A simplified method and a web-based application for the estimation of liquid and solid radioactive waste produced by in vitro nuclear medicine laboratories.

The aim was to develop a web application for the estimation of the radioactivity contained in liquid and solid waste produced by in vitro nuclear medicine laboratories. Median percentages of solid and liquid waste were estimated from successive runs of 44 in vitro kits. This data was fed into a web-based app, which estimates the activity of the waste and provides detailed record keeping. Median liquid/solid waste percentages were 77%/23% for RIA and 95%/5% for IRMA assays. Total waste activities were below regulatory discharge limits.

Absorbed dose estimation to cohabitants and co-travelers of patients treated with radioiodine for differentiated thyroid carcinoma.

OBJECTIVE: Thyroid remnant ablation with radioiodine is a well-established treatment for patients with differentiated thyroid carcinoma (DTC) after thyroidectomy. After hospitalization of approximately 2-4 days, these patients return home presenting a possible radiation hazard to the people around them. This work aims to estimate the possible radiation burden to people (co-travelers and cohabitants) which came in contact with the patients after their release from the hospital, analyzing data obtained during their hospitalization. MATERIALS AND METHODS: Data from 1065 patients were used to estimate the possible radiation burden to family members and people that came in contact with the patients, grouping them according to their age, type of contact with the patient (co-traveler, cohabitant) and patient family status, assuming different exposure scenarios for each group and based on the written precautions given to all patients before discharge. Relations between the iodine effective half-life (Teff), estimated from patient dose rate measurements during hospitalization, patient age and the method used for thyroid preparation for ablation (thyroid hormone withdrawal-THW or administration of recombinant human thyroid stimulating hormone-rhTSH) were also investigated. RESULTS: Median absorbed dose to adult cohabitants was estimated to be 8.3µSv (0.1-117.2µSv), to babies (0-5yr) 15.7µSv (1.2-196.1µSv), to young children (5-10yr) 13.1µSv (0.8-100.7µSv), to children (10-18yr) 8.4µSv (0.5-116.8µSv) and to co-travelers 4.8µSv (0.2-114.9µSv). The highest doses to cohabitants were estimated in the few cases where the patient was a single parent of one or more children (median children dose 28.9µSv, range 11.2-279.4µSv). A statistically significant difference in median Teff between THW (15.1h) and rhTSH (13.9h) patient groups was found. CONCLUSION: Provided necessary precautions are followed, radiation burden to the family members and co-travelers of DTC patients treated with radioiodine following thyroidectomy can be kept well below the corresponding dose limits and constraints.

Quality & safety aspects of nuclear medicine practice: Definitions and review of the current literature.

Current literature records a glaring discrepancy between the rapid developments and progress of medicine and the simultaneous deterioration of the quality and safety of the provided health care services. Bibliographic data as far as perceptions of quality and safety in nuclear medicine departments are concerned, are limited and frequently ambiguous. Most nuclear medicine departments provide the same types of services, but not the same quality of service, while patients' perceptions are not always matched by the perceptions of health care providers. The multidimensional nature of quality and safety, deriving from the different criteria and standards by which different groups of the population attempt to interpret and evaluate them, justifies these discrepancies, over most of quality's and safety's dimensions studied. Nuclear medicine's unique characteristic of using radiopharmaceuticals, exposing to ionizing radiation affects dramatically these perceptions, irrespective of whether quality and safety assurance measures already cover radiation protection, instrumentation maintenance, radiopharmaceutical handling, and the management of all the other aspects of patient care. On the other end of the spectrum, patient-centred practice, communication and proper information play as a well decisive role in ensuring patients' satisfaction.

Transcatheter management of valvular regurgitation beyond the aortic valve (mitral - tricuspid valve): Literature overview and future perspectives.

