Granulocyte transfusion vs. neutropenia — is there a chance to win this battle?

Bacterial and fungal infections remain a significant cause of morbidity and mortality in patients with prolonged severe neutropenia that results from the treatment of an underlying haematological malignancy. Granulocyte transfusions have been broadly used to prevent and/or treat life-threatening infections in these patients. The purpose of this review was to answer the question, “Are granulocyte transfusions effective in combating hazardous infections in haematology/oncology patients with neutropenia?”

The influence of non-radioactive iodine (127I) on the outcome of radioiodine (131I) therapy in patients with Graves’ disease and toxic nodular goitre

BACKGROUND: The aim of the study was to achieve an effective target dose in the thyroid by increasing the effective half-life (Teff) of 131I by use of iodide (127I) two days after 131I therapy in patients with hyperthyroidism with low Teff. MATERIAL AND METHODS: The study was carried out in two groups. Group A — 41 patients, and Group B — 14 patients, all the patients were with hyperthyroidism with Teff less than 3 days qualified for 131I therapy. Only group A patients received 600 μg of iodide a day for 3 days, two days after 131I therapy. Radioiodine uptake (RAIU) after 24 and 48 hours, thyroid scintiscan and ultrasonography were done before and after 12 months of 131I therapy. RESULTS: In group A a significant increase was seen in the Teff (5 days on average) resulting in an increase in the energy target dose by 28% and 37%, in patients with Graves’ disease (GD) and toxic nodular goitre (TNG), respectively. After one year of therapy 50% of GD and 93% of TNG patients achieved euthyroidism; 28% of GD and 3% of TNG patients were in hypothyroidism. In Group B, all the patients had radioiodine treatment failure and received a second therapeutic dose of 131I. CONCLUSIONS: Administration of 127I after 131I treatment can lead to an increase in its effective half-life. This will also increase the absorbed energy dose in thyroid tissue, thereby improving therapeutic outcome without administration of a higher or second dose of 131I. This may minimize whole-body exposure to radiation and reduces the cost of treatment. Nuclear Med Rev 2011; 14, 1: 9–1

Iodine isotope (131I) therapy for toxic nodular goitre: treatment efficacy parameters

BACKGROUND: When planning radioactive iodine therapy, itfrequently happens, both in Poland and world-wide, that inadequateattention is paid to such easily measurable parametersas: 1) the serum concentration of thyrotropin (TSH) beforeadministering radioiodine, which is a key factor for extranodular(non-autonomous) iodine uptake of the thyroid gland, 2) thyroidgland iodine uptake, and 3) the effective half-life of 131I (Teff.). Theaim of the study is to evaluate the impact of the above factorson the efficacy of 131I treatment in hyperthyroid patients.METHODS: The material consisted of 4140 patients: 2190 withautonomous toxic nodules (ATN) and 1950 with toxic multinodulargoitres (TMG). The patients were prepared for treatment insuch a way that the concentration of TSH did not exceed 0.1 mU/land Teff.< 5 days. The therapeutic activity of 131I was calculatedusing Marinelli’s formula. The selection of absorbed dose valuewas determined by the degree of suppression of extranodulartissue. Monitoring was performed every eight weeks.RESULTS: At one year after 131I administration showed thata euthyroid status was achieved in 94%, hypothyroidism was seen observed in 3%, while persistence or recurrence of hyperthyroidismin 3% of ATN patients and, respectively, 89%, 4% and7% of TMG patients.CONCLUSIONS: Patients with toxic nodular goitre who are to betreated with radioiodine should have the lowest possible serumconcentration of TSH. The suppression of extranodular determinesthe optimal value of absorbed dose for Marinelli’s formula

Parathyroid gland function after radioiodine (131I) therapy for toxic and non-toxic goitre

