Aortic dissection: How to identify it during an abdominal ultrasound examination and achieve a potentially lifesaving diagnosis.

Aortic dissection (AD) is a rare and potentially fatal condition that may be diagnosed late. During an emergency or elective abdominal ultrasound (US) examination, when going to evaluate the abdominal aorta for other reasons, it may happen that we find ourselves suspecting an AD. It is therefore important to know the US characteristics of this pathology to avoid wrong or missed diagnoses. Here, we present our practical experience regarding the application of US in the study of the abdominal aorta, which allowed us on several occasions to find an unexpected dissection in patients brought to our attention for other reasons.

The importance of ultrasound-guided biopsy: lesson from a case of liver metastasis from uveal melanoma.

Melanoma is an extremely aggressive malignant neoplasm. Uveal melanoma is the most common primary intraocular malignancy in adults, representing 3-5% of all melanomas. Liver metastases can be clinically detected in 10-20% of patients with metastatic disease from cutaneous melanoma. However, while liver is typically not the first site of disease spread in cutaneous melanoma, ocular melanoma has been showed to primarily metastasize from the eye to the liver; indeed, liver metastases are detected in approximately 87% of patients with metastatic uveal melanoma. Therefore, liver metastasis can be challenging to identify in early stages, thus being essentially asymptomatic until the disease has advanced. Here we report the case of a patient who came to our ultrasound unit reporting a large liver mass. Both contrast-enhanced abdominal computed tomography and magnetic resonance imaging did not establish a definitive diagnosis. The final diagnosis was made only through an ultrasound-guided biopsy of the mass, thus revealing a uveal melanoma metastasis. This is followed by a review of the literature on imaging follow-up of patients with melanoma.

Ultrasound-Assisted and Ultrasound-Guided Thoracentesis: An Educational Review.

Thoracentesis is one of the most important invasive procedures in the clinical setting. Particularly, thoracentesis can be relevant in the evaluation of a new diagnosed pleural effusion, thus allowing for the collection of pleural fluid so that laboratory tests essential to establish a diagnosis can be performed. Furthermore, thoracentesis is a maneuver that can have therapeutic and palliative purposes. Historically, the procedure was performed based on a physical examination. In recent years, the role of ultrasound has been established as a valuable tool for assistance and guidance in the thoracentesis procedure. The use of ultrasound increases success rates and significantly reduces complications. The aim of this educational review is to provide a detailed and sequential examination of the procedure, focusing on the two main modalities, the ultrasound-assisted and ultrasound-guided form.

Percutaneous radiofrequency ablation of ovarian cancer metastasis in the spleen: a therapeutic option to consider.

Splenic metastasis are rare clinical entities developing in less than 1% of all metastatic cancers and usually in the setting of disseminated disease. To date, splenectomy is traditionally the first line therapy in patient with splenic metastasis, however non-surgical therapies have been reported. Here we described the case of a 57-year-old patient with splenic metastasis from ovarian cancer successfully treated by percutaneous radiofrequency ablation. Furthermore, we performed a literature systematic review of the cases of splenic metastases treated by thermal ablation.

Portal Vein Thrombosis: State-of-the-Art Review.

Background: Portal vein thrombosis (PVT) is a rare disease with an estimated incidence of 2 to 4 cases per 100,000 inhabitants. The most common predisposing conditions for PVT are chronic liver diseases (cirrhosis), primary or secondary hepatobiliary malignancy, major infectious or inflammatory abdominal disease, or myeloproliferative disorders. Methods: PVT can be classified on the basis of the anatomical site, the degree of venous occlusion, and the timing and type of presentation. The main differential diagnosis of PVT, both acute and chronic, is malignant portal vein invasion, most frequently by hepatocarcinoma, or constriction (typically by pancreatic cancer or cholangiocarcinoma). Results: The management of PVT is based on anticoagulation and the treatment of predisposing conditions. The aim of anticoagulation in acute thrombosis is to prevent the extension of the clot and enable the recanalization of the vein to avoid the development of complications, such as intestinal infarction and portal hypertension. Conclusions: The treatment with anticoagulant therapy favors the reduction of portal hypertension, and this allows for a decrease in the risk of bleeding, especially in patients with esophageal varices. The anticoagulant treatment is generally recommended for at least three to six months. Prosecution of anticoagulation is advised until recanalization or lifelong if the patient has an underlying permanent pro-coagulant condition that cannot be corrected or if there is thrombosis extending to the mesenteric veins.

