Lung Ultrasound in COVID-19: Clinical Correlates and Comparison with Chest Computed Tomography.

Lung ultrasound (LUS) and chest computed tomography (chest CT) are largely employed to evaluate coronavirus disease 2019 (COVID-19) pneumonia. We investigated semi-quantitative LUS and CT scoring in hospitalized COVID-19 patients. LUS and chest CT were performed within 24 h upon admission. Both were analyzed according to semi-quantitative scoring systems. Subgroups were identified according to median LUS score. Patients within higher LUS score group were older (79 vs 60 years, p<0.001), had higher C-reactive protein (CRP) (7.2 mg/dl vs 1.3 mg/dl, p<0.001) and chest CT score (10 vs 4, p=0.027) as well as lower PaO2/FiO2 (286 vs 356, p=0.029) as compared to patients within lower scores. We found a significant correlation between scores (r=0.390, p=0.023). Both LUS and CT scores correlated directly with patients age (r=0.586, p<0.001 and r=0.399, p=0.021 respectively) and CRP (r=0.472, p=0.002 and r=0.518, p=0.002 respectively), inversely with PaO2/FiO2 (r=-0.485, p=0.003 and r=-0.440, p=0.017 respectively). LUS score only showed significant correlation with hs-troponin T, NT-pro-BNP, and creatinine (r=0.433, p=0.019; r=0.411, p=0.027, and r=0.497, p=0.001, respectively). Semi-quantitative bedside LUS is related to the severity of COVID-19 pneumonia similarly to chest CT. Correlation of LUS score with markers of cardiac and renal injury suggests that LUS might contribute to a more comprehensive evaluation of this heterogeneous population.

[Magnesium, calcium and potassium: "no one was born alone"]. / Magnesio, calcio e potassio: "Nessuno nasce solo o è nato per sé solo".

In contrast to other ions, magnesium is treated as an orphan by the body: there are no hormones that have a substantial role in regulating urinary magnesium excretion, and bone, the principal reservoir of magnesium, does not readily exchange with circulating magnesium.The Mg ++ is often overlooked by physicians in the differential diagnosis because it is considered insignificant, but its role is crucial for cells function, first of all neurons and cardiomyocytes. A condition of hypocalcemia associated with hypokalemia, especially in the presence of chronic renal failure, should raise suspicion of a lack of Mg ++.We report the case of an old man of 77 year with kidney transplant for 13 years, treated with cyclosporine, and sodium mycophenolate and steroid who, for about a month, accused impaired balance and walking instability, who fell accidentally down with wrist fracture.Blood tests showed hypocalcemia and hypokalemia, and so we required dosage of serum and urinary magnesium. A significant reduction in the ion plasma concentration was seen, associated to a fraction of excretion inappropriately high in relation to the degree of hypomagnesemia.The cause of this important renal loss is likely attributable to cyclosporine, a drug that has as a side effect the inhibition of the reabsorption of Mg ++ in the distal convoluted tubule. then, oral supplementation was started (244 mg of Mg ++ ion / day), with subsequent normalization, after a few days, not only of magnesiemia, but also in serum calcium and potassium levels, and improvement of neurological symptoms.Hypomagnesaemia is common in patients with renal transplantation in therapy with calcineurin inhibitors ICN, due to the effects of such drugs on the TRPM6 transporter present in the kidney distal convoluted tubule. To prevent complications caused by chronic and severe depletion of magnesium in this particular population, we recommend periodic monitoring of magnesium plasma levels.

[Review: UPDATE on magnesium metabolism]. / Review: UPDATE sul metabolismo del magnesio.

Magnesium is the second intracellular cation and the fourth most abundant mineral in the body. Low levels of magnesium have been associated with insulin resistance and type-2 diabetes mellitus, asthma, osteoporosis and chronic kidney disease (CKD). The use of proton pump inhibitors (PPIs) represents the most common cause of hypomagnesemia. The risk of hypomagnesemia, and consequently worsening of the renal function, is increased when diuretics are added to therapy in subjects treated with PPIs. Interestingly, diuretics and PPIs are two of the most used drugs in subjects with CKD. In this review, we described the mechanisms at the basis of the hypomagnesemia and the effect of this electrolyte disturbance in subjects with CKD.

