Impact of sarcopenia in SARS-CoV-2 patients during two different epidemic waves.

BACKGROUND: Sarcopenia was reported to be associated with poor clinical outcome, higher incidence of community-acquired pneumonia, increased risk of infections and reduced survival in different clinical settings. The aim of our work is to evaluate the prognostic role of sarcopenia in patients with the 2019 novel coronavirus disease (COVID-19). MATERIALS AND METHODS: 272 COVID-19 patients admitted to the University Hospital of Modena (Italy) from February 2020 to January 2021 were retrospectively studied. All included patients underwent a chest computed tomography (CT) scan to assess pneumonia during their hospitalization and showed a positive SARS-CoV-2 molecular test. Sarcopenia was defined by skeletal muscle area (SMA) evaluation at the 12th thoracic vertebra (T12). Clinical, laboratory data and adverse clinical outcome (admission to Intensive Care Unit and death) were collected for all patients. RESULTS: Prevalence of sarcopenia was high (41.5%) but significantly different in each pandemic wave (57.9% vs 21.6% p < 0.0000). At the multivariate analysis, sarcopenia during the first wave (Hazard Ratio 2.29, 95% confidence intervals 1.17 to 4.49 p = 0.0162) was the only independent prognostic factor for adverse clinical outcome. There were no significant differences in comorbidities and COVID19 severity in terms of pulmonary involvement at lung CT comparing during the first and second wave. Mixed pattern with peripheral and central involvement was found to be dominant in both groups. CONCLUSION: We highlight the prognostic impact of sarcopenia in COVID-19 patients hospitalized during the first wave. T12 SMA could represent a potential tool to identify sarcopenic patients in particular settings. Further studies are needed to better understand the association between sarcopenia and COVID-19.

Strong impact of sarcopenia as a risk factor of survival in resected gastric cancer patients: first Italian report of a Bicentric study.

Gastric cancer (GC) accounts for 4% of all cancers in Europe. Sarcopenia is a complex syndrome characterized by a loss of muscle mass and function associated with age, often present in neoplastic patients. Recently, several studies have shown a significant association between sarcopenia and poor prognosis in various pathological conditions. The current observational retrospective study investigates the association between sarcopenia and overall survival (OS) and recurrence-free survival (RFS) in patients with GC undergoing up-front surgery with curative intent. Resected GC patients' clinical records and CT images were retrospectively assessed. The preoperative CT calculation of the skeletal muscle index (SMI) at L3 level allowed us to categorize patients as sarcopenic or not. Kaplan-Meyer and univariate and multivariate Cox regression analyses were performed to determine the difference in survival and presence of independent prognostic factors. Fifty-five patients, 28 male and 27 female, out of 298 studied for gastric cancer were enrolled in the current study from two cancer referral centers in Italy. The preoperative CT calculation of the SMI at L3 level allowed us to identify 39 patients with and 16 without sarcopenia. A statistically significant difference between the sarcopenic and non-sarcopenic groups was observed in both OS and RFS (p < 0.023; p < 0.006). Moreover, sarcopenia was strongly correlated to a higher risk of recurrence in univariate and multivariate analysis (p < 0.02). Sarcopenia can be considered a critical risk factor for survival in patients with resectable GC treated with up-front surgery. Identifying sarcopenic patients at the time of diagnosis would direct selection of patients who could benefit from early nutritional and/or physical treatments able to increase their muscle mass and possibly improve the prognosis. More extensive multicenter studies are needed to address this issue.

Multimodal oncological approach in patients affected by recurrent hepatocellular carcinoma after liver transplantation.

OBJECTIVE: Hepatocellular Carcinoma (HCC) represents the fifth most common malignancy and the third cancer-related cause of death worldwide. Liver transplantation (LT) is an excellent treatment for patients with small HCC associated with cirrhosis. The purpose of this review is to investigate the possible strategies for the treatment of HCC recurrence after LT based on current clinical evidence. MATERIALS AND METHODS: A systematic literature search was performed independently by two of the authors using PubMed, EMBASE, Scopus and the Cochrane Library Central. The search was limited to studies in humans and to those reported in the English language. RESULTS: Thanks to the introduction of strict selection criteria, LT for HCC has achieved a survival rate of 85% at five years. However, the recurrence of HCC after transplantation remains a serious problem that affects about 20% of post-transplant cases. While most recurrences occur within the first 2 years, late recurrences have been described. The prognosis of recurrence is poor despite numerous proposals of the therapeutic option. Lower levels of immunosuppressive therapy and use of mammalian targets of rapamycin (mTORs) is a potential preventive strategy to reduce HCC recurrence post-Lt. Surgical resection and locoregional therapies (mainly TACE and RFA) play a very important role and are associated with improved survival. Conversely, multikinase inhibitors such as Sorafenib and their association with mTOR inhibitors play a role in cases of advanced HCC recurrence not suitable for the surgical or ablative approach. CONCLUSIONS: Treating HCC recurrence is a multidisciplinary workup involving hepatologists, surgeons, oncologists and radiologists in order to offer a patient-tailored therapy.

