Antibiotic Prophylaxis in Infants with Grade III, IV, or V Vesicoureteral Reflux.

BACKGROUND: The efficacy of continuous antibiotic prophylaxis in preventing urinary tract infection (UTI) in infants with grade III, IV, or V vesicoureteral reflux is controversial. METHODS: In this investigator-initiated, randomized, open-label trial performed in 39 European centers, we randomly assigned infants 1 to 5 months of age with grade III, IV, or V vesicoureteral reflux and no previous UTIs to receive continuous antibiotic prophylaxis (prophylaxis group) or no treatment (untreated group) for 24 months. The primary outcome was the occurrence of the first UTI during the trial period. Secondary outcomes included new kidney scarring and the estimated glomerular filtration rate (GFR) at 24 months. RESULTS: A total of 292 participants underwent randomization (146 per group). Approximately 75% of the participants were male; the median age was 3 months, and 235 participants (80.5%) had grade IV or V vesicoureteral reflux. In the intention-to-treat analysis, a first UTI occurred in 31 participants (21.2%) in the prophylaxis group and in 52 participants (35.6%) in the untreated group (hazard ratio, 0.55; 95% confidence interval [CI], 0.35 to 0.86; P = 0.008); the number needed to treat for 2 years to prevent one UTI was 7 children (95% CI, 4 to 29). Among untreated participants, 64.4% had no UTI during the trial. The incidence of new kidney scars and the estimated GFR at 24 months did not differ substantially between the two groups. Pseudomonas species, other non-Escherichia coli organisms, and antibiotic resistance were more common in UTI isolates obtained from participants in the prophylaxis group than in isolates obtained from those in the untreated group. Serious adverse events were similar in the two groups. CONCLUSIONS: In infants with grade III, IV, or V vesicoureteral reflux and no previous UTIs, continuous antibiotic prophylaxis provided a small but significant benefit in preventing a first UTI despite an increased occurrence of non-E. coli organisms and antibiotic resistance. (Funded by the Italian Ministry of Health and others; PREDICT ClinicalTrials.gov number, NCT02021006; EudraCT number, 2013-000309-21.).

Assessing Liver Fibrosis Using 2D-SWE Liver Ultrasound Elastography and Dynamic Liver Scintigraphy with 99mTc-mebrofenin: A Comparative Prospective Single-Center Study.

Background and Objectives: Many quantitative imaging modalities are available that quantify chronic liver disease, although only a few of them are included in clinical guidelines. Many more imaging options are still competing to find their place in the area of diagnosing chronic liver disease. We report our first prospective single-center study evaluating different imaging modalities that stratify viral hepatitis-associated liver fibrosis in a treatment-naïve patient group. Materials and Methods: The aim of our study is to compare and to combine already employed 2D shear wave elastography (2D-SWE) with dynamic liver scintigraphy with 99mTc-mebrofenin in chronic viral hepatitis patients for the staging of liver fibrosis. Results: Seventy-two patients were enrolled in the study. We found that both 2D-SWE ultrasound imaging, with dynamic liver scintigraphy with 99mTc-mebrofenin are able to stratify CLD patients into different liver fibrosis categories based on histological examination findings. We did not find any statistically significant difference between these imaging options, which means that dynamic liver scintigraphy with 99mTc-mebrofenin is not an inferior imaging technique. A combination of these imaging modalities showed increased accuracy in the non-invasive staging of liver cirrhosis. Conclusions: Our study presents that 2D-SWE and dynamic liver scintigraphy with 99mTc-mebrofenin could be used for staging liver fibrosis, both in singular application and in a combined way, adding a potential supplementary value that represents different aspects of liver fibrosis in CLD.

Impact of Carpal Tunnel Syndrome Surgery on Early Diagnosis and Treatment of Transthyretin Cardiac Amyloidosis.

