Papel de los factores inflamatorios sistémicos en los tumores neuroendocrinos gastroenteropancreáticos (TNE-GEP) tratados con péptidos marcados con radionúclidos (PRRT): de la biología a la teragnosis / Role of systemic inflammatory factors in gastroenteropancreatic neuroendocrine tumors (GEP-NETs) treated with peptide receptor radionuclide therapy (PRRT): From biology to theragnosis

Objetivo Los índices inflamatorios sistémicos se han validado como indicadores de inflamación sistémica como marcadores predictivos de mal pronóstico para diversas enfermedades oncológicas. Sin embargo, se desconoce el impacto pronóstico de los marcadores de inflamación sistémica en pacientes con tumores neuroendocrinos gastroenteropancreáticos (TNE-GEP) tratados con péptidos marcados con radionúclidos (PRRT). Métodos Realizamos un estudio observacional, retrospectivo, multicéntrico de 40 pacientes con TNEs-GEP y TNE de origen desconocido tratados con PRRT entre el 2016 y el 2020. Los marcadores inflamatorios sistémicos se calcularon de la siguiente manera: relación neutrófilos a linfocitos (NLR)=recuento de neutrófilos/recuento de linfocitos, relación de monocitos a linfocitos (MLR)=recuento de monocitos/recuento de linfocitos, relación de plaquetas a linfocitos (PLR)=recuento de plaquetas/recuento de linfocitos, relación de albúmina a linfocitos (ALR)=niveles de albúmina/recuento de linfocitos y relación derivada de neutrófilos a linfocitos (dNLR)=recuento de neutrófilos/(recuento de leucocitos – recuento de neutrófilos). Se utilizaron datos analíticos basales pretratamiento y después de la segunda dosis para el cálculo de los distintos índices. Resultados La mediana de edad fue de 63 años (rango 41-85), el 55% eran hombres. Los valores de corte de referencia para NLR fueron 2,61, para MLR 0,31, para PLR 110,14, para ALR 2,39 y para dNLR 1,71. Los valores de corte después de la segunda dosis fueron, para NLR 2,3, para MLR 0,3, para PLR 131,61, ALR 4,16 y dNLR 1,48. La mediana de la sobrevivencia libre de progresión (SLP) fue de 21,7 meses (IC del 95%: 10,7-32,8 m) y la supervivencia global (SG) fue de 32,1 meses (IC del 95%: 19,6-44,7 m), la SLP fue más corta en pacientes con NLR elevado (p=0,001), ALR (0,03) y dNLR (p=0,001) en el análisis basal. La tasa de control de enfermedad (DCR) fue del 81% y la tasa de respuesta objetiva (ORR) del 18% (AU)

Aim Systemic inflammatory factors have been validated as indicators of ongoing systemic inflammation that could be predictive markers of poor prognosis for oncological outcomes. However, the prognostic impact of systemic inflammation markers is unknown in patients with gastroenteropancreatic neuroendocrine tumors (GEP-NETs) treated with peptide receptor radionuclide therapy (PRRT). Methods We conducted an observational, retrospective, multicentric study of 40 patients with GEP or unknown origin NETs treated with PRRT between 2016 and 2020. The systemic inflammatory markers were calculated as follows: neutrophil to lymphocyte ratio (NLR)=neutrophil count/lymphocyte count, monocyte to lymphocyte ratio (MLR)=monocyte count/lymphocyte count, platelet to lymphocyte ratio (PLR)=platelet count/lymphocyte count, albumin to lymphocyte ratio (ALR)=albumin levels/lymphocyte count and derived Neutrophil to Lymphocyte ratio (dNLR)=neutrophil count/(leucocytes count – neutrophils count). Baseline analysis and after the second dose were used for the calculation of different ratios. Results The median age was 63 years (range 41–85), 55% were male. The baseline cut-off values for NLR were 2.61, for MLR 0.31, for PLR 110.14, for ALR 2.39 and for dNLR 1.71. The cut-off values after the 2° dose were, for NLR 2.3, for MLR 0.3, for PLR 131.61, ALR 4.16, and dNLR 1.48. Median progression-free survival (PFS) was 21.7 months (95% CI 10.7–32.8 months) and overall survival (OS) was 32.1 months (95% CI 19.6–44.7 months), PFS was shorter in patients with elevated NLR (P=0.001), ALR (0.03), and dNLR (P=0.001) in baseline analysis. DCR was 81% and ORR 18%. Conclusions In GEP or unknown origin NETs treated with PRRT, we have identified the predictive and prognostic impact of baseline systemic inflammatory factors (AU)

Descripción de un método de cuantificación diferente para la carga de amiloide (DPDload) y validación de SPECT/TC en amiloidosis cardíaca / Description of a different quantification method for amyloid burden (burdenDPD) and validation of SPECT/CT in cardiac amyloidosis