The growth of the available transcatheter treatment approaches for the mitral and tricuspid position was accompanied by important clinical trials and studies through the last years. The selection of appropriate candidates for transcatheter techniques requires significant insight into anatomical limitations of each patient undergoing clinical evaluation. Furthermore, technological characteristics of the available devices, and risks and benefits of each potential therapy, play the most important role in a physician's decision. This knowledge should be valuable to both interventional cardiologists and researchers. This paper aims to offer a concise overview of the technological advances in this field of Interventional Cardiology. Trials and studies announced at the major interventional cardiology congresses during 2018 and 2019 were systematically reviewed. Moreover, a literature search in PubMed for the same period identified an amount of publications eligible for inclusion, based on their relevance to the subject, and their potential impact on current guidelines of good clinical practice.

Serum leptin, adiponectin and ghrelin concentrations in post-menopausal women: Is there an association with bone mineral density?

OBJECTIVE: Adipokines and ghrelin exert well-documented effects on energy expenditure and glucose metabolism. Experimental data also support a role in bone metabolism, although data from clinical studies are conflicting. The purpose of this cross-sectional study was to investigate the association of serum concentrations of leptin, adiponectin and ghrelin with bone mineral density (BMD) in post-menopausal women. METHODS: BMD in lumbar spine and femoral neck, and circulating leptin, adiponectin and ghrelin concentrations were measured in 110 healthy post-menopausal women. Patients with secondary causes of osteoporosis were excluded. RESULTS: Osteoporosis was diagnosed in 30 (27%) women and osteopenia in 54 (49%). Serum leptin concentrations were positively correlated with both lumbar spine (r=0.343, p<0.01) and femoral neck BMD (r=0.370, p<0.01). Adiponectin concentrations were negatively associated with BMD at both sites (r=-0.321, p<0.01 and r=-0.448, p<0.01 respectively). No significant correlation between ghrelin concentrations and BMD was found. Osteoporotic women had lower body weight, body mass index (BMI) and leptin concentrations, but higher adiponectin concentrations compared with non-osteoporotic women. In multivariate stepwise regression analysis, the association of adiponectin concentrations with BMD remained significant only for femoral neck, after adjustment for body weight or BMI. CONCLUSIONS: An inverse association between adiponectin and femoral neck BMD was found in post-menopausal women, independently of body weight. The positive association between leptin and BMD was dependent on body weight, whereas no effect of ghrelin on BMD was evident.

Complex association between body weight and fracture risk in postmenopausal women.

Osteoporosis is a common disease, characterized by low bone mass with micro-architectural disruption and skeletal fragility, resulting in an increased risk of fracture. A substantial number of studies has examined the possible relationship between body weight, bone mineral density and fracture risk in post-menopausal women, with the majority of them concluding that low body weight correlates with increased risk of fracture, especially hip fracture. Controversies about the potential protective effect of obesity on osteoporosis and consequent fracture risk still exist. Several recent studies question the concept that obesity exerts a protective effect against fractures, suggesting that it stands as a risk factor for fractures at specific skeletal sites, such as upper arm. The association between body weight and fracture risk is complex, differs across skeletal sites and body mass index, and is modified by the interaction between body weight and bone mineral density. Some potential explanations that link obesity with increased fracture risk may be the pattern of falls and impaired mobility in obese individuals, comorbidities, such as asthma, diabetes and early menopause, as well as, increased parathyroid hormone and reduced 25-hydroxy-vitamin D concentrations.

Long-term results of combined approach in parotid sialolithiasis.

Combined sialendoscopic and transcutaneous approach in parotid sialolithiasis is a surgical option for large and impacted stones. The aim of this study is to assess the long-term results regarding postoperative stenosis, recurrent swellings and gland function. Prospective study in a tertiary referral center of patients with parotid sialolithiasis requiring combined approach. A total of 12 patients have been treated within a period of 3 years. Intraductal stents were placed in 9 of 12 cases. Scintigraphic evaluation of salivary glands and follow-up sialendoscopy performed 1 year postoperatively. In total, fourteen stones (two stones in two cases) were successfully removed along with two coexisted inflammatory polyps. Postoperative endoscopic evaluation revealed mild stenosis in 7 out of 12 cases without clinical significance as no recurrent swellings were reported. Scintigraphy showed normal gland function in 11 cases and mild hypofunction in 1 case with long-standing history of sialolithiasis. All patients were free of symptoms within the follow-up period of time (median follow-up 15.5 months). Combined approach is a safe, gland preserving and efficacious procedure in long term. The stenosis in the area of ductal surgical opening when present does not seem to be of clinical value.

