Failed endoscopic ultrasound-guided gallbladder drainage due to severe bleeding immediately rescued by redo-drainage under contrast-harmonic guidance

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EUS-guided transrectal drainage of pelvic fluid collections using electrocautery-enhanced lumen-apposing metal stents: a case series

Background and Aims: Pelvic fluid collections (PFCs) are frequent adverse events of abdominal surgery or inflammatory conditions. A percutaneous approach to deep PFCs could be challenging and result in a longer, painful recovery. The transvaginal approach has been considered easy but is limited by the difficulty of leaving a stent in place. The transrectal approach has been described, but issues related to fecal contamination were hypothesized. Data on EUS-guided transrectal drainage (EUS-TRD) with lumen-apposing metal stents (LAMSs) are few and suggest unsatisfactory outcomes. The aim of this study was to evaluate the safety and efficacy of EUS-TRD with LAMSs in patients with PFCs. Methods: A retrospective analysis of a prospectively maintained database on therapeutic EUS was conducted. All EUS-TRD procedures were included. Results: Five patients (2 male, age 44-89 years) were included. Four patients had postoperative PFCs, and 1 presented with a pelvic abscess complicating acute diverticulitis. Two of 5 had fecal diversion; the remaining 3 had unaltered large-bowel anatomy. One case had a concomitant abdominal collection, treated with percutaneous drainage in the same session. An electrocautery-enhanced LAMS delivery system (15 7 10 mm) was used in all cases. EUS-TRD was performed with the direct-puncture technique and lasted less than 10 minutes in 4 cases; in the remaining case, needle puncture and LAMS placement over a guidewire was required, and the procedure length was 14 minutes. The clinical success rate was 100%. LAMSs were removed after a median of 14 (range, 12-24) days. One patient reported partial proximal LAMS migration after 24 days (mild adverse event). No PFC recurrence was observed. Conclusion: EUS-TRD with LAMSs is a safe and effective technique for treatment of PFCs. The use of 15- 7 10-mm LAMSs allows rapid PFC resolution. EUS-TRD could be performed not only in patients with fecal diversion but also in cases of unaltered anatomy

EUS-guided gallbladder drainage in high-risk surgical patients with acute cholecystitis—procedure outcomes and evaluation of mortality predictors

Background: Recent evidences suggest that gallbladder drainage is the treatment of choice in elderly or high-risk surgical patients with acute cholecystitis (AC). Despite better outcomes compared to other approaches, endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is burdened by high mortality. The aim of the study was to evaluate predictive factors for mortality in high-risk surgical patients who underwent EUS-GBD for AC. Methods: A retrospective analysis of a prospectively maintained database was performed. Electrocautery-enhanced lumen-apposing metal stents were used; all recorded variables were evaluated as potential predictive factors for mortality. Results: Thirty-four patients underwent EUS for suspected AC and 25 (44% male, age 78) were finally included. Technical, clinical success rate and adverse events rate were 92%, 88%, and 16%, respectively. 30-day and 1-year mortality were 12% and 32%. On univariate analysis, age-adjusted Charlson Comorbidity Index (CCI) (OR 20.8[4–68.2]), acute kidney injury (AKI) (OR 21.4[2.6–52.1]) and clinical success (OR 8.9[1.2–11.6]) were related to 30-day mortality. On multivariate analysis, CCI and AKI were independently related to long-term mortality. Kaplan–Meier curves showed an increased long-term mortality in patients with CCI > 6 (hazard ratio 7.6[1.7–34.6]) and AKI (hazard ratio 11.3[1.4–91.5]). Conclusions: Severe comorbidities and AKI were independent predictive factors confirming of long-term mortality after EUS-GBD. Outcomes of EUS-GBD appear more influenced by patients’ conditions rather than by procedure success

Computer-aided Diagnosis of Melanocytic Lesions

Background The clinical diagnosis of melanoma could be difficult for a general practitioner and in some cases for dermatologists. To enhance and support the clinical evaluation of pigmented skin lesions a computer-aided diagnosis has been introduced. Objective The purposes of this study were 1) to provide dermatologists as well as general practitioners with a computer aided device in order to produce an objective risk level of the melanocytic lesions helping the clinician during the diagnostic pathway and 2) to compare the discrimination capacity of dermatologists and general practitioners, with the system of automated analysis. Methods 477 images of melanocytic lesions (42 melanomas and 435 melanocytic) evaluated in epiluminescence microscopy and recorded with x16 magnification were selected. A training set of 22 melanomas and 218 nevi has been randomized from the dataset. The test set has been formed by the complement (the remaining 20 melanomas and 217 nevi). Furthermore a set of images consisting in 31 melanomas and 103 nevi has been selected to compare the discrimination capacity of three general practitioners and three dermatologists with experience in dermoscopy (2 years), with the system of automated analysis ADAM. Sensitivity and specificity were estimated for observer assessments and computer diagnosis