Introducción Los radiotrazadores con afinidad ósea como el [99mTc]Tc-DPD han demostrado una alta sensibilidad y especificidad en el diagnóstico no invasivo de la amiloidosis cardíaca (AC) por transtirretina (ATTR-AC). Este estudio tiene como objetivo validar el uso de la SPECT/TC y evaluar la utilidad de la cuantificación de la captación (cargaDPD) en el tejido miocárdico como información potencial sobre la carga amiloide. Métodos Se trata de un análisis retrospectivo de 46 pacientes con sospecha de AC, en el que 23 casos con ATTR-AC fueron sometidos a dos métodos de cuantificación para estimar la carga amiloide (cargaDPD) a través de imágenes planares y de una SPECT/TC. Resultados La SPECT/TC aportó un valor añadido significativo en el diagnóstico del paciente con AC (p<0,05). La estimación de la carga amiloide comprobó que la pared del VI más afectada es el tabique interventricular en la mayoría de los casos, y la existencia de una relación significativa entre la captación de Perugini y la carga de DPD. Conclusiones Validamos la necesidad de la SPECT/TC como complemento de la imagen planar en el diagnóstico de la AC-TTR. Por su parte, el cálculo de la carga amiloide continúa siendo un área de investigación compleja y requiere de más estudios, con un mayor número de pacientes, que permitan validar un método estandarizado de cuantificación de la carga de amiloide, tanto para el diagnóstico como para el seguimiento del tratamiento (AU)

Background Bone tracers such as [99mTc]Tc-DPD have shown high sensitivity and specificity in the non-invasive diagnosis of transthyretin cardiac amyloidosis (ATTR-AC). This study aims to validate SPECT/CT and assess the usefulness of uptake quantification (burdenDPD) in the myocardial tissue as potential information on the amyloid burden. Methods In a retrospective analysis of 46 patients with suspected CA, 23 cases with ATTR-AC had two quantification methods conducted to estimate amyloid burden (burdenDPD) through planar scintigraphic scans and a SPECT/CT. Results SPECT/CT significantly provided an added value in the patient's diagnosis with CA (P<.05). The estimation of the amyloid burden substantiated that the most affected wall of the LV is the interventricular septum in most cases and the existence of a significant relationship between the Perugini score uptake and the burdenDPD. Conclusions We validate the need for SPECT/CT to complement planar imaging in diagnosing ATTR-AC. For its part, quantifying the amyloid load continues to be a complex area of research. It requires further studies with a larger number of patients to validate a standardized method of amyloid load quantification, both for diagnosis and treatment monitoring (AU)

Role of systemic inflammatory factors in gastroenteropancreatic neuroendocrine tumors (GEP-NETs) treated with peptide receptor radionuclide therapy (PRRT): From biology to theragnosis.

AIM: Systemic inflammatory factors have been validated as indicators of ongoing systemic inflammation that could be predictive markers of poor prognosis for oncological outcomes. However, the prognostic impact of systemic inflammation markers is unknown in patients with gastroenteropancreatic neuroendocrine tumors (GEP-NETs) treated with peptide receptor radionuclide therapy (PRRT). METHODS: We conducted an observational, retrospective, multicentric study of 40 patients with GEP or unknown origin NETs treated with PRRT between 2016 and 2020. The systemic inflammatory markers were calculated as follows: neutrophil to lymphocyte ratio (NLR)=neutrophil count/lymphocyte count, monocyte to lymphocyte ratio (MLR)=monocyte count/lymphocyte count, platelet to lymphocyte ratio (PLR)=platelet count/lymphocyte count, albumin to lymphocyte ratio (ALR)=albumin levels/lymphocyte count and derived Neutrophil to Lymphocyte ratio (dNLR)=neutrophil count/(leucocytes count - neutrophils count). Baseline analysis and after the second dose were used for the calculation of different ratios. RESULTS: The median age was 63 years (range 41-85), 55% were male. The baseline cut-off values for NLR were 2.61, for MLR 0.31, for PLR 110.14, for ALR 2.39 and for dNLR 1.71. The cut-off values after the 2° dose were, for NLR 2.3, for MLR 0.3, for PLR 131.61, ALR 4.16, and dNLR 1.48. Median progression-free survival (PFS) was 21.7 months (95% CI 10.7-32.8 months) and overall survival (OS) was 32.1 months (95% CI 19.6-44.7 months), PFS was shorter in patients with elevated NLR (p=0.001), ALR (0.03), and dNLR (p=0.001) in baseline analysis. DCR was 81% and ORR 18%. CONCLUSIONS: In GEP or unknown origin NETs treated with PRRT, we have identified the predictive and prognostic impact of baseline systemic inflammatory factors.

