Extravasated contrast volumetric assessment on computed tomography angiography in gastrointestinal bleeding:A useful predictor of positive angiographic findings

BACKGROUND Gastrointestinal bleeding(GIB)is a severe and potentially life-threatening condition,especially in cases of delayed treatment.Computed tomography angiography(CTA)plays a pivotal role in the early identification of upper and lower GIB and in the prompt treatment of the haemorrhage.AIM To determine whether a volumetric estimation of the extravasated contrast at CTA in GIB may be a predictor of subsequent positive angiographic findings.METHODS In this retrospective single-centre study,35 patients(22 men;median age 69 years;range 16-92 years)admitted to our institution for active GIB detected at CTA and further submitted to catheter angiography between January 2018 and February 2022 were enrolled.Twenty-three(65.7%)patients underwent endoscopy before CTA.Bleeding volumetry was evaluated in both arterial and venous phases via a semi-automated dedicated software.Bleeding rate was obtained from volume change between the two phases and standardised for unit time.Patients were divided into two groups,according to the angiographic signs and their concordance with CTA.RESULTS Upper bleeding accounted for 42.9%and lower GIB for 57.1%.Mean haemoglobin value at the admission was 7.7 g/dL.A concordance between positive CTA and direct angiographic bleeding signs was found in 19(54.3%)cases.Despite no significant differences in terms of bleeding volume in the arterial phase(0.55 mL vs 0.33 mL,P=0.35),a statistically significant volume increase in the venous phase was identified in the group of patients with positive angiography(2.06 mL vs 0.9 mL,P=0.02).In the latter patient group,a significant increase in bleeding rate was also detected(2.18 mL/min vs 0.19 mL/min,P=0.02).CONCLUSION In GIB of any origin,extravasated contrast volumetric analysis at CTA could be a predictor of positive angiography and may help in avoiding further unnecessary procedures.

A Novel-based Swin Transfer Based Diagnosis of COVID-19 Patients

The numbers of cases and deaths due to the COVID-19 virus have increased daily all around the world.Chest X-ray is considered very useful and less time-consuming for monitoring COVID disease.No doubt,X-ray is considered as a quick screening method,but due to variations in features of images which are of X-rays category with Corona confirmed cases,the domain expert is needed.To address this issue,we proposed to utilize deep learning approaches.In this study,the dataset of COVID-19,lung opacity,viral pneumonia,and lastly healthy patients’images of category X-rays are utilized to evaluate the performance of the Swin transformer for predicting the COVID-19 patients efficiently.The performance of the Swin transformer is compared with the other seven deep learning models,including ResNet50,DenseNet121,InceptionV3,EfficientNetB2,VGG19,ViT,CaIT,Swim transformer provides 98%recall and 96%accuracy on corona affected images of the X-ray category.The proposed approach is also compared with state-of-the-art techniques for COVID-19 diagnosis,and proposed technique is found better in terms of accuracy.Our system could support clin-icians in screening patients for COVID-19,thus facilitating instantaneous treatment for better effects on the health of COVID-19 patients.Also,this paper can contribute to saving humanity from the adverse effects of trials that the Corona virus might bring by performing an accurate diagnosis over Corona-affected patients.

