Concordance between freehand SPECT and conventional scintigraphy for sentinel lymph node detection in breast cancer.

INTRODUCTION: Freehand SPECT can be a useful imaging technique for preoperative planning of sentinel lymph node biopsy (SLNB) as it allows localization of the sentinel node by 3D and real-time tomographic imaging and determines its depth after a few minutes of scanning. The aim of the study was to evaluate the correlation between the number of detected SNs between freehand SPECT images and lymphoscintigraphy (LS). MATERIALS AND METHODS: 100 patients with a diagnosis of invasive breast cancer and no clinical evidence of lymph node involvement prospectively underwent SLNB. The preoperative study included freehand SPECT imaging at 15min after injection and LS imaging at 25 and 60-90min after injection (early and late). The observed agreement was analyzed and a concordance study was performed between the number of SNs detected with freehand SPECT and LS. RESULTS: The observed agreement in the detection of SNs between freehand SPECT and early LS was 72%; between freehand SPECT and late LS was 85%; and between early and late LS was 87%. In the concordance study, there was moderate concordance between freehand SPECT and early LS (kappa coefficient: 0.42); moderate-high concordance between freehand SPECT and late LS (kappa coefficient: 0.60); and moderate-high concordance between early and late LS (kappa coefficient: 0.70), with no significant differences between them (p-value=0.16). CONCLUSION: Freehand SPECT showed a moderate-high concordance with conventional imaging studies and could be a valid alternative for the presurgical study of SLNB in breast cancer.

Early molecular diagnosis of acute Chagas disease after transplantation with organs from Trypanosoma cruzi-infected donors.

Organ transplantation (TX) is a novel transmission modality of Chagas disease. The results of molecular diagnosis and characterization of Trypanosoma cruzi acute infection in naïve TX recipients transplanted with organs from infected deceased donors are reported. Peripheral blood and cerebrospinal fluid samples from the TX recipients of organs from infected donors were prospectively and sequentially studied for detection of T. cruzi by means of kinetoplastid DNA polymerase chain reaction (kDNA-PCR). In positive blood samples, a PCR algorithm for identification of T. cruzi Discrete Typing Units (DTUs) and quantitative real-time PCR (qPCR) to quantify parasitic loads were performed. Minicircle signatures of T. cruzi infecting populations were also analyzed using restriction fragment length polymorphism (RFLP)-PCR. Eight seronegative TX recipients from four infected donors were studied. In five, the infection was detected at 68.4 days post-TX (36-98 days). In one case, it was transmitted to two of three TX recipients. The comparison of the minicircle signatures revealed nearly identical RFLP-PCR profiles, confirming a common source of infection. The five cases were infected by DTU TcV. This report reveals the relevance of systematic monitoring of TX recipients using PCR strategies in order to provide an early diagnosis allowing timely anti-trypanosomal treatment.

Doctor, my patient has CDI and should continue to receive antibiotics. The (unresolved) risk of recurrent CDI.

Recurrence rate ranges from 12% to 40% of all cases of Clostridium difficile infection (CDI) and proposes an exceptional clinical challenge. Conventionally, treatment options of CDI have been limited to regimes of established antibiotics (eg, pulsed/tapered vancomycin) or "improvised" alternative antibiotics (eg. teicoplanin, tigecycline, nitazoxanide or rifaximin) occasionally even in combination, but faecal microbiota transplantation is emerging as a useful and quite safe alternative. In recent years, promising new strategies have emerged for effective prevention of recurrent CDI (rCDI) including new an-timicrobials (eg, fidaxomicin) and monoclonal antibodies (eg, bezlotoxumab). Despite promising progress in this area, difficulties remain for making the best use of these resources due to uncertainty over patient selection. This positioning review describes the current epidemiology of rCDI, its clinical impact and risk factors, some of the measures used for treating and preventing rCDI, and some of the emerging treatment options. It then describes some of the barriers that need to be overcome.

Experience of a fungal infection after cardiac surgery. / Infección fúngica tras cirugía cardiaca. Nuestra experiencia.

