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Year : 2010  |  Volume : 25  |  Issue : 3  |  Page : 111-116 Table of Contents   


Date of Web Publication25-Nov-2010

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How to cite this article:
. Miscellaneous. Indian J Nucl Med 2010;25:111-6

How to cite this URL:
. Miscellaneous. Indian J Nucl Med [serial online] 2010 [cited 2022 Jan 27];25:111-6. Available from:


Diuretic renography using 99mTc-EC before and after treatment of renal stone disease

Parghane Rahul, Kamaleshwaran KK, Chakraborty D, Mittal BR, Bhattacharya A, Singh B

Postgraduate Institute of Medical Education and Research, Department of Nuclear medicine, Chandigarh, India

Introduction: Renal stone disease (RSD) is one of the most common disorders of the urinary tract. Surgical techniques like percutaneous nephrolithotomy have also been developed to remove kidney stones when other treatment methods are not effective. Improvement in the function of these kidneys after surgery is usually followed by using diuretic renography with 99mTc-ethylene dicysteine (EC) which is proved to be a reliable non invasive test for diagnosis of upper urinary tract obstruction. Objectives: To evaluate the use of diuretic renography using 99mTc -EC in determining the function of kidneys with RSD before and after surgery. Materials and Methods: Retrospective analysis of medical records of renal scintigraphy with 99mTc-EC performed during the past 4 years was done. Out of 3780 cases, 550 (15%) patients were found to have RSD. 50 cases were undergone 99mTc EC diuretic renography. There were 34(72%) males and 16(28%) females with age between 7 to 66 years.11 patients had right side,16 had left side and remaining had bilateral RSD were referred to evaluate relative function and drainage of kidneys. Scintigraphy was done as per predefined protocol using 99mTc -EC with measurement of Tmax , relative function (RF). Results: Hydronephrosis was observed in 48 cases. Analysis of T½ revealed obstruction in 16(28%) patients and equivocaldrainage in 25(50%) patients and unobstructed drainage in remaining 9(22%).16 patients with obstructed drainage underwent surgery to improve drainage which on subsequent follow up scans showed improvement in drainage and function in 6 patients, remaining 10 after surgery didn't show any improvement. 25 patients with equivocal drainage, follow up renogram which revealed improvement in drainage in 3 patients, worsening in 4 patient and remained the same in 18 patients. 9 patients showing unobstructed drainage didn't underwent surgical intervention which on follow up showed same status of function and drainage which helped in conservative management of these patients. Conclusion: Our study suggests that 99mTc EC diuretic renal scintigraphy plays an important role in evaluation of renal functionand drainage in patients with RSD. This may be helpful in follow up to monitor the improvement in function after intervention.

Keywords: Tc99m EC, renogram, renal calculus disease


Developing and setting up of a nuclear medicine information management system

Baghel NS, Asopa R, Rajashekharrao B 1 , Nayak UN, Rajan MGR, Karunanidhi YR 2 , Subbalakshmi PV, Shailaja A

Radiation Medicine Centre, BARC, Tata Memorial Centre Annexe, Parel, Mumbai - 400 012, 1 Radiation Safety Systems Division (BARC), 2 Electronics Corporation of India Limited, Hyderabad, India

With the advent and progress of information technology in the present decade, high-performance networks are being installed in hospitals to implement an effective and reliable Hospital Information Management Systems (HIMS). The Radiation Medicine Centre (RMC), is one of the earliest and largest nuclear medicine centres in India and several thousand patients undergo diagnostic as well as therapeutic procedures with different radiopharmaceuticals. The evolution towards a fully digital department of nuclear medicine is driven by expectations of not only improved patient management but also a well-defined workflow along with prompt and quality patient services. The aim was to develop and set up a practical and utility based Nuclear Medicine Information Management System (NMIMS) for various functional procedures at RMC. A customised NMIMS is developed with M/s ECIL using ASP.NET and SQL server technology facilitated by an IBM x3650 M3 Server, 18 thin-clients/desktop PCs and windows 2008 server operating system & MS-SQL 2005 server software. The various modules have been developed to meet the requirements of different activities pertaining to patient appointment and scheduling, clinical assessment, radiopharmacy procedures, imaging and non-imaging studies and protocols, in-vitro laboratory tests, in-patient and out-patient treatment procedures, radiation protection and regulatory aspects and other routine operational procedures associated with patient management at RMC. The menus are developed as per scheduled workflow (SWF) in the department. The various aspects of SWF have been designed to ensure smooth, easy and trouble free patient management. Presently, the NMIMS has been developed excluding imaging data and we are in the process of setting up Picture Archiving Communication System (PACS) integrated to the existing database system, which will archive and facilitate imaging data in DICOM format in order to make a paperless department. The developed NMIMS is a browser-based online database system, which is independent of operating systems and enables prompt and reliable patient data access, information and management.

