Publications by authors named "Marcelo Queiroz"

61 Publications

What can we learn from surveys? A systematic review of survey studies addressing femoroacetabular impingement syndrome.

J Hip Preserv Surg 2020 Aug 29;7(3):439-447. Epub 2020 Oct 29.

Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada.

The purpose of this study was to systematically review the methodology, response rate and quality of survey studies related to femoroacetabular impingement (FAI) syndrome. A search was conducted on three databases (PubMed, EMBASE, MEDLINE) for relevant studies from database inception to 27 January 2020. Data extracted included study and survey characteristics, as well as response rates. The quality of the included studies was also assessed using a previously published quality assessment tool. Data were analysed with means, ranges, standard deviations, 95% confidence intervals and bivariate analysis. Eleven studies (13 surveys) were included in this review out of a total of 1608 initial titles found. Surveys were most often administered via the Internet (72%) to orthopaedic surgeons (54%). The mean response rate was 70.4%. The mean quality score was moderate 13.3/24 (SD ±4.3). The criterion that most often scored high was 'clearly defined purpose and objectives' (11/11). The most common survey topic investigated surgeons' knowledge regarding FAI diagnosis and management (n = 7). In addition, bivariate analysis between quality score and response rate showed no significant correlation (Spearman's rho = -0.090,  = 0.85). Overall, survey studies related to FAI syndrome most often use Internet-based methods to administer surveys. The most common target audience is orthopaedic surgeons. The topics of the surveys most often revolve around orthopaedic surgeons' knowledge and opinions relating to the diagnosis and management of FAI syndrome. The response rate is high in patient surveys and lower in larger surgeon surveys. Overall, the studies are of moderate quality.
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http://dx.doi.org/10.1093/jhps/hnaa039DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8081432PMC
August 2020

An international expert opinion statement on the utility of PET/MR for imaging of skeletal metastases.

Eur J Nucl Med Mol Imaging 2021 Feb 22. Epub 2021 Feb 22.

Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Boston, MA, USA.

Background: MR is an important imaging modality for evaluating musculoskeletal malignancies owing to its high soft tissue contrast and its ability to acquire multiparametric information. PET provides quantitative molecular and physiologic information and is a critical tool in the diagnosis and staging of several malignancies. PET/MR, which can take advantage of its constituent modalities, is uniquely suited for evaluating skeletal metastases. We reviewed the current evidence of PET/MR in assessing for skeletal metastases and provided recommendations for its use.

Methods: We searched for the peer reviewed literature related to the usage of PET/MR in the settings of osseous metastases. In addition, expert opinions, practices, and protocols of major research institutions performing research on PET/MR of skeletal metastases were considered.

Results: Peer-reviewed published literature was included. Nuclear medicine and radiology experts, including those from 13 major PET/MR centers, shared the gained expertise on PET/MR use for evaluating skeletal metastases and contributed to a consensus expert opinion statement. [18F]-FDG and non [18F]-FDG PET/MR may provide key advantages over PET/CT in the evaluation for osseous metastases in several primary malignancies.

Conclusion: PET/MR should be considered for staging of malignancies where there is a high likelihood of osseous metastatic disease based on the characteristics of the primary malignancy, hight clinical suspicious and in case, where the presence of osseous metastases will have an impact on patient management. Appropriate choice of tumor-specific radiopharmaceuticals, as well as stringent adherence to PET and MR protocols, should be employed.
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http://dx.doi.org/10.1007/s00259-021-05198-2DOI Listing
February 2021

Augmented Reality in Orthopedic Surgery Is Emerging from Proof of Concept Towards Clinical Studies: a Literature Review Explaining the Technology and Current State of the Art.

Curr Rev Musculoskelet Med 2021 Apr 5;14(2):192-203. Epub 2021 Feb 5.

Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland.

Purpose Of Review: Augmented reality (AR) is becoming increasingly popular in modern-day medicine. Computer-driven tools are progressively integrated into clinical and surgical procedures. The purpose of this review was to provide a comprehensive overview of the current technology and its challenges based on recent literature mainly focusing on clinical, cadaver, and innovative sawbone studies in the field of orthopedic surgery. The most relevant literature was selected according to clinical and innovational relevance and is summarized.

Recent Findings: Augmented reality applications in orthopedic surgery are increasingly reported. In this review, we summarize basic principles of AR including data preparation, visualization, and registration/tracking and present recently published clinical applications in the area of spine, osteotomies, arthroplasty, trauma, and orthopedic oncology. Higher accuracy in surgical execution, reduction of radiation exposure, and decreased surgery time are major findings presented in the literature. In light of the tremendous progress of technological developments in modern-day medicine and emerging numbers of research groups working on the implementation of AR in routine clinical procedures, we expect the AR technology soon to be implemented as standard devices in orthopedic surgery.
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http://dx.doi.org/10.1007/s12178-021-09699-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7990993PMC
April 2021

Patient Education in Orthopedics: the Role of Information Design and User Experience.

Curr Rev Musculoskelet Med 2021 Feb 6;14(1):9-15. Epub 2021 Jan 6.

Hip Group, Department of Orthopedics and Traumatology, Santa Casa de Sao Paulo School of Medical Sciences, Sao Paulo, SP, Brazil.

Purpose Of Review: This narrative review will focus on concepts and methods of Information Design and User Experience for patient education in orthopedics, with osteoarthritis as an application example.

Recent Findings: Information design can make complex health information clear according to the needs of the patients. Digital health presents new opportunities to design scalable educational interventions and may be improved with User Experience Design. Human-centered design methods such as user research, co-design, and prototype testing are being applied in orthopedics to achieve patient-centered care. Current international guidelines on osteoarthritis put patient education as one of the key care strategies. Educational interventions target preoperative education and osteoarthritis self-management, but current models could be enhanced. Patient education and health literacy are fundamental to face the burden of musculoskeletal pain. The collaboration between design and health is essential to deal with the demand for education, behavioral, and social change.
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http://dx.doi.org/10.1007/s12178-020-09683-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7930126PMC
February 2021

PET/MRI Characterization of Mucinous Versus Nonmucinous Components of Rectal Adenocarcinoma: A Comparison of Tumor Metabolism and Cellularity.

