Sources of error in direct radionuclide cystography in children and the need for a standardized, manometric apparatus.

Direct radionuclide cystography (DRC) is a safe and reliable method for the detection and follow-up of vesico-ureteral reflux (VUR). Since the first DRC was performed, during the early 60s, the method has undergone many refinements. Themanometric approach, which was first introduced in 1984, provides a correlation between the bladder pressure and VUR visualization. In this study the sources of error that may alter the results of DRC are discussed and a novel, standardized low costmanometric apparatus is suggested.

Anastomotic Leak and Perioperative Outcomes of Esophagectomy for Esophageal Cancer during the COVID-19 Pandemic: A Systematic Review and Meta-Analysis.

Background and Objectives: The coronavirus disease-2019 (COVID-19) pandemic influenced the healthcare system tremendously, as well as the number of elective surgical procedures worldwide. The aim of this study is to investigate the COVID-19 pandemic's impact on esophagectomies. Materials and Methods: The MEDLINE (via PubMed), Cochrane Library, and Google Scholar bibliographical databases were systematically searched. Original clinical studies investigating the outcomes of esophageal cancer surgery during the COVID-19 pandemic were deemed eligible. After exclusion criteria were applied, eight studies were considered eligible for inclusion. Results: Eight studies with non-overlapping populations, reporting on patients undergoing esophagectomy for resectable esophageal cancer during the COVID-19 pandemic, were included in our analysis, with a total of 18548 patients. Background characteristics for age, lung disease, smoking history as well as Body Mass Index and age were equal among the groups. The background of diabetes presented a statistically significant difference among the groups. Perioperative outcomes like reoperation rates, the length of intensive care unit stay, or readmission rates were not significantly increased during the pandemic. The 30-day readmission, and 30- and 90-day mortality were not affected either. The length of hospital stay was significantly lower in the non-pandemic period. Conclusions: The results of our study support the evidence that in the context of the COVID-19 pandemic, esophageal cancer operations took place safely and effectively, similarly to the standards of the non-COVID-19 era.

Vitamin D Alleviates Anxiety and Depression in Elderly People with Prediabetes: A Randomized Controlled Study.

Older people are prone to frailness, present poor adherence to pharmacotherapy, and often have adverse drug effects. Therefore, it is important to develop effective and safe interventions to mitigate the burden of anxiety and depression disorders in this population. The aim of this study was to investigate the effect of vitamin D supplementation on the anxiety and depression status of elderly people with prediabetes. Participants were randomly assigned a weekly dose of vitamin D3 of 25,000 IU (n = 45, mean age 73.10 ± 7.16 years) or nothing (n = 45, mean age 74.03 ± 7.64 years), in addition to suggested lifestyle measures. The State-Trait Anxiety Inventory subscales (STAI-T and STAI-S) and the Patient Health Questionnaire-9 (PHQ-9) were used to evaluate anxiety and depression levels, respectively, at baseline, 6, and 12 months. A total of 92.68% of the participants in the vitamin D group and 97.14% of the controls exhibited vitamin D deficiency (<20 ng/mL) at baseline. Mean STAI-T scores were lower in supplemented individuals than in the control group at 6 (38.02 ± 9.03 vs. 43.91 ± 7.18, p = 0.003) and 12 months (32.35 ± 7.77 vs. 44.97 ± 7.78, p < 0.001). The same pattern was evident for STAI-S scores at 6 (37.11 ± 7.88 vs. 43.20 ± 9.33, p = 0.003) and 12 months (32.59 ± 6.45 vs. 44.60 ± 9.53, p < 0.001). Supplemented participants demonstrated lower mean PHQ-9 scores compared to controls at 6 (15.69 ± 6.15 vs. 19.77 ± 8.96, p = 0.021) and 12 months (13.52 ± 5.01 vs. 20.20 ± 8.67, p < 0.001). Participants with deficiency and insufficiency at baseline experienced equal benefits of supplementation in terms of anxiety and depression scores. In conclusion, in a high-risk population, a weekly vitamin D supplementation scheme was effective in alleviating anxiety and depression symptoms. More studies are needed to elucidate the relevant mechanisms.

