Eculizumab treatment in patients with COVID-19: preliminary results from real life ASL Napoli 2 Nord experience.

OBJECTIVE: SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2)-related pneumonia, referred to as COVID-19 (Coronavirus Disease 19), is a public health emergency as it carries high morbidity, mortality, and has no approved specific pharmacological treatments. In this case series, we aimed to report preliminary data obtained with anti-complement C5 therapy with eculizumab in COVID-19 patients admitted to intensive care unit (ICU) of ASL Napoli 2 Nord. PATIENTS AND METHODS: This is a case series of patients with a confirmed diagnosis of SARS-CoV2 infection and severe pneumonia or ARDS who were treated with up to 4 infusions of eculizumab as an off-label agent. Patients were also treated with anticoagulant therapy with Enoxaparin 4000 IU/day via subcutaneous injection, antiviral therapy with Lopinavir 800 mg/day + Ritonavir 200 mg/day, hydroxychloroquine 400 mg/day, ceftriaxone 2 g/day IV, vitamine C 6 g/day for 4 days, and were on Non-Invasive Ventilation (NIV). RESULTS: We treated four COVID-19 patients admitted to the intensive care unit because of severe pneumonia or ARDS. All patients successfully recovered after treatment with eculizumab. Eculizumab induced a drop in inflammatory markers. Mean C Reactive Protein levels dropped from 14.6 mg/dl to 3.5 mg/dl and the mean duration of the disease was 12.8 days. CONCLUSIONS: Eculizumab has the potential to be a key player in treatment of severe cases of COVID-19. Our results support eculizumab use as an off-label treatment of COVID-19, pending confirmation from the ongoing SOLID-C19 trial.

When traditions become dangerous: Intestinal perforation from unusual foreign body-Case report and short literature review.

Gastrointestinal perforation (GI) is a common cause of acute abdomen in the emergency department that needs a prompt surgery intervention. Nowadays, CT examinations represent the method of choice to image patients with acute abdominal pain in emergency. GI perforations by foreign bodies ingested is rare and only <1% of ingested foreign bodies are believed to cause perforation of GI. MDCT is to be considered the best imaging method for identifying foreign bodies, the perforation site and the surgical treatment to be planned reliably. We presente a case of 70-year-old lady presented to our Emergency Department with acute abdominal pain.

Viroid-like RNAs from cherry trees affected by leaf scorch disease: further data supporting their association with mycoviral double-stranded RNAs.

Cherry trees from Spain affected by cherry leaf scorch (CLS), a fungal disease proposed to be caused by Apiognomonia erythrostoma, show symptoms (translucent-chlorotic leaf spots evolving into rusty areas) very similar to those of cherry chlorotic rusty spot disease (CCRS) and Amasya cherry disease, reported in Italy and Turkey, respectively. The three maladies are closely associated with 10-12 double-stranded viral RNAs, and CCRS is additionally associated with two cherry small circular RNAs (cscRNA1 and cscRNA2). Here, we report that a small viroid-like RNA similar to the CCRS-associated cscRNA1 is also present in CLS-affected trees, thus extending the link between the two diseases. Both CLS and CCRS cscRNA1 elements have common features, including sequence identity (88 %), a predicted quasi rod-like conformation with short bifurcations at both termini, and the presence of hammerhead ribozymes in the strands of both polarities. However, cscRNA2, apparently derived from cscRNA1 by deletion of a short hairpin, was not detected in CLS-affected material. Although the biological nature of cscRNAs is unknown, the identification of at least cscRNA1 in different cherry cultivars and in two distinct geographic areas (Spain and Italy), always in close association with the same mycoviral dsRNAs, supports that these viroid-like RNAs could be satellite RNAs.

Viroid-like RNAs from cherry trees affected by leaf scorch disease: further data supporting their association with mycoviral double-stranded RNAs.

Cherry trees from Spain affected by cherry leaf scorch (CLS), a fungal disease proposed to be caused by Apiognomonia erythrostoma, show symptoms (translucent-chlorotic leaf spots evolving into rusty areas) very similar to those of cherry chlorotic rusty spot disease (CCRS) and Amasya cherry disease, reported in Italy and Turkey, respectively. The three maladies are closely associated with 10-12 double-stranded viral RNAs, and CCRS is additionally associated with two cherry small circular RNAs (cscRNA1 and cscRNA2). Here, we report that a small viroid-like RNA similar to the CCRS-associated cscRNA1 is also present in CLS-affected trees, thus extending the link between the two diseases. Both CLS and CCRS cscRNA1 elements have common features, including sequence identity (88%), a predicted quasi rod-like conformation with short bifurcations at both termini, and the presence of hammerhead ribozymes in the strands of both polarities. However, cscRNA2, apparently derived from cscRNA1 by deletion of a short hairpin, was not detected in CLS-affected material. Although the biological nature of cscRNAs is unknown, the identification of at least cscRNA1 in different cherry cultivars and in two distinct geographic areas (Spain and Italy), always in close association with the same mycoviral dsRNAs, supports that these viroid-like RNAs could be satellite RNAs.

