Clinical and diagnostic findings in COVID-19 patients: an original research from SG Moscati Hospital in Taranto Italy.

The coronavirus disease 2019 (COVID-19) pandemic is a worldwide medical challenge due to the scarcity of proper information and remedial resources. The ability to efficiently avoid a further SARS-CoV-2 pandemic will, therefore, depend on understanding several factors which include host immunity, virus behavior, prevention measures, and new therapies. This is a multi-phase observatory study conducted in the SG Moscati Hospital of Taranto in Italy that was converted into COVID-19 Special Care Unit for SARS-Co-V2 risk management. Patients were admitted to the 118 Emergency Pre-Hospital and Emergency Department based on two diagnostic criteria, the nasopharyngeal swab assessed by reverse-transcriptase-polymerase-chain-reaction (RT-PCR) and CT-scan image characterized by ground glass opacity. Patients were divided into four groups, positive-positive (ER-PP), negative-positive (ER-NP), negative-negative (ER-NN) and a group admitted to the ICU (ER-IC). A further control group was added when the T and B lymphocyte subsets were analyzed. Data included gender, age, vital signs, arterial blood gas analysis (ABG), extensive laboratory results with microbiology and bronchoalveolar lavage fluid (BALF) which were analyzed and compared. Fundamental differences were reported among the groups. Males were significantly higher in PP, ICU, and NP groups, from 2 to 4-fold higher than females, while in the NN group, the number of females was mildly higher than males; the PP patients showed a marked alkalotic, hypoxic, hypocapnia ABG profile with hyperventilation at the time of admission; finally, the laboratory and microbiology results showed lymphopenia, fibrinogen, ESR, CRP, and eGFR were markedly anomalous. The total number of CD4+ and CD8+ T cells was dramatically reduced in COVID-19 patients with levels lower than the normal range delimited by 400/µL and 800/µL, respectively, and were negatively correlated with blood inflammatory responses.

Diagnosis and Management of Hepatic Artery Complications After Liver Transplantation.

BACKGROUND: We assessed the usefulness of color Doppler imaging in diagnosis and monitoring hepatic artery complications after liver transplantation. METHODS: Subjects were 421 liver transplant recipients who underwent serial ultrasound (US) color Doppler evaluations of the hepatic arteries after surgery. RESULTS: We saw 4 hepatic arterial complications after liver transplantation (13 thrombosis, 29 stenosis, 2 kinking, 2 pseudo-aneurysm, and 2 pseudo-aneurysm rupture). All subjects underwent US color Doppler examination periodically after surgery. In 6 cases of early thrombosis, hepatic arterial obstruction was diagnosed with absence of Doppler signals; in the other 7 cases (late hepatic artery thrombosis), thrombosis was suspected for the presence of intra-parenchymal "tardus-parvus" waveforms. In all of the cases, computed tomography angiography showed obstruction of the main arterial trunk and the development of compensatory collateral circles (late hepatic artery thrombosis). In 10 of the 29 cases of stenosis, Doppler ultrasonography examination revealed stenotic tract and intra-hepatic tardus-parvus waveforms; in 17 stenosis cases, the site of stenosis could not be identified, but intra-parenchymal tardus-parvus waveforms were recorded. In 2 patients, hepatic artery stenosis occurred with ischemic complications. CONCLUSIONS: The use of US color Doppler examination allows the early diagnosis of hepatic arterial complications after liver transplantation. Tardus-parvus waveforms indicated severe impairment of hepatic arterial perfusion from either thrombosis or severe stenosis. The presence of these indirect signs enhanced the accuracy of color Doppler diagnosis, and detection should prompt therapy.

Incidence and predictive factors for complications after uterine leiomyoma embolization.

