Diagnostic and therapeutic role of endoscopic ultrasound in liver diseases:A systematic review and meta-analysis

BACKGROUND In hepatology,the clinical use of endoscopic ultrasound(EUS)has experienced a notable increase in recent times.These applications range from the diagnosis to the treatment of various liver diseases.Therefore,this systematic review summarizes the evidence for the diagnostic and therapeutic roles of EUS in liver diseases.AIM To examine and summarize the current available evidence of the possible roles of the EUS in making a suitable diagnosis in liver diseases as well as the therapeutic accuracy and efficacy.METHODS PubMed,Medline,Cochrane Library,Web of Science,and Google Scholar databases were extensively searched until October 2023.The methodological quality of the eligible articles was assessed using the Newcastle-Ottawa scale or Cochrane Risk of Bias tool.In addition,statistical analyses were performed using the Comprehensive Meta-Analysis software.RESULTS Overall,45 articles on EUS were included(28 on diagnostic role and 17 on therapeutic role).Pooled analysis demonstrated that EUS diagnostic tests had an accuracy of 92.4%for focal liver lesions(FLL)and 96.6%for parenchymal liver diseases.EUS-guided liver biopsies with either fine needle aspiration or fine needle biopsy had low complication rates when sampling FLL and parenchymal liver diseases(3.1%and 8.7%,respectively).Analysis of data from four studies showed that EUS-guided liver abscess had high clinical(90.7%)and technical success(90.7%)without significant complications.Similarly,EUS-guided interventions for the treatment of gastric varices(GV)have high technical success(98%)and GV obliteration rate(84%)with few complications(15%)and rebleeding events(17%).CONCLUSION EUS in liver diseases is a promising technique with the potential to be considered a first-line therapeutic and diagnostic option in selected cases.

Multiparametric ultrasound as a new concept of assessment of liver tissue damage

Liver disease accounts for approximately 2 million deaths per year worldwide.All chronic liver diseases(CLDs),whether of toxic,genetic,autoimmune,or infectious origin,undergo typical histological changes in the structure of the tissue.These changes may include the accumulation of extracellular matrix material,fats,triglycerides,or tissue scarring.Noninvasive methods for diagnosing CLD,such as conventional B-mode ultrasound(US),play a significant role in diagnosis.Doppler US,when coupled with B-mode US,can be helpful in evaluating the hemodynamics of hepatic vessels and detecting US findings associated with hepatic decompensation.US elastography can assess liver stiffness,serving as a surrogate marker for liver fibrosis.It is important to note that interpreting these values should not rely solely on a histological classification.Contrast-enhanced US(CEUS)provides valuable information on tissue perfusion and enables excellent differentiation between benign and malignant focal liver lesions.Clinical evaluation,the etiology of liver disease,and the patient current comorbidities all influence the interpretation of liver stiffness measurements.These measurements are most clinically relevant when interpreted as a probability of compensated advanced CLD.B-mode US offers a subjective estimation of fatty infiltration and has limited sensitivity for mild steatosis.The controlled attenuation parameter requires a dedicated device,and cutoff values are not clearly defined.Quan-titative US parameters for liver fat estimation include the attenuation coefficient,backscatter coefficient,and speed of sound.These parameters offer the advantage of providing fat quantification alongside B-mode evaluation and other US parameters.Multiparametric US(MPUS)of the liver introduces a new concept for complete noninvasive diagnosis.It encourages examiners to utilize the latest features of an US machine,including conventional B-mode,liver stiffness evaluation,fat quantification,dispersion imaging,Doppler US,and CEUS for focal liver lesion characterization.This comprehensive approach allows for diagnosis in a single examination,providing clinicians worldwide with a broader perspective and becoming a cornerstone in their diagnostic arsenal.MPUS,in the hands of skilled clinicians,becomes an invaluable predictive tool for diagnosing,staging,and monitoring CLD.