Expresión inmunohistoquímica de VEGFR1 en carcinomas de pulmón de células no pequeñas: La expresión inferior de VEGFR1 se asocia con el subtipo de carcinoma de células escamosas y los valores elevados en SUVmáx en PET de 18F-FDG / Immunohistochemical expression of VEGFR1 in non small cell lung carcinomas: Lower VEGFR1 expression is asociated with squamous cell carcinoma subtype and high max SUV values in 18F-FDG PET

Antecedentes: Estudiar la posible relación entre la expresión inmunohistoquímica del receptor 1 del factor de crecimiento endotelial vascular (VEGFR1) y el valor máximo de captación estandarizada (SUVmáx) de la PET 18F-FDG en pacientes con cáncer de pulmón de células no pequeñas.Material y métodos:El estudio incluyó 39 pacientes con NSCLC (24 carcinomas de células escamosas y 15 adenocarcinomas). Según el estadio clínico, los pacientes se distribuyeron de la siguiente manera: 8 en estadio I, 7 en estadio II, 15 en estadio III y 9 en estadio IV. Se estudió la expresión inmunohistoquímica del VEGFR1 mediante la técnica de la matriz tisular utilizando el dispositivo de arreglo de tejidos (Beecher Instruments, Sun Prairie, WI), utilizando el anticuerpo policlonal contra el VEGFR1 (Santa Cruz Biotechnology, California, EE. UU.).Resultados: Se observó una expresión inmunohistoquímica positiva del VEGFR1 en 23 casos (59%). El número de tumores positivos no se relacionó con el estadio clínico pero hubo una asociación estadísticamente significativa diferente (p: 0,0009) entre la positividad de VEGFR1 y el tipo histológico, correspondiendo los mayores porcentajes de resultados positivos a los adenocarcinomas (93,3%) frente a los carcinomas escamocelulares (37,5%). Asimismo, los valores SUVmáx fueron mayores (p: 0,039) en los carcinomas VEGFR1 negativos que en los tumores VEGFR1 positivos (r: 4-32,1; 16,4+/-6,4 [mediana 16,1] vs. r: 3-47; 14,5+/-8,6 [12,8]).Conclusiones: Nuestros resultados nos llevaron a considerar que en el CPCNP, la expresión inmunohistoquímica negativa de VEGFR1 se asocia significativamente con el subtipo de carcinomas de células escamosas y con valores SUVmáx más altos en 18F-FDG-PET (AU)

Background: To study the possible relation between immunohistochemical expression of vascular endothelial growth factor receptor 1 (VEGFR1) and the maximum standardised uptake value (maxSUV) of 18F-FDG PET in patients with non small cell lung cancer.Material and methods: The study included 39 patients with NSCLC (24 squamous cell carcinomas and 15 adenocarcinomas). According to the clinical stage, the patients were distributed as follows: 8 stage I, 7 stage II, 15 stage III and 9 stage IV. Immunohistochemical expression of VEGFR1 was studied through the technique of tissue-matrix using tissue arrayer device (Beecher Instruments, Sun Prairie, WI), using the polyclonal antibody against VEGFR1 (Santa Cruz Biotechnology, California, USA).Results: Positive VEGFR1 immunohistochemical expression was noted in 23 cases (59%). The number of positive tumours was not related with clinical stage but there was a different statistically significant association (p:.0009) between VEGFR1 positivity and histological type, corresponding the greater percentages of positive results to adenocarcinomas (93.3%) versus in squamous cell carcinomas (37.5%). Likewise, maxSUV values were higher (p: .039) in negative VEGFR1 carcinomas than in positive VEGFR1 tumors (r: 4-32.1; 16.4+/-6.4 [median 16.1] vs. r: 3-47; 14.5+/-8.6 [12.8]).Conclusions: Our results led us to consider that in NSCLC, the negative VEGFR1 immunohistochemical expression is associated significantly with squamous cell carcinomas subtype and with higher maxSUV values in 18F-FDG-PET (AU)

Immunohistochemical expression of VEGFR1 in non small cell lung carcinomas: Lower VEGFR1 expression is asociated with squamous cell carcinoma subtype and high SUV max values in 18F-FDG PET.

