Comparison of renal parenchymal trauma after standard, mini and ultra-mini percutaneous tract dilation in porcine models.

OBJECTIVE: To evaluate whether reducing tract dilation diameter in PCNL (percutaneous nephrolithotomy) procedures results in minimizing of renal trauma of the percutaneous tract. METHODS: A percutaneous renal access tract was established bilaterally to 11 pigs. Two pigs were euthanized immediately after the experiment, while nine pigs were sacrificed 1 month later. The percutaneous accesses were dilated up to 30Fr, 22Fr or 12Fr. The animals underwent a contrast-enhanced computer tomography immediately after the procedure and 30 days later. DMSA-scintigraphy with SPECT-CT was also performed. The kidneys of all animals were harvested for histological evaluation. The volume of scar tissue and the percentage of renal volume replaced by scar tissue were calculated. RESULTS: Immediate post-procedural CT-scans revealed a significant difference in defect diameter among the three modalities. However, the scar volume calculated on CT-images and histopathology showed a significant difference only when 30Fr dilation was compared to 12Fr dilation. The percentage of scar volume was negligible in all cases, but there was still a statistical difference between 30 and 12Fr dilation. Dilation up to 22Fr revealed no statistical differences compared to the other two modalities. DMSA-scintigraphy showed no scar tissue in any case. CONCLUSION: Dilation up to 30Fr may cause a significantly larger scar tissue on renal parenchyma compared to 12Fr dilation as it was shown on CT-images and microscopic evaluation, but based on the DMSA/SPECT-CT this difference seems to be insignificant to the renal function. The scar tissue caused by 22Fr dilation seemed to have no significant difference from the other modalities.

Antegrade Endograft Deployment with Supra-Aortic Debranching to Treat Arch and Descending Thoracic Aortic Lesions. A Single-Center Experience.

BACKGROUND: Thoracic endovascular aortic repair (TEVAR) is a widely used procedure that has drastically changed the management of thoracic aortic diseases. We assess the effectiveness of supra-aortic debranching during antegrade TEVAR procedures with a retrospective analysis of our clinical experience. METHODS: Between December 2005 and April 2017, 55 patients underwent 64 TEVAR procedures. Among them, there were 8 male patients, mean age 72, who underwent hybrid antegrade stent-graft deployment. Particularly, for degenerative aneurysms of the aortic arch, 3 patients for aneurysm of descending thoracic aorta 3, for post-traumatic pseudoaneurysm 1, and for penetrating aortic ulcer 1 which had resulted in an aortoesophageal fistula. Proximal landing zones were Z0:1, Z1:3 and Z2:4. Type I hybrid aortic arch repair was performed in 1 case, carotid-carotid bypass in 2, carotid-subclavian in 5 and aorto-carotid in 1. RESULTS: The 30-day postoperative mortality was 12.5%. One patient suffered a temporary right hemiplegia which resolved after left aorto-carotid bypass. No endoleaks were observed postoperatively and in follow-up period. In the long term and a mean follow-up of 4.9 years, there were no deaths related to the stent-graft implantation or to revascularization procedures. Regarding the aortic arch rerouting procedure, there were no pseudoaneurysm or other anastomotic events. CONCLUSIONS: Antegrade delivery of the endograft, combined with hybrid and revascularization procedures of the supra-aortic vessels is a safe treatment modality, in complex hostile anatomies. However, further improvements are recommended due to the presence of neurologic complications and reinterventions.

Safety and Effectiveness of Mycophenolate Mofetil in Interstitial Lung Diseases: Insights from a Machine Learning Radiographic Model.