Keywords: Nuclear medicine, Hospital Information Management System (HIMS), Picture Archiving Communication System (PACS), DICOM


Tramline sign in bone scan in Ca lung patient: A case report

Prasad DC

Head Nuclear Medicine, BSR Cancer Hospital and Research Hospital, Bhilai, India

History A male patient of age 44yrs having H/O Bidi smoking. Complains weakness and loss of appetite since 3-4 months, cough since 2-3 months. He feels dyspnoea on exertion for 1 week. Whole Body Bone Scan Patient was referred for radionuclide bone scan. Skeletal scintigraphy was performed with 20 mCi 99mTc -Methylene Diphosponate. Whole body static imaging was done in anterior and posterior projections 3hrs after dose administration. Scan reveals Hypertrophic pulmonary osteoarthropathy. Characteristic pericortical uptake. The cortical "strips" of activity ("tramline sign") are evident as an irregular pattern in the long bones of the lower limbs, but are virtually absenting those of the upper limbs. Discussion Non-metastatic manifestations in Ca lung In patients with cancer of the lung, a frequent incidental observation will be the changes associated with hypertrophic pulmonary osteoarthropathy. In 48 cases reviewed by Ali et al 1 the extremities were invariably involved, although with asymmetry in 17% with the exception of the humerus, the proximal and distal portions of each long bone were involved with equal frequency. Involvement is also seen in the skull, scapulae, patellae &clavicles. The characteristics alteration in the long bones is intense pericortical uptake, the "tremline sign" as shown in figure. Changes in the hands may be obvious in the absence of clinical evidence of clubbing. After treatment of the associated disease, there is usually rapid regression of the scintigraphic changes. Normalization of the scan abnormalities has been reported with in 1 month of successful therapy.

Keywords: Tramline sign, hypertrophic pulmonary osteoarthropathy, pericortical uptake


Role of lung perfusion scintigraphy in predicting post-operative lung function in lung cancer patients undergoing pneumonectomy