STUDY QUESTION: What is the risk of complications after uterine leiomyoma embolization and what are the factors associated with complications? SUMMARY ANSWER: The cumulative risk of complications after embolization is relatively low even in the long term, but submucosal leiomyoma location may increase the risk. WHAT IS KNOWN ALREADY: A broad spectrum of complications after leiomyoma embolization have been described with widely varying rates. There is uncertainty over the actual risk of complications and the factors associated with this risk. STUDY DESIGN, SIZE, DURATION: This was a prospective cohort study of 288 consecutive women undergoing leiomyoma embolization in the general gynaecology clinic of a university teaching hospital between January 2001 and December 2010. PARTICIPANTS/MATERIALS, SETTING, METHODS: Complications occurring after embolization were categorized as major or minor according to the severity of their impact on health, the level of care required and the outcome. Cumulative complication rates were estimated by survival analysis and log-rank tests according to baseline variables. Multivariable Cox proportional hazards analysis was performed to adjust for confounders. MAIN RESULTS AND THE ROLE OF CHANCE: There were 48 patients who experienced a complication at a median of 5 months (95% confidence interval, 4.1-11.4) after embolization. Complications were minor in 38 patients and major in 10 patients. The cumulative overall complication rate was 13% (95% CI, 9.0-17.0) at 6 months, 16% (95% CI, 11.0-20.0) at 1 year, 17% (95% CI, 12.0-22.0) at 3 years and 18% (95% CI, 12.9-22.8) at 5 years. The most frequent complication (19/48, 39.6%) was leiomyoma expulsion, which occurred spontaneously in 13 (68.4%) of these cases and required assistance in 6 (31.6%) cases. Eight (2.8%) patients underwent re-intervention, including six hysteroscopic myomectomies, one laparoscopic myomectomy and one hysteroscopic adhesiolysis, as a result of a complication. Submucosal leiomyoma location was the only baseline variable associated with an increased risk for complications [Hazard ratio (HR), 2.28, 95% CI, 1.24-4.18, P = 0.008]. LIMITATIONS, REASONS FOR CAUTION: Our population did not include women of African descent, who have been reported to be at higher risk of post-procedural complications compared with Causcasian women. If such women were involved in the study, higher morbidity rates might have been observed. WIDER IMPLICATIONS OF THE FINDINGS: Women with submucosal leiomyomas at the time of embolization are more likely to have post-procedural complications. This is important new information for counselling patients contemplating this therapeutic approach. STUDY FUNDING/COMPETING INTERESTS: The authors have no competing interests to declare. The study was not supported by any external grant.

Incidence, management, and results of hepatic artery stenosis after liver transplantation in the era of donor to recipient match.

INTRODUCTION: Hepatic artery stenosis (HAS) is an important complication after liver transplantation. However, studies are not conclusive in terms of definition, incidence, best treatment, and timing of intervention. The aim of this study was to evaluate the incidence of SSHA that occurred in a single center over the past 12 years, pointing out diagnostic and therapeutic strategies. METHODS: The incidence of HAS was reviewed in 258 liver transplant recipients between January 1999 and December 2011. All patients underwent Doppler ultrasound (DUS) at fixed times. Multidetector computed tomographic angiography (MDCTA) was performed to confirm the DUS findings. RESULTS: HAS occurred in 23 cases (9.3%). In all cases diagnosis was performed by DUS resulting in a sensitivity of 100% and a specificity of 99.6%. Based on DUS and MDCTA data integration, in 10 cases we adopted the "wait and see" strategy, whereas 13 patients underwent interventional radiology techniques. CONCLUSION: DUS monitoring is efficacious in the diagnosis of HAS after liver transplantation. Interventional radiology procedures are safe and efficacious.

Cutting-balloon angioplasty of resistant ureteral stenosis as bridge to stent insertion.

Ureteral stenting is a routine, minimally invasive procedure performed for relief of benign or malignant obstruction. In case of ureteral stenosis, to allow a correct insertion of the stent, a predilatation of the ureter stenosis with a conventional balloon catheter can be necessary. In exceptional cases, it can be difficult to advance an 7-8 Fr JJ-catheter over a tight resistant ureter stenosis following unsuccessful high-pressure balloon dilatation. In the present report, we describe two cases of resistant ureter stenosis successfully dilated by a cutting-balloon following the failure of high-pressure balloon dilatation, allowing a correct and uncomplicated antegrade stent insertion.