Wstęp: Efekt terapeutyczny radiojodu (131I) w wolu łagodnym opiera się na emisji niszczącego tkanki promieniowania beta. Maksymalnyzasięg promieniowania beta 131I w tkance wynosi do 2,4 milimetra. Dlatego, też w zasięgu tego promieniowania mogą się znajdowaćsąsiadujące z tarczycą przytarczyce. Celem pracy była ocena czynności przytarczyc u chorych z wolem nadczynnym i normoczynnympoddanych terapii 131I w okresie do 5 lat od zastosowanego leczenia.Materiał i metody: Badania zostały wykonane u 325 chorych z łagodnym wolem (220 z wolem guzowatym nadczynnym (TNG), 25z wolem guzowatym obojętnym (NTNG) i 80 z chorobą Gravesa-Basedowa (GD) poddanych leczeniu 131I. Aktywność lecznicza 131Idla każdego pacjenta wyliczana była z wzoru Marinellego. W trakcie radiojodoterapii oznaczano stężenia fT3, fT4, TSH, iPTH, Ca2+, Cai fosforanów w surowicy tydzień przed podaniem 131I, i następnie w odstępach dwumiesięcznych przez rok po terapii oraz po 3 i 5 latach.Wyniki: U wszystkich chorych po 2 miesiącach od momentu rozpoczęcia leczenia zaobserwowano znamienny statystycznie wzrost stężeniaiPTH ponad normę (do wartości prawie dwukrotnie powyżej normy u pacjentów z TNG), który utrzymywał się aż do 10 miesiąca,a następnie ulegał normalizacji. Stężenia Ca2+, Ca i fosforanów u wszystkich leczonych pozostawały w zakresie normy w trakcie całegobadania. Stężenia fT3 i fT4 w surowicy po podaniu 131I szybko się normalizowały i pozostawały w zakresie normy do końca badania.Wnioski: Radiojodoterapia łagodnych schorzeń tarczycy prowadzi do powstania przejściowej (trwającej maksymalnie do 10 miesiąca odpodania radiojodu) nadczynności przytarczyc. Stan ten istotnie nie wpływa na stężenia wapnia i fosforanów w surowicy.(Endokrynol Pol 2013; 64 (5): 340–345)Introduction: The therapeutic effect of radioactive iodine (131I) on benign goitre consists of the emission of tissue-destructive beta-radiation. Since the range of beta 131I radiation in tissue can reach 2.4 mm, it can affect the adjacent parathyroid glands. The purpose of this paperis to assess parathyroid function in patients with toxic and non-toxic goitres, up to five years following 131I therapy.Material and methods: The study sample consisted of 325 patients with benign goitres (220 with toxic nodular goitre (TNG), 25 withnon-toxic nodular goitre (NTNG), and 80 with Graves’ disease (GD) treated with 131I. The therapeutic activity of 131I for each patient wascalculated using Marinelli’s formula. The serum levels of fT3, fT4, TSH, iPTH and Ca2+, Ca and phosphates were determined one week before131I administration, as well as every two months up to a year following the therapy, and then after three and five years post-treatment.Results: After two months following the administration of 131I, all the treated patients showed a statistically significant above normal increase in iPTH concentrations (amounting to a value almost twice the norm in patients with TNG), which remained stable up to ten months after treatment, to return to normal level in the following months. In all the patients, Ca2+, Ca, phosphates concentration remained within normal range throughout the course of the study. The concentrations of fT3 and fT4 quickly returned to normal after 131I administration, and remained within normal range until the completion of the study.Conclusion: Radioiodine treatment of benign thyroid disorders results in transient (up to ten months after 131I administration) hyperparathyroidism.The condition does not influence the level of calcium and phosphates concentration in any significant way. (Endokrynol Pol 2013; 64 (5): 340–345

Value of direct radionuclide cystography in diagnosing vesico-peritoneal fistulae

