Uso de la tomografía corporal total en pacientes con heridas de arma de fuego y hemodinámicamente inestables: ¿Rompiendo paradigmas de atención inicial? / Whole-body computed tomography in hemodynamically unstable patients with gunshot wounds: A paradigm shift in trauma management?

Introducción. El objetivo del estudio fue analizar el impacto del uso de la tomografía corporal total en la evaluación de los pacientes con trauma penetrante por proyectil de arma de fuego y hemodinámicamente inestables atendidos en un centro de referencia de trauma. Métodos. Se realizó un estudio analítico, retrospectivo, con base en un subanálisis del registro de la Sociedad Panamericana de Trauma ­ Fundación Valle del Lili. Se incluyeron los pacientes con trauma penetrante por proyectil de arma de fuego atendidos entre 2018 y 2021. Se excluyeron los pacientes con trauma craneoencefálico severo, trauma leve y en condición in extremis. Resultados. Doscientos pacientes cumplieron los criterios de elegibilidad, 115 fueron estudiados con tomografía corporal total y se compararon con 85 controles. La mortalidad intrahospitalaria en el grupo de tomografía fue de 4/115 (3,5 %) vs 10/85 (12 %) en el grupo control. En el análisis multivariado se identificó que la tomografía no tenía asociación significativa con la mortalidad (aOR=0,46; IC95% 0,10-1,94). El grupo de tomografía tuvo una reducción relativa del 39 % en la frecuencia de cirugías mayores, con un efecto asociado en la disminución de la necesidad de cirugía (aOR=0,47; IC95% 0,22-0,98). Conclusiones. La tomografía corporal total fue empleada en el abordaje inicial de los pacientes con trauma penetrante por proyectil de arma de fuego y hemodinámicamente inestables. Su uso no se asoció con una mayor mortalidad, pero sí con una menor frecuencia de cirugías mayores.

Introduction. This study aims to assess the impact of whole-body computed tomography (WBCT) in the evaluation of patients with penetrating gunshot wounds (GSW) who are hemodynamically unstable and treated at a trauma referral center. Methods. An analytical, retrospective study was conducted based on a subanalysis of the Panamerican Trauma Society-FVL registry. Patients with GSW treated between 2018 and 2021 were included. Patients with severe cranioencephalic trauma, minor trauma, and those in extremis were excluded. Patients with and without WBCT were compared. The primary outcome was in-hospital mortality, and the secondary outcome was the frequency of major surgeries (thoracotomy, sternotomy, cervicotomy, and/or laparotomy) during initial care. Results. Two hundred eligible patients were included, with 115 undergoing WBCT and compared to 85 controls. In-hospital mortality in the WBCT group was 4/115 (3.5%) compared to 10/85 (12%) in the control group. Multivariate analysis showed that WBCT was not significantly associated to mortality (aOR: 0.46; 95% CI 0.10-1.94). The WBCT group had a relative reduction of 39% in the frequency of major surgeries, with an associated effect on reducing the need for surgery (aOR: 0.47; 95% CI 0.22-0.98). Conclusions. Whole-body computed tomography was employed in the initial management of patients with penetrating firearm projectile injuries and hemodynamic instability. The use of WBCT was not associated with mortality but rather with a reduction in the frequency of major surgery.

Dosis efectivas asociadas a estudios híbridos SPECT-CT en pacientes adultos / Effective dose associated to hybrid SPECT-CT imaging in adult patients / Doses eficazes associadas a estudos de SPECT-CT híbridos em pacientes adultos