Contrast-enhanced sonography in blunt scrotal trauma().

The scope of this study was to determine whether contrast-enhanced ultrasonography (CEUS), compared with basic US, can increase diagnostic confidence and provide relevant information on blunt scrotal trauma. Over a period of 75 months we examined 40 patients seen consecutively for blunt scrotal trauma using high-resolution US, color-power Doppler, low mechanical index CEUS, and power Doppler after IV administration of contrast medium (SonoVue(®)). In the 24 cases that were positive, concordance between basal US and CEUS findings was grade 0 (absent) in 4 cases, grade 1 (low) in 3, grade 2 (moderate) in 8, and grade 3 (high) in 9. The relevance of the additional information provided by CEUS was classified as follows: high in 4/40 (10%), moderate 7/40 (17,5%), low 13/40 (32,5%), none in 14/40 (35%). Our findings demonstrate that CEUS is appreciably more sensitive in detecting damage caused by blunt scrotal trauma, particularly small lesions. It is also useful for differential diagnosis and marginalization of corpuscular fluid collections, fractures, and above all ruptures, which require immediate surgery. In our series 2 out of 3 (67%) patients with testicular rupture were diagnosed only by CEUS. We feel that the use of CEUS can significantly improve diagnostic confidence in cases of closed scrotal trauma although these conclusions need to be confirmed in larger case series.

Endovascular treatment of femoropopliteal stenoses/occlusions with a SilverHawk directional atherectomy device: immediate results and 12-month follow-up.

PURPOSE: This paper reports our immediate and 12-month follow-up results in the treatment of arterial stenoses/occlusions of the femoropopliteal region with the use of the SilverHawk directional atherectomy device (EV3, USA). MATERIALS AND METHODS: In an 18-month period, we treated 18 patients (13 men, five women, age range 39-81 years) with the SilverHawk directional atherectomy device. Inclusion criteria were symptomatic femoropopliteal stenosis/insufficiency, nonresponsiveness to medical therapy, and Rutherford categories 3-5. Exclusion criteria were based on the preliminary colour Doppler ultrasound (US) assessment and were plaque with a calcified component >50% and inadequate upstream and/or downstream vascular bed. Patients with severe vascular impairment, classified as TransAtlantic Inter-Society Consensus (TASC) D, were also excluded. RESULTS: The procedure was successfully completed in all cases, with evident recanalisation and sufficient wall remodelling. No major complication was observed. At assessment immediately after the procedure and over the following days, an improvement in clinical symptoms and in the Rutherford scale was observed. Follow-up at 2 and 12 months identified one case of distal reocclusion subsequently treated with amputation, and two cases of restenosis (primary patency 79%) successfully treated with a repeat procedure (secondary patency 96%). CONCLUSIONS: The SilverHawk directional atherectomy device proved to be an effective and safe tool in all our patients treated for femoropopliteal stenosis/occlusion, with a significant improvement in both imaging findings and clinical signs and symptoms.

Molecular characterization of the largest mycoviral-like double-stranded RNAs associated with Amasya cherry disease, a disease of presumed fungal aetiology.

The sequence of the four large (L) double-stranded RNAs (dsRNAs) associated with Amasya cherry disease (ACD), which has a presumed fungal aetiology, is reported. ACD L dsRNAs 1 (5121 bp) and 2 (5047 bp) potentially encode proteins of 1628 and 1620 aa, respectively, that are 37% identical and of unknown function. ACD L dsRNAs 3 (4458 bp) and 4 (4303 bp) potentially encode proteins that are 68% identical and contain the eight motifs conserved in RNA-dependent RNA polymerases (RdRp) of dsRNA mycoviruses, having highest similarity with those of members of the family Totiviridae. Both terminal regions share extensive conservation in all four RNAs, suggesting a functional relationship between them. As ACD L dsRNAs 1 and 2 do not encode RdRps, both are probably replicated by those from either ACD L dsRNA 3 or 4. Partial characterization of the equivalent L dsRNAs 3 and 4 associated with cherry chlorotic rusty spot revealed essentially identical sequences.

Living donor liver transplantation: early single-center experience.