INTRODUCTION: Treatment of interstitial lung diseases (ILDs) other than idiopathic pulmonary fibrosis (IPF) often includes systemic corticosteroids. Use of steroid-sparing agents is amenable to avoid potential side effects. METHODS: Functional indices and high-resolution computed tomography (HRCT) patterns of patients with non-IPF ILDs receiving mycophenolate mofetil (MMF) with a minimum follow-up of 1 year were analyzed. Two independent radiologists and a machine learning software system (Imbio 1.4.2.) evaluated HRCT patterns. RESULTS: Fifty-five (n = 55) patients were included in the analysis (male: 30 [55%], median age: 65.0 [95% CI: 59.7-70.0], mean forced vital capacity %predicted [FVC %pred.] ± standard deviation [SD]: 69.4 ± 18.3, mean diffusing capacity of lung for carbon monoxide %pred. ± SD: 40.8 ± 14.3, hypersensitivity pneumonitis: 26, connective tissue disease-ILDs [CTD-ILDs]: 22, other ILDs: 7). There was no significant difference in mean FVC %pred. post-6 months (1.59 ± 2.04) and 1 year (-0.39 ± 2.49) of treatment compared to baseline. Radiographic evaluation showed no significant difference between baseline and post-1 year %ground glass opacities (20.0 [95% CI: 14.4-30.0] vs. 20.0 [95% CI: 14.4-25.6]) and %reticulation (5.0 [95% CI: 2.0-15.6] vs. 7.5 [95% CI: 2.0-17.5]). A similar performance between expert radiologists and Imbio software analysis was observed in assessing ground glass opacities (intraclass correlation coefficient [ICC] = 0.73) and reticulation (ICC = 0.88). Fourteen patients (25.5%) reported at least one side effect and 8 patients (14.5%) switched to antifibrotics due to disease progression. CONCLUSION: Our data suggest that MMF is a safe and effective steroid-sparing agent leading to disease stabilization in a proportion of patients with non-IPF ILDs. Machine learning software systems may exhibit similar performance to specialist radiologists and represent fruitful diagnostic and prognostic tools.

Protracted severe COVID-19 pneumonia following rituximab treatment: caution needed.

The outcomes of COVID-19 in patients treated with biologic agents are a subject of intense investigation. Recent data indicated that patients under rituximab (RTX) may carry an increased risk of serious disease. We performed an electronic search in Medline and Scopus using the keywords rituximab and COVID-19. We present a rare case of severe, protracted COVID-19 pneumonia in a patient with mixed connective tissue disease (MCTD) who was infected a few days following RTX treatment. In a relevant literature search, we identified 18 cases of patients with rheumatic diseases (6 RA, 8 ANCA vasculitis, 3 systemic sclerosis and 1 polymyositis) treated with RTX who experienced an atypical and/or prolonged course of COVID-19 pneumonia with no evidence of cytokine storm. Our case indicates that RTX may unfavorably affect outcomes following SARS-CoV-2 infection. B cell depletion may dampen the humoral response against the virus; we may hypothesize that B cell-depleted patients may be protected from cytokine storm but on the other hand may have difficulties in virus clearance leading to a protracted course. Taking into account that COVID-19 vaccines are available we may consider delaying RTX infusions at least in patients without life threatening disease, until vaccination is completed.

Validation of the 3D SYM VEIN Symptom Assessment Tool.

OBJECTIVE: The aim was to validate the SYM VEIN consensus 3D scoring tool in chronic venous disease (CVD). METHODS: This was a prospective cohort study with a total of 35 consecutive patients with CVD. Patients with CVD undergoing saphenectomy were assessed with the revised Venous Clinical Severity Score (r-VCSS), the CIVIQ-20 quality of life score questionnaire, and the SYM VEIN consensus statement 3D system, pre-operatively and four weeks post-operatively. The total 3D score was tested for reliability, construct validity, and responsiveness. RESULTS: The total 3D score demonstrated good reliability and internal consistency (Cronbach's alpha 0.85). Principal component analysis identified three groups of symptoms (paraesthesia, burning pain, and pruritus, vs. heaviness, sensation of swelling and aching/pain, vs. restless leg and throbbing pain) demonstrating a high intragroup correlation and likely to share similar pathophysiology, indicative of adequate construct validity. The total 3D score showed a significant correlation with r-VCSS and CIVIQ-20 score (rho .46, p = .005 and rho .65, p < .001, respectively) indicative of adequate convergent validity. After saphenectomy, significant reductions (p < .001) of the total 3D, and 3D scores for all but two individual venous symptoms were observed, indicative of excellent responsiveness. Median total 3D score was reduced from 31 to 6 (83.8% decrease, p < .001), median r-VCSS was reduced from 6 to 0 (100% decrease, p < .001), and median CIVIQ-20 score was reduced from 24 to 14 (40% decrease, p < .001). The difference of median percentage change between r-VCSS and CIVIQ-20 score vs. total 3D score was significant (p = .005 and p < .001, respectively). CONCLUSION: The total SYM VEIN 3D score has good reliability, construct validity and excellent responsiveness, although less prone to change after saphenectomy compared with r-VCSS.