Introducción: la técnica de imagen híbrida de SPECT-CT combina la imagen de la tomografía por emisión de fotón único (SPECT) con el estudio de tomografía computada (TC), obteniendo información funcional y anatómica en un mismo estudio. La dosis efectiva total de radiación ionizante recibida en los estudios SPECT-CT puede ser estimada a partir de la dosis efectiva atribuible a la actividad administrada del radiofármaco y la dosis efectiva del componente de tomografía computada (TC). Objetivos: estimar la dosis efectiva total en los protocolos SPECT-CT utilizados en población adulta y determinar el aporte adicional del estudio TC sobre la dosis efectiva total. Método: se evaluaron 258 estudios SPECT-CT para estimar la dosis efectiva total aportada por la administración de los radiofármacos y los estudios de TC de baja dosis. Para estimar el aporte de ambos componentes se utilizaron factores de conversión específicos de cada radiofármaco y región explorada mediante TC. Resultados: la dosis efectiva total (media ± DS) en los estudios SPECT-CT fueron: 12,4 ± 1,44 mSv en el estudio de perfusión miocárdica, 1,14 ± 0,25 mSv en ganglio centinela de mama, 8,6 ± 0,6 mSv paratiroides, 1,48 ± 1,02 mSv tiroides y los estudios óseos de las regiones de cuello 4,5 ± 0,3, tórax 6,07 ± 0,3 mSv, abdomen y pelvis 6,1 ± 0,3 mSv. La dosis de radiación aportada por el estudio TC se encuentra entre 0,46 mSv para la región del tórax en el estudio de ganglio centinela de mama y 2,3 mSv para el SPECT-CT óseo en la región de abdomen y pelvis. Conclusión: se logró estimar la dosis efectiva en los protocolos SPECT-CT de uso clínico más frecuente en población adulta y el aporte de los estudios TC a la dosis efectiva total siendo relativamente baja comparado con la dosis aportada por los radiofármacos administrados con la excepción del estudio de ganglio centinela donde la contribución del componente TC es aproximadamente la mitad de la dosis efectiva total.

Introduction: SPECT-CT Hybrid image technique combines the SPECT (single-photon emission computed tomography) image with the CT (computerized tomography) image to obtain both functional and anatomical images in the same study. The total effective ionizing radiation dose received in SPECT-CT studies may be estimated based on the effective dose from the radiopharmaceutical administered and the effective dose from the CT (computerized tomography) component. Objectives: the study aims to estimate the total effective dose in SPECT-CT protocols applied for the adult population, and to determine the additional contribution from the CT component to the total effective dose. Method: 258 SPECT-CT studies were evaluated to estimate the total effective dose from the administration of radiopharmaceuticals and low dose CT studies. Specific conversion factors for each radiopharmaceutical and area of the body explored with the CT were used to estimate radiation doses from both components. Results: total effective dose (average ± SD) in the SPECT-CT studies was: 12.4 ± 1.44 mSv in the myocardial perfusion study, 1.14 ± 0.25 mSv in the breast sentinel lymph node study, 8.6 ± 0.6 mSv in the parathyroid study, 1.48 ± 1.02 mSv in the thyroid study. As to bone studies, doses found were: 4.5 ± 0.3, in neck studies, 6.07 ± 0.3 mSv in thoracic studies and 6.1 ± 0.3 mSv in abdominal and pelvic studies. The radiation dose from the CT study ranges from 0.46 mSv for the thoracic region on the breast sentinel lymph node study to 2.3 mSv for the bone SPECT-CT study of the abdominal and pelvic region. Conclusions: we managed to estimate the effective dose in the the most frequently used SPECT-CT protocols for the adult population and the contribution of CT studies to the total effective dose. It was found to be relatively low when compared to the dose contributed by the radiopharmaceuticals administered, with the exception of the sentinel lymph node study for which the contribution from the CT study is approximately half the total effective dose.

Introdução: a técnica de imagem híbrida SPECT-CT combina a imagem de tomografia por emissão de fóton único (SPECT) com o estudo de tomografia computadorizada (TC), obtendo informações funcionais e anatômicas no mesmo estudo. A dose efetiva total de radiação ionizante recebida em estudos SPECT-CT pode ser estimada a partir da dose efetiva atribuível à atividade administrada do radiofármaco e da dose efetiva do componente de tomografia computadorizada (TC). Objetivos: estimar a dose efetiva total nos protocolos SPECT-CT utilizados na população adulta e determinar a contribuição adicional do estudo de TC na dose efetiva total. Método : 258 estudos SPECT-CT foram avaliados para estimar a dose efetiva total fornecida pela administração de radiofármacos e estudos de TC de baixa dose. Para estimar a contribuição de ambos os componentes, foram utilizados fatores de conversão específicos para cada radiofármaco e região explorada pela TC. ⁠ Resultados: a dose efetiva total (média ± DP) nos estudos SPECT-CT foi: 12,4 ± 1,44 mSv no estudo de perfusão miocárdica, 1,14 ± 0,25 mSv no linfonodo sentinela mamário, 8,6 ± 0,6 mSv paratireoide, 1,48 ± 1,02 mSv estudos de tireoide e ossos das regiões do pescoço 4,5 ± 0,3, tórax 6,07 ± 0,3 mSv, abdômen e pelve 6,1 ±0,3mSv. A dose de radiação fornecida pelo estudo de TC está entre 0,46 mSv para a região do tórax no estudo do linfonodo sentinela da mama e 2,3 mSv para o SPECT-CT ósseo na região do abdome e pelve. Conclusão: foi possível estimar a dose efetiva nos protocolos de SPECT-CT mais utilizados clinicamente na população adulta e a contribuição dos estudos de TC para a dose efetiva total, sendo relativamente baixa em relação à dose fornecida pelos radiofármacos administrados com a exceção do estudo do linfonodo sentinela onde a contribuição do componente TC é aproximadamente metade da dose efetiva total.