Adult living donor liver transplantation (ALDLT) is an accepted procedure to overcome the organ shortage. The advantages of ALDLT must be balanced against the first concern of donor safety. We analyzed the results of our early experience among a series of eight ALDLT performed between April 2001 and October 2003. All patients were listed as United Network for Organ Sharing UNOS status 2b and 3. Transplant recipients consisted of four men and four women. The living donors included four sons, three daughters, and one son-in-law (ages 20 to 45 years). One donor was anti-HBc-positive and negative for hepatitis B virus-DNA by polymerase chain reaction analysis in serum and in liver tissue. GR/WR >0.8 and fatty liver <10% were considered suitable for the hepatectomy. Residual left lobe volume was at least 33%. No exogenous blood and blood products were transfused into the donors and a cell-saver device was used in all donors (blood loss 490 +/- 160 mL). All procedures were right lobe hepatectomy; in one case the middle hepatic vein was withdrawn with the right graft. The mean ischemia time was 1.5 +/- 0.5 hours. All donors survived the procedure. Median hospital stay was 8.5 +/- 2.1 days in all donors but one who had a long stay because of drug-related hepatitis. One graft was lost and one donor aborted because of preoperative overestimated volumetry. Complications were experienced by two donors (25%). Five recipients (62.5%) experienced major complications; one patient underwent retransplantation because of donor graft loss. Two biliary and two vascular complications (33.3%) occurred in three patients. No perioperative death occurred. Two patients died at 9 and 10 months after transplant because of heart and respiratory failure in the first case and tumor recurrence in the second. One-year actuarial survival is 75%. ALDLT using right lobe has gained acceptance to overcome the organ shortage. Donor selection criteria must be stringent with respect to residual donor hepatic volume, steatosis, and liver function.

Close structural relationship between two hammerhead viroid-like RNAs associated with cherry chlorotic rusty spot disease.

Analysis of the population of cherry small circular RNAs (cscRNAs) from trees affected by cherry chlorotic rusty spot (CCRS) showed two groups of variants with similar sequence but differing in size (394-415 and 372-377 nt for cscRNA1 and cscRNA2, respectively) because of the presence or absence of a 27-nt fragment folding into a hairpin in their predicted quasi-rod-like secondary structures. These structures were preserved by co-variations and compensatory mutations, as well as by additional complex rearrangements. The variability also preserved the central conserved core and the stability of the helices of the plus and minus hammerhead ribozymes, supporting their role in replication of cscRNAs. The smaller variants most likely derive from the larger through recombination events. Possible functional relationships between cscRNAs and certain mycoviral-like double-stranded RNAs, also associated with CCRS, are discussed.

First Report and High Prevalence in Noncherry Host of Cherry virus A in Italy.

Cherry virus A (CVA) has been reported to naturally infect sweet and sour cherry, apricot, peach, and plum but has not been associated with any symptoms. In the spring and summer of 2005, samples were collected in Prunus spp. germplasm collections in Campania (Italy) and analyzed by a polyvalent reverse transcription-polymerase chain reaction (RT-PCR) assay (1). Amplicons were sequenced, revealing CVA infection in seven apricot cultivars (Prunus armeniaca L.), one plum (Prunus domestica L.), and one cherry (Prunus avium L.). CVA sequences (GenBank Accession Nos. DQ445275 to DQ445292) compared among themselves and with databank sequences showed pairwise nucleotide sequence identity levels of 80.3 to 99.6% (86.8 to 100% for amino acid sequences), significantly extending the known variability range of CVA. The presence of CVA was confirmed by hybridization with a CVA-specific probe (P39) (2), targeting region different from that amplified in the polymerase chain reaction assay. All samples containing CVA were found to be in mixed infections with Apple chlorotic leaf spot virus (ACLSV) and Apricot pseudo-chlorotic leaf spot virus (plum, apricot), or ACLSV plus Cherry green ring mottle virus (cherry) so that CVA symptomatology could not be evaluated. To our knowledge, these results constitute the first report of the occurrence of CVA in Italy. They confirm the ability of CVA to naturally infect noncherry Prunus spp. hosts with surprisingly high prevalence levels (6 of 14 and 1 of 6 tested apricot and plum cultivars, respectively). References: (1) X. Foissac et al. Phytopathology 95:617, 2005. (2) W. Jelkmann J. Gen. Virol. 76:2015, 1995.

Bronchobiliary fistula evaluated with magnetic resonance imaging.

Bronchobiliary fistula (BBF) is a rare disorder consisting of a passageway between the biliary ducts and the bronchial tree. Many conditions may give rise to this development. Management of these fistulas is often difficult and can be associated with high morbidity and mortality rates. We present a case of BBF developing after hemihepatectomy in a 74-year-old man treated with endoscopic biliary drainage and illustrate MRCP findings.

