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Background: The syndrome of combined pulmonary fibrosis and emphysema (CPFE) is a recently described entity associating upper-lobe emphysema and lower-lobe fibrosis. We sought to evaluate differences in pulmonary function between CPFE patients with and without airflow obstruction., Subjects and Methods: Thirty-one CPFE patients were divided into two groups according to the presence or absence of irreversible airflow obstruction based on spirometry (forced expiratory volume in 1 second/forced vital capacity <70% following inhalation of a β2-agonist) as follows: CPFE patients with airflow obstruction (CPFE OB(+) group, n=11), and CPFE patients without airflow obstruction (CPFE OB(-) group, n=20). Pulmonary function, including respiratory impedance evaluated using impulse oscillometry and dynamic hyperinflation following metronome-paced incremental hyperventilation, was retrospectively analyzed in comparison with that observed in 49 chronic obstructive pulmonary disease (COPD) patients (n=49)., Results: In imaging findings, low-attenuation-area scores on chest high-resolution computed tomography, representing the degree of emphysema, were significantly lower in the CPFE OB(-) group than in the CPFE OB(+) and COPD groups. In contrast, the severity of pulmonary fibrosis was greater in the CPFE OB(-) group than in the CPFE OB(+) group. In pulmonary function, lung hyperinflation was not apparent in the CPFE OB(-) group. Impairment of diffusion capacity was severe in both the CPFE OB(-) and CPFE OB(+) groups. Impulse oscillometry showed that respiratory resistance was not apparent in the CPFE OB(-) group compared with the COPD group, and that easy collapsibility of small airways during expiration of tidal breath was not apparent in the CPFE OB(+) group compared with the COPD group. Dynamic hyperinflation following metronome-paced incremental hyperventilation was significantly greater in the COPD group than in the CPFE OB(-) group, and also tended to be greater in the CPFE OB(+) group than in the CPFE OB(-) group., Conclusion: The mechanisms underlying impairment of physiological function may differ among CPFE OB(+) patients, CPFE OB(-) patients, and COPD patients. CPFE is a heterogeneous disease, and may have distinct phenotypes physiologically and radiologically.

In order to estimate the pulmonary extravascular and intravascular spaces, lung uptake ratio of 201Tl (L/T) and lung distribution ratio of 99mTc-albumin (H/T'), expressed as ratios of total counts of the bilateral lungs to the administered doses of the radionuclides, were obtained from the both scintigrams with 201Tl and 99mTc-albumin respectively, using a scintillation camera coupling to a minicomputer. Mean values of L/T and H/T' were 2.8 +/- 0.8% and 4.9 +/- 1.4% in the controls, 3.9 +/- 1.8% and 5.3 +/- 1.9% in heart diseases without left heart failure, and 7.0 +/- 2.2% and 7.1 +/- 2.9% in those with left heart failure, respectively. Ratios of L/T to H/T' in diffuse interstitial pneumonia and heart diseases, especially in cases with left heart failure were higher than those in controls. The values of H/T' and L/T were inversely proportional to cardiac output and cardiac index, and the values of L/T were directly proportional to pulmonary artery wedge pressure, but the discrepancies of the relationship between these values and some clinical findings including cardiac output, cardiac index, pulmonary artery wedge pressure and other findings of left heart failure, were observed in not a few cases. In the regional pulmonary areas, lung uptake of 201Tl was in parallel with pulmonary perfusion in many cases, but the discrepancies between them were demonstrated in some cases, too. These methods seem to be useful for the estimation of the pulmonary extravascular and extravascular spaces, and for the detection of dysfunction of the left ventricle.

