Radiology of fibrosis part III: genitourinary system.

Fibrosis is a pathological process involving the abnormal deposition of connective tissue, resulting from improper tissue repair in response to sustained injury caused by hypoxia, infection, or physical damage. It can impact any organ, leading to their dysfunction and eventual failure. Additionally, tissue fibrosis plays an important role in carcinogenesis and the progression of cancer.Early and accurate diagnosis of organ fibrosis, coupled with regular surveillance, is essential for timely disease-modifying interventions, ultimately reducing mortality and enhancing quality of life. While extensive research has already been carried out on the topics of aberrant wound healing and fibrogenesis, we lack a thorough understanding of how their relationship reveals itself through modern imaging techniques.This paper focuses on fibrosis of the genito-urinary system, detailing relevant imaging technologies used for its detection and exploring future directions.

Prognostic Impact of Atrial Fibrillation Pattern and other Clinical Biomarkers in Patients with Stroke Admitted in a Tertiary Hospital in Cebu City from 2015-2022.

Background: The effect of atrial fibrillation (AF) patterns and clinical biomarkers among patients with AF-related stroke is still controversial. Objectives: The objective of this study is to determine the association of the pattern of AF and markers on routine blood tests with the outcome of patients after an AF-related stroke. Methods: This is a retrospective cohort study of patients with stroke and AF admitted in a tertiary hospital in Cebu City from 2015-2022. Patients' baseline characteristics, laboratory tests, ECG, and radiologic data were collected. Descriptive statistics such as mean and frequency were computed. The Kaplan-Meier method and the log-rank test were used to calculate the incidence time. The Cox regression analysis was used to determine factors associated with survival. A stepwise regression technique was used in model building. Results: The mortality rate of patients with AF-related stroke was 0.02. A Kaplan Meier survival estimate shows that patients with paroxysmal AF have better survival. Upon model building of variables, age, red cell distribution width (RDW), neutrophil-to-lymphocyte ratio (NLR), platelet count, low density lipid cholesterol (LDL-C), and pattern of AF were predictive of mortality in patients with AF-related stroke. Conclusions: Among AF-related stroke patients admitted at a tertiary hospital in Cebu City, pattern of AF, age, RDW, NLR, platelet count, and LDL-C were associated with mortality. The parameters associated with increased mortality could be easily assessed using an ECG, CBC, and lipid profile. These are all readily available and cost-efficient.

Post-COVID-19 Unilateral Upper Lip Numbness: A Case Report.

This is a case of a 63-year-old female with post-COVID-19 unilateral upper lip pain and numbness. Neurologic examination did not reveal any deficits other than deficits on pinprick in the maxillary division (V2) of the left trigeminal nerve. Brain neuroimaging showed signs of acute inflammation of the left maxillary sinus. Neuropraxia of the infraorbital nerve, a branch of the trigeminal nerve, was the diagnosis considered. Reports on trigeminal neurosensory changes following acute sinusitis are few, and isolated trigeminal neuropathy is rare except in cases of dental disorders. Up to this writing, there have been no reports on post-COVID-19 unilateral upper lip numbness and pain. This study will also serve as a concise review on the correlative neuroanatomy of the trigeminal nerve.

Predictors for Hemorrhagic Transformation among Patients with Ischemic Stroke Admitted in a Tertiary Hospital in the Philippines from July 2018-July 2019.