A Case Report of an Atypical Presentation of IgG4-Related Disease and Idiopathic CD4 Lymphocytopenia.

The IgG4-related disease is a fibroinflammatory disease characterized by tumefactive lesions, a dense lymphoplasmacytic infiltrate rich in IgG4-positive plasma cells, storiform fibrosis, and, often but not always, elevated serum levels of IgG4. Idiopathic CD4 lymphocytopenia is a heterogenic and rare syndrome characterized by the detection of a persistent absolute CD4 T cells count <300 cells/mm(3) (or <20% of total T cells) in more than one occasion and no evidence of HIV infection in absence of immunodeficiency or therapy associated with depressed levels of CD4 T cells. We report the case of a 50-year-old man with a multiorgan IgG4-related disease presenting in a temporal association with a profound and symptomatic idiopathic CD4 lymphocytopenia. Both clinical pictures improved after steroid treatment. Idiopathic CD4 lymphocytopenia has been associated with a number of autoimmune conditions but, to the best of our knowledge, this is the first case in which an association with the IgG4-related disease is reported.

[Candida peritonitis and sepsis due to Acinetobacter baumannii in peritoneal dialysis: an association with prognosis not always unfavourable]. / Peritonite da Candida e sepsi da Acinetobacter baumannii in dialisi peritoneale: un'associazione con prognosi non sempre infausta.

Fungal infections have a high incidence in patients receiving peritoneal dialysis. (1)Peritoneal dialysis is often complicated by peritonitis which has only minimally mycotic etiology, but nonetheless it is associated with 15-45% mortality (8). The opportunistic pathogens such as Candida can cause infection in immunocompromised conditions. Even the Acinetobacter tends to infect immunocompromised individuals and it has the same risk factors for infection as Candida: immunosuppression, malignancy, HIV positivity and all the other conditions of immunosuppression, central venous catheterization, mechanical ventilation and prolonged antibiotic therapy. The sepsis by Acinetobacter predicts a negative prognosis with the mortality rate between 20 to 60% (12), especially in cases of isolation of multi-resistant germs. We present a case report of a CKD patient undergoing peritoneal dialysis therapy who was hospitalized for acute pancreatitis, later complicated by the development of pancreatic pseudocysts, C. albicans peritonitis with hematologic spread of the fungus, superimposed Acinetobacter baumannii sepsis and pneumonia. She has been subjected to percutaneous drainage of pseudocysts, to switch from peritoneal dialysis to hemodialysis, to various evacuative thoracentesis, and to polymicrobial therapy (meropenem, teicoplanina, tigeciclina, linezolid, colimicina, fluconazolo, etc.) that allowed the resolution of sepsis. The peculiarity of this case is represented by the numerous morbidity that the patient developed simultaneously, with the genesis of a complex clinical picture, by the combination of infections due to Candida albicans and Acinetobacter baumannii. Successful treatment strategies allowed to fight and cure a medical condition associated with a high mortality rate.

Early recognition of the 2009 pandemic influenza A (H1N1) pneumonia by chest ultrasound.

