Multidisciplinary Approach to the Diagnosis and In-Hospital Management of COVID-19 Infection: A Narrative Review

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2 or COVID-19 disease) was declared a pandemic on 11th March 2020 by the World Health Organization. This unprecedented circumstance has challenged hospitals' response capacity, requiring significant structural and organizational changes to cope with the surge in healthcare demand and to minimize in-hospital risk of transmission. As our knowledge advances, we now understand that COVID-19 is a multi-systemic disease rather than a mere respiratory tract infection, therefore requiring holistic care and expertise from various medical specialties. In fact, the clinical spectrum of presentation ranges from respiratory complaints to gastrointestinal, cardiac or neurological symptoms. In addition, COVID-19 pandemic has created a global burden of mental illness that affects the general population as well as healthcare practitioners. The aim of this manuscript is to provide a comprehensive and multidisciplinary insight into the complexity of this disease, reviewing current scientific evidence on COVID-19 management and treatment across several medical specialties involved in the in-hospital care of these patients.

Lenograstim in the treatment of severe neutropenia in patients treated with Peg-IFN and ribavirin: the experience of a single hepatology unit

Lenograstim is a G-CSF that allows therapy with Peg-IFN-alpha to be continued in cases of haematotoxicity. This study evaluates the efficacy of lenograstim administration in a group of eight patients with chronic HCV-related hepatitis who developed neutropenia during antiviral treatment. Patients with absolute neutrophil counts less than 900 cells/mmc and early viral response received lenograstim at the dosage of 263 mcg 24 hours prior to administration of Peg-IFN alpha 2b. All patients receiving lenograstim completed the antiviral treatment (48 weeks) with standard doses of PEG-IFN alpha, with six of the eight patients (75%) showing a sustained virological response.

Vascular endothelial growth factor monitoring in advanced hepatocellular carcinoma patients treated with radiofrequency ablation plus octreotide: a single center experience

Local therapies such as radiofrequency ablation (RFA) represent a valuable choice in limited hepatocellular carcinoma (HCC) and are increasingly used also in advanced tumors. Medical treatments generally gave frustrating results in advanced HCC especially if comorbidities exist. Several biologic non-chemotherapeutic drugs are currently tested in HCC and, among them, octreotide was evaluated in single series of HCC patients reporting conflicting results. We have treated a series of 35 patients affected by advanced HCC (26 M and 9 F; age range: 55-85 years, median: 73 years) with RFA followed by octreotide to primarily evaluate the safety of combined treatment and to give preliminary evaluation on its activity. We have also evaluated serum VEGF changes during the study. Child A and Child B represented 60% and about 34% of the cases, respectively. Only two patients with Child C compensated cirrhosis were included in this study. All patients have multiple liver HCC nodules and one had bone metastases. Two complete responses, 3 partial responses and 23 disease stabilization for at least three months were obtained (overall response rate, 14,2%; clinical benefit, 80%). Mean overall survival was 31.4 months. The combined treatment was well tolerated. Statistically significant correlation was found between serum VEGF and tumor progression. In conclusion, the combination of RFA and octreotide was active in advanced HCC, however, confirmation in a larger series is required.

Tailored combined treatment with radiofrequency ablation plus octreotide in advanced hepatocellular carcinoma

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Background: Local therapies represent a valuable choice in small hepatocellular carcinoma (HCC), however, radiofrequency ablation (RFA) is increasingly used in advanced tumors. Medical treatments generally gave frustrating results in advanced hepatocellular carcinoma. Several biological non chemotherapeutic drugs are currently tested in HCC. Based on the expression of somatostatin receptor subtypes by HCC and the tolerability profile, octreotide was evaluated in single cases and small series of HCC patients and conflicting results are reported. Methods: 35 advanced HCC (26 males, 9 females; age range 55–85 years, median 73 years) were treated with RFA and octreotide with the aim to evaluate safety and determine the effect on disease control and survival. Testing regular and increasing doses of long-acting octreotide (from 20 to 30 mg monthly) were planned in the treatment schedule. Child A and Child B patients were 60% and about 34% of the cases, respectively. Only two patients with Child C compensated cirrhosis were included. All patients have multiple liver HCC nodules and one had bone metastases. Treatment with octreotide was maintained until disease progression or unacceptable toxicity. RFA was performed before or during treatment with octreotide according to medical evaluation. Results: In the majority of patients (65,7%) stable disease was obtained. In 3 patients (8,5%) progression of disease was documented. Clinical progression of underlying cirrhosis was identified in four patients and appear to condition the outcome, independently from HCC. Both medical and local treatments were well tolerated. Statistical evaluation was presented at ASCO 2007. Conclusions: The combined treatment with RFA and octreotide can be feasible in advanced HCC patients.

No significant financial relationships to disclose.

Diagnosis of benign and malignant portal vein thrombosis in cirrhotic patients with hepatocellular carcinoma: color Doppler US, contrast-enhanced US, and fine-needle biopsy

BACKGROUND

We assessed the role of contrast-enhanced ultrasound (CEUS) in the differential diagnosis between benign and malignant portal vein thrombosis in patients who had cirrhosis with hepatocellular carcinoma (HCC).

METHODS

Fifty-four consecutive patients who had cirrhosis, biopsy-proved HCC, and thrombosis of the main portal vein and/or left/right portal vein on US were prospectively studied with color Doppler US (CDUS) and CEUS. CEUS was performed at low mechanical index after intravenous administration of a second-generation contrast agent (SonoVue, Bracco, Milan, Italy). Presence or absence of CDUS signals or thrombus enhancement on CEUS were considered diagnostic for malignant or benign portal vein thrombosis. Twenty-eight patients also underwent percutaneous portal vein fine-needle biopsy (FNB) under US guidance. All patients were followed-up bimonthly by CDUS. Shrinkage of the thrombus and/or recanalization of the vessels on CDUS during follow-up were considered definitive evidence of the benign nature of the thrombosis, whereas enlargement of the thrombus, disruption of the vessel wall, and parenchymal infiltration over follow-up were considered consistent with malignancy. CDUS, CEUS, and FNB results were compared with those at follow-up.

RESULTS

Follow-up (4 to 21 months) showed signs of malignant thrombosis in 34 of 54 patients. FNB produced a true-positive result for malignancy in 19 of 25 patients, a false-negative result in six of 25 patients, and a true-negative result in three of three patients. CDUS was positive in seven of 54 patients. CEUS showed enhancement of the thrombus in 30 of 54 patients. No false-positive result was observed at CDUS, CEUS, and FNB. Sensitivities of CDUS, CEUS, and FNB in detecting malignant thrombi were 20%, 88%, and 76% respectively. Three patients showed negative CDUS and CEUS and positive FNB results; follow-up confirmed malignant thrombosis in these patients. One patient showed negative CDUS, CEUS, and FNB findings. However, follow-up of the thrombus showed US signs of malignancy. Another FNB confirmed HCC infiltration of the portal vein.

