Percutaneous ablation in perivascular-HCC: impact of liver parenchyma and characteristics of vascular structures on the outcomes.

AIM: Percutaneous radiofrequency ablation (RFA) is a standard treatment for small-HCC (<3 cm). However, some features such as proximity to intrahepatic vascular structures (perivascular location) seem to be related to short- and long-term outcomes. The aims of the study were to investigate the features related to ablation success and local tumor progression (LTP) in patients submitted to percutaneous ablation for perivascular-HCC. MATERIALS AND METHODS: From January 2010 to May 2021, 132 perivascular-HCC nodules ablated with US-guided single probe percutaneous RFA were retrospectively analyzed. Univariate analysis and multivariable Cox regression model were used to identify factors that were independently related to ablation success and LTP-free survival. RESULTS: The overall ablation success rate was 71.9% (n=95). Morbidity and mortality rates were 4.0% and 0.0%. The features related to ablation success: nodule size (≤20 mm vs. >20 mm) (OR 2.442, p=0.031), major vascular structures diameter (3-5 mm vs ≥ 5 mm) (OR 2.167, p=0.037) and liver parenchyma (cirrhosis vs no-cirrhosis) (OR 2.373, p=0.033). The following features resulted independently related to better LTP-free survival: nodule size ≤20 mm (HR 2.802, p=0.003), proximity to glissonean pedicles (HR 1.677, p=0.028), and major vascular structure diameter <5 mm (HR 1.987, p=0.041). CONCLUSIONS: Perivascular location confirmed to be a difficult and unfavorable indication for percutaneous ablation for HCC nodules. However, perivascular nodules not suitable for surgery with low-risk features (size <20 mm, proximity to glissonian pedicles and vascular diameter <5 mm) may be treated with RFA with satisfactory outcomes.

Defect detection in additively manufactured AlSi10Mg and Ti6Al4V samples using laser ultrasonics and phase shift migration.

Laser ultrasonics (LU) is a non-contact and non-destructive method with a high data acquisition rate, making it a promising candidate for in-situ monitoring of defects in different additive manufacturing (AM) processes, including laser powder bed fusion (LPBF) and directed energy deposition, as well as final part inspection. In order to see the effect of various artificial defect types on an LU sub-surface reconstruction, AlSi10Mg samples with side through-holes, as well as Ti6Al4V samples with bottom blind holes and trapped powder were printed using LPBF, and then ultrasound B-scans of the samples were obtained using an LU system. The resulting scan data was processed using a custom frequency domain phase shift migration (PSM) algorithm, to reconstruct the defects and their locations. Novel ways of pre-processing the B-scan, used as an input to PSM, and taking advantage of its frequency representation, are demonstrated. Newton's method was used to find a stationary phase approximation, used to account in the frequency domain for the fixed offset emitter-receiver arrangement within the PSM calculation. The Newton's method calculation time was reduced by 33%, by using an approximation of the phase function to find an initial guess. The smallest defects that were detected using this method were in the size range between 200 to 300µm for the bottom hole defects, using an 8 ns laser pulse duration. The effect of the laser on the surface of a part being built, and the challenges and further work needed to integrate LU in a LPBF machine for in-situ inspection are discussed.

On the application of sound radiation force for focusing of powder stream in directed energy deposition.

One of the challenges in directed energy deposition via powder feeding (DED-PF) is the powder stream divergence that results in low catchment efficiency (i.e., the fraction of particles added to the melt pool). This article introduces a new ultrasound-based powder focusing method referred to as ultrasound particle lensing (UPL), tailored for powder used in DED-PF. The method uses an ultrasound phased array to produce a small volume of high-intensity ultrasound with the required period averaged sound intensity profile. UPL was used to acoustically focus streams of Ti64 and SS 316L particles with an average size of 89µm and a particle speed of 0.6 m/s, exiting from a DED-PF nozzle analog. The e-1 powder stream widths downstream of the resulting force fields for both materials were reduced by 30%. The experimental results closely match Lagrangian and Eulerian simulations of the process. This novel setup offers the possibility of fast control of the powder stream divergence angle and effective diameter in the process zone during the DED-PF process. This will in turn improve the feature resolution and catchment efficiency of the process.

