Impact of COVID-19 on cardiovascular testing in the United States versus the rest of the world

Objectives: This study sought to quantify and compare the decline in volumes of cardiovascular procedures between the United States and non-US institutions during the early phase of the coronavirus disease-2019 (COVID-19) pandemic. Background: The COVID-19 pandemic has disrupted the care of many non-COVID-19 illnesses. Reductions in diagnostic cardiovascular testing around the world have led to concerns over the implications of reduced testing for cardiovascular disease (CVD) morbidity and mortality. Methods: Data were submitted to the INCAPS-COVID (International Atomic Energy Agency Non-Invasive Cardiology Protocols Study of COVID-19), a multinational registry comprising 909 institutions in 108 countries (including 155 facilities in 40 U.S. states), assessing the impact of the COVID-19 pandemic on volumes of diagnostic cardiovascular procedures. Data were obtained for April 2020 and compared with volumes of baseline procedures from March 2019. We compared laboratory characteristics, practices, and procedure volumes between U.S. and non-U.S. facilities and between U.S. geographic regions and identified factors associated with volume reduction in the United States. Results: Reductions in the volumes of procedures in the United States were similar to those in non-U.S. facilities (68% vs. 63%, respectively; p = 0.237), although U.S. facilities reported greater reductions in invasive coronary angiography (69% vs. 53%, respectively; p < 0.001). Significantly more U.S. facilities reported increased use of telehealth and patient screening measures than non-U.S. facilities, such as temperature checks, symptom screenings, and COVID-19 testing. Reductions in volumes of procedures differed between U.S. regions, with larger declines observed in the Northeast (76%) and Midwest (74%) than in the South (62%) and West (44%). Prevalence of COVID-19, staff redeployments, outpatient centers, and urban centers were associated with greater reductions in volume in U.S. facilities in a multivariable analysis. Conclusions: We observed marked reductions in U.S. cardiovascular testing in the early phase of the pandemic and significant variability between U.S. regions. The association between reductions of volumes and COVID-19 prevalence in the United States highlighted the need for proactive efforts to maintain access to cardiovascular testing in areas most affected by outbreaks of COVID-19 infection

Voxel based statistical analysis of brain SPECT in temporal lobe epilepsy patients

