Simultaneous laparoscopic removal of a Todani type II choledochal cyst and a microlithiasic cholecystitis.

Diverticula of the choledochus, better known as Todani type II cysts, are very rare and represent a predominantly pediatric pathology. Their identification by radiological methods, even if occasional, requires clinical doctors to request a surgical consultation, even for asymptomatic subjects, to proceed with their removal, given the risk of associated neoplasms. The laparoscopic approach for surgical treatment of these cysts has been recently introduced with excellent results. Due to the poor clinical records, currently there are neither shared protocols about their management nor long-term follow-up of operated patients. We report a case of an adult female suffering for years from biliary colic due to the presence of a duodenal diverticulum associated with microlithiasis' cholecystitis, who was laparoscopically treated, with excellent results in terms of symptomatic regression, reduced hospitalization, and no surgery-related complications.

A Comparison of XGBoost, Random Forest, and Nomograph for the Prediction of Disease Severity in Patients With COVID-19 Pneumonia: Implications of Cytokine and Immune Cell Profile.

Background and Aims: The aim of this study was to apply machine learning models and a nomogram to differentiate critically ill from non-critically ill COVID-19 pneumonia patients. Methods: Clinical symptoms and signs, laboratory parameters, cytokine profile, and immune cellular data of 63 COVID-19 pneumonia patients were retrospectively reviewed. Outcomes were followed up until Mar 12, 2020. A logistic regression function (LR model), Random Forest, and XGBoost models were developed. The performance of these models was measured by area under receiver operating characteristic curve (AUC) analysis. Results: Univariate analysis revealed that there was a difference between critically and non-critically ill patients with respect to levels of interleukin-6, interleukin-10, T cells, CD4+ T, and CD8+ T cells. Interleukin-10 with an AUC of 0.86 was most useful predictor of critically ill patients with COVID-19 pneumonia. Ten variables (respiratory rate, neutrophil counts, aspartate transaminase, albumin, serum procalcitonin, D-dimer and B-type natriuretic peptide, CD4+ T cells, interleukin-6 and interleukin-10) were used as candidate predictors for LR model, Random Forest (RF) and XGBoost model application. The coefficients from LR model were utilized to build a nomogram. RF and XGBoost methods suggested that Interleukin-10 and interleukin-6 were the most important variables for severity of illness prediction. The mean AUC for LR, RF, and XGBoost model were 0.91, 0.89, and 0.93 respectively (in two-fold cross-validation). Individualized prediction by XGBoost model was explained by local interpretable model-agnostic explanations (LIME) plot. Conclusions: XGBoost exhibited the highest discriminatory performance for prediction of critically ill patients with COVID-19 pneumonia. It is inferred that the nomogram and visualized interpretation with LIME plot could be useful in the clinical setting. Additionally, interleukin-10 could serve as a useful predictor of critically ill patients with COVID-19 pneumonia.

Unusual segmental ischemia of the small bowel from cocaine abuse.

Cocaine abuse is rising in the young population, triggering uncommon and potentially life-threatening causes of acute abdomen in this age group. The authors present the case of a 30-year-old man with emergency admission due to abdominal pain, with no history of drug abuse. Several signs and symptoms elicited toxicologic blood screening, which disclosed high serum levels of cocaine and its metabolites. Twelve hours after admission, the onset of acute abdomen with signs of diffuse peritonitis prompted surgical exploration through a minimally invasive approach. Two segmental small bowel ischemic loops and diffuse peritonitis, but no bowel perforation, were identified and treated by laparoscopic peritoneal lavage with 5 l of heated saline and intravenous administration of sodium heparin, 10 000 IU. Postoperative course was uneventful with home discharge on postoperative day 5. High index of suspicion is required to establish a prompt diagnosis and treatment of this uncommon cocaine abuse-related disease.