Measles-associated pneumonia and hepatitis during the measles outbreak of 2018.

Background Between 2017 and 2018, Greece experienced a measles outbreak, affecting >3000 patients, most of which were unvaccinated. Measles-associated pneumonia (MAP) is the most common serious compilation of the disease, but very few recent reports regarding its presentation are available. Materials and Methods Between January and May 2018, 11 adult patients presented to our department with acute measles virus infection, hypoxia and findings on chest X-ray. Clinical, laboratory and radiological data were collected and assessed. Nine out of eleven patients had hypoxic respiratory failure. Other complications included hepatitis, cholestasis and myositis, which were observed in the majority of patients. All patients received supplementary oxygen administration, whereas five patients required continuous positive airway pressure ventilation. Scoring of the radiological examinations performed was most notable for the presence of reticular opacities and consolidations. Statistical analysis demonstrated a significant association between PaO2/FiO2 values and the presence of reticular opacities, with PaO2/FiO2 decreasing as the mean value of the reticular opacities score increased (P = .02). Conclusion To our knowledge, this is the first report demonstrating an association between PaO2/FiO2 values and the presence of reticular opacities in patients with MAP. MAP should be suspected in any patient presenting with acute onset hypoxaemia and a reticular pattern on radiological examination, especially in outbreak settings. What is known Measles infections are on the rise in Europe, with epidemics affecting several European countries, resulting from suboptimal immunisation. The most common serious complication of measles is pneumonia, which is more common in adult patients and can cause significant morbidity. It is the most common cause of death due to measles. What is new In this report, we present 11 adults with measles-associated pneumonia, who presented with the combination of acute measles virus infection, hypoxia and findings on chest X-ray. To our knowledge, this is the first report demonstrating an association between the severity of hypoxaemia and the presence of reticular opacities on chest imaging studies.

Improved effectiveness of the repositionable GORE EXCLUDER AAA endoprosthesis featuring the C3 delivery system compared with the original GORE EXCLUDER AAA endoprosthesis for within the instructions for use treatment of aortoiliac aneurysms.

OBJECTIVE: To compare two endograft types, the original GORE EXCLUDER AAA endoprosthesis (W. L. Gore & Associates, Flagstaff, Ariz) with the repositionable GORE EXCLUDER featuring the C3 delivery system, which allows repositioning of the proximal part of the graft to achieve accurate placement in relation to the renal arteries, in unselected patients with aortoiliac aneurysms. In a second nested, substudy we investigated the relative effect of the standard Gore and Gore Dryseal introducer sheaths on intraoperative transfusion needs. METHODS: We retrospectively analyzed prospectively collected information. The primary composite outcome measure was the intraoperative misdeployment or migration of the endograft's main body, proximally or distally to the renals (leading to technical failure or requiring either placement of aortic cuff extenders or conversion to open repair). Secondary outcome measures included the composite long-term event of rupture and/or type I/III endoleak. RESULTS: A total of 313 consecutive patients (303 males; median age, 73 years) had either an original GORE EXCLUDER device (n = 174) or the new device (n = 139) placed between 2004 and 2011 and 2011 and 2017, respectively, to treat an infrarenal aortoiliac aneurysm or an isolated common iliac artery aneurysm. The primary composite outcome measure occurred more often in patients who had the original GORE EXCLUDER device placed (10.9% vs 3.6% for the new device; odds ratio, 0.30; 95% confidence interval, 0.11-0.84; P = .016), confirmed by multivariate logistic regression analysis. This difference between the two groups was exclusively driven by distal misdeployment or migration of the endograft (10.3% vs 2.9% for the new device; P = .01), mostly requiring aortic extender placement. Intraoperative blood transfusion rates were lower in patients who had the GORE Dryseal introducer sheath used (1.1% vs 18.9% for the original GORE introducer sheath; OR, 0.05; 95% confidence interval, 0.006-0.35; P < .001). At a mean follow-up of 1.7 years (maximum, 13 years), 11 patients developed the composite event. On univariate Cox analysis, significant predictors included female gender (P = .003), absence of dyslipidemia (P = .023), the primary outcome measure (P = .006), and failure to cannulate (P = .009), but not device type or other variables. On multivariate Cox regression, female gender (hazard ratio, 37; P < .001), chronic obstructive pulmonary disease (hazard ratio, 3.99; P = .045), the primary outcome measure of the study (hazard ratio, 8.9; P = .002), and failure to cannulate (hazard ratio, 43; P = .003) were all independent predictors. CONCLUSIONS: Our study has demonstrated that the repositionable GORE EXCLUDER has important safety characteristics compared with the original device and equivalent long-term effectiveness. Additional benefit was obtained with the use of the Gore Dryseal introducer sheath.