Discordance between MRI and bone scan findings in a child with acute complicated osteomyelitis: Scintigraphic features that contribute to the early diagnosis / Discordancia entre los hallazgos de resonancia magnética y gammagrafía ósea en niño con osteomielitis aguda complicada: aportación de patrones gammagráficos característicos en el diagnóstico precoz

Early diagnosis and prompt treatment of acute osteomyelitis are of paramount importance in children because they can prevent irreversible bone damage. Magnetic resonance imaging (MRI) with its superior spatial resolution and lack of ionizing radiation is routinely preferred over bone scan for this purpose. Increased blood flow, hyperemia and focally increased tracer uptake shown by "three phase" bone scan are the typical scintigraphic findings of acute osteomyelitis. In addition, diffuse uptake along the shaft of long bones and focal "cold" lesions are two special features that may be highly suggestive of infective periostitis, soft tissue sepsis and subperiosteal abscess formation, due to the loose attachment of periosteum to bone during childhood. We present a case of complicated osteomyelitis in a child with inconclusive MRI correctly diagnosed on the basis of these special scintigraphic findings resulting in treatment change from double i.v. Vancomycin - Ceftriaxone scheme to surgical intervention (AU)

El diagnóstico precoz y el tratamiento adecuado de la osteomielitis aguda es de suma importancia en los niños, ya que pueden prevenir el daño irreversible del hueso. La resonancia magnética (RM) por su superior resolución espacial y ausencia de radiación ionizante es la técnica utilizada en la práctica habitual antes que la gammagrafía ósea. El aumento del flujo sanguíneo y el incremento de captación focal del radiotrazador mostrado en la gammagrafía ósea de tres fases son los hallazgos gammagráficos típicos de osteomielitis aguda. Además, la captación difusa en la diafisis de huesos largos y una lesión focal "fría" son dos características especiales muy sugerente de periostitis, sepsis en tejidos blandos y formación de un absceso subperióstico, debido a la pérdida de unión del periostio al hueso durante la infancia. Presentamos un caso de osteomielitis complicada en un niño con RM no concluyente correctamente diagnosticada sobre la base de los hallazgos gammagráficos característicos originando el cambio de tratamiento de doble esquema de Vancomicina - ceftriaxona iv a intervención quirúrgica (AU)

Discordance between MRI and bone scan findings in a child with acute complicated osteomyelitis: scintigraphic features that contribute to the early diagnosis.

Early diagnosis and prompt treatment of acute osteomyelitis are of paramount importance in children because they can prevent irreversible bone damage. Magnetic resonance imaging (MRI) with its superior spatial resolution and lack of ionizing radiation is routinely preferred over bone scan for this purpose. Increased blood flow, hyperemia and focally increased tracer uptake shown by "three phase" bone scan are the typical scintigraphic findings of acute osteomyelitis. In addition, diffuse uptake along the shaft of long bones and focal "cold" lesions are two special features that may be highly suggestive of infective periostitis, soft tissue sepsis and subperiosteal abscess formation, due to the loose attachment of periosteum to bone during childhood. We present a case of complicated osteomyelitis in a child with inconclusive MRI correctly diagnosed on the basis of these special scintigraphic findings resulting in treatment change from double i.v. Vancomycin--Ceftriaxone scheme to surgical intervention.

Multivessel spontaneous dissection of the left coronary tree in the postpartum period: case report and review of the literature.