A 36-year-old female patient underwent a laparoscopic surgery to remove a uterine fibroid. The procedure failed to relieve the pelvic pain, although its nature changed. After a period of observation, the patient was re-admitted to hospital on suspicion of a vesico-uterine fistula to be differentiated with endometriosis. Diagnostic investigations — cystography, cystoscopy, computed tomography and magnetic resonance — did not reveal a fistula. Laparoscopy was performed, with a possible biopsy in order to eliminate endometriosis. The result was negative, but chronic progressive reactive/inflammatory lesions were noticed, possibly indicating the presence of a vesico-peritoneal fistula. Therefore, a direct radionuclide cystography was performed. The scintigraphic images single-photon emission computed tomography (SPECT/CT) showed a radioactive spot, indicative of a vesico-peritoneal fistula. The fistula was treated for three months by catheterisation of the urinary bladder. The follow-up SPECT-CT did not reveal any urine leakage from the bladder. The clinical symptoms disappeared as well

Bone scan in metabolic bone diseases. Review

Metabolic bone disease encompasses a number of disordersthat tend to present a generalized involvement of the wholeskeleton. The disorders are mostly related to increased boneturnover and increased uptake of radiolabelled diphosphonate.Skeletal uptake of 99mTc-labelled diphosphonate depends primarilyupon osteoblastic activity, and to a lesser extent, skeletalvascularity. A bone scan image therefore presents a functionaldisplay of total skeletal metabolism and has valuable role toplay in the assessment of patients with metabolic bone disorders.However, the bone scan appearances in metabolic bonedisease are often non-specific, and their recognition dependson increased tracer uptake throughout the whole skeleton. Itis the presence of local lesions, as in metastatic disease, thatmakes a bone scan appearance obviously abnormal. In theearly stages, there will be difficulty in evaluating the bone scansfrom many patients with metabolic bone disease. However, inthe more severe cases scan appearances can be quite strikingand virtually diagnostic.Metabolic bone disease encompasses a number of disordersthat tend to present a generalized involvement of the wholeskeleton. The disorders are mostly related to increased boneturnover and increased uptake of radiolabelled diphosphonate.Skeletal uptake of 99mTc-labelled diphosphonate depends primarilyupon osteoblastic activity, and to a lesser extent, skeletalvascularity. A bone scan image therefore presents a functionaldisplay of total skeletal metabolism and has valuable role toplay in the assessment of patients with metabolic bone disorders.However, the bone scan appearances in metabolic bonedisease are often non-specific, and their recognition dependson increased tracer uptake throughout the whole skeleton. Itis the presence of local lesions, as in metastatic disease, thatmakes a bone scan appearance obviously abnormal. In theearly stages, there will be difficulty in evaluating the bone scansfrom many patients with metabolic bone disease. However, inthe more severe cases scan appearances can be quite strikingand virtually diagnostic

Radiojodoterapia w chorobie Gravesa-Basedowa — czynniki wpływające na skuteczność leczenia w oparciu o analizę retrospektywną

