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ObjectiveTo assess the prevalence, characteristics and prognostic value of pulmonary hypertension (PH) and right ventricular dysfunction (RVD) in hospitalised, non-intensive care unit (ICU) patients with coronavirus disease 2019 (COVID-19).MethodsThis single-centre, observational, cross-sectional study included 211 patients with COVID-19 admitted to non-ICU departments who underwent a single transthoracic echocardiography (TTE). Patients with poor acoustic window (n=11) were excluded. Clinical, imaging, laboratory and TTE findings were compared in patients with versus without PH (estimated systolic pulmonary artery pressure >35 mm Hg) and with versus without RVD (tricuspid annular plane systolic excursion ResultsA total of 200 patients were included in the final analysis (median age 62 (IQR 52–74) years, 65.5% men). The prevalence of PH and RVD was 12.0% (24/200) and 14.5% (29/200), respectively. Patients with PH were older and had a higher burden of pre-existing cardiac comorbidities and signs of more severe severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (radiological lung involvement, laboratory findings and oxygenation status) compared with those without PH. Conversely, patients with RVD had a higher burden of pre-existing cardiac comorbidities but no evidence of more severe SARS-CoV-2 infection compared with those without RVD. The presence of PH was associated with a higher rate of in-hospital death or ICU admission (41.7 vs 8.5%, pConclusionsAmong hospitalised non-ICU patients with COVID-19, PH (and not RVD) was associated with signs of more severe COVID-19 and with worse in-hospital clinical outcome.Trial registration numberNCT04318366

Objective To assess the prevalence, characteristics and prognostic value of pulmonary hypertension (PH) and right ventricular dysfunction (RVD) in hospitalised, non-intensive care unit (ICU) patients with coronavirus disease 2019 (COVID-19). Methods This single-centre, observational, cross-sectional study included 211 patients with COVID-19 admitted to non-ICU departments who underwent a single transthoracic echocardiography (TTE). Patients with poor acoustic window (n=11) were excluded. Clinical, imaging, laboratory and TTE findings were compared in patients with versus without PH (estimated systolic pulmonary artery pressure >35 mm Hg) and with versus without RVD (tricuspid annular plane systolic excursion

Patients with inborn error diseases can be candidates for autologous haematopoietic stem cells (HSC) gene therapies (GT) but may require negative viral screening, including Hepatitis C (HCV), to allow HSC manipulation in Good Manufacturing Practices areas. In case of HCV positivity, patients might be excluded from life-saving treatments. As HCV antibodies could be negative in young infant immunodeficient patients due to their immature/impaired immune system, or positive due to maternal-fetal antibody transmission, the risk is usually also evaluated on the basis of the HCV-RNA. This article is protected by copyright. All rights reserved.

Several techniques have been described for safe dissection of the liver parenchyma. The aim of this study was to evaluate the feasibility and effectiveness of combining two different electronic devices, the ultrasonic dissector and the harmonic scalpel, during hepatic resection. One hundred consecutive patients who underwent liver resection between January and December 2004 were enclosed in the study. Patients requiring concomitant colic resection or biliary-enteric anastomosis were excluded from the study. Operative variables (type of procedure, operating time, Pringle time, blood losses, transfusions, and histological tumor exposure at the transection surface), hospital stay, and complications were recorded. The extent of hepatic resection was a minor resection in 31 and major in 69 cases. Median blood loss was 500 mL (range, 100–2000 mL) and the Pringle maneuver was used in 58 patients. Median operative time was 367 minutes (range, 150–660 minutes). Hepatic resection was performed in 32 cirrhotic livers. Surgical complications included one postoperative hemorrhage and two bile leaks. The overall morbidity and mortality rate was 14 and 1 per cent, respectively. In conclusion, the combined use of these electronic devices allows liver resection to be safely performed, even in cirrhotic patients, with the advantage of reducing surgical complications. A prospective randomized trial is needed to clarify the clinical benefits of liver resections performed combining these two devices.