INTRODUCTION: The clinical picture of the pandemic influenza A (H1N1)v ranges from a self-limiting afebrile infection to a rapidly progressive pneumonia. Prompt diagnosis and well-timed treatment are recommended. Chest radiography (CRx) often fails to detect the early interstitial stage. The aim of this study was to evaluate the role of bedside chest ultrasonography (US) in the early management of the 2009 influenza A (H1N1)v infection. METHODS: 98 patients who arrived in the Emergency Department complaining of influenza-like symptoms were enrolled in the study. Patients not displaying symptoms of acute respiratory distress were discharged without further investigations. Among patients with clinical suggestion of a community-acquired pneumonia, cases encountering other diagnoses or comorbidities were excluded from the study. Clinical history, laboratory tests, CRx, and computed tomography (CT) scan, if indicated, contributed to define the diagnosis of pneumonia in the remaining patients. Chest US was performed by an emergency physician, looking for presence of interstitial syndrome, alveolar consolidation, pleural line abnormalities, and pleural effusion, in 34 patients with a final diagnosis of pneumonia, in 16 having normal initial CRx, and in 33 without pneumonia, as controls. RESULTS: Chest US was carried out without discomfort in all subjects, requiring a relatively short time (9 minutes; range, 7 to 13 minutes). An abnormal US pattern was detected in 32 of 34 patients with pneumonia (94.1%). A prevalent US pattern of interstitial syndrome was depicted in 15 of 16 patients with normal initial CRx, of whom 10 (62.5%) had a final diagnosis of viral (H1N1) pneumonia. Patients with pneumonia and abnormal initial CRx, of whom only four had a final diagnosis of viral (H1N1) pneumonia (22.2%; P<0.05), mainly displayed an US pattern of alveolar consolidation. Finally, a positive US pattern of interstitial syndrome was found in five of 33 controls (15.1%). False negatives were found in two (5.9%) of 34 cases, and false positives, in five (15.1%) of 33 cases, with sensitivity of 94.1%, specificity of 84.8%, positive predictive value of 86.5%, and negative predictive value of 93.3%. CONCLUSIONS: Bedside chest US represents an effective tool for diagnosing pneumonia in the Emergency Department. It can accurately provide early-stage detection of patients with (H1N1)v pneumonia having an initial normal CRx. Its routine integration into their clinical management is proposed.

Ultrasound M-mode assessment of diaphragmatic kinetics by anterior transverse scanning in healthy subjects.

The purpose of this study was to set an effective standardized method to assess diaphragmatic kinetics by ultrasound. Forty healthy volunteers were submitted to a B- and M-mode ultrasound study using a convex transducer positioned in the subcostal anterior area for transverse scanning. Ultrasound examination was completed in 38/40 cases (95%), spending on average <10 min for examination. The resting and forced diaphragmatic excursions were 18.4 ± 7.6 and 78.8 ± 13.3 mm, respectively, unrelated to demographic or anthropometric parameters: intraobserver variability on three successive measurements resulted in 6.0% and in 3.9%, respectively. An inexperienced sonographer completed the ultrasound examination in 37/40 cases, spending on average >15 min, with significant, although marginal, interobserver variability (31.9% and 14.7% for resting and forced diaphragmatic excursion, respectively). Bedside ultrasonography by an anterior subcostal transverse scanning on semi-recumbent patient proves to be a safe, feasible, reliable, fast, relatively easy and reproducible way to assess diaphragm movement.

The ultrasonographic deep sulcus sign in traumatic pneumothorax.

A series of 186 patients with blunt chest trauma was studied with transthoracic ultrasonography to diagnose pneumothorax and to evaluate its size and location. The results were compared with bedside chest radiography and spiral CT scan. The prevalence of pneumothorax on CT scan was 56/186 (30.1%). Pneumothorax was proven on radiography in 30/56 cases without false positive results: "radiographic deep sulcus sign" was evident in 3/29 cases, 26/29 cases being occult. The ultrasound study demonstrated the presence of pneumothorax in 55/56 patients: one occult pneumothorax was missed and no false positive results were observed. The CT scan differed of +/-2.3 cm (range 1-5 cm) from the US study in evaluating size and location of pneumothorax. In conclusion, ultrasound study may detect occult pneumothorax undiagnosed by standard plain radiography. It reflects accurately the extent of pneumothorax if compared with CT scan, outlining the "ultrasonographic deep sulcus sign" on anterior chest wall.

Chest ultrasonography in lung contusion.