AJR Am J Roentgenol 2021 02 9;216(2):376-383. Epub 2020 Dec 9.

Department of Radiology and Oncology, Nuclear Medicine Division, Universidade de Sao Paulo Instituto do Cancer do Estado de Sao Paulo, Rua Doutor Ovidio Pires de Campos, 872 Sao Paulo, 05403-010, Brazil.

The purpose of this study was to evaluate whether FDG PET/MRI can be used to differentiate the mucinous from the nonmucinous components of primary rectal tumors and to compare the glycolytic metabolism on PET with tumor cellularity on DWI in both components. Ninety-nine patients who underwent FDG PET/MRI for staging of primary rectal cancer were included in this prospective analysis. MRI depicted the mucin component through the tumor volume. Separate volumes of interest were drawn on both mucinous and nonmucinous components and propagated to PET and apparent diffusion coefficient (ADC) mapping. Maximum and mean standardized uptake values (SUV, SUV) and maximum, mean, and minimum ADC values (ADC, ADC, ADC) were recorded and compared between areas with mucinous and nonmucinous components. Whole-body PET/MRI was also used to evaluate for the presence of distant metastases. Nonparametric testing was used to compare the two groups of patients: those with tumors with a mucinous component and those with tumors without a mucinous component. Logistic regression analysis was performed to calculate the association risk between mucinous component and metastatic disease. Seventeen patients (17.2%) had a mucinous component within the tumor on T2-weighted MRI. Most of these patients had advanced disease, the mucinous component tumors being in significantly higher T categories than the tumors without a mucinous component (88.2% vs 61.0%; = 0.032). SUV (7.4 vs 16.7; = 0.002) and SUV (5.4 vs 13.4; = 0.001) were significantly lower in tumors with a mucinous component than in those without a mucinous component. Tumor ADC measurements were not different between tumors with and those without a mucinous component (ADC, 1.4 vs 1.6; = 0.361). There was no association between presence of a mucinous component within the primary rectal tumor and presence of synchronous metastases (odds ratio, 1.1 [0.4-3.0]; = 0.904). Moreover, the occurrence of metastases in patients with mucinous component tumors (7/17 [41.2%]) was not different from that in patients with tumors without a mucinous component (28/82 [34.1%]) ( = 0.887). PET/MRI can be used to differentiate the mucinous and nonmucinous components within primary rectal adenocarcinoma on the basis of metabolic status. The FDG uptake is significantly lower in the mucinous component, but tumor cellularity based on MRI and DWI findings is not. Despite being associated with a higher T category in the sample of patients in this study, the presence of a mucinous component seems not to be associated with increased risk of synchronous metastases.
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http://dx.doi.org/10.2214/AJR.19.22627DOI Listing
February 2021

Reassessing Patterns of Response to Immunotherapy with PET: From Morphology to Metabolism.

Radiographics 2021 Jan-Feb;41(1):120-143. Epub 2020 Dec 4.

From the Departments of Radiology (L.B.C., M.A.Q., F.G.B., R.F.N., E.C.Z., M.M.R., J.F.G.M., G.G.C., C.A.B.) and Oncology (D.J.), Hospital Sírio-Libanês, Rua Dona Adma Jafet 115, 01308-060 São Paulo, SP, Brazil; and Department of Radiology and Oncology, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil (M.A.Q., J.F.G.M., G.G.C., C.A.B.).

Cancer demands precise evaluation and accurate and timely assessment of response to treatment. Imaging must be performed early during therapy to allow adjustments to the course of treatment. For decades, cross-sectional imaging provided these answers, showing responses to the treatment through changes in tumor size. However, with the emergence of immune checkpoint inhibitors, complex immune response patterns were revealed that have quickly highlighted the limitations of this approach. Patterns of response beyond tumor size have been recognized and include cystic degeneration, necrosis, hemorrhage, and cavitation. Furthermore, new unique patterns of response have surfaced, like pseudoprogression and hyperprogression, while other patterns were shown to be deceptive, such as unconfirmed progressive disease. This evolution led to new therapeutic evaluation criteria adapted specifically for immunotherapy. Moreover, inflammatory adverse effects of the immune checkpoint blockade were identified, many of which were life threatening and requiring prompt intervention. Given complex concepts like tumor microenvironment and novel therapeutic modalities in the era of personalized medicine, increasingly sophisticated imaging techniques are required to address the intricate patterns of behavior of different neoplasms. Fluorine 18-fluorodeoxyglucose PET/CT has rapidly emerged as one such technique that spans both molecular biology and immunology. This imaging technique is potentially capable of identifying and tracking prognostic biomarkers owing to its combined use of anatomic and metabolic imaging, which enables it to characterize biologic processes in vivo. This tailored approach may provide whole-body quantification of the metabolic burden of disease, providing enhanced prediction of treatment response and improved detection of adverse events. RSNA, 2020.
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http://dx.doi.org/10.1148/rg.2021200093DOI Listing
December 2020

Omentin: A novel therapeutic approach for the treatment of endothelial dysfunction in type 2 diabetes.

Free Radic Biol Med 2021 Jan 21;162:233-242. Epub 2020 Oct 21.

Institute of Physiology, ICBR, Faculty of Medicine, University of Coimbra, Portugal. Electronic address:

Background: Perivascular adipose tissue (PVAT) locally influences the functioning of blood vessels and promotes vascular complications associated with diabetes and obesity. The aim of this work was to study the impact of omentin-1 on endothelial function and PVAT in a non-obese type 2 diabetes mellitus animal model, Goto-Kakizaki (GK) rats with or without high fat diet.

Material And Methods: Diabetic GK rats were divided into four groups: 1) control group; 2) group treated with omentin-1; 3) group of GK rats fed a high fat diet (GKHFD) and 4) group of GKHFD treated with omentin-1. Several in vivo parameters such as adiposity and Lee indexes, lipid profile, fasting glucose levels, glucose and insulin tolerance tests were determined. At the vascular level, endothelial dependent and independent relaxation and contraction studies were performed in aortic rings in the absence (PVAT-) or in the presence (PVAT+) of thoracic PVAT. We also evaluated vascular oxidative stress and determined the pro-inflammatory status of PVAT.

