Brain death denotes the loss of function in both the cerebrum and the brain stem, leading to coma, absence of spontaneous respiration in the setting of adequate stimulus, and the cessation of all brain stem reflexes. Although spinal reflexes such as deep tendon, plantar flexion, and withdrawal reflexes may persist, recovery is not possible. The cessation of brain function qualifies as death because of its central role in coordinating vital bodily functions. Although brain death is largely determined by a clinical and neurologic examination, confounding variables may necessitate ancillary testing such as cerebral brain perfusion imaging.

Wild-type transthyretin cardiac amyloidosis (ATTRwt-CA) is a progressive myocardial disease characterized by an increased ventricular wall thickness. ATTRwt-CA is often accompanied by monoclonal gammopathy of undetermined significance (MGUS), as indicated by an abnormal serum-free light chain ratio or detection of monoclonal protein (M-protein) on serum immunofixation electrophoresis. Increasing evidence has emerged regarding the risk of venous thromboembolic disease in patients with MGUS. Herein, we report a case of ATTRwt-CA with M-protein, where the patient developed deep vein thrombosis (DVT). A 72-year-old man presented with gradual progressive swelling of the right lower extremity. He had undergone surgical treatment for bilateral carpal syndrome and lumbar spinal canal stenosis. He was diagnosed with DVT and severe left ventricular (LV) hypertrophy, and was treated with a direct factor Xa inhibitor. Given severe LV hypertrophy, the patient underwent further cardiac examinations. 99mTc-labelled pyrophosphate scintigraphy revealed grade 3 myocardial uptake. Serum immunofixation electrophoresis detected IgA-κ M-protein. An endomyocardial biopsy revealed amyloid deposits. Based on immunohistochemical staining and genetic testing, the patient was diagnosed as having ATTRwt-CA with IgA-κ M-protein. Therefore, clinicians should be aware that ATTRwt-CA is often associated with M-protein. Under these conditions, attention should be paid to both pathological issues.
UNASSIGNED: Wild-type transthyretin cardiac amyloidosis (ATTRwt-CA) is often accompanied by monoclonal gammopathy of undetermined significance (MGUS), as indicated by an abnormal serum-free light chain ratio or detection of monoclonal protein (M-protein). Meanwhile, increasing evidence has emerged about the risk of deep vein thrombosis (DVT) in patients with MGUS. We report a case of ATTRwt-CA with M-protein, in which DVT developed. Under these conditions, paying attention to both pathological aspects is warranted.

Although neuroendocrine tumours (NETs) are predominantly located in the gastrointestinal tract, pancreas, and lungs, they can also occur in uncommon places such as the biliary system, prostate, breast, head, neck, and even the spinal cord. We present the case of a 30-year-old woman who was referred to the urology clinic for right ureterohydronephrosis. Because the contrast-enhanced CT scan did not show signs of kidney stones or an upper urothelial tract cell carcinoma and was combined with renal scintigraphy, the kidney was not functional, and a left nephrectomy was performed. During the surgery, it was observed that the appendix was attached to the ureter by a tiny tumour. In addition, an appendectomy was also conducted. The pathological test indicated the presence of a NET that had invaded the ureter. The diagnosis was confirmed by immunohistochemical staining. The tissue has been positive for chromogranin and synaptophysin staining. Our work highlights the infrequency and difficulty of diagnosing NETs that invade the ureter. Conducting a thorough histological evaluation in patients with uncertain histopathological diagnoses is essential.

