Impact of controlled attenuation parameter on detecting fibrosis using liver stiffness measurement.

BACKGROUND: Liver fibrosis is often accompanied by steatosis, particularly in patients with non-alcoholic fatty liver disease (NAFLD), and its non-invasive characterisation is of utmost importance. Vibration-controlled transient elastography is the non-invasive method of choice; however, recent research suggests that steatosis may influence its diagnostic performance. Controlled Attenuation Parameter (CAP) added to transient elastography enables simultaneous assessment of steatosis and fibrosis. AIM: To determine how to use CAP in interpreting liver stiffness measurements. METHODS: This is a secondary analysis of data from an individual patient data meta-analysis on CAP. The main exclusion criteria for the current analysis were unknown aetiology, unreliable elastography measurement and data already used for the same research question. Aetiology-specific liver stiffness measurement cut-offs were determined and used to estimate positive and negative predictive values (PPV/NPV) with logistic regression as functions of CAP. RESULTS: Two thousand and fifty eight patients fulfilled the inclusion criteria (37% women, 18% NAFLD/NASH, 42% HBV, 40% HCV, 51% significant fibrosis ≥ F2). Youden optimised cut-offs were only sufficient for ruling out cirrhosis (NPV of 98%). With sensitivity and specificity-optimised cut-offs, NPV for ruling out significant fibrosis was moderate (70%) and could be improved slightly through consideration of CAP. PPV for significant fibrosis and cirrhosis were 68% and 55% respectively, despite specificity-optimised cut-offs for cirrhosis. CONCLUSIONS: Liver stiffness measurement values below aetiology-specific cut-offs are very useful for ruling out cirrhosis, and to a lesser extent for ruling out significant fibrosis. In the case of the latter, Controlled Attenuation Parameter can improve interpretation slightly. Even if cut-offs are very high, liver stiffness measurements are not very reliable for ruling in fibrosis or cirrhosis.

Cat-scratch disease in Northern Italy: atypical clinical manifestations in humans and prevalence of Bartonella infection in cats.

In this paper, we report an investigation on cat-scratch disease (CSD) in Northern Italy. Seventy-four cases of CSD were diagnosed at the San Matteo hospital, Pavia, during the period 2005-2010. Of these 74 patients, 18 (24.3 %) reported atypical clinical manifestations such as ocular papillitis, maculopapular eruptions, vertebral infection, pulmonary infiltrates, and granulomatous hepatitis. Contact with cats was documented for 61 patients (82.4 %), while cat-related trauma was reported for 49 patients (66.2 %). We subsequently investigated the presence of Bartonella infection in cats belonging to the above patients and in other domestic and stray cats from three provinces of Northern Italy. Among the 27 domestic cats tested, nine of the 11 belonging to the CSD patients and two of the remaining 16 were infected by B. henselae (81.8 % vs. 12.5 %). Out of over 1,300 stray cats examined, 23.1 % were seropositive for B. henselae; after culturing and genotyping, 17 % were found to be infected by B. henselae (15.5 %) or B. clarridgeiae (1.5 %).

Ex vivo assessment of serum cytokines in patients with cystic echinococcosis of the liver.

To investigate the usefulness of serum cytokine levels in the diagnosis of active cystic echinococcosis, we evaluated the cytokine profile of patients with hepatic cystic echinococcosis in different cyst stages, CE 1-2 (active), CE3a-3b (transitional) and CE4-5 (inactive). Ex vivo assessment of Th1 (IL12, TNFalpha) and Th2 (IL4, IL10) cytokines in sera was carried out using ELISA. Percentages of positive samples and median levels of IL12, TNFalpha and IL10 did not differ significantly between groups. However, patients with CE3b cysts, a stage clinically unresponsive to treatments, had statistically significantly higher median levels of IL4 and percentage of positive samples for IL4. We conclude that the analysis of serum cytokine dosage, at least in its present form, is not useful as a marker of cyst activity. However, our results support recent findings suggesting the chronic activity of CE3b cysts and suggest that this might be partly because of a skewed Th2 response.

Contrast-enhanced ultrasound in planning thermal ablation of liver metastases: Should the hypervascular halo be included in the ablation volume?().

