Framing doctor-managers' resilience during Covid-19 pandemic: A descriptive analysis from the Italian NHS.

With the aim of providing evidence about doctor-managers' resilience during the Covid-19 pandemic, this study analyzes the characteristics of 114 doctor-managers operating within the Italian National Health Service (NHS). During the emergency, doctor-managers had to show adaptive capacities to deal with unexpected situations and develop new paradigms, procedures, and quick responses to patients' needs. This is in line with resilience, and in this perspective, it is crucial to investigate resilience determinants. The paper, therefore, provides an identikit of the resilient doctor-manager. The research was conducted between November and December 2020. Primary data were collected through an online questionnaire consisting of six sections. Participation was voluntary and anonymous. Data were analyzed using quantitative techniques and employing Stata 16. Confirmatory Factor Analysis was employed to test construct validity and scale reliability. Results show that increasing levels of individual resilience are related to increasing levels of managerial identity. Moreover, physicians' individual resilience has a positive association with commitment, knowledge diffusion, and Evidence-Based Medicine adoption. Finally, physicians' individual resilience has a negative association with their role in the university, their specialty, and their gender. The study suggests some practical implications for healtcare organizations. In general, career paths are decided primarily on competency assessment, while an important role should be devoted to behavioral characteristics. Furthermore, organizations should take care of the levels of individual commitment and encourage professional networking because both help doctor-managers cope with uncertainty. The originality of the study relies on a fresh look at all previous work. There are currently few contributions in the literature to explore and investigate resilience elements in doctor-managers during the pandemic era.

Is 18F-fluorodeoxyglucose positron emission tomography/computed tomography useful to discriminate metachronous lung cancer from metastasis in patients with oncological history?

BACKGROUND: Solitary pulmonary nodules detected during follow-up in patients with previous cancer history have a high probability of malignancy being either a metachronous lung cancer or a metastasis. This distinction represents a crucial issue in the perspective of "personalized medicine," implying different treatments and prognosis. Aim, to evaluate the role of 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) in distinguishing whether solitary pulmonary nodules are metachronous cancers or metastases and the relationship between the nodule's characteristics and their nature. METHODS: From a single-institution database, we retrospectively selected all patients with a previous cancer history who performed 18F-FDG PET/CT to evaluate pulmonary nodules detected during follow-up, ranging from 5 mm to 40 mm, and histologically diagnosed as malignant. RESULTS: Between September 2009 and August 2017, 127 patients (80 males; mean age=70.2±8.5years) with 127 malignant nodules were included: 103/127 (81%) metachronous cancers, 24/127 (19%) metastases. In both groups, PET/CT provided good and equivalent detection rate of malignancy (81% vs. 83%). No differences between metachronous cancers and metastases were found in: patient's age (70.3±8.1 years vs. 69.5±9.7years), gender (males=63.1% vs. 62.5%), interval between previous cancer diagnosis and nodules' detection (median time=4years vs. 4.5years), location (right-lung=55% vs. 54%; upper-lobes=64% vs. 67%; central-site=31% vs. 25%), size (median size=17mm vs. 19.5mm), 18F-FDG standardized uptake value (median SUVmax=5.2 vs. 5.9). CONCLUSIONS: In oncological patients, despite its high detection rate, 18F-FDG PET/CT, as well as any other clinico-anatomical features, cannot distinguish whether a malignant solitary pulmonary nodule is a metachronous lung cancer or a metastasis, supporting the need of histological differential diagnosis.

Emerging topics and practical aspects for an appropriate use of amyloid PET in the current Italian context.

In May 2017 some representatives of the Italian nuclear medicine and neurological communities spontaneously met to discuss the issues emerged during the first two years of routine application of amyloid PET with fluorinated radiopharmaceuticals in the real world. The limitations of a binary classification of scans, the possibility to obtain early images as a surrogate marker of regional cerebral bloos flow, the need for (semi-)quantification and, thus, the opportunity of ranking brain amyloidosis, the correlation with Aß42 levels in the cerebrospinal fluid, the occurrence and biological meaning of uncertain/boderline scans, the issue of incidental amyloidosis, the technical pittfalls leading to false negative/positive results, the position of the tool in the diagnostic flow-chart in the national reality, are the main topics that have been discussed. Also, a card to justify the examination to be filled by the dementia specialist and a card for the nuclear medicine physician to report the exam in detail have been approved and are available in the web, which should facilitate the creation of a national register, as previewed by the 2015 intersocietal recommendation on the use of amyloid PET in Italy. The content of this discussion could stimulate both public institutions and companies to support further research on these topics.