Background and Objectives: Cardiac amyloidosis is an infiltrative, progressive, and restrictive cardiomyopathy that leads to heart failure, reduces life quality, and causes death. This is a multisystem disorder caused by mutations of the transthyretin protein and is associated not only with cardiac diseases or carpal tunnel syndrome but also with nerve, liver, lung, gastrointestinal tract, kidney, or eye pathologies. Carpal tunnel syndrome is an early red-flag symptom of transthyretin (TTR) cardiac amyloidosis; therefore, screening for unsuspected cardiac amyloidosis can be performed through histological testing of flexor retinaculum specimens gathered during carpal tunnel release surgery. Our case highlights that early detection and accurate diagnosis of a disease are important factors for improving clinical outcomes in patients with TTR amyloidosis. Case Summary: We report the case of a 71-year-old man who presented with bilateral carpal tunnel syndrome. Amyloid deposits were detected after carpal tunnel release surgery through histological testing of the synovial tissue. The patient was sent for a cardiological evaluation. Physical examination, laboratory tests, and the ECG revealed no significant changes. The diagnosis of amyloidosis was confirmed with multimodality imaging in the early stage, which helped to start specific medicamental treatment with the transthyretin stabilizer tafamidis. Conclusions: Our objective is to highlight the early recognition and specific medicamental treatment of cardiac amyloidosis for better patient prognosis and outcomes.

The incremental value of myocardial viability, evaluated by 18F-fluorodeoxyglucose positron emission tomography, and cardiovascular magnetic resonance for mortality prediction in patients with previous myocardial infarction and symptomatic heart failure.

OBJECTIVES: To find the imaging mortality predictors in patients with previous myocardial infarction (MI), symptomatic heart failure (HF), and reduced left ventricle (LV) ejection fraction (EF). METHODS: for the study 39 patients were selected prospectively with prior MI, symptomatic HF, and LVEF ≤40%. All patients underwent transthoracic echocardiography (TTE), single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI), 18F-FDG positron emission tomography (FDG PET). 31 patients underwent cardiovascular magnetic resonance (CMR) with late gadolinium enhancement (LGE). Patients were divided into two groups: 1 group - cardiac death; 2 group - no cardiac death. Myocardial scars were assessed on a 5-point-scale. Follow-up data was obtained. RESULTS: Imaging features disclosed significant difference (p < 0.05) of defect score (CMR and SPECT-PET), LV end-diastolic diameter (EDD) (TTE), LVEDD index (CMR), LV global longitudinal strain (CMR) and LV global circumferential strain (CMR) between the groups. Predictors of cardiac death were: LVEDD index (TTE) and LV global longitudinal strain. The cut-off values to predict cardiac death were: defect score (CMR) 25 (AUC, 79.5%; OR 1.8, 95% CI 1.2-2.7), SPECT-PET defect score 22 (AUC, 73.9%; OR 0.5, 95% CI 0.3-0.7), LVEDD (TTE) 58 mm (AUC, 88.4%; OR 23.6, 95% CI 2.6-217.7), LVEDDi 30 mm/m2 (TTE) (AUC, 73.6%; OR 22.0, 95% CI 1.9-251.5), LVEDDi 33.6 mm/m2 (CMR) (AUC, 73.6%; OR 22.0, 95% CI 1.9-251.5), LV global longitudinal strain -13.4 (AUC, 87.8%; OR 2.1, 95% CI 1.2-3.7) and LV global circumferential strain -16.3 (AUC, 76.1%; OR 1.9, 95% CI 1.2-3.0). CONCLUSIONS: Imaging features, such as defect score (CMR) >25, SPECT-PET defect score >22, LVEDD (TTE) >58 mm, LVEDDi (TTE) >30 mm/m2, LVEDDi (CMR) >33.6 mm/m2, LV global longitudinal strain -13.4 and LV global circumferential strain -16.3, may increase sensitivity and specificity of FDG PET and LGE CMR predicting of late mortality.

Quantitative Assessment of Liver Impairment in Chronic Viral Hepatitis with [99mTc]Tc-Mebrofenin: A Noninvasive Attempt to Stage Viral Hepatitis-Associated Liver Fibrosis.

