[Evaluation of enterogastric reflux in relation to functional status of the gallbladder]

The aim of the study was estimation of the relation between the gallbladder (GB) motility function and the presence and quantity of enterogastric reflux (EGR). We investigated 172 patients with: physiological GB function (filling and emptying)(FGB), impaired GB function (prolonged filling and ejection fraction < 45%) and afunctional gallbladder (AGB)(without visualization). The study was performed during 90 min (1 f/min) after i.v. application of 185 MB 99mTc-dietil IDA. After 30 min. test meal was given while at the end stomach was marked. According to the parameters from time activity curves over stomach and hepatobiliary system, the index of ERG was calculated, while GB filling and ejection fraction were estimated from the GB time/activity curve. We can conclude that EGR occurs more frequently in the patients with afunctional GB in comparison to those with functional and decreased motor function. Also, EGR quantity is in correlation with the impairment of the GB function.

Myocardial perfusion and left ventricular function in long-term follow-up and prognosis of electrostimulation cardiomyoplasty

BACKGROUND

Twenty two patients with congestive cardiac failure treated surgically by dynamic cardiomyoplasty (CMP) with m. latissimus dorsi were examined. Myocardial perfusion was assessed with (199)TlCl scintigraphy combined with dipyridamole stress-test. In order to obtain direct evidence of myocardial perfusion from muscular flap we also injected a bolus of (99m)Tc into a. thoracodorsalis, with simultaneous blood sampling from coronary sinus. Haemodynamic parameters were assessed using radionuclide angiography.

METHODS

In a year of follow-up all the patients were assigned to one of two groups: eleven patients demonstrated improvement in clinical status (first group) and in another group comprising eleven persons no positive effect or deterioration were obvious (second group). The patients of the first group before operation revealed two times less persistent defect size than patients of the second group. Analysis of integral index of persistent defect revealed more expressive differences between groups. Before the surgical treatment the patients with improvement in clinical status after cardiomyoplasty demonstrated greater size of reversible defect in comparison with patients of the second group. In the second group coronary fraction of thallium accumulation was 1.4 times higher in comparison to the first group, as the result of myocardial hypertrophy in patients with bad prognosis. There were no significant differences between the two groups in Il/m level before cardiomyoplasty. Before the surgical treatment the patients with improvement in clinical status after cardiomyoplasty demonstrated greater ejection fraction in comparison with patients of the second group.

RESULTS

Cardiomyoplasty led to a decrease in the mean size of reversible defects due to indirect revascularisation. This hypothesis was testified to by the fact that in patients after cardiomyoplasty nuclide appeared in coronary sinus at 10-12th seconds after injection into artery thoracodorsalis through anastomoses between the latissimus dorsi muscle and the myocardium. The time of appearance of the second wave of rise gamma-counting in blood samples from coronary sinus reflects the repeated entry of radiopharmaceutical in myocardium after recirculation.

Pulmonary granulocyte kinetics in relation to endothelial and granulocyte activation

The aim of the study was to measure the peripheral blood levels of soluble E-selectin in patients with systemic inflammation and compare them with in vivo granulocyte activation, pulmonary intravascular granulocyte pooling, pulmonary extravascular granulocyte migration and 99mTc-diethylenetriaminepenta-acetic acid (DTPA) aerosol clearance, an index of lung injury. The level of soluble E-selectin was measured by capture ELISA. Granulocytes were labelled with 111In and 99mTc for quantification of pulmonary granulocyte kinetics. The pulmonary vascular granulocyte pool (PGP) was expressed as a fraction of the total blood granulocyte pool. Pulmonary granulocyte migration was quantified on 24-h images using the 111In signal. Granulocyte activation was quantified as the percentage of circulating cells showing shape change ('primed'). Lung injury was assessed from the clearance rate of inhaled 99mTc-DTPA aerosol. Eighteen patients with systemic inflammation were studied: five with inflammatory bowel disease, eight with systemic vasculitis, four with graft versus host disease and one with a recent renal transplant. The peripheral blood levels of soluble E-selectin were significantly elevated in patients with systemic inflammation. The level of soluble E-selectin showed a significant association with granulocyte migration (Spearman rank correlation coefficient, Rs=0.53; P<0.05) but not with PGP or with the percentage of cells showing shape change (P>0.05 for both). Granulocyte migration was bimodal: patients were therefore subdivided into 'migrators' and 'non-migrators'. Soluble E-selectin level, 99mTc-DTPA clearance and PGP, but not the percentage of cells showing shape change, were significantly higher in migrators than in non-migrators. We conclude that pulmonary intravascular granulocyte pooling is increased in the presence of increased numbers of circulating primed granulocytes but increased pooling does not by itself promote granulocyte migration into the lung interstitium. Insofar as an elevated level of E-selectin in peripheral blood reflects vascular endothelial activation, the data are consistent with the notion that pulmonary endothelial activation is required, in addition to granulocyte activation and an expanded PGP, for granulocyte migration into lung parenchyma and, therefore, for lung injury to occur.

