Consensus on improving the comprehensive care of patients with acute heart failure.

The latest acute heart failure (AHF) consensus document from the Spanish Society of Cardiology (SEC, for its initials in Spanish), Spanish Society of Internal Medicine (SEMI), and Spanish Society of Emergency Medicine (SEMES) was published in 2015, which made an update covering the main novelties regarding AHF from the last few years necessary. These include publication of updated European guidelines on HF in 2016, new studies on the pharmacological treatment of patients during hospitalization, and other recent developments regarding AHF such as early treatment, intermittent treatment, advanced HF, and refractory congestion. This consensus document was drafted with the aim of updating all aspects related to AHF and to create a document that comprehensively describes the diagnosis, treatment, and management of this disease.

Consensus on improving the comprehensive care of patients with acute heart failure. / Consenso para la mejora de la atención integral de los pacientes con insuficiencia cardíaca aguda.

The latest acute heart failure consensus document from the Spanish Society of Cardiology, Spanish Society of Internal Medicine, and Spanish Society of Emergency Medicine was published in 2015, which made an update covering the main novelties regarding acute heart failure from the last few years necessary. These include publication of updated European guidelines on heart failure in 2016, new studies on the pharmacological treatment of patients during hospitalization, and other recent developments regarding acute heart failure such as early treatment, intermittent treatment, advanced heart failure, and refractory congestion. This consensus document was drafted with the aim of updating all aspects related to acute heart failure and to create a document that comprehensively describes the diagnosis, treatment, and management of this disease.

Clinical indications, image acquisition and data interpretation for white blood cells and anti-granulocyte monoclonal antibody scintigraphy: an EANM procedural guideline.

INTRODUCTION: Radiolabelled autologous white blood cells (WBC) scintigraphy is being standardized all over the world to ensure high quality, specificity and reproducibility. Similarly, in many European countries radiolabelled anti-granulocyte antibodies (anti-G-mAb) are used instead of WBC with high diagnostic accuracy. The EANM Inflammation & Infection Committee is deeply involved in this process of standardization as a primary goal of the group. AIM: The main aim of this guideline is to support and promote good clinical practice despite the complex environment of a national health care system with its ethical, economic and legal aspects that must also be taken into consideration. METHOD: After the standardization of the WBC labelling procedure (already published), a group of experts from the EANM Infection & Inflammation Committee developed and validated these guidelines based on published evidences. RESULTS: Here we describe image acquisition protocols, image display procedures and image analyses as well as image interpretation criteria for the use of radiolabelled WBC and monoclonal antigranulocyte antibodies. Clinical application for WBC and anti-G-mAb scintigraphy is also described. CONCLUSIONS: These guidelines should be applied by all nuclear medicine centers in favor of a highly reproducible standardized practice.

Hyponatraemia and congestive heart failure refractory to diuretic treatment. Utility of tolvaptan. / Hiponatremia e insuficiencia cardiaca congestiva refractaria a tratamiento diurético. Utilidad del tolvaptán.

Heart failure (HF) is currently one of the most significant healthcare problems in Spain and has a continuously increasing prevalence. Advances in our understanding of the various biological responses that promote cardiac remodelling and pulmonary venous congestion constitute the basis of current treatment. This article, prepared by members of the HF groups of the Spanish Society of Cardiology and the Spanish Society of Internal Medicine, discusses the current therapeutic strategies for patients with congestion refractory to diuretic treatment. The article includes our clinical experience with the use of tolvaptan as an additional treatment for congestion associated with hyponatraemia. To this end, we propose an algorithm for the use of tolvaptan in patients with congestive HF, natraemia <130mEq/l and poor response to conventional diuretic treatment.

Scintigraphic depiction of non-ossifying fibromas and the role of SPECT/CT.

Non-ossifying fibromas (NOF) are a benign entity of the developing bone, relatively common in children and young adults. Their location is most frequently metaphyseal. They are usually asymptomatic (unless associated to a fracture) and have a self-limited behavior, with spontaneous regression through a sclerotic consolidation. Plain X-ray is the main imaging tool for its diagnosis. However, an unclear X-ray may lead to further imaging studies. We present the case of a 17-year-old male with back pain and lower limb dysmetria referred for a bone scintigraphy to complete the diagnostic and assess disease extension and the subsequent MRI evaluation.

Common diagnostic flow charts for diagnosis and management of patients with an inflammatory bowel disease.

