BACKGROUND: The lack of anatomical details in standard (131)Iodine whole body scanning ((131)I WBS) interferes with the proper localization of metastatic differentiated thyroid carcinoma (DTC) lesions. In addition, nearby or overlapping variable physiological distribution of (131)I may affect the specificity of (131)I uptake, giving indeterminate results. The aim of this study was to demonstrate the clinical usefulness of simultaneous co-registration of (99m)Tc MDP bone scanning as an anatomical landmark with (131)I scanning in the evaluation of metastatic DTC.

MATERIAL AND METHODS: Twenty-five patients (16 females and 9 males, mean age +/- SD = 52 +/- 13 years) with metastatic DTC (17 papillary, 8 follicular), were included. Whole body scanning using a 256 x 1024 matrix and an 8 cm/min scan rate were obtained 48 hours after oral administration of 185-370 MBq 131I and 2 hours after IV administration of 185-370 MBq (99m)Tc MDP using a dual head gamma camera equipped with high energy parallel hole collimators. Occasionally, additional simultaneous co-registration of localised detailed images was also performed using a 256 x 256 matrix size. The two planar images were fused with optional fusion of SPECT images. The data from standard (131)I scanning and fused (131)I/ (99m)Tc-MDP scanning were separately assessed by two nuclear medicine physicians. Fusion images were considered to improve image interpretation in comparison with standard (131)I scanning when they provided better localization of lesions.

RESULTS: All lesions in the present study were validated by radiological images and clinical follow up for at least 12 months. Forty-eight metastatic lesions were confirmed as follows: 2 in the skull, 10 in the neck, 20 in the thorax, 12 in the pelvic-abdominal region and 4 in the extremities. Standard (131)I WBS showed 54 extra-thyroidal foci with 8 false positive lesions of which 2 were located in the scalp and 6 in the pelvic-abdominal region extra-skeleton (i.e. sensitivity 100%, specificity 86%). Out of the 48 validated lesions, 16 were indeterminately localized: 10 in the thorax (3 mediastinal nodal lesions, 5 vertebral lesions and 2 ribs) and 6 in the pelvic-abdominal region (2 upper sacral, 2 sacroiliac region and 2 ischial bone). Fusion images confirmed the precise localization of the pathological uptake in the validated 48 lesions (sensitivity 100%, specificity 100%). There were 2 (4%) indeterminate lesions in fused planar imaging that were clearly localized via fused SPECT images.

CONCLUSIONS: Fusion images using simultaneous co-registration of (131)I and (99m)Tc MDP scanning is a simple and feasible technique that improves the anatomically limited interpretation of scintigraphy using (131)I alone in patients with metastatic differentiated thyroid carcinoma. The diagnostic advantage of this technique seems to be more apparent in the thoracic and pelvic- abdominal regions in contrast to the neck and extremities.

p>Background: Valsalva maneuver one of the oldest method to diagnose heart failure, it’s cheap ,non-invasive ,bedside tool .Its well-studied in systolic heart failure patients which showed abnormal response either square wave or absent phase IV ,however in diastolic heart failure and diastolic dysfunction were not investigated .Methods: 70 patients were included in our study they were divided into three groups group 1 diastolic heart failure based on echocardiography and BNP above 100pgL/ml , group 2 diastolic dysfunction based on echocardiography and BNP less than 100 pg/ml and group 3 systolic heart failure ,they went all clinical examination ,BNP were taken ,Valsalva maneuver at 30 mmhg for at least 15 sec using two sphygmomanometers first connected to mouth piece and the other to monitor blood pressure while the physician auscultates brachial artery patient is asked to perform forced expiratory effort against closed airway for at least 15 second and then asked to release and absence or presence of Korotkoff sounds assessed and heart rate is recorded baseline and after strain and full study echocardiography and using in apical 4 chamber view Simpson method to measure right and left ventricle area at baseline , peak strain and after release .
Results: Group 2 showed overshooting of systolic blood pressure by a mean of 11 ± 6.41mmHg (p value = 0.001), 95% confidence interval (CI): [3.2-15.14] compared to baseline. Moreover, group 3 showed minimal overshooting with a mean of 3.34±4.17mmHg (p value = 0.002), 95% confidence interval (CI): [2.2-8.2], On the other hand, group 1 showed no overshooting, with a mean change of -3.6 ± 0.63mmHg (p value = 0.001), 95% confidence interval (CI): [9.34-2.5].
We demonstrated that Valsalva maneuver could differentiate patients with diastolic heart failure from those with diastolic dysfunction, with a sensitivity of 68%, specificity 75%, positive predictive value 71.4%, and negative predictive value 72%. Only group 2 in our study showed a clinically significant decrease in RV end-diastolic area during strain as compared to the baseline, with a mean value of 4.5 ± 0.14 cm2 (23.5 ± 0.4%; p value = 0.001),95% confidence interval (CI):[6.65+2.25]. On the other hand, group 1 showed a minimal decrease (0.9 ± 0.25 cm2; 5.3 ± 0.6%) and group 3 showed a minimal increase (1 ± 2.23 cm2; 5.6±5%). Group 2 showed a clinically significant decrease in LV end-diastolic area during strain as compared to the baseline, with a mean value of 6.1 ± 1.01 cm2 (19.3 ± 2%; p value = 0.001) 95% confidence interval (CI) :[8.2+-3.96]. Moreover, group 3 showed a smaller, but significant decrease (4.6 ± 0.98 cm2; 12.6 ± 0.7%), while group 1 demonstrated insignificant change.
Conclusion: VM showed significant overshooting in group 2 compared to other two groups ,not all heart failure patients had abnormal response based as risk factors as NYHA class and diuretics ,stiffness in myocardium affected the Valsalva response in diastolic heart failure group followed by systolic heart failure and finally diastolic dysfunction one ,There is decrease in left and right ventricle area during strain and gradually increase after release during normal Valsalva response which is greatly affected in HF patients .