all body and lung boundaries. The presence of 99Tcm-MAA in the lungs had no significant effect on the clinical interpretation of the single photon emission computed tomographic (SPECT) studies. It is concluded that this technique is feasible for clinical application and that it offers important advantages over other current methods.

Dual isotope brain SPECT imaging for monitoring cognitive activation: physical considerations

The physical considerations of using dual isotope brain SPECT imaging to monitor blood flow changes during cognitive activation studies were investigated. These factors included field uniformity, spatial resolution and crosstalk. Serial dual isotope single photon emission computed tomographic (SPECT) studies of a test tube phantom and an anthropomorphic brain phantom filled with 99Tcm and 123I were made over a 10 h period. The reconstructed counts in the 99Tcm and 123I windows were corrected for crosstalk and were plotted as a function of time. The plotted data from each window decreased over time with a half-life characteristic of each radionuclide. The relative difference between true 123I and 99Tcm region counts has to be of the order of 10% to be statistically significant at the P < 0.05 level.

Dual isotope brain SPECT imaging for monitoring cognitive activation: initial studies in humans

A dual isotope, single photon emission tomography (SPECT) technique using 99Tcm-hexamethylpropyleneamine oxime (HMPAO) and 123I-iodoamphetamine (IMP) was investigated to determine its suitability for assessing regional cerebral blood flow (rCBF) changes resulting from cognitive activation. The similarity of the 123I-IMP and 99Tcm-HMPAO distributions under the same physiological conditions was first investigated by administering the two agents to human subjects (n = 8) either simultaneously or at different times but during the performance of the same task. Normalized ratio images generated from the 99Tcm and 123I data showed that the two tracers distributed similarly in the left and right cerebral hemispheres when administered under similar physiological conditions. There was, however, a significant anterior/posterior gradient that appears to be the result of partial volume effects due to small differences in spatial resolution of the two agents. In two subjects, 99Tcm-HMPAO was administered during a resting period with eyes-closed and 123I-IMP was injected later during visual checkerboard stimulation. Ratio images showed a localized increase in the occipital lobes during the visual stimulation consistent with the expected increase in rCBF. The dual isotope strategy appears promising for study of changes in rCBF due to cognitive activation.

Sensitivity, resolution and image quality with a multi-head SPECT camera

This investigation sought to determine which collimation factors were most important in providing superior image quality with a three-headed SPECT device. The relationship between sensitivity, resolution and SPECT image quality was studied. Two different sets of parallel-hole collimators were used. The ultrahigh-resolution collimators have higher spatial resolution (8.9 versus 11.0 mm), but only 55% of the sensitivity of the high-resolution collimators. A phantom with hot rods was imaged with both collimator sets. Observers compared images with the ultrahigh-resolution collimators to images of varying counts with the high-resolution collimators and determined which high-resolution images matched the ultrahigh-resolution images in image quality. Eleven patient studies were acquired with both collimator sets for equal time, and observers chose which image set they preferred. Transverse images of brain and liver studies were simulated with varying resolution and counts and subjectively compared. The phantom study indicated that the improvement in resolution led to image quality comparable to increasing the number of counts by a factor of 2.5 to 3.4. The clinical studies showed that the ultrahigh-resolution collimators were preferred in a large majority of the cases. These trends were also seen in the simulation study. These results confirm that higher resolution collimators should be used with multihead SPECT devices. The improvement in resolution more than compensates for the loss in sensitivity, leading to an overall improvement in image quality.

Spatial resolution and count density requirements in brain SPECT imaging

A set of simulations has been performed to investigate the spatial resolution and count density requirements for brain SPECT imaging. Projections were drawn from a matrix representation of the Hoffman brain phantom. These projections were convolved with realistic point spread functions and Poisson noise was added to simulate a wide range of imaging situations normalized to a fixed imaging time. The projections were optimally smoothed with a Wiener filter and were reconstructed with a ramp filter. The quality of the reconstructed images was determined objectively from the normalized mean square between the simulated data and the true distribution. This ranking was validated against the preferences of a group of trained observers. The results from this study indicate that the optimal choice of spatial resolution (collimation) depends on the available count density. As the count density (normalized to 10 mm resolution) increases by a factor of 2.7, results from the simulations indicate that the optimal spatial resolution improves by 1 mm. For brain studies in which the administered activity is limited (such as 123I IMP), the optimal spatial resolution is approximately 8 to 9 mm. With 99Tcm labelled brain agents the amount of administered radioactivity can be increased six-fold and the optimal spatial resolution is predicted to fall to about 6 to 7 mm. If sensitivity is further increased by the use of a dedicated SPECT unit with multiple detectors, the optimal spatial resolution will be on the order of 4 to 5 mm.