Burden of an educational program on end of life management in a Internal Medicine ward: a real life report.

BACKGROUND AND AIM: Appropriate end of life (EOL) management in Internal Medicine wards is challanging. The aim of this study was to analyze the burden of an educational program on EOL management in a Internal Medicine ward. Materials and methods: We retrospectively analysed characteristics and management of patients consecutively died in an italian Internal Medicine ward along one year. We compared demographic, co-morbidity, pharmacological treatment in the last 48-hours of life and procedures during hospital stay in patients died six months before and after an educational program on palliative cares and EOL management addressed to a team of physicians and nurses. RESULTS: Study population was composed by 354 patients (190 females), with mean age ± DS 83.5 ± 10.6 years, one half admitted after the educational program. Eighty-four percent of deaths was exepected in the last 48 hours before exitus. Demographic characteristics and causes of hospitalization were not different before and after educational program. After the educational program the sharing of palliative care program with patient, relatives and/or caregivers (97.7% vs 85.8%, p=0.0001) and written order to withdrawal vital parameters relevation (39.5% vs 22%, p=0.0005) significantly increased, while difference in pharmacological classes prescribed in the last 48 hours of life was not find. Blood (54.8% vs 67.2%, p=0.0219) and arterial gas analysis (28.8% vs 39.5%, p=0.0435) samples in the last 48 hours of life were significantly reduced. Radiological and/or endoscopic examinations, red cells or platelets transfusion were reduced and palliative therapy was increased, despite difference between the two periods was not statistically significant. CONCLUSION: Educational program in Internal Medicine wards aimed to improve skills could contribute to make EOL management more appropriate and patient-oriented and it should be strongly encour-aged.

Granuloma piogénico tras blanqueamiento ocular cosmético / Pyogenic granuloma after cosmetic eye whitening

CASO CLÍNICO: Varón caucásico de 46 años con antecedente de hiperemia conjuntival crónica que acude a nuestra clínica 5 años después de realizar el procedimiento quirúrgico de blanqueamiento ocular cosmético. En la exploración observamos granuloma piógeno en el ojo derecho, además de uveítis anterior no granulomatosa aguda y escleritis necrosante en ambos ojos. RESULTADO: Se realizó una evaluación clínica con exclusión de enfermedades sistémicas completas. El granuloma piógeno se trató con resección quirúrgica y la uveítis anterior y escleritis necrosante se trataron con éxito con corticoesteroides sistémicos y metotrexato. CONCLUSIÓN: El blanqueamiento ocular cosmético quirúrgico podría tener como complicación el granuloma piógeno además de la escleritis necrosante y la uveítis anterior no granulomatosa y presentarse 5 años después del procedimiento. La resección quirúrgica es un tratamiento exitoso para esta presentación de granuloma piógeno

CLINICAL CASE: A 46-year-old caucasian male with a history of chronic conjunctival hyperemia, presented at our clinic 5 years after he underwent the surgical procedure of cosmetic eye whitening. On examination we observed pyogenic granuloma in the right eye; besides acute nongranulomatous anterior uveitis and necrotizing scleritis in both eyes. RESULT: Complete clinical evaluation and full work-up exclusion of systemic diseases was done. The pyogenic granuloma was treated with surgical resection, as well as anterior uveitis and necrotizing scleritis were successfully treated with systemic corticoesteroids and methotrexate. CONCLUSION: The surgical cosmetic eye whitening could have as complication the pyogenic granuloma in addition to necrotizing scleritis and nongranulomatous anterior uveitis; and be present 5 years after the procedure. The surgical resection is a successful treatment for this presentation of pyogenic granuloma

Pyogenic granuloma after cosmetic eye whitening. / Granuloma piogénico tras blanqueamiento ocular cosmético.