Study of Myocardial Perfusion in Obese Individuals without Known Ischemic Heart Disease / Estudo de Perfusão Miocárdica em Obesos sem Doença Cardíaca Isquêmica Conhecida

Abstract Background: Obesity is associated with an increased risk of type 2 diabetes mellitus (DM), ischemic heart disease (IHD) and cardiovascular mortality. Several studies have demonstrated the diagnostic and prognostic value of single photon computed tomography-myocardial perfusion scintigraphy (SPECT-MPI) in the evaluation of patients with suspected IHD, including in obese population. Data on clinical risk factors and their association with abnormal myocardial perfusion in obese patients are scarce in the Brazilian population. Objective: To determine the factors associated with abnormal myocardial perfusion in obese individuals without known IHD. Methods: We studied obese patients without known IHD who were referred for evaluation through SPECT-MPI between January 2011 and December 2016. Clinical variables and results of SPECT-MPI were obtained systematically. The distribution of continuous variables was assessed using the Shapiro-Wilk and Shapiro-Francia tests. We used the unpaired Student t test to compare the means of continuous variables with normal distribution and the Chi Square test for binomial variables analysis. A p value < 0.05 was considered statistically significant. The association of the clinical variables for the presence of factors associated with abnormal myocardial perfusion was determined by univariate and multivariate logistic regression analysis, and respective odds ratios (OR) and 95% confidence intervals (CI). Results: The study sample consisted of 5,526 obese patients. Mean body mass index (BMI) of our patients was 33.9 ± 3.7 kg/m2, 31% had DM, and myocardial perfusion abnormalities was observed in 23% of the total sample. The factors associated with abnormal myocardial perfusion on multivariate analysis were: age (OR: 1.02, 95% CI 1.01-1.03, p < 0.001), DM (OR: 1.57, 95% CI 1.31-1.88, p < 0.001), typical angina before the test (OR: 2.45, 95% CI: 1.82-3.31, p < 0.001), need for pharmacologic stress test (OR: 1.61, 95% CI: 1.26-2.07, p < 0.001), less physical effort evaluated in metabolic equivalents (METs) during the exercise treadmill test (OR: 0.89, 95% CI: 0.85-0.94, p < 0.001) and a lower post-stress left ventricular ejection fraction after stress (LVEF; OR: 0.989, 95% CI: 0.984-0.994, p < 0.001). Conclusion: The factors associated with abnormal myocardial perfusion in obese patients without known IHD were age, DM, presence of typical angina, ventricular dysfunction, and inability to undergo physical stress as clinical variables, in addition to functional capacity during physical stress.