CONCLUSION

CEUS seems to be the most sensitive and specific test for diagnosing malignant portal vein thrombosis in patients with cirrhosis.

Seeding from hepatocellular carcinoma after percutaneous ablation: color Doppler ultrasound findings

BACKGROUND

We describe the clinical and color Doppler ultrasound findings in a series of cases of seeding from hepatocellular carcinoma (HCC) observed in patients treated with percutaneous ablation therapy (PAT) over a 15-year period.

METHODS

We reviewed the clinical and imaging records of 12 patients with cirrhosis (nine men and three women, age range 51-82 years, mean age 63 years) that showed neoplastic seeding from HCC occurring after one or more PAT procedures. Five of 12 cases of seeding were observed as a complication of 1080 PAT procedures (0.46%) performed in 545 patients (0.96%) by two of the authors (L.T., G.F.) over a long period (15 years) at different institutions. The other seven patients had been treated with PAT procedures at other institutions and had come to our attention during post-treatment follow-up.

RESULTS

The 12 patients who had seeding nodules had undergone the following PAT procedures: multisession conventional percutaneous ethanol injection (PEI) without anesthesia (four patients), single-session PEI with general anesthesia (three patients), single-session PEI with general anesthesia plus multisession conventional PEI (four patients), and single-session PEI plus radiofrequency ablation (one patient). Seeding nodules ranged from 0.9 to 6.0 cm (mean 1.7 cm). Eleven of 12 seeding nodules appeared as hypervascular hypoechoic nodules with smooth and regular margins and multiple intralesional vascular signals.

CONCLUSIONS

Clinical and imaging findings of seeding from HCC should be recognized by physicians who perform follow-up ultrasound examinations of patients who are treated with PAT. Early diagnosis of seeding can be reliably made by scanning the abdominal wall with small probes in the area where the previous PAT has been performed. Hypoechoic hypervascular pattern of the seeding nodule allows definitive diagnosis.

[Interstitial laser photocoagulation in liver tumours: our experience]

Interstitial lasertherapy (ILT) is one of the percutaneous thermal procedures allowing the ablation of primary or secondary hepatic lesions. This technique can be performed without general anaesthesia, since the patient is completely painless, in spite of the high temperatures reached, because there are no sensitive fibers around the lesion. This study includes patients with small hepatocarcinomas (< 2 cm) non peripherically sited, far from the gallbladder and the hepatic hilum. Twenty patients suffering from 24 cirrhotic hepatocarcinomas (two patients showed two nodules) have been enrolled for the present study. Mean diameter of lesions was 1.8 cm (1.3-2 cm). One or more 21 G (length 20 cm) Chiba's needles were inserted under sonographic view into the lesions. The laser energy was switched on at 4 Watts for 4-6 minutes, until an amount of energy of 900-1800 Joule was reached. All the patients were discharged 48 hours after the procedure. Triphasic CT-scan with contrast were performed 7 to 14 days after ILT, in order to check its efficacy. CT-scan showed complete necrosis in all the nodules ranging from 1.5 to 3 cm. All the patients received only one IL T session, whose longest duration was 20 minutes. No major complications occurred. ILT of small hepatocarcinomas is a safe, efficient procedure, also feasible without anaesthesia. Differently from percutaneous radiofrequency, in fact, it shows the advantage of less pain, that can avoid the need for general anaesthesia.

[Interstitial laser treatment of small hepatocarcinoma on cirrhosis without anesthesia: feasibility study]

OBJECTIVE

We evaluated if interstitial laser photocoagulation (ILP) under ultrasound (US) guidance of intraparenchymal small HCC (<2 cm) in cirrhosis can be safely and effectively performed without any anesthesia.

PATIENTS AND METHODS

Twelve cirrhotic patients with 14 nodules of HCC (diameter 1.2-2.0 cm; mean: 1.7) underwent ILP. All procedures were performed without local or general anesthesia. Necrosis of the nodules was evaluated with triphasic contrast-enhanced CT.

RESULTS

Post-treatment CT showed complete necrosis in all cases. Pain occurred in 5 patients during the treatment was treated with iv pain-killer and only in 1 case the procedure was stopped before the scheduled time. No major complication occurred.

CONCLUSIONS

ILP under US guidance is feasible without any anesthesia in patients with small intraparenchymal HCC.

[Diagnosis of disseminated mycobacterial infection in AIDS patients by US-guided fine needle aspiration biopsy of lymphnodes and spleen]

Our aim was to evaluate the efficacy of abdominal US and fine-needle aspiration biopsy (FNAB) in the diagnosis of disseminated mycobacteriosis (DM) in patients with Acquired Immunodeficiency Syndrome (AIDS). We reviewed the US and clinical records of 18 AIDS patients (12 males; 22-43 years) with DM studied with abdominal US. 18 patients underwent fine-needle aspiration biopsy of enlarged abdominal lymphnodes and 11 underwent FNAB of the spleen. All aspirates were studied with acid-fast stain for fast examination and cultures for isolation of mycobacteria. Abdominal US showed: enlarged abdominal lymphnodes (diameter range: 5-35 mm; mean 17 mm) splenomegaly (spleen diameter range: 14-22 cm; mean: 16.2 cm) and hepatomegaly (right hepatic lobe thickness range: 14.5-18.5 cm) in all patients; multiple splenic abscesses (diameter range: 3-20 mm) in 11 patients; small intestine wall thickening in 5 patients (maximum bowel wall thickness range: 7-15 mm); mild to moderate ascites in 8 patients; pleural effusion in 4 patients; hyperechogenicity of the kidney cortex in 5 patients; peritoneal abscesses in one and a retroperitoneal abscess in one patient. fast-acid-stain of spleen and/or lymphnode FNAB specimens allowed early diagnosis of mycobateriosis in 18/18 cases (100%). Cultures of lymphnode aspirates grew mycobacteria in 10/18 patients (56%). Spleen aspirates grew mycobacteria in 11/11 patients (100%) Blood cultures were positive in 6/18 patients (33%). Diagnosis of species was M. tuberculosis in 9 and M. avium in 6 patients. In 3/18 patients (17%) all cultures were negative. In conclusion, abdominal US features suggest DM in AIDS patients. Spleen and/or lymphnode FNAB allows a specific diagnosis in 100% of the patients.

Disseminated mycobacterial infection in AIDS patients: abdominal US features and value of fine-needle aspiration biopsy of lymph nodes and spleen

BACKGROUND

We evaluated the efficacy of abdominal ultrasound (US) and fine-needle aspiration biopsy (FNAB) in the diagnosis of disseminated mycobacteriosis (DM) in acquired immunodeficiency syndrome (AIDS).