Evaluation of hemodynamic effects of extracranial carotid stenoses by adenosine-induced vasodilatation in combination with 99mTc-HMPAO SPECT

METHODS

Adenosine was evaluated in combination with 99mTc-HMPAO SPECT as an intravenous agent for the pharmacological stress-test of the regional cerebral blood flow (rCBF) in 12 patients with internal carotid artery (ICA) stenosis without neurologic deficit (8 subjects) or with minimal deficit (4 subjects). Also, the adenosine-induced effects on rCBF were correlated with the anatomic severity of ICA stenosis. Six normal age-matched volunteers served as control.

RESULTS

The rest 99mTc-HMPAO SPECT data did not reveal any significant interhemispheric asymmetry of perfusion either in ICA stenosis patients or in control subjects. No interhemispheric asymmetry was observed in control subjects during adenosine infusion either. In ICA stenosis the adenosine test did induce interhemispheric asymmetry of perfusion, which ranged between 0.73 and 0.96 when quantified as an interhemispheric ratio of 99mTc-HMPAO uptake. In 5 of the 12 patients with ICA stenosis, adenosine also elicited a short-term muscular weakness and/or skin paresthesia consistent with cerebral location of the related cortical zones in the stenosis-dependent hemisphere. No correlation was noted between the interhemispheric anatomic planimetric asymmetry of stenosis (as ratio of patent ICA vessel lumen areas) and perfusion asymmetry at rest. The planimetric asymmetry of stenosis correlated significantly with the adenosine-induced asymmetry of rCBF in ICA-dependent areas (r = 0.78, p < 0.02). The correlation could be observed beginning from the magnitude of 70-75% relatively to the cross-sectional area of the contralateral intact vessel, equivalent to 45-50% decrease in the arterial diameter as compared to the intact artery.

CONCLUSION

Therefore, the conclusion can be drawn that adenosine as a potent cerebral vasodilatator may be employed as a challenging agent for functional tests of rCBF and that the adenosine test facilitates detection of the hemodynamic effects of "minor" stenoses.

Quantification of breast cancer blood flow in absolute units using Gjedde-Rutland-Patlak analysis of 99mTc-MIBI uptake

BACKGROUND

Scintimammography with 99mTc-MIBI has been proven as efficient technique of diagnosis of breast cancer. Nevertheless, quantification of breast carcinoma blood flow (BCBF) in absolute units is not yet developed. To compensate this, we analysed kinetics of 99mTc-MIBI uptake in breast cancer using Gjedde-Rutland-Patlak (GRP) approach.

METHODS

If BC is radioactivity in breast cancer quantified by dynamic scintigraphy, C(h)-blood concentration of 99mTc-MIBI and K-transport constant, then, assuming 99mTc-MIBI uptake to breast carcinoma unidirectional for early minutes after injection and subjected to equation d(BC)/dt = K; C(h), classic GRP plot can be obtained from this by integration as BC/C(h)=K x (integral of C(h)(dt))/C(h) + V0 and placing [(integral of C(h)(dt))/C(h)] as X, and (A/Ch) as Y. The K can be then obtained as slope. K is breast cancer clearance equal to product (retention fraction); (blood flow) : K = E; BCBF. K can be calculated from A(t) and Ch(t) as asymptote of 99mTc-MIBI retention function h(t) = F-1[F[A(t)]/F[Ch(t)]], where F depicts Fourier transforms. The BCBF can be then obtained as ratio K/E. We employed the technique in 33 patients with breast carcinoma of stages T(1-3)N(0-3)M(0-1) injecting 99mTc-MIBI (370-510 MBq) as i.v. bolus. In 12 scintigraphy with 99mTc-MAA (370 MBq) injected via catheter intraaortically was performed as validation study.