Transanal eco-Doppler evaluation after hemorrhoidal artery embolization

BACKGROUND Hemorrhoidal artery embolization(Emborrhoid)is a novel method for the treatment of severe hemorrhoidal bleeding.Despite having a technical success rate of 93%-100%,the clinical success ranges between 63%and 94%,with a rebleeding rate of 13.6%.AIM To evaluate the effectiveness of this procedure in reducing hemorrhoidal flow and hemorrhoidal bleeding.METHODS This prospective observational pilot study was conducted at Division of General Surgery 1 and Tertiary Referral Pelvic Floor Center,Treviso Regional Hospital,Italy.In a 2 months period(February-March 2022),consecutive patients with hemorrhoidal bleeding scores(HBSs)≥4,Goligher scores of II or III,failure of non-operative management,and a candidate for Emborrhoid were included.Endoanal ultrasound with eco-Doppler was performed preoperatively and 1 month after the procedure.The primary endpoint was to quantify the changes in arterial hemorrhoidal flow after treatment.The secondary endpoint was to evaluate the correlation between the flow changes and the HBS.RESULTS Eleven patients underwent Emborrhoid.The overall pretreatment mean systolic peak(MSP)was 14.66 cm/s.The highest MSP values were found in the anterior left lateral(17.82 cm/s at 1 o’clock and 15.88 cm/s at 3 o’clock)and in the posterior right lateral(14.62 cm/s at 7 o’clock and 16.71 cm/s at 9 o’clock)quadrants of the anal canal.After treatment,the overall MSP values were significantly reduced(P=0.008)although the correlation between MSP and HBS changes was weak(P=0.570).A statistical difference was found between distal embolization compared with proximal embolization(P=0.047).However,the coil landing zone was not related to symptoms improvement(P=1.000).A significant difference in MSP changes was also reported between patients with type 1 and type 2 superior rectal artery(SRA)anatomy(P=0.040).No relationship between hemorrhoidal grades(P=1.000),SRA anatomy(P=1.000)and treatment outcomes was found.CONCLUSION The preliminary findings of this pilot study confirm that Emborrhoid was effective in reducing the arterial hemorrhoidal flow in hemorrhoidal disease.However,the correlation between the post-operative MSP and HBS changes was weak.Hemorrhoidal grade,SRA anatomy and type of embolization were not related to treatment outcomes.

Contrast-enhanced ultrasound evaluation of hepatic microvascular changes in liver diseases

AIM： To assess if software assisted-contrast-enhanced ultrasonography （CEUS） provides reproducible perfu- sion parameters of hepatic parenchyma in patients af- fected by chronic liver disease. METHODS： Forty patients with chronic viral liver dis- ease, with （n = 20） or without （n = 20） cirrhosis, and 10 healthy subjects underwent CEUS and video re- cordings of each examination were then analysed with Esaote＇s Qontrast software. CEUS dedicated software Qontrast was used to determine peak （the maximum signal intensity）, time to peak （TTP）, region of blood value （RBV） proportional to the area under the time- intensity curve, mean transit time （MTT） measured in seconds and region of blood flow （RBF）. RESULTS： Qontrast-assisted CEUS parameters dis- played high inter-observer reproducibility （κ： coefficients of 0.87 for MTT and 0.90 TTP）. When the region of in-terest included a main hepatic vein, Qontrast-calculated TTP was significantly shorter in cirrhotic patients （vs non-cirrhotics and healthy subjects） （71.0 ± 11.3 s vs 82.4±15.6 s, 86.3±20.3 s, P 〈 0.05）. MTIs in the patients with liver cirrhosis were significantly shorter than those of controls （111.9±22.0 s vs 139.4±39.8 s, P 〈 0.05）, but there was no significant difference between the cirrhotic and non-cirrhotic groups （111.9± 22.0 s vs 110.3 ±14.6 s）. Peak enhancement in the patients with liver cirrhosis was also higher than that observed in controls （23.9± 5.9 vs 18.9±7.1, P = 0.05）. There were no significant intergroup differences in the RBVs and RBFs. CONCLUSION： Qontrast-assisted CEUS revealed re- producible differences in liver perfusion parameters during the development of hepatic fibrogenesis.

Acute necrotizing pancreatitis as fi rst manifestation of primary hyperparathyroidism

We report the case of a female patient with severe acute necrotizing pancreatitis associated with hypercalcemia as first manifestation of primary hyperparathyroidism caused by a benign parathyroid adenoma.Initially the acute pancreatitis was treated conservatively.The patient subsequently underwent surgical resection of the parathyroid adenoma and surgical clearance of a large infected pancreatic pseudocyst.Although the association of parathyroid adenoma-induced hypercalcemia and acute pancreatitis is a known medical entity,it is very uncommon.The pathophysiology of hypercalcemia-induced acute pancreatitis is therefore not well known,although some mechanisms have been proposed.It is important to treat the provoking factor.Therefore,the cause of hypercalcemia should be identif ied early.Surgical resection of the parathyroid adenoma is the ultimate therapy.