METHODS

Twelve AIDS patients (nine male, three female; age range, 22-43 years) with DM underwent abdominal US within 2 days after admission with 3.5- to 5-MHz convex probes and a 7.5-MHz linear probe. All patients underwent FNAB of one or two enlarged abdominal lymph nodes. Eight patients underwent FNAB of the spleen. The aspirated specimens were stained with acid fast for quick examination and cultured for isolation of mycobacteria.

RESULTS

Abdominal US showed enlarged, hypoechoic, round or oval, abdominal lymph nodes (diameter, 10-35 mm; mean, 18 mm) in all patients; splenomegaly (spleen diameter, 14-22 cm; mean, 16.8 mm) in all patients; numerous splenic abscesses (diameter, 3-20 mm) in nine patients; hepatomegaly (right hepatic lobe thickness, 14.5-17 cm) in all patients; small intestinal wall thickening in five patients (maximum bowel wall thickness, 7-15 mm); mild to moderate ascites in six patients; pleural effusion in four patients; bilateral enlargement of the kidneys with hyperechogenicity of the cortex in three patients; and a retroperitoneal tubercular abscess in one patient. No complication occurred after FNAB of lymph nodes and spleens. Fast-acid stain of spleen and/or lymph node FNAB specimens allowed early diagnosis of mycobacteriosis in 12 of 12 cases (100%). Cultures of lymph node aspirates grew mycobacteria in six of 12 patients (50%). Spleen aspirates grew mycobacteria in nine of nine patients (100%). Blood cultures were positive in four of 12 patients (33%). Mycobacterium tuberculosis was diagnosed in six patients and M. avium in five.

CONCLUSION

Abdominal US features can suggest DM in AIDS patients. Spleen and/or lymph node FNAB indicated the specific diagnosis in 100% of patients.

Turner's syndrome mosaicism 45X/47XXX: an interesting natural history

Mosaicism 45X/47XXX is a sporadic form of ovarian dysgenesis. Many of the cases previously described were characterized by a variable phenotype expression. We here report the case of a 33-yr-old woman with recent secondary amenorrhea, weight loss and breast regression. Her menarche had occurred at the age of 11 yr and 6 months and her menstrual cycles had been regular until the age of 28; then, oligomenorrhea and hypertricosis developed. A pelvic ultrasound showed enlarged polycystic-like ovaries and normal uterus. She was treated with ethynil-estradiol and cyproterone acetate for one year. At the age of 31 yr, she underwent a pelvic ultrasound--which revealed normal volume of the ovaries--and hormonal assays including FSH (69 UI/l), LH (113 UI/l), 17beta-estradiol (88 pg/ml), plasma androgens and cortisol levels within normal ranges. No organ-specific autoantibodies toward ovaries, steroid-producing cells or adrenals were found. At the age of 33 yr, there was ultrasound evidence of streak-like ovaries. The patient's height was 145 cm and her weight 45 kg. She had normal female external genitalia, abnormal upper-to-lower body segment ratio, webbed neck, low posterior hair line, cubitus valgus, short and asymmetrical 4th metacarpi, hallux with lateral deviation and moderate scoliosis. No increase in ovarian steroids were found after GnRH-analogue triptorelin (0,1 mg sc) administration. The karyotype analysis on peripheral blood lymphocytes showed a mosaic 45X (90% cells) and 47XXX (10% cells). Diagnostic pelviscopy confirmed streak gonads. Chronic lymphocytic thyroiditis was diagnosed but no cardiovascular or kidney abnormalities were found. A neuro-psychological evaluation revealed emotional and social immaturity, disorders in motorial coordination, visual-spatial organization, as well as reading difficulties and impaired complex phrase construction. The presence of several somatic features of Turner's syndrome, neuro-psychological disorders and an interesting natural history probably depended on the quantitative proportion of 45X to 47XXX cell-lines in different tissues and organs. Estrogen and progestin replacement therapy led to weight gain, re-appearance of secondary sexual characteristics and a mild improvement in mental equilibrium.

Echo color Doppler findings in postpubertal mumps epididymo-orchitis

OBJECTIVE

To describe echo color Doppler features of mumps epididymo-orchitis in postpubertal boys and men.

METHODS

Color Doppler ultrasonographic examinations of the scrotum in 12 patients (14-34 years old) with serologically proven mumps and symptomatic epididymo-orchitis (pain and scrotal swelling) were compared with color Doppler ultrasonographic examinations of the scrotum in 10 healthy control subjects.

RESULTS

Clinically evident testicular involvement was bilateral in 1 patient and unilateral in 11 patients (9 left- and 2 right-sided). Four (33.3%) of 12 patients had swelling and a heterogeneous echo texture of the epididymis and hydrocele. Two (16.7%) of 12 patients had swelling of both the epididymis and didymus of the involved side, with a heterogeneous echo texture of the didymus due to hypoechoic, irregularly shaped, confluent intraparenchymal areas. Two (16.7%) of 12 patients had only unilateral mild hydrocele and no testicular abnormalities. In 4 (33.3%) of 12 cases, B-mode ultrasonographic examination did not show any testicular abnormalities or hydrocele. Hydrocele was anechoic in 4 cases and multiseptated in 4. In 12 (100%) of 12 patients, color Doppler and power Doppler ultrasonography showed hypervascularity in the parenchyma of the affected testicle. In 11 patients, spectral Doppler examination of the arteries at the testicular hilum showed a significantly lower mean +/- SD resistive index (0.54 +/- 0.03; range, 0.48-0.57) on the inflamed side compared with the opposite unaffected side (mean, 0.66 +/- 0.04; range, 0.71-0.60) (P < .001). In the patient with bilateral involvement, the mean resistive index values in the right and left testicular arteries were 0.57 and 0.55, respectively. The mean resistive index of the 13 inflamed testicles (0.54 +/- 0.03; range, 0.48-0.57) was significantly different from the mean resistive index values of the right (0.68 +/- 0.03) and left (0.67 +/- 0.04) testicular arteries in healthy control subjects (P < .001). The mean resistive index in the 11 unaffected testicles in our patients (0.66 +/- 0.04; range, 0.71-0.60) was not significantly different from the mean resistive index in healthy control subjects. CONCLUSION. Ultrasonographic findings in mumps orchitis are not specific. Echo color Doppler examination is more sensitive than ultrasonography alone for revealing testicular inflammation.

Transabdominal sonography of the normal gastroesophageal junction in children

PURPOSE

Because sonography identifies abnormalities of the gastroesophageal junction, it is essential to understand the normal sonographic anatomy. The aim of this study was to determine the normal sonographic appearance of the gastroesophageal junction and its variations and to provide measurements of the abdominal esophagus in asymptomatic, healthy children.