RESULTS

E values were essentially uniform over the population with overall mean 0.58 sd 0.06. Blood clearance curves did not differ between various stages also and were subjected to biexponential approximation. K was in all cases obtained from the slope of initial 3 min part of GRP plot, strongly linear (r > 0.95, p < 0.001) in all cases. 99mTc-MAA validation study revealed significant correlation with 99mTc-MIBI blood flow values (r = 0.94, p < 0.01). The BCBF(as ml/min/100 cm3) was in T1 12.85 sd. 4.76, in T2 15.87 sd. 1.78, in T3 17.35 sd. 2.45, and in T4 23.07 sd. 2.21, expressing tendency to increase with stage. Higher BCBF was significantly associated with metastatic spread and in patients with BCBF over 17 ml/min/100 cm3 distant mets were revealed in all cases.

CONCLUSION

Hence, analysis of early kinetics of 99mTc-MIBI in breast carcinoma provides correct estimates of blood flow in the neoplasm and can be applied in clinical studies and for calculation of cytostatic delivery to BC.

Bimodal granulocyte transit time through the human lung demonstrated by deconvolution analysis

The lungs are an important site of granulocyte pooling. The aim of the study is to quantify pulmonary vascular granulocyte transit time using deconvolution analysis, as has previously been performed to measure pulmonary red cell transit time. Granulocyte and red cell studies were performed in separate groups of patients. Both cell types were labelled with Tc-99m, which for granulocyte labelling was complexed with hexamethylpropyleneamine oxime (HMPAO). The red cell impulse response function (IRF) was monoexponential with a median transit time of 4.3 s. The granulocyte IRF was biexponential in 19 of 22 subjects, 18 of whom had systemic inflammation (inflammatory bowel disease, systemic vasculitis or graft-vs-host disease) and four were controls without inflammatory disease. The median transit time of the fast component ranged from 20 to 25 s and of the slow component 120-138 s in the four patient groups. The fraction of cells undergoing slow transit correlated significantly with (a) mean granulocyte transit time and (b) the fraction showing shape change in vitro. We conclude that granulocyte transit time through the pulmonary circulation is bimodal and that shape-changed (activated) cells transit more slowly that non-activated cells. The size of the fraction undergoing slow transit is closely related to mean granulocyte transit time and is an important determinant of the size of the pulmonary vascular granulocyte pool.

Relationship between granulocyte activation, pulmonary granulocyte kinetics and alveolar permeability in extrapulmonary inflammatory disease

1. The aim of the study was to examine the relationship between granulocyte activation, pulmonary intravascular granulocyte transit, pulmonary extravascular granulocyte migration and lung injury in patients with systemic conditions (bone marrow transplant recipients, inflammatory bowel disease and systemic vasculitis) in which abnormalities of pulmonary granulocyte traffic have previously been reported. 2. A double 111In-99mTc granulocyte labelling technique was used for quantification of granulocyte kinetics in 23 patients, of whom five were control patients. The pulmonary vascular granulocyte pool was measured from dynamic data centred on the 99mTc signal and expressed as a percentage of the total blood granulocyte pool. Granulocyte migration was quantified on 24 h images using the 111In signal. Granulocyte activation was measured as the percentage of cells showing a change in shape. The clearance rate of an inhaled aerosol of 99mTc-diethylenetriaminepenta-acetic acid (DTPA) was used as a marker of lung injury. 3. Pulmonary granulocyte pool, migration, activation and aerosol clearance, although highly variable in the patient groups, were, in general, elevated compared with the controls. 4. Granulocyte activation correlated with pulmonary granulocyte pool (Rs = 0.72, n = 22, P < 0.01), while the t1/2 of DTPA clearance correlated with migration (Rs = -0.84, n = 17, P < 0.01). Fifteen patients had an expanded pulmonary granulocyte pool, of whom six with no evidence of migration, had a normal DTPA clearance, while nine, who had an abnormal migration signal, had an accelerated DTPA clearance. The pulmonary granulocyte pool in these nine was significantly higher than in the six without a migration signal. 5. Activation of granulocytes results in delayed transit through the lung vasculature. With increasing margination, granulocytes migrate into the lung interstitium and injure the lung. An increased intravascular pool does not by itself lead to lung injury.

