Absceso del psoas secundario a apendicitis atípica en gestante. Presentación de un caso

El absceso del psoas es una enfermedad infecciosa infrecuente y de difícil diagnóstico, caracterizado por una colección purulenta a nivel de este músculo, que provoca un síndrome de respuesta inflamatoria sistémica. La infección puede ser primaria por diseminación hematógena, o secundaria, a partir de un foco infeccioso cercano. Su presentación durante el embarazo es rara, y predomina la forma primaria, razón por la cual se decidió realizar este artículo. Se presenta el caso de una gestante con 28,4 semanas de edad gestacional que ingresó por dolor inguinal con posterior irradiación a la cadera, flanco y región lumbar derechos; postura en flexión de la cadera derecha y marcha antiálgica, así como aparición, a los nueve días de iniciados los síntomas, de una masa dolorosa entre fosa ilíaca y flanco derechos. Los hallazgos de la ecografía abdominal y la resonancia permitieron el diagnóstico de un plastrón apendicular con un apéndice retrocecal, así como absceso del psoas derecho, los cuales se trataron con antibioticoterapia y drenaje percutáneo del absceso, con resultados satisfactorios. El absceso del psoas secundario puede constituir el debut de una apendicitis atípica retrocecal, y para su diagnóstico hay que tener un alto nivel de sospecha por su clínica inespecífica.

The psoas abscess is a rare infectious disease that is difficult to diagnose, characterized by a purulent collection at the level of this muscle, which causes a systemic inflammatory response syndrome. The infection can be primary by hematogenous dissemination, or secondary, from a nearby infectious focus. Its presentation during pregnancy is rare, and the primary form predominates, which is why it was decided to write this article. The case of a pregnant woman with a gestational age of 28.4 weeks who was admitted due to inguinal pain with subsequent irradiation to the right hip, flank, and lumbar region; flexed posture of the right hip and analgesic gait, as well as the appearance, nine days after the onset of symptoms, of a painful mass between the right iliac fossa and flank it is presented. The findings of the abdominal ultrasound and MRI allowed the diagnosis of an appendiceal plastron with a retrocecal appendix, as well as a right psoas abscess, which were treated with antibiotic therapy and percutaneous drainage of the abscess, with satisfactory results. Secondary psoas abscess may constitute the debut of atypical retrocecal appendicitis, and its diagnosis requires a high level of suspicion due to its non-specific symptoms.

The SWI/SNF chromatin remodeling complexes BAF and PBAF differentially regulate epigenetic transitions in exhausted CD8+ T cells.

CD8+ T cell exhaustion (Tex) limits disease control during chronic viral infections and cancer. Here, we investigated the epigenetic factors mediating major chromatin-remodeling events in Tex-cell development. A protein-domain-focused in vivo CRISPR screen identified distinct functions for two versions of the SWI/SNF chromatin-remodeling complex in Tex-cell differentiation. Depletion of the canonical SWI/SNF form, BAF, impaired initial CD8+ T cell responses in acute and chronic infection. In contrast, disruption of PBAF enhanced Tex-cell proliferation and survival. Mechanistically, PBAF regulated the epigenetic and transcriptional transition from TCF-1+ progenitor Tex cells to more differentiated TCF-1- Tex subsets. Whereas PBAF acted to preserve Tex progenitor biology, BAF was required to generate effector-like Tex cells, suggesting that the balance of these factors coordinates Tex-cell subset differentiation. Targeting PBAF improved tumor control both alone and in combination with anti-PD-L1 immunotherapy. Thus, PBAF may present a therapeutic target in cancer immunotherapy.

Radiation Safety and Accidental Radiation Exposures in Nuclear Medicine.