Linear endoscopic ultrasound:Current uses and future perspectives in mediastinal examination

This editorial elaborates on the current and future applications of linear endoscopic ultrasound(EUS),a substantial diagnostic and therapeutic modality for various anatomical regions.The scope of endosonographic assessment is broad and,among other factors,allows for the evaluation of the mediastinal anatomy and related pathologies,such as mediastinal lymphadenopathy and the staging of central malignant lung lesions.Moreover,EUS assessment has proven more accurate in detecting small lesions missed by standard imaging examinations,such as computed tomography or magnetic resonance imaging.We focus on its current uses in the mediastinum,including lung and esophageal cancer staging,as well as evaluating mediastinal lymphadenopathy and submucosal lesions.The editorial also explores future perspectives of EUS in mediastinal examination,including ultrasound-guided therapies,artificial intelligence integration,advancements in mediastinal modalities,and improved diagnostic approaches for various mediastinal lesions.

Practical approach to linear endoscopic ultrasound examination of the gallbladder

The gallbladder(GB)is a susceptible organ,prone to various pathologies that can be identified using different imaging techniques.Transabdominal ultrasound(TUS)is typically the initial diagnostic method due to its numerous well-established advantages.However,in cases of uncertainty or when a definitive diagnosis cannot be established,computed tomography(CT)or magnetic resonance imaging may be employed to provide more detailed information.Nevertheless,CT scans may sometimes offer inadequate spatial resolution,which can limit the differentiation of GB lesions,particularly when smaller yet clinically relevant abnormalities are involved.Conversely,endoscopic ultrasound(EUS)provides higher frequency compared to TUS,superior spatial resolution,and the option for contrast-enhanced harmonic imaging,enabling a more comprehensive examination.Thus,EUS can serve as a supplementary tool when conventional imaging methods are insufficient.This review will describe the standard EUS examination of the GB,focusing on its endosonographic characteristics in various GB path-ologies.

Primary parahiatal hernias:A case report and review of the literature

BACKGROUND Parahiatal hernias(PHHs)are rare occurring disease,with a reported incidence of 0.2%-0.35%in patients undergoing surgery for hiatal hernia.We found only a handful of cases of primary PHHs in the literature.The aim of this paper is to present a case of a primary PHH and perform a systematic review of the literature.CASE SUMMARY We report the case of a 60-year-old Caucasian woman with no history of thoracoabdominal surgery or trauma,which accused epigastric pain,starting 2 years prior,pseudo-angina and bloating.Based on imagistic findings the patient was diagnosed with a PHH and an associated type I hiatal hernia.Patient underwent laparoscopic surgery and we found an opening in the diaphragm of 7 cm diameter,lateral to the left crus,through which 40%-50% of the stomach had herniated in the thorax,and a small sliding hiatal hernia with an anatomically intact hiatal orifice but slightly enlarged.We performed closure of the defect,suture hiatoplasty and a“floppy”Nissen fundoplication.Postoperative outcome was uneventful,with the patient discharged on the fifth postoperative day.We performed a review of the literature and identified eight articles regarding primary PHH.All data was compiled into one tabled and analyzed.CONCLUSION Primary PHHs are rare entities,with similar clinical and imagistic findings with paraesophageal hernias.Treatment usually includes laparoscopic approach with closure of the defect and the esophageal hiatus should be dissected and analyzed.Postoperative outcome is favorable in all cases reviewed and no recurrence is cited in the literature.

Ultrasound-based elastography for the diagnosis of portal hypertension in cirrhotics