INTRODUCTION: Liver metastases often exhibit a hypervascular halo during the arterial phase of contrast-enhanced ultrasonography (CEUS). This finding has no correlates on baseline gray-scale imaging, and it has never been characterized. The aim of this study was to identify the features of this halo and determine whether it should be included in the ablation volume during thermal ablation procedures. MATERIALS AND METHODS: We prospectively enrolled 25 patients referred to our department for thermal ablation of liver metastases. Before treatment all patients underwent CEUS, and the maximum diameter of the metastatic lesion was measured before administration of the ultrasound contrast agent and during the arterial and portal venous phases of the contrast contrast-enhanced study. Maximum diameters in the different vascular phases were compared with the Turkey-Kramer test. Two biopsies were obtained from each lesion with a 21-gauge needle: 1) one from the center of the metastasis to confirm the diagnosis and 2) one from the hypervascular peripheral halo identified in the arterial phase at CEUS. RESULTS: The mean (±standard deviation) maximum lesion diameter was 2.67 ± 1.2 cm before contrast agent injection, 3.50 ± 1.4 cm during the arterial phase, and 2.71 ± 1.2 cm during the venous phase. The difference between maximum diameters measured before contrast enhancement and in the arterial phase was highly significant (mean: 0.84 ± 0.45 cm, p < 0.0001). Histological examination of halo specimens revealed inflammatory infiltrates with no evidence of tumor infiltration in 24/25 (96%) cases and normal hepatic parenchymal tissue in the 25th specimen. DISCUSSION: The hypervascular halo surrounding liver metastases during the arterial phase of CEUS represents a chronic inflammatory infiltrate, not tumor infiltration. However, since chronic inflammation appears to promote neovascularization and the production of tumoral growth factors, it seems wise to include the hypervascular halo in the intended-to-treat volume when planning the ablation procedure.

A simple sonographic scoring system combined with routine serology is useful in differentiating parasitic from non-parasitic cysts of the liver().

In the absence of a detached endocyst, unilocular echinococcal cysts of the liver may be difficult to distinguish from non-parasitic cysts. In an attempt to identify sonographic features that could help distinguish these two types of cysts, we retrospectively analyzed 64 cases of fluid-filled hepatic cysts whose parasitic nature was ultimately excluded. This experience allowed us to develop a simple scoring system that quantifies the likelihood that hepatic cysts are non-parasitic. Sonographic criteria, together with the results of standard serological testing for cystic echinococcosis, proved to be sufficiently specific to allow definitive diagnosis without resorting to further tests.

Percutaneous and surgical treatment of pyogenic liver abscesses: observation over a 21-year period in 148 patients.

BACKGROUND: Percutaneous drainage of pyogenic liver abscess has become first-line treatment. In the past surgical drainage was preferred in some centres. AIM: The aim of this retrospective study was to assess the effectiveness of percutaneous treatments and surgical drainage, in terms of treatment success, hospital stay and costs. PATIENTS: Data of 148 patients (90 males; 58 females; mean age, 61 yrs; range, 30-86 yrs) were retrospectively analysed. METHODS: Patients' outcomes, including the length of hospital stay, procedure-related complications, treatment failure and death, were recorded. Multiple logistic regression model was used for statistical analysis. RESULTS: One hundred and four patients (83 with solitary and 21 with multiple abscesses) were treated percutaneously, either by needle aspiration (91 patients) or catheter drainage (13 patients) depending on the abscess's size, and 44 patients (30 with solitary and 14 with multiple abscesses) were treated surgically. There was no statistically significant difference in patients' demographics or abscess characteristics between groups. Hospital stay was longer, and costs were higher in patients treated surgically (p<0.001). There was statistically significant difference in morbidity rate between groups (p<0.001). No death occurred in both groups. CONCLUSIONS: Percutaneous and surgical treatment of pyogenic liver abscesses are both effective, nevertheless percutaneous drainage carries lower morbidity and is cheaper.

The current role of abdominal ultrasound in the clinical management of patients with AIDS.