Orientadores: Fernando Cendes, Elba Cristina Sa de Camargo EtchebehereTese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciencias MedicasResumo: O statistical parametric mapping (SPM) é uma ferramenta de quantificação que tem sido usada no SPECT de perfusão cerebral (SPECT), mas apenas poucos trabalhos na literatura comparam a sua sensibilidade com a da análise visual em pacientes com epilepsia de lobo temporal (ELT) OBJETIVO: Avaliar a capacidade da análise com SPM no SPECT em detectar o foco epileptogênico e alterações perfusionais em regiões extra-temporais em pacientes com epilepsia de lobo temporal mesial (ELTM), comparando os seus achados com os da análise visual MÉTODOS: Foram realizados SPECTs ictal e interictal em 22 pacientes com ELTM refratários ao tratamento clínico. O lado do foco epileptogênico foi definido com base na história clínica, ressonância magnética, eletroencefaiogramas seriados e telemetria. Os SPECTs foram submetidos à análise visual sendo que os SPECTs interictal e ictal foram analisados em conjunto pelos observadores (SPECT-visual-inter e SPECT-visual-ictal). Foi aplicado o SPM2 que comparou os pacientes com um grupo controle de 50 indivíduos normais. No SPM foram realizadas as seguintes comparações: grupo de SPECT interictal com o grupo controle (SPM-grupo-inter); SPECT interictal de cada paciente com o grupo controle (SPM-indiv-inter); grupo de SPECT ictal com o grupo controle (SPM-grupo-ictal); SPECT ictal de cada paciente com o grupo controle (SPM-indiv-ictal). Foram também comparadas as intensidades das alterações perfusionais nos lobos temporais procurando-se por um aumento da perfusão no SPECT ictal em relação ao interictal (SPM-indiv-ictal/inter). RESULTADOS: Não foi observada nenhuma alteração perfusional significativa no SPM-grupo-inter Já no SPM-grupo-ictal o foco epileptogênico foi a região de hiperperfusão mais significativa No SPM-indiv-inter a sensibilidade na localização do foco foi de 45% e no SPM-indiv-ictal a sensibilidade foi de 64%. O SPM-indiv-ictal/inter apresentou a maior sensibilidade para detectar o foco dentre as análises realizadas no SPM (77%) A sensibilidade do SPECT-visual-inter foi de 68% e para o SPECT-visuai-ictal foi de 100%. Por outro lado, diversas áreas de hiperperfusão e hipoperfusão à distância no SPECT ictal foram detectadas principalmente com o SPM CONCLUSÃO: O SPM é uma ferramenta que não depende do operador e é capaz de demonstrar mais áreas de alteração perfusional à distância do foco epileptogênico do que a análise visual. Ele pode ajudar a entender melhor a patofisiologia das crises epilépticas em pacientes com ELTM estudando a relação das diferentes regiões corticais e subcorticais na gênese e na propagação das crises parciais. Entretanto, essa ferramenta não acrescentou um aumento na sensibilidade na localização do foco epileptogênico em relação á análise visual, tanto do SPECT interictal quanto do SPECT ictalAbstract: Statistical parametric mapping (SPM) is a quantitative tool which has been used in the brain perfusion SPECT (SPECT) However, few works in literature compare its sensitivity with the visual analysis in patients with temporal lobe epilepsy (TLE). PURPOSE: To investigate the capability of SPM analysis in SPECT to detect the epileptogenic focus and distant perfusion abnormalities in patients with mesial temporal lobe epilepsy (MTLE) and to compare these findings to the visual analysis. METHODS: Interictal and ictal SPECTs of 22 patients with refractory MTLE were performed. Epileptic foci were determined based on clinical history, magnetic resonance, electroencephalograms (EEG) and ictal video-EEG. SPECTs were submitted to visual analysis. Ictal and interictal SPECTs were analyzed together by the nuclear physicians (SPECT-visual-inter and SPECT-visual-ictal). It was also performed the SPM2 analysis which used a control group composed of 50 volunteers. The following comparisons were performed in SPM: interictal SPECT group with control group (SPM-group-inter); interictal SPECT from each patient with control group (SPM-indiv-inter); ictal SPECT group with control group (SPM-group-ictal), ictal SPECT from each patient with control group (SPM-indiv-ictal). It was also compared the perfusion intensity in temporal lobes looking for an increase in perfusion on ictal SPECT in relation to interictal SPECT (SPM-indiv-ictal/inter). RESULTS: No significant perfusion alterations were observed on SPM-group-inter. On the other hand, the epileptogenic temporal lobe was the region with most significant hypoperfusion on SPM-group-ictal. The sensitivity to localize the focus on SPM-indiv-inter was 45% and on SPM-indiv-ictal was 64%. The SPM-indiv ictal/inter revealed the highest sensitivity among the SPM analysis to detect the focus (77%). The sensitivity of SPECT-visual-inter was 68% and to SPECT-visual-ictal was 100%. On the other hand, several areas of distant hypoperfusion and hypoperfusion were detected mainly with SPM. CONCLUSION: SPM is a tool which does not depend on the operator and can detect more distant perfusion abnormalities than the visual analysis. It can improve the understanding of pathophysiology in seizures of patients with MTLE by studying the relation among different cortical and subcortical areas in the genesis and propagation of partial seizures. However, this tool did not increase the visual analysis sensitivity to localize the epileptogenic focus in interictal SPECT as well as in ictal SPECTDoutoradoNeurologiaDoutor em Ciências Médica

Technetium-99m-dimercaptosuccinic acid renal scintigraphy and single photon emission computed tomography/computed tomography in patients with sickle cell disease

