Clinical role of lung ultrasound for diagnosis and monitoring of COVID-19 pneumonia in pregnant women

Lung ultrasound has been suggested recently by the Chinese Critical Care Ultrasound Study Group and Italian Academy of Thoracic Ultrasound as an accurate tool to detect lung involvement in COVID-19. Although chest computed tomography (CT) represents the gold standard to assess lung involvement, with a specificity superior even to that of the nasopharyngeal swab for diagnosis, lung ultrasound examination can be a valid alternative to CT scan, with certain advantages, particularly for pregnant women. Ultrasound can be performed directly at the bed-side by a single operator, reducing the risk of spreading the disease among health professionals. Furthermore, it is a radiation-free exam, making it safer and easier to monitor those patients who require a series of exams. We report on four cases of pregnant women affected by COVID-19 who were monitored with lung ultrasound examination. All patients showed sonographic features indicative of COVID-19 pneumonia at admission: irregular pleural lines and vertical artifacts (B-lines) were observed in all four cases, and patchy areas of white lung were observed in two. Lung ultrasound was more sensitive than was chest X-ray in detecting COVID-19. In three patients, we observed almost complete resolution of lung pathology on ultrasound within 96 h of admission. Two pregnancies were ongoing at the time of writing, and two had undergone Cesarean delivery with no fetal complications. Reverse transcription polymerase chain reaction analysis of cord blood and newborn swabs was negative in both of these cases. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

How to perform lung ultrasound in pregnant women with suspected COVID-19

Under certain circumstances, such as during the current COVID-19 outbreak, pregnant women can be a target for respiratory infection, and lung examination may be required as part of their clinical evaluation, ideally while avoiding exposure to radiation. We propose a practical approach for obstetricians/gynecologists to perform lung ultrasound examination, discussing potential applications, semiology and practical aspects, which could be of particular importance in emergency situations, such as the current pandemic infection of COVID-19. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Imaging assessment of portal venous system: pictorial essay of normal anatomy, anatomic variants and congenital anomalies

The purpose of this pictorial essay is to describe anatomic variants and congenital anomalies of portal venous system and related liver parenchymal alterations. The imaging findings of some of these entities have been previously described in other articles, however this work encompasses all congenital anomalies of portal venous system with attention to their features on various imaging modalities; in particular we illustrated with detailed pictures all the main portal vein variants, congenital extra- and intra-hepatic porto-systemic venous shunts and portal vein aneurysm. Variants of portal branches and intrahepatic portosystemic shunts are quite uncommon, however, when present, they should be recognized before performing surgery or interventional procedures. Congenital absence of the portal vein is an important finding as the complete loss of portal perfusion predisposes the liver to focal or diffuse hyperplastic or dysplastic changes. Portal vein aneurysm is a rare clinical entity that can affect intra- and extra-hepatic portal branches; although usually asymptomatic, thrombosis can occur. Awareness of congenital variants of portal venous system among radiologists should allow a more confident diagnosis and permit an accurate planning of surgical procedures and percutaneous interventions; identification of portal system anomalies also suggest an accurate evaluation of associated hepatic parenchymal anomalies such as nodular regenerative hyperplasia, focal nodular hyperplasia (FNH), and adenomas with high risk of malignant transformation.

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.

Serum level of testosterone, dihydrotestosterone and IGF-1 during an acute exacerbation of COPD and their relationships with inflammatory and prognostic indices: a pilot study

AIM

Acute exacerbations (AECOPD) of negatively influence the natural history of chronic obstructive pulmonary (COPD) and they are related to muscle dysfunction. In this pathway hypogonadism could play a pivotal role. Our study wants to evaluate possible relationships among prognostic indexes of AECOPD, represented by Acute Physiology and Chronic Health Evaluation (APACHE) II, inflammation (serum amyloid A, SSA) and anabolic hormones, especially less studied steroids, like dihydrotestosterone (DHT) e free-testosterone (f-T).