Measurement of the pulmonary vascular granulocyte pool

We have developed a technique for measuring the pulmonary granulocyte pool (PGP) as a fraction of the whole body total blood granulocyte pool (TBGP). The technique "captures" a dose of 99mTc-labeled granulocytes in a region of interest (ROI) over the lung during first pass by integrating an input time-activity curve from an ROI over the pulmonary artery, superior vena cava, or right ventricle. The ratio of the estimated first-pass count rate and the count rate in the same lung ROI after equilibration of the cells between the circulating and pulmonary pools (15-30 min) represents the PGP/TBGP. The technique was validated in eight subjects by using 99mTc-labeled macroaggregated human serum albumin. With corrections for background and injected doses, the ratios of first-pass granulocyte-to-macroaggregated human serum albumin count rates given by the three input ROIs were close to unity [superior vena cava 0.98 +/- 0.079 (SD), right ventricle 1.01 +/- 0.070, and pulmonary artery 0.97 +/- 0.073]. Significant increases in PGP/TBGP were demonstrated in systemic inflammation. Thus, in patients with inflammatory bowel disease, it was 0.22 +/- 0.07 (n = 7) compared with 0.08 +/- 0.01 (n = 5) in control subjects. It was also elevated in patients with systemic vasculitis (0.34 +/- 0.07; n = 5), in transplant recipients (0.33 +/- 0.08; n = 5), and in patients with osteomyelitis (0.15 +/- 0.06; n = 4). We conclude that this is a valid technique for quantifying the PGP that is expanded in several conditions associated with systemic inflammation.

Technetium-99m and indium-111 double labelling of granulocytes for kinetic and clinical studies

A new technique of labelling granulocytes with both technetium-99m hexamethylpropylene amine oxime (HMPAO) and indium-111 in a single protocol was developed in order to exploit the advantages of each radiolabel in clinical and investigative studies. Fourteen patients were included in this prospective study. Granulocytes were labelled with both 111In-tropolonate and 99mTc-HMPAO. In vitro shape change assay and in vivo distribution and recovery studies were performed to assess the activation of and damage to these cells due to the labelling procedure. The comparative kinetics of 111In and 99mTc in the blood, liver, spleen, and bone marrow were studied by blood sampling and dual radionuclide imaging early (1 h) and late (24 h) after injection. The functional integrity of the double-labelled granulocytes and the feasibility of the technique were investigated in 14 patients with a painful prosthetic hip due to causes other than infection. The efficiency of double labelling was 63% (SD 14%) for 111In and 39% (SD 12%) for 99mTc-HMPAO. In vitro granulocyte activation and ex vivo recovery values were comparable to those from single radionuclide labelling. No artefactual granulocyte sequestration was seen in the lungs or liver. The radioactivity was distributed between the liver, spleen and bone marrow and, to a lesser extent, the lung. Early 99mTc counts in the liver, spleen and bone marrow, in relation to background, were significantly higher than 111In counts while the reverse was seen in late images.(ABSTRACT TRUNCATED AT 250 WORDS)

Granulocyte margination in bone marrow: comparison with margination in the spleen and liver

The kinetics of radiolabelled granulocytes in the reticuloendothelial system were studied in order to evaluate granulocyte margination in bone marrow. A total of 34 patients took part in a two-part study. In the first part, bone marrow uptake of indium-111-labelled granulocytes was retrospectively analysed in early (3-h) and late (24-h) images in 26 patients, 13 with bronchiectasis and 13 with enclosed abdominal abscesses. The ratios between early and late counts from the bone marrow, spleen, liver and inflammatory lesion were used to quantify granulocyte margination in bone marrow, postulating that if the lesion to bone marrow ratio at 24 h exceeds the value at 3 h, then the "excess" bone marrow counts on the early images would represent margination. In the second part, this suggestion was prospectively tested using Rutland-Patlak graphical and deconvolution analysis of dynamic data, acquired in 8 patients undergoing routine scanning with technetium-99m HMPAO-labelled granulocytes. In the first part of the study, it appeared that the bone marrow is a regional site of granulocyte margination, like the spleen, with at least one-half of the 3-h marrow signal arising from marginated granulocytes, compared with about two-thirds from the spleen. In the second part, it was found that the gradient of the Patlak plot, based on spleen and marrow, continuously decreased, consistent with bi-directional movement of cells between these organs and the blood. Granulocyte pooling in the marrow was confirmed with deconvolution analysis, which generated biphasic retention functions for marrow and spleen. These curves were also consistent with two-way granulocyte exchange, and gave mean cell transit times in both organs of about 12 min and probabilities of extraction on each pass of 5-10%. We conclude that granulocytes marginate in bone marrow to an extent similar to that in the spleen.