Blood pressure and glomerular filtration rate in youth with tuberous sclerosis complex.

Renal involvement is very common in tuberous sclerosis complex (TSC) and is characterized by the development of angiomyolipoma and cysts. The aims of the present study were to assess kidney function and clinical features of renal involvement in TSC, including kidney function and blood pressure (BP) levels in children, adolescents and young adults. Non-selected patients with a definite diagnosis of TSC attending the paediatric neurology outpatient department of a tertiary hospital were included in a cross-sectional study. All participants had a renal imaging study within 6 months of ambulatory blood pressure (BP) and glomerular filtration rate (GFR) assessment. Data on demographics, history, genotype, kidney function at diagnosis and last imaging were collected. Twenty patients were enrolled in this study with a median age of 15 years (IQR range 9 to 18). About 23.5% of the participants had ambulatory hypertension. Systolic BP levels correlated significantly with GFRDTPA values despite the absence of hyperfiltration. Patients that developed hypertension and possibly those with angiomyolipoma or cysts had higher GFR levels in childhood and adolescence. All the patients with ambulatory hypertension had angiomyolipoma or cysts on renal imaging studies. CONCLUSIONS: Hypertension may present with increased frequency in young patients with kidney disease associated with TSC. Routine ambulatory BP measurement should be part of the annual clinical assessment in patients with TSC. WHAT IS KNOWN: • Nearly half of the patients with TSC have a premature decline in their renal function in their fifth decade of life. • Hypertension and hyperfiltration have been proposed as modifiable factors of progression of renal decline in patients with TSC-related renal disease. WHAT IS NEW: • Hypertension is prevalent in youth with tuberous sclerosis complex. • SBP levels have a positive relation with GFR levels within the normal range of GFRDTPA values.

Cholethorax with biliopleural communication detected on [99mTc]mebrofenin hepatobiliary scintigraphy.

Bilious pleural effusion or cholethorax is a rare type of exudative pleural effusion. Here is presented a case of right-sided cholethorax, in which the direct communication between the pleural effusion with the biliary duct was visible only on the posteriori images of dynamic hepatobiliary scintigraphy with [99mTc]mebrofenin.

Radionuclide techniques for the detection of vesicoureteral reflux and their clinical significance.

We discuss and try to evaluate the detection of vesicoureteral reflux (VUR) by radionuclide techniques and especially direct radionuclide cystography (DRC). Direct radionuclide cystography is applied for more than half a century mainly in children. Vesicoureteral reflux has a complex pathology not yet completely understood and is often related to urinary tract infection (UTI) and renal parenchyma scarring that can lead to long-term renal function impairment. Since there is no consensus on the optimal imaging algorithm after the first febrile urinary tract infection, many imaging strategies have been proposed for VUR detection in the last decade, including or not DRC. Views opposing or accepting its use are also presented.

Myocardial ischemia in female patients with rheumatoid arthritis assessed with single photon emission tomography-myocardial perfusion imaging.

BACKGROUND: Non-specific cardiac symptoms in female patients with rheumatoid arthritis (RA) could indicate early cardiovascular disease. MATERIALS AND METHODS: Myocardial perfusion imaging (MPI), with 99mTc tetrofosmin stress-rest single photon emission computer tomography (SPECT), in 13 RA female patients with atypical cardiac symptoms, was compared to 44 weight- and age-matched females with similar cardiac complaints (control group). Smoking, hypertension, diabetes mellitus, dyslipidemia, obesity and cardiac heredity were recorded and compared between the study and control group. MPI was assessed using 17 segment polar map and with a scale of 0 to 5 scoring. RESULTS: Patients with RA demonstrated higher cardiovascular risk (46%) compared to control individuals (17%). In addition, patients with RA had more irreversible myocardial ischemic abnormalities in their MPI than the control group. Dyslipidemia and obesity was found more frequent in RA patients with MPI SSS ≥ 4. CONCLUSION: RA patients with atypical cardiac complaints are at higher risk for cardiovascular disease; early detection and monitoring of this patient group could potentially reverse or successfully manage the consequences of the upcoming cardiovascular disease.

