Allium Ureteral Stent as a Treatment for Ureteral Stricture: Results and Concerns.

INTRODUCTION: Ureteral strictures could be a chronic illness that leads to severe side effects and poor quality of life. A treatment with an Allium ureteral stent (URS), a self-expanding, large-caliber URS, was implemented in our department for ureteral stricture. Our study aim was to report the long-term results, including success rate, complications, and adverse effects. METHODS: We retrospectively collected data on all patients who were treated with an Allium URS in our department between January 2017 and January 2021. Demographic, clinical, radiological, and perioperative parameters were retrieved and analyzed. The primary outcome was stricture resolution rates following stent removal. RESULTS: Our cohort included 17 patients, 9 men and 8 women. The etiology of ureteral strictures was urolithiasis in 76.5% and pelvic procedure injury in 17.6%. The overall success rate was 35.29% in an average follow-up of 10.42 ± 2.39 months after stent removal. A higher failure rate was observed in the urolithiasis etiology group (90% vs. 66.7%, p = 0.38). The mean indwelling time of the Allium stent was 14.29 ± 1.29 months. CONCLUSIONS: Although an Allium URS could be considered as a feasible and attractive treatment of ureteral strictures, due to its minimal invasiveness, the success rate of this treatment is relatively low. Therefore, this option should be carefully considered and should be discouraged in young and fit patients and reserved for older unfit patients who are unwilling to undergo surgical repair of ureteral strictures.

Novel nanotech antioxidant cocktail prevents medical diagnostic procedures ionizing radiation effects.

Ionizing radiation (IR) exposure results in oxidative damage causing cytotoxic and genotoxic effects. Double-strand breaks (DSBs) are considered the most significant DNA lesions induced by ionizing radiation. The present study evaluates the radio protective effect of a novel antioxidant cocktail through quantification of DSB in peripheral blood lymphocytes (PBL) in vivo. The study included 16 consecutive patients who were divided into 2 groups, 6 patients received the novel antioxidant cocktail and 10 control patients. Blood samples were drawn from the patients undergoing bone scan, before the injection of the 99mTc MDP tracer and 2 h after the injection. Quantification of the IR damage was done by Immunofluorescence analysis of the phosphorylated histone, γ-H2AX, used to monitor DSB induction and repair in PBL. The radiation effect of the control group was measured by 2 variables, the average DBSs foci per nucleus and the percent of the DSB bearing cells in PBL. The findings showed a significant increase in the DSBs after isotope injection with an average increment of 0.29 ± 0.13 of foci/nucleus and 17.07% ± 7.68 more DSB bearing cells (p < 0.05). The cocktail treated group showed a lower difference average of - 2.79% ± 6.13 DSB bearing cells. A paired t-test revealed a significant difference between the groups (p < 0.005) confirming the cocktail's protective effect. The novel anti-oxidant treatment decreases the oxidative stress-induced DNA damage and can be considered as a preventative treatment before radiation exposure.

Axillary Lymph Nodes Hypermetabolism After BNT162b2 mRNA COVID-19 Vaccination in Cancer Patients Undergoing 18F-FDG PET/CT: A Cohort Study.