Platelet, Antiplatelet Therapy and Metabolic Dysfunction-Associated Steatotic Liver Disease: A Narrative Review.

Metabolic dysfunction-associated steatotic liver disease (MASLD) is not only related to traditional cardiovascular risk factors like type 2 diabetes mellitus and obesity, but it is also an independent risk factor for the development of cardiovascular disease. MASLD has been shown to be independently related to endothelial dysfunction and atherosclerosis. MASLD is characterized by a chronic proinflammatory response that, in turn, may induce a prothrombotic state. Several mechanisms such as endothelial and platelet dysfunction, changes in the coagulative factors, lower fibrinolytic activity can contribute to induce the prothrombotic state. Platelets are players and addresses of metabolic dysregulation; obesity and insulin resistance are related to platelet hyperactivation. Furthermore, platelets can exert a direct effect on liver cells, particularly through the release of mediators from granules. Growing data in literature support the use of antiplatelet agent as a treatment for MASLD. The use of antiplatelets drugs seems to exert beneficial effects on hepatocellular carcinoma prevention in patients with MASLD, since platelets contribute to fibrosis progression and cancer development. This review aims to summarize the main data on the role of platelets in the pathogenesis of MASLD and its main complications such as cardiovascular events and the development of liver fibrosis. Furthermore, we will examine the role of antiplatelet therapy not only in the prevention and treatment of cardiovascular events but also as a possible anti-fibrotic and anti-tumor agent.

The Role of Contrast-Enhanced Ultrasound in the Differential Diagnosis of Malignant and Benign Subpleural Lung Lesions.

Background: The application of transthoracic contrast-enhanced ultrasound (CEUS) to the study of peripheral lung lesions is still a topic of debate. The main objective of this review was to evaluate the diagnostic accuracy of CEUS in the diagnosis of malignant subpleural pulmonary consolidations and, therefore, differentiate them from benign ones. Methods: Papers published before December 2023 were detected through a search of PubMed, Cochrane library, and Embase. The pooled specificity and sensitivity, summary receiver operating characteristic (SROC) curve and diagnostic odds ratio (DOR) were used. Results: CEUS is characterized by a pooled sensitivity of 0.95 (95% CI: 0.93-0.97) and a pooled specificity of 0.93 (95% CI: 0.90-0.95) in differentiating benign and malignant subpleural lung diseases; the AUC of SROC was 0.97. Homogeneous CE was characterized by a pooled sensitivity of 0.43 (95% CI: 0.40-0.45) and the pooled specificity of 0.49 (95% CI: 0.46-0.52). Non-homogeneous CE displayed a pooled sensitivity of 0.57 (95% CI: 0.55-0.60) and a pooled specificity of 0.51 (95% CI: 0.48-0.54). The lack of CE displayed a pooled sensitivity of 0.01 (95% CI: 0.00-0.06) and a pooled specificity of 0.76 (95% CI: 0.64-0.85). Marked CE displayed a pooled sensitivity of 0.41 (95% CI: 0.37-0.44) and a pooled specificity of 0.54 (95% CI: 0.50-0.58). Non-marked CE displayed a pooled sensitivity of 0.59 (95% CI: 0.56-0.63) and a pooled specificity of 0.46 (95% CI: 0.42-0.50). The early AT displayed a pooled sensitivity of 0.04 (95% CI: 0.02-0.08) and a pooled specificity of 0.83 (95% CI: 0.77-0.87). The early wash out displayed a pooled sensitivity of 0.61 (95% CI: 0.48-0.72) and a pooled specificity of 0.98 (95% CI: 0.92-1.00). The delayed wash out displayed a pooled sensitivity of 0.15 (95% CI: 0.10-0.20) and a pooled specificity of 0.69 (95% CI: 0.62-0.75). Conclusions: CEUS is characterized by excellent diagnostic accuracy for the diagnosis of the malignancy of subpleural lung lesions. By separately analyzing the CEUS findings, the diagnostic accuracy values are considerably lower and not significant in some cases. The simultaneous evaluation of multiple CEUS features allows us to reach an excellent diagnostic accuracy. Non-homogeneous CE with early wash out are the most indicative features of malignancy of a lung lesion.

Understanding CEAP Classification: Insights from an Italian Survey on Corona Phlebectatica and Recurrent Active Venous Ulcers by Vascular Specialists.