Evaluation of Intratesticular Lesions With Strain Elastography Using Strain Ratio and Color Map Visual Grading: Differentiation of Neoplastic and Nonneoplastic Lesions.

OBJECTIVE: To investigate the role of strain elastography using calculated strain ratio and visual elastography score in differentiating nonneoplastic, benign, and malignant neoplastic intratesticular lesions. MATERIALS AND METHODS: The study was approved by the hospital review board as a retrospective review of 86 patients examined with gray scale, color Doppler ultrasonography and strain elastography (visual elastography score and strain ratio). Sensitivity, specificity, and positive and negative likelihood ratio of color Doppler and stain elastography were documented. Receiver operator characteristic curves assessed the diagnostic accuracy of strain elastography to discriminate nonneoplastic, benign, and malignant neoplasms. Histology or follow-up ultrasonography determined lesion character. RESULTS: Thirty-one of 86 (36.0%) intratesticular malignant neoplasms, 17 of 86 (19.8%) benign neoplasms, and 38 of 86 (44.2%) nonneoplastic lesions were confirmed with histology (n = 52) or follow-up sonography (n = 34); 89.5% of intratesticular lesions were heterogeneous or hypoechoic on gray scale, with no difference between benign and malignant. Sensitivity, specificity, positive and negative likelihood ratio for nonneoplasm versus neoplasm were documented: color Doppler: 68.8%, 97.4%, 26.5, 0.32; visual elastography score: 81.3%, 57.9%, 1.93, 0.32; strain ratio: 68.8%, 81.6%, 3.73, 0.38. Neoplastic lesions showed a higher strain ratio than nonneoplastic lesions (P < .001), with strong correlation between median strain ratio and visual elastography score (Spearman's coefficient, 0.693; P < .001). Strain ratio is a significantly better assessment than visual elastography score for malignant lesions (P = .025). Logistic regression analysis revealed significant associations between size (P = .001), hypervascularity (P < .001), and malignancy. CONCLUSION: Higher strain ratio and visual elastography score are associated with neoplastic lesions and offer an alternative to assess tissue characteristics but do not improve the diagnostic accuracy when compared with the color Doppler pattern.

Patient dose in brain perfusion imaging using an 80-slice CT system.

BACKGROUND AND PURPOSE: Brain CT Perfusion (CTP) is an X-ray imaging technique for the assessment of brain tissue perfusion, which can be used in several different entities. The aim of this study is the evaluation of the radiation dose to patients during a comprehensive brain CT prescription protocol (CPP) consisting of an unenhanced brain CT, a brain CT angiography and a CTP scan. MATERIALS AND METHODS: Eighteen patients were studied using an 80-slice CT system, with an iterative reconstruction algorithm. The volume Computed Tomography Dose Index (CTDIvol) and dose length product (DLP) were recorded from the dose report of the system. The calculation of effective dose (ED) was accomplished using the DLP values. RESULTS: For the CTP examinations, the CTDIvol ranged from 116.0 to 134.8mGy, with the mean value 119.5mGy. The DLP ranged from 463.9 to 539.2mGy·cm, with the mean value 478mGy·cm. For the CPP, the total ED ranged from 3.31 to 5.07mSv, with the mean value 4.37mSv. CONCLUSIONS: These values are lower than the values reported in corresponding studies, including studies utilizing CT systems with more slices.