Sustained oxygenation improvement after first prone positioning is associated with liberation from mechanical ventilation and mortality in critically ill COVID-19 patients: a cohort study

none95noBackground: Prone positioning (PP) has been used to improve oxygenation in patients affected by the SARS-CoV-2 disease (COVID-19). Several mechanisms, including lung recruitment and better lung ventilation/perfusion matching, make a relevant rational for using PP. However, not all patients maintain the oxygenation improvement after returning to supine position. Nevertheless, no evidence exists that a sustained oxygenation response after PP is associated to outcome in mechanically ventilated COVID-19 patients. We analyzed data from 191 patients affected by COVID-19-related acute respiratory distress syndrome undergoing PP for clinical reasons. Clinical history, severity scores and respiratory mechanics were analyzed. Patients were classified as responders (≥ median PaO2/FiO2 variation) or non-responders (< median PaO2/FiO2 variation) based on the PaO2/FiO2 percentage change between pre-proning and 1 to 3 h after re-supination in the first prone positioning session. Differences among the groups in physiological variables, complication rates and outcome were evaluated. A competing risk regression analysis was conducted to evaluate if PaO2/FiO2 response after the first pronation cycle was associated to liberation from mechanical ventilation. Results: The median PaO2/FiO2 variation after the first PP cycle was 49 [19–100%] and no differences were found in demographics, comorbidities, ventilatory treatment and PaO2/FiO2 before PP between responders (96/191) and non-responders (95/191). Despite no differences in ICU length of stay, non-responders had a higher rate of tracheostomy (70.5% vs 47.9, P = 0.008) and mortality (53.7% vs 33.3%, P = 0.006), as compared to responders. Moreover, oxygenation response after the first PP was independently associated to liberation from mechanical ventilation at 28 days and was increasingly higher being higher the oxygenation response to PP. Conclusions: Sustained oxygenation improvement after first PP session is independently associated to improved survival and reduced duration of mechanical ventilation in critically ill COVID-19 patients.noneScaramuzzo G.; Gamberini L.; Tonetti T.; Zani G.; Ottaviani I.; Mazzoli C.A.; Capozzi C.; Giampalma E.; Bacchi Reggiani M.L.; Bertellini E.; Castelli A.; Cavalli I.; Colombo D.; Crimaldi F.; Damiani F.; Fusari M.; Gamberini E.; Gordini G.; Laici C.; Lanza M.C.; Leo M.; Marudi A.; Nardi G.; Papa R.; Potalivo A.; Russo E.; Taddei S.; Consales G.; Cappellini I.; Ranieri V.M.; Volta C.A.; Guerin C.; Spadaro S.; Tartaglione M.; Chiarini V.; Buldini V.; Coniglio C.; Moro F.; Barbalace C.; Citino M.; Cilloni N.; Giuntoli L.; Bellocchio A.; Matteo E.; Pizzilli G.; Siniscalchi A.; Tartivita C.; Matteo F.; Marchio A.; Bacchilega I.; Bernabe L.; Guarino S.; Mosconi E.; Bissoni L.; Viola L.; Meconi T.; Pavoni V.; Pagni A.; Pompa Cleta P.; Cavagnino M.; Malfatto A.; Adduci A.; Pareschi S.; Melegari G.; Maccieri J.; Marinangeli E.; Racca F.; Verri M.; Falo G.; Marangoni E.; Boni F.; Felloni G.; Baccarini F.D.; Terzitta M.; Maitan S.; Becherucci F.; Parise M.; Masoni F.; Imbriani M.; Orlandi P.; Monetti F.; Dalpiaz G.; Golfieri R.; Ciccarese F.; Poerio A.; Muratore F.; Ferrari F.; Mughetti M.; Franchini L.; Neziri E.; Miceli M.; Minguzzi M.T.; Mellini L.; Piciucchi S.; Bartolucci M.Scaramuzzo G.; Gamberini L.; Tonetti T.; Zani G.; Ottaviani I.; Mazzoli C.A.; Capozzi C.; Giampalma E.; Bacchi Reggiani M.L.; Bertellini E.; Castelli A.; Cavalli I.; Colombo D.; Crimaldi F.; Damiani F.; Fusari M.; Gamberini E.; Gordini G.; Laici C.; Lanza M.C.; Leo M.; Marudi A.; Nardi G.; Papa R.; Potalivo A.; Russo E.; Taddei S.; Consales G.; Cappellini I.; Ranieri V.M.; Volta C.A.; Guerin C.; Spadaro S.; Tartaglione M.; Chiarini V.; Buldini V.; Coniglio C.; Moro F.; Barbalace C.; Citino M.; Cilloni N.; Giuntoli L.; Bellocchio A.; Matteo E.; Pizzilli G.; Siniscalchi A.; Tartivita C.; Matteo F.; Marchio A.; Bacchilega I.; Bernabe L.; Guarino S.; Mosconi E.; Bissoni L.; Viola L.; Meconi T.; Pavoni V.; Pagni A.; Pompa Cleta P.; Cavagnino M.; Malfatto A.; Adduci A.; Pareschi S.; Melegari G.; Maccieri J.; Marinangeli E.; Racca F.; Verri M.; Falo G.; Marangoni E.; Boni F.; Felloni G.; Baccarini F.D.; Terzitta M.; Maitan S.; Becherucci F.; Parise M.; Masoni F.; Imbriani M.; Orlandi P.; Monetti F.; Dalpiaz G.; Golfieri R.; Ciccarese F.; Poerio A.; Muratore F.; Ferrari F.; Mughetti M.; Franchini L.; Neziri E.; Miceli M.; Minguzzi M.T.; Mellini L.; Piciucchi S.; Bartolucci M