BACKGROUND: To study the possible relation between immunohistochemical expression of vascular endothelial growth factor receptor 1 (VEGFR1) and the maximum standardised uptake value (SUV max) of 18F-FDG PET in patients with non small cell lung cancer (NSCLC). MATERIAL AND METHODS: The study included 39 patients with NSCLC (24 squamous cell carcinomas and 15 adenocarcinomas). According to the clinical stage, the patients were distributed as follows: 8 stage I, 7 stage II, 15 stage III and 9 stage IV. Immunohistochemical expression of VEGFR1 was studied through the technique of tissue-matrix using Tissue Arrayer Device (Beecher Instruments, Sun Prairie, WI), using the polyclonal antibody against VEGFR1 (Santa Cruz Biotechnology, California, USA). RESULTS: Positive VEGFR1 immunohistochemical expression was noted in 23 cases (59%). The number of positive tumours was not related with clinical stage but there was a different statistically significant association (p:0,0009) between VEGFR1 positivity and histological type, corresponding the greater percentages of positive results to adenocarcinomas (93,3%) versus in squamous cell carcinomas (37,5%). Likewise, SUV max values were higher (p: 0,039) in negative VEGFR1 carcinomas than in positive VEGFR1 tumors (r: 4-32,1; 16,4+/-6,4 (median 16,1) vs r: 3-47; 14,5+/-8,6 (12,8)). CONCLUSIONS: Our results led us to consider that in NSCLC, the negative VEGFR1 immunohistochemical expression is associated significantly with squamous cell carcinomas subtype and with higher SUV max values in 18F-FDG-PET.

Immunohistochemical expression of VEGFR1 in non small cell lung carcinomas: Lower VEGFR1 expression is asociated with squamous cell carcinoma subtype and high max SUV values in 18F-FDG PET. / Expresión inmunohistoquímica de VEGFR1 en carcinomas de pulmón de células no pequeñas: La expresión inferior de VEGFR1 se asocia con el subtipo de carcinoma de células escamosas y los valores elevados en SUVmáx en PET de 18F-FDG.

BACKGROUND: To study the possible relation between immunohistochemical expression of vascular endothelial growth factor receptor 1 (VEGFR1) and the maximum standardised uptake value (maxSUV) of 18F-FDG PET in patients with non small cell lung cancer. MATERIAL AND METHODS: The study included 39 patients with NSCLC (24 squamous cell carcinomas and 15 adenocarcinomas). According to the clinical stage, the patients were distributed as follows: 8 stage I, 7 stage II, 15 stage III and 9 stage IV. Immunohistochemical expression of VEGFR1 was studied through the technique of tissue-matrix using tissue arrayer device (Beecher Instruments, Sun Prairie, WI), using the polyclonal antibody against VEGFR1 (Santa Cruz Biotechnology, California, USA). RESULTS: Positive VEGFR1 immunohistochemical expression was noted in 23 cases (59%). The number of positive tumours was not related with clinical stage but there was a different statistically significant association (p:.0009) between VEGFR1 positivity and histological type, corresponding the greater percentages of positive results to adenocarcinomas (93.3%) versus in squamous cell carcinomas (37.5%). Likewise, maxSUV values were higher (p: .039) in negative VEGFR1 carcinomas than in positive VEGFR1 tumors (r: 4-32.1; 16.4+/-6.4 [median 16.1] vs. r: 3-47; 14.5+/-8.6 [12.8]). CONCLUSIONS: Our results led us to consider that in NSCLC, the negative VEGFR1 immunohistochemical expression is associated significantly with squamous cell carcinomas subtype and with higher maxSUV values in 18F-FDG-PET.

Economic impact of improving patient safety using Sugammadex for routine reversal of neuromuscular blockade in Spain.

BACKGROUND: Neuromuscular blocking (NMB) agents are often administered to facilitate tracheal intubation and prevent patient movement during surgical procedures requiring the use of general anesthetics. Incomplete reversal of NMB, can lead to residual NMB, which can increase the risk of post-operative pulmonary complications. Sugammadex is indicated to reverse neuromuscular blockade induced by rocuronium or vecuronium in adults. The aim of this study is to estimate the clinical and economic impact of introducing sugammadex to routine reversal of neuromuscular blockade (NMB) with rocuronium in Spain. METHODS: A decision analytic model was constructed reflecting a set of procedures using rocuronium that resulted in moderate or deep NMB at the end of the procedure. Two scenarios were considered for 537,931 procedures using NMB agents in Spain in 2015: a scenario without sugammadex versus a scenario with sugammadex. Comparators included neostigmine (plus glycopyrrolate) and no reversal agent. The total costs for the healthcare system were estimated from the net of costs of reversal agents and overall cost offsets via reduction in postoperative pneumonias and atelectasis for which incidence rates were based on a Spanish real-world evidence (RWE) study. The model time horizon was assumed to be one year. Costs were expressed in 2019 euros (€) and estimated from the perspective of a healthcare system. One-way sensitivity analysis was carried out by varying each parameter included in the model within a range of +/- 50%. RESULTS: The estimated budget impact of the introduction of sugammadex to the routine reversal of neuromuscular blockade in Spanish hospitals was a net saving of €57.1 million annually. An increase in drug acquisition costs was offset by savings in post-operative pulmonary events, including 4806 post-operative pneumonias and 13,996 cases of atelectasis. The total cost of complications avoided was €70.4 million. All parameters included in the model were tested in sensitivity analysis and were favorable to the scenario with sugammadex. CONCLUSIONS: This economic analysis shows that sugammadex can potentially lead to cost savings for the reversal of rocuronium-induced moderate or profound NMB compared to no reversal and reversal with neostigmine in the Spanish health care setting. The economic model was based on data obtained from Spain and from assumptions from clinical practice and may not be valid for other countries.