Spontaneous coronary artery dissection is a rare cause of myocardial infarction predominantly associated with young women during the third trimester of pregnancy or during the postpartum period. Multivessel spontaneous coronary artery dissection is an even less frequent condition with limited reports in medical literature. Hormonal changes as well as hemodymanic stress are some of the factors that have been implicated in the etiology of this condition. However, the exact pathophysiological process leading to spontaneous coronary artery dissection has not yet been elucidated. The spectrum of clinical presentation ranges from mild symptoms to cardiac arrest. Herein, we report the case of a 39-year-old woman with spontaneous two coronary vessel dissection during her postpartum period presented with ST elevation myocardial infarction on electrocardiogram complicated with pulmonary edema and cardiorespiratory arrest.

Complex coronary artery anatomy in a patient with prolapsing left atrial myxoma.

The case of an asymptomatic patient with prolapsing left atrial myxoma, in whom preoperative coronary angiography revealed a rare coronary artery anatomy in the absence of atherosclerotic obstructive disease, is presented. There was a type IV dual left anterior descending (LAD) artery with intraseptal course of the right aortic sinus-connected (long) LAD artery and an ectopic left circumflex artery originating from the right aortic sinus and having a retroaortic course. The patient underwent successful surgical excision of the mass which was confirmed by histology to be cardiac myxoma. This particular coronary artery anatomy has only been described once, and this is the first reported case of its combination with cardiac myxoma. This report highlights the importance of differentiating between the possible courses of such ectopic coronary arteries. The angiographic signs which enabled differentiation of the intraseptal course of the long LAD artery from the malignant interarterial course with which it is frequently confused are presented.

Isolated right ventricular infarction during percutaneous coronary intervention.

Isolated right ventricular infarction (RVI) is an increasingly recognized cause of precordial ST-segment elevation (STE). A patient is described who developed STE in leads V1-V5 secondary to occlusion of the right ventricular branch during stent angioplasty to the right coronary artery. The pattern of precordial STE was thought to be suggestive of anteroseptal myocardial infarction because of progressive STE toward lead V3. Repeat angiography disclosed a patent left anterior descending artery. Subsequent scrutiny of the electrocardiogram (ECG) revealed that leads V2 and V3 were switched and ECG interpretation considering this technical error revealed STE in V2>V3, which favored RVI. Furthermore, the mean spatial ST vector was approximately +120° in the frontal plane producing ST-segment depression in lead I which argued against anteroseptal myocardial infarction and indicated right ventricular epicardial injury. This report highlights that analysis of the ECG using vector concepts is a useful adjunct to pattern recognition for the diagnosis of RVI.

New strategies in the treatment of coronary bifurcations.

Despite major improvements in stent technology (i.e., drug-eluting stents, DES), treatment of coronary bifurcations is an ever occurring problem of the interventional cardiology. While stenting the main branch with provisional side branch stenting seems to be the prevailing approach, in the era of DES various two-stent techniques emerged (crush) or were re-introduced (V or simultaneous kissing stents, crush, T, culottes, etc.) to allow stenting in the side branch when needed. New techniques in imaging like optical coherence tomography help in better understanding bifurcation anatomy and, thus, have the potential to help us better treat this challenging subset of lesions. In addition, new dedicated bifurcation stents have been proposed in an attempt to overcome limitations associated with current approaches, and they showed promising results in early studies; however, the safety and the efficacy of these devices remain to be seen in the ongoing and upcoming trials. This review focuses on the current approaches and the development of new techniques employed for the treatment of bifurcation disease.

Anosmia after general anaesthesia: a case report.

Although anaesthetic drugs are included among the aetiological factors of anosmia, limited reports exist of anosmia induced by general anaesthesia. We present the case of a 60-year-old female patient with a 3-month history of altered smell and taste immediately after recovery from general anaesthesia for a urological operation. The anaesthetic drugs used were fentanyl, propofol and sevoflurane. Clinical examination and a computed tomography brain scan did not reveal any pathology. Psychophysical testing showed anosmia and normal taste function. Imaging studies using single photon emission computed tomography of the brain were performed twice: as a baseline examination; and after odour stimulation with phenyl ethyl alcohol. Normal brain activity without reaction to odorous stimuli suggested peripheral dysfunction or stimuli transmission problems. The patient, after four months of olfactory retraining, demonstrated significant improvement. The onset of the dysfunction in relation with the imaging findings may imply that anaesthetics could induce the olfactory dysfunction.