Background and Objectives: The clinical relevance of "corona phlebectatica" and the management of risk factors for recurrence of venous ulcers in patients with chronic venous disease may be variable based on vascular specialists in different geographical areas of Italy. The aim of the present survey is to evaluate the management of patients with chronic venous disease by vascular specialists in different areas of the national territory. In particular, this involves ascertaining the clinical/prognostic relevance attributed to the presence of the "corona phlebectatica" as well as to the management of risk factors related to recurrence of venous ulcers. Materials and Methods: The web-based survey aimed at vascular medicine specialists with particular interest in venous disease. A questionnaire was developed, based on 12 questions, in relation to clinical assessment, risk factor management, and therapy in patients with chronic venous disease. Results: Almost all of the specialists involved actively participated in the survey, declaring that they personally manage chronic venous disease overall. There was a strong agreement in the prognostic consideration attributed to the presence of "corona phlebectatica" and to the management of risk factors for venous ulcer recurrence, regardless of the different geographical areas of interest. Conclusions: Accordingly with the results of this self-assessment survey, the skills and experience of the specialists involved appear to be of a good standard, both in the clinical evaluation and in the management of the progression of chronic venous disease. However, the need to reach more cultural insights into the correlations between chronic venous disease and risk factors correlated with disease progression emerges. Moreover, there was the need for a greater and tighter overall clinical control of a patient with chronic venous disease, also in relation to the presence of comorbidities.

Ultrasound diagnosis of a pseudoaneurysm of the internal right mammary artery.

One of the principles of managing trauma patients is that of their continuous re-evaluation over the hours and days. Even if the execution of the computed tomography method is classically recommended, especially in the most serious cases and in polytraumas with major dynamics, the clinician can use or request an ultrasound examination, especially in subsequent re-evaluations. Here we report a clinical case demonstrating how an ultrasound re-evaluation after the acute event can lead to a correct diagnosis of a rare complication of thoracic trauma. The findings were suggestive for a pseudoaneurysm of the internal right mammary artery. Subsequently, an ultrasound-guided injection of thrombin was carried out until complete interruption of the flow within the formation. At subsequent follow-up, no arterial or venous blush was highlighted.

Ultrasound-guided diagnosis on a parapharyngeal mass.

Masses in the parapharyngeal area are rare and often due to infectious phenomena arising from the oral cavity or pharynx which lead to abscess formation. Less frequently, the lesion can be neoplastic. Tumours of the parapharyngeal space are rare, accounting for less than 1% of all head and neck neoplasms. We report the case of a patient who came to our observation for mandibular pain. Multiparametric diagnostic imaging was done thus showing a parapharyngeal mass. An ultrasound guided biopsy was performed by a transcutaneous route with a high median approach at neck level, to characterize the mass in the right tonsillar region. The histological examination reported the final histological diagnosis of sarcomatoid carcinoma.

Breast ultrasound: An opportunity to detect unsuspected pleural and pulmonary abnormalities.

PURPOSE: While scanning women for breast US, is possible to observe changes in the appearance of the pleural line or in the most superficial portion of the lung. The objective of this single-center, prospective study was to determine the prevalence of a variety of pleural and pulmonary US findings during routine breast US. METHODS: In this study, there were 200 women undergoing standard breast US examination. The presence of pleural and pulmonary abnormalities in these cases was recorded. Two off-site reviewers confirmed the presence of pleura and lung changes. RESULTS: There was no abnormal finding in 168 out of 200 cases (84%) while there were one or more abnormal findings in 32 cases (16%). Pleural effusion was observed in 0.5% of cases, thickening of the pleural line 5% of cases, irregularity of the pleural line in 6% of cases, increased number of vertical artifacts in 9% of cases, subpleural nodulations in 2% of cases, and lung consolidation in 0.5%. CONCLUSION: Pleural and lung changes are not uncommon during breast US. Operators performing breast US examinations should be aware of the possibility to identify unsuspected pleuro-pulmonary abnormalities.

Contrast-Enhanced Ultrasound Follow-Up for Acute Pyelonephritis Patients.

Contrast-enhanced ultrasound (CEUS) is increasingly used in clinical practice as the first diagnostic method in patients with suspected pyelonephritis rather than abdominal CT with contrast medium, especially in young subjects. We performed a retrospective analysis on patients in for whom a CEUS examination was utilized as a follow-up method after acute pyelonephritis as normal clinical practice. Through evaluating all patients, in terms duration between CEUS examination and normalization (healing) of the renal disease, we found that the mean duration is 25.9 days. Our ultrasound findings did not induce any therapeutic modifications, not even in the cases in which the examination was repeated several times. Therefore, setting up a CEUS follow-up examination after 25 days from the first diagnosis can reduce the number of repeated tests, benefitting patients and the healthcare system in terms of reducing costs.