Site-specific effects of apolipoprotein E expression on diet-induced obesity and white adipose tissue metabolic activation.

Apolipoprotein E (APOE) has been strongly implicated in the development of diet induced obesity. In the present study, we investigated the contribution of brain and peripherally expressed human apolipoprotein E3 (APOE3), the most common human isoform, to diet induced obesity. In our studies APOE3 knock-in (Apoe3knock-in), Apoe-deficient (apoe-/-) and brain-specific expressing APOE3 (Apoe3brain) mice were fed western-type diet for 12week and biochemical analyses were performed. Moreover, AAV-mediated gene transfer of APOE3 to apoe-/- mice was employed, as a means to achieve APOE3 expression selectively in periphery, since peripherally expressed APOE does not cross blood brain barrier (BBB) or blood-cerebrospinal fluid barrier (BCSFB). Our data suggest a bimodal role of APOE3 in visceral white adipose tissue (WAT) mitochondrial metabolic activation that is highly dependent on its site of expression and independent of postprandial dietary lipid deposition. Our findings indicate that brain APOE3 expression is associated with a potent inhibition of visceral WAT mitochondrial oxidative phosphorylation, leading to significantly reduced substrate oxidation, increased fat accumulation and obesity. In contrast, peripherally expressed APOE3 is associated with a notable shift of substrate oxidation towards non-shivering thermogenesis in visceral WAT mitochondria, leading to resistance to obesity.

Distinct Roles of Apolipoproteins A1 and E in the Modulation of High-Density Lipoprotein Composition and Function.

In addition to high-density lipoprotein cholesterol (HDL-C) levels, HDL quality also appears to be very important for atheroprotection. Analysis of various clinical paradigms suggests that the lipid and apolipoprotein composition of HDL defines its size, shape, and functions and may determine its beneficial effects on human health. Previously, we reported that like apolipoprotein A-I (Apoa1), apolipoprotein E (Apoe) is also capable of promoting the de novo biogenesis of HDL with the participation of ATP binding cassette A lipid transporter member 1 (Abca1) and plasma enzyme lecithin:cholesterol acyltransferase (Lcat), in a manner independent of a functional Apoa1. Here, we performed a comparative analysis of the functions of these HDL subpopulations. Specifically, Apoe and Apoa1 double-deficient (Apoe(-/-) × Apoa1(-/-)) mice were infected with APOA1- or APOE3-expressing adenoviruses, and APOA1-containing HDL (APOA1-HDL) and APOE3-containing HDL (APOE3-HDL), respectively, were isolated and analyzed by biochemical and physicochemical methods. Western blot and lipidomic analyses indicated significant differences in the apolipoprotein and lipid composition of the two HDL species. Moreover APOE3-HDL presented a markedly reduced antioxidant potential and Abcg1-mediated cholesterol efflux capacity. Surprisingly, APOE3-HDL but not APOA1-HDL attenuated LPS-induced production of TNFα in RAW264.7 cells, suggesting that the anti-inflammatory effects of APOA1 are dependent on APOE expression. Taken together, our data indicate that APOA1 and APOE3 recruit different apolipoproteins and lipids on the HDL particle, leading to structurally and functionally distinct HDL subpopulations. The distinct role of these two apolipoproteins in the modulation of HDL functionality may pave the way toward the development of novel pharmaceuticals that aim to improve HDL functionality.

Advances in high-density lipoprotein physiology: surprises, overturns, and promises.

Emerging evidence strongly supports that changes in the HDL metabolic pathway, which result in changes in HDL proteome and function, appear to have a causative impact on a number of metabolic disorders. Here, we provide a critical review of the most recent and novel findings correlating HDL properties and functionality with various pathophysiological processes and disease states, such as obesity, type 2 diabetes mellitus, nonalcoholic fatty liver disease, inflammation and sepsis, bone and obstructive pulmonary diseases, and brain disorders.