Background and objectives-Chronic viral hepatitis B and C infections are one of the leading causes of chronic liver impairment, resulting in liver fibrosis and liver cirrhosis. An early diagnosis with accurate liver fibrosis staging leads to a proper diagnosis, thus tailoring correct treatment. Both invasive and noninvasive techniques are used in the diagnosis and staging of chronic liver impairment. Those techniques include liver biopsy, multiple serological markers (as either single tests or combined panels), and imaging examinations, such as ultrasound or magnetic resonance elastography. Nuclear medicine probes may also be employed in staging liver fibrosis, although the literature scarcely reports this. The purpose of our study was to investigate whether a dynamic liver scintigraphy with [99mTc]Tc-mebrofenin has any value in staging or grading chronic liver damage. Materials and Methods-We prospectively enrolled patients with chronic viral hepatitis B and C infection referred for liver biopsy. All patient underwent dynamic liver scintigraphy with 99mTc-mebrofenin prior to liver biopsy. Dynamic liver scintigraphy was performed immediately after intravenous tracer injection for 30 min scanning time. Multiple scintigraphy parameters were calculated (whole liver lobe and focal area time to peak (TTP), 30 min to peak ratio (30/peak), whole lobe and focal area slope index in 350 s (slope_350). Liver biopsy took place shortly after imaging. Results-We found that many dynamic scintigraphic parameters are positively or negatively associated with different stages of liver fibrosis. The main parameters that showed most value are the ratio between 30 min and the peak of the dynamic curve (30/peak_dex (ratio)), and liver clearance corrected for body surface area and liver area (LCL_m2_dm2 (%/min/m2/dm2)). Conclusions-Our present study proves that conducting dynamic liver scintigraphies with [99mTc]Tc-mebrofenin has potential value in staging liver fibrosis. The benefits of this method, including whole liver imaging and direct imaging of the liver function, provide an advantage over presently used quantitative imaging modalities.

Diagnostic Yield of Transbronchial Cryobiopsy Guided by Radial Endobronchial Ultrasound and Fluoroscopy in the Radiologically Suspected Lung Cancer: A Single Institution Prospective Study.

Transbronchial cryobiopsy (TBCB) is being studied in the diagnosis of peripheral lung lesions; however, there are only a few clinical studies around the world. The aim of our study was to evaluate the diagnostic values and safety of transbronchial cryobiopsy for radiologically suspected peripheral lung cancer. The prospective clinical study was executed from September 2019 to September 2021 at a tertiary clinical centre in Lithuania. A total of 48 patients out of 102 underwent combined procedures of transbronchial forceps biopsy (TBFB) and TBCB. Diagnostic values and safety outcomes of TBFB and TBCB were analysed. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy were 72.9%, 100%, 100%, 7.7%, and 88.0% for TBFB, 85.1%, 100%, 100%, 12.5%, and 93% for TBCB, as well as 91.5%, 100%, 100%, 20.0% and 96.7% for the combined procedures, respectively, with a significantly higher accuracy for cryobiopsies compared to forceps biopsies (p < 0.05). The diagnostic values for transbronchial cryobiopsies were similar, irrespective of the radial mini probe endobronchial ultrasound (RP-EBUS) position, lesion size or bronchus sign, however, the sensitivity of the combined procedures in cases with RP-EBUS adjacent to the target was significantly higher compared to TBFB (86.2% vs. 64.3%, p = 0.016). Samples of cryobiopsies were significantly larger than forceps biopsies (34.62 mm2 vs. 4.4 mm2, p = 0.001). The cumulative diagnostic yield of transbronchial cryobiopsy was 80.0% after the second biopsy and reached a plateau of 84.1% after four biopsies. No severe bleeding, pneumothorax, respiratory failure or death was registered in our study. TBCB is a potentially safe procedure, which increases diagnostic values in diagnosing peripheral lung lesions compared to TBFB.

Comparative Analysis of Myocardial Viability Multimodality Imaging in Patients with Previous Myocardial Infarction and Symptomatic Heart Failure.