Progressive fibrosis is encountered in almost all chronicliver diseases. Its clinical signs are diagnostic in advanced cirrhosis, but compensated liver cirrhosis is harder to diagnose. Liver biopsy is still considered the reference method for staging the severity of fibrosis, but due to its drawbacks(inter and intra-observer variability, sampling errors, unequal distribution of fibrosis in the liver, and risk of complications and even death), non-invasive methods were developed to assess fibrosis(serologic and elastographic). Elastographic methods can be ultrasound-based or magnetic resonance imaging-based. All ultrasoundbased elastographic methods are valuable for the early diagnosis of cirrhosis, especially transient elastography(TE) and acoustic radiation force impulse(ARFI) elastography, which have similar sensitivities and specificities, although ARFI has better feasibility. TE is a promising method for predicting portal hypertension in cirrhotic patients, but it cannot replace upper digestive endoscopy. The diagnostic accuracy of using ARFI in the liver to predict portal hypertension in cirrhotic patients is debatable, with controversial results in published studies. The accuracy of ARFI elastography may be significantly increased if spleen stiffness is assessed, either alone or in combination with liver stiffness and other parameters. Two-dimensional shearwave elastography, the Elast PQ technique and strain elastography all need to be evaluated as predictors of portal hypertension.

Two cases of imported malaria in Western Romania,2010-2011

Malaria is a major problem for European travelers to endemic regions.In Romania during 1980-2007 approximately 20 imported cases were detected annually.The aim of our short communication is to present 2 interesting cases of imported malaria detected in Western Romania.The first patienl was a 20-year female who traveled to India and acquired an infection with Plasmodium vivax(P.vivax).The second patient,a 60-year female,contracted an infection with Plasmodium falciparum(P.falciparum) during a trip to Ghana:the evolution of the disease was severe with many complications and the patient finally died.The cases presented revealed the difficulties in establishing a correct diagnosis of malaria in a non-endemic country, consequences of an incomplete taken anamnesis.Travel history should always represent a mandatory part of a well conducted investigation.At the same time,we must underline the importance of a correct and complete prophylaxis prior to every departure to tropical countries.

A rare case of renal hydatidosis in a child with congenital solitary kidney

Hydatid cyst of a solitary congenital kidney is a rare entity because of the small percentage of cases with renal hvdatidosis and the reduced number of cases with this renal anomaly.We report a case presenting this extremely rare combination and having a favorable outcome.The diagnosis was confirmed based on an association of iniagistic techniques and positive serology.The case was managed using a minimal invasive surgical technique(PAIR) that reduced the operative risks.Additionally,an antihelminthic agent[albendazole) was administered.To our knowledge,this is the first case with such comorbidity and treated through percutaneous approach.

Arrhythmia risk in liver cirrhosis

Interactions between the functioning of the heart and the liver have been described, with heart diseases affecting the liver, liver diseases affecting the heart, and conditions that simultaneously affect both. The heart is one of the most adversely affected organs in patients with liver cirrhosis. For example, arrhythmias and electrocardiographic changes are observed in patients with liver cirrhosis. The risk for arrhythmia is influenced by factors such as cirrhotic cardiomyopathy, cardiac ion channel remodeling, electrolyte imbalances,impaired autonomic function, hepatorenal syndrome, metabolic abnormalities, advanced age, inflammatory syndrome, stressful events, impaired drug metabolism and comorbidities. Close monitoring of cirrhotic patients is needed for arrhythmias, particularly when QT intervalprolonging drugs are given, or if electrolyte imbalances or hepatorenal syndrome appear. Arrhythmia risk may persist after liver transplantation due to possible QT interval prolongation, persistence of the parasympathetic impairment, post-transplant reperfusion and chronic immunosuppression, as well as consideration of the fact that the transplant itself is a stressful event for the cardiovascular system. The aims of the present article were to provide a review of the most important data regarding the epidemiology, pathophysiology, and biomarkers of arrhythmia risk in patients with liver cirrhosis, to elucidate the association with long-term outcome, and to propose future research directions.