Transarterial chemoembolization (TACE) for unresectable HCC: a new life begins?

BACKGROUND AND OBJECTIVES: To provide an overview on the loco-regional therapy performed by transarterial chemoembolization (TACE) in patients with hepatocellular carcinoma (HCC), either as sole, either as neoadjuvant to surgery or bridge therapy to orthotopic liver transplantation (OLT). EVIDENCE AND INFORMATION SOURCES: The current review is based on an analysis of the current literature and the caseload experience of the Authors on this topic. STATE OF THE ART: Chemoembolization combines de-arterialization of the tumor and selective delivery of chemotherapeutic agents into tumor's feeding vessels during angiography. Tumor ischemia raises the drug concentration compared to infusion alone and extends the retention of the chemotherapeutic drug. As locoregional therapy, TACE allows a complete local tumor control of 25-35% and permits an increase of survival in patients with intermediate HCC according to Barcelona-Clinic Liver Cancer (BCLC) classification. Excellent results were also achieved by combined therapies, such as with percutaneous ethanol injection or radiofrequency ablation, as neoadjuvant therapy prior to liver resection and in some circumstances as a bridging tool before liver transplantation. PERSPECTIVES: Drug eluting beads are microspheres that can be loaded with doxorubicin and induce toxic and ischemic necrosis with the same device; that allows an increase of drug selectively exposed to tumor cells and simultaneously a reduction of systemic toxicity. Tumor embolization induces a neoangiogenic reaction with a significant growth of adiacent satellites, so the association with sorafenib has a strong rationale for a combined therapy and is currently under investigation. CONCLUSIONS: Today TACE is the standard of care for treatment of intermediate hepatocellular carcinoma. To get the best performance it should be tailored according to the individual patient's condition.

Late development of splenic artery aneurysm after orthotopic liver transplantation: a case report.

Splenic artery aneurysm (SAA) is a rare complication after orthotopic liver transplantation (OLT). Although SAAs are often incidental findings, in some cases they present with signs and symptoms of abdominal mass or intra-abdominal hemorrhage. The diagnosis requires Doppler ultrasound and confirmation with computed tomography, magnetic resonance, or angiography. Endovascular techniques are preferred to surgery for the treatment of most SAAs. A variable interval from 6 days to 11 years has been reported between OLT and the diagnosis of SAA, justifying a lifelong scheduled surveillance of abdominal vessels by ultrasound after OLT. Herein we have reported a case of SAA that developed 16 years after OLT. This pathological condition was totally asymptomatic. Only routine abdominal ultrasound allowed its detection and subsequent successful treatment.

Preoperative right portal vein embolisation: indications and results.

PURPOSE: The purpose of this retrospective study was to evaluate the efficacy of right portal vein embolisation (PVE) in inducing contralateral liver hypertrophy before extended hepatectomy. MATERIALS AND METHODS: Twenty-six consecutive patients, 14 with liver metastases (ten from colorectal cancer; four from carcinoid tumours) and 12 with biliary cancers (ten Klatskin tumours; one gallbladder tumour; one intrahepatic cholangiocarcinoma) with insufficient predicted future remnant liver (FRL) underwent right PVE to induce hypertrophy of the contralateral hemiliver prior to surgical resection. Total liver volume, tumour volume and FRL volume were calculated on a 3D workstation. The ratio of the FRL to the total functional liver volume was <30% in all patients. RESULTS: The FRL volume increased by 5%-25% (15% on average) after right PVE in patients with liver metastases and by 9%-19% (14% on average) in patients with biliary cancers. In all patients, the ratio of FRL to functional liver volume was >or=30% after right PVE. No postoperative deaths due to severe liver failure occurred in the 20 patients who underwent extended hepatectomy. CONCLUSIONS: Right PVE extends the indications for hepatectomy in patients with liver metastases and those with biliary cancers who have an insufficient potential hepatic functional reserve.

Computed tomography imaging of vena cava filter complications: a pictorial review.