This paper presents the different views of the gastroenterologist, the radiologist and the nuclear medicine specialist in the management of inflammatory bowel disease. The role of clinical parameters and biochemical marker as well as the progressive use of the different imaging modalities: magnetic resonance, computerized tomography and nuclear medicine techniques is presented. The paper is an effort to combine the published European Crohn's and Colitis Organization, European Society of Gastrointestinal and Abdominal Radiology and European Association of Nuclear Medicine consensus with the conclusions of the multidisciplinary meeting organized in 2012 Milano during the EANM Congress with the objective of find a common diagnostic flowchart.

Imaging techniques for assessment of inflammatory bowel disease: joint ECCO and ESGAR evidence-based consensus guidelines.

The management of patients with IBD requires evaluation with objective tools, both at the time of diagnosis and throughout the course of the disease, to determine the location, extension, activity and severity of inflammatory lesions, as well as, the potential existence of complications. Whereas endoscopy is a well-established and uniformly performed diagnostic examination, the implementation of radiologic techniques for assessment of IBD is still heterogeneous; variations in technical aspects and the degrees of experience and preferences exist across countries in Europe. ECCO and ESGAR scientific societies jointly elaborated a consensus to establish standards for imaging in IBD using magnetic resonance imaging, computed tomography, ultrasonography, and including also other radiologic procedures such as conventional radiology or nuclear medicine examinations for different clinical situations that include general principles, upper GI tract, colon and rectum, perineum, liver and biliary tract, emergency situation, and the postoperative setting. The statements and general recommendations of this consensus are based on the highest level of evidence available, but significant gaps remain in certain areas such as the comparison of diagnostic accuracy between different techniques, the value for therapeutic monitoring, and the prognostic implications of particular findings.

Treatment of cystic craniopharyngioma with 90Y-Colloid. Four clinical cases.

Craniopharyngioma is a histologically benign and frequently cystic intracranial tumor. It may present aggressive behavior due to compression from nearby structures. Its therapeutic management is complicated because although surgery is the usual treatment of choice, it is not exempt of high morbidity and mortality and frequent tumor recurrence. In craniopharyngiomas with a significant cystic component,internal irradiation with radioactive isotopes is a therapeutic alternative to conventional treatments. We present the cases of four patients with cystic craniopharyngiomas who were treated with intracystic administration of 90Y-colloid, and their evolution after the treatment.

Platelet-function testing in patients undergoing neurovascular procedures: caught between a rock and a hard place.

In the context of neurointerventional procedures, clopidogrel hyper-responsiveness has been associated with hemorrhage; on the other hand, clopidogrel resistance has been associated with thromboembolism. This might seem to make a compelling argument in favor of routine platelet testing. Our reading of the literature leads us to conclude that routine platelet testing in neurointerventional procedures is not, unfortunately, ready for prime time.

Dabigatran (Pradaxa).

Dabigatran (Pradaxa) is a member of the relatively new class of antithrombotic drugs known as direct thrombin inhibitors (DTIs). It may supplant warfarin (Coumadin) in a number of applications as it may produce a more predictable, potent, and immediate anticoagulant effect, with fewer significant side effects and interactions, and requires less monitoring.

Utility of the PET-CT in the evaluation of early response to treatment in the diffuse large B-cell lymphoma. Preliminary results.

OBJECTIVE: To assess the role of FDG-PET/CT performed after the first cycles of chemotherapy in the prediction of response to treatment in patients with diffuse large B-cell lymphoma. METHODS: Twenty patients (mean age: 48 years) were included, 16 initial staging and 4 relapse. All patients underwent PET/CT at 3 times: 1) Baseline, 2) After 1-3 cycles of chemotherapy (early response assessment), and 3) End of treatment (evaluation of final response). Early PET/CT findings were correlated to the end-treatment PET/CT and follow-up. The evaluation of the response was established according to the decrease in uptake of the lesions (SUVmax). In the early assessment, a good response indicator (GRI) was obtained when the lesion disappeared or had more than 50% reduction in SUVmax. At the end of the treatment, a complete metabolic response (CMR) was determined in negative PET scans. Follow-up was superior to 19 months and final outcome was established as progression/relapse or no evidence of disease (NED). RESULTS: At the early treatment evaluation, 16/16 patients of initial staging (100%) and 2/4 of relapse (50%) achieved GRI. At the end of treatment evaluation, 14/16 patients of initial staging with GRI achieved CMR and 1/16 PMR: 14 were alive with NED in the follow-up while 1 relapsed. In the second group, 2/2 patients with GRI achieved CMR (100%): 1 continued with NED in the follow-up and another relapsed. CONCLUSION: FDG-PET/CT after the first cycles of chemotherapy is useful to monitor treatment due to its high negative predictive value (87.5%), using it to modify treatment early in the non-responders.