Introduction: Radioiodine (131I) isotope therapy is the method of choice in the treatment of Graves’ disease relapse. The efficiency of this method is dependent on many factors; therefore, the present paper aims to identify the parameters that have a crucial impact on the efficacy of radioiodine therapy for Graves’ disease.Material and methods: The authors performed a retrospective analysis of the medical documentation of 700 Graves’ disease sufferers treated with131I. The patients were divided into three groups depending on the thyroid-absorbed dose of 131I: group I — 100 Gy, II — 150 Gy, and III — 200 Gy. The authors assessed the influence of gender, age, presence of orbitopathy, TRab titres, thyroid mass, iodine uptake after 24 and 48 hours, and the absorbed dose on the treatment efficacy at one year post-131I administration.Results: The volume of thyroid gland (P < 0.002) and the thyroid-absorbed dose (P < 0.001) were the only factors that had a significant impact on the outcome of the treatment. The likelihood of hyperthyroidism persisting (odds ratio: 3.71, 95% confidence interval: 2.4–5.87) was greatest in patients from group I. In group II, with thyroid volume amounting both to 25 mL and to 25–50 mL, the percentage of hyperthyroidism was lowest (1 and 0%). However, with thyroid volume > 50 mL, the percentage of hyperthyroidism was lowest in group III (10%).Conclusions: The absorbed dose of 131I and the volume of the thyroid gland are two parameters that have a significant influence on the efficacy of radioiodine therapy for Graves’ disease. 150 Gy is the optimal dose for glands < 50 mL. A goitre > 50 mL requires an absorbed dose of 200 Gy in order to minimise the risk of recurrent hyperthyroidism. (Endokrynol Pol 2015; 66 (2): 126–131)Wstęp: Metodą z wyboru w leczeniu nawrotów choroby Gravesa-Basedowa jest terapia izotopowa radiojodem (131I). Efektywność tego leczenia zależy od wielu czynników, dlatego też celem pracy było wskazanie parametrów mających decydujący wpływ na skuteczności radiojodoterapii choroby Gravesa-Basedowa.Materiał i metody: Przeanalizowano retrospektywnie dokumentację medyczną 700 pacjentów z chorobą Gravesa leczonych 131I. Ze względu na dawkę pochłoniętą 131I w tarczycy, pacjentów podzielono na trzy grupy (grupa I — 100 Gy, II — 150 Gy, III — 200 Gy). Zbadano zależność płci, wieku, obecności orbitopatii, miana TRAb, masy tarczycy, jodochwytności tarczycy po 24 i 48 godzinach, dawki pochłoniętej na efektywność leczenia, po roku od podania 131I.Wyniki: Objętość tarczycy (P < 0,002), dawka pochłonięta w tarczycy (P < 0,001) miały jedynie istotny wpływ na wyniki terapii. Największe ryzyko utrzymywania się hipertyreozy (iloraz szans [OR] 3,71, 95% przedział ufności [CI] 2,4–5,87) wystąpiło u pacjentów z grupy I. W grupie II przy objętości tarczycy 25ml jak i 25-50ml odsetek hiperytreozy był najmniejszy (1 i 0%). Natomiast przy objętości tarczycy > 50 ml odsetek hipertyreozy był najmniejszy w grupie III (10%).Wnioski: Dawka pochłonięta 131I, objętość tarczycy to parametry mające istotny wpływ na skuteczności radiojodoterapii choroby Gravesa-Basedowa. Optymalną dawką pochłoniętą w tarczycy z objętością < 50 ml jest 150Gy. Wole (> 50 ml) wymaga dawki pochłoniętej 200Gy celem zminimalizowania nawrotu hipertyreozy. (Endokrynol Pol 2015; 66 (2): 126–131

Clinical application of intracardiac echocardiography in the ablation of atrial fibrillation

Background: The application of intracardiac echocardiography (ICE) in atrial fibrillation (AF) ablation may increase the success rate and decrease the complication rate of the procedure. We present our preliminary observations concerning the utility of ICE in AF ablation. Methods: In February and July 2004 we performed 6 radiofrequency (RF) ablations guided by ICE (EP Med Systems) in patients with atrial tachyarrhythmia. All patients had undergone at least three months of oral anticoagulation therapy before the procedure. For three days before ablation enoxaparin was administered. During each procedure the ICE catheter was placed in the right atrium. Transseptal puncture was guided by fluoroscopy and ICE imaging. After placement of the introducer in the left atrium a bolus of heparin (100 IU/kg) was administered followed by additional boluses (1000 IU/h). Electroanatomical isolation of the pulmonary vein ostia was performed with a 4 mm ablation catheter (RF energy was set at 50–55oC and 25–35 W). RF energy was titrated if microbubble formation was observed and delivery was immediately terminated when a brisk shower of bubbles was detected. Results: Transseptal puncture was performed at a typical location in all patients (atypical anatomy was not revealed by ICE). The microbubble effect was observed in all patients. In 1 patient the effect was observed despite a power reduction and the RF application had to be terminated. The following short (15-20 s) applications were performed with low RF energy. During the same procedure ICE imaging revealed 2 thrombi (2 and 5 mm) on the Lasso electrode. None of the patients experienced thromboembolic complications. Conclusions: Intracardiac echocardiography is a useful imaging method in RF ablation. Low RF-energy and standard anticoagulation treatment do not prevent the microbubble effect and the formation of small thrombi

