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COVID-19 pandemic is representing a serious challenge to worldwide public health. Lung Ultrasonography (LUS) has been signaled as a potential useful tool in this pandemic contest either to intercept viral pneumonia or to foster alternative paths. LUS could be useful in determining early lung involvement suggestive or not of COVID-19 pneumonia and potentially plays a role in managing decisions for hospitalization in isolation or admission in general ward. In order to face pandemic, in a period in which a large number of emergency room accesses with suspicious symptoms are expected, physicians need a standardized ultrasonographic approach, fast educational processes in order to be able to recognize both suggestive and not suggestive echographic signs and shared algorithms for LUS role in early management of patients.

PURPOSE: Hepatocellular adenoma (HCA) is a rare benign monoclonal neoplasm, recently categorized on genetic and histopathological basis into four subtypes with different biological behaviors. Since contrast-enhanced ultrasonography (CEUS) is nowadays a well-established technique for liver nodule characterization, the aim of our study was to assess CEUS features of HCAs to identify criteria that correlate with different HCA subtypes as compared to histopathologic examination and other imaging modalities. METHODS: We retrospectively analyzed data of patients with histology-proven HCA who underwent CEUS, computed tomography or magnetic resonance imaging (MRI) in seven different Italian ultrasound units. RESULTS: The study enrolled 19 patients (16 females; 69% with concomitant/prior use of oral contraceptives): the mean size of all HCAs was 4.2 cm (range 1.6–7.1 cm); 14/19 had inflammatory HCAs (I-HCA), 1/19 β-catenin-activated HCA, and the others unclassified HCAs. On CEUS, during the arterial phase, all but one HCA displayed a rapid enhancement, with 89% of these showing centripetal and 11% centrifugal filling pattern, whereas during the portal and late venous phase 58% of HCA showed washout and the remaining 42% displayed persistent enhancement. In particular, among I-HCAs 7/14 showed no washout, 3/14 and 4/14 showed washout in the portal or late phase, respectively. CONCLUSIONS: This dataset represents one of the few published experiences on HCAs and CEUS in Italy and shows that HCAs are hypervascularized in the arterial phase usually with a centripetal flow pattern and have a heterogeneous behavior in portal and late phase. In particular, occurrence of delayed washout on CEUS but not on MRI is frequently observed in the subtype of I-HCA.

Defective gallbladder emptying has been proposed as a possible accessory pathogenetic factor to explain the increased prevalence of gallstones in liver cirrhosis. In this study we have evaluated the fasting volume and the meal-stimulated emptying of the gallbladder, the plasma levels of estradiol and progesterone, and the basal and postprandial secretion of cholecystokinin in Child A cirrhotic patients compared to normal subjects. Basal (42.2 +/- 27 vs 22.8 +/- 8.4 ml) (P0.002) and residual (8.4 +/- 8.7 vs 4.6 +/- 3.8 ml) (P0.05) gallbladder volumes were higher in cirrhotics but neither the integrated gallbladder response to meal nor the maximal percentage of emptying was significantly different. Circulating estradiol and progesterone was slightly increased in only 1/13 and 5/13 cirrhotics, respectively. In eight cirrhotics and seven normals taken from the overall populations, the secretion of cholecystokinin was also measured. The fasting plasma level of cholecystokinin was higher in the cirrhotics (6.71 +/- 5.08 vs 2.02 +/- 0.46 pmol/liter) (P0.01). The meal-stimulated integrated plasma cholecystokinin response also was greater in cirrhotics (438.5 +/- 615 pmol/liter/270 min) than in normals (153 +/- 170.4 pmol/liter/270 min), but this difference was not significant because of the small study population. In spite of a normal kinetics of postprandial emptying, cirrhotic patients show increased fasting gallbladder volume and increased plasma levels of basal and postprandial cholecystokinin. Circulating estradiol and progesterone do not seem to be responsible for the large gallbladder volume found in liver cirrhosis.

In the period 1985-1988, 62 focal liver lesions in 58 cirrhotic patients were studied by ultrasonography; 12 of these focal lesions were documented to be regenerating lesions by echo-guided fine-needle biopsy. During an average follow-up period of 10.2 months (range 3-22 months), hepatocellular carcinoma was subsequently found in 10 of the cases of regenerating nodules, whereas the initial diagnosis of regenerating nodule was confirmed in the remaining two cases. Based upon this finding, it is suggested that every focal mass visualized by ultrasonography in a cirrhotic liver should either be considered to be a neoplastic lesion or at least a preneoplastic lesion if the possibility of either a metastatic or benign lesion (eg, hemangiomas, focal fatty liver change areas) can be excluded. Therefore either fine-needle aspiration or biopsy of all ultrasonographically revealed mass lesions within a cirrhotic liver is advised, such that early appropriate treatment for hepatocellular carcinoma can be instituted.