METHODS

Twenty-four patients (17 males; age 75 ± 13 yrs) were studied. On admission and at discharge a blood sample for total testosterone (T), DHT, insulin like grow factor 1 (IGF-1) and Serum Amyloid A (SSA) was obtained. f-T was calculated using Vermeulen's formula.

RESULTS

Descriptive statistical analysis shows reduced of T values (1.85 ± 2.28 ng/mL), f-T (0.028 ± 0.030 ng/mL), DHT (0.18 ± 0.19 ng/mL) and IGF-1 (91.840 ± 74.19 pg/mL). Calculating tertile for Apache II and SSA and using them as cut off point, three categories were made and used in the analysis (SSA< 10 mg/mL; 10-160 mg/mL; > 160 mg/mL); (APACHE II ≤ 10; 11-12; > 12). Using this classification, an inverse correlation between SAA and T (P = 0.01), f-T (0.01), DHT (0.001) and IGF-1 (P = 0.05) was found. Data show the same inverse relationship between APACHE II tertiles on one hand and T (P = 0.01) and f-T (P = 0.02) on the other hand.

CONCLUSION

Our data confirm systemic effects of AECOPD and the role of endocrinological derangements, suggesting a possible mechanism explaining them.

Outcomes and indications for intervention in non-operative management of paediatric liver trauma: a 5 year retrospective study

AIM

To determine the applicability of accurate computed tomography (CT) evaluation and embolization as non-operative management for liver trauma in a paediatric population.

MATERIAL AND METHODS

A retrospective observational study of 37 children (mean age 10.5 years) with hepatic trauma (28 blunt, 9 penetrating) admitted to a trauma referral centre over a 5 year period. All patients were evaluated with CT and scored with an Association for the Surgery of Trauma score. Inpatient information was reviewed for demographics, associated injuries, modes of management, efficacy and complications of management, and outcome.Statistical analysis was performed.

RESULTS

There were seven contusions, two grade I, two grade II, nine grade III, and 17 grade IV liver lacerations. Only two patients (grade IV, penetrating) underwent surgery for the management of bowel perforation. All children had non-surgical treatment of their liver trauma: three cases (grade IV) had primary angiography due to CT evidence of active bleeding and embolization was performed in two of these. Seven patients (two grade III, five grade IV)had angiography during the follow-up for evidence of a complicating pseudoaneurysm and embolization was performed in six of them. Embolization was successful in all the children; one minor complication occurred (cholecystitis). Endoscopic retrograde cholangiopancreatography (ERCP) plus stenting was performed in two cases for a bile leak. All 37 children had a positive outcome.

CONCLUSION

The present study demonstrates that non-operative management of hepatic trauma is applicable to children and may have a higher success rate than in adults.

Hepatic splenosis presenting as arterialised liver lesion in a patient with NASH

INTRODUCTION

Splenosis represents the heterotopic autotransplantation of splenic tissue after a traumatic splenic rupture and splenectomy. It is not a rare condition and it is estimated to occur in up to 67% of patients with traumatic splenic rupture.

CASE REPORT

We report one case of patient, affected by non alcoholic steatohepatitis (NASH), with a hypervascularised liver lesion, that the final histological examination revealed hepatic splenosis. This is a rare condition that may be misinterpreted as adenoma or hepatocellular carcinoma (HCC). Imaging techniques and features that might contribute to the diagnosis and may avoid invasive treatment are also discussed. Although hepatic splenosis is a rare condition, this diagnosis should be considered in patients with previous history of abdominal trauma and then the diagnosis of splenosis may be confirmed by Tc-99m-DRBC scintigraphy, avoiding biopsy or further surgery.

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.

Post-natal ultrasound morpho-dynamic evaluation of mild fetal hydronephrosis: a new management

BACKGROUND

Fetal hydronephrosis is the most common anomaly detected on antenatal ultrasound examination, affecting 1-5% pregnancies.