Caval filters are widely used in the prevention of pulmonary embolism. Filters have proved to be effective, but the complication rate is not negligible. Computed tomography (CT) provides a complete evaluation of the filter, including both caval and extracaval complications. In this review, we describe the normal CT aspect of cava filters, the classification of complications and their CT findings. Technical considerations for adequate CT imaging are also highlighted.

Hemosuccus pancreaticus secondary to intraductal rupture of a primary splenic artery aneurysm: diagnosis by ERCP and successful management by interventional radiology.

This report describes the case of a 65-year-old man with a prolonged history of gastrointestinal bleeding of unknown origin. During a 2-year period, he underwent 28 endoscopic procedures, three angiographies with or without heparin provocation, a nuclear scan, and abdominal magnetic resonance imaging, none of which were diagnostic. A blind ileocecal resection was also carried out. A diagnosis of hemosuccus pancreaticus secondary to a ruptured primary splenic artery aneurysm was obtained by endoscopic retrograde cholangiopancreatography, and successful interventional radiographic embolization of the splenic artery aneurysm was conducted. During a 17-month follow-up period, no relapse of gastrointestinal bleeding was observed.

Congenital absence of the portal vein associated with focal nodular hyperplasia in the liver in an adult woman: imaging and review of the literature.

We present a new case of congenital absence of the portal vein and focal nodular hyperplasia in the liver without additional congenital anomalies. Ultrasound, computed tomography, magnetic resonance imaging, and angiography depicted the splenic vein and the superior mesenteric vein joining and entering into the inferior vena cava without passing through the liver. The features of this patient and the 30 previously reported cases are reviewed.

Preoperative right portal vein embolization in patients with metastatic liver disease. Metastatic liver volumes after RPVE.

PURPOSE: To quantify liver metastases and future remnant liver (FRL) volumes in patients who underwent right portal vein embolization (RPVE) and to evaluate the effects of this procedure on metastase growth. MATERIAL AND METHODS: Nine patients with liver metastases from primary colon (n = 5), rectal lesions (n = 1) and carcinoid tumors (n = 3) underwent spiral CT to evaluate the ratio of the non-tumorous parenchymal volume of the resected liver to that of the whole liver volume (R2). Hand tracing was used to isolate the entire liver, the resected liver and metastase volumes. All patients with R2 > 60% underwent RPVE. RESULTS: FRL exhibited a 101-336 cm3 (average 241 cm3) increase in volume 1 month after RPVE. One patient refused surgery for 2 months and before surgery the increase in volume of the FRL was similar to that of other patients (180.64 cm3). Percent metastases volume from colorectal carcinoma in embolized liver parenchyma increased from 62.4% to 138.4% at 1 month and to 562% at 2 months after RPVE. Metastase volume from carcinoid tumors was unchanged. CONCLUSION: One month after RPVE, hypertrophy of the FRL is evident. In the embolized liver, there was a progressive increase in metastase volume from colorectal carcinoma while metastase volume from carcinoid tumor was unchanged in embolized and non-embolized liver.

Diagnostic imaging in lower limb atherosclerosis.

At present, there are a number of diagnostic imaging procedures for the evaluation of lower limb atherosclerosis. In particular, MR-angiography with contrast medium and multislice CT are rapidly developing. However, their role in clinical practice is still to be defined. In this article, first, the functional anatomy of peripheral arterial system divided into inflow arteries (aortoiliac trunk), outflow arteries (femoropoplietal trunk) and runoff arteries (leg and foot vessels), is examined. Then, image extraction with color-Doppler US, inflow MR-angiography with contrast material, multislice CT and angiography is briefly illustrated. The corresponding advantages and disadvantages, are indicated. The findings of combined imaging in relation to the various stages of atherosclerosis are analyzed. In particular, intimal thickening leading to occlusion is considered with respect to both morphology and flow alterations. Based on these considerations, the use of the different procedures is discussed in relation to the clinical presentation (no symptoms, claudication or pain, trophic lesions, during postoperative follow-up). For each stage, questions the radiologist should address for a correct approach and the best cost/benefit ratio, are described.

Color Doppler sonography in the diagnosis and monitoring of arterial complications after liver transplantation.