INTRODUCTION AND OBJECTIVES: Patients undergoing cardiac surgery can have post-operative complications, including infections. The aim of this article was to study the incidence, severity and risk factors of invasive candidiasis in these patients, based on the hypothesis that several factors (multiple transfusions and time on extracorporeal circulation) are related to invasive candidiasis. MATERIAL AND METHODS: The study included a prospective analysis of 669 patients undergoing scheduled cardiac surgery from April 2016 to December 2017. Control cultures were collected on admittance to the Surgical Intensive Care Unit. RESULTS: The incidence of invasive candidiasis was 2.69%, being confirmed in 1.79% of cases. The most frequently isolated Candida species was Candida auris. Mortality rate in the invasive candidiasis group was 11% in the immediate post-operative period and 22% at 30 days. After the univariate study, a statistically significant relationship was found between invasive candidiasis and multiple transfusions (OR 15.86; 95% CI: 5.15-69.4; p<.001). A statistically significant relationship was also found with other known risk factors in hospitalised patients. CONCLUSIONS: Multiple transfusions are associated with an increased risk of invasive candidiasis. Surveillance measures for fungal infection in patients with risk factors undergoing cardiac surgery should be implemented in hospitals with a high incidence of candidiasis.

Awareness with recall during general anaesthesia: a prospective observational evaluation of 4001 patients.

BACKGROUND: We have prospectively evaluated the incidence and characteristics of awareness with recall (AWR) during general anaesthesia in a tertiary care hospital. METHODS: This study involves a prospective observational investigation of AWR in patients undergoing general anaesthesia. Blinded structured interviews were conducted in the postanaesthesia care unit, on postoperative day 7 and day 30. Definition of AWR was 'when the patient stated or remembered that he or she had been awake at a time when consciousness was not intended'. Patient characteristics, perioperative, and drug-related factors were investigated. Patients were classified as not awake during surgery, AWR, AWR-possible, AWR-not evaluable. The perceived quality of the awareness episode, intraoperative dreaming, and sequelae were investigated. The anaesthetic records were reviewed to search for data that might explain the awareness episode. RESULTS: The study included 4001 patients. Incidence of AWR was 1.0% (39/3921 patients). If high risk for AWR patients were excluded, the incidence was 0.8%. After the interview on the seventh day, six patients denied having been conscious during anaesthesia; hence, the incidence of AWR in elective surgery was 0.6%. Factors associated with AWR were: anaesthetic technique incidence of 1.1% TIVA-propofol vs 0.59% balanced anaesthesia vs 5.0% O2/N2O-based anaesthesia vs 0.9% other anaesthetic techniques (mainly propofol boluses for short procedures), P=0.008; age (AWR 42.3 yr old vs 50.6 yr old, P=0.041), absence of i.v. benzodiazepine premedication (P=0.001), Caesarean section (C-section) (P=0.019), and surgery performed at night (P=0.013). More than 50% of patients reported intraoperative dreaming in the early interview, mainly pleasant. Avoidable human factors were detected from the anaesthetic records of most patients. Subjective auditory perceptions prevailed, together with trying to move or communicate, and touch or pain perception. CONCLUSIONS: A relatively high incidence of AWR and dreams during general anaesthesia was found. Techniques without halogenated drugs showed more patients. The use of benzodiazepine premedication was associated with a lower incidence of AWR. Age, C-section with general anaesthesia, and surgery performed at night are risk factors.

[Contribution of a portable hand-held miniature gamma camera in surgical treatment of primary hyperparathyroidism]. / Aportación de una minigammacámara portátil en el tratamiento quirúrgico del hiperparatiroidismo primario.

Primary hyperparathyroidism diagnosis and radioguided surgery by (99m)Tc-MIBI scintigraphy have become more generalized during recent years. The recent creation of a new portable hand-held miniature gamma camera opens new perspectives for this technique. We present a preliminary study of three patients with primary hyperparathyroidism in whom intraoperative scintigraphy with portable hand-held miniature gamma camera has been shown to be useful.

[Discrepancy between clinical and radiologic manifestations of an epidural hematoma after catheterization]. / Discordancia clínico-radiológica y resolución espontánea de un hematoma postcateterización epidural.