AIM

A new management in mild antenatal renal pelvis dilatation (ARPD), using a technique based on both morphological and dynamical evaluation.

MATERIALS AND METHODS

Prospective study conducted during a 36-months period in 180 consecutive newborns referred as having mild ARPD. Examinations consisted in a morphological ultra-sound (US) scan evaluating antero-posterior diameter, renal parenchyma, ureteral evidence and pelvis morphology and, subsequently, a dynamic evaluation to analyze any change of the urinary tract during bladder voiding. All children were evaluated both at 3rd day and 1 month after birth. They were divided among those with negative examinations and those with at least one positive scan, trying to discriminate within the latter, children suspected for transient pyelectasis from those suspected for organic pathology.

RESULTS

108 patients had normal US findings both at birth and at 1 month. The remaining 72 babies had at least one abnormal US examination: 54 were suspected for transient pyelectasis, while 18 suspected for organic pathology. At the end of the study, 61 babies (33.9%) had final diagnosis of transient pyelectasis and 11 cases (6.1%) of organic pathology. At one month the dynamic pattern of US findings had the highest negative predictive value, while renal parenchyma evaluation has the highest accuracy.

CONCLUSIONS

a dynamic US approach allowed to better select among infants suspected for transient pyelectasis from those suspected for organic pathology, avoiding unnecessary and invasive examinations in healthy babies.

Fluoroscopically guided balloon dilatation for the treatment of achalasia: long-term outcomes

To report the immediate and long-term outcomes following the fluoroscopically guided balloon dilatations performed in our department for the treatment of achalasia. We reviewed retrospectively all patients that underwent a fluoroscopically guided balloon dilatation because of achalasia in our department between April 2007 and September 2010. The follow-up was performed by interviews and/or investigation of the patient's medical and imaging records. The primary endpoints of the study were technical success, clinical success, major complication rates, and repeat dilatation rates because of recurrence of clinical symptomatology. Secondary endpoints were the rate of minor complications and the dilatation-free interval. Various parameters that could affect the clinical outcome were also analyzed. Thirty-nine consecutive patients (20 female) with a mean age 44 ± 17 years underwent 69 dilatations, while 10/39 (25.6%) patients had a history of a previous laparoscopic myotomy. The most common symptom was dysphagia (64/69, 92.7%), while regurgitation and/or retrosternal pain were present in 12/39 (30.7%) and 9/39 (23%) of the cases, respectively. Technical success was achieved in 98.5% (68/69). There were no procedure-related major complications. The mean balloon diameter used was 30 ± 3.9 mm, and the mean period of follow-up was 27.7 ± 16.0 months. Excellent or good initial responses were noted in 54/66 cases (81.8%). A repeated dilatation to deal with recurrence of symptoms was performed in 69.4% of the cases (25/36). In the majority of the cases, two dilatations were needed in order to achieve long-term relief from symptoms. A dilatation-free interval of 4 years was observed in 26.4%. Clinical success was achieved in 30/36 patients (83.3%). Subgroup analysis did not detect significantly different recurrence rates in patients with and without previous laparoscopic myotomy (50% vs. 69% respectively), those of young age (75% < 21 years vs. 68.8% > 21 years), and male gender (71.4% male vs. 55.0% females). The high redilatation rate was attributed to the utilization of smaller balloons by less experienced operators. Fluoroscopically guided balloon dilatation is a safe and effective method for the treatment of achalasia. Young age and prior Heller's laparoscopic myotomy were not associated with increased rates of recurrence rate or clinical failure.

Chest pain caused by tracheostomy tube malposition: the importance of choosing the right tube

We describe a case of chest pain caused by tracheostomy tube malposition in a 65-year old woman with chronic respiratory failure due to chronic obstructive pulmonary disease. This report highlights the importance of the correct choice of tracheostomy tube devices for mechanically ventilated and/or spontaneously breathing patients.