CLINICAL CASE: A 46-year-old caucasian male with a history of chronic conjunctival hyperemia, presented at our clinic 5 years after he underwent the surgical procedure of cosmetic eye whitening. On examination we observed pyogenic granuloma in the right eye; besides acute nongranulomatous anterior uveitis and necrotizing scleritis in both eyes. RESULT: Complete clinical evaluation and full work-up exclusion of systemic diseases was done. The pyogenic granuloma was treated with surgical resection, as well as anterior uveitis and necrotizing scleritis were successfully treated with systemic corticoesteroids and methotrexate. CONCLUSION: The surgical cosmetic eye whitening could have as complication the pyogenic granuloma in addition to necrotizing scleritis and nongranulomatous anterior uveitis; and be present 5 years after the procedure. The surgical resection is a successful treatment for this presentation of pyogenic granuloma.

Rapid microbiological tests for bloodstream infections due to multidrug resistant Gram-negative bacteria: therapeutic implications.

BACKGROUND: Treating severe infections due to multidrug-resistant Gram-negative bacteria (MDR-GNB) is one of the most important challenges for clinicians worldwide, partly because resistance may remain unrecognized until identification of the causative agent and/or antimicrobial susceptibility testing (AST). Recently, some novel rapid test for identification and/or AST of MDR-GNB from positive blood cultures or the blood of patients with bloodstream infections (BSIs) have become available. OBJECTIVES: The objective of this narrative review is to discuss the advantages and limitations of different rapid tests for identification and/or AST of MDR-GNB from positive blood cultures or the blood of patients with BSI, as well as the available evidence on their possible role to improve therapeutic decisions and antimicrobial stewardship. SOURCES: Inductive PubMed search for publications relevant to the topic. CONTENT: The present review is structured in the following way: (a) rapid tests on positive blood cultures; (b) rapid tests directly on whole blood; (c) therapeutic implications. IMPLICATIONS: Novel molecular and phenotypic rapid tests for identification and AST show the potential for favourably influencing patients' outcomes and results of antimicrobial stewardship interventions by reducing both the time to effective treatment and the misuse of antibiotics, although the interpretation about their impact on actual therapeutic decisions and patients' outcomes is still complex. Factors such as feasibility and personnel availability, as well as the detailed knowledge of the local microbiological epidemiology, need to be considered very carefully when implementing novel rapid tests in laboratory workflows and algorithms. Providing high-level, comparable evidence on the clinical impact of rapid identification and AST is becoming of paramount importance for MDR-GNB infections, since in the near future rapid identification of specific resistance mechanisms could be crucial for guiding rapid, effective, and targeted therapy against specific resistance mechanisms.

Multimodal retinal imaging in central serous chorioretinopathy treated with oral eplerenone or photodynamic therapy.

PurposeTo correlate function and structural optical coherence tomography (OCT) to optical coherence tomography angiography (OCT-A) measures in patients affected by central serous chorioretinopathy (CSC) and to describe their changes after treatments (ie oral eplerenone, half-fluence photodynamic therapy (PDT)).Patients and methodsTwenty eyes of 16 consecutive patients with treatment-naïve CSC undergoing either eplerenone or PDT were enrolled in this prospective, observational study. All patients underwent structural OCT and OCT-A at baseline and after therapy at months 1 and 3.ResultsEleven eyes of nine patients and nine eyes of seven patients underwent eplerenone or PDT treatment, respectively. Central macular thickness (CMT) and subretinal fluid (SRF) correlated to fovea avascular zone (FAZ) area (r=0.74 and r=0.71, P=0.01) and vessel density (r=0.77 and r=0.68, P=0.01) at deep capillary plexus (DCP). CMT (P=0.0011), SRF (P=0.0005), SFCT (P=0.0016), FAZ area at DCP (P=0.0334) improved at 3-month visit. A significant reduction of deep FAZ area was appreciated in eplerenone (P=0.0204) but not in PDT (P=0.5) group. SFCT reduction was significantly higher in PDT than eplerenone group (P=0.0347).ConclusionStructural and vascular parameters are correlated in CSC and they improve after different treatments. Both half-fluence PDT and oral eplerenone do not permanently damage choriocapillaris or other choroidal layers as evaluated by OCT-A.