Patients with AIDS present a wide variety of clinical manifestations through involvement of various organs. Ultrasonography (US) is easy to perform, safe, inexpensive, not invasive and repeatable. Those features are crucial for AIDS patients, who in industrialised countries are now mostly seen on an outpatient basis thanks to the introduction of Highly Active Antiretroviral Therapy. US can investigate most of the organs affected in AIDS and can guide biopsies, allowing the cyto-histological and microbiological investigations needed for a definitive diagnosis. This paper reviews the wide variety of applications of abdominal US and stresses its importance in the management of a complex and changing condition, particularly in settings where other more expensive imaging techniques are not--and will not be for a long time--available. The increasing use of portable/hand-carried scanners further adds to the value of the technique in such settings. With new treatments, prevalence and morbidity/mortality rates change, but new conditions and new side effects appear. US applications to these new conditions are discussed as well.

[Overview of therapeutic options for cystic echinococcosis]. / Attualità in tema di terapia dell'echinoccocosi cistica.

Surgical excision of echinococcal cyst has long been considered the only effective treatment for echinococcosis. However, the remarkable advances in imaging techniques, particularly ultrasound, made during the past 25 years have greatly facilitated diagnosis, treatment and follow-up. Today, chemotherapy and percutaneous treatments have become widely available. A major step forward in management of the disease came in 2001, when the WHO International Working Group on Echinococcosis (WHO-IWGE) came to a consensus by developing a standardized classification of ultrasound images in cystic echinococcosis. Thus, the most appropriate treatment for patients affected by this serious and sometimes life-threatening disease may now be chosen. An overview of the three main therapeutic options for abdominal- and particularly hepatic-cystic echinococcosis is presented, with focus on the indications and contraindications of each one. Data from long-term follow-up studies are also discussed, with emphasis on the resulting stage-specific criteria for treatment.

Twenty years of percutaneous treatments for cystic echinococcosis: a preliminary assessment of their use and safety.

Image-guided percutaneous treatments for echinococcal cysts were introduced in the mid-eighties. Today they represent a third therapeutic option, after surgery and benzimidazole derivatives. Two types of percutaneous treatments are available, based on the destruction of the germinal layer or the evacuation of the endocyst. To assess the extent of their use and their safety, a Medline search of the literature on this subject was performed. The number of cysts treated, their anatomical sites, the complications and, length of follow-up (when available), were all examined. The results show that percutaneous treatments for cystic echinococcosis are safe and efficacious in selected anatomical sites, provided basic safety issues are correctly addressed. However, before drawing final conclusions, a more detailed analysis of the literature is needed. Percutaneous treatments could be simplified and made more effective if a scolecidal agent could be found that melts the entire endocyst without causing harm to the biliary epithelium.

Ultrasound-guided fine needle biopsy of the spleen: high clinical efficacy and low risk in a multicenter Italian study.

The aim of this study was to evaluate the clinical efficacy and safety of the ultrasound-guided fine needle biopsy (UG-FNB) of the spleen in a large population of patients. We collected retrospectively the findings concerning the application of UG-FNB of the spleen from eight Italian clinical centers that utilized this technique for at least ten years. A data schedule was sent to all centers to collect information about techniques, results, and complications of UG-FNB of the spleen. We analyzed 398 biopsy procedures both on focal lesions (257 cases) and on splenic parenchyma (141 cases). The overall accuracy was 90.9% for the series as a whole, 84.9% for cytological sampling, 88.3% for microhistological sampling, and 90.3% for both cytological and histological sampling (double biopsy). Tissue core biopsy yielded better overall accuracy in patients with suspected splenic involvement by lymphoma (90.9% vs. 68.5% for cytology). The complication rate was low (no death cases, less than 1% for major complications, and 5.2% for all complications). No predictive factors were able to detect high-risk situations. The operator's skill (higher number of performed procedures) was significantly related to better overall accuracy. Conversely, the complication rate was not affected. UG-FNB of the spleen is a very effective diagnostic procedure with low risk for the patient. Aspiration cytology and core needle biopsy showed similar diagnostic yields, except for the diagnosis of splenic lymphoma, in which core needle biopsy obtained better results.