Results: Endothelium-dependent relaxation to acetylcholine, assessed by wire myography, was impaired in GK and GKHFD rats and improved by the omentin-1 treatment. In addition, vascular superoxide production was increased in the vascular wall of diabetic rats, accompanied by reduced nitric oxide bioavailability and significantly improved by omentin treatment. PVAT anti-contractile action found under physiological conditions was lost in type 2 diabetes, and partially recovered with omentin-1 administration. In addition, omentin-1 treatment significantly improved proinflammatory and pro-oxidant PVAT phenotype (decreasing C-reactive protein and nitrotyrosine levels). Furthermore, it was observed an improvement in various systemic and metabolic biochemical parameters of diabetic animals treated for one month with omentin.

Conclusions: Omentin-1 ameliorates endothelial dysfunction in type 2 diabetes and presents therapeutic potential for the treatment of vascular complications associated with type 2 diabetes.
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http://dx.doi.org/10.1016/j.freeradbiomed.2020.10.021DOI Listing
January 2021

Femoroacetabular Impingement and Acetabular Labral Tears - Part 3: Surgical Treatment.

Rev Bras Ortop (Sao Paulo) 2020 Oct 20;55(5):532-536. Epub 2020 Oct 20.

Faculdade de Ciências Médicas, Santa Casa de Misericórdia de São Paulo (FCMSCSP), São Paulo, SP, Brasil.

In the last 15 years, the diagnosis of femoroacetabular impingement has become more frequent; with the advance of surgical indications, different techniques have been developed. Surgical treatment includes a wide variety of options, namely: periacetabular osteotomy, surgical hip dislocation, arthroscopy with osteochondroplasty via a small incision, modified anterior approach technique, and exclusively arthroscopic technique. The type of approach should be chosen according to the complexity of the morphology of the femoroacetabular impingement and to the surgeon's training. The techniques most used today are arthroscopy, surgical dislocation of the hip, and periacetabular osteotomy. The present article aims to describe the current main surgical techniques used to treat femoroacetabular impingement, their indications, advantages and disadvantages, complications and clinical results.
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http://dx.doi.org/10.1055/s-0040-1714220DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7575401PMC
October 2020

Femoroacetabular Impingement and Acetabular Labral Tears - Part 2: Clinical Diagnosis, Physical Examination and Imaging.

Rev Bras Ortop (Sao Paulo) 2020 Oct 17;55(5):523-531. Epub 2020 Jul 17.

Grupo de Quadril, Departamento de Ortopedia e Traumatologia, Faculdade de Ciências Médicas, Santa Casa de Misericórdia de São Paulo (FCMSCSP), São Paulo, SP, Brasil.

The clinical diagnosis of femoral acetabular impingement (FAI) continues to evolve as the understanding of normal and pathological hips progresses. Femoral acetabular impingement is currently defined as a syndrome in which the diagnosis consists of the combination of a previously-obtained comprehensive clinical history, followed by a consistent and standardized physical examination with specific orthopedic maneuvers. Additionally, radiographic and tomographic examinations are used for the morphological evaluation of the hip, and to ascertain the existence of sequelae of childhood hip diseases and the presence of osteoarthritis. The understanding of the femoral and acetabular morphologies and versions associated with images of labral and osteochondral lesions obtained through magnetic resonance imaging (MRI) contributes to the confirmation of this syndrome in symptomatic patients, and helps in the exclusion of differential diagnoses such as iliopsoas tendon snaps, subspine impingement, ischiofemoral impingement, and other hip joint pathologies.
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http://dx.doi.org/10.1055/s-0040-1702954DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7575378PMC
October 2020

Femoroacetabular Impingement and Acetabular Labral Tears - Part 1: Pathophysiology and Biomechanics.

Rev Bras Ortop (Sao Paulo) 2020 Oct 2;55(5):518-522. Epub 2020 Apr 2.

Grupo de Quadril, Faculdade de Ciências Médicas, Santa Casa de São Paulo, São Paulo, SP, Brasil.

Femoroacetabular impingement (FAI) is an important cause of hip pain, and the main etiology of hip osteoarthritis in the young population. Femoroacetabular impingement is characterized by subtle alterations in the anatomy of the acetabulum and proximal femur, which can lead to labrum tearing. The acetabular labrum is essential to the stability of the hip joint. Three types of FAI were described: cam (anespherical femoral head), pincer (acetabular overcoverage) and mixed (characteristics of both cam and pincer). The etiology of FAI is related to genetic and environmental characteristics. Knowledge of this condition is essential to adequately treat patients presenting with hip pain.
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http://dx.doi.org/10.1055/s-0040-1702964DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7575372PMC
October 2020

Theranostics in Nuclear Medicine: Emerging and Re-emerging Integrated Imaging and Therapies in the Era of Precision Oncology.

Radiographics 2020 Oct;40(6):1715-1740

From the Department of Radiology, Hospital Sírio-Libanês, Rua Dona Adma Jafet 115, CEP 01308-060, São Paulo, SP, Brazil (J.F.G.M., R.F.N., A.M.C., E.C.Z., L.B.C., F.G.B., M.A.Q., G.G.C., C.A.B.); and Department of Radiology and Oncology, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil (J.F.G.M., A.M.C., M.A.Q., G.G.C., C.A.B.).