Recordando nuestra historia: hace 60 años se descubrió el radioinmunoanálisis / Remembering our history: 60 years ago radioimmunoanalysis was discovered

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Effectiveness and Safety of the Switch from Remicade® to CT-P13 in Patients with Inflammatory Bowel Disease.

BACKGROUND AND AIMS: To evaluate the clinical outcomes in patients with IBD after switching from Remicade® to CT-P13 in comparison with patients who maintain Remicade®. METHODS: Patients under Remicade® who were in clinical remission with standard dosage at study entry were included. The 'switch cohort' [SC] comprised patients who made the switch from Remicade® to CT-P13, and the 'non-switch' cohort [NC] patients remained under Remicade®. RESULTS: A total of 476 patients were included: 199 [42%] in the SC and 277 [58%] in the NC. The median follow-up was 18 months in the SC and 23 months in the NC [p < 0.01]. Twenty-four out of 277 patients relapsed in the NC; the incidence of relapse was 5% per patient-year. The cumulative incidence of relapse was 2% at 6 months and 10% at 24 months in this group. Thirty-eight out of 199 patients relapsed in the SC; the incidence rate of relapse was 14% per patient-year. The cumulative incidence of relapse was 5% at 6 months and 28% at 24 months. In the multivariate analysis, the switch to CT-P13 was associated with a higher risk of relapse (HR = 3.5, 95% confidence interval [CI] = 2-6). Thirteen percent of patients had adverse events in the NC, compared with 6% in the SC [p < 0.05]. CONCLUSIONS: Switching from Remicade® to CT-P13 might be associated with a higher risk of clinical relapse, although this fact was not supported in our study by an increase in objective markers of inflammation. The nocebo effect might have influenced this result. Switching from Remicade® to CT-P13 was safe.

Síndrome de web axilar secundario a la biopsia selectiva del ganglio centinela en cáncer de mama / Axillary web syndrome following sentinel node biopsy for breast cancer

Paciente de 49 años diagnosticada de carcinoma lobulillar infiltrante de mama derecha, intervenida mediante mastectomía y biopsia selectiva de ganglio centinela (BSGC). Los ganglios linfáticos centinela resecados fueron negativos para malignidad, motivo por el cual no fue necesaria la realización de linfadenectomía axilar. En el periodo posquirúrgico temprano la paciente presentó una sensación de tensión cutánea en el hueco axilar asociada a un cordón palpable doloroso, manifestación típica del síndrome de web axilar (SWA), una complicación poco conocida de las intervenciones quirúrgicas axilares, tanto invasivas como conservadoras. Mediante la presentación de este caso queremos centrar la atención en una entidad patológica cuya incidencia podemos estar infravalorando al no incluirla en estudios prospectivos de BSGC. Es importante que los médicos nucleares seamos conscientes de la existencia del SWA como una posible consecuencia de la BSGC, más frecuente que la infección, el seroma o el linfedema y de que debemos informar a los pacientes que firman el consentimiento (AU)

A 49 year-old woman diagnosed with infiltrating lobular breast carcinoma, underwent a right mastectomy and sentinel node biopsy (SLNB). The resected sentinel lymph nodes were negative for malignancy, with an axillary lymphadenectomy not being performed. In the early post-operative period, the patient reported an axillary skin tension sensation, associated with a painful palpable cord. These are typical manifestations of axillary web syndrome (AWS), a poorly known axillary surgery complication, from both invasive and conservative interventions. By presenting this case we want to focus the attention on a pathological condition, for which its incidence may be underestimated by not including it in SLNB studies. It is important for nuclear medicine physicians to be aware of AWS as a more common complication than infection, seroma, or lymphoedema, and to discuss this possible event with the patient who is consenting to the procedure (AU)

Axillary web syndrome following sentinel node biopsy for breast cancer. / Síndrome de web axilar secundario a la biopsia selectiva del ganglio centinela en cáncer de mama.