Role of magnetic resonance imaging in the detection of anastomotic biliary strictures after liver transplantation.

INTRODUCTION: Biliary complications after orthotopic liver transplantation (OLT) are the principal cause of morbidity and graft dysfunction, ranging in incidence from 5.8% to 30% of cases. Biliary strictures are the most frequent type of late complication. The aim of this study was to evaluate the role of magnetic resonance cholangiography (MRC) to detect biliary anastomotic strictures among patients undergone OLT with abnormal liver function tests. MATERIALS AND METHODS: One hundred twenty-one of 300 patients who underwent OLT were evaluated by MRC for clinically suspected anastomotic biliary strictures. In all patients, we performed various precholangiographic sequences including T1- and T2-weighted and MRC (radial SE 2D and SS-TSE 3D). Magnetic resonance imaging findings were subdivided as absence or presence of an anastomotic stricture. Diagnostic confirmation was obtained by endoscopic retrograde cholangiography (n=32), percutaneous transhepatic cholangiography (n=21) or surgical treatment (n=18). RESULTS: MRC detected 56 anastomotic biliary strictures, 53 of which were confirmed by other imaging modalities. MRC showed two false-negative cases and three false-positive cases. The sensitivity, specificity, positive and negative predictive values, and accuracy of MRC to detect biliary strictures were 96%, 96%, 95%, 97%, and 96%, respectively. CONCLUSION: MRC proved to be a reliable noninvasive technique to visualize the biliary anastomosis and depict biliary strictures after OLT. MRC should be used when a biliary anastomotic stricture is suspected in an OLT patient.

Role of magnetic resonance cholangiography in biliary complications of orthotopic liver transplantation.

PURPOSE: The aim of this study was to evaluate the role of magnetic resonance cholangiography (MRC) in the detection of biliary complications following orthotopic liver transplantation (OLT). MATERIALS AND METHODS: Seventy-eight transplant patients with clinically suspected biliary complications were evaluated with 1.5-T magnetic resonance imaging (MRI) using a surface coil. All patients were imaged with the following sequences: axial T1-weighted and axial and coronal T2-weighted, 2D spin echo (SE) breath-hold radial cholangiography, and coronal 3D single-shot turbo spin echo (SS-TSE) with respiratory triggering. Patients with negative MRI underwent clinical and sonographic followup. When biliary complications were present, diagnostic confirmation was obtained by endoscopic retrograde cholangiopancreatography (ERCP) (n=13), percutaneous transhepatic cholangiography (PTC) (n=20), ultrasonography (n=10) or computed tomography (CT) (n=2). In 11 cases, surgical confirmation was also obtained. RESULTS: MRC detected biliary complications in 44/78 patients, in particular, 42 biliary strictures (37 anastomotic and five intrahepatic), 40 of which were confirmed by other imaging modalities. In 25/37 cases of anastomotic stricture, preanastomotic dilatation of the biliary tract was also demonstrated. Other MRC-detected biliary complications were biliary sludge (n=4), biloma (n=5), and biliary stones (n=3). In four cases, PTC revealed biliary complications that had not been detected with MRC (false negative results). In two cases, MRC showed unconfirmed strictures of the intrahepatic ducts and biliodigestive anastomosis (false positive results). The sensitivity, specificity, positive (PPV) and negative (NPV) predictive values and diagnostic accuracy of MRC were 93.5%, 94.4%, 96.7%, 89.5% and 93.9%, respectively. CONCLUSIONS: Our results confirm that MRC is a reliable technique for depicting biliary anastomoses and detecting biliary complications after OLT. The high diagnostic accuracy of MRC indicates that this examination should be routinely employed in all OLT patients with clinically suspected biliary complications.

Contrast-enhanced MRI and PET-CT in the evaluation of patients with suspected local recurrence of rectal carcinoma.