Activity of Angiogenesis Inhibitors in Metastatic Epithelioid Hemangioendothelioma:A Case Report

This report describes a patient with metastatic epithelioid hemangioendothelioma treated with bevacizumab and nanoparticle albumin-bound paclitaxel.The treatment was well tolerated and led to the stabilization of an aggressive variant of the disease. This case report is the first one that describes the activity of the combination of chemotherapy and bevacizumab in epithelioid hemangioendothelioma.Literature describing the activity of bevacizumab and other agents(thalidomide,lenalidomide,and interferon) believed to possess anti-angiogenic activities is also reviewed.

Total neoadjuvant therapy vs standard therapy of locally advanced rectal cancer with high-risk factors for failure

BACKGROUND For locally advanced rectal cancer(LARC),standard therapy[consisting of neoadjuvant chemoradiotherapy(CRT),surgery,and adjuvant chemotherapy(ChT)]achieves excellent local control.Unfortunately,survival is still poor due to distant metastases,which remains the leading cause of death among these patients.In recent years,the concept of total neoadjuvant treatment(TNT)has been developed,whereby all systemic ChT-mainly affecting micrometastases-is applied prior to surgery.AIM To compare standard therapy and total neoadjuvant therapy for LARC patients with high-risk factors for failure.METHODS In a retrospective study,we compared LARC patients with high-risk factors for failure who were treated with standard therapy or with TNT.High-risk for failure was defined according to the presence of at least one of the following factors:T4 stage;N2 stage;positive mesorectal fascia;extramural vascular invasion;positive lateral lymph node.TNT consisted of 12 wk of induction ChT with capecitabine and oxaliplatin or folinic acid,fluorouracil and oxaliplatin,CRT with capecitabine,and 6-8 wk of consolidation ChT with capecitabine and oxaliplatin or folinic acid,fluorouracil and oxaliplatin prior to surgery.The primary endpoint was pathological complete response(pCR).In total,72 patients treated with standard therapy and 89 patients treated with TNT were included in the analysis.RESULTS Compared to standard therapy,TNT showed a higher proportion of pCR(23%vs 7%;P=0.01),a lower neoadjuvant rectal score(median:8.43 vs 14.98;P<0.05),higher T-and N-downstaging(70%and 94%vs 51%and 86%),equivalent R0 resection(95%vs 93%),shorter time to stoma closure(mean:20 vs 33 wk;P<0.05),higher compliance during systemic ChT(completed all cycles 87%vs 76%;P<0.05),lower proportion of acute toxicity grade≥3 during ChT(3%vs 14%,P<0.05),and equivalent acute toxicity and compliance during CRT and in the postoperative period.The pCR rate in patients treated with TNT was significantly higher in patients irradiated with intensity-modulated radiotherapy/volumetricmodulated arc radiotherapy than with 3D conformal radiotherapy(32%vs 9%;P<0.05).CONCLUSION Compared to standard therapy,TNT provides better outcome for LARC patients with high-risk factors for failure,in terms of pCR and neoadjuvant rectal score.

Giant hepatic extra-gastrointestinal stromal tumor treated with cytoreductive surgery and adjuvant systemic therapy:A case report and review of literature

BACKGROUND Primary extra-gastrointestinal stromal tumors(E-GIST)of the liver are rare.The clinical presentation may range from asymptomatic to bleeding or manifestations of mass effect.Oncologic surgery followed by adjuvant therapy with imatinib is the standard of care.However,under specific circumstances,a cytoreductive approach may represent a therapeutic option.We describe herein the case of an 84-year-old woman who presented with a tender,protruding epigastric mass.Abdominal computed tomography scan revealed a large,heterogeneous mass located across segments III,IV,V,and VIII of the liver.The initial approach was transarterial embolization of the tumor,which elicited no appreciable response.Considering the large size and central location of the tumor and the advanced age of the patient,non-anatomic complete resection was indicated.Due to substantial intraoperative bleeding and hemodynamic instability,only a near-complete resection could be achieved.Histopathology and immunohistochemical staining confirmed the diagnosis of primary E-GIST of the liver.Considering the risk/benefit ratio for therapeutic options,debulking surgery may represent a strategy to control pain and prolong survival.CASE SUMMARY Here,we present a case report of a patient diagnosed with E-GIST primary of the liver,which was indicated a cytoreductive surgery and adjuvant therapy with imatinib.CONCLUSION E-GIST primary of the liver is a rare conditional,the treatment is with systemic therapy and total resection surgery.However,a cytoreductive surgery will be necessary when a complete resection is no possible.