Choroidal excavation in choroidal osteoma complicated by choroidal neovascularization.

PurposeTo describe multimodal imaging features of choroidal osteoma (CO) complicated by choroidal neovascularization (CNV) and focal choroidal excavation (FCE).MethodsPatients presenting with CO and CNV between January and October 2016 were considered for this study. Diagnosis of CO was confirmed by ultrasound examination. All patients underwent multimodal imaging including optical coherence tomography (OCT), swept-source OCT angiography (DRI OCT Triton, Topcon, Inc., Tokyo, Japan) and fluorescein angiography (Spectralis HRA+OCT; Heidelberg Engineering, Heidelberg, Germany).ResultsTwo patients (one with bilateral CO) were included in the study. OCT showed a FCE in two eyes of two patients (one in correspondence of the CNV and the other adjacent to the CNV). OCT-A demonstrated presence of microvascular flow within neovascular network of the CNVs. Decalcification of the tumor was noted in correspondence of one eye with FCE.ConclusionsFCE may be found in eyes with choroidal osteoma and CNV. OCT-A was a valuable tool for detection of CNV complicating choroidal osteoma. Decalcification of choroidal osteoma may represent a common pathogenic pathway for development of FCE and CNV in choroidal osteoma.

Optical coherence tomography analysis of evolution of Bruch's membrane features in angioid streaks.

PurposeTo describe optical coherence tomography (OCT) features in the Bruch's membrane (BM) of eyes with angioid streaks (AS) and evaluate their evolution over the follow-up.Patients and methodsPatients with AS presenting between March 2016 and September 2016 at two tertiary referral centers were consecutively recruited in this study. Eligibility criteria included prior spectral domain (SD)-OCT images, taken at least 3 months before at the same referral center, with automated eye tracking and image alignment modules. Alterations of BM were described and compared to previous scans over the follow-up. Multimodal imaging was used to identify alteration of retinal pigment epithelium (RPE) and choroid.ResultsThirty-two eyes of 16 consecutive patients with AS were included. BM undulations, mostly observed around the optic nerve head, were found in 19 (59.4%) of 32 eyes. BM breaks were found in 31 (96.9%) out of 32 eyes. Evolution of BM undulations into BM breaks was observed in 5 eyes (15.6%). Choroidal neovascularization (CNV) was observed in 12 eyes (37.5%) during follow-up, typically in areas of BM interruption.ConclusionsBM undulations, probably caused by high stretching forces exerted on the BM around the optic nerve head, seem to precede some BM breaks. BM interruptions may be a preferred way for the growth of CNV, which was identified in one-third of our cases.

Previous bloodstream infections due to other pathogens as predictors of carbapenem-resistant Klebsiella pneumoniae bacteraemia in colonized patients: results from a retrospective multicentre study.

INTRODUCTION: the purpose of this retrospective multicenter study was to assess whether the risk of developing bloodstream infections (BSI) due to carbapenem-resistant Klebsiella pneumoniae (CRKP) in colonized patients is influenced by the occurrence of BSI due to other pathogens. METHODS: from January 2012 to March 2014, all patients with at least one rectal swab positive for CRKP and at least 30 days of previous hospital stay were included in the study. The primary outcome measure was CRKP BSI, defined as a time-to-event endpoint. The role of potential predictors was evaluated through univariable and multivariable Cox regression analyses, considering previous BSI as a time-dependent variable. RESULTS: during the study period, 353 patients met the inclusion criteria. Thirty-seven developed a CRKP BSI (11%). A higher incidence of CRKP BSI was observed in presence rather than in absence of previous BSI. In the final multivariable model of risk factors for CRKP BSI, multisite colonization (hazard ratio [HR] 13.73, 95% confidence intervals [CI] 3.29-57.32, p < 0.001), ICU stay (HR 3.14, 95% CI 1.19-8.31, p = 0.021), and previous BSI (p = 0.026, with the overall effect being mainly due to Enterococcus spp. BSI vs absence of BSI, HR 6.62, 95% CI 2.11-20.79) were associated with the development of CRKP BSI, while an inverse association was observed for age (HR 0.98, 95% CI 0.95-1.00, p = 0.027). CONCLUSIONS: previous BSI due to other pathogens were associated with an increased risk of CRKP BSI that was independent of other factors in colonized patients with prolonged hospital exposure.