Purpose Sickle cell disease (SCD) is a common hematologic hereditary disorder characterized by vaso-occlusive episodes affecting multiple organs, and substantially alters renal structure and function. We aimed to evaluate the utility of renal scintigraphy and single photon emission computed tomography/computed tomography (SPECT/CT) with technetium-99m-dimercaptosuccinic acid (Tc-99m-DMSA) in adult patients with SCD and no clinical evidence of renal insufficiency. Materials and methods Twenty-six patients (16 female) aged 23-58 years with SCD and no clinical evidence of renal insufficiency were prospectively studied. Planar and SPECT/CT images were, respectively, obtained after 3 and 4 hours of the injection of 110-180 MBq of Tc-99m-DMSA. The relative radiopharmaceutical uptake and renal length were, respectively, determined using SPECT and CT images. Planar and SPECT/CT images were visually analyzed to identify focal areas of Tc-99m-DMSA reduced uptake and anatomical deformities of the kidneys. Results Focal areas of reduced Tc-99m-DMSA uptake with an image aspect of renal scars or inflammation were present in 21/26 patients (81%). In 11/21 (52%) of these patients, the cortical lesions were clearly identified only on SPECT images. Prominent renal columns were observed in 17/26 (65%) patients. The left kidney tended to be more affected than the right kidney. Most patients had enlarged kidneys. Conclusion Tc-99m-DMSA scintigraphy and SPECT/CT identify renal lesions possible related to renal infarcts or infections in most adult patients with SCD and no clinical evidence of renal insufficiency. Prominent renal columns and increased renal size tend to occur in most of these patients401111581165CNPQ - Conselho Nacional de Desenvolvimento Científico e TecnológicoFAPESP – Fundação de Amparo à Pesquisa Do Estado De São Paulo311841/2018-02012/51833-

Manual lymphatic drainage and active exercise effects on lymphatic function do not translate into morbidities in women who underwent breast cancer surgery

PURPOSE: To evaluate the effects of levobupivacaine on neuromuscular transmission and neuromuscular blockade produced by pancuronium in vitro. METHODS: Thirty rats were distributed into groups (n = 5) according to the drug used alone or in combination: Group I - levobupivacaine (5 µg.mL-1); Group II - pancuronium (2 µg.mL-1); Group III - pancuronium (2 µg.mL-1) + levobupivacaine (5µg.mL-1). The following parameters were evaluated: 1) amplitude of diaphragmatic response to indirect stimulation, before and 60 minutes after the addition of levobupivacaine and pancuronium alone, and after the addition of levobupivacaine combined with pancuronium; 2) membrane potentials (MP) and miniature endplate potentials (MEPP). RESULTS: Levobupivacaine alone did not alter the amplitude of muscle response and MP. In preparations previoulsy exposed to levobupivacaine, the block with pancuronium was significantly denser (90.2 ± 15.2%), showing a significant difference (p=0.031) in comparison to the block produced by pancuronium alone (48.9% ± 9.8%). There was a decrease in the frequency and amplitude of MEPPs. CONCLUSION: Levobupivacaine potentiated the neuromuscular blockade produced by pancuronium, confirming a presynaptic action by a decrease in miniature endplate potentials.To evaluate manual lymphatic drainage (MLD) and active exercise effects on lymphatic alterations of the upper limb (UL), range of motion (ROM) of shoulder, and scar complications after breast cancer surgery. Design: Clinical trial. Setting: Health care ce982256263FAPESP - FUNDAÇÃO DE AMPARO À PESQUISA DO ESTADO DE SÃO PAULO2009/14864-