Rai Sujith, Shah S, Purandare NC, Pramesh CS, George K, Rangarajan V

Department of RadioDiagnosis, Tata Memorial Hospital, Parel,

Mumbai - 400012, India

Introduction: Surgery has been the mainstay of treatment for patients with early stage non-small cell lung cancer. There is an increased risk of postoperative complications, especially in patients with poor respiratory reserve, with pneumonectomy resulting in an unacceptable quality of life. The high risk of morbidity and mortality makes it mandatory to triage patients with anatomically resectable disease as suitable candidates for surgery. Aim: 1. The purpose of the study is to evaluate the role of lung perfusion scan in predicting postoperative lung function in lung cancer patients undergoing pneumonectomy based on the pre-operative Forced Expiratory Volume in 1 sec (FEV1). 2. The predicted post-operative FEV1 will be compared with the patient's lung function clinically based on a) number of days patient was on ventilation post-operatively, b) post-op respiratory complications/lung collapse. Materials and Methods: Imaging was done on Infinia Hawkeye (GE) dual headed gamma camera on 30 patients of lung cancer undergoing Pneumonectomy. Patients were injected 5 mCi of Tc99m-MAA and planar and tomographic images were obtained. A predicted postoperative value of FEV1 was calculated by the formula: postop predicted FEV1 = preop FEV1 - (FEV1 *% contribution by affected lung/100). Patient's post-operative FEV1 was calculated for pneumonectomy. Patient was observed post-operatively and the following parameters were noted 1) Number of days patient was on ventilation post-operatively 2) Post- operative respiratory complications/lung collapse Pre-operative PFT's and Tc99m-MAA lung perfusion scan was done on 30 patients (mean age 45yrs, range 18-64 yrs) and lung function in 1 st week post-pneumonectomy based on their number of days on ventilation post-operatively and respiratory complications/lung collapse was noted. Result: 1) 20 patients underwent left pneumonectomy, 10 patients underwent right Pneumonectomy. 2) Predicted FEV1 for pneumonectomy patients was (mean ± SD 1.49 ± 0.45 with a Range 0.8-2.45). 3) 2 Patients required post-operative ventilatory support and 1 patient developed respiratory complications/lung collapse. The predicted post-operative FEV1 in these 3 patients was in the range of 1 -1.4. None of the patients had COPD or other co-existing respiratory problems. 4) Rest of the 27 patients with no post-operative events had a mean predicted post-operative FEV1 of 1.51 L. Conclusion: Patients with predicted FEV1 above 1.5 litres did not have any post-pneumonectomy complications. Patients with a low or borderline predicted post operative FEV1 (1.0 to 1.4 L) showed a post operative respiratory morbidity. Thus the predicted Post-operative FEV1 based on Lung Perfusion Scintigraphy is clinically significant and should be used for pre-operative screening of patients undergoing Pneumonectomy.

Keywords: Lung Perfusion Scan, prediction of post-operative lung function, FEV


Initial experience of nuclear medicine in the Indian state of Uttrakhand: Optimisation of resources

Dhingra Vandana K, Saini S, Shiva Prasad G

Department of Nuclear Medicine, Cancer Research Institute, Himalayan Institute Hospital Trust, Dehradun, Uttrakhand, India Department of Surgical Oncology, Cancer Research Institute, Himalayan Institute Hospital Trust, Dehradun, Uttrakhand, India

Introduction: State of Uttrakhand located in Northern India is small with a population of about 8.4 million, and comprises of 93% hilly area. Ours is the one of the few tertiary care hospitals and medical college in the state of Uttrakhand. Ours is the first department of nuclear medicine in such a setting in the state and was commissioned in September 2009. Aim: To study pattern of patients referred for nuclear medicine procedures, demographics of referred patients, difficulties of centre at an isolated hilly state. We also studied related practical issues to optimally utilize available resources. Materials and Methods: All consecutive referrals for nuclear studies between September 2009 and March 2010 were included in the study. Results: A total of 453 patients underwent diagnostic nuclear scans.27 patients underwent low dose radioiodine therapy for thyrotoxicosis. Commonest performed procedures included renogram with Tc-99m DTPA scan, Tc-99m pertechnetate thyroid scan and Tc-99m MDP Bone scan to rule out skeletal metastasis. These findings are consistent with literature as these three scans form the commonest referrals worldwide. Conclusion: In our initial experience as a first of its kind nuclear medicine department in a tertiary care hospital and medical college in a hilly state most patients [98%] from within the State utilized services of nuclear medicine. Radioiodine therapy for thyrotoxicosis is very convenient and we observed100%compliance for patients within the state for patients coming to foothills for treatment. Nuclear medicine procedures provided added diagnostic and therapeutic advantage to patient care which was not previously available. With a well equipped laboratory as per guidelines of the country /region, radiation safety protocols in place, minimal but well trained staff, alternate week radioactivity from column generator, fractionation of common cold kits and same day scanning are additional ways to optimize services for patient convenience, care and cost effectiveness in a newly developed nuclear medicine laboratory in a periphery setup.