201Tl scintigraphy was performed in various bronchopulmonary diseases. Applying semiquantitative and visual assessments of grade of 201Tl was observed in various broncho-pulmonary diseases with multiple or numerous abnormal shadows in the lung fields, and obvious lung uptake was also shown even in some cases with few or no abnormal shadows. Positive results of moderate and marked lung uptake of 201Tl more than 60.0% were obtained in diffuse interstitial pneumonia, hypersensitivity pneumonitis, silicosis, the disseminated type of pulmonary tuberculosis and primary lung cancer. The ratio of radioactivity of the lung (maximum) to the upper mediastinum was 1.04 +/- 0.24 in healthy controls, and more than 2.0 in diffuse interstitial pneumonia, hypersensitivity pneumonitis and silicosis. The ratio of radioactivity of the right lung to the administered dose of 201Tl was 1.5 +/- 0.9% in healthy controls, and more than 3.0% in diffuse interstitial pneumonia, silicosis, the disseminated type of pulmonary tuberculosis and primary lung cancer. Lung uptake of 201Tl was diffuse, homogeneous and marked in diffuse interstitial pneumonia and hypersensitivity pneumonitis, while it was scattered and slight in chronic obstructive lung diseases. 201Tl scintigraphy seems to be useful for detecting interstitial disorders of the lung including edema, inflammatory and granulomatous changes, especially in cases with slightly abnormal or normal chest X-ray films.

In order to evaluate the clinical significance of 201Tl lung uptake, 201Tl myocardial scintigraphy was performed in 675 cases with various cardiac diseases. The lung uptake ratio of 201Tl (L/T) was calculated by ratio of the total radioactivity of the unilateral lung to the injected dose of 201Tl in 69 cases. Using both 201Tl scintigraphy and cardiac pool scintigraphy with 99mTc-human serum albumin, images of 201Tl of the intravascular space and extravascular space were obtained in 14 cases. The image of 201Tl of the extravascular space was almost the same as the original 201Tl image as regards the pattern of 201Tl-distribution, and the lung uptake ratio of the former was 95.7 +/- 2.8% of that of the latter. The mean values of L/T of the right and left lung were 1.5 +/- 0.9%, 1.2 +/- 0.6% in the healthy lungs, 2.8 +/- 1.4% and 1.4 +/- 0.7% in heart diseases without left heart failure, and 4.4 +/- 1.8% and 2.6 +/- 1.2% in those with left heart failure, respectively. Increased lung uptake ratio of 201Tl, which was related to post-capillary pulmonary hypertension, prolonged pulmonary circulation time and findings of left heart failure, was observed more frequently in mitral valvular diseases (72.2%) and dilated cardiomyopathies (60.0%). Increased lung uptake of 201Tl was associated with normal or increased pulmonary perfusion in many cases or areas, but with pulmonary hypoperfusion in some cases with post-capillary pulmonary hypertension, in whom both increased lung uptake of 201Tl and pulmonary hypoperfusion were shown in the lower lung fields.(ABSTRACT TRUNCATED AT 250 WORDS)

To estimate pulmonary hypertension in patients with various heart diseases, we devised a new method using perfusion lung scintigraphy with technetium-99m-labelled macroaggregated albumin. In this method, changes in the distribution of pulmonary perfusion caused by gravitational effects, namely, changes in the total count ratios of the right lung against the left lung between right and left lateral decubitus positions (rt/lt), were assessed in 62 patients and in 10 normal subjects. The rt/lt ratios were calculated as indices of the above changes. They correlated significantly with mean pulmonary arterial pressure (mPAP) (gamma = -0.62, P less than 0.001), pulmonary capillary wedge pressure (gamma = -0.63, P less than 0.001) and pulmonary arteriolar resistance (gamma = 0.50, P less than 0.001) in all subjects. In 17 patients with valvular heart diseases, the ratio correlated significantly with mPAP (gamma = -0.84, P less than 0.001). In 10 patients with various heart diseases, the U/S ratio, i.e. the index of changes in the count ratios of the upper field against the lower field for the right lung following postural change from the upright to the supine position, was also obtained as well as the rt/lt ratio. The latter evidenced a better correlation with mPAP (gamma = -0.90, P less than 0.001) than the former (gamma = -0.64, P less than 0.05). We conclude that this method is valuable as a noninvasive approach for the estimation of pulmonary hypertension.