An improved method for the quantification of left-to-right cardiac shunts

We have investigated a technique for quantifying QP/QS in left-to-right cardiac shunts. In this method, the gamma variate, which is fitted to the first-pass portion of the lung curve, is used to generate a curve, which simulates the response of a normal lung curve with systemic recirculation. The difference between this curve and the observed lung curve is then used to calculate QP/QS. This method was evaluated on a set of simulated lung time-activity curves with precisely known QP/QS values on a group of 11 patients with no clinical suspicion of cardiac shunt and on a group of 30 patients referred for cardiac shunt studies. The QP/QS in each of these studies was determined by three individuals using both the Maltz-Treves method and the new method. This method yielded QP/QS values that were more accurate on the simulated lung data and had less interobserver variation on all the studies than those obtained from the Maltz-Treves method.

Gestational changes in electrolyte transport, electrical activity, and permeability of the porcine placenta

1. The electrolyte transport capacities of the porcine placenta and fetal membranes (amnion, chorion, and allantois) during gestation (47-112 days) were assessed in vitro and in the absence of electrochemical, osmotic, or hydrostatic driving forces. Net transmural transport of 22Na and 36Cl across sections of porcine allantochorion-endometrium (ALCE), amniochorion-endometrium (AMCE), and allantoamnion (AA) mounted in Ussing chambers could not be detected at any stage of gestation. 2. These tissues were characterised throughout gestation by low electrical potential difference (PD; less than 5 mV, fetal side positive with respect to maternal side) and short circuit current (SCC; less than 16 microA.cm-2) which were amiloride and iodoacetate sensitive. 3. A periparturitent reversal in the polarity of PD to fetal side negative and a change in the direction of the SCC was observed in tissues obtained from sows (n = 3) at 111-112 day gestation. These changes were accompanied by a 73% increase in electrical resistance (R) and a 2-10-fold decrease in the permeability of tissues to Na and Cl. 4. Morphological studies revealed a decrease in the thickness of allantoamnion and a decrease in the height of epithelia from ALCE, AMCE, and AA during gestation, indicating a decrease in activity. These morphological changes only partly explained the pre-term electrophysiological changes in these tissues.

A method for obtaining an approximate Wiener filter

The Wiener restoration filter yields the minimum mean-square error between the restored image and the true object function. However, it has found limited use because, in its usual formulation, it requires information about the object power spectrum which is generally unknown. In this paper, it is shown that the Wiener filter can be derived from the noise-free image power spectrum, and a method is presented for estimating this from the observed data. From this estimate an approximate Wiener filter was calculated. The method was tested on three sets of simulated data which included a constant background, rectangular defects, and Gaussian defects at varying contrast and noise levels. The performance of the approximate Wiener filter was compared both to the true Wiener filter and to the standard 1-2-1 three-point smooth. The results confirmed that the approximate Wiener filter adapted to the information content of the observed data and closely matched the performance of the true Wiener filter. The approximate Wiener filter outperformed the three-point smooth in all cases, especially at low contrast and high noise levels. The approximate Wiener filter can be calculated without operator intervention and requires little additional computation time over conventional Wiener filter techniques.

A 3-D anthropomorphic brain phantom for ECT applications

A three-dimensional (3-D) anthropomorphic brain phantom was developed for ECT (emission computed tomography) applications. This phantom is made up of a stack of interlaced plates as an insert in a water tank containing radioactive solution. The thickness of the plates in the stack is chosen to create the desired spatial frequency content and object contrast between simulated grey and white matter regions for tracers commonly used to study regional blood flow or metabolism. The transverse, sagittal, and coronal SPECT images acquired with a rotating camera system show a realistic simulation of the grey matter distribution in a human brain.

Radioiodinated fatty acid esters in the management of hepatocellular carcinoma: preliminary findings

Radioiodinated fatty acid esters, such as lipiodol or ethiodol, are localized in the hypervascular hepatocellular carcinoma (HCC) for a long time following intra-arterial hepatic injection, enabling delivery of high internal radiation to the tumor. The desired radiation can easily be delivered to small HCC, less than 5 cm in diameter, in single or multiple procedures with an 8-week interval. For larger tumors, [131I]lipiodol or [131I]ethiodol in conjunction with chemotherapy emulsion, Ivalon embolization or all three combinations should be considered for maximal clinical results. A strong beta emitter with shorter physical half-life, i.e. 90Y will be more effective in the management of HCC if one can label lipiodol with 90Y.

Dosimetry of iodine-131 ethiodol in the treatment of hepatoma

The in vivo distribution and kinetics of [131I]Ethiodol injected through the hepatic artery have been measured on a group of four patients with hepatocellular carcinoma. The [131I]Ethiodol was distributed predominantly in the liver (70-90%) and lungs (10-20%) and was selectively concentrated and retained in the patients with massive and multinodular hepatomas with approximately 10% of the administered activity localizing in tumor. The radioactivity in the blood 2 hr postinjection was less than 0.1% and was never higher than 0.9% of the administered activity. The radioactivity cleared from normal liver tissue with an effective half-life of approximately 4 days while the clearance time from the tumor was 20-25% longer. Activity in the lungs initially increased and then cleared with a 5-day effective half-life. Based on these measurements, the estimated dose per mCi of [131I]Ethiodol administered is 31 rad to the liver, 22 rad to the lungs, 1.9 rad to the total body and 239 rad to a 4-cm diameter tumor. These results suggest that [131I]Ethiodol has the potential to deliver curative radiation doses to hepatomas with acceptable radiation burdens to normal tissues.