Keywords: Initial experience, Nuclear Medicine laboratory, Uttrakhand, India


To evaluate the clinical efficacy of a 99mTc-Scintibact for the diagnosis of orthopedic infections: First results

Kaur Parvinder 1 , Singh B, Babbar AK 1 , Sharma AK 1 , Sarika, Kaul Ankur 1 , Mittal Bhagwant R, Mishra AK 1

Department of Nuclear Medicine and PET, PGIMER, Chandigarh, 1 Radiopharmacy and Cyclotron Center, INMAS, DRDO, Delhi, India

Objectives: A novel approach to infection imaging is the use of radio labeled antibiotics. With the advent of time, the micro-organisms develop resistance to the extensively used antibiotics and there is a need to radiolabel newer generation antibiotics to increase the sensitivity and specificity of this imaging modality. In this study, we evaluated the clinical utility of 99mTc labeled ceftriaxone for the detection of orthopedic infections. Materials and Methods: Ceftriaxone- a third-generation cephalosporin antibiotic was successfully labeled with Tc-99m with radiolabeling efficiency (≤99%) and formulated into a ready to use single vial kit preparation (Brand Name: Scintibact). Fourteen patients (10M; 4F, mean age 37.7 yrs, range 22-65 yrs) with clinical and radiological suspicion of orthopedic infection were recruited. All the patients underwent a 3-phase bone scan (740 MBq, 99mTc-MDP, i.v. injection) followed by (4 days later) 99mTc- ceftriaxone scanning (static/isotime images at 1h, 4h, 24h after i.v. administration of 555.0MBq activity of the radiotracer). Whole body scintibact scanning was also done to study the biodistribution of the radiotracer. The sample aspirates from site involved were taken and analyzed for the microbial growth. Results: Scintibact scan findings were positive in 11/14 and culture positive in 11/14 patients. The diagnostic accuracy of the technique was found to be 71.0%, sensitivity and specificity were 80% and 75% respectively. The bio-distribution studies indicated that 2/3 rd and 1/3 rd of the radiotracer excretes through the renal and hepato-biliary routes which corroborated with our animal experimentation performed using this preparation. Conclusions: Single vial kit preparation of Scintibact has reasonably good accuracy in the diagnosis of orthopedic infections. The use of this formulation needs to be validated in a large cohort of patients also in few treated and symptomatic cases of bone infection.

Keywords: Scintibact TM infection imaging, orthopedic infection, ceftriaxone


14 C glucose uptake and turnover, a biomarker in benzo(a)pyrene induced lung carcinogenesis: Role of curcumin and resveratrol

Malhotra Anshoo, Nair P, Dhawan DK

Department of Biophysics, Panjab University, Chandigarh, India

The aim of the present study was to explore the synergistic potential of curcumin and resveratrol in modulation of glucose metabolism by studying 14 C glucose uptake, turnover in the lung slices and ultra-histoarchitectural changes during benzo(a)pyrene (BP)induced lung carcinogenesis in mice. The mice were segregated into five treatment groups which included group I (normal control), group II (BP treated), group III (BP+curcumin treated), group IV (BP+resveratrol treated) and group V (BP+curcumin+resveratrol treated). Animals in Group II were given a single intraperitoneal injection of Benzo(a)pyrene in corn oil at a dose level of 100mg/Kg body weight. Group III animals were given curcumin orally in drinking water at a dose level of 60 mg /Kg/ body weight, thrice a week. Animals in Group IV were given resveratrol orally at a dose level of 5.7 microgram/ml drinking water, thrice a week. Animals in group V were given a combined treatment of curcumin and resveratrol in a similar manner as was given to group III and group IV animals, respectively. All the animals had free access to the diet and water and the treatments continued for a total duration of 22 weeks. The morphological and ultra-histoachitecural analyses confirmed lung carcinogenesis, in the BP treated mice. Tumor incidence and tumor multiplicity were observed to be 88% and 1.75 respectively in the BP treated mice. A statistically significant increase in the uptake of !4 C glucose was observed in the lung slices of BP treated mice. Further, radiorespirometric analyses of 14 C turnover also showed a significant increase in the lung slices of BP treated mice. The ultra-histoarchitecture of the BP treated mice revealed disruption in cellular integrity along with nuclear deformation. Mitochondria were swollen and cytoplasm appeared granular along with extensive vacuolization. Further, spaces between the endothelium, epithelium and basement membrane indicative of lung injury and edema were observed in the BP treated mice. Supplementation with curcumin alone to BP treated mice resulted in a significant decrease in the tumor incidence as well as tumor multicity which were observed to be 77% and 1.42 respectively. Also, resveratrol significantly decreased tumor incidence and tumor multiplicity to 75% and 1.33 respectively. However, upon combined supplementation with phytochemicals, an appreciable decrease in the tumor incidence and multiplicity was observed which was found to be 66% and 1.16 respectively. Further, Supplementation with curcumin alone to BP treated mice resulted in statistically significant moderation in 14 C glucose uptake. Interestingly, individual treatment with resveratrol as well as combined treatment of both phytochemicals brought statistically significant moderation in 14 C glucose uptake as well as 14 C glucose turnover in the BP treated mice. Also, phytochemicals supplementation individually as well as in combination appreciably improved ultra histoarchitecture of lungs. The present study concludes that combined supplementation with curcumin and resveratrol modulates glucose metabolism and improves ultra-histoarchitectural changes during lung carcinogenesis and 14 C uptake and turnover can be used as biomarker for the assessment of carcinogenesis.