Theranostics refers to the pairing of diagnostic biomarkers with therapeutic agents that share a specific target in diseased cells or tissues. Nuclear medicine, particularly with regard to applications in oncology, is currently one of the greatest components of the theranostic concept in clinical and research scenarios. Theranostics in nuclear medicine, or nuclear theranostics, refers to the use of radioactive compounds to image biologic phenomena by means of expression of specific disease targets such as cell surface receptors or membrane transporters, and then to use specifically designed agents to deliver ionizing radiation to the tissues that express these targets. The nuclear theranostic approach has sparked increasing interest and gained importance in parallel to the growth in molecular imaging and personalized medicine, helping to provide customized management for various diseases; improving patient selection, prediction of response and toxicity, and determination of prognosis; and avoiding futile and costly diagnostic examinations and treatment of many diseases. The authors provide an overview of theranostic approaches in nuclear medicine, starting with a review of the main concepts and unique features of nuclear theranostics and aided by a retrospective discussion of the progress of theranostic agents since early applications, with illustrative cases emphasizing the imaging features. Advanced concepts regarding the role of fluorine 18-fluorodeoxyglucose PET in theranostics, as well as developments in and future directions of theranostics, are discussed. RSNA, 2020 See discussion on this article by Greenspan and Jadvar.
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http://dx.doi.org/10.1148/rg.2020200021DOI Listing
October 2020

Errata - Is it Important to Know Where to Place the Spherical Marker for Hip Replacement Digital Planning??

Rev Bras Ortop (Sao Paulo) 2020 Aug 31;55(4):508. Epub 2020 Aug 31.

Grupo de Quadril, Departamento de Ortopedia e Traumatologia, Faculdade de Ciências Médicas da Santa Casa de São Paulo (FCMSCSP), Irmandade Santa Casa de Misericórdia, São Paulo, SP, Brasil.

[This corrects the article DOI: 10.1055/s-0039-1693052.][This corrects the article DOI: 10.1055/s-0039-1693052.].
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http://dx.doi.org/10.1055/s-0040-1715596DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7458751PMC
August 2020

Prostate-specific Membrane Antigen PET: Therapy Response Assessment in Metastatic Prostate Cancer.

Radiographics 2020 Sep-Oct;40(5):1412-1430. Epub 2020 Aug 7.

From the Departments of Radiology (F.G.B., M.A.Q., R.F.N., P.R.D., E.C.Z., L.B.C., J.F.G.M., C.A.B.) and Oncology (D.A.B.), Hospital Sírio-Libanês, Rua Dona Adma Jafet 115, São Paulo, SP, CEP 01308-060, Brazil (F.G.B., M.A.Q., R.F.N., P.R.D., E.C.Z., L.B.C., J.F.G.M., C.A.B.); Department of Radiology and Oncology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil (M.A.Q., D.A.B., J.F.G.M., C.A.B.); and Department of Nuclear Medicine, University Hospital of Zurich, Zurich, Switzerland (D.A.F.).

Therapy response assessment is a critical step in cancer management, leading clinicians to optimize the use of therapeutic options during the course of the disease. Imaging is a pivotal biomarker for therapy response evaluation in oncology and has gained wider use through the development of reproducible data-based guidelines, of which the Response Evaluation Criteria in Solid Tumors is the most successful example. Disease-specific criteria have also been proposed, and the Prostate Cancer Working Group 3 criteria are the mainstay for prostate cancer (PC). However, conventional imaging evaluation in metastatic PC has several limitations, including the inability to detect small-volume disease, the high prevalence of bone (nonmeasurable) lesions at imaging, and the established role of serum prostate-specific antigen (PSA) levels as the biomarker of choice for response assessment and disease progression. In addition, there are an increasing number of newer treatment options with various effects on imaging features. Prostate-specific membrane antigen (PSMA) PET has improved patient selection for newer treatments, such as metastasis-directed therapy (MDT) or radionuclide therapy. The role of PSMA PET in response assessment for many metastatic PC therapeutic options (MDT, androgen deprivation therapy, chemotherapy, radionuclide therapy, and immunotherapy) is an evolving issue, with emerging data showing good correlation with PSA levels and clinical outcome. However, there are specific implications of each therapy (especially androgen deprivation therapy and immunotherapy) on PSMA expression by PC cells, leading to potential pitfalls and inaccuracies that must be known by radiologists. Despite some limitations, PSMA PET is addressing gaps left by conventional imaging methods (eg, CT and bone scanning) and nonimaging biomarkers (PSA levels) in metastatic PC therapy response assessment, a role that can be improved with advances like refinement of interpretation criteria and whole-body tumor burden quantification. RSNA, 2020See discussion on this article by Barwick and Castellucci.
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http://dx.doi.org/10.1148/rg.2020200058DOI Listing
August 2020

Is it Important to Know Where to Place the Spherical Marker for Hip Replacement Digital Planning?

Rev Bras Ortop (Sao Paulo) 2020 Jun 7;55(3):353-359. Epub 2019 Nov 7.

Grupo de Quadril, Departamento de Ortopedia e Traumatologia, Faculdade de Ciências Médicas da Santa Casa de São Paulo (FCMSCSP), Irmandade Santa Casa de Misericórdia, São Paulo, SP, Brasil.

 The present paper aims to evaluate the influences of individual characteristics in radiographic magnification and to identify the most accurate method for radiographic calibration.  During radiographical exam of 50 patients with hip prosthesis, anthropometric data was collected and 4 spherical metal markers with 25 mm diameters were positioned: at the greater trochanter level and lateral to it, over the pubic symphysis, between the thighs at the greater trochanter level, and over the exam table. Since the prosthesis head is the best internal radiographic marker for hip arthroplasty, it was our calibration parameter. Two examiners measured the markers' image for further analysis.  The sample consisted of 50 participants, 19 of whom were male. A difference in pubic symphysis magnification was found. Other individual characteristics (weight, height and body mass index) had weak correlation. The higher accuracy of the markers was at the greater trochanter, between 68.4 and 78.9%, visualized in only19 radiographs. The marker positioned between the thighs was visualized in all radiographs, with an accuracy ranging from 30 to 46%.  Of all individual characteristics, only gender influences magnification at the pubic symphysis. We suggest the use of two spherical markers: at the greater trochanter, due the best accuracy, and between the thighs, considered the best positioning for better visibility.
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http://dx.doi.org/10.1055/s-0039-1693052DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7316537PMC
June 2020

Diagnostic accuracy of FDG-PET/MRI versus pelvic MRI and thoracic and abdominal CT for detecting synchronous distant metastases in rectal cancer patients.

Eur J Nucl Med Mol Imaging 2021 Jan 20;48(1):186-195. Epub 2020 Jun 20.

Nuclear Medicine Division, Department of Radiology and Oncology, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Rua Doutor Ovidio Pires de Campos, 872, Sao Paulo, SP, 05403-010, Brazil.

