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Purpose Malnutrition is a significant issue for pediatric patients with cancer. We sought to evaluate the effectiveness and complication rate of percutaneous endoscopic gastrostomy (PEG) placement in pediatric oncology patients. Methods A retrospective chart review was performed on 49 pediatric oncology patients undergoing PEG placement at Johns Hopkins All Children's Hospital between 2000 and 2016. Demographic and clinical characteristics, complications, absolute neutrophil count at time of PEG placement and at time of complications, length of stay, and mortality were identified. Weight-for-age Z-scores were evaluated at time of- and six months post-PEG placement. Results The overall mean weight-for-age Z-score improved by 0.73 (p

Purpose Cannabis hyperemesis (CH) is an under-recognized condition in patients with chronic or cyclic vomiting and who regularly use cannabis. Once thought to be rare, it is now increasingly recognized in both adults and children. We report a case series of adolescent patients with CH who presented at a single institution over 10 years. Methods Patients were included if they had a diagnosis code of cannabis-related or cyclic vomiting, experienced the onset of regular vomiting after starting to regularly use cannabis, and if no other diagnosis was found to better explain the presentation. Thirty-four patients aged 13–20 years (median 17 years) met the inclusion criteria. Results The presenting clinical features were broadly similar to adult CH: cyclic nausea and emesis after at least 3 months of regular cannabis use, abdominal pain, change in bowel habit, and symptomatic relief from hot showers or baths. No antiemetic was found to be of particular benefit. Follow-up was recorded in under half of the patients; documentation of drug history was also frequently incomplete. Clinicians should consider CH when assessing any adolescent with cyclic or chronic vomiting. Conclusions A detailed drug history, preferably taken in the absence of parents or other involved adults and corroborated by urine drug screening, is helpful in substantiating the diagnosis. Further prospective studies are needed to confirm the incidence, prevalence, presenting features, and the effectiveness of treatments, including drug counseling and cessation. Based on our findings, we propose pragmatic criteria to aid in the diagnosis of pediatric CH.

The renal excretion of Tc-99m bone imaging agents often permits the identification of urinary tract abnormalities on bone scans. In this case report, identification of focal intrarenal stasis of the excreted bone imaging agent led to additional anatomic imaging and the identification of a renal medullary carcinoma (RMC) in an adolescent black male undergoing evaluation for back pain. RMC is a rare, highly aggressive renal neoplasm found almost exclusively in young individuals with sickle cell trait (SCT) or hemoglobin SC disease. The prognosis of RMC is poor because the malignancy is usually refractory to chemotherapy and radiotherapy, with metastatic disease commonly present at the time of diagnosis.

A 63-year-old female patient with a recent left posterior cerebral artery infarction and pyelonephritis presented with persistent fevers despite adequate intravenous antibiotic therapy. Whole-body gallium-67 scintigraphy was performed to evaluate for occult infection. Tracer accumulated bilaterally in the kidneys consistent with the previously diagnosed pyelonephritis. Relatively intense uptake was also noted in the area of a known occipitoparietal infarct. Incidentally noted was an abnormal focus of increased tracer uptake in the retroareolar region of the right breast. Subsequent guided core biopsy of the right breast mass demonstrated a previously undiagnosed invasive ductal carcinoma.

We report on a young woman from the United Kingdom with L-dopa-responsive parkinsonism with a trinucleotide repeat expansion in her spinocerebellar ataxia 2 (SCA2) gene. The case further extends the phenotype of SCA2 and emphasizes the importance of SCA screening in young-onset parkinsonism, irrespective of ethnic origin.

The clinical and morphologic findings in the case of a 47-year-old man with fibrosing mediastinitis, most probably due to histoplasmosis, are described. Radionuclide angiography demonstrated obstruction of the superior vena cava with collateral vascularization. Computed tomography demonstrated a large calcific mass interposed between the pulmonary artery and superior vena cava suggesting potential pulmonary vasculature involvement. For this reason, pulmonary scintigraphy was performed which showed right lung perfusion and ventilation defects. Radionuclide angiography and pulmonary scintigraphy complement each other in determining the extent of vascular involvement with fibrosing mediastinitis. However, contrast venography is necessary to correctly delineate the anatomy of the obstructed superior vena cava and its collaterals.

The effect of a standardized meal on left ventricular (LV) ejection fraction (EF) was determined by equilibrium radionuclide angiography in 16 patients with stable congestive heart failure but without pulmonary or valvular heart disease. LVEF was determined in the fasting state and 15, 30, and 45 minutes after a meal. Patients with moderately depressed fasting LVEF (30 to 50%), Group I, had a mean increase of 6.9 +/- 2.9% (p less than 0.005) in the LVEF at 45 minutes after the meal. Patients with severely depressed fasting LVEF (less than 30%), Group II, had no change after the meal. It is concluded that significant increases in LVEF may occur after meals in patients with moderate but not severe left ventricular dysfunction. Equilibrium radionuclide angiography studies that are not standardized for patients' mealtimes may introduce an important unmeasured variable that will affect the validity of data in serial studies of left ventricular function.