Keywords: Uptake, curcumin, resveratrol


3 H thymidine an indicator of benzo(a)pyrene induced lung carcinogenesis: Role of quercetin and curcumin

Nair Parveen, Malhotra A, Dhawan DK

Department of Biophysics, Panjab University, Chandigarh, India

Lung cancer is responsible for most of the cancer related deaths and calls for new approaches to control the menace. In the present study chemopreventive efficacy of curcumin and quercetin was investigated against benzo(a)pyrene (BP) induced lung carcinogenesis. The mice were segregated into five groups which included normal control, BP treated, BP+curcumin treated, BP+quercetin treated and BP+curcumin+quercetin treated groups. The morphological and histological analyses of tumor nodules confirmed lung carcinogenesis, after 22 weeks of single i.p injection of BP at a dose of 100mg/Kg body weight to mice. Tumor incidence and tumor multiplicity were observed to be 88% and 1.75, respectively in the BP treated mice. A statistically significant increase in the uptake of 3 H thymidne indicative of increased DNA synthesis which in turn is the marker of uncontrolled cancer cell proliferation, was observed in the in the lung slices of BP treated mice. Further, BP treatment resulted in marked disruption in the histoarchitecture of lungs. Nuclei were enlarged, thickening of epithelium was seen. Structure-less masses of cells were visible all over. Nuclear pleomorphism and decreased cytoplasmic contents were also observed in BP treated mice. Squamous epithelial metaplasia, severe epithelial thickening and alveolar vocuolizations in distal airways indicative of lung carcinogensis were also observed in the BP treated mice. Supplementation with curcumin alone resulted in a significant decrease in the tumor incidence as well as tumor multicity which were observed to be 77% and 1.42 respectively. Also, quercetin significantly decreased tumor incidence and tumor multiplicity to 70% and 1.28 respectively. However, upon combined supplementation with phytochemicals, an appreciable decrease in the tumor incidence and multiplicity was observed which was found to be 60% and 1.00 respectively. Further, Supplementation with curcumin alone to BP treated mice resulted in statistically significant moderation in 3 H thymidine uptake. Interestingly, moderation in 3 H thymidine uptake was more pronounced upon combined supplementation with curcumin and quercetin in the BP treated mice. Also, phytochemicals supplementation individually as well as in combination appreciably improved histoarchitecture of lungs. The present study concludes, combined supplementation with curcumin and quercetin control cancer cell proliferation by moderating DNA synthesis and improves ultra-histoarchitectural changes during lung carcinogenesis.