Neuraxial techniques are considered safe if certain guidelines are followed, but they are not risk free. We report the case of an 81-year-old woman with an invasive bladder tumor who underwent radical cystectomy with a Bricker-type procedure. General anesthesia was used and epidural analgesia was also provided for surgical and postoperative pain management. Late in the postoperative recovery period a large epidural hematoma was diagnosed based on radiologic signs of spinal cord compression, in the absence of symptoms other than mild and progressive back pain that developed after extubation. The surgeon decided against emergency surgery to reduce compression. Symptoms resolved gradually, and a magnetic resonance image 45 days after discharge confirmed that the hematoma was smaller. In addition to the usual safety recommendations for epidural anesthesia with regard to drugs that alter hemostasis, it is important to bear in mind circumstances that have pharmacokinetic repercussions and that increase risk. Lower back pain can be a warning sign. Some cases may resolve spontaneously.

[Determination of dose calibrator setting of the capintec CRC-35R for samarium-153]. / Determinación del factor de calibración para el samario-153 en el activímetro de dosis CRC-35R.

OBJECTIVE: The aim of this work is to determine the calibration factor for Sm-153 and evaluate the influence of the geometry in the activity measurements in order to administer accurately the activity to the patient. METHODS: The calibration factor for Sm-153 was determinated using the Sm-153 sources commonly used in clinical practice and the calibrator response in a known calibration setting. The geometry correction factor for the vial and the plastic syringe was calculated using the real activity indicated by the manufacturer and the activity measured in the vial and in the plastic syringe. RESULTS: The calibration factor obtained is 239 +/- 4 and the correction factor which takes in consideration the geometry is 0,87 +/- 0,07. The activity measured in the syringe is eighteen percent higher to activity measured in the vial. CONCLUSION: This method allows to measure accurately the activity of Sm-153 in vial and syringe applying this geometry correction factor to determine accurately the activity administered to the patient.

Non-antibiotic treatment for infectious diseases.

The abuse and uncontrolled use of antibiotics has resulted in the emergence and spread of resistant bacteria. The utility of conventional antibiotics for the treatment of bacterial infections has become increasingly strained due to increased rates of resistance coupled with reduced rates of development of new agents. As a result, multidrug-resistant, extensively drug-resistant, and pan-drug-resistant bacterial strains are now frequently encountered. This has led to fears of a "post-antibiotic era" in which many bacterial infections could be untreatable. Alternative non-antibiotic treatment strategies need to be explored to ensure that a robust pipeline of effective therapies is available to clinicians. The new therapeutic approaches for bacterial infections (beyond antibiotics) may provide a way to extend the usefulness of current antibiotics in an era of multidrug-resistant (MDR) bacterial infections.

[In vitro activity of voriconazole against yeast and algae isolates according to new resistance pattern cut-off points]. / Actividad in vitro del voriconazol frente a levaduras y algas con los nuevos puntos de corte del patrón de resistencia.

Voriconazole is a second-generation triazole derived from fluconazole but with greater potency and spectrum of activity, showing good in vitro activity against Candida, Cryptococcus and Aspergillus species, and other filamentous and dimorphic fungi. It can be administered orally or intravenously. It was initially approved in 2002 by the U.S. Food and Drug Administration as a treatment option for invasive aspergillosis and Fusarium and S. apiospermum infections showing resistance or intolerance to other antifungals; later on, it also received approval in the United States and Europe as a treatment option for esophageal candidiasis; candida infection in non-neutropenic patients; disseminated candidiasis of skin, abdomen, kidney and bladder; and injuries. Recently, the Clinical Laboratory Standard Institute established some provisional break points for voriconazole, classifying isolates with an MICor=4 mg/l as resistant. In line with these new data, we performed a systematic review of literature on in vitro activity of voriconazole against yeast and algae isolates, and compared it to that of fluconazole and itraconazole. The review included a total of 27,340 yeast isolates, 24,177 of Candida species, 2,726 of Cryptococcus species, 453 of other species, and 104 Prototheca. The yeast isolates resistant to voriconazole is approximately 1%, and 71% of fluconazole-resistant isolates are susceptible to voriconazole.