To the Editor We read with great interest the paper ‘‘Efficacy of locoregional ablation therapy of HCC in a population of liver transplanted patients’’ recently published in Digestive Diseases and Sciences [1]. We agree with the authors that there is not clear evidence that the loco-regional ablation therapies (LAT) performed during the waiting time for liver transplantation contain intrahepatic progression of hepatocellular carcinoma (HCC); in fact, controlled randomized trials on this topic are lacking. However, regardless of the size of the treated tumor, radiofrequency ablation (RFA) has been shown to provide complete necrosis in 47–66% of the cases at explant analysis, and these rates increase to 62–78% when considering only HCCs smaller than 3 cm [2–4]. On the other hand, in patients treated by transarterial chemoembolization (TACE), the rate of hepatocellular carcinoma (HCC) complete necrosis has been reported to range between 16% and 27% [5, 6]. Although there is not certain evidence that complete tumor necrosis induced by bridge treatments impacts on survival of HCC patients after LT, it is reasonable to argue that patients without evidence of viable tumor in the explanted liver could have a better prognosis. We think that the rate of tumor complete necrosis reported by Morisco et al. in their series (7%) is surprisingly low, and that this feature is probably related to the treatments performed. In fact, although TACE, RFA, and percutaneous ethanol injection (PEI) are the most widely used bridge therapies for HCC in patients listed for LT and are considered curative treatments for HCC [7], in Morisco et al.’s series only 9 out of 26 patients were treated by TACE or TAE, only 1 with PEI, and none with RFA. On the other hand, the authors included patients treated by therapies either without proven curative efficacy such as epirubicin infusion, or not well specified such as ‘‘lipiodol combined technique’’ or ‘‘131-I labelled’’ that are nor fully explained in the ‘‘Patients and methods’’ section. Based upon these considerations, it is not surprising that in Morisco et al.’s series the recurrence rate of HCC was not significantly different between patients with and without previous LAT (11.5% versus 8.5%). There are no controlled randomized studies comparing the impact of bridge therapies on disease-free survival after LT performed in cirrhotic patients with HCC. However, in the three large previously cited series in which RFA was used as bridge treatment to LT, the rate of tumor recurrence was low, ranging between 0% and 4% [2–4]. Furthermore, in the largest available case-control study comparing HCC patients submitted or not submitted to TACE before LT, a trend for a lower rate of recurrence was found in the treated patients (13% versus 23%) even if this difference did not reach statistical significance [5].

The authors report the results of a randomized study in which comparison was made between two different kinds of treatment in patients affected by uncomplicated duodenal ulcer endoscopically diagnosed. The first group was treated with 1 g of cimetidine per day, during a period of four weeks (200 mg three times a day and 400 mg at bedtime); the second with a liquid Al−Mg antacid compound, 210 ml/day (30 ml, 1 and 3 hr after meals and 30 ml before bedtime) for four weeks. Fifty-one patients were studied, 27 treated with cimetidine, 24 with antacids. At the end of the four-week period, 21 patients (77.7%) in the cimetidine group and 18 patients (75%) in the antacid group were completely healed. Benign side effects were remarked in both types of treatment, none of which made it necessary to suspend treatment. No significant variation of the basal and peak acid output before and after each kind of treatment was observed, while a slight but significant increase in fasting serum gastrin concentration was noted after treatment in the antacid group.

Gastric wall thickness (body-antrum) was blind measured prospectively by real-time ultrasound in 58 patients (30 with gastric cancer and 28 healthy) who had previously undergone endoscopy. Gastric wall thickness on the average measured 15.933 +/- 4.471 mm in the neoplastic patients and 5.107 +/- 1.100 mm in the normal subjects. Seven millimeters was the highest value found in the normal subjects (4 cases) and the minimum value found in the neoplastic patients (1 case). Knowing the normal gastric wall thickness value on a standard ultrasound examination of the upper abdomen is useful, as ultrasound is often performed as a screening or first-step procedure, in order to address the patients with higher values toward more specific techniques.