PURPOSE: This study aimed to evaluate the role of contrast-enhanced magnetic resonance imaging (MRI) and positron emission tomography-computed tomography (PET-CT) in the assessment of local recurrence of rectal cancer. MATERIALS AND METHODS: Among 200 patients scheduled for CT follow-up, 60 (48 low risk; 12 high risk) were selected due to CT findings suspicious for or suggestive of local recurrence. Patients underwent contrast-enhanced MRI and PET-CT within 2 weeks. Biopsy was considered the gold standard in 39 cases and follow-up at 6 and 12 months in the remaining 21. RESULTS: Local recurrence was confirmed by histology in 15 cases (7 low risk; 8 high risk) and was excluded in 21 cases by long-term follow-up and in 24 by histology. Sensitivity, specificity, positive and negative predictive value and accuracy were 86.7%, 68.9%, 48.1%, 93.9% and 73.3% for contrast-enhanced MRI and 93.3%, 68.9%, 50%, 96.9% and 75% for PET-CT. CONCLUSIONS: Contrast-enhanced MRI and PET-CT can help in the detection of local recurrence of rectal cancer, even though their roles in early detection remains debatable, as the value of these techniques in current surveillance protocols is still to be defined.

Liver transplantation due to iatrogenic injuries: two case reports.

The transjugular intrahepatic portosystemic shunt (TIPS) is an acceptable procedure that has proven benefits in the treatment of patients who have complications from portal hypertension due to liver cirrhosis. In the literature few reports have described complications after TIPS placement. Initial surgery and local hemostasis have been needed to manage abdominal bleeding: if this treatment is insufficient, it may be necessary to perform a liver transplantation. This report describes the role of liver transplantation to manage dangerous complications in 2 patients after TIPS placement, when surgical procedures and hemostasis were unable to stop the bleeding.

Radiologic imaging of the transplanted bowel.

BACKGROUND: The radiologic evaluation of the transplanted bowel is largely unknown and rather complex because it involves several techniques that depend on indications and times that have not been fully defined. METHODS: From December 2000 to November 2002 in the Section of Radiology I of the University of Modena and Reggio Emilia (Modena, Italy), 11 patients with transplanted bowel were studied with different methods: traditional radiologic evaluation with contrast agent (all patients), evaluation of transit time with radiopaque markers (five patients), ultrasonographic (US) evaluation of the intestinal wall and Doppler US of the vascular axes (five patients), computed tomographic (CT) evaluation (all patients), and magnetic resonance (MR) evaluation of the bowel and the vascular axes (five patients). Traditional contrast examination enabled evaluation of the gastroesophageal transit and cardia functionality; anatomy and integrity of the anastomoses (proximal and distal); time of gastric emptying; morphology, tone, and kinesis of the transplanted small bowel loops and time of global transit. The study of transit with radiopaque markers was carried out in five patients to define the time of transit through the entire transplanted bowel, confirm recovery of intestinal motility, and identify possible abnormalities. The US examination was carried out in five patients to evaluate the morphology, thickness, and echo structural features of the intestinal loops. Color Doppler was performed to visualize the superior mesenteric artery and a wall arteriole of the sampled loop. CT examination was performed 2 to 4 weeks after surgery to evaluate the anatomy of the transplanted organs, arterial and venous anastomoses in case of complications identified with other methods or suspected, and periodically in the follow-up of patients who underwent transplantation due to Gardner syndrome. The protocol for MR evaluation of the bowel included coronal single-shot fast spin-echo T2-weighted sequences, axial and/or sagittal single-shot fast spin-echo T2-weighted sequences, coronal fast multiplanar spoiled gradient-echo (FMP- SPGR) sequences, coronal FMPSPGR sequences with and without administration of intravenous paramagnetic contrast agent, and axial or sagittal FMPSPGR fat-saturated sequences performed after dynamic gadolinium administration. RESULTS AND CONCLUSION: The study of transit with radiopaque markers was useful in patients with chronic intestinal pseudo-obstruction because it identified recovery and normalization of motility. Traditional contrast examination of the gastrointestinal tract continues to play an important role in transplanted patients because it is a simple examination that allows evaluation of the graft anatomy and recovery of motility of the residual native bowel and the transplanted loops. Moreover, it plays a crucial role in early detection of major postoperative complications such as intestinal obstruction, perforation, fistulas, and anastomotic complications (stenosis and dehiscence). CT examination is crucial for the detection of fluid collections, abscesses, and fistulas because it can serve as a guide of drainage and during follow-up of patients with Gardner syndrome can be used to investigate all possible sites in which desmoids might arise in addition to their relation to the graft. Because patients with transplanted bowel are generally rather a young population of reproductive age and because of technologic advances, MR may represent an effective method that does not use ionizing radiation and can therefore substitute for traditional radiologic evaluation. US represents a quick examination technique that is easily available and well tolerated by patients, and it has a role to play in the follow-up of transplanted patients and in the identification of major postoperative complications. However, its role in monitoring possible rejection remains to be defined with studies on wider and more representative samples.

Gadolinium-enhanced MRI with dynamic evaluation in diagnosing the local recurrence of rectal cancer.