Bone, brain, and gallium scintigrams are presented of a 48-year-old man with biopsy-proven cerebral amyloidosis. Brain scintigraphy revealed a well-circumscribed accumulation of Tc-99m pertechnetate in the amyloidoma. Bone scintigraphy using Tc-99m methylenediphosphonate likewise exhibited increased activity in the same area. Gallium-67 citrate, however, failed to localize within the amyloidoma.

A 54-year-old man presenting with symptoms and signs of pulmonary embolism demonstrated gallium-67 accumulation within the right lower lung field in the region of a pulmonary embolism with effusion. An associated infectious process was ruled out. This is contrary to the usual clinical experience and identifies a potential pitfall in the use of gallium-67 as an aid in the differential diagnosis of pulmonary embolism and pneumonitis.

Gallium-67 citrate scintigraphy of a 26-year-old woman with systemic sarcoidosis demonstrated abnormal radiotracer uptake within multiple biopsy-proven sarcoidal cutaneous lesions and within both lobes of the thyroid gland. The etiology of the thyroidal uptake of the Ga-67 was uncertain but it may represent sarcoidal involvement of the gland.

The accuracy of the hepatobiliary scan in the diagnosis of acute cholecystitis was determined at a major United States Army Medical Center. Fortytwo patients with complete medical records were selected for the study. There was 18 positive findings and 24 negative findings. The accuracy rate for the positive fingings for acute cholecystitis was 97 percent, whereas the accuracy rate for the negative findings was 100 percent. The accuracy of the hepatobiliary scan was found to be similar to that reported in the literature.

A report is presented of a man who had a ruptured abdominal aortic aneurysm identified incidental to bone scintigraphy. The bone scan revealed displacement of the left kidney to nearly a horizontal axis and indicated the need for more definitive evaluation. Renal scintigraphy and computed tomography correctly demonstrated a ruptured, but contained abdominal aortic aneurysm.

Cerebral computed tomography, with and without iodinated contrast, revealed the appearance and evolution of lesions in a 32-year-old man with multiple sclerosis. Two areas were enhanced with contrast, with one showing a mild mass effect and rim of enhancement. Serial brain scintigraphy using technetium-/sub 99m/ glucoheptonate, following the computed tomography, showed the appearance and regression of corresponding regions of increased uptake. Computed tomography one day prior to brain scintigraphy failed to demonstrate a region of increased accumulation of radiotracer. One week later, however, evidence of a corresponding unenhanced defect was noted on computed tomography. Clinical correlation is given additionally.

Nuclear medicine imaging techniques are being more widely applied to study a variety of lung injuries. Ventilation and perfusion imaging is often superior to other roentgenographic techniques for establishing the diagnosis and demonstrating the extent of such injuries. At several large burn centers, the Xe-133 washout technique has become the cornerstone for diagnosing early inhalation injury. The overall accuracy of this procedure is 92%. Regional decreases in ventilation and perfusion can reliably localize aspirated radiolucent foreign bodies. Disproportionate perfusion changes are often the earliest indicator of radiation pneumonitis and other forms of vascular injury. Other types of injury, such as gastropulmonary aspiration, blunt trauma, and near-drowning, require further evaluation before the ultimate role of nuclear imaging is defined. An imaging technique to assess capillary permeability in the adult respiratory distress syndrome would be of great clinical benefits.

Squamous cell carcinoma of the esophagus eroded into the central airway with production of left main bronchus occlusion and aspiration pneumonia of the right lower lobe.

A case of anaerobic hepatic abscess (Bacteroides fragilis), which initially was imaged as a cold defect on Ga-67 citrate scintigraphy and, following percutaneous drainage, became Ga avid, is presented. Proposed mechanisms for this occurrence are given.

Cardiovascular abnormalities developed in a patient during a proteinsparing modified fasting diet. Syncope was the complaint at the time of examination. Hypotension, persistent QTcinterval prolongation, and a low QRS voltage were observed before the development of refractory ventricular tachycardia. At autopsy, antemortem thrombi were attached to the left ventricular endocardium and a fenestrated aortic valvule. Strick proteinsparing modified fasting is not without risk of sudden death even with close medical supervision. (JAMA240:120-122, 1978)

• A widened renal fossa on the posterior view during liver-spleen scintigraphy using technetium Tc 99m sulfur colloid raises the possibility of renal or extrarenal disease. We encountered four patients with prominent renal fossae on liver-spleen scans. They were subsequently found to have lesions involving the right adrenal gland. Potential adrenal disease should be considered in patients whose liver-spleen scans show widened renal fossae. (Arch Intern Med 1984;144:2355-2356)

Sixteen patients clinically suspected of having gastrointestinal hemorrhage were studied by abdominal scintigraphy with RBCs labeled in vitro with technetium Tc 99m. Ten of 11 actively bleeding patients had positive scintigrams, with bleeding localized to the duodenum in one, ascending colon in five, sigmoid colon in six, and rectosigmoid colon in one. Scintigraphic findings were corroborated by clinical, endoscopic, arteriographic, and surgical findings. Retention of this blood-pool radiotracer in the vascular compartment allows noninvasive diagnosis of acute, as well as slow or intermittent, bleeding for up to 24 hours after intravenous administration. (JAMA1982;247:789-792)