Background: Among the multiple scoring systems for hemorrhagic transformation, only few of these address spontaneous hemorrhagic transformation after an ischemic stroke, with most done with Western population data. Objectives: This study aims to identify the predictors for hemorrhagic transformation among patients with ischemic stroke admitted in a tertiary hospital in Cebu City, Philippines. Methods: This is a retrospective cohort study of patients with ischemic stroke admitted in a tertiary hospital in Cebu City. Patients' baseline characteristics, clinical, and radiologic data were collected. Chi square test and t-test were used to determine which variables were significantly different between patients with and without hemorrhagic transformation. Odds ratio (OR) and 95% confidence interval (CI) were determined to measure the association between the different variables and hemorrhagic transformation. Results: A total of 500 ischemic stroke patients were included in the study. There were 28 (6%) ischemic stroke patients with Hemorrhagic Transformation. The mean age of these patients is 66.93 ± 12.42 years, 48.8% male, 10.8% had atrial fibrillation, and 2.4% had myocardial infarction. Controlling for the effect of confounders, white blood cell count (OR 1.11; 95% CI 1.03-1.19), myocardial infarction (OR 5.25; 95% CI 1.13-24.34), and presence of brain edema (OR 2.86; 95% CI 1.05-7.80) were significant predictors of hemorrhagic transformation. Conclusion: White blood cell count, presence of brain edema, and myocardial infarction were significantly associated with hemorrhagic transformation among ischemic stroke patients.

Radiology of fibrosis. Part I: Thoracic organs.

Sustained injury from factors such as hypoxia, infection, or physical damage may provoke improper tissue repair and the anomalous deposition of connective tissue that causes fibrosis. This phenomenon may take place in any organ, ultimately leading to their dysfunction and eventual failure. Tissue fibrosis has also been found to be central in both the process of carcinogenesis and cancer progression. Thus, its prompt diagnosis and regular monitoring is necessary for implementing effective disease-modifying interventions aiming to reduce mortality and improve overall quality of life. While significant research has been conducted on these subjects, a comprehensive understanding of how their relationship manifests through modern imaging techniques remains to be established. This work intends to provide a comprehensive overview of imaging technologies relevant to the detection of fibrosis affecting thoracic organs as well as to explore potential future advancements in this field.

Radiology of fibrosis part II: abdominal organs.

Fibrosis is the aberrant process of connective tissue deposition from abnormal tissue repair in response to sustained tissue injury caused by hypoxia, infection, or physical damage. It can affect almost all organs in the body causing dysfunction and ultimate organ failure. Tissue fibrosis also plays a vital role in carcinogenesis and cancer progression. The early and accurate diagnosis of organ fibrosis along with adequate surveillance are helpful to implement early disease-modifying interventions, important to reduce mortality and improve quality of life. While extensive research has already been carried out on the topic, a thorough understanding of how this relationship reveals itself using modern imaging techniques has yet to be established. This work outlines the ways in which fibrosis shows up in abdominal organs and has listed the most relevant imaging technologies employed for its detection. New imaging technologies and developments are discussed along with their promising applications in the early detection of organ fibrosis.

Percutaneous radiofrequency ablation of ovarian cancer metastasis in the spleen: a therapeutic option to consider.

Splenic metastasis are rare clinical entities developing in less than 1% of all metastatic cancers and usually in the setting of disseminated disease. To date, splenectomy is traditionally the first line therapy in patient with splenic metastasis, however non-surgical therapies have been reported. Here we described the case of a 57-year-old patient with splenic metastasis from ovarian cancer successfully treated by percutaneous radiofrequency ablation. Furthermore, we performed a literature systematic review of the cases of splenic metastases treated by thermal ablation.

Water reuse of treated domestic wastewater in agriculture: Effects on tomato plants, soil nutrient availability and microbial community structure.