In order to assess blood volume of the cardiac chambers and lungs, distribution ratio of 99mTc-albumin (HSA) was obtained from radionuclide angiocardiogram and non-gated or gated equilibrium cardiac pool scintigram, using a scintillation camera coupled to a minicomputer. The radio-activity of 99mTc of the entire cardiac blood pool including the large vessels (T), the right ventricle including the right atrium (RV) and the left ventricle (LV) was calculated from the 30 degrees anterior oblique cardiac pool scintigram. That of the both lungs (Lu) was calculated from the anterior cardiac pool scintigram. The radioactivity of total injected dose of HSA (H) was estimated from the initial transit of the tracer obtained by the radionuclide angiocardiogram. Then, distribution ratio of HSA of the each region of interest was expressed as RV/H, LV/H, T/H and Lu/H. RV/H, LV/H and T/H were 3.4 +/- 0.6%, 3.1 +/- 0.5% and 10.4 +/- 2.0% in controls, 6.0 +/- 0.8%, 2.6 +/- 0.8% and 14.2 +/- 2.4% in cor pulmonale, and 7.9 +/- 1.7%, 7.7 +/- 3.5% and 20.7 +/- 4.3% in heart diseases with left heart failure, respectively. Lu/H was 4.9 +/- 1.4% in controls, 4.4 +/- 1.1% in cor pulmonale and 6.6 +/- 1.9% in heart diseases without left heart failure. LV/H was correlated with left ventricular end-diastolic volume by contrast ventriculography. LV/H and RV/H were related with functional classification of NYHA. In conclusion, these parameters may be utilized as indices of the volume of blood pool of the heart chambers and lungs, and this method seems to be clinically applicable for the evaluation of pathophysiology in heart diseases.

RI-angiography with 99mTcO4- was carried out using a scintillation camera with a digital minicomputer for the purpose of imaging of bronchial blood flow in various lung diseases, and as application of dual radioisotope techniques, other imagings such as tumor imaging with 197HgCl2 or 67Ga-citrate and/or perfusion imaging with 99mTc-MAA, were performed simultaneously in patients remaining the same position, too. The image as a iso-count map extracted out of the image of 197HgCl2, 67Ga-citrate or 99mTc-MAA, was superimposed to the brightness image of RI-anigogram (aortic phase). By these procedures, the image of bronchial blood flow were obtained in some patients with lung cancer, pulmonary tuberculosis, lung abscess, and chronic bronchitis. The dual radioisotope techniques using RI-angiography and the other imaging were useful to make isotope diagnosis of lung diseases more reliable, and the image superimposition methods using RI-angiogram and the image of tumor or perfusion, were useful to improve anatomic orientation of the former.

On intravenous administration of 201TlCl (74 MBq (2 mCi), initial transit of it through the heart as well as subsequent uptake by the chest were recorded in the supine position using a scintillation camera coupling to a small digital computer, and remaining the patient in the same position perfusion scintigram with 99mTc-macroaggregated albumin (MAA) or transmission scintigram with a point source of 99mTcO4- too. The radioactivity of total injected dose of 201Tl (T) was calculated from the entire region on the initial transit of the tracer bolus through the heart, and that of unilateral lung (L) was done from the anterior image of 201Tl on which isocount map of the perfusion image or transmission one was superimposed. By these procedures, the lung uptake ratio of 201Tl was calculated by ratio of L/T, and expressed as percentage per entire unilateral lung and mean value (%) per pixel. The average values of the lung uptake ratio in circulatory diseases were 4.0 +/- 1.2% in the right lung, 2.7 +/- 1.2% in the left lung, and in respiratory diseases 4.5 +/- 2.1% and 2.3 +/- 1.0%, respectively. This technique is useful to quantify the lung uptake of 201Tl on the lung scintigram with 201TlCl.