Computed tomography cephalometric and upper airway measurements in patients with OSA and erectile dysfunction.

PURPOSE: Erectile dysfunction (ED) has been linked to obstructive sleep apnea (OSA). This study used computed tomography (CT) to identify cephalometric and upper airway anatomic features in patients with OSA that correlate with the presence of ED. METHODS: In this prospective study, 20 CT cephalometric and upper airway measurements, most commonly associated with OSA, were analyzed in 53 age- and BMI-matched consecutive eligible subjects. Twenty-two were diagnosed with OSA and ED (OSA+/ED+), 17 with OSA without ED (OSA+/ED-), and 14 without OSA and ED (OSA-/ED-) serving as a control group. RESULTS: Although OSA+/ED+ did not differentiate significantly in CT measurements from OSA+/ED-, they showed more alterations when compared to OSA-/ED-, which included narrower bony oropharynx, longer soft palate and uvula (PNS-P), and narrower retropalatal and retrolingual airway diameter (p < 0.05). Binary forward stepwise model analysis showed that PNS-P was the only significant variable in the predictive model for ED in patients with OSA (OR = 1.129, 95 % CI = 1.0005-1.268, p = 0.041). In the OSA+/ED+ group, PNS-P correlated with the percentage of total sleep time with oxygen saturation <90 % (r = 0.61, p < 0.01) and was the only determinant in the relevant predictive model (n = 22, model R = 0.612, adjusted R (2) = 0.337, F = 10.167, p < 0.005). CONCLUSIONS: Characteristics of the craniofacial and upper airway structures suggest that a longer soft palate and uvula may be important risk factors for the concurrence of ED in patients with OSA. Only OSA+/ED+ showed significant narrowing in the retropalatal, retrolingual, and bony oropharynx level when compared with BMI-matched OSA-/ED-.

Automated 3D ιnterstitial lung disease εxtent quantification: performance evaluation and correlation to PFTs.

In this study, the performance of a recently proposed computer-aided diagnosis (CAD) scheme in detection and 3D quantification of reticular and ground glass pattern extent in chest computed tomography of interstitial lung disease (ILD) patients is evaluated. CAD scheme performance was evaluated on a dataset of 37 volumetric chest scans, considering five representative axial anatomical levels per scan. CAD scheme reliability analysis was performed by estimating agreement (intraclass correlation coefficient, ICC) of automatically derived ILD pattern extent to semi-quantitative disease extent assessment in terms of 29-point rating scale provided by two expert radiologists. Receiver operating characteristic (ROC) analysis was employed to assess CAD scheme accuracy in ILD pattern detection in terms of area under ROC curve (A z ). Correlation of reticular and ground glass volumetric pattern extent to pulmonary function tests (PFTs) was also investigated. CAD scheme reliability was substantial for ILD extent (ICC = 0.809) and distinct reticular pattern extent (0.806) and moderate for distinct ground glass pattern extent (0.543), performing within inter-observer agreement. CAD scheme demonstrated high accuracy in detecting total ILD (A z = 0.950 ± 0.018), while accuracy in detecting distinct reticular and ground glass patterns was 0.920 ± 0.023 and 0.883 ± 0.024, respectively. Moderate and statistically significant negative correlation was found between reticular volumetric pattern extent and diffusing capacity, forced expiratory volume in 1 s, forced vital capacity, and total lung capacity (R = -0.581, -0.513, -0.494, and -0.446, respectively), similar to correlations found between radiologists' semi-quantitative ratings with PFTs. CAD-based quantification of disease extent is in agreement with radiologists' semi-quantitative assessment and correlates to specific PFTs, suggesting a potential imaging biomarker for ILD staging and management.

Intraoperative radio-guided localization of parathyroid adenomas using 3D freehand SPECT technology.