PURPOSE: Recognition of the pattern of FDG uptake in hypermetabolic axillary lymph nodes (HALs) and association with recent messenger RNA (mRNA) vaccination are important to prevent patient anxiety and further needless examinations or costly biopsies in cancer patients. MATERIALS AND METHODS: This study was a retrospective cohort study in a single tertiary care institution. We investigate the occurrence and pattern of HAL on FDG PET/CT scans from 650 consecutive cancer patients with recent BNT162b2 mRNA COVID-19 vaccination. RESULTS: Between December 20, 2020, and February 8, 2021, 650 patients (351 female patients [54%]; mean age, 68.9 years) had recent mRNA COVID-19 vaccination and an FDG PET/CT scan. HALs were found in 57 (14.5%) of 394 patients (95% confidence interval [CI], 10.9%-18.7%) 12.3 ± 5.9 (1-22) days after dose 1 and in 111 (43.3%) of 256 patients (95% CI, 35.3%-52.2%; P < 0.0001) after 7.5 ± 5.4 (1-22) days after dose 2. There was no difference between dose 1 and dose 2 concerning SUVmax (3.7 ± 1.8 [1.3-11.3] and 4.5 ± 3.9 [1.4-26.3], P = 0.13, respectively), SUVmean (2.1 ± 1.0 [0.7-6.5] and 2.7 ± 2.4 [0.8-17], P = 0.08, respectively), and reactogenicity volume (2.7 ± 2.3 [0.2-11.6] cm3 and 2.7 ± 2.4 [0.2-15.5] cm3, P = 0.98, respectively). There was no difference in number and in size of positive lymph nodes between dose 1 and dose 2: 3.2 ± 2.2 (1-10) and 3.7 ± 2.4 (1-12) (P = 0.18), and 1.4 ± 0.4 cm (0.7-2.5 cm) and 1.5 ± 0.4 cm (0.6-3.2 cm) (P = 0.75), respectively. CONCLUSIONS: A cluster pattern of hypermetabolic ipsilateral small axillary lymph nodes is common after mRNA COVID-19 vaccination, mainly after the second injection.

[TREATMENT OF ONCOLOGY PATIENTS DURING THE CORONA VIRUS ERA].

BACKGROUND: Cancer patients are more at risk to contract SARS-CoV-2 and may develop many more severe complications, along with high mortality rates relative to the cancer-free population. The outbreak of the epidemic was characterized by a high rate of infection from person to person, however medical systems remained fully functional. Following most international guidelines, adaptations were made to the performance level of oncology treatments, and the service was to continue as usual. Moreover, the corona virus epidemic era was characterized by new challenges such as emergency work schedules, additional hygiene measures and social distancing. Furthermore, the medical staff used Personal Protection Equipment and resource preparedness for a larger outbreak and probable collapse of the health system. Therefore, changes have been made in the form and delivery of patient care and treatments. This article presents the work format employed in the Oncology Unit at Bnai Zion Medical Center during the COVID-19 epidemic. The newly adjusted protocol included four areas: staff, patients, infrastructure and malignant disease types.

First line Immunotherapy for Non-Small Cell Lung Cancer.

Immunotherapy for non-small cell lung cancer (NSCLC) is incorporated increasingly in first line treatments protocols. Multiple phase 3 studies have tested different medications targeting programmed death receptor 1 (PD-1), programmed death-ligand 1 (PD-L1), cytotoxic T-lymphocyte-associated protein 4 (CTLA-4), with or without chemotherapy. The inclusion criteria differ between the various clinical trials, including the cut-off levels of PD-L1 expression on tumor cells, and the tumor histology (squamous or non-squamous). Patients with tumor expression levels of PD-L1 ≥ 50% are candidates for treatment with single agent Pembrolizumab or Atezolizumab. Patients with PD-L1 < 50% are candidates for immunotherapy with pembrolizumab as a single agent if PL-1 > 1%; immunotherapy doublet, Nivolumab and Ipilimumab, or single agent immunotherapy combined with chemotherapy. Here we review phase 3 clinical trials utilizing immunotherapy in the first line for treatment of NSCLC, including Pembrolizumab in KEYNOTE-024, KEYNOTE-042, KEYNOTE-189 and KEYNOTE-407; Nivolumab and Ipilimumab in CHECKMATE-227 and CHECKMATE 9LA; and Atezolizumab in IMpower110, IMpower130 and IMpower150.

[MANAGING LUNG CANCER PATIENTS' CARE DURING THE COVID-19 PANDEMIC].

BACKGROUND: Lung cancer patients who contract the new coronavirus, appear to have a greater risk for severe COVID-19 illness along with early deterioration and death. However, the prognosis may depend on the cancer stage and the type of treatment administered. OBJECTIVES: Establishing updated treatments and care management regulations for lung cancer patients during the COVID-19 pandemic, based on worldwide clinical experience. METHODS: This article reviews the main recommendations described by the American and European Oncology Societies managing lung cancer patients infected by COVID-19. RESULTS: In the current pandemic setting, attempts should be made to avoid jeopardizing the prognosis of lung cancer patients, by maintaining current guidelines in oncology practice. In cases of patients with active infection, the recommendation is to hold treatment until recovery. For other patients, due to the aggressive nature of lung cancer, the guidelines suggest not to delay curative treatments in non-metastatic disease and provide palliative treatment in shortened protocols. CONCLUSIONS: The present summary of guideline recommendations provides different management strategies for patients with lung cancer. These care approaches attempt to solve new challenges raised by the COVID-19 pandemic. Each specific case must be considered individually.

