Vaccine effectiveness against severe COVID-19 during the Omicron wave in Germany: results from the COViK study.

PURPOSE: COViK, a prospective hospital-based multicenter case-control study in Germany, aims to assess the effectiveness of COVID-19 vaccines against severe disease. Here, we report vaccine effectiveness (VE) against COVID-19-caused hospitalization and intensive care treatment during the Omicron wave. METHODS: We analyzed data from 276 cases with COVID-19 and 494 control patients recruited in 13 hospitals from 1 December 2021 to 5 September 2022. We calculated crude and confounder-adjusted VE estimates. RESULTS: 21% of cases (57/276) were not vaccinated, compared to 5% of controls (26/494; p < 0.001). Confounder-adjusted VE against COVID-19-caused hospitalization was 55.4% (95% CI: 12-78%), 81.5% (95% CI: 68-90%) and 95.6% (95%CI: 88-99%) after two, three and four vaccine doses, respectively. VE against hospitalization due to COVID-19 remained stable up to one year after three vaccine doses. CONCLUSION: Three vaccine doses remained highly effective in preventing severe disease and this protection was sustained; a fourth dose further increased protection.

Sonographically Detected Hepatic Portal Venous Gas - Prevalence, Causes, and Clinical Implications.

PURPOSE: Hepatic portal venous gas (HPVG) is a rare clinical finding, often caused by a severe underlying disease. In the literature as well as in clinical practice, HPVG is considered "signum malum" with a poor prognosis and bowel ischemia as the most common cause. Most studies are based on the results of computed tomography (CT) examinations. The aim of this retrospective study is to report on the prevalence, causes, and clinical course of HPVG in a monocentric cohort of abdominal ultrasound (US) investigations. MATERIALS AND METHODS: The US database of an academic teaching hospital was searched with specific keywords (timespan 01/2000 to 12/2020). Reports, pictures, and clinical data of all cases with HPVG were re-evaluated. RESULTS: Out of 134 804 US examinations, 8 HPVG cases were identified. There was a wide variety of underlying diseases, with mesenteric ischemia being seen in only 2 cases. 5 patients were discharged in stable condition, with 4 of them having undergone surgical treatment. 2 patients who had rejected further measures died, and one was lost to follow-up. DISCUSSION: HPVG is a rare phenomenon in clinical US. However, ultrasonographic prevalence is comparable to the prevalence in CT studies. Underlying diseases are mostly severe, and in nearly all cases an underlying cause can be found by thorough investigation. In some cases, US may even be superior to CT scans for the detection of HPVG. Despite its rarity, every sonographer should know the typical sonographic presentation of HPVG, and appropriate images should be included in US teaching modules.

Gastric NET Subtypes: Do We Need An Additional One?

Depending on etiology, prognosis and malignant potential, recent S2k guideline differentiates gastric neuroendocrine tumors (gNET) in 4 types with different treatment implications.We report on a 55-year-old patient with the accidental finding of a 15 mm gNET. Apart from a prolonged use of proton pump inhibitors (PPI) for 20 years as a treatment for gastroesophageal reflux disease, there were no other associations or risk factors for gNETs. Formally, this patient would have been classified as a type III gNET, implicating gastric surgery. From a pathophysiological point of view, however, the assumed prolonged gastrin hypersecretion would have justified an assignment as a type I gNET. The gNET was resected by ESD, but histology showed an R1 situation. After cessation of PPIs, there is no recurrence so far. Besides, the initially documented numerous and large gland polyps showed an impressive regression only a few weeks after cessation of PPI.This case points to a probably underestimated gap in the present gNET classification. On the basis of present literature, the therapeutic dilemma of PPI-associated gNETs is discussed. A new assignment of PPI associated gNETs as type Ib could help to overcome this dilemma.

An Unusual Case of Iron-Deficiency Anemia: The Culprit Hides in the Aorta.