The reuse of treated wastewater (TWW) in agriculture for crop irrigation is desirable. Crop responses to irrigation with TWW depend on the characteristics of TWW and on intrinsic and extrinsic soil properties. The aim of this study was to assess the response of tomato (Solanum lycopersicum L.) cultivated in five different soils to irrigation with TWW, compared to tap water (TAP) and an inorganic NPK solution (IFW). In addition, since soil microbiota play many important roles in plant growth, a metataxonomic analysis was performed to reveal the prokaryotic community structures of TAP, TWW and IFW treated soil, respectively. A 56-days pot experiment was carried out. Plant biometric parameters, and chemical, biochemical and microbiological properties of different soils were investigated. Shoot and root dry and fresh weights, as well as plant height, were the highest in plants irrigated with IFW followed by those irrigated with TWW, and finally with TAP water. Plant biometric parameters were positively affected by soil total organic carbon (TOC) and nitrogen (TN). Electrical conductivity was increased by TWW and IFW, being such an increase proportional to clay and TOC. Soil available P was not affected by TWW, whereas mineral N increased following their application. Total microbial biomass, as well as, main microbial groups were positively affected by TOC and TN, and increased according to the following order: IFW > TWW > TAP. However, the fungi-to-bacteria ratio was lowered in soil irrigated with TWW because of its adverse effect on fungi. The germicidal effect of sodium hypochlorite on soil microorganisms was affected by soil pH. Nutrients supplied by TWW are not sufficient to meet the whole nutrients requirement of tomato, thus integration by fertilization is required. Bacteria were more stimulated than fungi by TWW, thus leading to a lower fungi-to-bacteria ratio. Interestingly, IFW and TWW treatment led to an increased abundance of Proteobacteria and Acidobacteria phyla and Balneimonas, Rubrobacter, and Steroidobacter genera. This soil microbiota structure modulation paralleled a general decrement of fungi versus bacteria abundance ratio, the increment of electrical conductivity and nitrogen content of soil and an improvement of tomato growth. Finally, the potential adverse effect of TWW added with sodium chloride on soil microorganisms depends on soil pH.

Transduodenal robotic ampullectomy: tips and tricks and strategies for postoperative duodenal fistula management (with video).

Transduodenal Ampullectomy (TA) is a procedure for resecting low-malignancy ampullary tumors, with postoperative fistula as a notable complication. This study aims to clarify the indications for TA, outline the surgical robotic technique, and emphasize the importance of comprehensive complication management alongside the surgical approach. This multimedia article provides a detailed exposition of the robotic TA surgical technique, including the most important steps involved in exposing and reimplanting biliary and pancreatic ducts. The procedure encompasses the mobilization of the hepatic flexure of the colon, an extensive Kocher maneuver for duodenal mobilization, and ampulla exposure through a duodenal incision. Employing retraction loop sutures enhances surgical field visibility. Reconstruction involves securing pancreatic and biliary ducts to the duodenal mucosa, each tutored with a silicon catheter, and suturing for ampullectomy completion. The total operative time was 380 min. Final histopathology disclosed high-grade dysplasia with an isolated focus of adenocarcinoma (pT1), accompanied by clear resection margins. A postoperative duodenal fistula occurred, managed successfully through conservative treatment, utilizing subcutaneous drainage. Despite accurate robotic TA execution, complications may arise. This study underscores the importance of a comprehensive approach, incorporating meticulous surgical technique and effective complication management, to optimize patient outcomes.

Bilateral pheochromocytomas: clinical presentation and morbidity rate related to surgery technique and genetic status.

Background: Pheochromocytomas (PHEOs) are rare catecholamine-secreting adrenal tumors. Approximately 60-90% of bilateral PHEOs are hereditary. We retrospectively analyzed the clinical characteristics of patients with bilateral PHEOs and the morbidity rate (malignancy, tumor recurrence and adrenal insufficiency (AI) rate) related to surgery technique and genetic status of the patients. Results: Fourteen patients (12.5%, nine women, five men) had synchronous or metachronous bilateral PHEOs (out of 112 PHEO patients who underwent surgery between 1976 and 2021). The median age at diagnosis was 32 years (9-76) (three were children). Nine patients (64.2%) presented synchronous bilateral tumors, five (35.7%) contralateral metachronous tumors, 2-12 years after the first surgical intervention; three (21.4%) were metastatic. Median follow-up: 5 years (1-41), IQR 19 months. A total of 78.5% had a germline mutation (eight RET gene with MEN2A syndrome, three VHL syndrome, three not tested). Post-surgery recurrence was noted in 16.6% of patients (one with MEN2A syndrome and metastatic PHEOs, one with VHL syndrome), with similar rates after total adrenalectomy or cortical-sparing adrenal surgery. AI was avoided in 40% after cortical-sparing surgery. Conclusion: Bilateral PHEOs are usually associated with genetic syndromes. The surgical technique for patients with hereditary bilateral PHEOs should be chosen based on a personalized approach, as they are at higher risk for developing new adrenal tumors requiring additional surgeries.