Minimally invasive surgical treatment of intrahepatic cholangiocarcinoma:A systematic review

BACKGROUND Intrahepatic cholangiocarcinoma(ICC)is the second most common primary liver cancer and is characterized by an aggressive behavior and a dismal prognosis.Radical surgical resection represents the only potentially curative treatment.Despite the increasing acceptance of laparoscopic liver resection for surgical treatment of malignant liver diseases,its use for ICC is not commonly performed.In fact,to achieve surgical free margins a major resection and/or vascular and/or biliary reconstructions is often needed,as well as an associated lymph node dissection.AIM To review and summarize the current evidences on the minimally invasive resection of ICC.METHODS A systematic review of the literature based on the criteria predetermined by the investigators was performed from the 1st of January 2009 up to the 1st of January2021 in 4 databases(PubMed,Scopus,Google Scholar,and Cochrane databases).All retrospective and prospective studies reporting on the comparative outcomes of open vs minimally invasive treatment of ICC were included.An evaluation of manuscripts quality was achieved using Methodological Index for Non-Randomized Studies criteria and Newcastle-Ottawa Scale.RESULTS After a systematic search 9 studies fulfilled the inclusion criteria.Among the all 3012 included patients,2450 were operated by an open approach and 562 by a minimally invasive(laparoscopic)approach.Baseline characteristics,tumor characteristics,surgical outcomes and oncological outcomes were collected and analyzed,highlighting values with a statistical significant difference between patients treated with open or laparoscopic approach.Shorter hospital stay and lower intraoperative blood losses were reported by some Authors in minimally invasive surgery,on the contrary,in the open group there was a higher number of lymphadenectomies and a higher percentage of major hepatectomies.CONCLUSION Minimally invasive resection of ICC has some short-term benefits and it is safe and feasible only in selected centers with a high experience in laparoscopic approach for liver surgery.Minimally invasive surgery,actually,was considered mainly in patients with a tumor with a diameter<5 cm,without invasion of main biliary duct or main vessel and no vascular or biliary reconstructions were planned.Further studies are needed to elucidate its impact on long term oncologic outcomes.

Sphincter-preserving R0 total mesorectal excision with resection of internal genitalia combined with pre-or postoperative chemoradiation for T4 rectal cancer in females

AIM: To evaluate the impact of chemoradiation admi- nistered pre- or postoperatively on prognosis in females following R0 extended resection with sphincter- preserving total mesorectal excision (TME) for locally advanced rectal cancer and to assess the association between chemoradiation and intra- and postoperative variables. METHODS: Twenty-one females were treated for locally advanced but preoperatively assessed as primarily resectable rectal cancer involving reproductive organs. Anterior resection with TME and excision of internal genitalia was combined with neo- or adjuvant chemoradiation. Two-year disease-free survival analysis was performed with the Kaplan-Meier method and log- rank test. The association between chemoradiation and other variables was evaluated with the Fisher’s exact test and Mann-Whitney test. RESULTS: Survival rate decreased in anaemic females (51.5% vs 57.4%), in patients older than 60 years (41.8% vs 66.7%) with poorly differentiated cancers (50.0% vs 55.6%) and tumors located ≤ 7 cm from the anal verge (42.9% vs 68.1%) but with the lack of importance. Patients with negative lymph nodes and women chemoradiated preoperatively had significantly favourable prognosis (85.7% vs 35.7%; P= 0.03 and 80.0% vs 27.3%; P = 0.01, respectively). Preoperative chemoradiation compared to adjuvant radiochemotherapy was not significantly associated with the duration of surgery, incidence of intraoperative bowel perforation and blood loss ≥ 1 L, rate of postoperative bladder and anorectal dysfunction, and minimal distal resection margin. It significantly influenced minimal radial margin (mean 4.2 mm vs 1.1 mm; P < 0.01). CONCLUSION: Despite involving internal genitalia, long-term disease-free survival and sphincter preservation may be achieved with combined-modality therapy for females with T4 locally advanced rectal carcinoma. Neoadjuvant chemoradiation does not compromise functional results and may significantly improve oncological outcomes probably due to enhanced radial clearance.