[Scintigraphy with labelled leukocytes in acute pancreatitis. Preliminary results]. / Gammagrafía con leucocitos marcados en la pancreatitis aguda. Resultados preliminares.

This study aims to evaluate the contribution of the 99mTc-HMPAO labelled leukocyte in the prognostic assessment of patients with acute pancreatitis. We have compared the usual methods of prognostic evaluation (computed tomography CT and the Ranson clinical score scale) with the scintigraphic findings in 23 consecutive patients with a clinical diagnosis of mild or severe acute pancreatitis. All 6 patients with severe pancreatitis showed an uptake which was mostly mild. 9/17 patients with mild pancreatitis showed uptake, which also frequently had a low intensity. When the severity index of CT was compared with the leukocyte results, the only patient with a high severity index showed a grade 3 uptake. However, in over 50% of the patients with a low severity index, uptake, generally having a low intensity, was found. When the uptake degree was compared with the Ranson score level, we observed a predominance of mild uptake in both patients with mild and severe pancreatitis. Considering these results, we believe that the lack of uptake in the leukocyte study in a patient with acute pancreatitis can be interpreted as a good prognosis sign. The significance of the finding of uptake in the pancreatic area is uncertain and studies should be performed in larger sized samples.

[Diagnostic value of parathyroid localization techniques in surgery for primary hyperparathyroidism]. / Valor diagnóstico de las técnicas de localización paratiroidea en la cirugía del hiperparatiroidismo primario.

OBJECTIVES: To determine the accuracy of imaging techniques for localization of nodular lesions of parathyroid glands. MATERIAL AND METHODS: Seventy one patients were prospectively enrolled and underwent surgical examination for primary hyperparathyroidism. Ultrasonography (US), 201Tl/99mTc parathyroid subtraction scintigraphy and 99mTc MIBI scintigraphy were evaluated. RESULTS: The sensitivity and specificity for combined 201Tl/99mTc parathyroid subtraction scintigraphy and US for parathyroid adenomas were 72.27% and 89.22% respectively. The combination of 99mTc MIBI scintigraphy and US resulted in improved specificity (93.67%) and positive predictive value (80.39%). The accuracy of the localizing studies was lower for patients with hyperplasia. CONCLUSIONS: The combination of scintigraphy and US is the best approach for localization of nodules. In most cases, the two techniques are complementary.

[Treatment protocols and follow-up of differentiated thyroid carcinoma: results of a questionnaire sent to the Spanish Metabolic Therapy Units]. / Los protocolos de tratamiento y seguimiento del carcinoma diferenciado de tiroides: resultados de un cuestionario enviado a las Unidades de Terapia Metabólica españolas.

OBJECTIVE: To know the treatment and follow-up protocols of differentiated thyroid carcinoma patients in Spanish Metabolic Therapy Units, the clinical variability between them and the adaptation to the consensus guidelines. MATERIALS AND METHODS: Analysis of the results obtained from the questionnaire submitted by E-mail to the Spanish Society of Nuclear Medicine (SEMNIM) members on the treatment and follow-up of differentiated thyroid carcinoma patients. A descriptive study was made of the qualitative variables (frequency, percentage) and quantitative variables (mean, standard deviation). RESULTS: Twenty Radiometabolic Therapy Units responded to the questionnaire. In spite of the varied origin of the patients, the Units receive sufficient clinical information and have specialized surgeons. There is variability in the surgical protocols and indication for ablation in patients with intermediate and low risk of recurrence. The Units agree on the use of (131)I doses for ablation and therapy, but show great variability regarding the preparation protocols (previous (131)I-whole body scan or other imaging techniques, (131)I-whole body scan dose, diet and radioiodine contrast prohibition, total dose per patient). Nuclear Medicine physicians perceive radioiodine adverse effects and prevention methods are used. The post-ablation follow-up protocol differs between Units. CONCLUSIONS: Treatment and follow-up protocols of differentiated thyroid carcinoma patients in the Spanish Radiometabolic Therapy Units show variability in aspects such as surgery and ablation indications, patient preparation for radioiodine therapy and follow-up. Our clinical practice differs in several aspects from the recent consensus guideline recommendations.