Characterization of Apricot pseudo-chlorotic leaf spot virus, A Novel Trichovirus Isolated from Stone Fruit Trees.

ABSTRACT A trichovirus closely related to Apple chlorotic leaf spot virus (ACLSV) was detected in symptomatic apricot and Japanese plum from Italy. The Sus2 isolate of this agent cross-reacted with anti-ACLSV polyclonal reagents but was not detected by broad-specificity anti- ACLSV monoclonal antibodies. It had particles with typical trichovirus morphology but, contrary to ACLSV, was unable to infect Chenopodium quinoa and C. amaranticolor. The sequence of its genome (7,494 nucleotides [nt], missing only approximately 30 to 40 nt of the 5' terminal sequence) and the partial sequence of another isolate were determined. The new virus has a genomic organization similar to that of ACLSV, with three open reading frames coding for a replication-associated protein (RNA-dependent RNA polymerase), a movement protein, and a capsid protein, respectively. However, it had only approximately 65 to 67% nucleotide identity with sequenced isolates of ACLSV. The differences in serology, host range, genome sequence, and phylogenetic reconstructions for all viral proteins support the idea that this agent should be considered a new virus, for which the name Apricot pseudo-chlorotic leaf spot virus (APCLSV) is proposed. APCLSV shows substantial sequence variability and has been recovered from various Prunus sources coming from seven countries, an indication that it is likely to have a wide geographical distribution.

Parosteal lipoma of the rib. CT findings and pathologic correlation.

Parosteal lipoma is a rare benign tumor composed of adipose tissue contiguous to the periosteum of the underlying bone. These tumors are slow-growing, nontender masses that affect, almost exclusively, the diaphysis of the long bones of the upper and lower limbs. We hereby describe the CT characteristics with the correlative pathological findings in a rare case of parosteal lipoma of the rib.

Detection of Mirizzi syndrome with magnetic resonance cholangiopancreatography: laparoscopic or open approach?

Imaging of the gallbladder and biliary tract has changed dramatically in the past 20 years. Magnetic resonancecholangiopancreatography provides a noninvasive alternative to endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography in the diagnosis of Mirizzi syndrome. In this laparoscopic era, when diagnosis is certain, surgeons must choose between a laparoscopic and a traditional open approach. The authors review their cases of hepatobiliary surgery during the period 1993-2000. Three cases of Mirizzi syndrome (0.4%) were observed among 712 surgical hepatobiliary patients (two type 1 cases and one type 2 case). The authors suggest that with Mirizzi syndrome type 1, laparoscopy together with peroperative cholangiography should be used to resolve anatomic doubts. If clipping of the cystic duct is possible and certain, then laparoscopy may be continued and finished. In the case of cholecystocholedochal fistula (Mirizzi syndrome type 2), when the diagnosis is determined before surgery, the authors believe that laparoscopy is dangerous. Adhesions, inflammation, and anatomy changes may cause injuries to the main bile duct, so an open traditional approach is suggested.

Role of contrast-enhanced helical CT in the evaluation of acute thoracic aortic injuries after blunt chest trauma.

The purpose of this retrospective study was to determine the value of contrast-enhanced helical CT for detecting and managing acute thoracic aortic injury (ATAI). Between June 1995 and February 2000, 1419 consecutive chest CT examinations were performed in the setting of major blunt trauma. The following CT findings were considered indicative of ATAI: intimal flap; pseudoaneurysm; contour irregularity; lumen abnormality; and extravasation of contrast material. On the basis of these direct findings no further diagnostic investigations were performed. Isolated mediastinal hematoma on CT scans was considered an indirect sign of ATAI: In these cases, thoracic aortography was performed even if CT indicated normal aorta. Seventy-seven patients had abnormal CT scans: Among the 23 patients with direct CT signs, acute thoracic aortic injuries was confirmed at thoracotomy in 21. Two false-positive cases were observed. The 54 remaining patients had isolated mediastinal hematoma without aortic injuries at CT and corresponding negative angiograms. The 1342 patients with negative CT scans were included in the 8-month follow-up program and did not show any adverse sequela based on clinical and radiographic criteria. Contrast-enhanced helical CT has a critical role in the exclusion of thoracic aortic injuries in patient with major blunt chest trauma and prevents unnecessary thoracic aortography. Direct CT signs of ATAI do not require further diagnostic investigations to confirm the diagnosis: Isolated aortic bands or contour vessel abnormalities should be first considered as possible artifacts or related to non-traumatic etiologies especially when mediastinal hematoma is absent. In cases of isolated mediastinal hematoma other possible sources of bleeding should be considered before directing patients to thoracic aortography.