Background and Objectives: To compare the accuracy of multimodality imaging (myocardial perfusion imaging with single-photon emission computed tomography (SPECT MPI), 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET), and cardiovascular magnetic resonance (CMR) in the evaluation of left ventricle (LV) myocardial viability for the patients with the myocardial infarction (MI) and symptomatic heart failure (HF). Materials and Methods: 31 consecutive patients were included in the study prospectively, with a history of previous myocardial infarction, symptomatic HF (NYHA) functional class II or above, reduced ejection fraction (EF) ≤ 40%. All patients had confirmed atherosclerotic coronary artery disease (CAD), but conflicting opinions regarding the need for percutaneous intervention due to the suspected myocardial scar tissue. All patients underwent transthoracic echocardiography (TTE), SPECT MPI, 18F-FDG PET, and CMR with late gadolinium enhancement (LGE) examinations. Quantification of myocardial viability was assessed in a 17-segment model. All segments that were described as non-viable (score 4) by CMR LGE and PET were compared. The difference of score between CMR and PET we named reversibility score. According to this reversibility score, patients were divided into two groups: Group 1, reversibility score > 10 (viable myocardium with a chance of functional recovery after revascularization); Group 2, reversibility score ≤ 10 (less viable myocardium when revascularisation remains questionable). Results: 527 segments were compared in total. A significant difference in scores 1, 2, 3 group, and score 4 group was revealed between different modalities. CMR identified "non-viable" myocardium in 28.1% of segments across all groups, significantly different than SPECT in 11.8% PET in 6.5% Group 1 (viable myocardium group) patients had significantly higher physical tolerance (6 MWT (m) 3892 ± 94.5 vs. 301.4 ± 48.2), less dilated LV (LVEDD (mm) (TTE) 53.2 ± 7.9 vs. 63.4 ± 8.9; MM (g) (TTE) 239.5 ± 85.9 vs. 276.3 ± 62.7; LVEDD (mm) (CMR) 61.7 ± 8.1 vs. 69.0 ± 6.1; LVEDDi (mm/m2) (CMR) 29.8 ± 3.7 vs. 35.2 ± 3.1), significantly better parameters of the right heart (RV diameter (mm) (TTE) 33.4 ± 6.9 vs. 38.5 ± 5.0; TAPSE (mm) (TTE) 18.7 ± 2.0 vs. 15.2 ± 2.0), better LV SENC function (LV GLS (CMR) −14.3 ± 2.1 vs. 11.4 ± 2.9; LV GCS (CMR) −17.2 ± 4.6 vs. 12.7 ± 2.6), smaller size of involved myocardium (infarct size (%) (CMR) 24.5 ± 9.6 vs. 34.8 ± 11.1). Good correlations were found with several variables (LVEDD (CMR), LV EF (CMR), LV GCS (CMR)) with a coefficient of determination (R2) of 0.72. According to the cut-off values (LVEDV (CMR) > 330 mL, infarct size (CMR) > 26%, and LV GCS (CMR) < −15.8), we performed prediction of non-viable myocardium (reversibility score < 10) with the overall percentage of 80.6 (Nagelkerke R2 0.57). Conclusions: LGE CMR reveals a significantly higher number of scars, and the FDG PET appears to be more optimistic in the functional recovery prediction. Moreover, using exact imaging parameters (LVEDV (CMR) > 330 mL, infarct size (CMR) > 26% and LV GCS (CMR) < −15.8) may increase sensitivity and specificity of LGE CMR for evaluation of non-viable myocardium and lead to a better clinical solution (revascularization vs. medical treatment) even when viability is low in LGE CMR, and FDG PET is not performed.

Early Radiation-Induced Sarcoma in an Adolescent Treated for Relapsed Hodgkin Lymphoma with Nivolumab.

Radiation-induced sarcoma (RIS) has been reported as a late secondary malignancy following radiotherapy for various types of cancer with a median latency of 10 years. We describe an early RIS that developed in an adolescent within three years of treatment (including PD-L1 check-point inhibitor Nivolumab) of a relapsed classic Hodgkin lymphoma (HL) and was diagnosed post-mortem. The patient died of the progressive RIS that was misleadingly assumed to be a resistant HL based on the positive PET/CT scan. Repetitive tumor biopsies are warranted in cases of aggressive and multi-drug resistant HL to validate imaging findings, ensure correct diagnosis and avoid overtreatment.

Ischemic Muscle Necrosis of Lower Extremities in Peripheral Arterial Disease: The Impact of 99mTc-MDP Scintigraphy on Patient Management.

Background and objectives: The objective of this study was to assess the value of a whole-body bone scintigraphy using 99m technetium labelled-methyl diphosphonate (99mTc-MDP) for the diagnosis and the assessment of grades of muscle damage after prolonged acute or chronic obstruction of the main arteries in lower extremities. Material and Methods: Fifty consecutive patients were selected for the study. The patients' condition had not improved after primary peripheral arterial reconstruction operation or limb amputation and after conservative treatment. The clinical suspicion was of arterial obstruction and muscle necrosis. All the patients underwent whole-body scintigraphy with 99mTc-MDP. Muscle necrosis was identified as an increased soft tissue uptake of 99mTc-MDP. Results: Forty-five patients had gross muscle necrosis detected on whole-body scintigraphy with 99mTc-MDP and were histologically confirmed after repeated surgery (necrectomy or amputation) or by muscle biopsy, if only fasciotomy was performed. The location and extent of muscle injury were assessed preoperatively and the findings were confirmed in all 45 patients. Twelve patients with clinically suspected minor muscle damage, which was confirmed as relatively minor muscle necrosis on 99mTc-MDP scintigraphy, were treated conservatively. The clinical outcome of all 50 patients was favorable. The 99mTc-MDP scintigraphy, in detection of muscular necrosis, demonstrated sensitivity, specificity, and accuracy of 97.3% (95% confidence interval (CI) 85.4% to 99.3%), 30.77% (95% confidence interval (CI) 9.09% to 61.43%), and 80% (95% confidence interval (CI) 66.28% to 89.97%), respectively. Conclusion: The 99mTc-MDP scintigraphy is a valuable tool in the detection of muscular necrosis. It is able to define location, extent, and grade of involvement. Therefore, it has a clinical impact in patient management, allowing clinicians to select adequate treatment policy and specify the scope of necrectomy.