Lower sensitivity of serum (1,3)-ß-d-glucan for the diagnosis of candidaemia due to Candida parapsilosis.

The aim of this study was to evaluate the sensitivity and the levels of 1,3-ß-d-glucan (BDG) among patients with candidaemia due to different Candida species. Retrospective study of all patients who had a single-species candidaemia and BDG testing performed within 48 h from the onset of candidaemia during 2009-2015 was performed. Factors influencing the sensitivity of BDG, including the presence of a central venous catheter, antifungal therapy and Candida species, were analysed in univariate and multivariate models. In all, 107 patients with the following Candida distribution were included: 46 (43%) Candida albicans, 37 (35%) Candida parapsilosis, and 24 (22%) other species. BDG sensitivity and levels were the highest in C. albicans candidaemia and lowest for C. parapsilosis (respectively, 72% and 410 pg/mL for C. albicans, 41% and 39 pg/mL for C. parapsilosis, and 63% and 149 pg/mL for other species; p 0.015 and p 0.003). In multivariate analysis, Candida species (parapsilosis versus others) was the only factor influencing the sensitivity of BDG (OR 0.3, 95% CI 0.1-0.7, p 0.006). The sensitivity of BDG in candidaemia seems highly dependent on the fungal species, with the lowest being for C. parapsilosis.

Risk factors for bloodstream infections due to colistin-resistant KPC-producing Klebsiella pneumoniae: results from a multicenter case-control-control study.

The increasing prevalence of colistin resistance (ColR) Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae (Kp) is a matter of concern because of its unfavourable impact on mortality of KPC-Kp bloodstream infections (BSI) and the shortage of alternative therapeutic options. A matched case-control-control analysis was conducted. The primary study end point was to assess risk factors for ColR KPC-Kp BSI. The secondary end point was to describe mortality and clinical characteristics of these infections. To assess risk factors for ColR, 142 patients with ColR KPC-Kp BSI were compared to two controls groups: 284 controls without infections caused by KPC-Kp (control group A) and 284 controls with colistin-susceptible (ColS) KPC-Kp BSI (control group B). In the first multivariate analysis (cases vs. group A), previous colistin therapy, previous KPC-Kp colonization, ≥3 previous hospitalizations, Charlson score ≥3 and neutropenia were found to be associated with the development of ColR KPC-Kp BSI. In the second multivariate analysis (cases vs. group B), only previous colistin therapy, previous KPC-Kp colonization and Charlson score ≥3 were associated with ColR. Overall, ColR among KPC-Kp blood isolates increased more than threefold during the 4.5-year study period, and 30-day mortality of ColR KPC-Kp BSI was as high as 51%. Strict rules for the use of colistin are mandatory to staunch the dissemination of ColR in KPC-Kp-endemic hospitals.

DNA bacterial load in children with bacteremic pneumococcal community-acquired pneumonia.