In a 72-year-old patient with anemia (Hb 7 g/dl), duodenoscopy exhibited an area of polypous irregular-looking mucosa. Histology revealed duodenal infiltration by epithelioid tumor cells, immunhistochemically positive for endothelial cell markers (CD34, CD31, ERG). Ultrasonography showed thrombotic material in the otherwise unremarkable abdominal aorta with some uptake of contrast bubbles on CEUS. Histological and clinical diagnosis assumed an epithelioid angiosarcoma of the thoraco-abdominal aorta at the level of the visceral and renal arteries with duodenal metastases.To prevent further shedding of tumor cells and aortic rupture, a branched stent-graft was placed into the thoraco-abdominal aorta. Palliative chemotherapy with gemcitabine and docetaxel was started, leading to a partial remission after 6 cycles. Three months later, however, there was a progress of the duodenal masses with new pulmonal and osseous metastases. Thirteen months after the initial diagnosis, death occured due to a hemorrhagic shock caused by a hematothorax.Aortic tumors are exceedingly rare, with only slightly more than 220 cases reported so far. In most cases, diagnosis is made either at autopsy or after an emergency operation for embolic complications like embolic intestinal ischemia. With an overall median survival of 8 months, prognosis is very poor.This case sensitizes for the correct sonographic interpretation of aortic "thrombi" in an otherwise normally appearing aorta, possibly with the aid of CEUS. Besides, it demonstrates the relatively early and uncommon diagnosis of an aortic angiosarcoma by the combination of endoscopy, immunohistochemistry, and ultrasonography.

[Unusual cause of hypercalcemia in pregnancy]. / Ungewöhnliche Ursache einer Hyperkalzämie in der Schwangerschaft.

BACKGROUND: Neuroendocrine tumors (NET) diagnosed during pregnancy are extremely rare. This case report describes diagnosis and treatment of a metastasized pancreas NET that became symptomatic in the second trimester. CASE DESCRIPTION: A 33-year-old patient presented to the emergency department in the 19th week of pregnancy (WOP) with persistent diarrhea. Laboratory tests showed a pronounced hypercalcemia (3.53 mmol/l). Imaging revealed a mass in the pancreatic corpus/tail with extensive liver metastasis. Histologically, a NET (G2, SSTR-positive) with paraneoplastic parathormone-related-peptide secretion was found to be the cause of hypercalcemia. Under a treatment with octreotide, calcium values normalized and diarrhea stopped. After delivery of a healthy child (32.WOP via cesarean section) tumor progress was found. The pancreatic mass was resected completely, the liver metastases as far as possible. Postoperatively, in a CT scan, residual suspicious liver lesions could be found, and a palliative therapy with lanreotide was initiated. With this treatment, the patient has been asymptomatic for one year, and serum calcium remained normal. The child developed normally. DISCUSSION: This unusual case shows that even in extensively metastasized symptomatic NETs during pregnancy, there may be sufficient diagnostic and therapeutic options that allow for a continuation of pregnancy in close interdisciplinary cooperation under careful risk-benefit assessment for mother and child.

[Lung Ultrasound on Admission to a Covid Decision Unit - Helpful in Differential Diagnosis or a Waste of Time?] / Thoraxsonografie bei Aufnahme auf einer COVID-Verdachtsstation ­ differenzialdiagnostisch hilfreich oder Zeitverschwendung?

BACKGROUND: In patients with Covid-19, typical and often severe lung lesions have been reported. In addition to the use of chest CT, the diagnostic benefit of lung ultrasound has been advocated.This trial investigates if in patients presenting with symptoms compatible with Covid-19, lung ultrasound is of use in the early differential diagnosis. METHODS: This study includes 46 patients of the first wave of the Covid-19 pandemic (23 with confirmed infection, 23 controls with later on excluded infection), who were initially admitted to the Covid Decision Unit of an academic teaching hospital under the clinical suspicion of SARS-CoV-2 infection. All patients were examined by pulmonary ultrasound shortly after admission. The final diagnosis of infection was made or ruled out by means of - sometimes repeated - PCR of nasal/pharyngeal swabs.Findings of SARS-CoV-2 patients and controls were compared and analyzed for significant differences in chest sonographic parameters. RESULTS: There were significant differences in the lung ultrasound findings of both groups. In the Covid group there were significantly fewer A-lines, more pathological B-lines (increased or confluent) and more consolidations. Pleural effusions were significantly more frequent in the control group. The calculated lung ultrasound score (LUS) was higher in the Covid group than in the control group. However, a reliable differentiation between the two groups was not possible due to the wide range and overlap.  CONCLUSION: In a clinical setting, lung ultrasound reveals more frequent and different lesions in SARS-CoV-2 infected patients than in patients in whom the initial clinical suspicion was not confirmed. However, due to the overlap of findings between the two groups, lung ultrasound was not suitable to differentiate with sufficient certainty between SARS-CoV-2 infected and non-infected patients.

A patient with lower gastrointestinal bleeding: common history, very uncommon cause, minimally invasive treatment.