The incidence of pyogenic liver abscess is about 10 cases per million persons per year, or 15 cases per 100,000 hospital admissions, with a lethality rate of 6–14 %, even if treated [1, 2]. The patient usually is middle aged, and the incidence is higher between the fifth and sixth decade (the period in which the incidence of biliary disease is higher as well). No difference can be observed as regards sex and ethnic or geographical origin.

Focal nodular hyperplasia (FNH) is a benign tumorlike condition of the liver with no known potential for malignant transformation. FNH accounts for approximately 8 % of all primary hepatic tumors and is the second most common benign liver tumor after hemangioma. FNH is in most of cases an asymptomatic incidental finding. The stability in size of most FNH lesions, the lack of potential for malignant transformation, and the extremely low risk of rupture and hemorrhage support a conservative approach for management of most patients with radiologically convincing or histologically proven FNH. When symptoms occur, in patients in with the diagnosis is not clear and if there is the evidence of progressive growth surgery should be considered.

Background Based on previous studies in experimental models, pro-inflammatory Th1 cytokines (i.e. TNF-α and IFN-γ) are thought to play a pathogenic role in hepatic ischemia/reperfusion injury, while anti-inflammatory Th2 cytokines (i.e. IL-4 and IL-10) have been associated with reduced liver disease severity. To test the relevance of these concepts in humans, cytokine expression profiles were characterized in liver biopsies from patients undergoing hepatic resection following intermittent portal clamping. Methods Twelve patients were analyzed for the intrahepatic expression of TNF-α, IFN-γ, IL-4 and IL-10 before and about 90 min after the last reperfusion. In addition, parameters of liver damage including sALT and serum levels of TNF-α were analyzed at 2, 24 and 48 h after surgery. Results When compared with pre-reperfusion liver specimens, all post-reperfusion biopsies showed significantly increased levels of TNF-α and IFN-γ mRNAs. Conversely IL-4 and IL-10 mRNA levels were significantly increased in only seven patients. A negative correlation was observed between Th2 cytokines (IL-4, IL-10) and ALT and serum levels of TNF-α. Furthermore, the presence of hepatic steatosis was significantly associated with lower intrahepatic contents of IL-4 and IL-10. Conclusions The results suggest that the local early expression of Th2 cytokines may contribute to attenuate liver injury following ischemia reperfusion in humans. The early imbalance between pro- and anti-inflammatory cytokines seen in steatotic liver subjected to I/R could explain, at least partially, the decreased tolerance of steatotic livers to I/R injury.

We evaluated the feasibility and effectiveness of combining two different electronic devices, the ultrasonic dissector (UD) and the harmonic scalpel (HS), during hepatic resection. One hundred consecutive patients underwent liver resection using UD plus HS between January and December 2 004 (UD + HS group). The ultrasonic dissector was used to fracture liver parenchyma and the uncovered vessel was sealed using the HS. Surgical outcomes were compared with 100 consecutive patients who underwent liver resection using the clamp crushing method. Operative variables, postoperative liver function, hospital stay, and type and number of complications were compared. The two groups were equivalent in term of demographic and pathologic variables. The UD + HS group had a decreased blood loss (500 ml versus 700 ml, P = 0.005), number of patients transfused (22 versus 39, P = 0.009), tumor exposure at the transection surface (4 versus 12, P = 00.012), and hospital stay (7 versus 8.5 days, P = 0.020). Postoperative major complications, in particular, fluid collection and biliary fistula, were significantly less frequent in the UD + HS group (2 versus 9, P = 0.030). A longer operative time was recorded in the UD + HS group (385 versus 330 minutes, P = 0.001). The combined use of UD with HS allows liver resection to be safely performed, with the advantage of reducing blood losses and surgery-related complications. The only major disadvantage may be a longer transection time.