Tricuspid regurgitation after implantable cardioverter-defibrillator implantation in patients with arrhythmogenic right ventricular cardiomyopathy

Introduction. The problem of lead-induced tricuspid regurgitation (LITR) in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) is poorly investigated. Patients with high risk of adverse outcome usually receive implantable cardioverter-defibrillator (ICD) as a prevention of sudden cardiac death (SCD). nfortunately, the insertion of ICD into the right ventricle is supposed to exacerbate tricuspid regurgitation.As ICD (or cardiac resynchronization therapy defibrillator) seems to be necessity in prevention of SCD in quite large group of patients, we aimed to evaluate frequency of LITR and further outcome in these persons.Material and methods. In a database of 55 patients with ARVC and ICD implanted in prevention of SCD, we selected 35 patients (mean age 48.78 ± 13.56 years) with data suitable for analysis. Based on the results of echocardiography, study population was divided into 2 groups: TR+ group with worsening of tricuspid regurgitation (TR) defined as its deterioration to higher grade and TR– group (without worsening of TR).Results. In 65.71% of patients TR worsened after ICD implantation. Mean time of observation was 91.06 ± 55.32 months. In TR+ group, 2 patients (8.7%) died because of heart failure and 1 patient died in a traffic accident. In TR– group 1 patient (8.33%) died because of heart failure and 1 patient had heart transplantation (results were statistically insignificant).Conclusions. We couldn’t prove that the worsening of TR was associated with worsening of clinical outcome. Furtherstudies are needed to assess an influence of LITR on prognosis in patients with ARVC and ICD implanted.Introduction. The problem of lead-induced tricuspid regurgitation (LITR) in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) is poorly investigated. Patients with high risk of adverse outcome usually receive implantable cardioverter-defibrillator (ICD) as a prevention of sudden cardiac death (SCD). nfortunately, the insertion of ICD into the right ventricle is supposed to exacerbate tricuspid regurgitation.As ICD (or cardiac resynchronization therapy defibrillator) seems to be necessity in prevention of SCD in quite large group of patients, we aimed to evaluate frequency of LITR and further outcome in these persons.Material and methods. In a database of 55 patients with ARVC and ICD implanted in prevention of SCD, we selected 35 patients (mean age 48.78 ± 13.56 years) with data suitable for analysis. Based on the results of echocardiography, study population was divided into 2 groups: TR+ group with worsening of tricuspid regurgitation (TR) defined as its deterioration to higher grade and TR– group (without worsening of TR).Results. In 65.71% of patients TR worsened after ICD implantation. Mean time of observation was 91.06 ± 55.32 months. In TR+ group, 2 patients (8.7%) died because of heart failure and 1 patient died in a traffic accident. In TR– group 1 patient (8.33%) died because of heart failure and 1 patient had heart transplantation (results were statistically insignificant).Conclusions. We couldn’t prove that the worsening of TR was associated with worsening of clinical outcome. Furtherstudies are needed to assess an influence of LITR on prognosis in patients with ARVC and ICD implanted

Single, very low dose (0.03 mg) of recombinant human thyrotropin (rhTSH) effectively increases radioiodine uptake in the I-131 treatment of large nontoxic multinodular goiter