Purpose: We compared the diagnostic accuracy of detecting distant metastases for baseline rectal cancer staging between PET/MRI and conventional staging (CS).

Materials And Methods: This prospective study from November 2016 to April 2018 included 101 rectal adenocarcinoma patients for primary staging. These patients underwent whole-body PET/MRI in addition to CS (pelvic MRI and thoracic and abdominal contrast-enhanced CT). Different readers analyzed CS and PET/MRI findings for primary tumor, nodal, and metastatic staging. The presence, number, and location of metastases were recorded according to the organ involved (non-regional lymph nodes (LNs), liver, lungs, or others). Lesions were defined as positive, negative, or indeterminate. The number of lesions per organ was limited to 10. The McNemar test was used to compare the accuracies.

Results: PET/MRI exhibited a higher accuracy in detecting metastatic disease than CS in all patients (88.4% vs. 82.6%, p = 0.003) and in patients with extramural vascular invasion (EMVI) (88.9% vs. 85.5%, p = 0.013). The detection rate of PET/MRI was superior to that of CS for all lesions [84.1% vs. 68.9%, p = 0.001], as well as those in the liver (89.2% vs. 84.2%), non-regional LNs (90.0% vs. 36.7%), and lungs (76.4% vs. 66.9%). PET/MRI correctly classified 19/33 (57.5%) patients with indeterminate lesions on CS.

Conclusion: PET/MRI yields higher accuracy than CS for detecting distant synchronous metastases in the baseline staging of patients with rectal cancer and EMVI. PET/MRI exhibited a higher detection rate than CS for identifying non-regional LNs, hepatic lesions, and pulmonary lesions as well as correctly classifying patients with indeterminate lesions.

Trial Registration: NCT02537340.
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http://dx.doi.org/10.1007/s00259-020-04911-xDOI Listing
January 2021

Recovery of bioactive compounds from white grape ( L.) stems as potential antimicrobial agents for human health.

Saudi J Biol Sci 2020 Apr 2;27(4):1009-1015. Epub 2020 Mar 2.

Centre for the Research and Technology of Agro-Environmental and Biological Sciences, University of Trás-os-Montes and Alto Douro (CITAB-UTAD), 5000-801 Vila Real, Portugal.

The grape is a matrix rich in bioactive compounds and its production generates large quantities of by-products, such as grape stems, which, to date, present low commercial value. However, there is a growing interest in the application of this material as a source of phenolic compounds. Therefore, the present study aims at assessing the phytochemical profile of (poly)phenolic extracts of white Portuguese grape stem varieties produced in the (Portugal). The antioxidant activity determined by several assays, as well as the antimicrobial activity using the disc diffusion method against human gastrointestinal pathogenic bacteria of the hydromethanolic extracts, were evaluated. This work presents very positive results as the rich composition in phenolic compounds (94.71-123.09 mg GA and 0.02-73.79 mg g for the total phenol content and for individual phenolics, respectively) presented by grape stems can explain the high antioxidant (0.37-1.17 mmol Trolox g) and antimicrobial activities against, essentially, Gram-positive bacteria, and in some cases with higher efficacy than commercial antibiotics. Thus, demonstrating that this wine by-product should deserve greater attention from the pharmaceutical industries due to its excellent biological properties and characteristics not yet applied.
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http://dx.doi.org/10.1016/j.sjbs.2020.02.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7105666PMC
April 2020

Nonprostatic diseases on PSMA PET imaging: a spectrum of benign and malignant findings.

Cancer Imaging 2020 Mar 14;20(1):23. Epub 2020 Mar 14.

Department of Radiology, Hospital Sirio-Libanes, Rua Dona Adma Jafet, 91, Sao Paulo, ZIP: 01308-050, Brazil.

PSMA PET imaging was originally used to assess biochemical recurrence of prostate cancer (PCa), but its clinical use was promptly extended to detection, staging and therapy response assessment. The expanding use of PSMA PET worldwide has also revealed PSMA ligand uptake in diverse nonprostatic diseases, which raised questions about the specificity of this imaging modality. Although not very common initially, a growing number of pathologies presenting PSMA uptake on PET have been reported in the last few years, and a proper interpretation of PSMA PET imaging findings suddenly became challenging and, to some extent, confusing. Compared to cytoplasmic PSMA expression in nonprostatic cells, the molecular features of apical PSMA expression in PCa cells can help to distinguish these various conditions. Correlations of imaging findings to patient history, to the expected pattern of disease spread and mainly to computed tomography (CT) and/or magnetic resonance imaging (MRI) characteristics will reinforce the distinction of lesions that are more likely related to PCa from those that could lead to an incorrect diagnosis. The overall benefits of endothelial PSMA expression, which is associated with the neovasculature of malignant neoplasms, will be highlighted, stating the potential use of PSMA ligand uptake as a theranostic tool. This review aims to cover the collection of nonprostatic diseases, including benign and malignant tumors, in a didactic approach according to disease etiology, with discussion of bone-related conditions and inflammatory and infectious processes.
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http://dx.doi.org/10.1186/s40644-020-00300-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7071711PMC
March 2020

Perivascular adipose tissue in age-related vascular disease.

Ageing Res Rev 2020 05 26;59:101040. Epub 2020 Feb 26.

Institute of Physiology, iCBR, Faculty of Medicine, University of Coimbra, Portugal. Electronic address:

Perivascular adipose tissue (PVAT), a crucial regulator of vascular homeostasis, is actively involved in vascular dysfunction during aging. PVAT releases various adipocytokines, chemokines and growth factors. In an endocrine and paracrine manner PVAT-derived factors regulate vascular signalling and inflammation modulating functions of adjacent layers of the vasculature. Pathophysiological conditions such as obesity, type 2 diabetes, vascular injury and aging can cause PVAT dysfunction, leading to vascular endothelial and smooth muscle cell dysfunctions. We and others have suggested that PVAT is involved in the inflammatory response of the vascular wall in diet induced obesity animal models leading to vascular dysfunction due to disappearance of the physiological anticontractile effect. Previous studies confirm a crucial role for pinpointed PVAT inflammation in promoting vascular oxidative stress and inflammation in aging, enhancing the risk for development of cardiovascular disease. In this review, we discuss several studies and mechanisms linking PVAT to age-related vascular diseases. An overview of the suggested roles played by PVAT in different disorders associated with the vasculature such as endothelial dysfunction, neointimal formation, aneurysm, vascular contractility and stiffness will be performed. PVAT may be considered a potential target for therapeutic intervention in age-related vascular disease.
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http://dx.doi.org/10.1016/j.arr.2020.101040DOI Listing
May 2020

Nutrients, Antinutrients, Phenolic Composition, and Antioxidant Activity of Common Bean Cultivars and their Potential for Food Applications.