Exploring public interest in gut microbiome dysbiosis, NAFLD, and probiotics using Google Trends.

Scientific interest related to the role of gut microbiome dysbiosis in the pathogenesis of non-alcoholic fatty liver disease (NAFLD) has now been established and is constantly growing. Therefore, balancing dysbiosis, through probiotics, would be a potential therapy. In addition to scientific interest, on the other hand, it is important to evaluate the interest in these topics among the population. This study aimed to analyze, temporally and geographically, the public's interest in gut microbiome dysbiosis, NAFLD, and the use of gut probiotics. The most widely used free tool for analyzing online behavior is Google Trends. Using Google Trends data, we have analyzed worldwide volume searches for the terms "gut microbiome", "dysbiosis", "NAFLD" and "gut probiotic" for the period from 1, January 2007 to 31 December 2022. Google's relative search volume (RSV) was collected for all terms and analyzed temporally and geographically. The RSV for the term "gut microbiome" has a growth rate of more than 1400% followed, by "gut probiotics" (829%), NAFLD (795%), and "dysbiosis" (267%) from 2007 to 2012. In Australia and New Zealand, we found the highest RSV score for the term "dysbiosis" and "gut probiotics". Moreover, we found the highest RSV score for the term "NAFLD" in the three countries: South Korea, Singapore, and the Philippines. Google Trends analysis showed that people all over the world are interested in and aware of gut microbiome dysbiosis, NAFLD, and the use of gut probiotics. These data change over time and have a geographical distribution that could reflect the epidemiological worldwide condition of NAFLD and the state of the probiotic market.

Post-COVID-19 unilateral upper lip numbness: A case report

@#This is a case of a 63-year-old female with post-COVID-19 unilateral upper lip pain and numbness. Neurologic examination did not reveal any deficits other than deficits on pinprick in the maxillary division (V2) of the left trigeminal nerve. Brain neuroimaging showed signs of acute inflammation of the left maxillary sinus. Neuropraxia of the infraorbital nerve, a branch of the trigeminal nerve, was the diagnosis considered. Reports on trigeminal neurosensory changes following acute sinusitis are few, and isolated trigeminal neuropathy is rare except in cases of dental disorders. Up to this writing, there have been no reports on post-COVID-19 unilateral upper lip numbness and pain. This study will also serve as a concise review on the correlative neuroanatomy of the trigeminal nerve.

Prognostic impact of Atrial Fibrillation Pattern and other Clinical Biomarkers in patients with stroke admitted in a Tertiary Hospital in Cebu City from 2015-2022

Background@#The effect of atrial fibrillation (AF) patterns and clinical biomarkers among patients with AF-related stroke is still controversial. @*Objectives@#The objective of this study is to determine the association of the pattern of AF and markers on routine blood tests with the outcome of patients after an AF-related stroke. @*Methods@#This is a retrospective cohort study of patients with stroke and AF admitted in a tertiary hospital in Cebu City from 2015-2022. Patients’ baseline characteristics, laboratory tests, ECG, and radiologic data were collected. Descriptive statistics such as mean and frequency were computed. The Kaplan–Meier method and the log-rank test were used to calculate the incidence time. The Cox regression analysis was used to determine factors associated with survival. A stepwise regression technique was used in model building. @*Results@#The mortality rate of patients with AF-related stroke was 0.02. A Kaplan Meier survival estimate shows that patients with paroxysmal AF have better survival. Upon model building of variables, age, red cell distribution width (RDW), neutrophil-to-lymphocyte ratio (NLR), platelet count, low density lipid cholesterol (LDL-C), and pattern of AF were predictive of mortality in patients with AF-related stroke. @*Conclusions@#Among AF-related stroke patients admitted at a tertiary hospital in Cebu City, pattern of AF, age, RDW, NLR, platelet count, and LDL-C were associated with mortality. The parameters associated with increased mortality could be easily assessed using an ECG, CBC, and lipid profile. These are all readily available and cost-efficient.