The effect of cardiac shock wave therapy on myocardial function and perfusion in the randomized, triple-blind, sham-procedure controlled study.

BACKGROUND: Recent triple-blind sham procedure-controlled study revealed neutral effects of the cardiac shock wave therapy (CSWT) on exercise tolerance and symptoms in patients with stable angina. Current data about the effects of CSWT on global and regional myocardial contractility and perfusion is limited. Hereby we report the results of an imaging sub-study that evaluated the capacity of CSWT to ameliorate myocardial ischemia induced during dobutamine stress echocardiography (DSE) and cardiac single photon emission computed tomography (SPECT). METHODS: Prospective, randomized, triple-blind, sham procedure-controlled study enrolled 72 adult subjects who complied with defined inclusion criteria. The subjects were assigned to the OMT + CSWT and the OMT + sham procedure study groups with 1:1 ratio. Application of the CSWT covered all segments of the left ventricle. Imaging ischemia tests were performed in 59 study patients: DSE and SPECT before the CSWT treatment and after 6 months, with DSE carried out additionally at 3 months after randomization. Co-primary endpoints of the study were: change in wall motion score index (WMSI), representing the stress-induced impairment of regional myocardial function, and change in summed difference score (SDS), representing the amount of perfusion defect. RESULTS: OMT + CSWT and OMT + sham procedure study groups included 30 and 29 patients, respectively. Regional myocardial contractility during DSE significantly improved at 3 months follow-up in OMT + CSWT group compared to baseline as shown by WMSI at stress (1.4 ± 0.4 vs 1.6 ± 0.4, p = 0.001), but not in OMT + sham procedure group (1.5 ± 0.3 vs 1.6 ± 0.4, p = 0.136). The difference in stress DSE results between both study groups disappeared after 6 months. SPECT results demonstrated a significant reduction of inducible ischemia in OMT + CSWT group compared to OMT + sham procedure group at 6 months follow-up (SDS dropped from 5.4 ± 3.7 to 3.6 ± 3.8 vs 6.4 ± 5.9 to 6.2 ± 5 respectively, p = 0.034). CONCLUSIONS: Cardiac shock wave treatment showed the ability to reduce stress-induced myocardial ischemia, as assessed by wall motion abnormalities and perfusion defects, compared to sham procedure. TRIAL REGISTRATION: Clinicaltrials.gov ( NCT02339454 ). The trial was registered retrospectively on 12 January 2015.

Is Abdominal Aortic Aneurysm Behavior after Endovascular Repair Associated with Aneurysm Wall Density on Computed Tomography Angiography?

Background and objectives: Abdominal aortic aneurysm (AAA) growth is unpredictable after the endovascular aneurysm repair (EVAR). Continuing aortic wall degradation and weakening due to hypoxia may have a role in post-EVAR aneurysm sac growth. We aimed to assess the association of aortic wall density on computed tomography angiography (CTA) with aneurysm growth following EVAR. Materials and Methods: A total of 78 patients were included in the study. The control group consisted of 39 randomly assigned patients without aortic pathology. Post-EVAR aneurysm sac volumes on CTA were measured twice during the follow-up period to estimate aneurysm sac behavior. A maximum AAA sac diameter, aortic wall and lumen densities in Hounsfield units (HU) on CTA were measured. A relative aortic wall density (the ratio of aortic wall to lumen densities) was calculated. A statistical data analysis was performed using standard methods. Results: An increase in the AAA sac volume was observed in 12 (30.8%) cases. Median relative aortic wall density on CTA scores in both the patient and the control group at the level of the diaphragm were similar: 0.15 (interquartile range (IQR), 0.11-0.18) and 0.16 (IQR 0.11-0.18), p = 0.5378, respectively. The median (IQR) relative aortic wall density score at the level of the maximum AAA diameter in the patient group was lower than at the level below renal arteries in the control group: 0.10 (0.07-0.12) and 0.17 (0.12-0.23), p < 0.0001, respectively. The median (IQR) relative growing AAA sac wall density score was lower than a relative stable/shrinking AAA sac wall density score: 0.09 (0.06-0.10) and 0.11 (0.09-0.13), p = 0.0096, respectively. Conclusions: A lower aortic aneurysm wall density on CTA may be associated with AAA growth after EVAR.