Keywords: Thymidine, curcumin, carcinogenesis


New horizons of I-123 MIBG scintigraphy and barriers to it's clinical use

Rathore B, Paknikar S, Novotny J, Holdeman K, Zahiri H, Hankins J

University of Nebraska Medical Center (UNMC), Creighton University Medical Center (CUMC), USA

Introduction: The unequivocal role of MIBG scintigraphy in the evaluation of Neuroblastoma and Pheochromocytoma is well documented and is practiced widely in clinical medicine. But there are many more clinical uses of I-123 MIBG which have been researched extensively however they have not been put into clinical practice. I-123 MIBG scintigraphy has a demonstrated role in many cardiac, neurodegenerative and lung conditions. Sympathetic neuronal imaging has clinical relevance since it becomes impaired in various cardiac and neurodegenerative diseases and forms the basis of pathophysiology of those diseases.

Purpose of the Study: 1) Critical review of medical literature and summarizing newer uses of MIBG scintigraphy. 2) Interviewing specialists in different fields of medicine to analyze the barriers to using MIBG Scintigraphy for these newer indications. 3) Measuring the Heart to Mediastinal Ratio (HMR) in a small group of adult patients who had undergone MIBG scintigraphy for conventional indications and correlating their cardiac sympathetic dysfunction to the HMR. Materials and Methods: Retrospective review of medical records and both planar and SPECT MIBG images in a group of 26 adult patients. These patients had undergone I-123 MIBG scintigraphy for reasons other than cardiac diseases, usually suspected pheochromocytoma or paraganglioma. Regions of interest were drawn over the heart and mediastinum using the 24 hour post injection anterior planar images. Counts per pixel in the heart were divided by counts per pixel in the mediastinum and a Heart to Mediastinal Ratio (HMR) was calculated and correlated to extent of cardiac sympathetic dysfuction. Medical literature review revealed an enormous amount of statistically proven data for the use of I-123 MIBG scintigraphy in the assessment of sympathetic neuronal system dysfunction in various cardiac, neurodegenerative and lung conditions. However, it is still not being used in clinical practice. Therefore we chose to interview two cardiologists, two neurologists and two pulmonologists to identify various barriers in the use of I-123 MIBG scintigraphy in clinical practice. Results: a) 14/26 patients had HMR < 1.6 and had significant cardiac disease eg. CHF, coronary artery disease (CAD), cardiomyopathy and/or arrhythmias. b) 3/26 patients had HMR ≥ 1.6 and had no cardiac disease. c) 3/26 patients had HMR ≥ 1.6 and had significant cardiac history. d) 6/26 patients had HMR < 1.6 and had no cardiac history. The results were concluded to be statistically insignificant but they demonstrated the same trend as other studies. A majority of subjects (14/26) with HMR < 1.6 had significant cardiac sympathetic dysfunction. One of the main reasons for the results being statistically insignificant was a very small sample size. Another reason for results being statistically insignificant could be, that we calculated HMR at 24 hours while other studies calculated HMR at 15 minutes and 4 hours post injection. Moreover our study was retrospective, ordered for the indication of either suspected pheochromocytoma or neuroblastoma and not for the specific indication of the assessment of cardiac sympathetic dysfunction. We analyzed the data in retrospect for the assessment of cardiac sympathetic dysfunction based on HMR. Secondly, interviewing two specialists each, in the fields of Cardiology, Neurology and Pulmonology we came to following conclusions about the barriers in the clinical use of I-123 MIBG scintigraphy. Conclusions: 1) In the medical literature I-123 MIBG scintigraphy has a demonstrated role in evaluating sympathetic dysfunction in many cardiac, neurodegenerative and lung conditions which can be put towards various clinical uses. However, the medical community still needs to establish a unanimous consensus regarding the clinical applications of MIBG scintigraphy for unconventional indications. 2) There is need for randomized controlled trials (RCT) for the use of I-123 MIBG scintigraphy in the evaluation of various disease processes before it can be incorporated into clinical practice. 3) It is necessary to increase awareness amongst clinicians about possibility of use of I-123 MIBG scintigraphy in the evaluation of various disease processes apart from the conventional indications of I-123 MIBG scintigraphy. 4) It is necessary to alleviate fear amongst clinicians about excessive radiation exposure from the MIBG scan. 5) More research work should be concentrated on Diastolic heart failure and finding hard end points based on MIBG scintigraphy, which will help clinicians in the decision making process, per request by cardiologists. 6) More research needs to be directed towards differentiation between Parkinson's and Multiple Systemic Atrophy as well as differentiation of  Lewy body dementia More Details from dementia of Alzheimer's type (DAT) per request by neurologists. 7) So far there is no treatment available for sympathetic dysfunction and pulmonary fibrosis. Clinical use of I-123 MIBG scans will eventually become much more prevalent once treatment becomes available for these conditions since there will be immediate benefit of diagnosing sympathetic dysfunction on I-123 MIBG scans. So research should be directed towards finding treatment for sympathetic dysfunction and pulmonary fibrosis. 8) Integration of research work in different parts of the country and world regarding use of I-123 MIBG scintigraphy for other than conventional uses is imperative. 9) Regulatory and Insurance issues for payment of the test is another hurdle in the way of use of I-123 MIBG for non conventional clinical indications, but they will be dealt with after clinicians from relevant specialties have reached a unanimous consensus about the definite proven role of I-123 MIBG scintigraphy for reasons other than neuroblastomas and pheochromocytomas. 10) The results of the study correlating cardiac sympathetic dysfunction to HMR although were concluded to be statistically insignificant but they demonstrated the same trend as other studies. A majority of subjects (14/26) with HMR < 1.6 had significant cardiac sympathetic dysfunction.