Clopidogrel (plavix).

Clopidogrel is an inhibitor of platelet aggregation, indicated for the prevention of ischemic stroke and in-stent thrombosis. However, it has a number of drawbacks, including an increased risk of hemorrhage; a clinical effect that is slow in onset and irreversible; a genetically determined variability in its clinical potency; and interactions with other commonly administered drugs.

[Measurement of 75Se-SeHCAT abdominal retention in the initial diagnosis of Bile Acid Absorption (BAM)]. / Medición de la absorción de los ácidos biliares en el diagnóstico inicial de la diarrea crónica.

AIM: To evaluate the usefulness of the (75)SeHCAT abdominal retention (AR) measurement in the early diagnosis of diarrhea syndrome (DS). METHODS: Thirty-seven patients with diarrhea syndrome within the first month of evolution were prospectively evaluated. The (75)Se-SeHCAT abdominal retention was measured 4 and 7 days post-administration of 0.01 mCi of (75)SeHCAT. The test was performed prior to treatment and at 3 months when the baseline study was positive. The test was considered positive if the RA was <25% at 4(th) and <10% on the 7th day. The patients were visited at 3 months. Depending on the response, 3 groups were established: a) complete response: normalization of stool frequency, b) partial response, decrease of frequency or c) no response. RESULTS: Group A: The AR of (75)Se-SEHCAT was normal in 21 patients. Six were diagnosed of colonic diverticulosis, 8 of irritable bowel syndrome, 1 of lymphocytic colitis, 1 of post-gastroenteritis syndrome, 1 of celiac disease and 1 of stenosis of the cardia. Four are still under study. Group B: The AR of (75)Se-SEHCAT decreased in 16 patients. All showed abnormal AR at day 7 and all but 1 at day 4. Following administration of cholestyramine resin, 8 (50%) presented partial response and 8 (50%) complete response. At 3 months, AR had increased at day 4 and 9 at day 7. CONCLUSION: The measurement of (75)SEHCAT abdominal retention allows the early diagnosis of bile acid malabsorption in 43% of the patients with DS. Measurement at 7 days seems more accurate than that at 4 days.

Avaliação do desempenho na pós-desmama para uma população bovina multirracial Aberdeen Angus x Nelore utilizando-se diferentes modelos genéticos / Post weaning performance evaluation for a multibreed Aberdeen Angus x Nellore population using different genetic models

Com o objetivo de testar modelos genéticos alternativos ao aditivo-dominante em populações multirraciais, foram utilizadas informações do peso ao sobreano (PS) de 35.931 novilhos, filhos de 752 touros e 30.535 vacas das raças Aberdeen Angus (A) e Nelore (N) e de diversos grupos genéticos possíveis por meio do cruzamento entre elas. Foram testados cinco diferentes modelos (M) genéticos: o M1 continha o efeito genético fixo aditivo direto (AD), heterozigótico direto (HD), epistático direto (ED) e aditivo-conjunto direto (ACD); o M2, igual ao M1, menos o efeito ACD; o M3, igual ao M1, menos o efeito ED; o M4, igual ao M1, menos os efeitos ED e ACD; e o M5, igual ao M1, menos os efeitos HD, ED e ACD. Os modelos foram submetidos a três métodos de análise diferentes: método dos quadrados mínimos (MQM), regressão de cumeeira (RC) e máxima verossimilhança restrita (REML). O método de RC produziu estimativas de coeficientes com magnitudes e sinais explicados biologicamente. As estimativas dos efeitos, das (co)variâncias, dos parâmetros e dos valores genéticos diferiram entre os modelos, indicando a importância da correta escolha do modelo de análise, devendo-se ter conhecimento prévio do fenômeno estudado e sua interpretação biológica e sempre preceder à escolha de um modelo de análise genética multirracial o estudo da relação existente entre as variáveis independentes. Importantes efeitos adicionais ao efeito AD foram acrescentados pelas inclusões dos efeitos HD e ED aos modelos de análise. A notação matemática dos efeitos ACD, aplicada atualmente na literatura e testada neste estudo, não foi capaz de explicar a complementaridade entre raças como esperado, havendo problemas com casos de multicolinearidade entre os efeitos estudados.