METHODS

In this prospective study, 124 healthy children (75 boys and 49 girls), aged 2 days-12 years, underwent abdominal sonography. With the patient in a supine position, the transducer was placed under the xiphoid and the ultrasound beam was directed cephalad through the window of the left lobe of the liver. The length of the abdominal esophagus was measured from the point at which it penetrated the diaphragm to the gastroesophageal junction. The thickness was measured on the anterior wall at the midpoint of the abdominal esophagus.

RESULTS

The gastroesophageal junction was identified by sonography in all of the children. The mean length of the abdominal portion of the esophagus ranged from 18 mm in the newborns to 34 mm in children older than 6 years. The wall thickness ranged from 2.4 mm to 5.7 mm.

CONCLUSIONS

Our results indicate that visualization of the gastroesophageal junction and measurement of the abdominal esophagus are readily achievable with real-time sonography in healthy children.

Hydatid liver cyst: an 11-year experience of treatment with percutaneous aspiration and ethanol injection

OBJECTIVE

To report an 11-year experience of treatment of hydatid liver cysts with double percutaneous aspiration and injection of alcohol.

METHODS

Of the 129 patients with 174 hydatid liver cysts admitted to our department between January 1988 and January 1999, 79 patients with 119 vital hydatid liver cysts were selected for double percutaneous aspiration and injection of alcohol. Under ultrasonographic guidance, cystic cavities were first drained through fine needles, and then 95% sterile ethanol was injected and left in situ. The same procedure was repeated 3 days later without reaspiration of the injected alcohol. General anesthesia without endotracheal intubation was performed in 21 selected cases.

RESULTS

Double percutaneous aspiration and injection of alcohol was completed in 78 patients with 118 hydatid liver cysts. In 1 case the procedure could not be accomplished because of an intracystic hemorrhage. A total of 254 punctures were performed, and the ethanol injected per session ranged between 12 and 250 mL. The mean hospital stay was 2.9 days (range, 2-7 days). The overall median follow-up was 48 months (range, 6-122 months). At the last ultrasonographic examination, 45.8% of the treated hydatid liver cysts had a solid pattern, 47.4% were no longer appreciable, and 6.8% had a minimal liquid component. Intracystic relapse occurred in 5% of the patients. In no case were any new cysts observed either in different hepatic segments or in any extrahepatic location. The morbidity rate was 9%, and 1 death occurred (mortality rate, 1.3%).

CONCLUSIONS

Over a long period, double percutaneous aspiration and injection of alcohol proved to be a substantially safe, effective, and low-cost procedure for hydatid liver cyst treatment.

Ultrasound-guided percutaneous ethanol injection under general anesthesia for the treatment of hepatocellular carcinoma on cirrhosis: long-term results in 268 patients

OBJECTIVE

Percutaneous ethanol injection (PEI) under general anesthesia (One-shot PEI) is a therapy for large and multiple hepatocellular carcinoma (HCC) by the injection of a large amount of ethanol into the tumor. We report our results with 5-year survival rates in patients with HCC on cirrhosis treated with One-shot PEI.

PATIENTS AND METHODS

From October 1992 to March 1998, 268 cirrhotic patients (age 42-82 years; 191 males; 95 Child-Pugh's A class, 150 B and 23 C class of cirrhosis) with 515 HCC nodules underwent One-shot PEI. Diameter of HCC nodules ranged from 0.6 to 14 cm (mean 5.02 +/- 2.2 cm; median: 4 cm). One hundred and thirty-eight patients had a single nodule (range 3.2-14 cm; mean 5.6 +/- 2.1 cm), 130 had multiple nodules, up to six nodules (mean 2.9 nodules) (range 0.6-11 cm; mean 4.8 +/- 2.1 cm)

RESULTS

CT showed complete necrosis in 357/506 nodules (70%). Five patients (1.8%) with nine nodules died as a result of the procedure (variceal bleeding in three cases, liver failure in one and hemoperitoneum in one). The overall survival rates were 93, 83, 74, 65 and 59% at 1, 2, 3, 4 and 5 years, respectively. Survival rates were 90, 84, 82 and 82% at 12, 24, 36 and 48 months, respectively, in patients with a single nodule less than or = 5 cm, and 97, 71, 59, 59 and 59% at 12, 24, 36, 48 and 60 months, respectively, in patients with single nodule >5 cm. Patients with multiple nodules had survival rates of 97, 89, 75, 60 and 60% at 12, 24, 36, 48 and 60 months, respectively.

CONCLUSION

PEI of large and multiple HCC showed survivals similar to conventional PEI for patients with smaller tumors.

[Ultrasonography in the diagnosis of post-pubertal epidemic parotitis and its complications]

PURPOSE

To assess the yield of US in the study of salivary glands and other organs involved in post-pubertal mumps.

PATIENTS AND METHODS

We examined 68 patients with serologically proven post-pubertal mumps (age range 14-34 years). All patients were symptomatic, with fever and salivary gland swelling in 25 cases, marked hyperamylasemia in 32, epigastric pain in 9, unilateral scrotal swelling and/or pain in 19 cases and acute bronchitis in 1 case. All patients underwent US of salivary glands, neck lymph nodes, abdomen and scrotum with 48 hours of admission.

RESULTS

Salivary glands: Parotid and submandibular glands showed normal echotexture in all patients. The parotid glands also showed multiple hypeoechoic intraparenchymal lymph nodes which were, ovoid or rounded, with smooth margins and a central hyperechoic area, with diameter ranging 3-14 mm (mean 5.4). No intraparenchymal lymph nodes were observed in submandibular glands. Neck: All patients had enlarged submandibular lymph nodes (maximum diameter ranging 5-22 mm; mean 11 mm); swelling was always bilateral and it was symmetric in 19/68 patients (30%) versus asymmetric because of prevailing right side involvement (more numerous and bigger nodes) in the other 47/68 cases (70%). All lymph nodes showed a benign pattern, with an ovoid or elongated shape, homogeneous hypoechoic echotexture and a hyperechoic hilum. Abdomen: The pancreas showed normal volume and normal parenchymal echotexture in all patients. Liver and spleen were always normal. Testes: US showed mild unilateral hydrocele in 10 cases, hydrocele and unilateral swelling of epidymis in 5 cases, hydrocele and swelling of both epidymis and didymis with inhomogeneous echotexture because of intraparenchymal hypeoechoic areas in 2 cases. There were no US changes in 2 cases.

CONCLUSIONS

US of the salivary glands shows a specific pattern in post-pubertal mumps which has never been reported for other salivary gland diseases. In contrast US signs in other organs are not specific.

Interstitial laser photocoagulation under ultrasound guidance of liver tumors: results in 104 treated patients

OBJECTIVE

To evaluate the efficacy and complications of interstitial laser photocoagulation (ILP) under ultrasound (US) guidance as a technique for focal ablation of liver tumors in patients with normal and impaired hepatic function.