Predictors for hemorrhagic transformation among patients with Ischemic stroke admitted in a Tertiary Hospital in the Philippines from July 2018-July 2019

Background@#Among the multiple scoring systems for hemorrhagic transformation, only few of these address spontaneous hemorrhagic transformation after an ischemic stroke, with most done with Western population data. @*Objectives@#This study aims to identify the predictors for hemorrhagic transformation among patients with ischemic stroke admitted in a tertiary hospital in Cebu City, Philippines.@*Methods@#This is a retrospective cohort study of patients with ischemic stroke admitted in a tertiary hospital in Cebu City. Patients’ baseline characteristics, clinical, and radiologic data were collected. Chi square test and t-test were used to determine which variables were significantly different between patients with and without hemorrhagic transformation. Odds ratio (OR) and 95% confidence interval (CI) were determined to measure the association between the different variables and hemorrhagic transformation. @*Results@#A total of 500 ischemic stroke patients were included in the study. There were 28 (6%) ischemic stroke patients with Hemorrhagic Transformation. The mean age of these patients is 66.93 ± 12.42 years, 48.8% male, 10.8% had atrial fibrillation, and 2.4% had myocardial infarction. Controlling for the effect of confounders, white blood cell count (OR 1.11; 95% CI 1.03-1.19), myocardial infarction (OR 5.25; 95% CI 1.13-24.34), and presence of brain edema (OR 2.86; 95% CI 1.05-7.80) were significant predictors of hemorrhagic transformation.@*Conclusion@#White blood cell count, presence of brain edema, and myocardial infarction were significantly associated with hemorrhagic transformation among ischemic stroke patients.

Genetic screening for hereditary transthyretin amyloidosis with polyneuropathy in western Sicily: Two years of experience in a neurological clinic.

BACKGROUND AND PURPOSE: Hereditary transthyretin amyloidosis with polyneuropathy (ATTRv-PN) is caused by mutations in the TTR gene, leading to misfolded monomers that aggregate generating amyloid fibrils. METHODS: A prospective systematic genetic screening for ATTRv-PN was proposed in patients presenting with a sensory-motor idiopathic polyneuropathy and two or more "red flags" among the following: family history of polyneuropathy or cardiopathy, bilateral carpal tunnel syndrome, cardiac insufficiency, renal amyloidosis, lumbar tract stenosis, autonomic dysfunction, idiopathic gastrointestinal disease, amyloid deposits on biopsy, and vitreous opacities. The detection rate was calculated, and nonparametric analyses were carried out to underline differences among screened positive versus negative patients. RESULTS: In the first step, 145 suspected patients underwent genetic testing, revealing a diagnosis of ATTRv-PN in 14 patients (10%). Then, cascade screening allowed early recognition of 33 additional individuals (seven symptomatic ATTRv-PN patients and 26 presymptomatic carriers) among 84 first-degree relatives. Patients with a positive genetic test presented a higher frequency of unexplained weight loss, gastrointestinal symptoms, and family history of cardiopathy. CONCLUSIONS: A systematic screening for ATTRv-PN yielded an increased recognition of the disease in our neurological clinic. Unexplained weight loss associated with axonal polyneuropathy had the highest predictive value in the guidance of clinical suspicion. A focused approach for the screening of ATTRv-PN could lead to an earlier diagnosis and identification of asymptomatic carriers, who will be promptly treated after a strict follow-up at the clinical onset.

The surgical treatment of Morgagni hernias in adults: a systematic review for the standardization of laparoscopic surgical repair.