Antioxidants (Basel) 2020 Feb 23;9(2). Epub 2020 Feb 23.

Centre for the Research and Technology of Agro-Environmental and Biological sciences, University of Trás-os-Montes and Alto Douro (UTAD-CITAB), 5000-801 Vila Real, Portugal.

L. is the most commonly consumed legume in the world, given its high vegetable protein content, phenolic compounds, and antioxidant properties. It also represents one of the most sustainable, low-carbon and sources of food available at present to man. This study aims to identify the nutrients, antinutrients, phenolic composition, and antioxidant profile of 10 common bean cultivars (Arikara yellow, butter, cranberry, red kidney, navy, pinto, black, brown eyed, pink eyed, and tarrestre) from two harvest years, thereby assessing the potential of each cultivar for specific applications in the food industry. Navy and pink eyed beans showed higher potential for enrichment of foodstuffs and gluten-free products due to their higher protein and amino acid contents. Additionally, red kidney, cranberry and Arikara yellow beans had the highest content of phenolic compounds and antioxidant properties, which can act as functional ingredients in food products, thus bringing health benefits. Our study highlights the potential of using specific bean cultivars in the development of nutrient-enriched food and as functional ingredients in diets designed for disease prevention and treatment.
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http://dx.doi.org/10.3390/antiox9020186DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7070695PMC
February 2020

Post-Treatment Classification for Acetabular Chondral Lesions in Hip Arthroscopy.

Rev Bras Ortop (Sao Paulo) 2019 Dec 27;54(6):679-684. Epub 2019 Aug 27.

Grupo de Quadril, Departamento de Ortopedia e Traumatologia, Faculdade de Ciências Médicas da Santa Casa de São Paulo (FCMSCSP), Irmandade Santa Casa de Misericórdia, São Paulo, SP, Brasil.

 To describe a postarthroscopic treatment classification system for acetabular chondral damage in the hip and to report the intraobserver and interobserver reliability of such classification.  This is a retrospective review of ninety-nine digital video recordings made during arthroscopic surgery. Patients who underwent arthroscopic treatment for femoroacetabular impingement and evaluated at the hip arthroscopy outpatient clinic between March 2015 and March 2016 were included in the study. Patients with a history of previous hip surgery, radiologic evidence of advanced osteoarthritis (Tönnis grade > 2), who underwent labral resection, or whose digital recordings were incomplete or of insufficient quality for adequate review were excluded. Two orthopedic surgeons, who did not participate in the surgery, independently reviewed the video recordings and classified the remaining acetabular cartilage using the post-treatment classification system. Intraobserver and interobserver analysis was then conducted using intraclass correlation coefficient (ICC).  Excellent intraobserver reliability (ICC = 0.790;  < 0.001) and interobserver reliability (ICC = 0.882;  < 0.001) were observed. Both ICC values were statistically significant.  The posttreatment classification of the remaining acetabular cartilage has excellent intra and interobserver reliability.
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http://dx.doi.org/10.1055/s-0039-1693049DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6952289PMC
December 2019

Comparative Evaluation of Cross-table and Ducroquet Incidences for Measurement of the Hip Alpha Angle.

Rev Bras Ortop (Sao Paulo) 2019 Jul 20;54(4):428-433. Epub 2019 Aug 20.

Serviço de Radiologia, Hospital Sírio Libanês, São Paulo, SP, Brasil.

 The purpose of the present paper is to compare the equivalence of the measurement of the alpha angle using the Ducroquet and cross-table lateral views.  We have recruited 90 patients, resulting in 95 hips. We have standardized the realization of the radiographic views. The incidence of the lateral cross-table views were taken with 15° of internal rotation with the patient in the supine position, and the incidence of the Ducroquet views was standardized with the patient in the supine position, with 90° of flexion and 45° of abduction of the hip. The alpha angle was measured in both lateral views, by two musculoskeletal radiologists. The measurements were performed in 2 different times: an initial evaluation and another 4 weeks afterwards. The t Student test was used and calculated the intraclass correlation coefficient (ICC).  We have found a good intraobserver correlation for both views in different times; there was no statistically significant difference between the measurements performed by the two views. However, the interobserver correlation was low.  In conclusion, the Ducroquet profile view is a good choice for the α angle measurement and can be used instead of the cross-table view.
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http://dx.doi.org/10.1055/s-0039-1693044DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6701969PMC
July 2019

Does Computed Tomography Improve Reproducibility in the Classification of Transtrochanteric Fractures?

Rev Bras Ortop (Sao Paulo) 2019 Jul 20;54(4):361-367. Epub 2019 Aug 20.

Grupo de Quadril, Departamento de ortopedia e Traumatologia, Faculdade de Ciências Médicas da Santa Casa de São Paulo (FCMSCSP), Irmandade Santa Casa de Misericórdia, São Paulo, SP, Brasil.