PATIENTS AND METHODS

A total of 104 patients, 77 with 85 nodules of hepatocellular carcinoma on cirrhosis (29 in Child-Pugh A class, 43 in B e 5 in C class) and 27 patients with hepatic metastases (25 from colon, two from lung carcinoma) underwent ILP under US guidance. Depending on tumor size up to four needles were inserted in the tumor and multiple laser illuminations were performed in one or multiple sessions. Necrosis of the nodules was evaluated with triphasic contrast-enhanced CT.

RESULTS

Ninety-four patients underwent a single ILP session and nine patients two sessions. CT showed complete necrosis in 70 out of 85 HCC nodules in 65 treated patients and in 24 out of 31 patients with metastases. Three Child C class patients dropped out the control of efficacy by CT because of severe liver failure associated in one case with transient paralytic ileum. One of these patients died 2 months after treatment. Two patients with metastasis dropped the completion of the treatment because of complication occurred after the ILP session (one paralytic ileum, one gastric haemorrage).

CONCLUSIONS

ILP under US guidance is effective in inducing complete necrosis in small and large liver tumors. Nevertheless, ILP can cause severe derangement of liver function in patients with advanced cirrhosis.

[The echo-guided interstitial laser photocoagulation of malignant liver tumors. The authors' personal technic, immediate results and short-term complications in patients with normal and altered liver function]

PURPOSE

The literature studies about interstitial laser photocoagulation of liver tumors mainly deal with the treatment of liver metastasis in patients with normal liver function. We report our personal experience with interstitial laser photocoagulation in patients with liver tumors (mostly cirrhotics with hepatocellular carcinoma). Our aim was to evaluate the short term efficacy of percutaneous interstitial laser photocoagulation in inducing focal ablation of liver tumors and the possible complications in patients with normal and impaired liver function.

MATERIAL AND METHODS

Sixty-six patients (52-80 years; 42 men), 47 with 51 hepatocellular carcinoma nodules (diameter = 1.6-6.6 cm; mean 3.1 cm) on cirrhosis (18 in Child-Pugh A class, 24 in B e 5 in C class) and 19 patients with single liver metastasis (17 from colon, 2 from lung carcinoma; diameter = 3.9 cm; mean: 4.5 cm) underwent interstitial laser photocoagulation under ultrasound guidance. Depending on tumor size up to four needles were inserted in the tumor and multiple laser illuminations were performed: in nodules < or = 2 cm a single optical fiber and a single needle insertion were used, in nodules > 2 < 3 cm, 2-3 fibers were used with a single laser illumination, in nodules > 3 < 4 cm, 4 fibers were inserted and two laser illuminations were performed in the same session after 1.5 cm withdrawal of all fibers in the tumor, in nodules > 4 cm 2 sessions with 2 laser illuminations per session were performed. Necrosis of the nodules was evaluated with triphasic Helical CT 7 days after treatment. Patients with incomplete necrosis at CT were treated with additional interstitial laser photocoagulation sessions to attain complete necrosis.

RESULTS

Fifty-eight patients underwent a single interstitial laser photocoagulation session, 7 patients 2 session and 1 patient 3 sessions. The range of administered energy per patient was 1200-32,000 Joules (mean: 6700 J). CT showed complete necrosis of 47 nodules in 43 patients with hepatocellular carcinoma and in 15/18 patients with metastasis. Three Child C class patients with mild ascites and hyperbilirubinemia before procedure (nodules O: 1.9, 3.5 and 5.8 cm) dropped out of CT follow-up because of severe liver function impairment with increased ascites and hyperbilirubinemia, associated with transient ileum paraliticus in 1 case. One of these patients died two months after treatment. Two patients with metastasis dropped out of treatment because of complications occurred after the interstitial laser photocoagulation session (1 ileum paraliticus, 1 gastric hemorrhage) and another one refused to continue the treatment.

Cloning and characterization of the lipooligosaccharide galactosyltransferase II gene of Haemophilus ducreyi

Haemophilus ducreyi is the etiologic agent of chancroid, a genital ulcer disease. The lipooligosaccharide (LOS) is considered to be a major virulence determinant and has been implicated in the adherence of H. ducreyi to keratinocytes. Strain A77, an isolate from the Paris collection, is serum sensitive, poorly adherent to fibroblasts, and deficient in microcolony formation. Structural analysis indicates that the LOS of strain A77 lacks the galactose residue found in the N-acetyllactosamine portion of the strain 35000HP LOS as well as the sialic acid substitution. From an H. ducreyi 35000HP genomic DNA library, a clone complementing the defect in A77 was identified by immunologic screening with monoclonal antibody (MAb) 3F11, a MAb which recognizes the N-acetyllactosamine portion of strain 35000HP LOS. The clone contained a 4-kb insert that was sequenced. One open reading frame which encodes a protein with a molecular weight of 33,400 was identified. This protein has homology to glycosyltransferases of Haemophilus influenzae, Haemophilus somnus, Neisseria species, and Pasteurella haemolytica. The putative H. ducreyi glycosyltransferase gene was insertionally inactivated, and an isogenic mutant of strain 35000HP was constructed. The most complex LOS glycoform produced by the mutant has a mobility on sodium dodecyl sulfate-polyacrylamide gel identical to that of the LOS of strain A77 and lacks the 3F11-binding epitope. Structural studies confirm that the most complex glycoform of the LOS isolated from the mutant lacks the galactose residue found in the N-acetyllactosamine portion of the strain 35000HP LOS. Although previously published data suggested that the serum-sensitive phenotype of A77 was due to the LOS mutation, we observed that the complemented A77 strain retained its serum-sensitive phenotype and that the galactosyltransferase mutant retained its serum-resistant phenotype. Thus, the serum sensitivity of strain A77 cannot be attributed to the galactosyltransferase mutation in strain A77.

Percutaneous ethanol injection of large autonomous hyperfunctioning thyroid nodules

PURPOSE

To verify the effectiveness of percutaneous ethanol injection (PEI) in the treatment of large (>30-mL) hyperfunctioning thyroid nodules.

MATERIALS AND METHODS

Twelve patients (eight women, four men; age range, 26-76 years) with a large hyperfunctioning thyroid nodule (volume range, 33-90 mL; mean, 46.08 mL) underwent PEI treatment under ultrasonographic (US) guidance. US was used to calculate the volume of the nodules and to assess the diffusion of the ethanol in the lesions during the procedure. When incomplete necrosis of the nodule was depicted at scintigraphy performed 3 months after treatment, additional PEI sessions were performed.

RESULTS

Four to 11 PEI sessions (mean, seven) were performed in each patient, with an injection of 3-14 mL of 99.8% ethanol per session (total amount of ethanol per patient, 30-108 mL; mean, 48.5 mL). At scintigraphy after treatment in all patients, recovery of extranodular uptake, absence of uptake in the nodule, and normalization of thyroid-stimulating hormone (thyrotropin) levels were observed. In all patients, US showed volume reductions of 30%-50% after 3 months and 40%-80% after 6-9 months. Side effects were self-limiting in all patients. During the 6-48-month follow-up, no recurrence was observed.