Brown tumors, an exceptional bone complication of severe primary (PHP) or renal (secondary) hyperparathyroidism (RHP), are caused by long-standing, elevated parathormone (PTH)-induced osteoclast activation causing multinucleated giant cell conglomerates with hemosiderin deposits in addition to the local production of cytokines and growth factors. We aim to present an adult case series including two females displaying this complication as part of a multidisciplinary complex panel in high PTH-related ailments. The approach was different since they had distinct medical backgrounds and posed a wide area of challenges amid real-life settings, namely, a 38-year-old lady with PHP and long-term uncontrolled hypercalcemia (with a history of pregnancy-associated PHP, the removal of a cystic jaw tumor, as well as a family and personal positive diagnosis of polycystic kidney disease, probably a PHP-jaw tumor syndrome), as well as, a 26-year-old woman with congenital single kidney and chronic renal disease-associated RHP who was poorly controlled under dialysis and developed severe anemia and episodes of metabolic acidosis (including one presentation that required emergency hemodialysis and was complicated with convulsive seizures, followed by resuscitated respiratory arrest). Both subjects displayed a severe picture of PHP/RHP with PTH levels of >1000 pg/mL and >2000 pg/mL and elevated serum bone turnover markers. Additionally, they had multiple brown tumors at the level of the ribs and pelvis (asymptomatically) and the spine, skull, and pelvis (complicated with a spontaneous cervical fracture). As an endocrine approach, the control of the underlying parathyroid disease was provided via surgery in PHP (for the postparathyroidectomy hungry bone syndrome) via medical intervention (with vitamin D analogs) in RHP. Additionally, in this case, since the diagnosis was not clear, a multidisciplinary decision to perform a biopsy was taken (which proved inconclusive), and the resection of the skull tumor to confirm the histological traits. This series highlights the importance of addressing the entire multidisciplinary panel of co-morbidities for a better outcome in patients with PHP/RHP-related brown tumors. However, in the instance of real-life medicine, poor compliance and reduced adherence to recommendations might impair the overall health status. Thus, sometimes, a direct approach at the level of cystic lesion is taken into consideration; this stands for a narrow frame of decision, and it is a matter of personalized decision. As seen here, brown tumors represent the hidden face of PHP/RHP, primarily the complex and severe forms, and awareness is essential even in the modern era.

UNASSIGNED: There is no consensus on how to predict post-transplant function of donation after circulatory death (DCD) kidneys. Thus, we aimed to identify renal scintigraphy parameters that could predict 1-year kidney function.
UNASSIGNED: In this single center study, we included all consecutive DCD kidney recipients between 2013 and 2021 (n = 29). Patients who did not have a scintigraphy within 10 days of transplantation (n = 3), recipients of multiple organs and less than 18 years old were excluded (n = 1). Primary endpoint was the estimated glomerular filtration rate (eGFR).
UNASSIGNED: Median eGFR and serum creatinine at 1 year were 67 µmol/L (56-81) and 111 ml/min (99-132), respectively. Among parameters tested, the 3rd/2nd-minute activity ratio had the best diagnostic performance (AUC: 0.74 and 0.71, for eGFR and creatinine) 1 year post transplantation. Using 1.21 as the best cut off, the 3rd/2nd-minute activity ratio specificity and sensitivity to predict eGFR >60 ml/min was 0.82 and 0.83. Renal function was significantly better at 1 week, 3, 6, and 12 months after transplantation in patients with 3rd/2nd-minute activity ratios above 1.21.
UNASSIGNED: This study suggests that the 3rd/2nd-minute activity ratio can predict graft function at 1 year. The benefit of post-transplant scintigraphy should be further validated in a prospective cohort.

[This corrects the article DOI: 10.3389/frtra.2022.1065415.].

A 74-year-old Japanese man was admitted to our hospital for catheter ablation of paroxysmal atrial fibrillation. Transthoracic echocardiography revealed basal interventricular septal hypertrophy without apical sparing. Cardiac magnetic resonance imaging revealed late gadolinium enhancement in the hypertrophic lesions. The Kumamoto criteria was one point, and the patient had no carpal tunnel syndrome. However, technetium-99m pyrophosphate scintigraphy revealed an accumulation in the basal region of the left ventricle. A skin biopsy revealed transthyretin (TTR) amyloid deposition. A TTR gene examination revealed no variants. This case suggests that amyloid deposition in TTR may occur in the basal area of the interventricular septum.