Medical radiation accidents and unintended events may lead to accidental or unintended medical exposure of patients and exposure of staff or the public. Most unintended exposures in nuclear medicine will lead to a small increase in risk; nevertheless, these require investigation and a clinical and dosimetric assessment. Nuclear medicine staff are exposed to radiation emitted directly by radiopharmaceuticals and by patients after administration of radiopharmaceuticals. This is particularly relevant in PET, due to the penetrating 511 keV γ-rays. Dose constraints should be set for planning the exposure of individuals. Staff body doses of 1-25 µSv/GBq are reported for PET imaging, the largest component being from the injection. The preparation and administration of radiopharmaceuticals can lead to high doses to the hands, challenging dose limits for radionuclides such as 90Y and even 18F. The risks of contamination can be minimized by basic precautions, such as carrying out manipulations in purpose-built facilities, wearing protective clothing, especially gloves, and removing contaminated gloves or any skin contamination as quickly as possible. Airborne contamination is a potential problem when handling radioisotopes of iodine or administering radioaerosols. Manipulating radiopharmaceuticals in laminar air flow cabinets, and appropriate premises ventilation are necessary to improve safety levels. Ensuring patient safety and minimizing the risk of incidents require efficient overall quality management. Critical aspects include: the booking process, particularly if qualified medical supervision is not present; administration of radiopharmaceuticals to patients, with the risk of misadministration or extravasation; management of patients' data and images by information technology systems, considering the possibility of misalignment between patient personal data and clinical information. Prevention of possible mistakes in patient identification or in the management of patients with similar names requires particular attention. Appropriate management of pregnant or breast-feeding patients is another important aspect of radiation safety. In radiopharmacy activities, strict quality assurance should be implemented at all operational levels, in addition to adherence to national and international regulations and guidelines. This includes not only administrative aspects, like checking the request/prescription, patient's data and the details of the requested procedure, but also quantitative tests according to national/international pharmacopoeias, and measuring the dispensed activity with a calibrated activity meter prior to administration. In therapy with radionuclides, skin tissue reactions can occur following extravasation, which can result in localized doses of tens of Grays. Other relevant incidents include confusion of products for patients administered at the same time or malfunction of administration devices. Furthermore, errors in internal radiation dosimetry calculations for treatment planning may lead to under or over-treatment. According to literature, proper instructions are fundamental to keep effective dose to caregivers and family members after patient discharge below the Dose constraints. The IAEA Basic Safety Standards require measures to minimize the likelihood of any unintended or accidental medical exposures and reporting any radiation incident. The relative complexity of nuclear medicine practice presents many possibilities for errors. It is therefore important that all activities are performed according to well established procedures, and that all actions are supported by regular quality assurance/QC procedures.

The Thalamic Arteriovenous Malformations Have Better Prognosis than Basal Ganglia Malformations Regarding Obliteration: Prognostic Factors Analysis.

BACKGROUND: Arteriovenous malformations (AVMs) are rare vascular congenital lesions that affect mainly patients during their productive years of life. In order to obtain a better quality of life for patients with this disease, a multidisciplinary approach is recommended. Radiosurgery is one of the treatment modalities available for AVMs, but many factors may influence the effectiveness of this strategy. Classically, it has been said that deep-seated lesions have a particular behavior compared with AVMs in other regions, but a differentiation between thalamic lesions and those located in the basal ganglia has not been made. METHODS: Institutional records for central core AVMs treated with radiosurgery between January 2004 and January 2014 were retrospectively analyzed. Brainstem lesions were excluded from the analysis. RESULTS: Forty-nine patients with deep-seated AVMs were included. Forty-three (87.8%) were located in the thalamus and 6 (12.2%) in the area of basal ganglia. The nidus mean volume was 4.1 cm3 (SD: 4.1), the maximum diameter mean was of 19.5 mm (SD: 8.0). The prescription dose was 18.2 Gy (SD: 2.1), and the follow-up time was 75.8 months (SD: 32.5). There was a greater obliteration rate in thalamic AVMs compared with those located in the basal ganglia: 81.4% versus 33.3% (P = 0.026), respectively. There was no association between categorical variables and obliteration rate. CONCLUSIONS: Stereotactic radiosurgery is a good option for patients with thalamic and basal ganglia AVMs, but a multidisciplinary approach to decision-making is mandatory in order to achieve the best results.

Characterization and Biomarker Analyses of Post-COVID-19 Complications and Neurological Manifestations.

As the SARS-CoV-2 pandemic continues, reports have demonstrated neurologic sequelae following COVID-19 recovery. Mechanisms to explain long-term neurological sequelae are unknown and need to be identified. Plasma from 24 individuals recovering from COVID-19 at 1 to 3 months after initial infection were collected for cytokine and antibody levels and neuronal-enriched extracellular vesicle (nEV) protein cargo analyses. Plasma cytokine IL-4 was increased in all COVID-19 participants. Volunteers with self-reported neurological problems (nCoV, n = 8) had a positive correlation of IL6 with age or severity of the sequalae, at least one co-morbidity and increased SARS-CoV-2 antibody compared to those COVID-19 individuals without neurological issues (CoV, n = 16). Protein markers of neuronal dysfunction including amyloid beta, neurofilament light, neurogranin, total tau, and p-T181-tau were all significantly increased in the nEVs of all participants recovering from COVID-19 compared to historic controls. This study suggests ongoing peripheral and neuroinflammation after COVID-19 infection that may influence neurological sequelae by altering nEV proteins. Individuals recovering from COVID-19 may have occult neural damage while those with demonstrative neurological symptoms additionally had more severe infection. Longitudinal studies to monitor plasma biomarkers and nEV cargo are warranted to assess persistent neurodegeneration and systemic effects.