An 81-year-old patient with significant cardiac comorbidities, a history of sigmoid resection 6 years ago, and iliac bypass surgery 19 years ago presented with mild hematochezia for the previous 3 days. While hemodynamically stable at first, he developed massive bleeding during preparation for colonoscopy and underwent a short course of cardiopulmonary resuscitation. Colonoscopy revealed no active bleeding but a protuberance of the colonic wall and a coagulation clot. In ultrasonography immediately after endoscopy, a large aneurysm was diagnosed and diagnosis of an iliaco-colonic fistula was assumed. CT scan demonstrated a large pseudoaneurysm of the distal anastomosis after iliaco-iliac bypass. With endovascular treatment, the original lumen of the iliac artery could be recanalized, and 2 covered stents were placed to cover both anastomosis of the prosthetic bypass leading to a complete shutdown of bypass perfusion. A double-barreled transversostoma was established to minimize contamination of the aneurysmal sac. Seven months after these procedures, the patient is well and free of infection.Though aorto- or iliaco-colonic fistula after aortic or iliac surgery are very rare, endoscopists should be aware of their possibility. A high index of clinical suspicion in patients with prior abdominal vascular bypass surgery should prompt rapid imaging studies, possibly before endoscopy. In critically ill patients, endovascular treatment may be a suitable alternative and result in a favorable outcome.

Straight Vessel Pattern and Rapid Filling Time: Characteristic Findings on Contrast-Enhanced Sonography of Testicular Lymphoma.

Six patients with 7 lesions that were histologically confirmed as primary testicular lymphoma were preoperatively investigated with a standardized sonographic protocol including contrast-enhanced sonography. Duplex and contrast-enhanced sonography showed marked hypervascularization in all 7 lesions. On contrast-enhanced sonography, the filling time of lymphomatous lesions was significantly shorter than the filling time of a size-matched sample of 10 patients with seminomas (P < .0001). The sonographic hallmarks of testicular lymphoma in our case series were as follows: (1) sharply demarcated homogeneous hypoechoic testicular lesions with marked hypervascularization; (2) a rapid (<7 seconds) filling time of contrast bubbles; and (3) a straight and parallel course of intralesional vessels on contrast-enhanced sonography.

Effectiveness of vaccines in preventing hospitalization due to COVID-19: A multicenter hospital-based case-control study, Germany, June 2021 to January 2022.

We included 852 patients in a prospectively recruiting multicenter matched case-control study in Germany to assess vaccine effectiveness (VE) in preventing COVID-19-associated hospitalization during the Delta-variant dominance. The two-dose VE was 89 % (95 % CI 84-93 %) overall, 79 % in patients with more than two comorbidities and 77 % in adults aged 60-75 years. A third dose increased the VE to more than 93 % in all patient-subgroups.

Editorial.

Dear Colleagues, It is a special pleasure to introduce the first issue of Ultrasound International Open in a still difficult year - a year, in which many of us had concerns and clinical tasks reaching far beyond basic or clinical science on ultrasonography (US). Thus, I am delighted to draw your attention to some interesting and important new papers teaching us on various aspects of our every day's US practice.

[Sudden exercise dyspnea in a young woman - an interdisciplinary case in the emergency room]. / Plötzliche Belastungsdyspnoe bei einer jungen Frau ­ internistisch-gynäkologisches Grenzgebiet in der Notaufnahme.

HISTORY: A 39-year-old woman with suddenly occurring exercise dyspnea is admitted under the suspicion of pulmonary embolism. In medical history, she mentions a recently completed fertility treatment. FINDINGS AND DIAGNOSIS: Clinically, the patient is in good condition. D-dimers and hCG are markedly elevated. Sonography reveals pronounced ascites, a large right-sided pleural effusion and multicystic, clearly enlarged ovaries. In conjunction with medical history and confirmed by the gynecologists, the diagnosis of ovarian hyperstimulation syndrome (OHSS) is made, classified as grade II-III (moderate to severe). THERAPY AND COURSE: Thrombembolic prophylaxis with Certoparin 3000 IU/d is established as sole therapy. The course of the disease is self-limited. CONCLUSION: OHSS is primarily a gynaecological condition, but physicians may encounter it with exercise dyspnea or abdominal pain as presenting symptoms. Symptoms can be treated well at an early stage, and severe courses can usually be prevented. In this case, clinical history and sonography could disprove the initially suspected diagnosis of pulmonary embolism.

Editorial.