Are the simplified methods to estimate Ki in 18F-FDG PET studies feasible in clinical routine? Comparison between three simplified methods.

BACKGROUND: The aim of this study was to verify the feasibility, in clinical practice, of three simplified methods (Hunter, Sadato and another one proposed by our group) to calculate Ki and MRglu of 18F-FDG, comparing the results with those derived by the linear regression (LR) method (considered the golden standard), and also with SUV. METHODS: Forty-five patients (32males, mean age 69±9years) with non-small-cell-lung cancer prospectively enrolled, underwent dynamic 18F-FDG PET-CT over the thorax. Ki was estimated as follows: from a static acquisition and performing one venous blood sampling using the Hunter method; multiplying the SUV for the average plasma clearance rate (kP(T)) and for the initial distribution volume (V0bw) without performing any blood sampling using the Sadato method; multiplying the SUV for a factor F (which encompasses the mean value of haematocrit and plasma volume, both according to patient's sex) without performing any blood sample using ours method. Wilcoxon signed rank and coefficient of determination (R2) were used for statistical analysis. RESULTS: No significant difference was observed between the Ki and MRglu estimated by all three simplified methods and the Ki and MRglu estimated by LR. The highest P values and the lower values of mean differences were observed with our method compared with LR: Ki=0.0392±0.0178 min-1 vs. Ki=0.0392±0.0202 min-1 (P=0.897, MD=0.0001 min-1), respectively; MRglu= 4.47±2.23 ml/min/100g vs. MRglu= 4.43±2.38 ml/min/100g (P=0.839, MD= -0.0373 mL/min/100g), respectively. The highest correlation was observed between the Ki estimated by both Hunter and our methods and the Ki estimated by LR: R2=0.87, R2=0.86, respectively. A good correlation (R2=0.83) was observed between SUV and Ki estimated by LR. CONCLUSIONS: These three simplified methods represent a valid alternative to the more invasive and complex full kinetic analysis. Their "pros" are: the non-invasiveness, the feasibility, the good correlation with the golden standard; their "cons" is that full kinetic analysis provides highest accuracy in Ki determination. Therefore, in clinical oncology routine, the nuclear physicians can choose among different simplified methods especially for monitoring the response to treatment, for tumour grading, and for prognostic stratification, letting the full kinetic analysis to specific centre/studies.

CD68+ cell count, early evaluation with PET and plasma TARC levels predict response in Hodgkin lymphoma.

Early response evaluation with [(18) F]fluordeoxyglucose (FDG) positron emission tomography after 2 cycles of chemotherapy (interim PET) has been indicated as the strongest predictor for outcome in classical Hodgkin lymphoma (HL). We studied the prognostic role of the number of tumor-infiltrating CD68+ cells and of the plasma levels of TARC (thymus and activation-regulated chemokine) in the context of interim PET in 102 patients with classical HL treated with Adriamycin, Bleomycin, Vinblastine, Dacarbazine (ABVD). After 2 ABVD cycles, interim PET according to Deauville criteria was negative (score 0-3) in 85 patients and positive (score 4-5) in 15 patients (2 patients technically not evaluable). TARC levels were elevated in 89% of patients at diagnosis, and decreased after 2 cycles in 82% of patients. Persistently elevated TARC levels in 18% of patients were significantly associated with a positive PET result (P = 0.007). Strong predictors for progression-free survival (PFS) were a negative interim PET (85% vs. 28%, P < 0.0001) and CD68+ cell counts <5% (89% vs. 67%, P = 0.006), while TARC levels at diagnosis and at interim evaluation had no prognostic role. In multivariate analysis, interim PET, CD68+ cell counts and presence of B-symptoms were independently associated with PFS. We conclude that although TARC levels are a biomarker for early response evaluation, they cannot substitute for interim PET as outcome predictor in HL. The evaluation of CD68 counts and B-symptoms at diagnosis may help to identify low-risk patients regardless positive interim PET.