Assessment of multi-modality evaluations of obscure gastrointestinal bleeding

AIMTo determine the frequency of bleeding source detection in patients with obscure gastrointestinal bleeding (OGIB) who underwent double balloon enteroscopy (DBE) after pre-procedure imaging [multiphase computed tomography enterography (MPCTE), video capsule endoscopy (VCE), or both] and assess the impact of imaging on DBE diagnostic yield.METHODSRetrospective cohort study using a prospectively maintained database of all adult patients presenting with OGIB who underwent DBE from September 1st, 2002 to June 30th, 2013 at a single tertiary center.RESULTSFour hundred and ninety five patients (52% females; median age 68 years) underwent DBE for OGIB. AVCE and/or MPCTE performed within 1 year prior to DBE (in 441 patients) increased the diagnostic yield of DBE (67.1% with preceding imaging vs 59.5% without). Using DBE as the gold standard, VCE and MPCTE had a diagnostic yield of 72.7% and 32.5% respectively. There were no increased odds of finding a bleeding site at DBE compared to VCE (OR = 1.3, P = 0.150). There were increased odds of finding a bleeding site at DBE compared to MPCTE (OR = 5.9, P < 0.001). In inpatients with overt OGIB, diagnostic yield of DBE was not affected by preceding imaging.CONCLUSIONDBE is a safe and well-tolerated procedure for the diagnosis and treatment of OGIB, with a diagnostic yield that may be increased after obtaining a preceding VCE or MPCTE. However, inpatients with active ongoing bleeding may benefit from proceeding directly to antegrade DBE.

Calcific left atrium:A rare consequence of endocarditis

Usually, cardiac calcifications are observed in aortic and mitral valves, atrio-ventricular plane, mitral annulus, coronary arteries, pericaridium(usually causing constrictive pericarditis) and cardiac masses. Calcifications of atrial walls are unusual findings that can be identified only using imaging with high spatial resolution, such as cardiac magnetic resonance and computed tomography. We report a case of a 43-year-old patient with no history of heart disease that underwent cardiac evaluation for mild dyspnoea. The echocardiogram showed a calcific aortic valve and a hyper-echogenic lesion located in atrio-ventricular plane. The patient was submitted to cardiac magnetic resonance and to computed tomography imaging to better characterize the localization of mass. The clinical features and location of calcified lesion suggest an infective aetiology causing an endocarditis involving the aortic valve, atrioventricular plane and left atrium. Although we haven't data to support a definite and clear diagnosis, the clinical features and location of the calcified lesion suggest an infective aetiology causing an endocarditis involving the aortic valve, atrio-ventricular plane and left atrium. The patient was followed for 12 mo both clinically and by electrocardiogram and echocardiography without worsening of clinical, electrocardiographic and echocardiographic data. Cardiac magnetic resonance imaging and computed tomography are ideal methods for identifying and following over time patients with calcific degeneration in the heart.

Review on radiological evolution of COVID-19 pneumonia using computed tomography

BACKGROUND Pneumonia is the main manifestation of coronavirus disease 2019(COVID-19)infection.Chest computed tomography is recommended for the initial evaluation of the disease;this technique can also be helpful to monitor the disease progression and evaluate the therapeutic efficacy.AIM To review the currently available literature regarding the radiological follow-up of COVID-19-related lung alterations using the computed tomography scan,to describe the evidence about the dynamic evolution of COVID-19 pneumonia and verify the potential usefulness of the radiological follow-up.METHODS We used pertinent keywords on PubMed to select relevant studies;the articles we considered were published until October 30,2020.Through this selection,69 studies were identified,and 16 were finally included in the review.RESULTS Summarizing the included works’findings,we identified well-defined stages in the short follow-up time frame.A radiographic deterioration reaching a peak roughly within the first 2 wk;after the peak,an absorption process and repairing signs are observed.At later radiological follow-up,with the limitation of little evidence available,the lesions usually did not recover completely.CONCLUSION Following computed tomography scan evolution over time could help physicians better understand the clinical impact of COVID-19 pneumonia and manage the possible sequelae;a longer follow-up is advisable to verify the complete resolution or the presence of long-term damage.