Long-term hypercoagulability, endotheliopathy and inflammation following acute SARS-CoV-2 infection.

INTRODUCTION: both symptomatic and asymptomatic SARS-CoV-2 infections - coined Coronavirus disease 2019 (COVID-19) - have been linked to a higher risk of cardiovascular events after recovery. AREAS COVERED: our review aims to summarize the latest evidence on the increased thrombotic and cardiovascular risk in recovered COVID-19 patients and to examine the pathophysiological mechanisms underlying the interplay among endothelial dysfunction, inflammatory response and coagulation in long-COVID. We performed a systematic search of studies on hypercoagulability, endothelial dysfunction and inflammation after SARS-CoV-2 infection. EXPERT OPINION: endothelial dysfunction is a major pathophysiological mechanism responsible for most clinical manifestations in COVID-19. The pathological activation of endothelial cells by a virus infection results in a pro-adhesive and chemokine-secreting phenotype, which in turn promotes the recruitment of circulating leukocytes. Cardiovascular events after COVID-19 appear to be related to persistent immune dysregulation. Patients with long-lasting symptoms display higher amounts of proinflammatory molecules such as tumor necrosis factor-α, interferon γ and interleukins 2 and 6. Immune dysregulation can trigger the activation of the coagulation pathway. The formation of extensive microclots in vivo, both during acute COVID-19 and in long-COVID-19, appears to be a relevant mechanism responsible for persistent symptoms and cardiovascular events.

Training and learning ultrasound: survey on a sample of Italian students, impact and role inside the core curriculum of degree courses in medicine and surgery.

PURPOSE: Ultrasound is essential in the clinical practice of many medical specialties due to non-invasiveness, rapidity of examination, low costs and simplicity. Many specialized companies and universities pointed out its potential as a teaching tool for medical students. The aim of our study is to evaluate the impact of an ultrasound course on a sample of students attending the fourth, fifth and sixth year of the degree course in Medicine, highlighting changing in satisfaction and preparation. Another target is to verify the capability of a course on ultrasound to positively impact on participants knowledge and competences. METHODS: Students attending 6 training courses of Medicine held between 2017 and 2019 were recruited. Five trainings held during an Italian society of ultrasound in medicine and biology (SIUMB) congress, in a session dedicated to students, and one during an elective didactic activity (ADE) held in Chieti University. A questionnaire was given to the students before and after the course, in order to assess the impact of the course on the motivation and knowledge. Moreover, a test was also administered at the end of the theoretical part, with questions relating to the notions learned. RESULTS: There was an 81% of correct response to the learning questionnaire by calculating the mean of 5 SIUMB courses performed. The students are strongly motivated to continue learning ultrasound already from the beginning of the course, and this result remains unchanged in the questionnaire administered at the end. The interest of students towards this method is high, and they would ultrasound courses within the Medicine degree, even before participating in the training. It was evident how students positively assessed the course in relation to the acquisition of skills and knowledge, albeit with a tendency to acquire more knowledge rather than skills. CONCLUSIONS: Our data support the usefulness of including ultrasound into the curriculum of medical students and on its use as a teaching tool. Students are highly motivated and perceive a significant improvement in both skills and knowledge following the proposed courses. Hands-on part is necessary in the training course on ultrasonography.

Ultrasound Imaging of the Sciatic Nerve.

The sciatic nerve (SN) is the biggest nerve in the human body and innervates a large skin surface of the lower limb and several muscles of the thigh, leg, and foot. It originates from the ventral rami of spinal nerves L4 through S3 and contains fibers from both the posterior and anterior divisions of the lumbosacral plexus. After leaving the neural foramina, the nerve roots merge with each other forming a single peripheral nerve that travels within the pelvis and thigh. Non-discogenic pathologies of the SN are largely underdiagnosed entities due to nonspecific clinical tests and poorly described imaging findings. Likewise, to the best of our knowledge, a step-by-step ultrasound protocol to assess the SN is lacking in the pertinent literature. In this sense, the aim of the present manuscript is to describe the normal sono-anatomy of the SN from the greater sciatic foramen to the proximal thigh proposing a standardized and simple sonographic protocol. Then, based on the clinical experience of the authors, a few tips and tricks have been reported to avoid misinterpretation of confounding sonographic findings. Last but not least, we report some common pathological conditions encountered in daily practice with the main purpose of making physicians more confident regarding the sonographic "navigation" of a complex anatomical site and optimizing the diagnosis and management of non-discogenic neuropathies of the SN.