This study was conducted to evaluate the association between pneumococcal DNA load and parapneumonic pleural effusion (PPE) in children with community-acquired pneumonia. Bacterial load was quantified and related to the presence of PPE with or without empyema in 72 otherwise healthy children aged ≤5 years who were hospitalised because of radiographically confirmed CAP and showed a real-time polymerase chain reaction that was positive for Streptococcus pneumoniae. The proportion of children with a high bacterial load (i.e. ≥265 DNA copies/mL) was larger among the subjects with PPE than those without it. Multivariate analysis showed that a high bacterial load was significantly associated with PPE (OR 8.65; 95% CI 1.10-67.8 vs a bacterial load of <125 copies/mL). Children with infection due to pneumococcal serotype 19A were at highest risk of developing PPE (OR 7.44; 95% CI 1.10-50.4 vs all other typeable serotypes). The patients with CAP due to pneumococcal serotypes that are not included in the 13-valent conjugate vaccine (PCV13) were more frequently affected by PPE than those with infections associated with serotypes included in the vaccine, except for serotype 19A. Bacterial loads of ≥265 DNA copies/mL are significantly associated with PPE, and serotype 19A is significantly associated with a high bacterial load and the development of PPE. The mean bacterial load of the patients with empyema was higher than that of patients with simple PPE. Although further studies are required, it seems that serotypes not included in PCV13 can play a major role in causing a higher bacterial load and PPE.

Jet or intensive care unit ventilator during simulated percutaneous transtracheal ventilation: a lung model study.

BACKGROUND: Percutaneous transtracheal ventilation (PTV) via a jet ventilator (PTJV) is considered a rescue technique in difficult airway management. However, whether a conventional ventilator can generate adequate ventilation via PTV is not known. Our goal was to evaluate the tidal volume (V(T)) generated by a conventional ventilator during simulated PTV compared with PTJV in a lung model. METHODS: A lung model simulating an adult lung was used. A catheter was inserted through the artificial trachea and connected to either a jet ventilator or a conventional ventilator. The direction of catheter insertion was perpendicular to the trachea, pointing towards the lung and away from the lung. The jet ventilator was operated at 344.7 kPa. The conventional ventilator was operated in the pressure mode at peak inspiratory pressures of 40-90 cm H(2)O. RESULTS: The jet ventilator generated larger V(T) [817 (336) ml] when the catheter was pointing towards the lung than when pointing away from the lung or perpendicular to the trachea [121 (41) and 69 (24) ml, respectively, P<0.01]. With the conventional ventilator, changes in V(T) at different direction of catheter insertion were much less [222 (81) ml catheter pointing towards the lung, 229 (121) ml perpendicular to the trachea, and 187 (97) ml away from the lung]. CONCLUSIONS: Our result demonstrated that PTJV was effective only when the catheter was pointing towards the lung and requires high operating pressure. A conventional ventilator can generate reasonable minute ventilation through the transtracheal catheter less dependent on directions of catheter insertion and should be considered during emergent PTV.

Cytokine genetic profile in Whipple's disease.

Whipple's disease (WD) is a very rare chronic systemic condition characterised by a Th2/T regulatory (Treg) dysregulated immune response versus Tropheryma whipplei, a bacterium widely diffuse in the environment. To investigate whether this Th2/Treg polarised response has a genetic background, we investigated the Th1, Th2, Th17 and Treg cytokine genetic profile of 133 patients with WD. Thanks to the European Consortium on WD (QLG1-CT-2002-01049), the polymorphism of 13 cytokine genes was analysed in 111 German and 22 Italian patients using the polymerase chain reaction with sequence-specific primers (PCR-SSP) technique. The frequencies of the genotypes, haplotypes and functional phenotypes were compared with those obtained in 201 German and 140 Italian controls. Clinical heterogeneity was also considered. Functionally, WD patients may be considered as low producers of TGF-ß1, having an increased frequency of the genotype TGF-ß1+869C/C,+915C/C [12.3 % vs. 3.81 %, odds ratio (OR) = 4.131, p = 0.0002] and high secretors of IL-4, carrying the genotype IL-4-590T/T (5.34 % vs. 1.17 %, OR = 5.09, p = 0.0096). No significant association was found between cytokine polymorphism and clinical variability. Analogously to the recent cellular findings of a Th2/Treg polarised response, we showed that the cytokine genetic profile of WD patients is skewed toward a Th2 and Treg response. This was similar in both German and Italian populations. However, the significant deviations versus the controls are poorer than that expected on the basis of these recent cellular findings.