Resumo Fundamento: A obesidade associa-se a um risco aumentado de diabetes mellitus do tipo 2 (DM), doença cardíaca isquêmica (DCI) e mortalidade cardiovascular. Vários estudos demonstraram o valor diagnóstico e prognóstico da cintilografia de perfusão miocárdica com tomografia computadorizada por fóton único (CPM-SPECT) na avaliação de pacientes com suspeita de DCI, inclusive na população de obesos. Dados sobre fatores de risco clínicos, e sua associação com perfusão miocárdica anormal em obesos, são escassos na população brasileira. Objetivo: Determinar quais são os fatores associados à anormalidade de perfusão miocárdica em obesos sem DCI conhecida. Métodos: Estudamos pacientes obesos sem DCI conhecida que foram encaminhados para avaliação por CPM-SPECT entre janeiro de 2011 até dezembro de 2016. Variáveis clínicas e resultados da CPM-SPECT foram obtidos de forma sistematizada. A distribuição das variáveis contínuas foi avaliada utilizando-se os testes de Shapiro-Wilk e Shapiro-Francia. Utilizou-se o teste t de Student não pareado para comparar as médias das variáveis contínuas com distribuição normal, e o teste do Chi quadrado para análise das variáveis binomiais. Considerou-se o valor de p < 0,05 como estatisticamente significativo. A associação das variáveis clínicas para a presença de anormalidade de perfusão miocárdica foi determinada por análise de regressão logística univariada e multivariada, calculando-se e apresentando-se os respectivos odds ratios (OR) e intervalos de confiança (IC) de 95. Resultados: A amostra do estudo foi de 5.526 pacientes obesos. O índice de massa corporal médio dos nossos pacientes foi de 33,9 ± 3,7 kg/m2, 31% eram portadores de DM, e anormalidades de perfusão foram observadas em 23% do total da amostra. Os fatores associados à anormalidade de perfusão miocárdica, após análise multivariada, foram: idade (OR: 1,02, IC 95%: 1,01-1,03, p < 0,001), DM (OR: 1,57, IC 95%: 1,31-1,88, p < 0,001), presença de angina típica antes do exame (OR: 2,45, IC 95%: 1,82-3,31, p < 0,001), necessidade de utilização de protocolo com estresse farmacológico (OR: 1,61, IC 95%: 1,26-2,07, p < 0,001), menor esforço físico avaliado em equivalentes metabólicos durante o teste ergométrico (OR: 0,89, IC 95%: 0,85-0,94, p < 0,001) e menor fração de ejeção do ventrículo esquerdo após estresse (OR: 0,989, IC 95%: 0,984-0,994, p < 0,001). Conclusão: Os fatores associados à anormalidade de perfusão miocárdica em pacientes obesos sem DCI conhecida foram idade, DM, presença de angina típica, disfunção ventricular e incapacidade para o estresse físico como variáveis clínicas, além da capacidade funcional durante o estresse físico.

Evaluación de la recurrencia de tumores musculoesqueléticos mediante gammagrafía complementada con SPECT/CT con talio-201 en población pediátrica / Evaluation of recurrence of musculoskeletal tumors with thallium-201 scintigraphy plus SPECT/CT in pediatric population

Resumen Introducción: Los estudios de imagen, como la tomografía simple y contrastada, son la primera aproximación diagnóstica para detectar la recurrencia de tumores musculoesqueléticos. El objetivo de este estudio retrospectivo fue demostrar la utilidad de la gammagrafía acoplada a tomografía computarizada por emisión de fotón único (SPECT/CT) con talio-201(201Tl) en la valoración de tumores musculoesqueléticos malignos con sospecha de recurrencia o enfermedad metastásica. Métodos: Se realizaron 72 estudios gammagráficos y de SPECT/CT para la valoración de la recurrencia locorregional y a distancia, al menos 8 semanas tras la última terapia, en 42 pacientes con diferentes tipos de tumores musculoesqueléticos malignos, como osteosarcoma, sarcoma de Ewing, rabdomiosarcoma, retinoblastoma, sarcoma sinovial y tumor de Wilms en el Hospital Infantil de México. Se calcularon el valor predictivo positivo (VPP) y el intervalo de confianza del gammagrama y de la SPECT/CT en comparación con el resultado del análisis histopatológico y el seguimiento clínico y radiológico para identificar la recurrencia. Resultados: La gammagrafía fue anormal en 30 (71.4%) de los 42 pacientes. Se detectaron 33 lesiones (30 pacientes) por gammagrafía y 25 (21 pacientes) por telerradiografía de tórax y tomografía de dos regiones. La SPECT/CT se realizó en 30 pacientes y se detectaron 12 lesiones adicionales al rastreo planar. El VPP con la gammagrafía fue del 82%, y con la SPECT/CT, del 100%. Conclusión: La gammagrafía con 201Tl puede considerarse un estudio adecuado para identificar los sitios de viabilidad tumoral, con alto grado de certeza diagnóstica al complementar con SPECT/CT.

Abstract Background: Imaging studies, particularly simple and contrast-enhanced tomography, constitute the first diagnostic approach to detect recurrence of musculoskeletal tumors. The aim of the present retrospective study was to demonstrate the usefulness of scintigraphy plus SPECT/CT (single photon emission computed tomography) with thallium-201 (201Tl) in the evaluation of malignant musculoskeletal tumors with suspicion of recurrence or metastatic disease. Methods: Eight weeks after the last therapy, 72 scintigraphy and SPECT/CT studies were performed to assess regional recurrence and metastatic disease in 42 patients with different types of malignant musculoskeletal tumors, such as osteosarcoma, Ewing's sarcoma, rhabdomyosarcoma, retinoblastoma, synovial sarcoma, and Wilms tumor at the Hospital Infantil de México Federico Gómez. The positive predictive value (PPV) and the confidence interval of the scintigraphy and SPECT/CT were calculated when compared with the results of the histopathological analysis and the clinical and radiological follow-up for the identification of recurrence. Results: Scintigraphy was abnormal in 30 (71.4%) of the 42 patients; 33 lesions (30 patients) were detected by scintigraphy and 25 lesions (21 patients) by chest X-ray and tomography of two regions. The SPECT/CT was performed on 30 patients, where 12 lesions were detected in addition to the planar scintigraphy. Scintigraphy showed a PPV of 82%; SPECT/CT, 100%. Conclusion: 201Tl-scintigraphy can be considered as an adequate study to identify the sites of tumor viability with a high degree of diagnostic certainty combined with the SPECT/CT technique.