Two-session Radiosurgery as Initial Treatment for Newly Diagnosed Large, Symptomatic Brain Metastases from Breast and Lung Histology.

Introduction Surgery is considered the treatment of choice for patients with large, symptomatic brain metastases. This report describes a series of patients treated with upfront two-session radiosurgery rather than surgery for large brain metastases from breast and lung histology. Methods From October 2016 to January 2019, 10 consecutive patients with neurologic symptoms from large brain metastases producing mass effects underwent two sessions of radiosurgical treatments 30 days apart. The response was assessed by imaging and clinical evaluations.  Results Ten patients had a total of 36 tumors; of these, 22 lesions with a mean volume of 12.3 ml (range, 7-78.4 ml) underwent two-session radiosurgery. The mean prescription dose for the first treatment was 13 Gy (range, 9-18 Gy) to the 50% isodose line, and the intratumoral mean dose was 17.9 Gy (12-22.9). All 10 patients had neurological symptoms, with a mean Karnofsky physical score (KPS) of 60 (range, 50-70) on the day of treatment. None of these patients required neurosurgical or emergency consultation related to worsening of neurological symptoms between the first and second treatments. At 30 days, the mean KPS was 80 and maintained at 80 at the last follow-up (range, 60-100; P=0.002), and mean lesion volume was 4.1 ml (range, 1.3-70 ml). The mean prescription dose for the second treatment was 12 Gy (range, 9-18 Gy) to the 50% isodose line, and the intratumoral mean dose was 17.9 Gy (11-22.4). The mean overall survival was 24 months (range, 3-32 months). At last follow-up, three patients (30%) had died, two of systemic progression and one of tumor progression, and at one year, local tumor control was 91% and 19 (86%) lesions showed documented local control at last follow up. In those tumors that progressed, the mean time to progression was eight months (range, 5-20 months), and the mean time to surgery was nine months (range, 5-32 months). Conclusion Two-session radiosurgery proved to be a safe treatment for patients with large, symptomatic metastases in this series. Neurological worsening after radiosurgery for large lesions of breast and lung histology may be an infrequent event. This strategy in radiosurgery may have neurological benefits for these patients providing adequate local tumor control while reducing the need of upfront surgery at diagnosis.

Implementation of Quality Systems in Nuclear Medicine: Why It Matters. An Outcome Analysis (Quality Management Audits in Nuclear Medicine Part III).

The International Atomic Energy Agency (IAEA) developed a comprehensive program-Quality Management Audits in Nuclear Medicine (QUANUM). This program covers all aspects of nuclear medicine practices including, but not limited to, clinical practice, management, operations, and services. The QUANUM program, which includes quality standards detailed in relevant checklists, aims at introducing a culture of comprehensive quality audit processes that are patient oriented, systematic, and outcome based. This paper will focus on the impact of the implementation of QUANUM on daily routine practices in audited centers. Thirty-seven centers, which had been externally audited by experts under IAEA auspices at least 1 year earlier, were invited to run an internal audit using the QUANUM checklists. The external audits also served as training in quality management and the use of QUANUM for the local teams, which were responsible of conducting the internal audits. Twenty-five out of the 37 centers provided their internal audit report, which was compared with the previous external audit. The program requires that auditors score each requirement within the QUANUM checklists on a scale of 0-4, where 0-2 means nonconformance and 3-4 means conformance to international regulations and standards on which QUANUM is based. Our analysis covering both general and clinical areas assessed changes on the conformance status on a binary manner and the level of conformance scores. Statistical analysis was performed using nonparametric statistical tests. The evaluation of the general checklists showed a global improvement on both the status and the levels of conformances (P < 0.01). The evaluation of the requirements by checklist also showed a significant improvement in all, with the exception of Hormones and Tumor marker determinations, where changes were not significant. Of the 25 evaluated institutions, 88% (22 of 25) and 92% (23 of 25) improved their status and levels of conformance, respectively. Fifty-five requirements, on average, increased from nonconformance to conformance status. In 8 key areas, the number of improved requirements was well above the average: Administration & Management (checklist 2); Radiation Protection & Safety (checklist 4); General Quality Assurance system (checklist 6); Imaging Equipment Quality Assurance or Quality Control (checklist 7); General Diagnostic (checklist 9); General Therapeutic (checklist 12); Radiopharmacy Level 1 (checklist 14); and Radiopharmacy Level 2 (checklist 15). Analysis of results related to clinical activities showed an overall positive impact on both the status and the level of conformance to international standards. Similar results were obtained for the most frequently performed clinical imaging and therapeutic procedures. Our study shows that the implementation of a comprehensive quality management system through the IAEA QUANUM program has a positive impact on nuclear medicine practices.

