Argentine consensus recommendations for lung cancer screening programmes: a RAND/UCLA-modified Delphi study.

BACKGROUND: Lung cancer (LC) screening improves LC survival; the best screening method in terms of improving survival is low-dose CT (LDCT), outpacing chest X-ray and sputum cytology. METHODS: A consensus of experts in Argentina was carried out to review the literature and generate recommendations for LC screening programmes. A mixed-method study was used with three phases: (1) review of the literature; (2) modified Delphi consensus panel; and (3) development of the recommendations. The Evidence to Decision (EtD) framework was used to generate 13 evaluation criteria. Nineteen experts participated in four voting rounds. Consensus among participants was defined using the RAND/UCLA method. RESULTS: A total of 16 recommendations scored ≥7 points with no disagreement on any criteria. Screening for LC should be performed with LDCT annually in the population at high-risk, aged between 55 and 74 years, regardless of sex, without comorbidities with a risk of death higher than the risk of death from LC, smoking ≥30 pack-years or former smokers who quit smoking within 15 years. Screening will be considered positive when finding a solid nodule ≥6 mm in diameter (or ≥113 mm3) on baseline LDCT and 4 mm in diameter if a new nodule is identified on annual screening. A smoking cessation programme should be offered, and cardiovascular risk assessment should be performed. Institutions should have a multidisciplinary committee, have protocols for the management of symptomatic patients not included in the programme and distribute educational material. CONCLUSION: The recommendations provide a basis for minimum requirements from which local institutions can develop their own protocols adapted to their needs and resources.

Emerging concepts in heart failure management and treatment: focus on point-of-care ultrasound in cardiogenic shock.

Point-of-care ultrasound (POCUS) plays a strategic role in the diagnostic and therapeutic evaluation of critically ill patients and, especially, in those who are haemodynamically unstable. In this context, POCUS allows a more precise identification of the cause, its differential diagnosis, the eventual coexistence with another entity and, finally, guiding of the therapeutic approach. It implies a portable use of ultrasound in acute settings covering different specified protocols, such as echocardiography, vascular, lung or abdominal ultrasound. This article reviews POCUS application in the emergency department or the intensive care unit, focused on severely compromised patients with cardiogenic shock with an emergent bedside assessment. Considering the high mortality rate of this entity, POCUS provides the intensivist/clinician with an appropriate tool for accurate diagnoses and a timely management plan. The authors propose practical algorithms for the diagnosis of patients using POCUS in these settings. This article is part of the Emerging concepts in heart failure management and treatment Special Issue: https://www.drugsincontext.com/special_issues/emerging-concepts-in-heart-failure-management-and-treatment.

Transbronchial biopsies' histopathological findings leading to successful late steroid therapy in Covid-19 acute respiratory failure.

We present results from clinical, radiologic, gas exchange, lung mechanics, and fibre-optic bronchoscopy-guided transbronchial biopsies in a case of acute respiratory failure due to SARS-CoV-2 (Covid-19). This report highlights the pulmonary, immunological, and inflammatory changes found during acute diffuse alveolar damage and the later organizing phase. An early diffuse alveolar damage pattern with predominant epithelial involvement with active recruitment of T cells and monocytes was observed followed by a late organizing pattern with pneumocyte hyperplasia, inflammatory infiltration, prominent endotheliitis, and secondary germinal centers. The patient's deterioration paralleling the late immuno-pathological findings based the decision to administer intravenous corticosteroids, resulting in clinical, gasometric, and radiologic improvement. We believe that real-time clinicopathological correlation, along with the description of the immunological processes at play, will contribute to the full clinical picture of Covid-19 and might lead to a more rational approach in the precise timing of anti-inflammatory, anti-cytokine, or steroid therapies.

A Novel Surgical Technique to Assure Donor and Recipient Safety: Pyloric to Segment 4 Arterial Reconstruction.

BACKGROUND: Strategies to extend the pool of organs include and promote the use of segmental liver grafts. While performing a living donor left lateral segment (LLS) liver transplant and in split procedures, the hepatic artery´s division becomes critical when a dominant segment 4 artery (S4A) emerges from the left hepatic artery (LHA). We aim to describe a novel technique that consists of performing microsurgical reconstruction from the pyloric artery (PA) to S4A. CASE REPORTS: A 45-y-old living donor was evaluated to use his LLS as a graft for a pediatric recipient. During the procedure, a dominant S4A born from the LHA was dissected. To obtain an appropriate LHA length and diameter for the recipient, it was necessary to transect it. An extended right lobe split graft was used in a 61-y-old patient. The S4A born from LHA had to be sectioned during the split procedure. In both cases, segment 4 remained incompletely perfused. The PA was dissected with enough length to be rotated, to perform a microsurgical anastomosis to the S4A, recovering parenchyma's color and Doppler signal while vascular permeability was demonstrated using CT scan. There was no biliary or cut surface complication. CONCLUSIONS: PA to S4A reconstruction is a simple and novel technique that can be used for LLS and extended right lobe split graft and might contribute to increase donor selection and reduce living donor and recipient S4A-related complications.