CONCLUSION

PEI is an effective and safe technique for the treatment of large hyperfunctioning thyroid nodules.

Percutaneous ethanol injection under general anesthesia for hepatocellular carcinoma: 3 year survival in 112 patients

OBJECTIVE

percutaneous ethanol injection (PEI) under general anesthesia (One Shot PEI) is a new therapy for large and multiple hepatocellular carcinoma (HCC) by the injection of large amount of ethanol in the tumor. We report our results with 3 years survival rates in patients with HCC on cirrhosis treated with One Shot PEI.

PATIENTS AND METHODS

between October 1992 and July 1996, 112 cirrhotic patients (79 males; age: 45-80; mean: 64 years) with 215 HCC nodules (diameter 0.6-14 cm; mean 4.1 cm) underwent One Shot PEI. Fifty-three patients had a single nodule (diameter=3-14 cm; mean=4. 5 cm), 59 had two or more (two to five) nodules (diameter=0.6-13 cm; mean=4.9). Ethanol injected ranged between 16 and 120 ml per session. Survival rates were calculated according to Kaplan-Meier method and Wilcoxon test was used for statistical analysis.

RESULTS

five patients died within 7 h-10 days after the treatment for rupture of esophageal varices in three cases, rupture of subcapsular HCC in one case and liver failure in one case. In the remaining 107 patients, dynamic CT or spiral CT, performed 72 h-1 month after the treatment, showed complete necrosis in 76 cases (71%) and incomplete necrosis (although always ?50%) in 31. Survival rates at 1, 2, 3 years in all 107 patients were 88, 76, and 76% respectively. Survival rates in Child A Class patients were 100, 92, 92% and in Class B patients were 84, 72, and 72% at 1, 2, 3 years respectively; in Class C were 70 and 40% at 1 and 2 years respectively (P=0.01). Survival rates in patients with single nodule were 95, 82 and 82% at 1, 2 and 3 years, while in patients with multiple nodules were 80, 68 and 58% at 1, 2 and 3 years respectively (P=n.s.). During the follow-up (6-46 months) 48 patients showed intrahepatic recurrences; 41 out of them were retreated with new sessions of One Shot PEI or traditional PEI.

CONCLUSIONS

PEI One Shot is more aggressive than traditional PEI. Survival rates of PEI One Shot seems similar to those obtainable by conventional PEI and even better than surgery.

[Ultrasonography-guided percutaneous ethanol injection in large an/or multiple liver metastasis]

INTRODUCTION

Percutaneous ethanol injection (PEI) under sonographic guidance is an effective therapy for hepatocellular carcinoma on cirrhosis, while less favorable results have been reported for liver metastases. Surgery and/or other new treatments (i.e., interstitial thermotherapy) are indicated only for small metastases (< 3 cm) and surgeons no longer perform the palliative debulking of neoplastic masses.

PATIENTS AND METHODS

From March, 1994, to December, 1997, thirty-three patients with 62 large (> 3.5 cm) and/or multiple liver metastases, who were not eligible for surgery nor thermotherapy, were treated with one-shot PEI under general anesthesia. The diameter of the nodules ranged 35-92 mm (mean: 39); the lesions were single in 15 patients and localized in both the right and the left lobe in 19 patients. 25-110 ml ethanol were injected per session. Post-treatment results were assessed with dynamic or dual-phase spiral CT; therapeutic success was defined as the absence of hyperdense lesion areas.

RESULTS

Complete necrosis of the metastases was shown in 10 patients (30.3%). Necrosis rate ranged 70-90% in 21 patients (64%) and was 50% in 2 patients (5.7%). Survival rates were 94%, 80%, 80% and 44% at 12, 24, 36 and 44 months, respectively. No major complications were observed. Seeding of neoplastic cells along the needle tract has been never observed to date.

DISCUSSION

Metastasis diameter and number impact on long-term survival. PEI under general anesthesia allows to treat also the patients who are not eligible for other treatments and to inject large amounts of ethanol per session in different tumor areas because metastases usually set on in an otherwise healthy liver.

CONCLUSIONS

One-shot PEI can cause major, even complete, tumor necrosis in large and multiple liver metastases. The absence of any important complications and the survival rates in our series seem to indicate that one-shot PEI is effective for tumor debulking in patients not eligible for surgery and other alternative treatments.

Facile construction of mutations in Haemophilus ducreyi using lacZ as a counter-selectable marker

Haemophilus ducreyi is a Gram-negative bacterium which is the causative agent of chancroid, an ulcerative sexually transmitted disease. In order to understand the pathogenesis of H. ducreyi disease, studies designed to identify potential virulence determinants and construct mutants deficient in the elaboration of these determinants have been undertaken in several laboratories. At the present time, construction of isogenic mutants is accomplished by electroporation of linearized DNA containing insertionally inactivated H. ducreyi genes followed by selection for the resistance marker encoded on the inactivated gene. In our experience, certain mutants are difficult to construct using this procedure. In the construction of strains containing lacZ as a reporter gene, we observed that the growth of lacZ expressing H. ducreyi was inhibited in the presence of X-gal. We have exploited this observation to develop a new strategy for the construction of isogenic H. ducreyi mutants.

[Ultrasonography in diagnostic and therapeutic management of the abscesses due to Actinomyces spp]

A case of abscess of masseter muscle by Actinomyces spp. is described. Ultrasound-guided fine needle aspiration allowed diagnosis by cytology. Specific antibiotic treatment was started and US-follow-up showed complete healing of the lesion with restitution ad integrum of the muscle.

Reverse flow in intrahepatic portal vessels and liver function impairment in cirrhosis