Hepatic injury secondary to warm ischemia-reperfusion (I/R) injury and alterations in haemostatic parameters are often unavoidable events after major hepatic resection. The release of inflammatory mediator is believed to play a significant role in the genesis of these events. It has been suggested that preoperative steroid administration may reduce I/R injury and improve several aspects of the surgical stress response. The aim of this prospective randomized study was to investigate the clinical benefits on I/R injury and systemic responses of preoperatively administered corticosteroids. Seventy-six patients undergoing liver resection were randomized either to a steroid group or to a control group. Patients in the steroid group received preoperatively 500 mg of methylprednisolone. Serum levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin, coagulation parameters, and inflammatory mediators, interleukin 6 and tumor necrosis factor alpha were compared between the 2 groups. Length of stay, and type and number of complications were recorded as well. Postoperative serum levels of ALT, AST, total bilirubin, and inflammatory cytokines were significantly lower in the steroid than in the control group at postoperative days 1 and 2. Changes in hemostatic parameters were also significantly attenuated in the steroid group. In conclusion, the incidence of postoperative complications in the steroid group tended to be significantly lower than the control group. It is of clinical interest that preoperative steroids administration before major surgery may reduce I/R injury, maintain coagulant/anticoagulant homeostasis, and reduce postoperative complications by modulating the inflammatory response.

Background Wedge resection (WR) for colorectal liver metastases (CLM) has become more common in an attempt to preserve liver parenchyma. However, some investigator have reported that WR is associated with a higher incidence of positive margin and an inferior survival compared with anatomic resection (AR) 1. Objectives This study evaluated survival, margin status, and pattern of recurrence of patients with CLM treated with WR or AR. Methods We identified 208 consecutive patients, in a single institutional database from 1995 to 2004, who underwent either WR or AR. WR was defined as a nonanatomic resection and AR was defined as single resection of one or two liver segments. Patients with combined WR–AR and patients requiring resection of more than two segments or radiofrequency ablation were excluded from the analysis. Results One hundred six patients underwent WR and 102 patients had AR. There were no differences in the rate of positive surgical margin (P = 0.146), overall recurrence rates (P = 0.211), and patterns of recurrence between the two groups (P = 0.468). The median survival was 32 months for WR and 42 for AR, with 5-year survival rates of 29% and 27% respectively, with no significant difference (P = 0.308). Morbidity was similar between the two groups. Conclusions WR is a safe procedure and does not disadvantage the patients in terms of tumor recurrence and overall survival. J. Surg. Oncol. 2008;97:503–507. © 2008 Wiley-Liss, Inc.

Alterations in hemostatic parameters are a common finding after major hepatic resection. There is growing evidence that inflammation has a significant role in inducing coagulation disarrangement that follows major surgery. To determine whether preoperative methylprednisolone administration has a protective effect against the development of coagulation disorders, we evaluated the effect of preoperative steroids administration on changes in hemostatic parameters and plasma levels of inflammatory cytokines in patients undergoing liver surgery. Seventy-three patients undergoing liver resection were randomized to a steroid group or to a control group. Patients in the steroid group received 500 mg of methylprednisolone preoperatively. Serum levels of coagulation parameters (prothrombin time, platelets, fibrinogen, plasma fibrin degradation products [D-dimer], antithrombin III) and inflammatory mediators (IL-6 and TNF-alpha) were measured before and immediately after the operation and on postoperative days 1, 2, and 5. Multivariate analysis was performed to identify factors related to the characteristics of the patients and surgery affecting coagulation parameters between the two groups. Decreases in antithrombin III, platelet count and fibrinogen levels, prolongation of prothrombin time, and increases in the plasma fibrin degradation products were significantly suppressed by the administration of methylprednisolone. Cytokines production was also significantly suppressed by the administration of methylprednisolone, and there was significant correlation between plasma levels of cytokines and coagulation alterations. These findings suggest that preoperative methylprednisolone administration inhibits the development of coagulation disarrangements in patients undergoing liver resection, possibly through suppressing the production of inflammatory cytokines.