Prostate cancer evaluation using PET quantification in 68Ga-PSMA-11 PET/MR with attenuation correction of bones as a fifth compartment.

BACKGROUND: Tissues with low magnetic resonance (MR) signals, such as bones and lungs differ considerably in their attenuation properties, requiring special considerations for attenuation correction. We evaluated the impact of using the five-compartment segmentation model, which incorporates bones, in 68Ga-PSMA-11 PET/MR studies in patients undergoing evaluation for prostate cancer. METHODS: Prostate cancer patients underwent dedicated prostate 68Ga-PSMA-11 PET/MR followed by whole-body 68Ga-PSMA-11 PET/CT. Coronal µmap images of the pelvis derived from four- and five-compartment segmentation models of magnetic resonance attenuation correction (MRAC) were produced. Standardized uptake values (SUV) calculated by the four and five-compartment MRAC models and by computed tomography attenuation correction (CTAC) were compared and correlated in normal prostate tissue, gluteus muscle, sacrum, intra-prostatic lesions and metastases (i.e., bone lesions and involved lymph nodes), and prostatic lesions to gluteus (L/G) ratio. RESULTS: Twenty-six patients (mean age 69.4±9.3 years) were included in the study. Twenty-five patients presented for prostate cancer staging and one patient was evaluated for recurrent disease. There was a statistically significant difference between SUVs of the gluteus, sacrum, prostatic lesions and normal prostate tissue measured by the four-compartment vs. the five-compartment MRAC models, with a medium effect size. Very good to good correlation between SUV measured using the four-compartment MRAC model and SUV measured using the five-compartment model were noted in all lesional and non-lesional areas. Very good to good correlation was noted between four-compartment MRAC and CTAC SUVs of prostatic lesions and L/G ratio and between five-compartment MRAC and CTAC SUVs of prostatic lesions, L/G ratio and metastatic lesions. CONCLUSIONS: 68Ga-PSMA-11 PET/MR using the five-compartment segmentation model affects SUV measurements in prostate lesions and in the normal prostate and therefore patient follow-up studies must be conducted using the same segmentation model.

The Use of Tissue Adhesive for Tumor Bed Closure during Partial Nephrectomy is Associated with Reduced Devascularized Functional Volume Loss.

OBJECTIVES: To quantitatively compare the functional renal volume loss, following nephron sparing surgery (NSS) between patients in whom tumor bed closure was done by biological tissue adhesive and those who were managed by standard suture technique. METHODS: From our institutional NSS database we retrospectively collected patients who had two sequential quantitative single-photon emission computed tomography of 99mTc-dimercaptosuccinic acid uptake studies, the first study immediately before surgery and the second one 3-6 months following surgery. The study group included 69 patients: 26 (37.7%) patients in the sealant group (BioGlue®) and 43 (62.3%) patients in the standard suture group. RESULTS: No statistically significant differences were noted in the baseline clinical and pathological characteristics of the studied groups. However, there were several statistically significant differences in operative variables: patients in the suture group had larger amount of blood loss (3-fold), longer ischemia time (26.6 vs. 21 minutes,) and slightly longer operation time. Patients in whom tumor bed was closed by sutures had nearly 3-fold higher parenchymal loss compared to patients managed by sealant (26.28 vs. 8.92 ml, p = 0.048). CONCLUSIONS: The use of tissue sealant during tumor bed reconstruction is associated with reduced devascularized parenchymal mass loss and should be considered among modifiable surgical factors during NSS.

Radionuclide Methods in the Diagnosis of Sacroiliitis in Patients with Spondyloarthritis: An Update.