Comparison of creatinine and cystatin formulae with 51 Chromium-ethylenediaminetetraacetic acid glomerular filtration rate in patients with decompensated cirrhosis.

BACKGROUND AND AIM: Evaluation of renal function, that is, glomerular filtration rate (GFR), has become very important, but conventional mathematical formulae for GFR assessment are inaccurate in patients with cirrhosis. The aim of the present study was to compare serum creatinine (sCr)-based and serum cystatin C (cysC)-based estimated GFR (eGFR) formulae with 51 Chromium-ethylenediaminetetraacetic acid GFR (51 Chr-GFR) in patients with stable decompensated cirrhosis. METHODS: In 129 Caucasian patients with decompensated cirrhosis, we assessed sCr-based GFRs [Modification of Diet in Renal Disease and chronic kidney disease-epidemiology (CKD-EPI)-sCr formulae], cysC-based GFRs [Hoek, Larsson, and CKD-EPI-cysC equations], and the mathematical formulae, which combined both sCr and cysC [i.e. CKD-EPI-sCr-cysC and the specific for cirrhotics formula recently proposed by Mindikoglu et al. (Mindikoglu-eGFR)]. Multivariate linear regression analysis was used for GFR predictors in our cohort. RESULTS: The correlations between 51 Chr-GFR and all mathematical formulae were good (Spearman r2 > 0.68, P < 0.001). Modification of Diet in Renal Disease and CKD-EPI-sCr had lower bias (6.6 and -4.8, respectively), compared with the other eGFRs, while Mindikoglu-eGFR and CKD-EPI-sCr-cysC formulae had greater precision (17.1 and 17.3, respectively), compared with the other eGFRs. CKD-EPI-sCr and Mindikoglu-eGFR had higher accuracy (39% and 41%, respectively), compared with the other eGFRs. The factors independently associated with the 51 Chr-GFR were age, cysC, and sCr, and the new derived formula had lower bias (0.89) and similar precision (17.2) and accuracy (41%) with Mindikoglu-eGFR formula. CONCLUSION: The specific mathematical formulae derived from patients with cirrhosis seem to provide superior assessment of renal function, compared with the conventional used sCr-based and cysC-based formulae.

The diagnostic performance of (99m)Tc-HMPAO radiolabeled leucocytes scintigraphy in the investigations of infection. A single center experience.

OBJECTIVE: This study aims to evaluate the diagnostic efficacy of (99m)Tc-HMPAO-labeled white blood cells scintigraphy (RL-WBC scan) in a variety of infectious processes. Despite the technical difficulties of labeling WBCs without altering their viability/pathophysiologic integrity and the lengthy imaging procedure, the RL-WBC scan has gained an evolving role in the detection of occult infection. METHODS: Retrospective review of 66 patient files (34 males and 32 females) that underwent this functional imaging test from September 2013 until September 2015. Their mean age was 58.39±18.63 (range: 11-84) years. Twenty seven of them were investigated for fever of unknown origin, 6 with suspicion of inflammatory bowel disease, 9 with aneurysm of celiac artery before or after abdominal endovascular aortic repair, 6 with joint prostheses, 5 with diabetic angiopathy, and 13 had rather undefined symptoms. RESULTS: The mean labeling yield of the leukocytes with the lipophilic complex (99m)Tc-HMPAO was 57.4±8.6. The RL-WBC scan was positive in 39/66 patients, including 16/27 patients with fever of unknown origin and 8/9 patients with aortic aneurysm/graft infection. It showed expected/suspected localization of radioactivity in 23 patients, whereas 11 of them had equivocal signs of infection. In 16 patients, a significant change in patients' management was conferred, as non-suspected locations of inflammatory process were detected, based on early functional alterations derived from leukocyte recruitment. CONCLUSION: The RL-WBC scan (i) is extremely useful in the diagnosis of perigraft tissue infection and osteomyelitis (except for spine) with high rate of sensitivity and specificity (≈90%) when timely used, and (ii) may provide valuable information in patients with fever of unknown origin, inflammatory bowel disease or vague symptoms. False positive results have been noticed mainly due to artifacts, co-existent skeletal lesions or in the early postoperative course because of the nonspecific radionuclide uptake in the healing tissue. On the other hand, false negative results may appear in delayed aortic graft infection, etc. Difficulties arise in the discrimination between infection and sterile inflammatory lesions accompanying atheromatosis or grafts/prostheses. Our experience shows that there should take place a closer co-operation between nuclear medicine physicians and clinicians to ensure the rational selection of the patients that would benefit from this complex diagnostic procedure, in order to get the optimal results concerning in vivo inflammation/abscess visualization.