BACKGROUND: Radioiodine therapy (RIT) in patients with large nontoxic multinodular goiter (MNG) recently becomes more common method in comparison to surgery (especially in elderly patients and with contraindications because of severe chronic diseases other systems). Repeatedly low thyroid radioactive iodine uptake (RAIU) decreases effectiveness of RIT or makes it impossible. The recombinant human thyrotropin can increase RAIU and improve the results of RIT. The aim of the study was to assess the influence of a single very low dose (0.03 mg) of rhTSH on RAIU and thyroid function in euthyroid (MNG-EU) and subclinical hyperthyroid (MNG-SC) patients with a large multinodular goiter. MATERIAL AND METHODS: 40 patients (14 male, 26 female, age 57–80 yr) with large non-toxic MNG over 80 grams and with baseline RAIU < 40% were included into the double-blind randomized study and divided into two groups: rhTSH-group and control group. First group received the single intramuscular injection of 0.03 mg rhTSH and the second received placebo. The RAIU were measured 24 and 48 hours after the rhTSH and then all the patients were administered therapeutic doses of I-131. TSH and free thyroxine levels were measured at 1st and 2nd day after the injection of rhTSH and later, at 4 and 8 weeks after the RIT. RESULTS: The mean RAIU increased significantly from 30.44 ± 7.4% to 77.22 ± 8.7% (p < 0.001). There were no statistically significant differences in RAIU between euthyroid (MNG-EU) and subclinically hyperthyroid (MNG-SC) patients. The peak of serum TSH was noticed 24 hours after rhTSH injection and in MNG-EU patients it has remained within normal range, similarly as fT4. In the MNG-SC group the administration of rhTSH resulted in a significant increase in the TSH values after 24 hours, whose mean level slightly exceeded the upper limit of the normal range with normalization at 48 hours. 8 weeks after the RIT, the TSH and fT4 levels did not exceed the normal range and did not differ in a statistically significant way. Conclusions: Even the single very low dose of rhTSH increases the values of RAIU in significant way, in euthyroid and subclinically hyperthyroid patients. The administration of rhTSH is well-tolerated. Neoadjuvant administration of a low dose (0.03 mg) of rhTSH before I-131 seems to be an optimal method of management which may increase the effectiveness of RIT and decrease the exposure of the patients to absorbed doses of ionizing radiation.BACKGROUND: Radioiodine therapy (RIT) in patients with large nontoxic multinodular goiter (MNG) recently becomes more common method in comparison to surgery (especially in elderly patients and with contraindications because of severe chronic diseases other systems). Repeatedly low thyroid radioactive iodine uptake (RAIU) decreases effectiveness of RIT or makes it impossible. The recombinant human thyrotropin can increase RAIU and improve the results of RIT. The aim of the study was to assess the influence of a single very low dose (0.03 mg) of rhTSH on RAIU and thyroid function in euthyroid (MNG-EU) and subclinical hyperthyroid (MNG-SC) patients with a large multinodular goiter. MATERIAL AND METHODS: 40 patients (14 male, 26 female, age 57–80 yr) with large non-toxic MNG over 80 grams and with baseline RAIU < 40% were included into the double-blind randomized study and divided into two groups: rhTSH-group and control group. First group received the single intramuscular injection of 0.03 mg rhTSH and the second received placebo. The RAIU were measured 24 and 48 hours after the rhTSH and then all the patients were administered therapeutic doses of I-131. TSH and free thyroxine levels were measured at 1st and 2nd day after the injection of rhTSH and later, at 4 and 8 weeks after the RIT. RESULTS: The mean RAIU increased significantly from 30.44 ± 7.4% to 77.22 ± 8.7% (p < 0.001). There were no statistically significant differences in RAIU between euthyroid (MNG-EU) and subclinically hyperthyroid (MNG-SC) patients. The peak of serum TSH was noticed 24 hours after rhTSH injection and in MNG-EU patients it has remained within normal range, similarly as fT4. In the MNG-SC group the administration of rhTSH resulted in a significant increase in the TSH values after 24 hours, whose mean level slightly exceeded the upper limit of the normal range with normalization at 48 hours. 8 weeks after the RIT, the TSH and fT4 levels did not exceed the normal range and did not differ in a statistically significant way. Conclusions: Even the single very low dose of rhTSH increases the values of RAIU in significant way, in euthyroid and subclinically hyperthyroid patients. The administration of rhTSH is well-tolerated. Neoadjuvant administration of a low dose (0.03 mg) of rhTSH before I-131 seems to be an optimal method of management which may increase the effectiveness of RIT and decrease the exposure of the patients to absorbed doses of ionizing radiation