Molecular diagnosis in cat allergy

Domestic cats represent one of the most common sources of indoor allergens.All over the world,many households own cats,whose allergens are persistent and widespread.Cat allergy itself is frequent,and its symptoms vary from rhinoconjunctivitis to life-threatening asthma.In vitro diagnosis using precision medicine allergy immunoassays is important because natural cat dander extracts may differ in quality and quantity of some of the individual allergen components and other molecules.In the component-resolved diagnosis of cat allergy,singleplex and multiplex specific immunoglobulin(Ig)E assays include use of the cat-specific major allergen,secretoglobin Fel d 1(as a species-specific molecule),other allergen components(such as lipocalins Fel d 4,cross-reacting with other animal similar molecules,and Fel d 7,present in small quantities in natural extracts),and serum albumin Fel d 2(related to the cat-pork syndrome).IgA Fel d 5 and IgM Fel d 6 are not available as allergen components in the current commercial IgE immunoassays,but they may impair the in vitro diagnostic evaluation of cat allergy because galactose-α1,3-galactose is an IgE-binding epitope of these native feline allergens.The benefits of molecular-based cat allergy diagnosis are continually evaluated,as the role of recombinant allergen components already known is detailed and new other molecules of interest may be discovered in the future.

The influence of metabolic imbalances and oxidative stress on the outcome of critically ill polytrauma patients: a review

The critically ill polytrauma patient presents with a series of associated pathophysiologies secondary to the traumatic injuries. The most important include systemic inflammatory response syndrome (SIRS), sepsis, oxidative stress (OS), metabolic disorders, and finally multiple organ dysfunction syndrome (MODS) and death. The poor outcome of these patients is related to the association of the aforementioned pathologies. The nutrition of the critically ill polytrauma patient is a distinct challenge because of the rapid changes in terms of energetic needs associated with hypermetabolism, sepsis, SIRS, and OS. Moreover, it has been proven that inadequate nutrition can prolong the time spent on a mechanical ventilator and the length of stay in an intensive care unit (ICU). A series of mathematical equations can predict the energy expenditure (EE), but they have disadvantages, such as the fact that they cannot predict the EE accurately in the case of patients with hypermetabolism. Indirect calorimetry (IC) is another method used for evaluating and monitoring the energy status of critically ill patients. In this update paper, we present a series of pathophysiological aspects associated with the metabolic disaster affecting the critically ill polytrauma patient. Furthermore, we present different non-invasive monitoring methods that could help the intensive care physician in the adequate management of this type of patient.

The role of computer-assisted systems for upper-endoscopy quality monitoring and assessment of gastric lesions

This article analyses the literature regarding the value of computer-assisted systems in esogastroduodenoscopy-quality monitoring and the assessment of gastric lesions.Current data show promising results in upper-endoscopy quality control and a satisfactory detection accuracy of gastric premalignant and malignant lesions,similar or even exceeding that of experienced endoscopists.Moreover,artificial systems enable the decision for the best treatment strategies in gastriccancer patient care,namely endoscopic vs surgical resection according to tumor depth.In so doing,unnecessary surgical interventions would be avoided whilst providing a better quality of life and prognosis for these patients.All these performance data have been revealed by numerous studies using different artificial intelligence(AI)algorithms in addition to white-light endoscopy or novel endoscopic techniques that are available in expert endoscopy centers.It is expected that ongoing clinical trials involving AI and the embedding of computer-assisted diagnosis systems into endoscopic devices will enable real-life implementation of AI endoscopic systems in the near future and at the same time will help to overcome the current limits of the computer-assisted systems leading to an improvement in performance.These benefits should lead to better diagnostic and treatment strategies for gastric-cancer patients.Furthermore,the incorporation of AI algorithms in endoscopic tools along with the development of large electronic databases containing endoscopic images might help in upper-endoscopy assistance and could be used for telemedicine purposes and second opinion for difficult cases.

Is Surgery a Good Choice for Patients over 100 Years with Hip Fracture?

Introduction: Elderly patients represent a difficult category of surgical candidates for orthopedic surgery because they have multiple associated diseases and a high degree of osteoporosis. Presentation of Case: We present the case of a 103 years old woman with a pertrohanteric hip fracture treated successfully using a 135° dynamic hip screw. Discussion: There are many discussions about this kind of patients regarding postoperative complications, duration of hospitalization, stage of recovery and the patient’s status at discharge. Conclusion: We conclude that surgery may benefit patients who are over 100 year-old.