Comprehensive Auditing in Nuclear Medicine Through the International Atomic Energy Agency Quality Management Audits in Nuclear Medicine Program. Part 2: Analysis of Results.

The International Atomic Energy Agency has developed a program, named Quality Management Audits in Nuclear Medicine (QUANUM), to help its Member States to check the status of their nuclear medicine practices and their adherence to international reference standards, covering all aspects of nuclear medicine, including quality assurance/quality control of instrumentation, radiopharmacy (further subdivided into levels 1, 2, and 3, according to complexity of work), radiation safety, clinical applications, as well as managerial aspects. The QUANUM program is based on both internal and external audits and, with specifically developed Excel spreadsheets, it helps assess the level of conformance (LoC) to those previously defined quality standards. According to their level of implementation, the level of conformance to requested standards; 0 (absent) up to 4 (full conformance). Items scored 0, 1, and 2 are considered non-conformance; items scored 3 and 4 are considered conformance. To assess results of the audit missions performed worldwide over the last 8 years, a retrospective analysis has been run on reports from a total of 42 audit missions in 39 centers, three of which had been re-audited. The analysis of all audit reports has shown an overall LoC of 73.9 ± 8.3% (mean ± standard deviation), ranging between 56.6% and 87.9%. The highest LoC has been found in the area of clinical services (83.7% for imaging and 87.9% for therapy), whereas the lowest levels have been found for Radiopharmacy Level 2 (56.6%); Computer Systems and Data Handling (66.6%); and Evaluation of the Quality Management System (67.6%). Prioritization of non-conformances produced a total of 1687 recommendations in the final audit report. Depending on the impact on safety and daily clinical activities, they were further classified as critical (requiring immediate action; n = 276; 16% of the total); major (requiring action in relatively short time, typically from 3 to 6 months; n = 604; 36%); whereas the remaining 807 (48%) were classified as minor, that is, to be addressed whenever possible. The greatest proportion of recommendations has been found in the category "Managerial, Organization and Documentation" (26%); "Staff Radiation Protection and Safety" (17.3%); "Radiopharmaceuticals Preparation, Dispensing and Handling" (15.8%); and "Quality Assurance/Quality Control" and "Management of Equipment and Software" (11.4%). The lowest level of recommendations belongs to the item "Human Resources" (4%). The QUANUM program proved applicable to a wide variety of institutions, from small practices to larger centers with PET/CT and cyclotrons. Clinical services rendered to patients showed a good compliance with international standards, whereas issues related to radiation protection of both staff and patients will require a higher degree of attention. This is a relevant feedback for the International Atomic Energy Agency with regard to the effective translation of safety recommendations into routine practice. Training on drafting and application of standard operating procedures should also be considered a priority.

Bocio endotorácico remanente a seis años de postiroidectomía total / Unusual endothoracic goiter after six year of total post-thyroidectomy

El bocio endotorácico remanente se define como el hallazgo de tejido tiroideo mediastinal después de una tiroidectomía total. Es una entidad infrecuente y generalmente el tumor se encuentra en el mediastino anterior, en posición retroesternal. Se presenta el caso de un paciente con bocio endotorácico remanente postiroidectomía total diagnosticado 6 años después. Se le realizó una exéresis a la enferma de la lesión sin complicaciones intra ni posoperatorias(AU)

Unusual endothoracic goiter is defined as the finding of mediastinal thyroid tissue after total thyroidectomy. It is uncommon and generally the tumor is located in the anterior mediastinum at retrosternal position. This was a patient with unusual endothoracic goiter after total thyroidectomy and diagnosed six years later. The lesion was excised with no intraoperative or postoperative complications(AU)

Incidencia de falla renal aguda inducida por rabdomiolisis en pacientes con traumas multiples en el Hospital Nacional Rosales desde enero hasta diciembre del 2014 / Incidence of Acute Renal Failure Induced by Rhabdomyolysis in Multiple Trauma Patients at the Rosales National Hospital from January to December 2014