Using perfusion lung scintigram, motion of the regional pulmonary area and lung edge during ventilation was analyzed in 30 patients with various respiratory diseases. Images at maximal inspiration (I) and expiration (E) were obtained after the intravenous injection of 99mTc macroaggregated albumin (222-370 MBq) using a scintillation camera coupling to a small digital computer. Radioactivity in each pixels (E and I) and number of pixels in the both lungs (AE and AI) were calculated from the image of E and I. Changes of the regional pulmonary radioactivity during ventilation were calculated according to an expression as (E-I)/I, and the image of (E-I)/I was obtained too. The image of (E-I)/I consisted of positive and negative components. The image of positive (E-I)/I visualized the motion of the regional pulmonary area, and sum of positive (E-I)/I in the both lungs was correlated with vital capacity (r = 0.83, p less than 0.001). The image of negative (E-I)/I superimposed with the edges of the lung at maximal inspiration and expiration revealed the limits of the motion of the lung edge during ventilation. These results suggest that this technique is useful to estimate the regional pulmonary ventilation and motion of the lung edge.

In order to evaluate 201Tl-accumulation in lung, 201Tl imaging was performed using a scintillation camera coupling to a small digital computer, and blood clearance of it was examined. After the injection of 74 MBq(2mCi) of 201Tl-chloride, the serial images and static images were obtained. In order to obtain the image of 201Tl in the extravascular space [TE(x, y)], a subtraction technique was performed as follows; after 2 anterior views of 201Tl were obtained using a 20% window centered at 80 keV [T0(x, y)] and 140 keV [T140(x, y)] respectively, and blood sample was taken, radionuclide angiocardiography with 185 MBq (5 mCi) of 99mTc-human serum albumin and it's static image were done in the same supine position and blood sample was taken too. The radioactivity of 201Tl(T) and 99mTc(HB) in the blood was counted by a autogamma scintillation counter. Then the image of TE(x, y) was obtained by the following formula; TE(x, y)=T0(x, y)-[H(x, y)-T140(x, y)]TB/HB. Following results were obtained; (1) The disappearance of 201Tl from the blood was rapid and 15 min after the injection only 10 approximately 15% of the activity after 1 min was present in the blood. (2) The lung activity in the time activity curve decreased rapidly to reach plateau within 100 approximately 150 sec after the injection. (3) The image of 201Tl in the extravascular space was nearly equal to the original one as regard to the radioactivity of 201Tl in lung.

Clinical significance of diffuse lung uptake of 201Tl was studied in 244 cases of various heart diseases. The grade of lung uptake of 201Tl was assessed by total lung uptake ratio (L/T), maximal lung uptake ratio (Max/T), lung to myocardium or mediastinum counts ratio (M/H or M/Med) and visual grade. L/T, Max/T, M/H and M/Med were directly correlated with pulmonary arterial pressure (PCW), and inversely correlated with cardiac output (CO) and cardiac index (CI). Among them, L/T was the best index to assess PCW, that was correlated with PCW (r = 0.65), CO (r = -0.53) and CI (r = -0.45). The visual grade of 201Tl lung uptake was correlated with L/T, and the increased lung uptake was associated with a higher PCW and a lower CO as well as a lower CI. Diffuse increased lung uptake of 201Tl was observed in 29 of 41 cases (70.7%) with myocardial infarction, 25 of 29 cases (86.2%) with mitral valvular diseases and 9 of 10 cases (90.0%) with combined valvular diseases, in addition, in most cases with left heart failure and cases of NYHA 3 and 4, but that was not rarely observed in cases of NYHA 2 and without left heart failure. In heart diseases, 201Tl myocardial scintigraphy seems to be valuable for detection of left heart failure including pulmonary congestion and interstitial pulmonary edema. Total lung uptake ratio (L/T) may be useful for estimation of PCW, and the visual grade of 201Tl lung uptake may be applicable as routine index for grading of lung uptake of 201Tl.