A 49 year-old woman diagnosed with infiltrating lobular breast carcinoma, underwent a right mastectomy and sentinel node biopsy (SLNB). The resected sentinel lymph nodes were negative for malignancy, with an axillary lymphadenectomy not being performed. In the early post-operative period, the patient reported an axillary skin tension sensation, associated with a painful palpable cord. These are typical manifestations of axillary web syndrome (AWS), a poorly known axillary surgery complication, from both invasive and conservative interventions. By presenting this case we want to focus the attention on a pathological condition, for which its incidence may be underestimated by not including it in SLNB studies. It is important for nuclear medicine physicians to be aware of AWS as a more common complication than infection, seroma, or lymphoedema, and to discuss this possible event with the patient who is consenting to the procedure.

Platypnea-orthodeoxia syndrome: importance of patient position for correct diagnosis at the time of 99mTc-MAA injection / Síndrome platipnea-ortodeoxia: importancia de la posición del paciente en el momento de la inyección de 99mTc-MAA para un correcto diagnóstico

A 65-year-old male presented with unexplained hypoxia that became exacerbated by an upright posture (platypnea-orthodeoxia syndrome) secondary to hepatopulmonary syndrome (HPS). A 99mTc-macroaggregated albumin pulmonary perfusion scan revealed a right to left shunt of 29% in the sitting position, which had not been previously detected when the radiotracer injection was performed with the patient in supine position, nor was it diagnosed using another non-invasive imaging method (transthoracic contrast echocardiography and angio-CT). A transesophageal echocardiography was contraindicated due to the presence of esophageal varices. The administration of the radiopharmaceutical in sitting position for the study of the pulmonary perfusion allowed us to confirm the presence of the shunt and consider the patient a candidate for liver transplantation (AU)

Varón de 65 años de edad que presentó hipoxia sin explicación que se exacerbaba en sedestación (síndrome platipnea-ortodeoxia) secundaria a un síndrome hepatopulmonar (SHP). Una gammagrafía de perfusión pulmonar con macroagregados de albúmina 99mTc- reveló un cortocircuito derecha a izquierda, de 29% en la posición sentada que no se había detectado previamente cuando la inyección del radiotrazador se realizó con el paciente en posición supina, ni fue diagnosticado por otros métodos de imagen no invasivo (ecocardiografía transtorácica de contraste y la angio-TC). Una ecocardiografía transesofágica estaba contraindicada debido a la presencia de varices esofágicas. La administración del radiofármaco en sedestación nos permitió confirmar la presencia del cortocircuito y considerar al paciente candidato para trasplante hepático (AU)

Platypnea-orthodeoxia syndrome: Importance of patient position for correct diagnosis at the time of (99m)Tc-MAA injection.

A 65-year-old male presented with unexplained hypoxia that became exacerbated by an upright posture (platypnea-orthodeoxia syndrome) secondary to hepatopulmonary syndrome (HPS). A (99m)Tc-macroaggregated albumin pulmonary perfusion scan revealed a right to left shunt of 29% in the sitting position, which had not been previously detected when the radiotracer injection was performed with the patient in supine position, nor was it diagnosed using another non-invasive imaging method (transthoracic contrast echocardiography and angio-CT). A transesophageal echocardiography was contraindicated due to the presence of esophageal varices. The administration of the radiopharmaceutical in sitting position for the study of the pulmonary perfusion allowed us to confirm the presence of the shunt and consider the patient a candidate for liver transplantation.

[Cost analysis of the use of botulinum toxin type A in Spain]. / Análisis de costes del uso de toxina botulínica A en España.

OBJECTIVE: To estimate treatment costs of blepharospasm, cervical dystonia(CD), upper limb spasticity (ULS) and spasticity in children with cerebral palsy (SCCP) with botulinum neurotoxin type A (BoNT-A) in Spain. METHOD: Annual BoNT-A treatment costs were calculated (2013 ex-factory price () applying RDL 8/2010 and RDL 9/2011 deductions), based on initial dose (id), average dose (ad) and maximum dose (md) according to Summary of Product Characteristics of Botox® (100U/50U), Dysport®(500U) and Xeomin® (100U) and considering the use of complete vials.In addition, annual treatment costs were calculated considering the useof vials in more than one patient and also patient population annual treatment costs based on diseases' prevalence. RESULTS: Annual BoNT-A treatment costs per patient were estimated at between 265 and 2,120 with savings from 10% to 55% accordingto the selected BoNT-A. CD and ULS treatment provided the greatest cost per patient. Botox® provided greater savings in ULS (id/ad), CD(id), and in blepharospasm and SCCP (id/ad/md). Dysport® treatment was less costly in CD (md) and ULS (md), while Xeomin® was in CD(ad). Based on the estimated treated population in Spain, the annual treatment costs ranged from 368,392 to 13,958,836 depending on indication, dose and BoNT-A considered. CONCLUSIONS: The appropriate BoNT-A choice would lead to considerable savings for the National Health System. Botox® would generate lower costs per patient than other BoNT-A products in 9 out of 12 scenarios considered.