New perspectives of volemic resuscitation in polytrauma patients:a review

Nowadays,fluid resuscitation of multiple trauma patients is still a challenging therapy.Existing therapies for volume replacement in severe haemorrhagic shock can lead to adverse reactions that may be fatal for the patient.Patients presenting with multiple trauma often develop hemorrhagic shock,which triggers a series of metabolic,physiological and cellular dysfunction.These disorders combined,lead to complications that significantly decrease survival rate in this subset of patients.Volume and electrolyte resuscitation is chal enging due to many factors that overlap.Poor management can lead to post-resuscitation systemic inflammation causing multiple organ failure and ultimately death.In literature,there is no exact formula for this purpose,and opinions are divided.This paper presents a review of modern techniques and current studies regarding the management of fluid resuscitation in trauma patients with hemorrhagic shock.According to the literature and from clinical experience,al aspects regarding post-resuscitation period need to be considered.Also,for every case in particular,emergency therapy management needs to be rigorously respected considering al physiological,biochemical and biological parameters.

MATHEMATICAL MODELING OF CELL DYNAMICS AFTER ALLOGENEIC BONE MARROW TRANSPLANTATION

In this paper a basic mathematical model is introduced to describe the dynamics of three ceil lines after allogeneic stem cell transplantation： normal host cells, leukemic host cells and donor cells. Their evolution is one of competitive type and depends upon kinetic and cell-cell interaction parameters. Numerical simulations prove that the evolution can ultimately lead either to the normal hematopoietic state achieved by the expansion of the donor cells and the elimination of the host cells, or to the leukemic hematopoietic state characterized by the proliferation of the cancer line and the suppression of the other cell lines. One state or the other is reached depending on cell-cell interactions （anti-host, anti-leukemia and anti-graft effects） and initial cell concentrations at transplantation.The model also provides a theoretical basis for the control of post-transplant evolution aimed at the achievement of normal hematopoiesis.

Unstable mallet fractures： a comparison between three different techniques in a multicenter study

Objective： Management of mallet fractures is still a matter of discussion throughout the literature. For some authors, mallet fractures involving more than 1/3 of the articular surface and palmar subluxation of the distal phalanx require surgical treatment. In this study we retrospectively compared three different techniques for mallet fractures： Kirschner wire fixation with extension block pinning （EBP） of the distal interphalangeal joint, Kirschner wires used as joysticks （KWJ） and interfragmentary miniscrews for open reduction and internal fixation （ORIF）. Methods： Fifty-eight mallet fractures with palmar subluxation in 58 patients were treated with the aforementioned surgical techniques. Twenty mallet fractures in 20 patients 18 to 70 years old （average 42 years） were operated upon by EBP, 16 patients 22 to 56 years old （average 56 years） were operated upon using KWJ and 22 patients 22 to 54 years old （average 36 years） received OR/F. Follow-up time was 6 to 58 months （average 21 months）. The following intraoperative parameters were considered： intraoperative time, number of Kirschner wires/screws and technical problems. Postoperative parameters included work absence and complications. The radiological evaluation was based on A-P and lateral views preoperatively and interviews at follow-up time. Bone union was defined by radiological evidence of bone trabeculae crossing the fracture site on at least one view. Clinical evaluation involved range of motion （ROM） test with a goniometer. Based on these measurements, a functional Crawford score was established. Results： All fractures healed. In the KWJ group, intraoperative time was shorter and total ROM was wider （72° vs 58° and 54 °）; in the ORIF group, return to work was faster （2.7 weeks vs 7.2 weeks and 6 weeks） but a little higher complication rate due to screw positioning has been found. Functional results as to total ROM, distal interphalangeal lag extension and Crawford classification were similar. Conclusions： We demonstrate the advantages of the use of the three techniques and bone consolidation in all cases with no signs ofosteoarthritis. Screw fixation is more technically demanding （longer intraoperative time and more complications） but allows earlier mobilization and faster returning to work. EBP and KWJ techniques are faster to perform with no complications but require a careful management of the pin tracts. There is no statistically significant difference as to functional results.