Relationship between clinical remission of perianal fistulas in Crohn’s disease and serum adalimumab concentrations:A multicenter cross-sectional study

BACKGROUND Crohn’s disease(CD)is complicated by perianal fistulas in approximately 20%of patients.Achieving permanent fistula closure remains a challenge for physicians.An association between serum anti-tumor necrosis factor-αconcentrations and clinical outcomes in patients with CD has been demonstrated;however,little information is available on serum adalimumab(ADA)concentrations and remission of perianal fistulas in such patients.AIM To study the relationship between serum ADA concentrations and clinical remission of CDassociated perianal fistulas.METHODS This cross-sectional study of patients with CD-associated perianal fistulas treated with ADA was performed at four French hospitals between December 2013 and March 2018.At the time of each serum ADA concentration measurement,we collected information about the patients and their fistulas.The primary study endpoint was clinical remission of fistulas defined as the absence of drainage(in accordance with Present’s criteria),with a PDAI≤4,absence of a seton and assessment of the overall evaluation as favorable by the proctologist at the relevant center.We also assessed fistula healing[defined as being in clinical and radiological(magnetic resonance imaging,MRI)remission]and adverse events.RESULTS The study cohort comprised 34 patients who underwent 56 evaluations(patients had between one and four evaluations).Fifteen patients had clinical remissions(44%),four of whom had healed fistulas on MRI.Serum ADA concentrations were significantly higher at evaluations in which clinical remission was identified than at evaluations in which it was not[14(10-16)vs 10(2-15)μg/mL,P=0.01].Serum ADA concentrations were comparable at the times of evaluation of patients with and without healed fistulas[11(7-14)vs 10(4-16)μg/mL,P=0.69].The adverse event rate did not differ between different serum ADA concentrations.CONCLUSION We found a significant association between high serum ADA concentrations and clinical remission of CD-associated perianal fistulas.

Health-related quality of life in patients that have undergone liver resection:A systematic review and meta-analysis

BACKGROUND Mortality after hepatectomy has decreased,and the quality of various surgical approaches to hepatectomy have been evaluated.Various assessments of quality of life(QOL)after hepatectomy have been developed and investigated in different clinical settings.AIM To conduct a systematic review and meta-analysis to examine two clinical topics:Laparoscopic hepatectomy vs open hepatectomy,and preoperative QOL status vs postoperative QOL status.METHODS A systematic literature search was performed using PubMed and MEDLINE,including the Cochrane Library Central.The following inclusion criteria were set for inclusion in this meta-analysis:(1)Studies comparing preoperative QOL and postoperative QOL;and(2)Studies comparing QOL between laparoscopic hepatectomy and open hepatectomy.RESULTS A total of 8 articles were included in this meta-analysis.QOL was better after laparoscopic hepatectomy than after open hepatectomy.CONCLUSION The outcomes of evaluations of QOL after hepatectomy can depend on the type of questionnaire used,the timing of the assessment,and the etiology of the hepatic disease.