Objetivo: Estimar el coste de tratamiento de blefarospasmo, distoníacervical (DC), espasticidad del brazo del adulto (EBA) yespasticidad del niño con parálisis cerebral infantil (EPCI) con laspresentaciones de neurotoxina botulínica tipo A (NTB-A) enEspaña.Método: Se calculó el coste anual de tratamiento con NTB-A(, 2013; PVL oficial publicado aplicando deducciones del RDL8/2010 y RDL 9/2011), en función de la dosis inicial (di), dosismedia (dm) y dosis máxima (dmax) en base a los viales porsesión según fichas técnicas de Botox® (100U y 50U), Dysport®(500U) y Xeomin® (100U), considerando los músculos comunesen cada indicación. Adicionalmente, se calculó el coste considerandola población total de pacientes según prevalencia y lareutilización de viales en más de un paciente.Resultados: El coste anual/paciente con NTB-A supondría entre265y 2.120con un ahorro entre el 10% y 55% según laNTB-A seleccionada. DC y EBA presentarían el mayor coste/paciente. Botox® generaría un menor coste en EBA (di/dm) y DC(di) y en blefarospasmo y EPCI (di/dm/dmax). Dysport® tiene elmenor coste en DC (dmax) y EBA (dmax) y Xeomin® en DC(dm). El coste anual por población según prevalencia suponeentre 368.392y 13.958.836según indicación, dosis y NTBAseleccionada.Conclusiones: Una selección adecuada de las presentaciones deNTB-A para cada indicación permitiría generar importantesahorros para el Sistema Nacional de Salud. Botox® conseguiríamenores costes anuales/paciente frente al resto de NTB-A en 9de los 12 escenarios considerados.

Análisis de costes del uso de toxina botulínica A en España / Cost analysis of the use of botulinum toxin type A in Spain

Objetivo: Estimar el coste de tratamiento de blefarospasmo, distonía cervical (DC), espasticidad del brazo del adulto (EBA) y espasticidad del niño con parálisis cerebral infantil (EPCI) con las presentaciones de neurotoxina botulínica tipo A (NTB-A) en España. Método: Se calculó el coste anual de tratamiento con NTB-A(Euros, 2013; PVL oficial publicado aplicando deducciones del RDL8/2010 y RDL 9/2011), en función de la dosis inicial (di), dosis media (dm) y dosis máxima (dmax) en base a los viales por sesión según fichas técnicas de Botox(R) (100U y 50U), Dysport(R)(500U) y Xeomin® (100U), considerando los músculos comunes en cada indicación. Adicionalmente, se calculó el coste considerando la población total de pacientes según prevalencia y la reutilización de viales en más de un paciente. Resultados: El coste anual/paciente con NTB-A supondría entre 265Euros y 2.120Euros con un ahorro entre el 10% y 55% según la NTB-A seleccionada. DC y EBA presentarían el mayor coste/paciente. Botox(R) generaría un menor coste en EBA (di/dm) y DC(di) y en blefarospasmo y EPCI (di/dm/dmax). Dysport(R) tiene el menor coste en DC (dmax) y EBA (dmax) y Xeomin® en DC(dm). El coste anual por población según prevalencia supone entre 368.392 Euros y 13.958.836 Euros según indicación, dosis y NTB-A seleccionada. Conclusiones: Una selección adecuada de las presentaciones de NTB-A para cada indicación permitiría generar importantes ahorros para el Sistema Nacional de Salud. Botox(R) conseguiría menores costes anuales/paciente frente al resto de NTB-A en 9 de los 12 escenarios considerados

Objective: To estimate treatment costs of blepharospasm, cervical dystonia (CD), upper limb spasticity (ULS) and spasticity in children with cerebral palsy (SCCP) with botulinum neurotoxin type A (BoNT-A) in Spain. Method: Annual BoNT-A treatment costs were calculated (2013 ex-factory price (Euros) applying RDL 8/2010 and RDL 9/2011 deductions), based on initial dose (id), average dose (ad) and maximum dose (md) according to Summary of Product Characteristics of Botox® (100U/50U), Dysport® (500U) and Xeomin® (100U) and considering the use of complete vials. In addition, annual treatment costs were calculated considering the use of vials in more than one patient and also patient population annual treatment costs based on diseases’ prevalence. Results: Annual BoNT-A treatment costs per patient were estimated at between Euros265 and Euros2,120 with savings from 10% to 55% according to the selected BoNT-A. CD and ULS treatment provided the greatest cost per patient. Botox® provided greater savings in ULS (id/ad), CD(id), and in blepharospasm and SCCP (id/ad/md). Dysport® treatment was less costly in CD (md) and ULS (md), while Xeomin® was in CD(ad). Based on the estimated treated population in Spain, the annual treatment costs ranged from Euros368,392 to Euros13,958,836 depending on indication, dose and BoNT-A considered. Conclusions: The appropriate BoNT-A choice would lead to considerable savings for the National Health System. Botox® would generate lower costs per patient than other BoNT-A products in 9 out of 12 scenarios considered (AU)