The Diagnostic Role of Lung Ultrasound and Contrast-Enhanced Ultrasound in Pulmonary Embolism.

The diagnosis of pulmonary embolism (PE) relies essentially on a probabilistic approach that requires careful clinical assessments, targeted laboratory tests, and the use of appropriate imaging tools. Nowadays, the diagnostic gold standard is computed tomographic pulmonary angiography. Lung ultrasound (LUS) can play a role in the diagnosis of PE mainly by allowing the visualization of peripheral lung infarctions. Hypoechoic, pleural-based parenchymal consolidation is the most typical and common finding of pulmonary infarction. More than 85% of infarct lesions are wedge-shaped, extending to the pleural surface and are localized to where the patient complains of pleuritic chest pain. Contrast-enhanced ultrasound can be performed in addition to basic ultrasound examination to ascertain nonvascularization of the consolidation, thus confirming that the lesion is an infarct. The aim of this narrative review is to summarize the latest evidence on the application of LUS to the diagnosis of PE, focusing purely on thoracic/lung signs.

Multiparametric Ultrasound Diagnostic Approach to Malignancy-Mimicking Adenomatoid Tumors of the Scrotum: Is Strain Elastography Enough?

Background: Paratesticular tumors (PTs) are very uncommon, accounting for almost 5% of intrascrotal tumors. Of these, adenomatoid tumors (ATs) represent about 30% and most frequently arise in the tail of the epididymis. Ultrasound (US) examination is the first-choice imaging method employed for the evaluation of the scrotum. Unfortunately, there are no specific US-imaging features useful for distinguishing an AT from a malignant lesion. To increase diagnostic accuracy and confidence, new sonographic techniques have incorporated real-time tissue elastography (RTE) under the assumption that malignant lesions are "harder" than benign lesions. Case report: In our paper, we describe a very rare case of a 60-year-old patient with a giant paratesticular mass mimicking malignancy when examined using RTE, i.e., it was stiffer than the surrounding tissue (a hard pattern), which, upon histologic examination, was identified as an AT. Discussion: Our case underscores that there is also a significant overlap between different types of scrotal lesions when RTE is used for examination. Thus, if a PT is found, the imaging approach should always be supplemented with more definitive diagnostic methods, such as FNAC or FNAB, which are the only diagnostic methods capable of leading to a certain diagnosis. Conclusions: Alongside underlining the importance of pre-operative imaging for making correct diagnoses and selecting the correct therapy, we wish to draw our readers' attention to this report in order to demonstrate the clinical implications of a giant AT presenting as stiff lesions when examined using SE.

Gender, Obesity, Fat Distribution and 25-Hydroxyvitamin D.

Background and Objectives: Obesity is a worldwide disease associated with systemic complications. In recent years, there has been growing interest in studying vitamin D but data related to obese subjects are still poor. AIM: The aim of this study was to evaluate the relationship between obesity degree and 25-hydroxyvitamin D [25(OH)D] levels. Materials and Methods: We recruited 147 Caucasian adult obese patients (BMI > 30 Kg/m2; 49 male; median age 53 years), and 20 overweight subjects as control group (median age 57 years), who had been referred to our Obesity Center of Chieti (Italy) between May 2020 and September 2021. Results: The median BMI was 38 (33-42) kg/m2 for obese patients and 27 (26-28) kg/m2 for overweight patients. 25(OH)D concentrations were lower in the obese population compared to the overweight population (19 ng/mL vs. 36 ng/mL; p < 0.001). Considering all obese subjects, a negative correlation was observed between 25(OH)D concentrations and obesity-related parameters (weight, BMI, waist circumference, fat mass, visceral fat, total cholesterol, LDL cholesterol) and glucose metabolism-related parameters. 25(OH)D was also negatively correlated with blood pressure. Conclusions: Our data confirmed the inverse relationship between obesity and blood concentration of 25(OH)D and highlighted how 25(OH)D levels decrease in the presence of glucose and lipid metabolism alterations.