In order to evaluate alternative genetic models to the additive dominant model, weights at yearling (PS) of 35,931 animals, sired by 752 bulls and 30,535 cows of Aberdeen Angus (A) and Nellore (N) breeds and the genetic groups from their crosses were used. Five different genetic models (M) were tested: M1, containing the direct additive fixed genetic effect (DA), heterozygote direct (HD), epystatic direct (ED), and direct joint additive direct (DJA); M2 was equal to M1, excluding DJA effect; M3 was equal to M1, excluding ED effect; M4 was equal M1, excluding ED and ACD effects, and M5 was equal to M1, excluding HD, ED, and DJA effects. The models were analyzed by different methods: Least Square Means Method (MQM), Ridge Regression Method (RC), and Restricted Maximum Likelihood Method (REML). Estimated coefficients by RC showed magnitude and sign which were biologically explained. The estimates of the covariances, parameters, and genetic values varied among the models, indicating the importance of the correct choice of the model for analysis, being necessary a previous knowledge of the studied phenomenon and its biological interpretation. Besides, it should always be considered the relationship between the independent variables before choosing a multibreed genetic analysis model. Important additional effects to the DA effect were considered by the inclusion of the HD and ED effects to the models for analysis. The DJA math notation, currently used in the literature and tested in the present study, was not able to explain the breed complementarity, due to the multi colinearity among the studied effects.

[Positive sentinel node risk in relation to oestrogen receptors in breast cancer in premenopausal and postmenopausal women]. / Relación entre el riesgo de metástasis en el ganglio centinela y los receptores estrogénicos en pacientes pre y posmenopáusicas con cáncer de mama.

OBJECTIVE: The influence of the relationship between pre- and post-menopausal stage of patients with breast cancer (BC) and the risk of sentinel lymph node (SLN) metastasis as well as the influence of oestrogen receptor (ER) status within each one of these groups were analyzed. METHODS: A BC database with 1,388 patients was analysed. Three age groups were studied: A, elderly postmenopausal, 200 patients, ≥ 70 years old; B, younger postmenopausal, 89 patients, 55-69 years old; C, premenopausal, 85 patients, <55 years old. In each group 2 subgroups were analyzed: positive ER and negative ER tumours. Data analysed: SLN-positive patients, non-sentinel node (NSN)-positive patients, non-surgical detections (NSD) and non disease-free (NDF) patients after a follow-up of 52 months. STATISTICAL ANALYSIS: chi-squared test, significance: P ≤ 0.05. RESULTS: SLN metastasis was significantly (P<0.025) more common in premenopausal than in postmenopausal patients, and within those, mainly in negative ER tumours. Positive-NSN increases slightly in premenopausal patients (exclusively in negative ER tumours). NDF patients are similar in the 3 groups and in all of them it is much more frequent in negative ER tumours. CONCLUSION: SLN metastasis varies significantly according to hormonal state and not according to age, being more frequent in premenopausal patients and mainly in ER negative tumours.

[Evaluation of the anxiety state in patients receiving radioiodine treatment or who undergo a sentinel lymph node examination in the Nuclear Medicine Department]. / Valoración del estado de ansiedad de los pacientes que reciben un tratamiento con radioyodo o son sometidos a una exploración de ganglio centinela en el servicio de Medicina Nuclear.

OBJECTIVE: To analyze the presence of anxiety in patients referred to a Nuclear Medicine Department (NMD). MATERIAL AND METHODS: A total of 148 patients were included: 67 were referred for radioiodine therapy, 48 with hyperthyroidism (HT), 19 with differentiated thyroid carcinoma (DTC), and 81 were referred for detection and biopsy of the sentinel node in breast cancer (BC). The following documents were filled out: personal data, a state-trait anxiety inventory, a scale of pre-disposing factors causing anxiety and an information questionnaire. Anxiety-predisposing factors and the influence of the information on the presence of anxiety were studied. RESULTS: HT patients: 47% had anxiety in the moment of the visit that was not related to the level of information received. The factor that worried them the most was the radioiodine administration. Being the first visit to a NMD significantly influenced (p<0.05) on the presence of anxiety. DTC patients: 42% had anxiety in the moment of the visit not related to the level of information received. The factor that worried them the most was the illness itself. No factor had a significant influence on the presence of anxiety. BC patients: 53% had anxiety in the moment of the visit that was not related to the level of information received. What worried them the most were the results. Having anxiety and/or depression significantly influenced (p<0.05) the presence of anxiety. CONCLUSION: The quantity of information given before a procedure in a NMD does not influence on the presence of anxiety. Nevertheless, it is our duty to give the best possible information.

[Evaluation by "statistical parametric mapping" of the cerebral perfusion changes in patients with carotid artery stenosis after endarterectomy]. / Evaluación mediante mapas estadísticos paramétricos de los cambios de la perfusión cerebral en pacientes con estenosis de la arteria carótida sometidos a endarterectomía.