Objectives: Our aim was to describe the hemodynamic patterns and assess the prevalence of reversal of flow (RF) in intrahepatic portal vessels (IPV) in patients with chronic active hepatitis (CAH) and patients with cirrhosis. Patients : 100 consecutive patients with CAH, and 178 consecutive cirrhotic patients (48 Child A, 114 Child B and 38 Child C class) underwent Echo-Color-Doppler for evaluation of flow direction in segmental IPV, right and left portal vein (RPV, LPV), in main portal vein (MPV), splenic vein (SV), superior mesenteric vein (SMV) and porto-systemic shunts (paraumbilical, spleno-renal, left gastric vein). The patients were followed-up clinically for 3-15 months. Results: Patients with CAH showed RF in SV in 1/100 and hepatopetal flow in MPV, SMV, SV, IPV in 99/100 patients. Eleven of 178 (6.2%) cirrhotic patients showed RF only in the SV, 3/178 (1.7%) showed alternating ('back and forth') flow only in IPV, RPV and LPV with continuous hepatopetal flow in PV and 10/178 (5.6%) showed completely RF in IPV. Four of ten patients of this last group showed hepatopetal flow in MPV. The other six patients showed RF in MPV associated with hepatofugal flow through a large left gastric vein in three cases and through the SV in three cases. The other cirrhotic patients (154/178=86.5%) showed hepatopetal flow in IPV, MPV, SMV and SV. In no case RF in SMV was observed. Prevalence of RF in IPV was significantly higher in Child C patients (8/31=25.8%) than Child B patients (5/104=4.7%) and than in Child A patients (0%) (p<0.01). Prevalence of Child C class was significantly higher in patients with RF in IPV (8/13=61.5%) than in patients with RF only in extraepatic portal vessels (2/11=18.2%) and patients without RF (21/154=13.6%) (p<0.001). No patient with RF in IPV was in Child A class. Incidence of death was significantly higher in patients with RF in IPV than in patients without RF and patients with RF only in SV. Conclusions: RF in IPV is not a rare event (9% in our series) that mainly occurs in cirrhosis with advanced liver function impairment. Copyright 1997 Elsevier Science Ireland Ltd.

[Use of a microwave device for dental instrument sterilization: possibilities and limitations]

BACKGROUND

The aim of the present study was the evaluation of the effectiveness as sterilizer of a modified version of a microwave device, which was previously tested by the same authors and found unsatisfactory.

MATERIALS AND METHODS

Dental mirrors were contaminated by 10(4)-10(9) microorganisms of Stapbylococcus aureus and spores of Bacillus subtilis and Bacillus stearothermophilus. The inocula used were both wet and dry. The duration of the treatment was 4 minutes. Three series of tests were made: 1) microwaves and "adjuvant" solution (as suggested by the producer of the device); 2) microwaves only (in place of the "adjuvant" solution, a Na Cl 0.9% was used); 3) "adjuvant" solution only (into an oven at 25 degrees C).

RESULTS

In the 1st and 3rd series of tests all the microorganisms and the spores were killed. In the 2nd series of tests a bactericidal effect against some, not all, microorganisms of the S. aureus species and against spores of B. subtilis and B. stearothermophilus was found.

CONCLUSIONS

The results of this study suggest that the device tested has a sterilizing activity, which, however, is not due to the activity of microwaves only; but to the combined activity of microwaves, "adjuvant" solution and temperature (since inside the device, at the end of the treatment the temperature on the mirrors was 94 degrees C).

Hepatic abscess caused by Salmonella typhi: diagnosis and management by percutaneous echo-guided needle aspiration

Three cases of liver abscesses due to Salmonella typhi (2 solitary, 1 with double localization in the right lobe) are described in which specific diagnosis was based on percutaneous echo-guided aspiration of the lesions. Haemocultures and coprocultures were negative, in all cases, and pus-cultures of aspirated material from cavities grew Salmonella typhi; Widal became significantly positive only in one patient 15 days after discharge. Percutaneous needle drainage, combined with chloramphenicol therapy, was successfully performed under echo guidance; only in one case was a second aspiration needed three days after the first one. Fever disappeared within 48-72 hours after drainage of the abscess. No complications or side-effects were observed.

One-shot percutaneous ethanol injection of liver tumors under general anesthesia: preliminary data on efficacy and complications

PURPOSE

To verify the efficacy of ultrasound (US)-guided injection of large amounts of ethanol into large or multiple liver lesions, in a single session under general anesthesia (one-shot PEI) for percutaneous ablation of hepatic tumors.

METHODS

Twenty-nine patients (27 with 51 hepatocellular carcinoma (HCC) nodules on cirrhosis, diameter range 1.0-9.0 cm; two patients with a single metastasis from the gastroenteric tract, 5.0 and 9.0 cm, respectively, in diameter) were treated with one-shot PEI.

RESULTS

The total volume of alcohol delivered per patient ranged from 16 to 210 ml. Mean ethanol volume in all patients was 49 ml. Dynamic computed tomography (CT) examination showed complete necrosis in 41 of 50 lesions. Two patients died of hypovolemic shock due to massive upper gastrointestinal bleeding, 3 and 7 days, respectively, after the interventional procedure. All the remaining patients are alive (follow-up 5-14 months) except one who died of liver failure 5 months after. New HCC nodules occurred in six patients within 6 months and one intralesional relapse was recorded.

CONCLUSION

In this preliminary experience, one-shot PEI is as effective in inducing liver tumor necrosis as traditional PEI; its advantages are shorter treatment time and the capability of treating larger and multiple liver lesions.

[Not Available]

Authors describe three cases of liver abscesses due to Salmonella typhi (2 solitary, 1 with double localization in the right lobe) in which specific diagnosis was based on US examination with aspiration and culture of the pus. In all cases cultures of biologic fluids were negative; Widal test became significantly positive only in one patient 15 days after discharge. Percutaneous drainage was performed under US guidance; only in one case a second aspiration was needed three days after the first one. Fever disappeared within 48-72 hours after abscess's drainage. Complications and side-effects were never observed.

Pyogenic liver abscesses: 13 years of experience in percutaneous needle aspiration with US guidance

PURPOSE

To determine the efficacy of percutaneous needle aspiration (PNA) with antibiotic therapy in treatment for pyogenic liver abscess (PLA).

MATERIALS AND METHODS

One hundred fifteen patients (59 male; 56 female; age range, 16-86 years; mean age, 45.3 years) with 147 PLAs (mean diameter, 6.8 cm; range, 3-16 cm) underwent PNA with ultrasound (US) guidance and antibiotic therapy. Needle caliber (22-16 gauge) was tailored to PLA volume. If necessary, PNA was repeated every 3-7 days.

RESULTS

Three hundred one PNAs were performed (range, 1-4 per patient; mean, 2.2 per patient). A single puncture was sufficient in 57 patients. Cure (normalization of clinical and laboratory parameters and resolution of hepatic lesions) was achieved in 113 patients (98.3%). Two patients with large PLAs required surgery. Patients were hospitalized 7-24 days (mean, 9 days). In the last eight patients, all abscesses were evacuated in one session. Neither complications nor deaths ensued. Recurrence of PLA was not observed in any patient during follow-up (6-36 months).

CONCLUSION

US-guided PNA with antibiotic therapy in treatment for PLA is a valid alternative to prolonged catheter drainage.