Arterial Destiffening Starts Early after Renal Artery Denervation.

INTRODUCTION: Renal artery denervation (RDN) is a new widely discussed method in treatment of hypertension. Most of the RDN studies assessed BP and arterial changes 3 and 6 months after the procedure, but there is a lack of trials that investigated early changes after RDN. AIM: To investigate aortic stiffness 24-48 hours after the procedure and thus to examine whether RDN might have an early additive value for a cardiovascular risk decline beyond the lowering of blood pressure. METHODS: RDN was performed for 73 patients with resistant hypertension. Arterial stiffness and central haemodynamics were measured before the procedure, the next day after the procedure, and subsequently after 1, 3, 6, and 12 months. RESULTS: Within 48 hours, RDN significantly reduced aortic pulse wave velocity (AoPWV) from 11.3±2.7 to 10.3±2.6 m/s (p=0.001); reduction was sustained at months 1, 3, 6, and 12. Early changes in the AoPWV value did not correlate with changes in office systolic or diastolic BP (p=0.45; p=0.33). Furthermore, the higher the initial AoPWV value, the greater the reduction of AoPWV observed after 6 months: Q1 8.4±1, Δ0.05±1.6 / Q2 10.1±0.4, Δ1.1±1.4 / Q3 12.2±0.8, Δ1.8±1.7 / Q4 15.3±1.7, Δ2.8±2.1 (p=0.002). CONCLUSIONS: Early and sustained effects on AoPWV observed in our study suggest that RDN may have additional effects on reducing arterial stiffness and cardiovascular risk.

Impact of renal sympathetic denervation on cardiac sympathetic nerve activity evaluated by cardiac MIBG imaging.

AIMS: The objective of the present study was to investigate an effect of renal artery sympathetic denervation (RASD) on patients with resistant hypertension and RASD effect on cardiac sympathetic nerve activity. It is known that an abnormally activated sympathetic tone is associated with progression of heart failure (HF). METHODS AND RESULTS: We investigated 16 patients with resistant arterial hypertension (mean age 54.88±7.89 years, mean 24-hr ambulatory blood pressure [BP] systolic 161.07±20.12 mmHg, diastolic 97.6±16.25 mmHg, using 6.44±0.96 antihypertensive drugs), who underwent bilateral RASD. Echocardiography, 24-hr ambulatory BP and 123I-metaiodobenzylguanidine (123I-MIBG) scintigraphy were performed before and six months after RASD. There were no significant changes in 24-hr ambulatory systolic and diastolic BP before RASD and six months after it: systolic BP before RASD was 161.07±20.12 mmHg and 144.93±17.27 mmHg after (p=0.050); diastolic BP before RASD was 97.6±16.25 mmHg and 89.87±12.33 mmHg after (p=0.182). We observed a significant change in cardiac sympathetic nerve activity assessed by 123I-MIBG scintigraphy, as an increase of late heart-to-mediastinum (H/M) ratio, varying from 2.21±0.47 to 2.35±0.52 m/s (p=0.02). CONCLUSIONS: Selective RASD significantly reduces cardiac sympathetic overdrive assessed by 123I-MIBG scintigraphy. Presumably, this positively affects HF progression in patients with resistant arterial hypertension.

Tumour-induced osteomalacia: a literature review and a case report.