Intreduction: Melanoma is an extremely aggressive form of skin neoplasia, an important stage in the diagnostic and treatment is identifying the dissemination at the lymphatic level. For a more accurate staging, the sentinel lymph node biopsy technique is performed, which in most of the time addresses one, respectively 2 locations, but cases with sentinel nodes in 3 lymphatic basins have rarely been described. Case report: We present a case of melanoma located in the right lumbar region, which from the point of view of histopathological features has a Breslow index of 4.2 mm, classified in the pT4b stage. After the CT evaluation was performed, it was decided that there is indication for performing the sentinel lymph node technique and excision with a margin of safety. Scintigraphy revealed that sentinel lymph nodes were identified in 3 different regions, respectively the right axilla and bilateral inguinal. Conclusions: Melanoma located on the trunk can present different lymphatic routes for the sentinel lymph nodes, unlike that on the limbs where certain patterns are present. Identifying these lymph nodes in cases like this involves a challenge both from a diagnostic and surgical point of view.

BACKGROUND: High-flow nasal cannula (HFNC) systems employ different methods to provide aerosol to patients. This study compared delivery efficiency, particle size, and regional deposition of aerosolized bronchodilators during HFNC in neonatal, pediatric, and adult upper-airway and lung models between a proximal aerosol adapter and distal aerosol circuit chamber.
METHODS: A filter was connected to the upper airway to a spontaneously breathing lung model. Albuterol was nebulized using the aerosol adapter and circuit at different clinical flow settings. The aerosol mass deposited in the upper airway and lung was quantified. Particle size was measured with a laser diffractometer. Regional deposition was assessed with a gamma camera at each nebulizer location and patient model with minimum flow settings.
RESULTS: Inhaled lung doses ranged from 0.2-0.8% for neonates, 0.2-2.2% for the small child, and 0.5-5.2% for the adult models. Neonatal inhaled lung doses were not different between the aerosol circuit and adapter, but the aerosol circuit showed marginally greater lung doses in the pediatric and adult patient models. Impacted aerosols and condensation in the non-heated HFNC and aerosol delivery components contributed to the dispersion of coarse liquid droplets, high deposition (11-44%), and occlusion of the supine neonatal upper airway. In contrast, the upright pediatric and adult upper-airway models had minimal deposition (0.3-7.0%) and high fugitive losses (∼24%) from liquid droplets leaking out of the nose. The high impactive losses in the aerosol adapter (56%) were better contained than in the aerosol circuit, resulting in less cannula sputter (5% vs 22%), fewer fugitive losses (18% vs 24%), and smaller inhaled aerosols (5 µm vs 13 µm).
CONCLUSIONS: The inhaled lung dose was low (1-5%) during HFNC. Approaches that streamline aerosol delivery are needed to provide safe and effective therapy to patients receiving aerosolized medications with this HFNC system.

Cardiac amyloidosis, characterized by amyloid fibril deposition in the myocardium, leads to restrictive cardiomyopathy and heart failure. This review explores recent advancements in imaging techniques for diagnosing and managing cardiac amyloidosis, highlighting their clinical applications, strengths, and limitations. Echocardiography remains a primary, non-invasive imaging modality but lacks specificity. Cardiac MRI (CMR), with Late Gadolinium Enhancement (LGE) and T1 mapping, offers superior tissue characterization, though at higher costs and limited availability. Scintigraphy with Tc-99m-PYP reliably diagnoses transthyretin (TTR) amyloidosis but is less effective for light chain (AL) amyloidosis, necessitating complementary diagnostics. Amyloid-specific PET tracers, such as florbetapir and flutemetamol, provide precise imaging and quantitative assessment for both TTR and AL amyloidosis. Challenges include differentiating between TTR and AL amyloidosis, early disease detection, and standardizing imaging protocols. Future research should focus on developing novel tracers, integrating multimodality imaging, and leveraging AI to enhance diagnostic accuracy and personalized treatment. Advancements in imaging have improved cardiac amyloidosis management. A multimodal approach, incorporating echocardiography, CMR, scintigraphy, and PET tracers, offers comprehensive assessment. Continued innovation in tracers and AI applications promises further enhancements in diagnosis, early detection, and patient outcomes.