[3 different methods for evaluating Streptococcus mutans in the saliva]

Three different methods for detection and count of Streptococcus mutans in saliva have been compared with a microbiological method in order to estimate their efficacy and practicality. The study has been carried out on fifty children of six-eleven years old. The first method (stamp method) derives from that of Kohler and Bratthall, improved on the sampling, without saliva stimulation and, hence, more rapid. Furthermore, using a tongue depressor with a shovel-like extremity, we can either restrict the area where the grown colonies must be counted, avoiding any mistake, and stamp the spatula in the centre of the plate, not in the border, as the original method described, pressing it with the same force in every part, so that almost all the saliva collected can be plated on the Streptococcus mutans selective medium. As stated by this method, a tongue depressor is pressed first on the subject's tongue, then on a plate containing the medium. After incubation, the Streptococcus mutans colonies are counted on the plate's area limited by the stamp of the extremity of the spatula. According to Emilson we can also discriminate Streptococcus mutans and Streptococcus sobrinus colonies. The second method is a "strip mutans test" (Dentocult): saliva is stimulated making the subject chew a piece of paraffin and then it is collected passing a plastic spatula for ten times on the child's tongue. The spatula is introduced into a tube containing a liquid medium selective for Streptococcus mutans and then incubated.(ABSTRACT TRUNCATED AT 250 WORDS)

Unilocular hydatid liver cysts: treatment with US-guided, double percutaneous aspiration and alcohol injection

Sixteen hydatid liver cysts in 14 patients were treated with a percutaneous double puncture-aspiration-injection (D-PAI) technique with alcohol used as the scolecidal agent. With ultrasound guidance, fine-needle drainage of cysts was performed, and 95% sterile alcohol was injected and left in situ to partly refill the cystic cavities. The same procedure, without reaspiration of the injected alcohol, was performed 3 days later. Viability of scoleces was assessed at each aspiration. Benzoimidazolic drugs were administered 1 week before and 3 weeks after the procedure, to reduce the risk of seeding scoleces. Follow-up ranged from 8 to 28 months (mean, 14 months). Six cysts disappeared within 40-75 days of completion of D-PAI. In the other patients, smaller liquid areas or hypo- or hyperechoic solid masses were observed. Anaphylactoid reactions did not occur. In one patient, a biliary fistula developed after the first aspiration; the second ethanol injection was postponed until 6 months later but was effective. Viable scoleces were found at the second aspiration in only two patients whose hepatic liver cysts completely healed. Serologic titers substantially decreased in seven cases and became negative in two.

Exploitation of statistical tables: conceptual interaction with epidemiologic data

Health-care applications need flexible data and interaction models capable of dealing with data of different natures coming from different sources. These applications are usually devoted to diverse user groups, often casual or novice. The user interface must help the user to understand the database information content in his or her querying process. The authors synthetically describe FLN, a system featuring an integrated interaction with epidemiologic data. In an integrated model the statistical aspects of data (macro data) are represented, together with the intensional and extensional views of the variables involved in statistical tables.

[Percutaneous therapy of hydatid cyst of the liver with ultrasound-guided double puncture-aspiration and alcoholization]

Fourteen patients (9 females, 5 males; age range: 22-80 years) with 16 univesiculated hydatid cysts of the liver (O ranging 4.2-14 cm) underwent two sessions of puncture-aspiration-alcohol injection (D-PAI) under real-time US guidance at 3-day intervals. Two patients had postoperative recurrences. One patient was pregnant (9 weeks' gestation): her cyst doubled its volume over 2 months. One patient had HBV chronic hepatitis treated by means of interferon: also in this case the cyst doubled its volume. The remaining were high-risk patients for surgery or had refused operation. At US follow-up (ranging 4-24 months) 6 cysts exhibited complete reconstitution of liver parenchyma. In the extant patients two different US patterns were observed: 1) liquid areas with detached inner membranes (4 cysts); 2) solid inhomogeneous areas (6 cysts). In these cases the volume was reduced by 50-80%. No allergic complication occurred either during or after the procedure. Two patients only were affected with vomiting and fever, which resolved in a few hours. Our results indicate D-PAI of univesiculated hydatid cysts of the liver to be an effective alternative to surgery.

Echo-guided percutaneous puncture: a safe and valuable therapeutic tool for amebic liver abscess

To clarify the therapeutic role of echo-guided percutaneous puncture (EPP) in management of amebic liver abscess, 20 patients (24 abscesses) received metronidazole plus EPP. Fluid was aspirated through Chiba needles under real-time sonographic guidance so as to reduce cavity size to less than 3 cm. Not more than two EPPs were necessary in the majority of cases and no complication followed the procedure. This scheme resulted in a shortening of time of both hospitalization (less than or equal to 20 days) and liver lesion healing as assessed by ultrasound (less than or equal to 4 months). It is concluded that EPP is a valuable and safe therapeutic tool for hepatic amebic abscess.

[Clinical significance of hyperechogenic focal lesions of the cirrhotic liver]

A review was made of the ultrasonographic (US) examinations performed over the period 1981-1986; 27 cirrhotic patients with hyperechoic liver lesions were identified, whose diagnoses had been made by means of either US-guided percutaneous biopsy, or laparoscopy, or autopsy. In 24 patients hepatocellular carcinomas nodules (HCC) were found, associated with cirrhosis, while in 3 cases only cirrhosis was seen. In the above mentioned 3 cases, a 2-year US follow-up showed no variation in the size of the nodules. These data confirm the importance of US in the screening of risk HCC patients, and point out that--however small--hyperechoic lesions in a cirrhotic liver suggest the cancerization of the substanding cirrhosis.

Cirrhosis: value of caudate to right lobe ratio in diagnosis with US

To verify the value of ultrasound (US) in the diagnosis of cirrhosis, the ratio of transverse caudate lobe width to right lobe width (C/RL) was determined with US in 25 healthy subjects and 156 consecutive patients with either histologically proved acute viral, chronic persistent, or chronic active hepatitis or cirrhosis. The C/RL ratio had a sensitivity of 43%, a specificity of 100%, and an accuracy of 79% in cirrhosis. The sensitivity was very low in alcoholic cirrhosis, low in cryptogenic cirrhosis, and high in hepatitis B virus related cirrhosis. In spite of its fairly low overall sensitivity, the C/RL ratio is a useful measurement in assessing chronic liver disease because of its high specificity in cirrhosis.

End-organ and drug-induced vestibular nystagmus

The occurrence of spontaneous, positional and paroxysmal positional nystagmus was studied in patients with end-organ lesions, and in subjects with drug-induced central vestibular nystagmus. Repeated vestibular examination using electronystagmography for assessment of spontaneous and positional nystagmus in the standard head positions was carried out. The findings indicate that the paroxysmal positional nystagmus is the most frequently seen nystagmus prior to its disappearance in end-organ induced nystagmus and also the most frequently seen in drug-induced nystagmus. The direction changing type of nystagmus was very frequently encountered in end-organ lesions. These findings indicate that the type of horizontal vestibular nystagmus by itself is of no diagnostic value in localizing the site of the lesion and that the various types reflect different degrees of vestibular compensation that occur prior to their disappearance. The value of various classifications of positional nystagmus lies mainly in that they help describe the nystagmus clinically.