BACKGROUND: At early stages, the diagnosis of local recurrence of rectal cancer is often difficult and magnetic resonance imaging (MRI) is currently considered the most accurate method for diagnosing recurrence. We evaluated the role of unhenhanced and gadolinium-enhanced MRI for the diagnosis of local recurrence of rectal cancer. METHODS: Thirty-six patients, suspected of having a pelvic recurrence of rectal cancer, were evaluated by a high field strength MRI unit. Unenhanced spin-echo T1- and T2-weighted sequences and gadolinium-enhanced dynamic fast multiplanar spoiled gradient recalled sequences were performed in all patients. The dynamic images were re-elaborated with semiquantitative postprocessing by plotting intensity-time curves and calculating the percentage of signal increase at the end of the first postcontrast dynamic sequence. The pelvic lesions were classified as recurrent or not recurrent by applying the following diagnostic criteria: (a) morphology and signal intensity of the lesion in unenhanced sequences and (b) percentage of enhancement in dynamic enhanced sequences. Diagnosis was confirmed by computed tomography-guided needle biopsy (12 patients), surgery (four patients), clinical and imaging follow-up (20 patients). RESULTS: The diagnosis was local recurrence in 15 patients and noncancerous lesions in 21 patients. Unenhanced MRI had 80% sensitivity and 86% specificity. Analysis of the percentage of enhancement showed 87% sensitivity and 100% specificity. CONCLUSION: In agreement with the literature, our results showed a high sensitivity and specificity for dynamic MRI. This technique thus can be considered an important adjunct to unenhanced MRI, especially in selected cases in which unenhanced MRI cannot rule out local recurrences. However, these results must be validated by further investigations.

Magnetic resonance imaging in evaluating functional disorders of female pelvic floor.

PURPOSE: To evaluate the diagnostic capabilities of MRI in the study of functional diseases of the female pelvic floor. MATERIALS AND METHODS: Ten healthy volunteers and 30 patients with clinically suspected pelvic floor deficiency, with or without pelvic organ prolapse, were evaluated by a high field strength magnet operating at 1.5 T. In each case SSFSE sequences (TR/TE:25720/67) in axial, coronal and sagittal planes, both at rest and during Valsalva's manoeuvre, were performed. Based on the MRI findings using fixed and mobile anatomical landmarks, the functional disease of the pelvic floor was diagnosed and quantified based on the identification and grading of visceral prolapse. The MRI findings were compared with the clinical findings in all cases and with the surgical data in the 7 patients who had undergone surgery. RESULTS: The MR image quality was adequate in all cases. In the group of symptomatic women MRI diagnosed: urethral hypermobility syndrome: 22 cases; isolated abnormalities of the anterior compartment: 8 cases of cystocele (low grade: 2, middle grade: 2, severe: 4); isolated abnormalities of the middle compartment: 6 cases of hysterocele (low grade: 2, middle grade: 4); isolated abnormalities of the posterior compartment: 5 cases of low-grade rectocele; 2 cases of enterocele (1 low grade, 1 middle grade); multi-compartment abnormalities: 11 cases; joint prolapse of anterior and middle compartment: 5 cases; joint prolapse of posterior and middle compartment: 3 cases; joint prolapse of anterior, middle and posterior compartment: 3 cases. The values of both fixed and mobile landmarks were significantly higher in the symptomatic group compared with the healthy volunteers. MRI confirmed the pelvic examination findings in all cases; in particular MRI findings were in total agreement with the clinical severity of prolapse, as defined by the Baden-Walker classification. In 7 cases MRI detected additional alterations (4 cases of hysterocele and 3 of enterocele) that had been missed at clinical evaluation. DISCUSSION AND CONCLUSIONS: In our experience MRI made an important contribution to the diagnosis and grading of functional disorders of the female pelvic floor and pelvic organ prolapse. The ability to simultaneously demonstrate both muscular and ligamentous structures and pelvic viscera, without using X-rays or contrast agents, is the main reason for the good results achieved by MRI and for its widespread use in this disorder. Furthermore the use of fast, breath-hold sequences can provide high-quality images both at rest and during Valsalva's manoeuvre. In conclusion MRI proved to be an accurate imaging tool that is more sensitive than clinical pelvic evaluation in diagnosing and grading functional disorders of the female pelvic floor and pelvic visceral prolapse.

Glutathione (GSH) in human stomach mucosa.

The role of glutathione and its function in patients affected by carcinoma and ulcer was studied. The dramatical decrease of this tripeptide evidenced by the authors, demonstrates its fundamental role in the above mentioned pathologies and permits to formulate a hypothesis of therapeutic presidium for some substances (e.g. cysteine), that showed to be able in recovering normal glutathione levels.