La falla renal aguda (FRA) inducida por rabdomiolisis en el paciente con múltiples traumas es altamente mortal. La identificación de rabdomiolisis y FRA, permite reducir la morbi-mortalidad. La rabdomiolisis se determina con los valores séricos de creatinquinasa (CK) y la FRA se establece con la monitorización de la creatinina sérica (Cr) y el gasto urinario. Este proyecto tenía como objetivo describir la incidencia de FRA inducida por rabdomiolisis en los pacientes con múltiples traumas que consultan en el Hospital Nacional Rosales (HNR) en el periodo de un año. El HNR es el principal centro de consulta y referencia a nivel nacional, cuenta con el equipo necesario para manejo de estos pacientes, y no se ha descrito la incidencia de este problema

Fibrotecoma extraovárico gigante retroperitoneal / Giant Retroperitoneal Extraovarian Fibrothecoma

El fibrotecoma ovárico es una neoplasia poco frecuente y su localización extraovárica es más rara aún. Se observa generalmente como tumor sólido unilateral, de tamaño variable, en mujeres premenopáusicas. En su mayoría, es benigno y puede ser funcionales o no. Actualmente solo se han reportado tres pacientes y solo una de ellas de localización retroperitoneal. Se presenta un caso de una paciente con fibrotecoma extraovárico gigante retroperitoneal. Se realizó a la paciente exéresis de la lesión sin complicaciones intra ni posoperatorias.

Ovarian fibrothecoma is a rare malignancy and its extraovarian location is even rarer. It is generally seen as unilateral solid tumor, of variable size, in premenopausal women. It is mostly benign and it can be functional or not. Currently only three patients have been reported and only one of retroperitoneal location. A case of a patient with giant retroperitoneal extraovarian fibrothecoma is presented in this paper. The patient underwent excision of the lesion showing no intraoperative or postoperative complications.

Impact of SPECT corrections on 3D-dosimetry for liver transarterial radioembolization using the patient relative calibration methodology.

PURPOSE: Many centers aim to plan liver transarterial radioembolization (TARE) with dosimetry, even without CT-based attenuation correction (AC), or with unoptimized scatter correction (SC) methods. This work investigates the impact of presence vs absence of such corrections, and limited spatial resolution, on 3D dosimetry for TARE. METHODS: Three voxelized phantoms were derived from CT images of real patients with different body sizes. Simulations of (99m)Tc-SPECT projections were performed with the SIMIND code, assuming three activity distributions in the liver: uniform, inside a "liver's segment," or distributing multiple uptaking nodules ("nonuniform liver"), with a tumoral liver/healthy parenchyma ratio of 5:1. Projection data were reconstructed by a commercial workstation, with OSEM protocol not specifically optimized for dosimetry (spatial resolution of 12.6 mm), with/without SC (optimized, or with parameters predefined by the manufacturer; dual energy window), and with/without AC. Activity in voxels was calculated by a relative calibration, assuming identical microspheres and (99m)Tc-SPECT counts spatial distribution. 3D dose distributions were calculated by convolution with (90)Y voxel S-values, assuming permanent trapping of microspheres. Cumulative dose-volume histograms in lesions and healthy parenchyma from different reconstructions were compared with those obtained from the reference biodistribution (the "gold standard," GS), assessing differences for D95%, D70%, and D50% (i.e., minimum value of the absorbed dose to a percentage of the irradiated volume). γ tool analysis with tolerance of 3%/13 mm was used to evaluate the agreement between GS and simulated cases. The influence of deep-breathing was studied, blurring the reference biodistributions with a 3D anisotropic gaussian kernel, and performing the simulations once again. RESULTS: Differences of the dosimetric indicators were noticeable in some cases, always negative for lesions and distributed around zero for parenchyma. Application of AC and SC reduced systematically the differences for lesions by 5%-14% for a liver segment, and by 7%-12% for a nonuniform liver. For parenchyma, the data trend was less clear, but the overall range of variability passed from -10%/40% for a liver segment, and -10%/20% for a nonuniform liver, to -13%/6% in both cases. Applying AC, SC with preset parameters gave similar results to optimized SC, as confirmed by γ tool analysis. Moreover, γ analysis confirmed that solely AC and SC are not sufficient to obtain accurate 3D dose distribution. With breathing, the accuracy worsened severely for all dosimetric indicators, above all for lesions: with AC and optimized SC, -38%/-13% in liver's segment, -61%/-40% in the nonuniform liver. For parenchyma, D50% resulted always less sensitive to breathing and sub-optimal correction methods (difference overall range: -7%/13%). CONCLUSIONS: Reconstruction protocol optimization, AC, SC, PVE and respiratory motion corrections should be implemented to obtain the best possible dosimetric accuracy. On the other side, thanks to the relative calibration, D50% inaccuracy for the healthy parenchyma from absence of AC was less than expected, while the optimization of SC was scarcely influent. The relative calibration therefore allows to perform TARE planning, basing on D50% for the healthy parenchyma, even without AC or with suboptimal corrections, rather than rely on nondosimetric methods.