Keywords: I-123 MIBG, conventional indications, cardiac sympathetic dysfunction


Role of diuretic radionuclide renography in the evaluation of unilateral ureteropelvic junction obstruction after pyeloplasty

Arun S, Chakraborthy D, Senthil R, Kamaleshwaran KK, Bhattacharya A, Singh B, Mittal BR

Postgraduate Institute of Medical Education and Research, Department of Nuclear Medicine, Chandigarh, India

Introduction: The incidence of ureteropelvic junction obstruction (UPJO) is about 1 in 1000 newborns with a left sided predominance. UPJO is the most common cause of urinary tract obstruction in children. Boys outnumber girls in a ratio of 2:1. Diuretic renography has proved to be a reliable non invasive test for assessing obstruction and differential function of the kidneys and assessing improvement after surgical intervention. Objectives : To assess the improvement in function and drainage in post operative cases of UPJO after pyeloplasty using DRR. Materials and Methods : Retrospective analysis of diuretic renograms for the past 8 years were reviewed. Among 156 patients with UPJO, 33 patients had pre and post pyeloplasty renography. Study included 13 females and 20 males in the age group range of 3months to 56 yrs with an average age of 16.1yrs. 23 (69.7%) patients had left side UPJO. The median time at which post pyeloplasty scintigraphy was done was 2.5 months. Scintigraphy was done as per predefined protocol using 99mTc -EC with measurement of relative function (RF) of each kidney. Diuretic was given at 10 min of study. Improvement in relative function of the diseased kidney was taken as an increase in ≥5% in relative function of that kidney post operatively, and deterioration in relative function taken as a decrease in relative function by ≥5% post operatively. An increase or decrease in renal function of less than 5% is considered to be a non significant change in renal function. Results : Hydronephrosis is noted in all the patients. 22 cases had evidence of obstruction at PUJ in the pre op renogram, of whom 19(86%) showed relieved obstruction post op study. Remaining 3 cases showed persistent obstruction of which 2 showed deterioration in function. 11 cases had no evidence of obstruction, underwent pyeloplasty in which 2 showed improvement in function, 2 showed deterioration and remaining stable function. Among the 33 cases only 6 (18%) patients showed improvement in relative function of diseased kidney post pyeloplasty, 7 (21%) patients showed deterioration in renal function, whereas 20 (61%) showed stable renal function in post op scan. Conclusion : Our study suggests that 99m Tc EC renal scintigraphy plays a significant role in assessment of drainage and renal function, post pyeloplasty in UPJO patients. Our study shows that in most patients, post pyeloplasty the obstruction was relieved, but majority showed no significant improvement in renal function in diseased kidney post operatively done as early as 2 months. So for follow up for improvement in function DRR should be done more than 2 months after pyeloplasty.