Cardiovascular implantable electronic device infection: delayed vs standard FDG PET-CT imaging.

BACKGROUND: Positron emission tomography-computed tomography (PET-CT) with (18)F-fluorodeoxyglucose (FDG) has emerged as a rapidly evolving diagnostic tool for infectious diseases. However, the optimal imaging time in this clinical setting is not clear yet. The aim of this study is to investigate whether delayed (3 hours) FDG PET-CT could increase the diagnostic accuracy of this technique compared to standard (1 hour) imaging in the detection of septic foci involving the pocket and/or pacing leads in patients with suspected cardiovascular implantable electronic device (CIED) infection scheduled for device removal. METHODS AND RESULTS: Twenty-seven patients underwent standard and delayed imaging. PET-CT results were compared to bacteriological cultures after CIED removal. Fifteen controls free of infection underwent PET-CT imaging as part of investigation of malignancy. The diagnostic accuracy of delayed imaging was significantly higher than 1-hour scan for lead infection (70% vs 51%, P = .024). No significant difference was found between standard and delayed diagnostic accuracy for pocket or device infection. Semi-quantitative analysis showed that mean pocket and lead target-to-background ratio were significantly higher on delayed compared to standard imaging (3.7 ± 1.9 vs 1.6 ± 1.1, P = .0002; 3.0 ± 1.3 vs 0.7 ± 1.0, P = .01). CONCLUSIONS: Delayed FDG PET-CT imaging should be considered at least in patients with negative 1-hour scan and founded suspicion of pacing lead infection.

Chronic motor cortex stimulation in patients with advanced Parkinson's disease and effects on striatal dopaminergic transmission as assessed by 123I-FP-CIT SPECT: a preliminary report.

OBJECTIVE: The objective of this study was to assess striatal dopamine transporter availability in patients with advanced Parkinson's disease (PD) before and after 13 months of unilateral extradural motor cortex stimulation (EMCS) with [123I]N-ω-fluoropropyl-2-ß-carbo-methoxy-3-ß-(4-iodophenyl)nortropane single photon emission computed tomography (123I-FP-CIT SPECT). METHODS: Six PD patients (five women and one man, aged 63.2 ± 5.6 years) underwent 123I-FP-CIT SPECT and clinical evaluation [Unified Parkinson's Disease Rating Scale (UPDRS) and Parkinson's Disease Quality of Life Scale (PDQL)] preoperatively, 8 and 13 months after EMCS. Striatum-to-occipital cortex, caudate-to-occipital cortex and putamen-to-occipital cortex 123I-FP-CIT uptake ratios were calculated using the region of interest method. RESULTS: Total and part III UPDRS scores significantly decreased at 8 and 13 months after stimulation (P=0.02 and 0.04, respectively); UPDRS part II and PDQL scores improved after 13 months (P=0.02 and 0.04, respectively). No significant differences in 123I-FP-CIT uptake ratios between baseline and follow-up were found in the examined regions. However, a progressive reduction in 123I-FP-CIT uptake ratios in the striatum contralateral to the implant was found. In contrast, no further decrease in 123I-FP-CIT uptake ratios was detected in the striatum ipsilateral to the implant. There were no correlations between changes in 123I-FP-CIT uptake ratios with disease duration, changes in medication dosage and motor UPDRS scores. CONCLUSION: Despite a small but highly selected sample of advanced PD patients, our results showed that no further dopamine transporter reduction occurred in the striatum ipsilateral to the implant side. This finding could lead to the hypothesis that EMCS might elicit a 'neuroprotective' effect, as suggested by significant clinical benefits.

Cardiac metastases of Ewing sarcoma detected by 18F-FDG PET/CT.

Positron emission tomography (PET) is widely used in the diagnostic evaluation and staging of different malignant tumors. The role of PET/computed tomographic scan in detecting distant metastases in the workup of Ewing sarcoma in children or young adults is less well defined. We report a case of a boy affected by a metastatic Ewing sarcoma with cardiac asymptomatic metastasis detected by F-FDG PET/computed tomography.