ARTIFICIAL INTELLIGENCE TO EVALUATE METABOLIC TUMOR BURDEN IN PRIMARY STAGING OF RECTAL CANCER WITH 18F-FDG PET/CT

Introduction/Justification: The use of artificial intelligence using convolutional neural networks in clinical practice is recent. Thus, a growing need exists to validate software performance in different tasks in different diseases. Objectives: To evaluate the performance of artificial intelligence software to determine metabolic tumor burden in the primary staging of rectal cancer. Materials and Methods: A cross-sectional retrospective analysis was conducted on 51 histology-proven rectal cancer patients (35% females; mean age = 61 years) who underwent a staging 18F-FDG PET/CT. Whole-body metabolic tumor burden parameters (wbMTV and wbTLG) were quantified semi-automatically and through AI algorithm (Syngovia VB60; Siemens Healthineers Medical Solutions). The AI software's ability to correctly identify and classify the primary lesion, regional lymph nodes, and distant metastases was evaluated. In addition, the intraclass correlation coefficient (ICC) was applied to evaluate concordance between the AI-based software and the semiautomatic software in determining wbMTV and wbTLG. Values above 0.7 were considered to indicate substantial agreement. Resultados: The AI and semiautomatic tumor burden metrics correlated strongly for both wbMTV (ICC = 1.00; 95% CI = 0.94 - 0.99; P < 0.0000) and wbTLG (ICC = 1.00; 95% CI = 0.80 – 0.90; P < 0.0000). Additionally, the AI software's ability to correctly identify lesions compared to the documented staging was better for the identification of distant metastasis (78,57% of patients), mildly adequate to identify regional lymph nodes (50,00%) and had poor performance for identification of the primary lesion (5,76%). On the other hand, the time spent calculating these metrics was less by AI than by the semiautomatic method, especially in patients with advanced disease. Conclusion: The determination of whole-body metabolic tumor burden on 18F-FDG PET/CT with artificial intelligence software is challenging because of the physiologic bowel activity. However, deep learning may have the ability to overcome these challenges and may therefore improve the primary staging of rectal cancer

DMSA-99mTc SPECT/CT AND DTPA-99mTc IMAGES IN CROSS FUSED RENAL ECTOPIA: A CASE REPORT

Introduction/Justification: Crossed fused renal ectopia is a rare congenital anomaly resulting from embryological alterations, in which the ectopic kidney is contralateral to the insertion of its ureter into the bladder. This condition is generally asymptomatic, however, it is associated with renal complications and is usually found incidentally in radiological and molecular imaging studies. There are few reports in the literature demonstrating the combined results of molecular imaging and hybrid studies of this condition. This study aims to demonstrate the findings of static renal scintigraphy with 99mTc-DMSA, including SPECT/CT images, and dynamic renal scintigraphy with 99mTc-DTPA in a patient with crossed fused renal ectopia. Report: A 54-year-old female patient was diagnosed with stage IVa squamous cell carcinoma of the cervix causing right hydronephrosis due to extrinsic obstruction, requiring the placement of a double-J catheter. During the investigation, the patient was submitted to renal scintigraphy with 99mTc-DMSA, with SPECT/CT images, and dynamic renal scintigraphy with 99mTc-DTPA. Static images were obtained in the anterior, posterior, anterior and posterior obliques, and lateral abdominal projections and SPECT/CT images after 3 hours of intravenous injection of 99mTc-DMSA. A left ectopic kidney fused to the right kidney was observed, located to the right of the midline. Tubular function was normal in the left kidney and markedly decreased in the right kidney. Bilateral renal scars were detected. After 5 days, sequential images were acquired at intervals of 2 seconds for 1 minute and every 15 seconds for 25 minutes, in the anterior and posterior abdominal projections, immediately after intravenous injection of 99mTc-DTPA, with additional images after furosemide intravenous injection. Markedly decreased glomerular function was observed in the right kidney, and normal function in the left kidney, with signs of crossed fused renal ectopia (left ectopic kidney) and pyelocalyceal dilation on the right, with obstructive pattern. Conclusion: Crossed fused renal ectopia is a rare condition. Scintigraphy images with 99mTc-DMSA and 99mTc-DTPA allow accurate evaluation of the various functional alterations of the kidneys resulting from this anomaly. Obtaining SPECT/CT images with 99mTc-DMSA contributes to the good correlation between functional and anatomical changes of the disease. 99mTc-DMSA and 99mTc-DTPA images are also useful for evaluation of tubular and glomerular renal function in crossed fused renal ectopia. Additionally, the anatomical and functional correlation with the hybrid SPECT/CT method enables the evaluation of abnormalities with more precision