Iofetamine HCI I-123 brain scanning in stroke: a comparison with transmission CT

Although IMP scans fail to show fine anatomical details of the brain, because of poor resolution of a single head rotational system, adequate information is offered by the scans to localize most perfusion defects caused by stroke. The following conclusions can be drawn from our study: 1. The planar IMP brain scans processed through the computer are sensitive in the early diagnosis of acute stroke except for small and deeply localized lesions. 2. The SPECT IMP imaging is more sensitive than the planar or transmission CT scans in the early diagnosis of stroke. Semiquantitative evaluations are feasible with IMP SPECT. 3. Neither transmission CT nor IMP SPECT are sensitive in the detection of acute lacunar infarcts. 4. In acute infarction, the transmission CT is usually negative or minimally positive in the early stages, while impaired uptake of IMP occurs immediately after the onset of the stroke. In acute stroke, the extent of the perfusion defect on IMP is usually greater than the abnormality seen on the transmission CT. 5. On followup studies, IMP scans show improved perfusion reflecting physiologic changes, while transmission CT scans show further dense anatomical changes when compared to the initial studies. 6. Hyperemic changes are likely due to collateral circulation or luxury perfusion. This finding suggests that the IMP reflects local cerebral blood flow in strokes.

A precise method for correcting count-rate losses in scintillation cameras

Quantitative studies performed with scintillation detectors often require corrections for lost data because of the finite resolving time of the detector. Methods that monitor losses by means of a reference source or pulser have unacceptably large statistical fluctuations associated with their correction factors. Analytic methods that model the detector as a paralyzable system require an accurate estimate of the system resolving time. Because the apparent resolving time depends on many variables, including the window setting, source distribution, and the amount of scattering material, significant errors can be introduced by relying on a resolving time obtained from phantom measurements. These problems can be overcome by curve-fitting the data from a reference source to a paralyzable model in which the true total count rate in the selected window is estimated from the observed total rate. The resolving time becomes a free parameter in this method which is optimized to provide the best fit to the observed reference data. The fitted curve has the inherent accuracy of the reference source method with the precision associated with the observed total image count rate. Correction factors can be simply calculated from the ratio of the true reference source rate and the fitted curve. As a result, the statistical uncertainty of the data corrected by this method is not significantly increased.

Septal infarction demonstrated on technetium-99m PYP SPECT

The case of a 62-year-old man with an acute myocardial infarction detected by planar Tc-99m PYP imaging is presented. The use of SPECT imaging provided more information with regard to infarct localization by demonstrating uptake by the septum, a finding not apparent on the conventional planar images.

Technetium-99m pyrophosphate scintigraphy for the detection of acute myocardial infarction. How useful is it?

To evaluate the contribution of Tc-99m pyrophosphate scintigraphy (TPS) on the overall management of patients suspected of having acute myocardial infarction (AMI), hospital records of 58 consecutive patients who underwent TPS, were evaluated in depth. The results indicate that TPS was essential for the diagnosis of AMI in 16% of the patients. TPS was most rewarding in perioperative patients and in patients with borderline or uninterpretable electrocardiographic and enzyme changes. Also, in some cases, TPS was able to confirm or exclude the diagnosis of AMI prior to the confirmation by serial electrocardiograms (ECG) and serial enzyme changes. TPS was less rewarding in patients with clinically low index of suspicion for AMI. It may also be confusing in patients with high clinical likelihood of AMI and a history of prior myocardial infarction because of the possibility of persistently positive TPS in some of these patients. Considering the limitations of ECGs, the cardiac enzymes, and atypical clinical presentations in the patient population we evaluated, TPS appears to be fairly accurate when the scintigraphic findings are compared with the final diagnosis at the time of discharge from the hospital.

Enhancement of SPECT images by Fourier filtering the projection image set

Tomographic images from rotating gamma camera systems are often difficult to interpret because of poor contrast and high noise levels. A method is presented for improving the quality of these images by Fourier filtering the projection image set prior to reconstruction. A two-dimensional circularly symmetric Gaussian function is used as the spatial frequency filter. This filter can be optimized to enhance contrast and suppress noise in the projection image set in a straightforward and simple manner from the power spectra of representative projections. Preprocessing of the projections makes it possible to use a ramp reconstruction filter. The resulting tomographic sections show a dramatic improvement in image quality.

Neutrophil labeling: problems and pitfalls

The use of neutrophils labeled with gamma-emitting radionuclides has been shown to be acceptable for in vivo kinetic studies as well as for imaging inflammatory foci. Among the gamma-emitting radionuclides, indium-111 appears to be the agent of choice. Labeling neutrophils with 111In, however, is a relatively new technique. Although simple to perform, it involves several stages, none of which could be carried out without problems. These are discussed and the current research aimed at eliminating the problems is outlined. The knowledge of specific chemotactic receptors and surface antigens has stimulated investigations into selective neutrophil labeling that will continue to be challenging and exciting.