Application of technetium-99m hexamethylpropylene amine oxime single-photon emission tomography to neurologic prognosis in patients undergoing urgent carotid surgery

In this study we aimed to work out a quantitative prognostic index for preoperative assessment of brain technetium-99m hexamethylpropylene amine oxime (HMPAO) single-photon emission tomography (SPET) in patients referred for urgent carotid endarterectomy due to acute obstructive disease of the internal carotid artery (ICA) and neurological deficit. To this end we compared data from preoperative SPET studies with the postinterventional changes in neurological status in 20 patients (17 males, three females; mean age 53 years, SD 4 years) with acute ischaemic cerebral disorders induced by obstruction of the ICA. Carotid obstruction was diagnosed by ultrasound B-mode study. All patients underwent urgent carotid endarterectomy from the ICA. Patients were divided into two groups in accordance with the results of postoperative follow-up: group A comprised patients with significant (more than 3 points) postoperative improvement in neurological condition as quantified by the Canadian Neurological Scale (11 patients); group B consisted of patients with minimal improvement or deterioration (nine, three of whom died). All patients were studied preoperatively by 99mTc-HMPAO SPET. The volume of nonperfused tissue (VS, cm3) was quantified using the Mountz technique. Hypoperfused volume (Vhypoperf, cm3) in the affected hemisphere was calculated as the total volume of voxels with 99mTc-HMPAO uptake < 90% of the contralateral symmetric voxels. Discriminant prognostic function was calculated by discriminant analysis as: PF = 0.072 x VS + 29.46x(VS/Vhypoperf). Patients with preoperative PF values < 8.20 demonstrated postoperative improvement in neurological status, while the group with PF > 8.90 comprised patients who demonstrated minimal improvement or deterioration. PF values in the range 8.20-8.90 carried an indefinite prognosis. We conclude that the preoperative 99mTc-HMPAO SPET can be used for the selection of patients in whom improvement in neurological status may be expected after urgent surgical correction of acute extracranial obstruction of the ICA.

Quantification of pulmonary uptake of indium-111 labelled granulocytes in inflammatory bowel disease

This study describes a method for quantifying the pulmonary trapping of indium-111 labelled polymorphonuclear (PMN) cells in patients with inflammatory bowel disease (IBD) in comparison to non-inflamed controls. Twenty patients with extensive IBD were studied by 111In-PMN scintigraphy. Gamma-camera images were obtained at 2.5-4 h (early) and 20-25 h (late) after the injection of autologous PMNs labelled in plasma with 111In-tropolonate. Local uptake in the chest, iliac bone marrow, spleen and liver was quantified as the counts per pixel per second per MBq of injected 111In for both early and late scans. Fourteen subjects without inflammatory disease were studied as controls. IBD patients showed significantly greater loss of splenic activity between early and late scans compared with controls (mean +/- SD: -35.7% +/- 16.6% versus -4.5% +/- 6.1%, P < 0.001). There was no significant difference between control and IBD groups with respect to liver and bone marrow uptake on both early and late scans. Chest uptake was significantly higher in patients with IBD on both early (6.4 +/- 1.6 cps/MBq/pix) and late (5.6 +/- 1.5 cps/MBq/pix) scans, compared with the controls (4.8 +/- 1.3 cps/MBq/pix, P < 0.005 and 3.4 +/- 1.0 cps/MBq/pix, P < 0.001 respectively). The chest uptake in the control group on the late scans demonstrated a significant linear correlation with iliac uptake (y = 0.23x + 0.41, r = 0.87, n = 14). Assuming in controls that there is no parenchymal uptake of 111In, this regression enables an estimate to be made, based on iliac counts, of the count rate from bone marrow in the chest wall.(ABSTRACT TRUNCATED AT 250 WORDS)