COMPARISON OF 68GA-PSMA AND 18F-FDG-PET/CT IN THE ASSESSMENT OF DESMOID TUMORS

Introduction/Justification: Recently, the tracer Prostate Specific Membrane Antigen (PSMA), which can be labeled with the radioisotopes 68Ga or 18F, has been commercially introduced. Theoretically, as the name suggests, it is a substance specific to the membrane of prostate cells and prostate cancer. However, several studies have shown that it is also a marker of neoangiogenesis, leading to its uptake in various other neoplasms and benign diseases. Objectives: This study aims to evaluate the utility of radiolabeled PSMA in detecting desmoid tumors, comparing it to 18F-luorodeoxyglucose (FDG). Materials and Methods: Three participants with a confirmed diagnosis of desmoid tumor underwent PET/CT examinations with 18F-PSMA and 18F-FDG, with a maximum interval of 3 days between examinations. Images were visually compared lesion by lesion and the maximum standardized uptake value (SUV) was calculated for each lesion and each radiopharmaceutical. Results: All lesions presented uptake of both 68Ga-PSMA and 18F-FDG. In the first patient, 3 lesions were identified: a mass adjacent to the pancreas measuring 5.4 cm (FDG: SUV = 2.0) (PSMA: SUV = 8.2), a mass in the right iliac fossa measuring 7.7 cm (FDG: SUV = 3.8) (PSMA: SUV = 5.7), and another involving the duodenojejunal transition measuring 4.1 cm (FDG: SUV = 1.9) (PSMA: SUV = 3.7). In the second patient, a mass was identified adjacent to the head and uncinate process of the pancreas measuring 9.2 cm (FDG: SUV = 9.8) (PSMA: SUV = 6.1). In the third patient, an irregular retroperitoneal mass was identified at the level of the aortic bifurcation (FDG: SUV = 2.3) (PSMA: SUV = 2.4). Conclusion: Desmoid tumors can demonstrate uptake of both 68Ga-PSMA and 18F-FDG. The intensity of tracer uptake in the lesions is variable, with some showing greater uptake of FDG, others of PSMA, suggesting a potential complementary role for these radiotracers in desmoid tumors

COMPARISON OF 18F-FDG AND 18F-PSMA PET/CT IN PATIENTS WITH NON-SMALL CELL LUNG CANCER

Introduction/Justification: Lung cancer remains a major global cause of mortality. While 18F-FDG PET/CT is widely utilized for detection, staging, and monitoring, detecting increased glucose metabolism in tumor cells, it lacks theranostic potential. The prostate-specific membrane antigen (PSMA) tracer, initially linked to prostate cancer, is also recognized as a marker of neoangiogenesis, accumulating in various neoplasms and showing promising theranostic capabilities. Objectives: This study aims to compare the uptake patterns of 18F-FDG and 18F-PSMA in primary and metastatic lesions of non-small cell lung cancer. Materials and Methods: Four male patients diagnosed with non-small cell lung cancer (including two adenocarcinomas, one squamous cell carcinoma, and one unspecified type), aged between 58 and 71 years, underwent PET/CT imaging. 18F-FDG PET/CT scans were performed 60 minutes after intravenous administration of 0.1 mCi/kg of 18F-FDG, while 18F-PSMA PET/CT scans were obtained 90 minutes after intravenous injection of 0.1 mCi/kg of 18F-PSMA. Imaging data were analyzed by two nuclear medicine physicians and one radiologist. The maximum standardized uptake value (SUVmax) of each lesion was measured for both radiotracers in the primary tumor, lymph nodes, and metastatic sites identified through visual analysis, considering values obtained above the cardiac blood pool measured in the left atrium. Results: A total of 100 lesions were detected, with 82 identified using 18F-FDG and 92 using 18F-PSMA. Eight lesions were exclusively detected by 18F-FDG, while 14 were only identified by 18F-PSMA. The median SUVmax of lesions in 18F-FDG and 18F-PSMA images was 5.3 (1.7 – 25.0) and 3.7 (0.7 - 12.4), respectively. Brain lesions were more readily identified on 18F-PSMA images, whereas liver lesions were more notable on 18F-FDG images due to the intense physiological uptake of 18F-FDG and 18F-PSMA in the brain and liver, respectively. Conclusion: Both 18F-FDG-PET/CT and 18F-PSMA-PET/CT have the ability to identify most lesions of non-small cell lung cancer. Although 18F-PSMA images detected a greater number of lesions, the uptake intensity is generally higher with 18F-FDG. These findings suggest that the two radiopharmaceuticals may have complementary roles in lung cancer by independently detecting lesions with higher glycolytic activity or greater neoangiogenesis, or both simultaneously, which could contribute to a more personalized approach in managing these patients. The results also suggest a possible theranostic approach in selected patients with high uptake of PSMA. Further investigations involving a larger patient cohort are essential to validate these findings