With the aging of the population, there was a significant increase in the prevalence of hip fractures, with high mortality rates, sequelae and expenses. Understanding the fracture profile and classifying it correctly is critical to define the appropriate treatment. Several radiographic classifications have been developed for transtrochanteric fractures, such as Tronzo, Evans-Jensen, AO and Boyd-Griffin, but their reproducibility is not always satisfactory. The present review aimed to elucidate whether the addition of computed tomography (CT) implies a greater reproducibility than simple radiography in the classification of transtrochanteric fractures, and whether this is a better examination to identify the fracture trait. A search was conducted in the PubMed, Lilacs, Scielo and Cochrane databases between July 2016 and June 2017, limited to the last 15 years. All retrospective, prospective and systematic reviews articles published in the English language, with evaluation of men and/or women, were considered for review. We have excluded case reports, studies that evaluated tomography or radiographs in isolation, and duplicate studies. The research presented 112 articles, of which 5 contemplated the proposed criteria. Reproducibility for the classification of transtrochanteric fractures presented variable results and was influenced by factors such as the type of classification, the use of the simplified or complete classification, the specialty of the evaluator, his experience, and the methodology proposed by the works. There are indications that there is benefit for the use of CT, especially for fractures considered unstable, but its use as a tool to ensure better reproducibility (intra- and interobserver) remains controversial and needs further studies.
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http://dx.doi.org/10.1055/s-0039-1693045DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6701962PMC
July 2019

Regorafenib in Patients with Antiangiogenic-Naïve and Chemotherapy-Refractory Advanced Colorectal Cancer: Results from a Phase IIb Trial.

Oncologist 2019 09 7;24(9):1180-1187. Epub 2019 Jun 7.

Department of Radiology and Oncology, Instituto do Câncer do Estado de São Paulo, São Paulo, Brazil.

Background: Regorafenib is a multikinase inhibitor with antiangiogenic effects that improves overall survival (OS) in metastatic colorectal cancer (mCRC) after failure of standard therapies. We investigated the efficacy and safety of regorafenib in antiangiogenic therapy-naïve chemotherapy-refractory advanced colorectal cancer.

Patients And Methods: This single-center, single-arm, phase IIb study (NCT02465502) enrolled adults with mCRC whose disease had progressed on, or who were intolerant to, standard therapy, but who were antiangiogenic therapy-naïve. Patients received regorafenib 160 mg once daily for 3 weeks per 4-week cycle. The primary endpoint was progression-free survival (PFS) rate at week 8.

Results: Of 59 treated patients, almost half had received at least four prior lines of therapy. Patients received a median of 86% of the planned dose. The week 8 PFS rate was 53% (95% confidence interval [CI], 39.1-64.3); median PFS was 3.5 months (95% CI, 1.8-3.6). Median OS was 7.4 months (95% CI, 5.3-8.9). Tumor response (RECIST version 1.1) was 2%, and metabolic response rate (criteria from the European Organisation for Research and Treatment of Cancer) was 41%. The most frequently reported regorafenib-related grade ≥3 adverse events were hypertension (36%), hand-foot skin reaction (HFSR, 25%), and hypophosphatemia (24%). There were no regorafenib-related deaths. An exploratory analysis showed that patients with grade ≥2 HFSR had longer OS (10.2 months) with regorafenib treatment versus those with grades 0-1 (5.4 months).

Conclusion: These findings support the antitumor activity of regorafenib in antiangiogenic-naïve patients with chemotherapy-refractory mCRC.

Implications For Practice: The multikinase inhibitor regorafenib improved overall survival in the phase III CORRECT and CONCUR trials in heavily pretreated patients with treatment-refractory metastatic colorectal cancer (mCRC). Exploratory subgroup analysis from CONCUR suggested that regorafenib treatment prior to targeted therapy (including bevacizumab) may improve outcomes. In this single-center, single-arm phase IIb study, regorafenib demonstrated antitumor activity in 59 antiangiogenic-naïve patients with chemotherapy-refractory mCRC. Further studies should assess the efficacy of regorafenib in this patient population, as well as explore the reasons behind improved outcomes among patients who had a metabolic response and those who developed hand-foot skin reaction.
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http://dx.doi.org/10.1634/theoncologist.2019-0067DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6738304PMC
September 2019

Pseudoprogression on PSMA PET imaging of a mCRPC patient under anti-PD1 treatment.

Eur J Nucl Med Mol Imaging 2019 Jul 22;46(7):1576-1577. Epub 2019 Apr 22.

Department of Radiology, Hospital Sírio-Libanês, Rua Dona Adma Jafet 115, São Paulo, SP, CEP 01308-060, Brazil.

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http://dx.doi.org/10.1007/s00259-019-04328-1DOI Listing
July 2019

Aberrant Hypermetabolism of Benign Uterine Leiomyoma on 18F-FDG PET/CT.

Clin Nucl Med 2019 Jun;44(6):e413-e414

Department of Gynecologic Oncology-Hospital Sírio-Libanês, São Paulo, Brazil.

Leiomyomas are prevalent benign smooth muscle tumors in the uterus, displaying variable degrees of FDG uptake on PET/CT. The glucose metabolism intensity of those lesions relies on biologic features and markedly increased FDG accumulation is more typically related to malignant diseases, as in the case of leiomyosarcomas. Notwithstanding that uterine fibroids typically exhibit mild to moderate FDG uptake, in this article we report a case of unexpectedly intense hypermetabolism of a benign uterine leiomyoma on a PET/CT scan performed for initial staging of a breast cancer patient.
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http://dx.doi.org/10.1097/RLU.0000000000002580DOI Listing
June 2019

Revisiting Prostate Cancer Recurrence with PSMA PET: Atlas of Typical and Atypical Patterns of Spread.

Radiographics 2019 Jan-Feb;39(1):186-212

From the Department of Radiology, Hospital Sírio-Libanês, Rua Dona Adma Jafet 115, CEP 01308-060, São Paulo, SP, Brazil; and Department of Radiology and Oncology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil (M.A.Q., P.C.C.V., J.F.G.M., G.G.C., C.A.B.).