The Pattern of Eosinophil Count among Nigerians with Frequent Use of the Commonly Available Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

Introduction: Non-steroidal anti-inflammatory drugs (NSAIDs) use is very common. NSAIDs use could be associated with elevated eosinophil count which could be a class effect or patient-related. Inflammation could be the link between NSAIDs use and eosinophilia. Aims: To compare the pattern of eosinophil count in the peripheral blood of frequent users of NSAIDs and healthy controls. Methodology: Two hundred (one hundred frequent users of NSAIDs and 100 healthy controls) participants who had no known risk factor for kidney disease and had given informed consent were recruited. Blood was taken to determine the white cell count and differentials, serum electrolyte and creatinine, and random blood sugar. Results: The mean age of NSAIDs users was not significantly different from controls, P = 0.3. The mean eosinophil count was higher in males than females. The incidence of eosinophilia in NSAIDs users was 4%. The mean Eosinophil count of NSAIDs users was insignificantly higher than controls, 164.3 ± 51 6 vs 135. 6 ± 53.4, P = 0.4. The mean platelet count of NSAIDs users was significantly higher compared to controls, P = 0.04. The mean hematocrit of NSAIDs users was significantly lower than the controls, P = 0.02. Propionic acid derivatives were associated with the highest eosinophil count. Eosinophil count was positively related to age and serum creatinine and inversely related to blood glucose, hematocrit and glomerular filtration rate. Conclusion: The incidence of eosinophilia was 4%. The eosinophil count was higher in frequent NSAIDs users than occasional and non-users, in males than females and with use propionic acid derivatives compared to other NSAIDs. The Eosinophil count was positively related to age and platelet count. Being commoner in inflammatory states, the tissue destruction associated with elevated EC can be avoided by the prevention and prompt treatment of inflammatory conditions.

CT colonography:Friend or foe of practicing endoscopists

AIM:To investigate the perceived impact of computed tomographic colonography(CTC) on endoscopists' current and future practice.METHODS:A 21-question survey was mailed to 1570 randomly chosen American Society for Gastrointestinal Endoscopy(ASGE) members.Participants reported socio-demographics,colonoscopy volume,percentage of colonoscopies performed for screening,and likelihood of integration of CTC into their practice.RESULTS:A total of 367 ASGE members(23%) returned the questionnaire.Respondents were predominantly male(> 90%) and white(83%) with an average age of 49 years.Most respondents(58%) had no plans to incorporate CTC into daily practice and only 7% had already incorporated CTC into daily practice.Private practice respondents were the least likely to incorporate this modality into their daily practice(P=0.047).Forty-three percent of participants were willing to take courses on CTC reading,particularly those with the highest volume of colonoscopy(P=0.049).Forty percent of participants were unsure of CTC's impact on future colonoscopy volume while 21% and 18% projected a decreased and increased volume,respectively.The estimated impact of CTC volume varied significantly by age(P=0.002).Respondents > 60 years felt that CTC would increase colonoscopy,whereas those < 40 years thought CTC would ultimately decrease colonoscopy.CONCLUSION:Practicing endoscopists are not enthusiastic about the incorporation of CTC into their daily practice and are unsure of its future impact on their practice.

Single organ hepatic artery vasculitis as an unusual cause of epigastric pain:A case report

BACKGROUND Single-organ vasculitis(SOV)is characterized by inflammation of a blood vessel,affecting one organ,such as the skin,genitourinary system,or the aorta without systemic features.Gastrointestinal SOV is rare,with hepatic artery involvement reported only in two prior published cases.Herein,we presented a case of isolated hepatic artery vasculitis presenting after Pfizer-BioNTech mRNA corona virus disease 2019(COVID-19)vaccination.CASE SUMMARY A 50-year-old woman with hypertension presented to our Emergency Department with recurrent diffuse abdominal pain that localized to the epigastrium and emesis without diarrhea that began eight days after the second dose of the PfizerBioNTech COVID-19 vaccine.Blood work revealed an elevated C-reactive protein(CRP)of 19 mg/L(normal<4.8 mg/L),alkaline phosphatase 150 U/L(normal 25-105 U/L),gamma-glutamyl transferase(GGT)45 U/L(normal<43 U/L)and elevated immunoglobulins(Ig)G 18.4 g/L(normal 7-16 g/L)and IgA 4.4 g/L(normal 0.7-4 g/L).An abdominal computed tomography revealed findings in keeping with hepatic artery vasculitis.A detailed review of her history and examination did not reveal infectious or systemic autoimmune causes of her presentation.An extensive autoimmune panel was unremarkable.COVID-19polymerase chain reaction nasopharyngeal swab,human immunodeficiency virus,viral hepatitis and Heliobacter pylori serology were negative.At six months,the patient’s symptoms,and blood work spontaneously normalized.CONCLUSION High clinical suspicion of SOV is required for diagnosis in patients with acute abdominal pain and dyspepsia.

