Contrast-enhanced ultrasound (CEUS) for the evaluation of focal liver lesions - a prospective multicenter study of its usefulness in clinical practice.

PURPOSE: To assess the value of contrast-enhanced ultrasound (CEUS) for differentiating malignant from benign focal liver lesions (FLLs) and for diagnosing different FLL types. MATERIAL AND METHODS: CEUS performed in 14 Romanian centers was prospectively collected between February 2011 and June 2012. The inclusion criteria were: age > 18 years; patients diagnosed with 1 - 3 de novo FLLs on B-mode ultrasound; reference method (computed tomography (CT), magnetic resonance imaging (MRI) or biopsy) available; patient's informed consent. FLL lesions were characterized during CEUS according to the European Federation of Societies for Ultrasound in Medicine and Biology guidelines. For statistical analysis, indeterminate FLLs at CEUS were rated as false classifications. RESULTS: A total number of 536 cases were included in the final analysis, 344 malignant lesions (64.2 %) and 192 benign lesions (35.8 %). The reference method was: CT/MRI - 379 cases (70.7 %), pathological exam - 150 cases (27.9 %) and aspiration of liver abscesses - 7 cases (1.4 %). CEUS was conclusive in 89.3 % and inconclusive in 10.7 % of cases. To differentiate between malignant and benign FLLs, CEUS had 85.7 % sensitivity, 85.9 % specificity, 91.6 % positive predictive value, 77.1 % negative predictive value and 85.8 % accuracy. The CEUS accuracy for differentiation between malignant and benign liver lesions was similar in tumors with diameter ≤ 2 cm and those with diameter > 2 cm. CONCLUSION: CEUS represents a useful method in clinical practice for differentiating between malignant and benign FLLs detected on standard ultrasonography, and the results of this study are in concordance with previous multicenter studies: DEGUM (Germany) and STIC (France).

Nutritional risk screening and prevalence of malnutrition on admission to gastroenterology departments: a multicentric study.

BACKGROUND AND AIMS: There is little awareness and a lack of data on the prevalence of hospital malnutrition in gastro-enterology departments. Since part of these patients are referred for surgical treatment and poor nutritional status is a known risk factor for perioperative morbidity, we conducted a prospective study aimed to screen for the nutritional risk and assess the prevalence and risk factors of malnutrition in gastro-enterology departments in Romania. METHODS: We included patients consecutively admitted to 8 gastroenterology units over a period of three months in our study. Nutritional risk was evaluated using NRS 2002. Malnutrition was defined using BMI ( 20 kg m2) or and 10% weight loss in the last six months. RESULTS: 3198 patients were evaluated, 51.6% males and 48.4% females, with the mean age of 54.5 Â+- 14.3 years. Overall percentage of patients at nutritional risk was 17.1%, with the highest risk for patients with advanced liver diseases (49.8%), oncologic (31.3%), inflammatory bowel diseases (20.2%), and pancreatic diseases (18.9%). The overall prevalence of malnutrition was of 20.4%, higher for advanced liver diseases (39.4%), inflammatory bowed diseases (30.6%), oncologic (26.8%) and pancreatic diseases (23%). Independent risk factors for malnutrition were younger age (p 0.0001), female gender (p 0.0001), a higher (A ≥ 3) NRS (p 0.0001), presence of neoplasm (p 0.0001), of advanced liver disease (p=0.0003) and a reduction of 25% of dietary intake (p 0.0001). CONCLUSIONS: One in five patients admitted to gastroenterology units could benefit from prompt nutritional intervention. Correction of nutritional status is mandatory before any surgical procedure. Emphasis on nutritional evaluation at admission and beginning of nutritional therapy where needed are particularly required in patients with advanced liver diseases, digestive neoplasms, inflammatory bowel diseases and pancreatic diseases. ABBREVIATIONS: NRS= nutritional risk score, BMI = body mass index, IBD = inflammatory bowel diseases.

McKittrick-Wheelock syndrome: a rare etiology of acute renal failure associated to well-differentiated adenocarcinoma (G1) arising within a villous adenoma.

INTRODUCTION: Large villous adenomas or adenocarcinomas of the rectum can determine secretory diarrhea, associated with a depleting syndrome of prerenal acute renal failure, hyponatremia, hypokalemia, and hypoproteinemia, with favorable prognosis if early detected and properly treated. The syndrome is rare, with approximately 50 cases reported in the literature. AIM: Acute renal failure, caused by fluids and electrolytes hypersecretion, secondary to a malignant rectal villous adenoma is revealed in a 55-year-old patient, admitted with major hydro-electrolytic and acid-base disturbances to our Nephrology Department. CASE PRESENTATION: The 55-year-old male patient had a nine months history of mucous diarrhea, for which he was treated unsuccessfully by GP's and infectionists. The symptomatology aggravated progressively and the patient was admitted through ICU with oligoanuria, severe dehydration and hydro-electrolytic and acid-base disturbances. Rectosigmoidoscopy revealed a giant villous adenoma at the rectum. Conservative therapy initially improved, and finally normalized renal function and made possible surgical resection of the tumor, with an excellent evolution afterwards. CONCLUSIONS: The McKittrick-Wheelock syndrome is a rare, life-threatening condition that requires interdisciplinary medical diagnosis and treatment, but has a good prognosis if renal function is recovered in time and makes possible curative tumoral resection.