Sacroiliitis, inflammation of the sacroiliac joint (SIJ), is the hallmark of ankylosing spondylitis and spondyloarthritis (SpA) in general. The arsenal of recommended diagnostic modalities for imaging of the SIJ is scanty and, in practice, includes only conventional X-rays and magnetic resonance imaging (MRI). This review suggests that bone scintigraphy, particularly single-photon emission computed tomography (SPECT) with calculation of indices, or SPECT in combination with low-dose computed tomography (CT) can be a sensitive and specific tool for the diagnosis of sacroiliitis and can be used as part of the individualized approach to the diagnosis of axial SpA. In addition, [18F]fluoride positron emission tomography (PET)/CT imaging and immunoscintigraphy, using labeled monoclonal anti-cytokine antibodies, are promising methods of current scientific interest in this field.

More Realistic Face Model Surface Improves Relevance of Pediatric In-Vitro Aerosol Studies.

BACKGROUND: Various hard face models are commonly used to evaluate the efficiency of aerosol face masks. Softer more realistic "face" surface materials, like skin, deform upon mask application and should provide more relevant in-vitro tests. Studies that simultaneously take into consideration many of the factors characteristic of the in vivo face are lacking. These include airways, various application forces, comparison of various devices, comparison with a hard-surface model and use of a more representative model face based on large numbers of actual faces. AIM: To compare mask to "face" seal and aerosol delivery of two pediatric masks using a soft vs. a hard, appropriately representative, pediatric face model under various applied forces. METHODS: Two identical face models and upper airways replicas were constructed, the only difference being the suppleness and compressibility of the surface layer of the "face." Integrity of the seal and aerosol delivery of two different masks [AeroChamber (AC) and SootherMask (SM)] were compared using a breath simulator, filter collection and realistic applied forces. RESULTS: The soft "face" significantly increased the delivery efficiency and the sealing characteristics of both masks. Aerosol delivery with the soft "face" was significantly greater for the SM compared to the AC (p< 0.01). No statistically significant difference between the two masks was observed with the hard "face." CONCLUSIONS: The material and pliability of the model "face" surface has a significant influence on both the seal and delivery efficiency of face masks. This finding should be taken into account during in-vitro aerosol studies.

Feasibility of aerosol drug delivery to sleeping infants: a prospective observational study.

OBJECTIVES: Delivery of inhaled medications to infants is usually very demanding and is often associated with crying and mask rejection. It has been suggested that aerosol administration during sleep may be an attractive alternative. Previous studies in sleeping children were disappointing as most of the children awoke and rejected the treatment. The SootherMask (SM) is a new, gentle and innovative approach for delivering inhaled medication to infants and toddlers. The present pilot study describes the feasibility of administering inhaled medications during sleep using the SM. DESIGN: Prospective observational study. SETTING: Out patients. PARTICIPANTS: 13 sleeping infants with recurrent wheezing who regularly used pacifiers and were <12 months old. INTERVENTION: Participants inhaled technetium99mDTPA-labelled normal saline aerosol delivered via a Respimat Soft Mist Inhaler (SMI) (Boehringer-Ingelheim, Germany) and SM + InspiraChamber (IC; InspiRx Inc, New Jersey, USA). OUTCOMES: The two major outcomes were the acceptability of the treatment and the lung deposition (per cent of emitted dose). RESULTS: All infants who fulfilled the inclusion criteria successfully received the SM treatment during sleep without difficulty. Mean lung deposition (±SD) averaged 1.6±0.5% in the right lung. CONCLUSIONS: This study demonstrated that the combination of Respimat, IC and SM was able to administer aerosol therapy to all the sleeping infants who were regular pacifier users with good lung deposition. Administration of aerosols during sleep is advantageous since all the sleeping children accepted the mask and ensuing aerosol therapy under these conditions, in contrast to previous studies in which there was frequent mask rejection using currently available devices. CLINICAL TRIAL REGISTRY: NCT01120938.

Imaging-guided hyperstimulation analgesia in low back pain.