Parathyroidectomy for primary hyperparathyroidism (PHPT) could have poor outcomes, even with accurate preoperative localization of the adenomas, because their intraoperative localization can be challenging. Freehand single photon emission computed tomography (fhSPECT) is a new technique for radio-guided intraoperative navigation. Its use during parathyroidectomy could be useful and such data are limited. We herein present our experience on the feasibility of fhSPECT for intraoperative detection of abnormal parathyroid glands. We retrospectively reviewed the clinical data of 55 patients (30-77 years old) with PHPT due to parathyroid adenomas, that were subjected to parathyroidectomy from 12/2017 to 7/2022. In average, 111 ± 74 MBq of Tc-99 m Sestamibi were injected intravenously, approximately 2 h before the operation and fhSPECT was used to generate 3D images during parathyroidectomy. Measurements of PTH and calcium levels were performed preoperatively, postoperatively and 4-6 months after the procedure. FhSPECT successfully identified the parathyroid adenoma in all the patients. It took 3 min (median time) for fhSPECT to detect at least one radioactive spot in all patients. The mean duration of the operation was 66.6 ± 7.3 min. Forty-nine patients out of 55 had solitary and 6/55 had multiple adenomas, whereas 6/55 had ectopic abnormal parathyroid glands. None of the patients had persistent hyperparathyroidism during follow-up. To the best of our knowledge, this is the largest series of patients with PHPT that underwent fhSPECT assisted parathyroidectomy. Our data suggest that this navigation system is helpful in identifying parathyroid adenomas intraoperatively.

Assessing the use of haemostatic sealants in tubeless percutaneous renal access and their effect on renal drainage and histology: an experimental porcine study.

OBJECTIVE: To evaluate the mid-term effects of haemostatic sealant application during tubeless percutaneous nephrolithotomy (PCNL) on renal drainage and histology in an in vivo porcine study. MATERIALS AND METHODS: Bilateral percutaneous access was established in 28 porcine renal units. At the end of the procedure, a type 1 absorbable fish origin collagen powder, a human fibrinogen- and thrombin-coated sponge or a cross-linked gelatin granule/topical thrombin matrix were randomly placed on the nephrostomy tracts. Four nephrostomy accesses were left intact and served as controls. No percutaneous tube, ureteric stent or bladder catheter was left in place postoperatively. Computed tomography urography on postoperative days 1, 15, 30 and 40 was used to access renal drainage. On postoperative day 40, all animals were killed and both kidneys from each animal were harvested for histological evaluation. RESULTS: Evidence of risk for drainage occlusion after sealant application was found. The use of haemostatic sealants was associated with significant histological lesions in the renal parenchyma, regardless of which sealant was used. No sealant was identified as superior to the others. Nephrostomy tracts that were left without sealant application (control group) were associated with no morbidity and fewer histopathological changes. CONCLUSIONS: Based on these experimental results, the safety of the application of haemostatic sealants in tubeless PCNL should be reassessed, focusing not only on the potential of such materials to occlude urinary drainage but also on their effect on renal histology. Further investigation is considered necessary.

Non-dynamic and multiphase CT protocols for parathyroid glands imaging: a review of technical parameters, radiation dose and diagnostic accuracy.

INTRODUCTION: Our purpose was to review the scientific literature and collect information regarding clinical and technical parameters of different single- or multiphase CT protocols, their diagnostic performance and patient dose during parathyroid imaging. EVIDENCE ACQUISITION: PubMed and Scopus databases were searched for studies investigating the diagnostic performance of CT in detecting parathyroid lesions and the corresponding patients' dose. The following information was retrieved for each article: CT system, number, combination and time interval between phases, scanning length, sensitivity, specificity, accuracy, positive and negative predictive values, contrast enhancement in Hounsfield Units (HUs), technical and exposure parameters, and dose indices. Fifty studies published during the last sixteen years (2005-2021) were reviewed. EVIDENCE SYNTHESIS: A large discrepancy in the number and combination of phases, as well as clinical and technical parameters of the CT protocols was indicated. The variations in patients' doses are mainly due to scanners' technology, number and combination of phases, the extent of scanning length, technical parameters (tube voltage, tube current modulation, pitch, reconstruction algorithms), and patient-related parameters. Technical parameters are not always adjusted appropriately to the clinical question or patient size. These variations indicate a large potential to optimize dose during parathyroid imaging without compromising diagnostic performance. The potential is to decrease the number of phases or use low tube voltage protocols, tube current modulation, iterative reconstruction, and reduce the scanning length during some phases. CONCLUSIONS: The reporting results could inform researchers about the current status of CT parathyroid imaging and guide their future efforts to optimize both patients' dose and corresponding image quality.