The introduction of prostate-specific membrane antigen (PSMA) in clinical practice has revolutionized evaluation of biochemical recurrence of prostate cancer after curative-intent treatment. The high expression of this glycoprotein in prostate cancer cells makes PSMA imaging superior to the current conventional staging methods, namely bone scanning and CT. The high capability of PSMA imaging for identifying very small previously undetected lesions has been widely demonstrated in the literature, leading to a rethinking of patient management by oncologists, urologists, and radiation oncologists. The typical and predictable patterns of spread in prostate cancer are still more prevalent, such as spread to pelvic lymph nodes and bone metastasis, but different patterns of disease spread are becoming more commonly recognized with higher reliability because PSMA imaging allows detection of more typical and atypical lesions than conventional imaging. Furthermore, it is important for the reading physician to recognize and understand the typical disease spread and the most prevalent atypical prostate cancer relapses, not only to heighten the relevancy of reports but also to improve imaging consultancy in multispecialty oncologic practice. RSNA, 2019.
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http://dx.doi.org/10.1148/rg.2019180079DOI Listing
March 2020

Clinical perspectives of PSMA PET/MRI for prostate cancer.

Clinics (Sao Paulo) 2018 09 21;73(suppl 1):e586s. Epub 2018 Sep 21.

Departamento de Radiologia, Hospital Sirio-Libanes, Sao Paulo, SP, BR.

Prostate cancer imaging has become an important diagnostic modality for tumor evaluation. Prostate-specific membrane antigen (PSMA) positron emission tomography (PET) has been extensively studied, and the results are robust and promising. The advent of the PET/magnetic resonance imaging (MRI) has added morphofunctional information from the standard of reference MRI to highly accurate molecular information from PET. Different PSMA ligands have been used for this purpose including 68gallium and 18fluorine-labeled PET probes, which have particular features including spatial resolution, imaging quality and tracer biodistribution. The use of PSMA PET imaging is well established for evaluating biochemical recurrence, even at low prostate-specific antigen (PSA) levels, but has also shown interesting applications for tumor detection, primary staging, assessment of therapeutic responses and treatment planning. This review will outline the potential role of PSMA PET/MRI for the clinical assessment of PCa.
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http://dx.doi.org/10.6061/clinics/2018/e586sDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6142859PMC
September 2018

A review on the development of urease inhibitors as antimicrobial agents against pathogenic bacteria.

J Adv Res 2018 Sep 4;13:69-100. Epub 2018 May 4.

Departamento de Química, Centro de Ciências Exatas, Universidade Estadual de Londrina, Londrina, PR, Brazil.

Ureases are enzymes that hydrolyze urea into ammonium and carbon dioxide. They have received considerable attention due to their impacts on living organism health, since the urease activity in microorganisms, particularly in bacteria, are potential causes and/or factors contributing to the persistence of some pathogen infections. This review compiles examples of the most potent antiurease organic substances. Emphasis was given to systematic screening studies on the inhibitory activity of rationally designed series of compounds with the corresponding SAR considerations. Ureases of , the usual model in antiureolytic studies, are emphasized. Although the active site of this class of hydrolases is conserved among bacteria and vegetal ureases, the same is not observerd for allosteric site. Therefore, inhibitors acting by participating in interactions with the allosteric site are more susceptible to a potential lack of association among their inhibitory profile for different ureases. The information about the inhibitory activity of different classes of compounds can be usefull to guide the development of new urease inhibitors that may be used in future in small molecular therapy against pathogenic bacteria.
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http://dx.doi.org/10.1016/j.jare.2018.05.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6077150PMC
September 2018

Impact of 68GA-PSMA PET / CT on treatment of patients with recurrent / metastatic high risk prostate cancer - a multicenter study.

Int Braz J Urol 2018 Sep-Oct;44(5):892-899

Universidade Estadual de Campinas (UNICAMP), Campinas, Brasil.

Purpose: The purpose of our study was to evaluate the clinical impact of 68Ga-PSMA PET / CT in the setting of biochemical recurrence of prostate cancer.

Materials And Methods: We retrospectively evaluated 125 prostate cancer patients submitted to the 68Ga-PSMA PET / CT due to biochemical recurrence. The parameters age, Gleason score, PSA levels, and the highest SUVmax were correlated to potential treatment changes. The highest SUVmax values were correlated with age and Gleason score. The median follow-up time was 24 months.

Results: 68Ga-PSMA PET / CT led to a treatment change in 66 / 104 (63.4%) patients (twenty-one patients were lost to follow-up). There was a significant change of treatment plan in patients with a higher Gleason score (P = 0.0233), higher SUVmax (p = 0.0306) and higher PSA levels (P < 0.0001; median PSA = 2.55 ng / mL).

Conclusion: 68Ga-PSMA PET / CT in prostate cancer patients with biochemical recurrence has a high impact in patient management.
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http://dx.doi.org/10.1590/S1677-5538.IBJU.2017.0632DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6237542PMC
December 2018

Risk Factors and Treatment Options for Failure of a Two-Stage Exchange.

Curr Rev Musculoskelet Med 2018 Sep;11(3):420-427

Department of Orthopaedic Surgery, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil.

Purpose Of Review: Although a two-stage exchange revision is reported to have a high success rate, this strategy may fail as a treatment for prosthetic joint infection (PJI). When it does, resection arthroplasty, arthrodesis, amputation, and chronic antibiotic suppression may play a role. The purpose of this review is to determine which are the main risk factors for a two-stage exchange failure and to analyze the indications and results of resection arthroplasty, arthrodesis, amputation, and antibiotic chronic suppression for PJI.

Recent Findings: Recent literature demonstrates that the main risk factors for a two-stage exchange failure are as follows: hemodialysis, obesity, multiple previous procedures, diabetes mellitus, corticosteroid therapy, hypoalbuminemia, immunosuppression, rheumatological conditions, coagulation disorders, and infection due to multidrug-resistant (MDR) bacteria or fungal species. Regarding microorganisms, besides Staphylococcus aureus, Streptococcus spp., Enterobacteriaceae species such as Klebsiella pneumoniae and Enterobacter sp., Pseudomonas aeruginosa, or Acinetobacter baumannii, and fungus including Candida sp. are also considered risk factors for a two-stage exchange failure. Resection arthroplasty, arthrodesis, and amputation have a limited role. Chronic suppression is an option for high-risk patients or unfeasible reconstruction. In summary, we report the main risk factors for a two-stage exchange failure and alternative procedures when it occurs. Future research on patient-specific risk factors for a two-stage exchange may aid surgical decision-making and optimization of outcomes.
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http://dx.doi.org/10.1007/s12178-018-9504-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6105486PMC
September 2018