Health-related quality of life profiles, trajectories, persistent symptoms and pulmonary function one year after ICU discharge in invasively ventilated COVID-19 patients, a prospective follow-up study

none112siBackground: Health-related quality of life (HRQoL) impairment is often reported among COVID-19 ICU survivors, and little is known about their long-term outcomes. We evaluated the HRQoL trajectories between 3 months and 1 year after ICU discharge, the factors influencing these trajectories and the presence of clusters of HRQoL profiles in a population of COVID-19 patients who underwent invasive mechanical ventilation (IMV). Moreover, pathophysiological correlations of residual dyspnea were tested. Methods: We followed up 178 survivors from 16 Italian ICUs up to one year after ICU discharge. HRQoL was investigated through the 15D instrument. Available pulmonary function tests (PFTs) and chest CT scans at 1 year were also collected. A linear mixed-effects model was adopted to identify factors associated with different HRQoL trajectories and a two-step cluster analysis was performed to identify HRQoL clusters. Results: We found that HRQoL increased during the study period, especially for the significant increase of the physical dimensions, while the mental dimensions and dyspnea remained substantially unchanged. Four main 15D profiles were identified: full recovery (47.2%), bad recovery (5.1%) and two partial recovery clusters with mostly physical (9.6%) or mental (38.2%) dimensions affected. Gender, duration of IMV and number of comorbidities significantly influenced HRQoL trajectories. Persistent dyspnea was reported in 58.4% of patients, and weakly, but significantly, correlated with both DLCO and length of IMV. Conclusions: HRQoL impairment is frequent 1 year after ICU discharge, and the lowest recovery is found in the mental dimensions. Persistent dyspnea is often reported and weakly correlated with PFTs alterations. Trial registration: NCT04411459.mixedGamberini L.; Mazzoli C.A.; Prediletto I.; Sintonen H.; Scaramuzzo G.; Allegri D.; Colombo D.; Tonetti T.; Zani G.; Capozzi C.; Dalpiaz G.; Agnoletti V.; Cappellini I.; Melegari G.; Damiani F.; Fusari M.; Gordini G.; Laici C.; Lanza M.C.; Leo M.; Marudi A.; Papa R.; Potalivo A.; Montomoli J.; Taddei S.; Mazzolini M.; Ferravante A.F.; Nicali R.; Ranieri V.M.; Russo E.; Volta C.A.; Spadaro S.; Tartaglione M.; Chiarini V.; Buldini V.; Coniglio C.; Moro F.; Orlando S.; Fecarotti D.; Cilloni N.; Giuntoli L.; Bellocchio A.; Matteo E.; Pizzilli G.; Siniscalchi A.; Tartivita C.; Cavalli I.; Castelli A.; Marchio A.; Bacchilega I.; Bernabe L.; Facondini F.; Morini L.; Bissoni L.; Viola L.; Meconi T.; Pavoni V.; Venni A.; Pagni A.; Cleta P.P.; Cavagnino M.; Guzzo A.; Malfatto A.; Adduci A.; Pareschi S.; Bertellini E.; Maccieri J.; Marinangeli E.; Racca F.; Verri M.; Falo G.; Marangoni E.; Ottaviani I.; Boni F.; Felloni G.; Baccarini F.D.; Terzitta M.; Maitan S.; Tutino L.; Senzi A.; Consales G.; Becherucci F.; Imbriani M.; Orlandi P.; Candini S.; Golfieri R.; Ciccarese F.; Poerio A.; Muratore F.; Ferrari F.; Mughetti M.; Giampalma E.; Franchini L.; Neziri E.; Miceli M.; Minguzzi M.T.; Mellini L.; Piciucchi S.; Monari M.; Valli M.; Daniele F.; Ferioli M.; Nava S.; Lazzari Agli L.A.; Valentini I.; Bernardi E.; Balbi B.; Contoli M.; Padovani M.; Oldani S.; Ravaglia C.; Goti P.Gamberini L.; Mazzoli C.A.; Prediletto I.; Sintonen H.; Scaramuzzo G.; Allegri D.; Colombo D.; Tonetti T.; Zani G.; Capozzi C.; Dalpiaz G.; Agnoletti V.; Cappellini I.; Melegari G.; Damiani F.; Fusari M.; Gordini G.; Laici C.; Lanza M.C.; Leo M.; Marudi A.; Papa R.; Potalivo A.; Montomoli J.; Taddei S.; Mazzolini M.; Ferravante A.F.; Nicali R.; Ranieri V.M.; Russo E.; Volta C.A.; Spadaro S.; Tartaglione M.; Chiarini V.; Buldini V.; Coniglio C.; Moro F.; Orlando S.; Fecarotti D.; Cilloni N.; Giuntoli L.; Bellocchio A.; Matteo E.; Pizzilli G.; Siniscalchi A.; Tartivita C.; Cavalli I.; Castelli A.; Marchio A.; Bacchilega I.; Bernabe L.; Facondini F.; Morini L.; Bissoni L.; Viola L.; Meconi T.; Pavoni V.; Venni A.; Pagni A.; Cleta P.P.; Cavagnino M.; Guzzo A.; Malfatto A.; Adduci A.; Pareschi S.; Bertellini E.; Maccieri J.; Marinangeli E.; Racca F.; Verri M.; Falo G.; Marangoni E.; Ottaviani I.; Boni F.; Felloni G.; Baccarini F.D.; Terzitta M.; Maitan S.; Tutino L.; Senzi A.; Consales G.; Becherucci F.; Imbriani M.; Orlandi P.; Candini S.; Golfieri R.; Ciccarese F.; Poerio A.; Muratore F.; Ferrari F.; Mughetti M.; Giampalma E.; Franchini L.; Neziri E.; Miceli M.; Minguzzi M.T.; Mellini L.; Piciucchi S.; Monari M.; Valli M.; Daniele F.; Ferioli M.; Nava S.; Lazzari Agli L.A.; Valentini I.; Bernardi E.; Balbi B.; Contoli M.; Padovani M.; Oldani S.; Ravaglia C.; Goti P