3.0T MR Coronary Angiography after Arterial Switch Operation for Transposition of The Great Arteries-Gd-FLASH Versus Non-Enhanced SSFP.A Feasibility Study

Background:Patency of the coronary arteries is an issue after reports of sudden cardiac death in patients with transposition of the great arteries(TGA)operated with arterial switch(ASO).Recent studies give rise to concern regarding the use of ionising radiation in congenital heart disease,and assessment of the coronary arteries with coronary MR angiography(CMRA)might be an attractive non-invasive,non-ionising imaging alternative in these patients.Theoretically,the use of 3.0T CMRA should improve the visualisation of the coronary arteries.The objective of this study was to assess feasibility of 3.0T CMRA at the coronary artery origins by comparing image quality with non-contrast CMRA in ASO TGA patients to healthy age-matched controls,and by comparing image quality with non-contrast CMRA to contrast enhanced CMRA in the patient group.Material and methods:Twelve patients,9-15 years(mean 11.9 years,standard deviation 1.5 years),and 12 age-matched controls(mean 12.7 years,standard deviation 1.7 years)were examined with 3D balanced steady-state free precession(SSFP).Nine of twelve patients had Gadolinium-enhanced fast low-angle shot(Gd-FLASH)performed after SSFP.Image quality at the coronary artery origins was evaluated subjectively with a 10 cm figurative visual analogue scale(fVAS)and objectively by signal-to-noise and contrast-to-noise ratio(SNR,CNR).Results:All,but one,coronary artery origins were identified.No significant difference in image quality scores was found between patients and controls with SSFP(mean values 6.5 cm—9.1 cm in patients and 7.0 cm—8.0 cm in controls,p-values>0.1).With SSFP,intra-observer fVAS mean score was 6.7 cm—8.6 cm and with Gd-FLASH 7.7 cm—8.7 cm.CNR was higher with Gd-FLASH(p<0.03).Intra-observer agreement index(AI)with SSFP was moderate-to-good(0.43–0.71)and with Gd-FLASH good(0.64–0.79)in all origins.Inter-observer AI was good in the left main stem(LMS)with SSFP(0.65).With Gd-FLASH inter-observer AI was good in LMS(0.78)and moderate(0.5)in the left anterior descending artery,but lacking in the other origins though with a good agreement on Bland-Altman plots.Conclusions:Our findings indicate a better,more reproducible image quality with Gd-FLASH than with non-contrast SSFP CMRA on 3.0T for evaluation of the coronary artery origins in ASO TGA children and adolescents.

Central and peripheral neurological involvement in monoclonal gammopathies of undetermined significance

Several studies have suggested a pathogenetic role of paraproteinaemias in PNS damage. Over the few last years, the presence of symptomatic or subclinical PNS lesions in CNS diseases like multiple sclerosis has been described. On the other hand, CNS demyelinating lesions and cervical atrophy have been re- ported in patients affected by chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). Very few cases of MGUS associated with CNS disease alone or with both CNS and PNS disease have been re- ported. Since 1999, we have been studying 16 patients (8 M, 8 F), with a mean age 60.2 ± 13.4, affected by MGUS associated with symptomatic neurological central and/or peripheral diseases. Patients affected with lymphomas, lupus erithematosus and other immunological diseases were excluded. Involvement of both PNS and CNS was not associated to a particular type of paraproteinemia: monoclonal IgM were found in 8 patients;monoclonal IgG in 6 patients and mono- clonal IgA in 1 patient and Igl in 1 patient. High anti- nervous system autoantibodies were found in 10/16 patients and antiMAG antibodies were detected in patients with paraproteinemic demyelinating neuropathy (PDN). High reactivity anti-nervous system might support the hypothesis of a pathogenetic role of MGUS in these neurological diseases. Nevertheless, at present, we cannot exclude that there is only a circumstantial association between MGUS and neurological damages, particularly concerning CNS.