UNLABELLED: The efficacy of carotid endartectomy (CE) in cerebrovascular accidents produced by carotid stenosis can be evaluated with the cerebral perfusion with single photon emission tomography, using statistical parametric mapping (SPM). MATERIAL AND METHODS: Twelve patients with significant carotid stenosis who underwent endartectomy were included in the study. All underwent a cerebral perfusion study with 99mTc-etilen cisteinato dietilester (ECD) at baseline and after the endartectomy. Using SPM, the baseline/post-surgery study was compared independently with the control group made up of 20 patients and the corresponding parametric statistical mappings were obtained. Changes in extension (k(E) or voxel number) and intensity (change in the T value) of the significantly hypoperfused zones and direction of these changes were evaluated. RESULTS: In the group of 12 patients, improvement of the post-surgical cerebral perfusion was observed in 5 patients with an average 50.56% decrease in the extension of the hypoperfused zones and average 30.9% decrease of intensity. Four patients showed an average 85.53% increase in the extension of cerebral hypoperfusion and of 34.21% in intensity. No significant changes between both studies were found in three patients. CONCLUSIONS: SPM has been shown to be a useful tool that makes it possible to objectify the cerebral brain flow changes produced after the surgical intervention, evaluating the changes in extension and intensity of the significantly hypoperfused zones.

Fatores de correção para perímetro escrotal ao sobreano para tourinhos mestiços Aberdeen Angus x Nelore / Adjustment factors for scrotal circumference at yearling for crossbred Aberdeen Angus x Nelore young bulls

Obtiveram-se fatores de correção (FC) para o perímetro escrotal ao sobreano (PES) para os efeitos de grupo genético (GG), heterozigose individual (HI), peso ao sobreano (PS) e idade do animal à pesagem de sobreano (IDS), utilizando-se registros de peso corporal e medidas de perímetro escrotal obtidos de 11.662 tourinhos das raças Aberdeen Angus, Nelore e de produtos do cruzamento entre elas, criados nas regiões Sul, Sudeste e Centro-Oeste do Brasil, nascidos entre 1987 e 2001. Os coeficientes de regressão que geraram os FC foram estimados pelo método dos quadrados mínimos, adotando um modelo que incluiu os efeitos de grupo de contemporâneos ao sobreano (GC), GG, heterozigose materna (HM), HI, PS e IDS. Todos os efeitos incluídos no modelo foram significativos (P<0,01) sobre PES. A média observada e respectivo desvio-padrão para PES foi 29,90±3,55cm. Foi observado efeito polinomial de segunda ordem de PS sobre PES. Foram verificados ganhos decrescentes no PES à medida que o POS aumentou, ou seja, os maiores acréscimos foram observados em animais recém desmamados. O efeito linear de PS sobre PES foi 0,06695804±0,00345000cm/kg, e o efeito quadrático, 0,00005252±0,00000508cm/kg². Para IDS o efeito linear foi de 0,02176450±0,00038568cm/dia. Aumentos de HI e HM promoveram incremento no PES e de GG, decréscimos. Os fatores incluídos no modelo foram importantes fontes de variação que devem ser considerados no ajuste de PES para seleção de tourinhos para melhora da precocidade sexual.

Adjustment factors (AF) for scrotal circumference at yearling (SCY) were figured out for effects of genetic group (GG), individual heterozygosis (IH), yearling weight (YW), and age of the animal at yearling weight (AYW) using body weight and scrotal circumference records from 11,662 Aberdeen Angus, Nelore, and their crosses. The animals were born from 1987 to 2001 and were raised in the South East and Central West Regions of Brazil. The regression coefficients to obtain AF were estimated by least squares means method. The model included the fixed effects of contemporaneous group at yearling (CG), maternal heterozygosis (MH), IH, and the covariates YW (linear and quadratic effects) and AYW (linear effect). All the factors included in the model showed significant effects (P<0.01) on SCY. The mean and standard deviation for SCY were 29.90±3.55cm. Quadratic effect of YW on SCY was also observed. Decreases in SCY with the increase in YW was found. High SCY was observed immediately after post-weaning. The YW effects on SCY were 0.06695804±0.00345000cm/kg (linear effect) and -0.00005252±0.00000508cm/kg² (quadratic effect). The AYW linear effect on SCY was 0.02176450±0.00038568cm/day. The factors included in the model are important sources of variation to adjust SCY for the selection of young bulls in order to improve sexual precocity.