Objectives To assess the safety of hepatic resections in the very old patient by comparing the outcome in patients younger and older than 75 years. Methods Thirty-two resections in 31 patients ≥75 years (Over-75 Group) were compared with 164 resections in 162 patients

Depending on the stage of the primary colorectal cancer, liver metastases occur in 20% to 70% of patients and represent the major cause of death in this disease.1,2 Surgical resection remains the only treatment that can, to date, ensure long-term survival in 25% to 40% of patients.3–8 It should be considered whenever liver metastases can be totally resected with clear margins and when there is no nonresectable extrahepatic disease. However, using the current indications for surgery, only 15% to 20% of patients with colorectal liver metastases are suitable for surgical resection.1,2 When liver metastases are nonresectable, palliative chemotherapy increases survival and enhances quality of life.9 Progresses including more efficient chemotherapy drugs such as oxaliplatin or irinotecan10,11 have opened new perspectives in the treatment of resectable and nonresectable liver metastases. These drugs can render resectable previously unresectable liver metastases.12–16 When liver metastases are resectable, the benefit of neoadjuvant chemotherapy on reducing the risks of recurrence after surgery is not yet demonstrated. However, in case of synchronous metastases, chemotherapy is often prescribed between the resection of the colorectal primary and the liver surgery. The risks of liver resections have been reduced in recent years. Postoperative mortality is less than 5% in most reported series.5–7 Postoperative morbidity, including transient liver failure, hemorrhage, subphrenic abscesses, and biliary fistula, occur in 20% to 40% of patients.3–8 It is not clearly established whether systemic preoperative chemotherapy increases the risks of surgery due to injury of liver parenchyma. Recent data have suggested that prolonged systemic chemotherapy could induce steatosis and microvascular changes such as peliosis or sinusoidal congestion.17 Sclerosing cholangitis, dilatation, and fibrosis of the central veins and moderate hepatocellular necrosis or cholestasis in the centrilobular area have been reported with the intra-arterial use of fluorodeoxyuridine, a 5-fluorouracil (5-FU) metabolite.13,17 These pathologic changes can be responsible for an increased risk of bleeding during surgery as the parenchyma tends to be more congested and friable.13,15 Hepatic arterial chemotherapy prior to liver resection was associated with an increased postoperative morbidity in one series (57% versus 18%).13 The consequences of systemic chemotherapy on liver parenchyma and on postoperative course following resections have not been specifically analyzed in the reports that have studied resectability following preoperative chemotherapy. The populations studied were heterogeneous regarding the duration and the regimens of preoperative chemotherapy, the extent of liver resections performed and the clamping methods used.12,14,16,18–20 The pathologic changes induced by chemotherapy in these patients have not been reported. The present study was designed to analyze the effects of preoperative systemic chemotherapy on remnant liver parenchyma and to assess the consequences on postoperative mortality, morbidity, and liver function tests. Among patients having received liver resection for metastases from colorectal cancer, we selected a homogeneous subgroup of patients who received a major liver resection under total vascular exclusion. In theory, the removal of more than three hepatic segments with continuous occlusion of hepatic inflow and outflow is at higher risk of inducing postoperative mortality and morbidity; therefore, this subgroup offers the better chances of showing an influence of preoperative chemotherapy.

The aim of this retrospective study was to evaluate the influence of age on the outcome of liver resection. A total of 129 consecutive liver resections were divided into two groups: greater than or equal to 70 years old [old group (O-group)] and < 70 years old [young group (Y-group)]. The two groups were first compared for the variables potentially affecting the postoperative course, including diagnosis, concomitant diseases, previous abdominal surgery, type of operation (major or minor resection), associated procedures, presence and length of portal clamping, intraoperative blood losses and transfusions, and length of operation. The outcome of liver resections was evaluated in terms of postoperative mortality, morbidity, transfusions, and length of hospitalization. The Y-group included 97 resections in 95 patients, aged 55.9 +/- 10.5 years (mean +/- SD; range: 23-69 years), and the O-group included 32 resections in 32 patients, aged 73.7 +/- 3.2 years (mean +/- SD; range: 70-82 years. The O-group included more hepatocellular carcinomas (46.9% versus 20.6%, p = 0.002) and cardiovascular diseases (15.2% versus 1.0%,p = 0.004). The two groups were comparable (p > 0.05) when evaluated for all other listed variables. As regards the postoperative outcome, the length of hospitalization was similar (median, range: 9.5 days, 5-60 days in the Y-group and 9 days, 5-48 days in the O-group) and the need for postoperative transfusions were not statistically different. Mortality included one case among young patients, while no deaths were recorded among elderly patients. Postoperative morbidity was higher in Y-group than in O-group (21.6% versus 9.4%, p = 0.2). In conclusion, the age factor does not negatively affect the outcome of liver resections.