A Morgagni hernia is a congenital diaphragmatic hernia that is rarely diagnosed in adults, and the technique for its repair has not yet been standardized. This review will give an overview of the different laparoscopic methods reported by other authors, highlighting the key points indicating a good repair to help standardize the technique. A systematic review of the available articles on PubMed was conducted according to PRISMA 2020 by two authors independently in May 2022. Only articles written in English were included. A total of 180 case reports of laparoscopic Morgagni's hernia repair procedures were found; direct repair was performed in 59 patients, mesh was used in 119 patients, and mesh was not used in 2 patients. The hernia sac was removed in 71 patients, and the defect was closed before mesh placement in 49 patients. Nonabsorbable, dual or biologic mesh was used. The mean operative time was 92.65 min for direct repair and 84.11 min for mesh repair. One recurrence was reported in the direct repair series. The optimal method of repair has not yet been identified. The laparoscopic approach is associated to fewer complications and facilitates a faster recovery than the open approach. Several manoeuvres have been reported to help surgeons, who are not trained in laparoscopic knotting, perform extracorporeal knotting. Mesh should be placed when tension is too high after a direct repair or when primary closure cannot be achieved.

Differential expression patterns of purinergic ectoenzymes and the antioxidative role of IL-6 in hospitalized COVID-19 patient recovery.

Introduction: We have acquired significant knowledge regarding the pathogenesis of severe acute respiratory syndrome caused by coronavirus 2 (SARS-CoV-2). However, the underlying mechanisms responsible for disease recovery still need to be fully understood. Methods: To gain insights into critical immune markers involved in COVID-19 etiopathogenesis, we studied the evolution of the immune profile of peripheral blood samples from patients who had recovered from COVID-19 and compared them to subjects with severe acute respiratory illness but negative for SARS-CoV-2 detection (controls). In addition, linear and clustered correlations between different parameters were determined. Results: The data obtained revealed a significant reduction in the frequency of inflammatory monocytes (CD14+CD16+) at hospital discharge vs. admission. Remarkably, nitric oxide (NO) production by the monocyte compartment was significantly reduced at discharge. Furthermore, interleukin (IL)-6 plasma levels were negatively correlated with the frequency of NO+CD14+CD16+ monocytes at hospital admission. However, at the time of hospital release, circulating IL-6 directly correlated with the NO production rate by monocytes. In line with these observations, we found that concomitant with NO diminution, the level of nitrotyrosine (NT) on CD8 T-cells significantly diminished at the time of hospital release. Considering that purinergic signaling constitutes another regulatory system, we analyzed the kinetics of CD39 and CD73 ectoenzyme expression in CD8 T-cells. We found that the frequency of CD39+CD8+ T-cells significantly diminished while the percentage of CD73+ cells increased at hospital discharge. In vitro, IL-6 stimulation of PBMCs from COVID-19 patients diminished the NT levels on CD8 T-cells. A clear differential expression pattern of CD39 and CD73 was observed in the NT+ vs. NT-CD8+ T-cell populations. Discussion: The results suggest that early after infection, IL-6 controls the production of NO, which regulates the levels of NT on CD8 T-cells modifying their effector functions. Intriguingly, in this cytotoxic cell population, the expression of purinergic ectoenzymes is tightly associated with the presence of nitrated surface molecules. Overall, the data obtained contribute to a better understanding of pathogenic mechanisms associated with COVID-19 outcomes.

Clinical presentation of sporadic and hereditary pheochromocytoma/paraganglioma.