Infarto de miocardio silente diagnosticado por SPECT de perfusión miocárdica en mujer joven con lupus eritematoso sistémico / Silent myocardial infarction diagnosed by myocardial perfusion SPECT in a young woman with systemic lupus erythematosus

La ateroesclerosis prematura y su consecuente enfermedad coronaria tienen un papel fundamental en los pacientes con lupus eritematoso sistémico, incluso en las mujeres premenopáusicas, siendo unas de las principales causas de mortalidad en el lupus de larga evolución. Presentamos el caso de una mujer premenopáusica de 42 años, fumadora, con antecedentes de hipertensión arterial, colecistectomía y lupus de 23 años de evolución, en tratamiento con AINE, esteroides y antipalúdicos. La paciente acude por dolor opresivo precordial con moderados esfuerzos. Ante la sospecha de cardiopatía isquémica se inicia estudio cardiológico y se realiza una SPECT de perfusión miocárdica que objetivó un defecto de perfusión intenso y extenso anteroapical, con muy ligera reperfusión en las imágenes de reposo, compatible con el diagnóstico de infarto agudo en la región apical e isquemia en el territorio de la arteria descendente anterior, confirmada por el cateterismo cardíaco(AU)

Premature atherosclerosis and its consequent heart disease play a crucial role in patients with systemic lupus erythematosus, even in premenopausal women. It is one of the leading causes of death in long evolution lupus. We present the case of a 42-year-old premenopausal woman, smoker, with a history of hypertension, cholecystectomy and lupus for 23 years, treated with NSAID, steroids and antimalarial drugs. The patient consulted due to chest pain on moderate efforts. Due to the suspicion of ischemic heart disease, a cardiology study was initiated, performing a myocardial perfusion SPECT. This revealed an intense and extensive anterolateral perfusion defect, with very light reperfusion in rest images, consistent with the diagnosis of acute infarction in the apical region and ischemia in the territory of the left anterior descending artery, which was confirmed later by cardiac catheterization(AU)

[Silent myocardial infarction diagnosed by myocardial perfusion SPECT in a young woman with systemic lupus erythematosus]. / Infarto de miocardio silente diagnosticado por SPECT de perfusión miocárdica en mujer joven con lupus eritematoso sistémico.

Premature atherosclerosis and its consequent heart disease play a crucial role in patients with systemic lupus erythematosus, even in premenopausal women. It is one of the leading causes of death in long evolution lupus. We present the case of a 42-year-old premenopausal woman, smoker, with a history of hypertension, cholecystectomy and lupus for 23 years, treated with NSAID, steroids and antimalarial drugs. The patient consulted due to chest pain on moderate efforts. Due to the suspicion of ischemic heart disease, a cardiology study was initiated, performing a myocardial perfusion SPECT. This revealed an intense and extensive anterolateral perfusion defect, with very light reperfusion in rest images, consistent with the diagnosis of acute infarction in the apical region and ischemia in the territory of the left anterior descending artery, which was confirmed later by cardiac catheterization.

Quantitative renal cortical perfusion in human subjects with magnetic resonance imaging using iron-oxide nanoparticles: influence of T1 shortening.

BACKGROUND: Using conventional contrast agents, the technique of quantitative perfusion by observing the transport of a bolus with magnetic resonance imaging (MRI) is limited to the brain due to extravascular leakage. PURPOSE: To perform quantitative perfusion measurements in humans with an intravascular contrast agent, and to estimate the influence of the T1 relaxivity of the contrast agent on the first-pass response. MATERIAL AND METHODS: Renal cortical perfusion was measured quantitatively in six patients with unilateral renal artery stenosis using a rapid gradient double-echo sequence in combination with an intravenous bolus injection of NC100150 Injection, an intravascular contrast agent based on iron-oxide nanoparticles. The influence of T1 relaxivity was measured by comparing perfusion results based on single- and double-echo data. RESULTS: The mean values of cortical blood flow, cortical blood volume, and mean transit time in the normal kidneys were measured to 339+/-60 ml/min/100 g, 41+/-8 ml/100 g, and 7.3+/-1.0 s, respectively, based on double-echo data. The corresponding results based on single-echo data, which are not compensated for the T1 relaxivity, were 254+/-47 ml/min/100 g, 27+/-3 ml/100 g, and 6+/-1.2 s, respectively. CONCLUSION: The use of a double-echo sequence enabled elimination of confounding T1 effects and consequent systematic underestimation of the perfusion.