Dear colleagues, It is a pleasure to introduce you to the 2nd issue of UIO in 2017, demonstrating, again, the wide applications and promising developments in ultrasonography. The issue starts with a special editorial from Ioan Sporea from Romania, very well known for his scientific work on the clinical significance of elastography. Dr. Sporea outlines the central role of modern sonographic techniques for clinical decision making in modern hepatology. Together with the great advances in the treatment of chronic viral hepatitis, ultrasonography with elastography and CEUS as a "one stop shopping" facility may give us all the information we need to proceed to treatment, thus superseding liver biopsy in many (though definitively not all) patients with liver disease.

Real-Time Elastography and Contrast-Enhanced Ultrasonography in the Evaluation of Testicular Masses: A Comparative Prospective Study.

This study investigates the usefulness of contrast-enhanced ultrasound (CEUS) and real-time elastography (RTE) for the characterization of testicular masses by comparing pre-operative ultrasound findings with post-operative histology. Sixty-seven patients with 68 sonographically detected testicular masses underwent B-mode, color-coded Doppler sonography (CCDS), CEUS and RTE according to defined criteria. For RTE, elasticity score (ES), difference of elasticity score (D-ES), strain ratio (SR) and size quotient (Qsize) were evaluated. Histopathologically, 54/68 testicular lesions were neoplastic (47 malignant, 7 benign). Descriptive statistics revealed the following results (neoplastic vs. non-neoplastic) for sensitivity, specificity, positive predictive value, negative predictive value and accuracy, respectively: B-mode, 100%, 43%, 87%, 100%, 88%; CCDS 81%, 86%, 96%, 55%, 82%; CEUS 93%, 85%, 96%, 73%, 91%; ES 98%, 25%, 85%, 75%, 85%; D-ES 98%, 50%, 90%, 83%, 89%; SR 90%, 45%, 86%, 56%, 81%; and Qsize 57%, 83%, 94%, 28%, 61%. B-mode with CCDS remains the standard for assessing testicular masses. In characterization of testicular lesions, CEUS clearly outperformed all other modalities. Our study does not support the routine use of RTE in testicular ultrasonography because of its low specificity.

[Partynight outcome]. / Folgen einer Partynacht.

HISTORY AND CLINICAL FINDINGS: An 18 year old girl was admitted with progressive painful dysphagia and a severe hemorrhagic endoscopically impassable esophagitis. She reported to have consumed an unknown liquid from a small flask on a party three weeks ago. Later on, this liquid was identified as a party- and sex-drug known as "Poppers", designed to be consumed by sniffing. On admission she had difficulties in swallowing liquids and even saliva. She had lost 8 kg of weight during the last 3 weeks. Clinical examination revealed tachycardia, a moderate tenderness in the epigastrium and sparse bowel sounds. Investigation and treatment: On endoscopy, there was a severe corrosion injury of the esophagus with a consecutive stenosis at 40 cm ab ore. The stenosis could not be passed even with a 4.9 mm instrument. After initial placement of a feeding tube the stenosis was dilated with Savary-Bougies. In the following years, the patient suffered from recurrent stenosis due to excessive scar formation. Repeated treatment with longitudinal incisions by needle knife and steroid injections improved symptoms to a tolerable degree. 5 years after ingestion, the patient still carries a long segment esophageal scarring with mild to moderate stenosis. CONCLUSION: The party drug Poppers is an organic nitrogen compound that has increasingly come into use over the past years. It may cause severe and life threatening esophageal chemical burn injury. Symptoms of painful dysphagia after intake of an "unknown" liquid party drug should raise the suspicion of an accidental oral ingestion of Poppers.

Dysfunction of the hypothalamic-pituitary-glandular axes and relation to Child-Pugh classification in male patients with alcoholic and virus-related cirrhosis.