Not the final published version, BACKGROUND: A high proportion of individuals receiving highly active antiretroviral treatment (HAART) complain of sexual dysfunction (SD), encompassing a lack of desire or erectile dysfunction. OBJECTIVE: To determine whether SD was associated with particular components of the HAART regimens and to identify risk factors for the development of SD in patients on HAART. METHODS: A survey among patients with HIV infection using an anonymous questionnaire was conducted in 10 European countries between December 1998 and December 1999. A total of 904 individuals currently receiving antiretroviral agents were included in the analyses. RESULTS: A decrease in sexual interest was significantly more frequently reported by subjects (men and women) using HAART containing protease inhibitors (PI) (308/766, 40%), compared with PI-naive patients (22/138, 16%; OR 3.55; 95% CI 2.15--5.89). In addition, a significantly larger number of PI-experienced men reported a decrease in sexual potency (216/628, 34%) compared with PI-naive men (12/99, 12%; OR 2.56; 95% CI 1.33--5.03). In multivariate analyses the following factors were associated with a decrease in sexual interest: a current PI-containing regimen, a history of a PI regimen, symptomatic HIV infection, age and homosexual contact as HIV transmission mode. Factors associated with a decrease in sexual potency were: current use of a PI-containing regimen, symptomatic HIV disease, age and the use of tranquillisers. CONCLUSION: SD appears to be a common side-effect of HAART regimens containing a PI. The potential association between SD and other side-effects of HAART, such as lipodystrophy syndrome and neuropathy, should be investigated further.

month later. One week later uterine bleeding restarted; repeated for a four-month history of meno-metrorrhagia and sub- sequent anaemia; thereafter, she received a combined blood examinations were normal as before. During this oral contraceptive with resolution of the haemorrhage. second episode of meno-metrorrhagia soluble inter- Ten months later, while she was still taking an oral con- leukin-2 receptor

Inihibition of cytokine response by methylprednisolone attenuates antithrombin reduction following hepatic resection

Neurologic manifestations of brucellosis occur in 2-5% of patients.l.* The clinical pictures of neurobrucellosis are characteristically protean: they include meningoencephalitis, meningovascular complications, parenchymatous dysfunctions, peripheral neuropathy/radiculopathy and various degrees of behavioral abnormalities, sometimes leading to acute psychosis. From the clinical series available, meningitis has been referred as the most frequent presentation of neurobrucellosis, occurring in at least the 50% of cases;‘,” meningitis is most often acute, but subacute or chronic presentations are not rare and may lead to disseminated encephalomyelitis with diffuse central nervous system (CNS) demyelinization.3*4 In contrast, Bruceh abscess formation within the CNS has been described up to now in just one child with multiple brain abscesses.’ We here report the first case of neurobrucellosis with intramedullary abscess in an adult. A 24-year-old man from Sicily was admitted to the regional Hospital for high degree continuous fever and night sweats; fever had lasted for about two months and had been treated with a one-week course of oral prednisolone, before the patient was admitted to hospital. The patient remembered eating some fresh goat’s cheese in the recent past. Thus, brucellosis was suspected and the Brucella melitensis serum agglutination test (SAT) was performed. This was positive at a 1:SOO titer. A six-week cycle of rifampin 600 mglday and doxycycline 100 mg b.i.d. was given; both the fever and the agglutinins normalized. Six months later he complained of abrupt onset of fever, hypostenia of the left leg, and paresthesias of the right leg, with consequent impaired walking. A contrast-enhanced magnetic resonance imaging (MRI) of the brain and the spinal cord showed a focal lesion of 15 mm diameter within the dorsal tract of the spinal cord, near to the third intervertebral space; the abscess was surrounded by perilesional edema, had a partially liquid core and a ring enhancement was evident after Gadolinium in