Intrathoracic stomach mimicking bone metastasis from thyroid cancer in whole-body iodine-131 scan diagnosed by SPECT/CT

SUMMARY The whole-body iodine-131 scintigraphy is an imaging technique in monitoring patients with a history of thyroid cancer. Although the rate of false positives is negligible, it is not nonexistent. We report the case of an intervened and treated patient for thyroid cancer with good clinical and biochemical response. Scintigraphic findings were consistent with unsuspected bone metastasis. Fused SPECT/CT data allowed accurate diagnosis of giant diaphragmatic hernia associated with intrathoracic stomach, a very rare pathology that can lead to false positive results.

Evaluación de la capacidad de penetración de partículas a cavidades perinasales usando el nebulizador PARI LC SPRINT® SINUS con técnica modificada en individuos sanos y portadores de rinosinusitis crónica por fibrosis quística con cirugía de cavidades perinasales / Evaluation of the penetration ability into perinasal sinuses of particles using the PARI LC SPRINT® SINUS nebulizer with a modified technique in healthy individuals and in cystic fibrosis patients with chronic rhinosinusitis with endoscopic sinus surgery

Introducción: En pacientes con rinosinusitis crónica (RSC) por fibrosis quística (FQ), los microorganismos que colonizan la vía aérea alta son los mismos que dañan el pulmón. Los tratamientos locales con nebulización de las cavidades perinasales (CPN) serían de ayuda. Objetivo: Evaluar la penetración de las partículas nebulizadas a las cavidades perinasales. Material y método: Voluntarios sanos y pacientes con RSC por FQ con cirugía endoscópica funcional (CEF). Se utilizó el nebulizador pulsátil que PARI LC SPRINT® SINUS. La penetración de partículas a las CPN se evaluó con fusión de imágenes cintigráficas SPECT y de tomografía computarizada (CT). Resultados: Se evaluaron 5 voluntarios y 2 pacientes con FQ. El procedimiento indicado por el fabricante del nebulizador fue imposible de realizar. Se modificó la forma de nebulización. Se observó solo el 9% del material nebulizado en las CPN en voluntarios y el 4% en pacientes. Una proporción importante del material nebulizado se depositó en pulmones y tubo digestivo. Conclusión: Los resultados iniciales motivaron la interrupción del estudio original considerando que sería difícil demostrar la diferencia en la efectividad del nebulizado para alcanzar las CPN entre pacientes con y sin CEF. Además, el depósito mayoritario del nebulizado fuera de las CPN, impide aclarar el valor del efecto local respecto a un posible efecto por vía general.

Introduction: In cystic fibrosis patients with chronic rhinosinusitis, the same microorganisms that colonize the upper airway are the ones who damage the lung. Local treatments by nebulization of perinasal sinuses would be helpful in these cases. Aim: To evaluate the penetration ability of nebulized particles into perinasal sinuses. Material and method: Healthy volunteers and cystic fibrosis patients with chronic rhinosinusitis with endoscopic sinus surgery had nasal nebulization using the pulsating nebulizer PARI LC Sprint® SINUS. Fusion of scintigraphic SPECT and CT images was used to evaluate the particles penetration ability into perinasal sinuses. Results: Five volunteers and 2 patients with CF were evaluated. It was not possible to perform the nebulization procedure as indicated by the manufacturer. A continous nebulization was done instead. 9% of the nebulized material was deposited in the perinasal sinuses in volunteers and 4% in patients with CF, while the rest of the particles were distributed in the body, specially in lungs and digestive tract. Conclusions: The main deposition of the nasal nebulized solution was outside the perinasal sinuses. These results led to discontinuation of the study because it would be difficult to prove a difference in the effectiveness of nebulized particles among patients with and without surgery. It also seems impossible to define the real value of local perinasal sinus therapies considering a probable systemic effect.