Perforación intestinal por espina de pescado: a propósito de un caso / Intestinal Perforation by Fish Bone: a Case Report

La ingestión de cuerpos extraños durante la alimentación es frecuente, siendo en su mayoría espinas de pescado y huesos de pollo. En gran parte de los casos ocurre accidentalmente en personas alcohólicas, con enfermedad mental o que usan prótesis dentaria. Generalmente pasan a través del tubo digestivo sin causar daño y son expulsadas cerca de los 7 días de la ingestión, pero en algunos pacientes produce perforación del tubo digestivo, siendo las zonas más afectadas las regiones ileocecal y rectosigmoidea por su angulación. Presentamos un paciente masculino de 54 años de edad con perforación yeyunal por espina de pescado ingerida con 5 días de anterioridad, al que se le realizó sutura de la perforación, evolucionando satisfactoriamente.

The ingestion of foreign bodies during the intake is frequent; in the majority of the cases are fish or chicken bones. It generally occurs in alcoholics, mental illness patients or persons using dental prosthesis. Therefore its passes through the digestive tract without causing damage, a few patients present digestive perforation, and the most affected zones are the ileocecal and rectosigmoid regions. A patient with yeyunal perforation by fish bone ingested 5 days ago was presented. The patient required suture of perforation, the progress was satisfactory.

Diverticulosis yeyunoileal: a propósito de un caso con perforación / Yeyuno-ileal Diverticulosis: a Case Report with Bowel Perforation

La diverticulosis yeyunoileal es una enfermedad rara que afecta con mayor frecuencia a hombres y mayores de 60 años. Los divertículos son más frecuentes en yeyuno, y se observa asociación con iguales lesiones en otras vísceras como colon y vejiga. La enfermedad generalmente es asintomática y la complicación más frecuente es la diverticulitis, por lo que se diagnostica incidentalmente en estudios radiológicos contrastados o en laparotomías. Se presenta un caso de una paciente de 87 años con antecedentes de hipertensión arterial y cardiopatía isquémica, que aquejaba dolor abdominal generalizado de 48 h de evolución, intenso, acompañado de náuseas, distensión abdominal y reacción peritoneal globalmente, por lo que fue intervenida quirúrgicamente de urgencia, encontrándose la presencia de diverticulosis yeyunoileal con divertículo yeyunal perforado, por lo que se realizó resección y anastomosis de intestino delgado. La paciente falleció por edema agudo del pulmón en la Unidad de Cuidados Intensivos del Hospital General Docente Enrique Cabrera, La Habana, Cuba.

Yeyuno-ileal diverticulosis is a rare illness that affects more frequently men and older than 60 years. Diverticula are more frequently in yeyuno than ileum, and are associated with similar lesions in colon or bladder. It is generally asymptomatic and diverticulitis is the most frequent complication that is why it is diagnosed through radiologic studies or laparotomies. An 87- year-old patient with hypertension and previous heart attack, who was complaining of generalized abdominal pain of 48 hours of evolution, intense, besides nausea, abdominal growth and tenderness. Because of these, she was operated for acute abdomen finding a yeyuno-ileal diverticulosis with a yeyunal diverticula perforated, that required resection and anastomosis of large bowel. The patient died from acute lung edema in the Intensive Care Unit of Enrique Cabrera General Teaching Hospital, Havana, Cuba.

Hernia de Amyand. Presentación de un caso / Amyand’s Hernia. A Case Report

El apéndice cecal en un saco herniario inguinal, con o sin apendicitis, es denominado hernia de Amyand. Se observa aproximadamente en el 1 % de los casos de hernia inguinal, es mucho más frecuente en los varones, y en el lado derecho, debido a la localización del apéndice cecal. Clínicamente, se presenta como una hernia inguinal complicada, con síntomas como fiebre o signos de oclusión intestinal mecánica, en dependencia del estado del apéndice. Este último determina el tipo de acceso quirúrgico y la reparación herniaria. Se presenta el tercer caso de hernia de Amyand atendido en el Hospital Enrique Cabrera, paciente al que se le realizó apendicectomía y herniorrafia inguinal, evolucionando satisfactoriamente.

