Risk Factors for Pulmonary Air Leak and Clinical Prognosis in Patients With COVID-19 Related Acute Respiratory Failure: A Retrospective Matched Control Study.

Background: The role of excessive inspiratory effort in promoting alveolar and pleural rupture resulting in air leak (AL) in patients with SARS-CoV-2 induced acute respiratory failure (ARF) while on spontaneous breathing is undetermined. Methods: Among all patients with COVID-19 related ARF admitted to a respiratory intensive care unit (RICU) and receiving non-invasive respiratory support, those developing an AL were and matched 1:1 [by means of PaO2/FiO2 ratio, age, body mass index-BMI and subsequent organ failure assessment (SOFA)] with a comparable population who did not (NAL group). Esophageal pressure (ΔPes) and dynamic transpulmonary pressure (ΔPL) swings were compared between groups. Risk factors affecting AL onset were evaluated. The composite outcome of ventilator-free-days (VFD) at day 28 (including ETI, mortality, tracheostomy) was compared between groups. Results: Air leak and NAL groups (n = 28) showed similar ΔPes, whereas AL had higher ΔPL (20 [16-21] and 17 [11-20], p = 0.01, respectively). Higher ΔPL (OR = 1.5 95%CI[1-1.8], p = 0.01), positive end-expiratory pressure (OR = 2.4 95%CI[1.2-5.9], p = 0.04) and pressure support (OR = 1.8 95%CI[1.1-3.5], p = 0.03), D-dimer on admission (OR = 2.1 95%CI[1.3-9.8], p = 0.03), and features suggestive of consolidation on computed tomography scan (OR = 3.8 95%CI[1.1-15], p = 0.04) were all significantly associated with AL. A lower VFD score resulted in a higher risk (HR = 3.7 95%CI [1.2-11.3], p = 0.01) in the AL group compared with NAL. RICU stay and 90-day mortality were also higher in the AL group compared with NAL. Conclusion: In spontaneously breathing patients with COVID-19 related ARF, higher levels of ΔPL, blood D-dimer, NIV delivery pressures and a consolidative lung pattern were associated with AL onset.

To the Editor: Pathophysiology of Splenic Arteriovenous Fistula.

A splenic arteriovenous fistula causes a "prehepatic" hypertension in the portal venous system with the double mechanism of an increased blood amount and mainly its high pressure inflow. It aggravates for a secondary fibrosis of the portal vein branches and "capillarization" of the hepatic sinusoids, adding a further "intra-hepatic" component. The subsequent development of portosystemic collaterals induces the risk of gastrointestinal hemorrhages All this suggests to perform a close monitoring of every case of splanchnic aneurysm or pseudo-aneurysm, through the current cross-section imaging tools, for their possible evolution in an arteriovenous fistula, and to consider an early therapy, also endovascular, before any secondary damage of the liver parenchyma. In this case the treatment of the portal vein hypertension can be "ethiological" and resolutive.

Cytoproliferative activity in colorectal poorly differentiated clusters: Biological significance in tumor setting.

BACKGROUND: Poorly differentiated clusters (PDCs) have gained a significant prognostic role in colorectal carcinomas (CRCs) being associated to high risk of lymph node metastasis, shorter survival time and poor prognosis. The knowledge in PDC biology is not completely clear. MATERIALS AND METHODS: We assessed Ki-67 LI in 45 CRCs showing ≥10 PDCs. We distinguished PDCs at the periphery of the tumor masses (pPDCs) from those within the tumor masses (cPDCs). We chose 3 cut-offs of Ki-67 labeling index (Ki-67 LI): <10%, 10-50%, and >50% of the labeled cells. RESULTS: Ki-67 LI in pPDCs was<10% in 37 cases (82%), 10-50% in 6 cases (13%) and >50%in 2 cases (5%); Ki-67 LI in cPDCs was<10% in 4 cases (23.5%), 10-50% in 4 (23.5%) and >50% in 9 (54%). Ki-67 LI in tumor budding foci (TBs) was <10% in 8 cases (32%), 10-50% in 8 (32%) and >50% in 9 (36%). The difference of Ki-67 LI reaches the statistical significance (p < 0.005). Ki-67 LI <10% in the pPDCs was associated with nodal metastases (pN+) (p < 0.0001), pTNM stage III and IV(p < 0.0001) and TB (p < 0.001). Ki-67 LI > 50% in cPDC was significantly associated withpT3-pT4 and advanced pTNM stages (p < 0.0001), N+ (p = 0.0001) and LVI (p < 0.05). CONCLUSION: Different Ki-67 LI detected between cPDCs and pPDCs suggesting a biological difference in PDCs. An actively proliferating central tumor areas can be distinguished from the peripheral portion of the tumors in which the cells interact with the stroma acquiring invasive and metastatic potential.

Idiopathic chylous peritonitis mimicking acute appendicitis A case report.

We report an uncommon case of idiopathic acute chylous peritonitis mimicking an acute appendicitis in a 30-year-old female patient with a 2-day history of abdominal pain, nausea and vomiting. Chylous ascites is a rare form of ascites characterized by the presence of a milky fluid rich in triglycerides. It occurs as a result of a damage to the lymphatic system due to trauma or other benign and malignant pathologies. Although the most common clinical presentation is progressive painless abdominal distension, less frequently it can cause acute abdomen symptoms. The management is based on identifying and treating the underlying pathology. Aspiration of the fluid and drainage are the only therapy required if a clinically diagnosis cannot be made. Surgical laparoscopic exploration is necessary to make a diagnosis and to treat effectively acute abdomen cases.In the absence of a significant determining pathology, we talk about idiopathic chylous peritonitis. KEY WORDS: Chylous ascites, peritonitis, laparoscopy.