Low back pain in patients with myofascial pain syndrome is characterized by painful active myofascial trigger points (ATPs) in muscles. This article reviews a novel, noninvasive modality that combines simultaneous imaging and treatment, thus taking advantage of the electrodermal information available from imaged ATPs to deliver localized neurostimulation, to stimulate peripheral nerve endings (Aδ fibers) and in turn, to release endogenous endorphins. "Hyperstimulation analgesia" with localized, intense, low-rate electrical pulses applied to painful ATPs was found to be effective in 95% patients with chronic nonspecific low back pain, in a clinical validation study.

Lung aerosol deposition in suckling infants.

INTRODUCTION: Aerosol therapy in infants may be greatly compromised by face mask rejection due to squirming and crying. Lung aerosol deposition in crying infants may thereby be greatly reduced. Since 'suckling' on a pacifier calms infants, they should more readily accept a face mask that incorporates a pacifier. However, since infants must breathe nasally while suckling, lung aerosol deposition may be reduced due to impaction in the nose. The aim of the present pilot study was to compare lung aerosol deposition while suckling on a pacifier incorporated into a mask with that obtained while inhaling from a conventional mask. METHODS: Twelve infants <12 months old and who regularly used pacifiers participated as their own controls. Lung aerosol deposition was measured scintigraphically (technetium-(99m)DTPA-labelled normal saline aerosol, MMAD (Mass Median Aerodynamic Diameter) 3 um and GSD (Geometric Standard Deviation) of 2) via jet nebuliser using a conventional mask versus 'suckling' on their pacifier incorporated into a unique mask. RESULTS: Mean lung deposition (± SD) while suckling using a mask with attached pacifier (1.6 ± 0.5% in the right lung) was similar to that with a conventional mask (1.7 ± 0.9%, p=0.81). CONCLUSIONS: Lung aerosol deposition during nasal breathing while suckling on a pacifier-equipped mask is similar to that in infants breathing quietly using a conventional mask, and results comparable with previous data in infants and in nasal breathing models of an infant's upper respiratory tract. Using a pacifier during aerosol treatment in infants may be as efficient as conventional treatment without a pacifier.

A novel image-guided, automatic, high-intensity neurostimulation device for the treatment of nonspecific low back pain.

Purpose. The current pilot study investigates the effectiveness of a novel device in the management of chronic low back pain (LBP). This device is able to automatically measure skin impedance in a selected body area and, immediately afterwards, to stimulate multiple points that are targeted according to differentiation in their electrical properties (peripheral nerve ends-milinated A δ fibers) with high-intensity electrical stimulation. Materials and Methods. Nineteen outpatients were included in the study, 15 females (79%) and 4 men (21%), mean age 52.1 ± 10.8 years, all diagnosed with nonspecific chronic LBP. The protocol consisted of 6 treatment sessions, 2-4 days apart. Each session included a <1 minute automatic impedance screening, followed by a 20-minute treatment of lowest impedance points according to proprietary algorithms. Outcome Measures. The primary outcome measure consisted of changes in pain intensity as measured on a 100 mm pain visual analogue scale (VAS) obtained at enrollment, before and 2 hours after each treatment. Secondary outcome measures were the Oswestry Disability Index (ODI) and lumbar flexion range of motion (ROM) obtained at baseline and each week during treatment. Results. The mean ± SD baseline VAS score for all participants was 61 ± 14. There were no significant changes in VAS scores between enrollment and before the first treatment (55 ± 16; P = .102). During treatment, VAS scores decreased significantly compared with baseline scores by 39 ± 17 mm (P < .001). Notably, VAS scores of all the patients, except for one, decreased by more than 20 mm after the fourth treatment, thus showing marked improvement in 95% of enrolled patients. ODI decreased throughout the entire treatment period, with significant changes from baseline already at the first week (P = .001). Lumbar flexion ROM showed a mean increase of 2.1 cm during treatment, but was not statistically significant. Conclusion. The results of the current pilot study show that treatment with this novel device produced a clinically significant reduction in back pain in 95% of patients after four treatment sessions. The decrease both in pain and perceived disability, combined with the improvement in ROM, support further investigation of the use of this therapy in the treatment of LBP.