Pheochromocytomas (PHEO) and paragangliomas (PGL) can occur sporadic or within genetic predisposition syndromes. Despite shared embryology, there are important differences between PHEO and PGL. The aim of this study was to describe the clinical presentation and disease characteristics of PHEO/PGL. A retrospective analysis of consecutively registered patients diagnosed with or treated for PHEO/PGL in a tertiary care centre was performed. Patients were compared according to anatomic location (PHEO vs PGL) and genetic status (sporadic vs hereditary). In total, we identified 38 women and 29 men, aged 50 ± 19 years. Of these, 42 (63%) had PHEO, and 25 (37%) had PGL. Patients with PHEO presented more frequently with sporadic than hereditary disease (45 years vs 27 (77%) vs 8 (23%)) than patients with PGL (9 (36%) vs 16 (64%), respectively) and were older at diagnosis (55 ± 17 vs 40 ± 18 years, P = 0.001), respectively). About half of the cases in both PHEO and PGL were diagnosed due to disease-related symptoms. In patients with PHEO, tumour diameter was larger (P = 0.001), metanephrine levels higher (P = 0.02), and there was more frequently a history of cardiovascular events than in patients with PGL. In conclusion, we found that patients with PGL more frequently have a hereditary predisposition than those with PHEO, contributing to the fact that diagnosis is generally made earlier in PGL. Although diagnosis in both PHEO and PGL was mostly due to related symptoms, patients with PHEO more often presented with cardiovascular comorbidities than those with PGL which might relate to a higher number of functionally active tumours in the former.

Gut Microbiome in the Progression of NAFLD, NASH and Cirrhosis, and Its Connection with Biotics: A Bibliometric Study Using Dimensions Scientific Research Database.

There is growing evidence that gut microbiota dysbiosis is linked to the etiopathogenesis of nonalcoholic fatty liver disease (NAFLD), from the initial stage of disease until the progressive stage of nonalcoholic steatohepatitis (NASH) and the final stage of cirrhosis. Conversely, probiotics, prebiotics, and synbiotics have shown promise in restoring dysbiosis and lowering clinical indicators of disease in a number of both preclinical and clinical studies. Additionally, postbiotics and parabiotics have recently garnered some attention. The purpose of this bibliometric analysis is to assess recent publishing trends concerning the role of the gut microbiome in the progression of NAFLD, NASH and cirrhosis and its connection with biotics. The free access version of the Dimensions scientific research database was used to find publications in this field from 2002 to 2022. VOSviewer and Dimensions' integrated tools were used to analyze current research trends. Research into the following topics is expected to emerge in this field: (1) evaluation of risk factors which are correlated with the progression of NAFLD, such as obesity and metabolic syndrome; (2) pathogenic mechanisms, such as liver inflammation through toll-like receptors activation, or alteration of short-chain fatty acids metabolisms, which contribute to NAFLD development and its progression in more severe forms, such as cirrhosis; (3) therapy for cirrhosis through dysbiosis reduction, and research on hepatic encephalopathy a common consequence of cirrhosis; (4) evaluation of diversity, and composition of gut microbiome under NAFLD, and as it varies under NASH and cirrhosis by rRNA gene sequencing, a tool which can also be used for the development of new probiotics and explore into the impact of biotics on the gut microbiome; (5) treatments to reduce dysbiosis with new probiotics, such as Akkermansia, or with fecal microbiome transplantation.

Awake laparoscopic cholecystectomy: A case report and review of literature.

BACKGROUND: Laparoscopic cholecystectomy (LC) is one of the most widely practiced surgical procedures in abdominal surgery. Patients undergo LC during general anaesthesia; however, in recent years, several studies have suggested the ability to perform LC in patients who are awake. We report a case of awake LC and a literature review. CASE SUMMARY: A 69-year-old patient with severe pulmonary disease affected by cholelithiasis was scheduled for LC under regional anaesthesia. We first performed peridural anaesthesia at the T8-T9 level and then spinal anaesthesia at the T12-L1 level. The procedure was managed in total comfort for both the patient and the surgeon. The intra-abdominal pressure was 8 mmHg. The patient remained stable throughout the procedure, and the postoperative course was uneventful. CONCLUSION: Evidence has warranted the safe use of spinal and epidural anaesthesia, with minimal side effects easily managed with medications. Regional anaesthesia in selected patients may provide some advantages over general anaesthesia, such as no airway manipulation, maintenance of spontaneous breathing, effective postoperative analgesia, less nausea and vomiting, and early recovery. However, this technique for LC is not widely used in Europe; this is the first case reported in Italy in the literature. Regional anaesthesia is feasible and safe in performing some types of laparoscopic procedures. Further studies should be carried out to introduce this type of anaesthesia in routine clinical practice.