PURPOSE: We assessed the usefulness of color Doppler imaging in the diagnosis and monitoring of arterial complications after liver transplantation. METHODS: Subjects were 142 liver transplant recipients who underwent serial color Doppler sonographic evaluations of the hepatic arteries after surgery. Patients with abnormal sonographic findings underwent subsequent angiography. RESULTS: Eighteen subjects experienced 20 hepatic arterial complications (13 thromboses and 7 stenoses). In 7 of the 13 thrombosis incidents, hepatic arterial obstruction occurred within a month of surgery and was evident from the absence of Doppler signals; angiography confirmed the absence of hepatic arterial perfusion in these cases. In the other 6 thrombosis cases, the thrombosis developed 3 or more months after surgery and became apparent from the absence of color Doppler signals at the level of the main arterial trunk and the presence of intraparenchymal "tardus parvus" waveforms. In these cases, angiography showed obstruction of the main arterial trunk and the development of compensatory collateral vessels. In 3 of the 7 cases of stenosis, high flow velocities were recorded at the site of the narrowing, and intrahepatic tardus parvus waveforms were present. In the other 4 stenosis cases, the site of stenosis could not be identified, but intraparenchymal tardus parvus waveforms were recorded. CONCLUSION: The use of color Doppler sonography allows the early diagnosis of hepatic arterial complications after liver transplantation. Tardus parvus waveforms indicated severe impairment of hepatic arterial perfusion, from either thrombosis or severe stenosis. The presence of these waveforms enhanced the accuracy of color Doppler diagnosis (100% positive predictive value), and their detection should prompt angiography.

Pancreas-preserving total gastrectomy for gastric cancer.

BACKGROUND: Pancreas-preserving total gastrectomy for gastric cancer has been proposed to remove lymph nodes along the upper border of the pancreas without performing a distal pancreatic resection. However, the original technique includes the ligation of the splenic artery at its origin and thus carries the risk of pancreatic necrosis. HYPOTHESIS: A technique of pancreas-preserving total gastrectomy that includes ligation of the splenic artery approximately 5 cm distally from the root may reduce the risk of postoperative pancreatic necrosis. DESIGN: Case series. SETTING: Both primary and referral hospital care. PATIENTS: Hospital records of 228 consecutive patients who, according to a personal technique, underwent D3 pancreas-preserving total gastrectomy for gastric cancer from 1981 to 1997 were reviewed. MAIN OUTCOME MEASURES: Surgical complications, postoperative deaths, and survival. RESULTS: Hospital morbidity and mortality were 33.3% and 3.9%, respectively. No patients experienced pancreatic necrosis. The 5-year survival rate after curative resection was 53.6%: 96.9% for stage IA, 76.3% for stage IB, 63.0% for stage II, 35.6% for stage IIIA, 27.0% for stage IIIB, and 20.3% for stage IV (N3-positive patients) disease. CONCLUSION: Results of the present study show the efficacy of this method of radical resection for gastric cancer as demonstrated by the low incidence of postoperative complications and high survival rates.

Percutaneous intravascular retrieval of embolised fragments of long-term central venous catheters.

Embolisation of a catheter fragment is a rare mechanical complication of long-term central venous access devices. From 1995 to 1999 we observed 10 cases: the cause of embolisation was the 'pinch-off syndrome' in half of the cases, and in 8 cases out of 10 the fragment had embolised in the pulmonary arterial vessels. Percutaneous transvenous retrieval was successful in all cases; it was performed mainly (8 cases out of ten) through the left transfemoral route, using a single-snare-loop device sometimes associated with a pig-tail catheter. We had no mortality and no major complications. On the basis of our experience, we believe that catheter embolisation of long-term central venous devices can be effectively prevented by adequate insertion technique, proper management of the device during its clinical use, and accurate removal technique. Nonetheless, should catheter em-bolisation occur, the patient should be referred to a Centre with adequate experience in the field of interventional radiological techniques. Should the radiological retrieval procedure fail, evidence from the literature suggests that leaving the fragment in embolisation site might be safer than open extraction by surgical thoracotomy, particularly in oncological patients with reduced life expectancy.