OBJECTIVE: To investigate anterior pituitary function (adrenal, somatotropic, thyroid and gonadal axes, and prolactin) in relation to the Child-Pugh score in male patients with alcoholic and virus-related liver cirrhosis. METHOD: Anterior pituitary function was evaluated in 52 male cirrhotics (26 Child-Pugh class A (CPA), 16 Child-Pugh class B (CPB) and 10 Child-Pugh class C (CPC)) by a combined pituitary stimulation test, and was compared with 50 age-matched controls. RESULTS: A normal cortisol response to corticotropin-releasing hormone (CRH) stimulation was demonstrated in 57.6% of CPA patients, 31.1% of CPB patients and 20% of CPC patients, while basal levels of adrenocorticotropic hormone (ACTH) and cortisol in cirrhotics were comparable to those in controls. Levels of basal growth hormone (P < 0.001) and stimulated growth hormone (P < 0.01) were significantly higher in cirrhotics compared with controls, while levels of insulin-like growth factor 1 (IGF-1) were significantly lower (P < 0.001). Basal prolactin levels were elevated significantly in CPC patients (P < 0.01), while stimulated prolactin as well as basal and stimulated thyroid-stimulating hormone (TSH) levels were comparable. Basal luteinizing hormone levels were significantly higher in CPA (P < 0.001) and CPB (P < 0.001) patients, and stimulated luteinizing hormone levels were significantly lower in CPC patients than in controls (P < 0.005). Basal and stimulated follicle-stimulating hormone (FSH) levels were comparable in all groups. Child-Pugh score was correlated positively to prolactin and was correlated negatively to IGF-1, stimulated luteinizing hormone and free testosterone. CONCLUSIONS: In cirrhotics, the hypothalamic-pituitary-adrenal and -gonadal axes and prolactin secretion are impaired. Growth hormone response to growth hormone-releasing hormone (GHRH) is accelerated in cirrhotics. Thus, elevated basal and stimulated levels of growth hormone probably reflect compensation for low levels of IGF-1, which are associated with deteriorating liver function. The aetiology of cirrhosis was found to have no influence on the degree of alteration of the hypothalamic-pituitary-glandular axes.

Gallbladder motility in healthy volunteers: effects of age, gender, body mass index, and hair color.

BACKGROUND/AIMS: Ultrasonographic determination of gallbladder motility is sparsely performed in clinical practice as the examination is considered to be time consuming and there is uncertainty about a number of parameters possibly influencing the results. The aims of this study were a) to establish normal values for a simple ultrasonographic test and b) to evaluate the influence of different parameters on gallbladder motility. METHODOLOGY: In 62 systematically age- and sex-matched healthy volunteers, ultrasonographic measurements of gallbladder volume (ellipsoid method, planimetry and sum-of-cylinders method) were performed fasting and 5, 10, 20, 30, 40, 50, 60, 70 and up to 75 min after stimulation with a standardized high-caloric liquid meal. RESULTS: Using the ellipsoid method, gallbladder fasting volume (V0) reached a mean value (+/- SD) of 24.6 +/- 10.0 mL with an ejection fraction of 65.9 +/- 19.1%. Age, gender and hair color did not influence parameters of gallbladder contraction. Body mass index showed a weak correlation with V0 but not with ejection fraction. There was a highly significant correlation between the ellipsoid method and longitudinal planimetry and the sum-of-cylinders method, respectively. CONCLUSIONS: Ultrasonographic measurement of gallbladder motility in healthy volunteers shows a very wide scattering of normal values. In the interpretation of gallbladder emptying, age, gender and body mass index do not have to be considered. Determination of gallbladder motility may be performed by a rather simple approach with oral stimulation and ellipsoid method or longitudinal planimetry as easily applicable ultrasonographic measurements.

[Acute mesenteric ischemia--frequently overlooked and often fatal]. / Die akute mesenteriale Ischämie--häufig übersehen und häufig letal.

BACKGROUND: Acute mesenteric ischemia still carries an appallingly high mortality rate. Subsets of acute mesenteric ischemia comprise mesenteric artery embolism and thrombosis, mesenterial vein thrombosis and non occlusive mesenteric ischemia. DIAGNOSIS: Clinical presentation initially is often dominated by a discrepancy between severe subjective pain and relatively unspectacular findings on physical examination. The key to better survival rates (and the main problem in clinical practice) are early and, if indicated, invasive and aggressive diagnosis and treatment. Unfortunately, there are no non invasive diagnostic tests of sufficient sensitivity and specificity so far, and mesenterial angiography (or abdominal CT, if mesenterial venous thrombosis is suspected) remains the gold standard of diagnosis. TREATMENT: In the obstructive forms of arterial mesenteric ischemia, the main therapeutic step after stabilization of the circulation remains an early laparotomy with embolectomy or revascularization and, if appropriate, resection of infarcted bowel. In patients with nonocclusive mesenteric ischemia, counteraction of mesenteric vasoconstriction is the main therapeutic principle. OBJECTIVES: This review describes the different forms of acute mesenteric ischemia and gives an overview of the currently established and recommended forms of diagnosis and treatment.