Tumour-induced osteomalacia (TIO) is a rare paraneoplastic syndrome characterised by severe hypophosphataemia and osteomalacia, with renal phosphate wasting that occurs in association with tumour. The epidemiology likewise aetiology is not known. The clinical presentation of TIO includes bone fractures, bone and muscular pains, and sometimes height and weight loss. TIO may be associated with mesenchymal tumours which may be benign or malignant in rare cases. Mesenchymal tumour itself may be related to fibroblast growth factor 23 (FGF23), which is responsible for hypophosphataemia and phosphaturia occurring in this paraneoplastic syndrome. Hypophosphataemia, phosphaturia and elevated alkaline phosphatase are the main laboratory readings that may lead to more precise investigations and better diagnosis. Finding the tumour can be a major diagnostic challenge and may involve total body magnetic resonance imaging, computed tomography and scintigraphy using radiolabelled somatostatin analogue. The treatment of choice for TIO is resection of a tumour with a wide margin to insure complete tumour removal, as recurrences of these tumours have been reported. We provide here an overview on the current available TIO case reports and review the best practices that may lead to earlier recognition of TIO and the subsequent treatment thereof, even though biochemical background and the long-term prognosis of the disease are not well understood. This review also includes a 4-year-long history of a patient that featured muscular pains, weakness and multiple stress fractures localised in the hips and vertebra with subsequent recovery after tumour resection. Because the occurrence of such a condition is rare, it may take years to correctly diagnose the disease, as is reported in this case report.

Complicated congenital gluteal arteriovenous malformation with hemorrhage in pregnancy.

Extracranial congenital arteriovenous malformations (AVMs) are rare clinical entities that can be progressive in nature. The influence of pregnancy on lesion progression has been discussed in the past. This report presents an unusual case of 23-year-old primigravida woman who presented at 36 weeks' gestation with complicated necrotic ulceration and hemorrhage of the right gluteal region. A hyperpigmented mark with varicosities was initially noted at birth, but during pregnancy it showed remarkable progression and was first identified as an AVM. After hemorrhage control and induced delivery, the lesion was successfully treated with several embolizations. Complete wound healing was achieved, but because of partial recurrence at 3 years, repeat embolization was performed, with satisfactory clinical improvement and residual 25% arteriovenous shunting on transarterial lung perfusion scintigraphy study. AVM complications during pregnancy are uncommon, and this case supports the prior opinion that pregnancy can stimulate lesion progression. Especially in undiagnosed and previously untreated cases, this can lead to life-threatening complications for the mother and fetus. Long-term lesion management usually requires combined endovascular and surgical treatment.

Diagnostic methods, treatment modalities, and follow-up of extracranial arteriovenous malformations.

OBJECTIVE: Arteriovenous malformations (AVMs) are an uncommon vascular pathology that remains challenging to accurately diagnose and successfully treat. This study introduces a novel way to evaluate AVM treatment outcomes using transarterial lung perfusion scintigraphy (TLPS) and reports our treatment results. MATERIAL AND METHODS: The patients treated for extracranial AVMs were studied retrospectively. Diagnosis and outcomes were based on clinical data, ultrasonography, magnetic resonance imaging, computed tomography, angiography, and TLPS studies. The influence of gender; location, form, and stage of AVMs; first attempt at treatment; and treatment modalities was analyzed. Outcomes were defined as positive (cure, improvement, and remission) or negative (no remission and aggravation). RESULTS: Of the 324 patients with congenital vascular malformations, 129 (39.8%) presented with AVMs, and the data of 56 treated patients with AVMs were analyzed. Of the 29 patients in the endovascularly treated group, 15 in the surgically treated group, and 12 in the combined treatment group, 24 (82.8%), 14 (93.3%), and 10 patients (83.3%), respectively, had positive outcomes (P>0.05). All outcomes were positive in surgically treated patients with extratruncular limited AVMs, and these patients were more likely to be cured as compared with those who had other forms of AVMs (OR, 5.8; 95% CI, 1.1-29; P=0.02). The patients with more advanced AVMs (stages III and IV) and with AVMs in the gluteal and pelvic region were more likely to have the worst outcomes than those with stage II AVMs (OR, 8.2; 95% CI, 1-72; P=0.03) and with AVMS in other locations (OR, 5.8; 95% CI, 1.1-29; P=0.02), respectively. Gender and age did not significantly influence treatment results (P>0.05). The TLPS data of 17 patients showed AV shunting ranging from 0% to 92%, which combined with other results helped identify 9 patients who needed further interventions, 6 who were treated successfully, and 2 who had insignificant shunting. CONCLUSIONS: The best outcomes were achieved in surgically treated patients with localized lesions and less advanced AVMs. For the first time in Lithuania, a modified TLPS method has been introduced that enhances a hemodynamic assessment of AV shunting and provides with a more accurate evaluation of AVMs to better serve in planning future treatments.