Factors influencing liberation from mechanical ventilation in coronavirus disease 2019: multicenter observational study in fifteen Italian ICUs

Background: A large proportion of patients with coronavirus disease 2019 (COVID-19) develop severe respiratory failure requiring admission to the intensive care unit (ICU) and about 80% of them need mechanical ventilation (MV). These patients show great complexity due to multiple organ involvement and a dynamic evolution over time; moreover, few information is available about the risk factors that may contribute to increase the time course of mechanical ventilation. The primary objective of this study is to investigate the risk factors associated with the inability to liberate COVID-19 patients from mechanical ventilation. Due to the complex evolution of the disease, we analyzed both pulmonary variables and occurrence of non-pulmonary complications during mechanical ventilation. The secondary objective of this study was the evaluation of risk factors for ICU mortality. Methods: This multicenter prospective observational study enrolled 391 patients from fifteen COVID-19 dedicated Italian ICUs which underwent invasive mechanical ventilation for COVID-19 pneumonia. Clinical and laboratory data, ventilator parameters, occurrence of organ dysfunction, and outcome were recorded. The primary outcome measure was 28 days ventilator-free days and the liberation from MV at 28 days was studied by performing a competing risks regression model on data, according to the method of Fine and Gray; the event death was considered as a competing risk. Results: Liberation from mechanical ventilation was achieved in 53.2% of the patients (208/391). Competing risks analysis, considering death as a competing event, demonstrated a decreased sub-hazard ratio for liberation from mechanical ventilation (MV) with increasing age and SOFA score at ICU admission, low values of PaO2/FiO2 ratio during the first 5 days of MV, respiratory system compliance (CRS) lower than 40 mL/cmH2O during the first 5 days of MV, need for renal replacement therapy (RRT), late-onset ventilator-associated pneumonia (VAP), and cardiovascular complications. ICU mortality during the observation period was 36.1% (141/391). Similar results were obtained by the multivariate logistic regression analysis using mortality as a dependent variable. Conclusions: Age, SOFA score at ICU admission, CRS, PaO2/FiO2, renal and cardiovascular complications, and late-onset VAP were all independent risk factors for prolonged mechanical ventilation in patients with COVID-19. Trial registration: NCT04411459