Presence of the vermiform appendix in an inguinal hernia sac, with or without appendicitis, is called Amyand’s hernia. It occurs in approximately 1% of inguinal hernia patients. It is more common in men and is frequently found on the right side due to the location of the appendix. Clinically, it presents as a complicated inguinal hernia causing symptoms such as fever or signs of mechanical intestinal obstruction, depending on the state of the appendix. The latter determines the type of surgical approach and hernia repair. The third Amyand’s hernia case treated at the Enrique Cabrera Hospital is presented. The patient underwent an appendectomy and inguinal hernia repair with satisfactory outcomes.

Fibrotecoma extraovárico gigante retroperitoneal / Giant Retroperitoneal Extraovarian Fibrothecoma

El fibrotecoma ovárico es una neoplasia poco frecuente y su localización extraovárica más rara aún. Se observa por lo general, como tumor sólido unilateral, de tamaño variable, en mujeres premenopáusicas. En su mayoría es benigno y puede ser funcionales o no. En la actualidad se han reportado tres pacientes y solo una de ellas de localización retroperitoneal. Se realizó este trabajo con el objetivo de describir el diagnóstico y tratamiento de esta rara enfermedad. Argumentada a través, de la presentación de un caso de fibrotecoma extraovárico gigante retroperitoneal; se le efectuó a la enferma la exéresis de la lesión sin complicaciones intra ni posoperatorias.

Ovarian fibrothecoma is a rare neoplasm and its extraovarian location is even rarer. It is usually seen as unilateral solid tumor, of variable size, in premenopausal women. It is usually seen as unilateral solid tumor, of variable size, in premenopausal women. Mostly it is benign and it can be functional. At present, three patients have been reported and only one has it in retroperitoneal location. This paper was conducted to describe the diagnosis and treatment of this rare disease. Reasoned through the presentation of a case of a giant retroperitoneal extraovarian fibrothecoma; He will be performed at the patient's tumor was excision without intra or postoperative complications. The patient underwent the excision of the lesion without intra or postoperative complications.

Differences in 3D dose distributions due to calculation method of voxel S-values and the influence of image blurring in SPECT.

This study compares 3D dose distributions obtained with voxel S values (VSVs) for soft tissue, calculated by several methods at their current state-of-the-art, varying the degree of image blurring. The methods were: 1) convolution of Dose Point Kernel (DPK) for water, using a scaling factor method; 2) an analytical model (AM), fitting the deposited energy as a function of the source-target distance; 3) a rescaling method (RSM) based on a set of high-resolution VSVs for each isotope; 4) local energy deposition (LED). VSVs calculated by direct Monte Carlo simulations were assumed as reference. Dose distributions were calculated considering spheroidal clusters with various sizes (251, 1237 and 4139 voxels of 3 mm size), uniformly filled with (131)I, (177)Lu, (188)Re or (90)Y. The activity distributions were blurred with Gaussian filters of various widths (6, 8 and 12 mm). Moreover, 3D-dosimetry was performed for 10 treatments with (90)Y derivatives. Cumulative Dose Volume Histograms (cDVHs) were compared, studying the differences in D95%, D50% or Dmax (ΔD95%, ΔD50% and ΔDmax) and dose profiles.For unblurred spheroidal clusters, ΔD95%, ΔD50% and ΔDmax were mostly within some percents, slightly higher for (177)Lu with DPK (8%) and RSM (12%) and considerably higher for LED (ΔD95% up to 59%). Increasing the blurring, differences decreased and also LED yielded very similar results, but D95% and D50% underestimations between 30-60% and 15-50%, respectively (with respect to 3D-dosimetry with unblurred distributions), were evidenced. Also for clinical images (affected by blurring as well), cDVHs differences for most methods were within few percents, except for slightly higher differences with LED, and almost systematic for dose profiles with DPK (-1.2%), AM (-3.0%) and RSM (4.5%), whereas showed an oscillating trend with LED.The major concern for 3D-dosimetry on clinical SPECT images is more strongly represented by image blurring than by differences among the VSVs calculation methods. For volume sizes about 2-fold the spatial resolution, D95% and D50% underestimations up to about 60 and 50% could result, so the usefulness of 3D-dosimetry is highly questionable for small tumors, unless adequate corrections for partial volume effects are adopted.

Phase I single-dose study of intracavitary-administered Nimotuzumab labeled with 188 Re in adult recurrent high-grade glioma.