Evaluation of Reliability and Validity of the RALE and BRIXIA Chest-X Ray Scores in Patients Hospitalized with COVID-19 Pneumonia.

INTRODUCTION: Chest X-rays are commonly used to assess the severity in patients that present in the emergency department with suspected COVID-19 pneumonia, but in clinical practice quantitative scales are rarely employed. AIMS: To evaluate the reliability and validity of two semi-quantitative radiological scales in patients hospitalized for COVID-19 pneumonia (BRIXIA score and RALE score). METHODS: Patients hospitalized between October 2021 and March 2022 with confirmed COVID-19 pneumonia diagnosis were eligible for inclusion. All included patients had a chest X-ray taken in the ED before admission. Three raters that participated in the treatment and management of patients with COVID-19 during the pandemic independently assessed chest X-rays. RESULTS: Intraclass coefficients for BRIXΙA and RALES was 0.781 (0.729-0.826) and 0.825 (0.781-0.862) respectively, showing good to excellent reliability overall. Pairwise analysis was performed using quadratic weighted kappa showing significant variability in the inter-rater agreement. The prognostic accuracy of the two scores for in-hospital mortality for all raters was between 0.753 and 0.763 for BRIXIA and 0.737 and 0.790 for RALES, demonstrating good to excellent prognostic value. Both radiological scores were significantly associated with inhospital mortality after adjustment for 4C Mortality score. We found a consistent upwards trend with significant differences between severity groups in both radiological scores. CONCLUSION: Our findings suggest that BRIXIA and RALES are reliable and can be used to assess the prognosis of patients with COVID-19 requiring hospitalization. However, the inherent subjectivity of radiological scores might make it difficult to set a cut-off value suitable for all assessors.

A retrospective survey to establish institutional diagnostic reference levels for CT urography examinations based on clinical indications: preliminary results.

Objective. To establish institutional diagnostic reference levels (IDRLs) based on clinical indications (CIs) for three- and four-phase computed tomography urography (CTU).Methods. Volumetric computed tomography dose index (CTDIvol), dose-length product (DLP), patients' demographics, selected CIs like lithiasis, cancer, and other diseases, and protocols' parameters were retrospectively recorded for 198 CTUs conducted on a Toshiba Aquilion Prime 80 scanner. Patients were categorised based on CIs and number of phases. These groups' 75th percentiles of CTDIvoland DLP were proposed as IDRLs. The mean, median and IDRLs were compared with previously published values.Results. For the three-phase protocol, the CTDIvol(mGy) and DLP (mGy.cm) were 22.7/992 for the whole group, 23.4/992 for lithiasis, 22.8/1037 for cancer, and 21.2/981 for other diseases. The corresponding CTDIvol(mGy) and DLP (mGy.cm) values for the four-phase protocol were 28.6/1172, 30.6/1203, 27.3/1077, and 28.7/1252, respectively. A significant difference was found in CTDIvoland DLP between the two protocols, among the phases of three-phase (except cancer) and four-phase protocols (except DLP for other diseases), and in DLP between the second and third phases (except for cancer group). The results are comparable or lower than most studies published in the last decade.Conclusions. The CT technologist must be aware of the critical dose dependence on the scan length and the applied exposure parameters for each phase, according to the patient's clinical background and the corresponding imaging anatomy, which must have been properly targeted by the competent radiologist. When clinically feasible, restricting the number of phases to three instead of four could remarkably reduce the patient's radiation dose. CI-based IDRLs will serve as a baseline for comparison with CTU practice in other hospitals and could contribute to national DRL establishment. The awareness and knowledge of dose levels during CTU will prompt optimisation strategies in CT facilities.