Effects of parenteral pharmacological magnesium loading on insulin secretion in experimental thyrotoxicosis.

Thyrotoxicosis is characterised by decreased magnesium pool and also insulin resistance. The present study is evaluating the parameters of glucose metabolism under pharmacological magnesium loading in experimentally induced thyrotoxicosis, in rats. Insulin secretion was significantly increased in thyrotoxicosis compared to controls, expressing probably the status of insulin resistance due to thyroxine excess. After intraperitoneal magnesium infusion, plasma magnesium reached pharmacologically high concentrations and insulin secretion decreased significantly, but this decrease was not accompanied by alterations of glucose homeostasis. In controls, we also found a tendency towards the decrease of insulin secretion after magnesium loading, but it did not reach statistical significance. Thus, insulin secretion seems more sensitive to the inhibitory effects of magnesium overload in experimental thyrotoxicosis.

Parathormone and calcitonin secretion in endemic goiter.

The investigations performed on 160 females of adult age with goiter and clinical signs of spasmophilia followed up the serum and urinary calcium and magnesium. The calcitonin and parathormone circulating levels were also determined. Although the levels of serum and urinary calcium and magnesium appear normal in adult subjects with simple goiter, decreased levels of the circulating parathormone were confirmed in most cases. The values of circulating calcitonin were within normal limits. The moderate hypoparathyroidism noted is an indication of the possible association of "parathyroid dystrophy" with endemic goiter.

Late hypothyroidism following subacute thyroiditis.

The authors followed up the incidence of permanent hypothyroidism in 35 patients with subacute thyroiditis (SAT) in their past history. The investigations were made one to four years after the acute episode. Ten of these presented repeated recurrences despite the therapy with glucocorticoids. The investigations included serum determination by RIA of T4, T3, TSH and thyroglobulin as well as of circulating thyroid antibodies. Permanent hypothyroidism subsequent to SAT occurred in two patients. In one of them it occurred following thyroid surgery performed for repeated recurrences. Both patients presented high levels of circulating thyroglobulin antibodies suggesting a possible transition to autoimmune thyroiditis. In the authors' opinion permanent hypothyroidism is likely to develop after SAT only in association with an autoimmune process or after thyroid surgery.

Calcitonin secretion in thyroid insufficiency.

The level of circulating calcitonin was followed up in 30 patients with severe hypothyroidism, diagnosed clinically and by laboratory examinations. Four of the patients under study had goiter. The complex investigation of phosphorus-calcium metabolism, including radioimmunoassay of calcitonin was made under basal conditions and after calcium loading. The results revealed low basal urinary calcium excretion and an increased skeletal uptake of calcium after loading. Calcitonin secretion persisted in 8 of the patients under basal conditions and it increased after calcium loading in another 14 of them, accounting for the increased "skeletal avidity" for calcium. The persistence of calcitonin secretion supports an earlier clinical observation concerning the relative integrity of the skeleton in patients with hypothyroidism. In the hypothyroid patients with goiter the results do not differ from those obtained in the remaining patients.

Calcitonin secretion in hyperthyroidism.

The level of circulatory calcitonin was determined by the RIA method in 45 hyperthyroid patients in evolution, before and after calcium stimulation or after pentagastrin injection. The basal calcitonin secretion was increased in only 7 of the 45 patients studied, exceeding 500 pg/ml. After a slow calcium loading the mean of calcitonin increased, but with variable individual values. The rapid calcium loading was not followed by significant increases after 30 minutes. After pentagastrin a secretory peak of over 1,800 pg/ml was obtained in 4/5 cases. Results point out the state of the calcitonin-secreting system in hyperthyroidism and its possible role in the skeleton protection in these patients.

Skeletal calcium retention in hyperthyroidism and in vitro calcitonin inactivation.

Studies on patients with severe hyperthyroidism revealed an increased skeletal avidity for calcium, expressed in terms of net retention, after a three-hour i.v. load of 10mg Ca/kg body weight. For the same hyperthyroid subjects the calcitonin inactivating potency of the sera was tested in vitro. The results were expressed as restant hypocalcemic potency of the calcitonin after incubation with the serum fractions. In hyperthyroid subjects two fractions in dilutions of 1:10 reduced the hypocalcemic activity of calcitonin by 75%. In normals this activity appeared only in one fraction. All these results suggest a prompt calcitonin release during calcium infusion which is however less efficient, probably because of the increased amount of calcitonin inactivating factor present in sera. The serum inactivating factor generally contributes to the short-time activity of calcitonin both in normals and in some clinical states with bone calcium imbalance.