The Bnai Zion Planar Method: a simplified technique for the quantitation of the absolute renal uptake of (99m)Tc-DMSA in children.

AIM AND PURPOSE: Radionuclide imaging of the kidneys using dimercaptosuccinic acid chelate labeled with technetium-99m (Tc-DMSA) is a well-established method for evaluating the extent of kidney parenchymal involvement in the scenario of urinary tract infection and for the estimation of the functional renal mass. We have developed a simplified technique, Bnai Zion Planar Method (BZPM), to estimate absolute DMSA uptake by the kidneys, which uses a shorter time of acquisition and does not require cumbersome calculations of attenuation correction. The aim of this study was to validate this technique by comparing it with the Quantitative DMSA single-photon emission computed tomography (SPECT) (QDMSA) measurements as the reference method. METHODS: Sixty-one consecutive children (mean age 5.4+/-4.8 years) were included in the study. Absolute uptake of the radiopharmaceutical by the kidneys was measured using the QDMSA SPECT methods described earlier with data acquisition of 20 min. Kidney volumes and radioactivity concentration measurements were calculated on the reconstruction data using the threshold method. For the simplified technique (BZPM), a planar posterior view of the kidneys was acquired for 1 min at the end of the QDMSA SPECT study. RESULTS: In both kidneys we observed a significant strong correlation between the two methods. BZPM measurements were very similar to those obtained using the validated QDMSA method, as determined by linear regression analysis (Pearson's r=0.924, P<0.001), r(2)=0.854. The uptake according to QDMSA can be predicted by the uptake measured by the BZPM method using the following regression equation: QDMSA=0.445+1.061 BZPM. CONCLUSION: BZPM estimation in children using the newly proposed planar method was found to be nearly identical to the validated QDMSA SPECT method.

A new noninvasive device for measuring central ejection dP/dt mathematical foundation of cardiac dP/dt measurement using a model for a collapsible artery.

We have developed a novel non-invasive device for the measurement of one of the most sensitive indices of myocardial contractility as represented by the rate of increase of intraventricular pressure (left ventricular dP/dt and arterial dP/dt performance index (dP/dt(ejc)). Up till now, these parameters could be obtained only by invasive catheterization methods. The new technique is based on the concept of applying multiple successive occlusive pressures on the brachial artery from peak systole to diastole using a inflatable cuff and plotting the values against time intervals that leads to the reconstruction of the central aortic pressure noninvasively. The following describes the computer simulator developed for providing a mathematical foundation of the new sensor. At the core of the simulator lies a hemodynamic model of the blood flow on an artery under externally applied pressure. The purpose of the model is to reproduce the experimental results obtained in studies on patients (Gorenberg et al. in Cardiovasc Eng: 305-311, 2004; Gorenberg et al. in Emerg med J 22 (7): 486-489, 2005) and a animal model where ischemia resulted from balloon inflation during coronary catheterization (Gorenberg and Marmor in J Med Eng Technol, 2006) and to describe correlations between the dP/dt(ejc) and other hemodynamic variables. The model has successfully reproduced the trends observed experimentally, providing a solid in-depth understanding of the hemodynamics involved in the new measurement. A high correlation between the dP/dt(ejc) and the rate of pressure rise in the aorta during the ejection phase was observed. dP/dt(ejc) dependence on other hemodynamic parameters was also investigated.

Facilitation of aerosol ventilation scanning for diagnosis of pulmonary emboli in uncooperative dyspneic patients.

Acute pulmonary thromboembolism (PE) is a common cause of death in hospital patients. Quick and accurate diagnosis significantly decreases mortality. Many medical facilities still have ventilation/perfusion lung scans as the only available and preferred screening test for suspected PE. Although testing requires the patient's cooperation, many patients with PE are dyspneic and uncooperative.This case report illustrates a novel method of obtaining high-quality radionuclide aerosol ventilation scintigraphs in uncooperative patients by means of an easy to use hood (BabyAir; BabyBreath, Or Akiva, Israel). There is no need for patients to neither undertake difficult breathing maneuvers nor to use a mouth-piece or mask.