Unusual spontaneous porto-systemic shunt: The importance of diagnosing non-anatomical porto-systemic shunts to improve portal flow in pediatric living-related liver transplantation. Case report.

Collateral circulation secondary to liver cirrhosis may cause the development of large PSSs that may steal flow from the main portal circulation. It is important to identify these shunts prior to, or during the transplant surgery because they might cause an insufficient portal flow to the implanted graft. There are few reports of "steal flow syndrome" cases in pediatrics, even in biliary atresia patients that may have portal hypoplasia as an associated malformation. We present a 12-month-old female who received an uneventful LDLT from her mother, and the GRWR was 4.8. During the early post-operative period, she became hemodynamically unstable, developed ascites, and altered LFT. The post-operative ultrasound identified reversed portal flow, finding a non-anatomical PSS. A 3D CT scan confirmed the presence of a mesocaval shunt through the territory of the right gonadal vein, draining into the right iliac vein, with no portal inflow into the liver. The patient was re-operated, and the shunt was ligated. An intraoperative Doppler ultrasound showed adequate portal inflow after the procedure; the patient evolved satisfactorily and was discharged home on day number 49. The aim was to report a case of post-operative steal syndrome in a pediatric recipient due to a mesocaval shunt not diagnosed during the pretransplant evaluation.

Rechazo en trasplante pulmonar: ¿cómo evaluarlo por tomografía computada multidectector? / Lung Transplant Rejection: How to Evaluate by Multidetector Computed Tomography?

El trasplante pulmonar es una opción terapéutica válida para mejorar la sobrevida de pacientes con enfermedades respiratorias en fase avanzada. La supervivencia tras el trasplante de pulmón ha mejorado en gran medida como resultado de los avances en la técnica quirúrgica, la cuidadosa preservación de órganos de donantes, las mejoras en la terapia inmunosupresora y el reconocimiento precoz de complicaciones con el uso de técnicas de imagen. Nuestro objetivo es proporcionar una guía radiológica del rechazo agudo y crónico del trasplante pulmonar. Se describirán los hallazgos por tomografía computada multidetector (TCMD).

Lung transplantation is a valid therapeutic option to prolong survival in patients with end-stage pulmonary disease. Survival after lung transplantation has greatly improved as a result of advances in surgical techniques, careful preservation of donor organs, progress in immunosuppressive therapy, and the use of imaging techniques for an early recognition of complications. Our goal is to provide a radiology guide of acute and chronic rejection of lung transplants. The fndings of multidetector computed tomography (MDCT) studies are described.

Reconstrucción mamaria con colgajos de perforantes de la arteria epigástrica inferior: utilidad de la angio tomografía computada multidetector en la planificación prequirúrgica / Breast reconstruction with perforator flaps of the inferior epigastric artery: utility multidetector computed tomography angiography in preoperative planning

Objetivo: Valorar la utilidad de la Angio Tomografía Computada Multidetector (Angio TCMD) como principal herramienta diagnóstica en la evaluación prequirúrgica de pacientes mastectomizadas que serán sometidas a una reconstrucción mamaria con colgajo autólogo pediculado tipo DIEP (Deep inferior epigastric artery). Población: Entre abril de 2008 y marzo de 2011 se estudiaron 11 pacientes, a las cuales se les realizó posteriormente una recontrucción mamaria con colgajo autólogo. Método: localizar la arteria perforante responsable de la irrigación del colgajo que sería utilizado para la reconstrucción mamaria. Se correlacionaron los hallazgos de la Angio TCMD con el Doppler de Ultrasonidos intraoperatorio y posteriormente con los hallazgos de la disección quirúrgica. Conclusión: La Angio TCM con recontrucción tridimensional fue sumamente útil en la elección y ubicación de la arteria perforante de mayor calibre y menor trayecto intramuscular, convirtiendose en una excelente herramienta prequirúrgica para la planificación del colgajo de perforantes. Esto le permitió una reducción significativa del tiempo quirúrgico disminuyendo la morbimortalidad intra y postoperatoria.