A probabilistic assessment of the diagnosis of paraganglioma/pheochromocytoma based on clinical criteria and biochemical/imaging findings.

UNLABELLED: Paragangliomas (PGL) and pheochromocytomas (P) are rare neural-crest-derived neoplasms. Very recently guidelines on diagnosis and treatment of PGL/P have been presented by the US Endocrine Society. In the following overview we assessed the implementation of these guidelines with probabilistic reasoning (calculating with Fagan nomograms the post-test probability of PGL/P for a given pre-test probability). CONCLUSION: Biochemical evaluation of PGL/P showed excellent diagnostic characteristics with post-test probabilities that are very different from the pre-test probabilities, thus a positive biochemical test is usually indicative of disease whereas a negative one usually rules out disease. The post-test probabilities of anatomical and functional imaging modalities (i.e. in nuclear medicine) were different from the pre-test probabilities but to a lesser degree than the biochemical tests; furthermore in biochemically-proven PGL/P a negative imaging modality is not useful, while a positive one may indicate only one of multiple foci of metastatic/extra-adrenal disease. Thus, regarding imaging modalities, they should be combined in order to get the most of their characteristics for the localization of PGL/P.

Umbilical metastasis as primary manifestation of cancer: a small series and review of the literature.

Umbilical metastasis is a rare manifestation of intra-abdominal cancer. It appears either as the first sign of a primary malignancy or as metastatic site of an already diagnosed cancer, representing an ominous prognostic finding. We report three cases of umbilical metastasis as the first sign of an underlying malignancy. Hypotheses about pathophysiology of umbilical metastasis are based on the embryological origin of the umbilicus and its residual communication with systematic, portal and lymphatic circulation.

Emotional impairment in a patient with amyotrophic lateral sclerosis: a (99m)Tc-HMPAO SPET brain study.

Behavioral abnormalities have been reported in patients with amyotrophic lateral sclerosis (ALS) but their aetiology is not yet clearly defined. We report on the case of a 48 years old woman with long standing bulbar onset ALS referred to our department for brain perfusion scan for the evaluation of behavioral and emotional disorders. The patient's scores on the neuropsychological tests were satisfactory while magnetic resonance imaging showed no structural brain abnormalities. However, cerebral blood flow imaging with single photon emission tomography with technetium-99m-hexamethyl propylamine oxime demonstrated bilateral frontal cortex hypoperfusion, as well as perfusion defects in the left parietal, temporal and occipital lobes. In conclusion, the reduced regional cerebral blood flow in the frontal lobes might be suggestive of underlying cortical disturbance and potentially explain the patient's symptoms.

A "reverse" Maffucci's syndrome: case report and short review of the literature.

Maffucci's syndrome is a congenital, non-hereditary mesodermal dysplasia associated with multiple enchondromas and after some years accompanied by hemangiomas. We describe a rare case of "reverse" Maffucci's syndrome in a 42-year-old woman who has suffered from multiple hemangiomas for the last 24 years. The last two years she complained for heel pain. Bone scintigraphic examination showed abnormal findings in the left calcaneal bone. The scintigraphy, radiology and histology findings revealed multiple enchondromas, so the diagnosis was changed into Maffucci's syndrome. After one year, the left calcaneal bone showed sarcomatous transformation.