Keywords: Diuretic Renography, Tc-99m EC, post-pyeloplasty


Clean room for the production of cold kits: Two year experience with the production of kits for 99mTc radiopharmaceuticals

Muralidharan Sheela H, Nair Preeti, Ghodke Archana S, Pillai Thara, Sheri Kumar Uma, Vanaja R, Mehra Kiran S, Sachdev SS, Sivaprasad N

Radiopharmaceuticals Programme, Board of Radiation and Isotope Technology. Mumbai, India

A new clean room has been designed and constructed at Radiopharmaceuticals programme; BRIT keeping in view the functional aspects for the production of 'cold' kits for the preparation of 99mTc radiopharmaceuticals for supply to nuclear medicine centers and is in operation, since October, 2008. This clean room is the first clean room in the country designed exclusively for cold kit production. The clean room was validated and trial batches were produced and quality controlled prior to put it in regular production operation. A clean room is a room where population of particles, whether living or non-living, is minimum and its generation i.e. introduction and propagation is controlled. The clean rooms are classified as per the standard of cleanliness expressed in the number of particles permitted per unit volume of area for e.g. the dispensing area is a class 100 area where the number of particles permitted is not more than 100 particles of 0.5 μm per cu. feet. The clean room for kit production consists of various area areas meant for different purposes related to production under GMP. The clean room consists of 1) material entry area for sterile glass wares and pharmaceuticals grade chemicals and reagents 2) weighing room for weighing the various ligands 3) Sets of change rooms, separately for ladies and gents, 4) air locks corridor to prevent particle entry 5) buffer zone 6) formulation area where dissolution of ligands and addition of other chemicals are done and 7) dispensing area, where the formulated solutions are dispensed into serial vials. All areas are interconnected with pass boxes for material transport and an aseptic corridor for people movement. The different area are designed, equipped and maintained according to the usage and operational need. The air borne particles are measured using a particle counter and the number of viable micro organisms is counted by settle plate method using agar plates. These methods are used regularly to monitor the environment and air quality in the clean room before and during production. Validation results are documented after each production. Stringent measures are taken to ensure high quality clean and practically particle free environment inside the clean room. A regular and thorough cleaning of walls, floor and other surfaces are done using disinfectants such as 70% ethyl alcohol and isopropyl alcohol. The table tops and lyophiliser chamber are cleaned with disinfectants prior to production. The lyophilize is located in call 100 area with loading port opening in the clean room, where as the maintenance is carried out from outside the clean room Number of persons entering into the clean room is limited according to the requirement as less number of people in clean room, lesser will be the chance of contamination with particles, since people are the one of the main sources of particle generation. Only the required number of personnel allowed to enter the clean room after replacing their shoes, with sterile foot ware and garments with sterile laboratory clothing (special non particle shedding), comprising of shoe cover, head cover, nose mask, hand gloves and laboratory clothing to cover the entire body. The movement of personnel inside the clean room is restricted and materials are transferred from one area to the other through pass boxes. The clean environment is maintained by separate AHU (air handling unit) located out side the clean room. A technical crew maintain the AHU unit and maintain record of parameters such as humidity, air flow, blower speed, chiller temperature etc. During a typical batch production not more than two persons are present in the formulation room. The formulated solution (filtered through 0.22μ membrane filter) is passed though a pass box between the formulation and dispensing area. The no. of people allowed in the dispensing area which is a critical area of class 100 is restricted to not more than four that too no person is allowed to be in between direct flow of HEPA filtered air and the dispensing table. The number of vials to be dispensed is arranged in trays and 1 ml of the formulated sterile solution is dispensed into each vial and the vials are transferred in to the lyophlisation chamber. Sterile vials are introduced into class 100 area and the vials are removed after lyophilisation though a pass box. After lyophilisation vials are sealed with aluminum caps and stored at 2-10ΊC. Since the commissioning of the new clean room, about 120 batches of 10 different kit products were prepared and 1, 20,000 kit vials were supplied to various hospitals for nuclear medicine investigation

Keywords: Tc-99m, technetium, kits, cleanroom, class 100, Production


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