Radioimmunotherapy (RIT) may improve the management of malignant gliomas. A Phase I clinical trial was performed to evaluate, for the first time, the toxicity and clinical effect of an intracavitary administration of a single dose of Nimotuzumab (h-R3) labeled wit (188)Re. Nimotuzumab is a humanized monoclonal antibody directed against epidermal growth factor receptors. Three patients with anaplastic astrocytoma (AA) and 8 with glioblastoma multiforme (GBM) were intended to be treated with 3 mg of mAb labelled with 10 or 15 mCi of (188)Re. In patients treated with 10 mCi (n=6) transitory worsening of pre-existing neurological symptoms were observed. Two patients treated with 15 mCi (n=4) developed early severe neurological symptoms and one also developed late severe toxicity (radionecrosis). In the group treated with 10 mCi, 1 GBM patient died in progression 6 months after the treatment, 2 patients (1 GBM and 1 AA) developed stable disease during 3 months. One GBM patient had partial response for more than 1 year and 2 patients (1 GBM and 1 AA) were asymptomatic and in complete response after 3 years of treatment. Maximal tolerated dose of the radioimmunoconjugate (188)Re-Nimotuzumab was 3 mg of the h-R3 labelled with 10 mCi of (188)Re. The radioimmunoconjugate showed a high retention in the surgical created resection cavity and the brain adjacent tissues with a mean value of 85.5 % of the injected dose one hour post-administration. This radioimmunoconjugate may be relatively safe and a promising therapeutic approach for treating high grade gliomas.

Biodistribution and internal dosimetry of the 188Re-labelled humanized monoclonal antibody anti-epidemal growth factor receptor, nimotuzumab, in the locoregional treatment of malignant gliomas.

OBJECTIVE: To evaluate the biodistribution, internal radiation dosimetry and safety of the 188Re-labelled humanized monoclonal antibody nimotuzumab in the locoregional treatment of malignant gliomas. METHODS: Single doses of 370 or 555 MBq of 188Re-labelled nimotuzumab were locoregionally administered to nine patients with recurrent high-grade gliomas, according to an approved dose-escalation study. SPECT, planar scintigraphy and magnetic resonance images were combined for dosimetric and pharmacokinetic studies. Blood and urine samples were collected to evaluate clinical laboratory parameters and for absorbed doses calculations. Biodistribution, internal dosimetry, human anti-mouse antibody response and toxicity were evaluated and reported. RESULTS: The 188Re-nimotuzumab showed a high retention in the surgically created resection cavity with a mean value of 85.5+/-10.3%ID 1 h post-injection. It produced mean absorbed doses in the tumour region of approximately 24.1+/-2.9 Gy in group I (patients receiving 370 MBq) and 31.1+/-6.4 Gy in group II (patients receiving 555 MBq); the normal organs receiving the highest absorbed doses were the kidneys, liver and urinary bladder. About 6.2+/-0.8%ID was excreted by the urinary pathway. The maximum tolerated dose was 370 MBq because two patients showed severe adverse effects after they received 555 MBq of 188Re-nimotuzumab. No patient developed human anti-mouse antibody response. CONCLUSIONS: A locoregional single dose of 188Re-labelled nimotuzumab of approximately 370 MBq could be used safely in the routine treatment of patients suffering with high-grade gliomas. The efficacy of this therapy needs to be evaluated in a phase II clinical trial.

Phase I/II clinical trial of the humanized anti-EGF-r monoclonal antibody h-R3 labelled with 99mTc in patients with tumour of epithelial origin.

AIM: To evaluate the biodistribution, internal radiation dosimetry and toxicity of the humanized MAb h-R3 labelled with Tc in humans. METHODS: Twenty-five patients with suspected epithelial-derived tumours were included in this study and divided into two groups: group I consisted of 10 patients who received 3 mg/1110 MBq (3 mg/30 mCi); and group II consisted of 15 patients who received 6 mg/2220 MBq (6 mg/60 mCi). Single photon emission computed tomography (SPECT) and planar images, and multiple blood and urine samples were collected up to 24 h after injection. Haematological parameters and adverse effects were classified according to the WHO criteria. Biodistribution, human anti-mouse antibody (HAMA) response and absorbed doses were estimated and reported. RESULTS: Liver, spleen, kidneys and heart were identified as source organs. Their higher uptakes were 53.3+/-6.4%ID, 2.0+/-1.4%ID, 9.8+/-4.3%ID and 2.8+/-0.9%ID, respectively. The urinary bladder and large intestine also had a significant uptake. The mean urinary excretion was around 22%ID. The liver received the highest absorbed doses followed by the kidneys and the urinary bladder wall. There were no haematological or biochemical abnormalities with clinical significance related to the product. No patient developed HAMA response. Preliminary analysis of clinical results showed a sensitivity of 76.5% and a specificity of 100%. CONCLUSIONS: The results of this study suggest that Tc-h-R3 could be used in patients in a safe and effective way, for the diagnosis of epithelial-derived tumours at the two evaluated dose levels.