Treatment of bifurcation lesions with two stents: one year angiographic and clinical follow up of crush versus T stenting.

OBJECTIVES: To compare long term outcomes of the crush versus the T technique in bifurcation lesions. DESIGN: 182 consecutive patients were identified who underwent percutaneous coronary interventions for bifurcation lesions with drug eluting stents between April 2002 and January 2004. Two techniques were used according to the operator's discretion: crush (group C, n = 121) or T (group T, n = 61). RESULTS: In-hospital outcome differed significantly between the two groups. Angiographic follow up was available for 142 (78%) patients. Groups C and T did not differ significantly regarding late loss (0.42 (0.39) mm v 0.34 (0.35) mm, p = 0.52) and rate of restenosis (16.2% v 13.0%, p = 0.80) in both the main and the side branch without final kissing balloon post-dilatation. However, when final kissing balloon post-dilatation was performed, group C had significantly lower late lumen loss (0.23 (0.21) mm v 0.37 (0.33) mm, p = 0.02) and restenosis rate (8.6% v 26.5%, p = 0.04) in the side branch. At one year's clinical follow up, group C compared with group T had lower rates of target lesion revascularisation (14.0% v 31.1%, p = 0.01) and target vessel revascularisation (16.5% v 32.8%, p = 0.02). CONCLUSIONS: In non-selected bifurcation lesions treated with drug eluting stents, the restenosis rate remains relatively high in the side branch. Compared with the T stenting technique, crush stenting with kissing balloon post-dilatation is associated with a reduced rate of restenosis in the side branch.

Somatostatin receptor expression in vivo and response to somatostatin analog therapy with or without other antineoplastic treatments in advanced medullary thyroid carcinoma.

The long-term treatment of metastatic medullary thyroid carcinoma (MTC) with somatostatin (SST) analogs was evaluated in 22 patients with persistant or relapsed disease and with in vivo positive SST receptor (SSTR) tumors. After surgical intervention all patients but one, initially or at a later time, had persistenly (15) or after relapse (7) elevated serum calcitonin (CT, 252-69482 pg/ml) and carcinoembryonic antigen (CEA, 8-1130 ng/ml) concentrations; also, all of them showed positive uptake in 111In-pentetreotide scanning. Daily doses of 0.4-1.0 mg octreotide subcutaneously, or monthly doses of 20-30 mg long-acting octreotide (LAR) intramuscularly for 3-21 months were administered. Systemic chemotherapy (Ch) with or without external radiotherapy (eRT) was given to 13 patients simultaneously. A beneficial effect on pre-existing diarrhea was observed in 8 patients (subjective partial remmission, sPR 36.4%); 10 other patients showed stable disease, while in 4 a worsening of pre-existing diarrhea was observed. CT and CEA concentrations decreased more than 25% in 4 out of 22 patients (18%) and 11 patients showed a decrease of less than 25% (biological SD). No objective response in tumour growth was demonstrated. Patients (10 survivors in group B) treated with Ch+eRT plus Octerotide showed higher sR (92.5%), lower mortality (23.1%), longer mean time to death (130 months) and longer mean total survival (mts) time (145 months) in comparison to group A patients who had 66.7% sR, 33.3% mortality, only 88.5 months mean time to death and 101 months mts-time. Long-term octreotide and octreotide-LAR treatment offers a subjective and biological partial remission in one third and in one fourth of the MTC patients respectively, but it does not improve the natural course of the tumor. It remains to be answered if these drugs, combined with other antineoplastic therapies, have a synergistic effect relating to treatment response and to patient survival and mortality.