STUDY OBJECTIVE: Despite the high prevalence of chest trauma and its high morbidity, lung contusion (LC) often remains undiagnosed in the emergency department (ED). The present study investigates the possible clinical applicability of chest ultrasonography for the diagnosis of LC in the ED in comparison to radiography and CT. MATERIALS AND METHODS: One hundred twenty-one patients admitted to the ED for blunt chest trauma were investigated using ultrasonography by stage III longitudinal scanning of the anterolateral chest wall to detect LC. Data were retrospectively collected in an initial series of 109 patients (group 1) and prospectively in the next 12 patients (group 2). All patients who presented with pneumothorax were excluded. After the ultrasound study, all patients were submitted to chest radiography (CXR) and CT. The sonographic patterns indicative of LC included the following: (1) the alveolointerstitial syndrome (AIS) [defined by increase in B-line artifacts]; and (2) peripheral parenchymal lesion (PPL) [defined by the presence of C-lines: hypoechoic subpleural focal images with or without pleural line gap]. RESULTS: The diagnosis of LC was established by CT scan in 37 patients. If AIS is considered, the sensitivity of ultrasound study was 94.6%, specificity was 96.1%, positive and negative predictive values were 94.6% and 96.1%, respectively, and accuracy was 95.4%. If PPL is alternatively considered, sensitivity and negative predictive values drop to 18.9% and 63.0%, respectively, but both specificity and positive predictive values increased to 100%, with an accuracy of 65.9%. Radiography had sensitivity of 27% and specificity of 100%. CONCLUSIONS: Chest ultrasonography can accurately detect LC in blunt trauma victims, in comparison to CT scan.

[Asthma: current therapeutic approach]. / Asma bronchiale: iter terapeutico.

Asthma is a chronic reversible respiratory disease characterized by inflammation and bronchial smooth muscle contraction. The therapeutic approach must improve the acute symptoms, avoid disease exacerbations and prevent the pulmonary functional decay.

[A case of cardiogenic syncope in a drug-addict patient]. / Un caso di sincope di origine cardiogena in paziente farmaco-dipendente.

Torsade de pointes is a polymorphic ventricular tachycardia, associated with prolonged QT interval and characterized by twisting of the mean electrical axis of the QRS complexes around an isoelectric line. The long QT syndrome can be divided into two categories, congenital and acquired. The congenital long QT syndrome may be caused by some gene mutation, whereas the acquired form is usually associated with drugs and electrolyte imbalance. It usually remains asymptomatic or causes presyncope, although it may degenerate into ventricular fibrillation and may cause sudden death. The different presentation depends on the polymorphism that characterizes genotypic and phenotypic expression of proteic channel subunits, and on drug toxicity that provoke subunit dysfunction. The case report presented here is an example of prolonged QT interval syndrome in a patient with cocaine abuse and electrolyte disturbances.

Cardiopulmonary bypass in man: role of the intestine in a self-limiting inflammatory response with demonstrable bacterial translocation.

BACKGROUND: Cardiopulmonary bypass provokes a systemic inflammatory reaction that, in 1% to 2% of all cases, leads to multiorgan disfunction. The aim of this study was to evaluate the possible role of the intestine in the pathogenesis and development of this reaction. METHODS: Eleven selected patients scheduled for elective coronary artery bypass graft surgery were enrolled in a open, prospective clinical study. Gastric tonometry, chromium-labeled test and double sugar intestinal absorption tests, polymerase chain reaction microbial DNA test, and measurement of cytokines and transcriptional factor (nuclear factor kappaB) activation were performed. RESULTS: During the postoperative period, gastric pH remained stable (range,7.2 to 7.3). The partial pressure for carbon dioxide gradient between the gastric mucosa and arterial blood increased significantly (from 1 to 23 mm Hg), peaking in the sixth postoperative hour. Interleukin 6 increased significantly over basal levels, peaking 3 hours after cardiopulmonary bypass (96.3 versus 24 pg/mL). Nuclear factor kappaB never reached levels higher than those observed after lipopolysaccharide stimulation. Escherichia coli translocation was documented in 10 patients: in eight cases from removal of aortic cross-clamps and in two cases from the first postoperative hour. With respect to basal value (6.4%), the urine collection revealed a significant increase in excretion of the radioisotope during the first 24 hours after surgery (39.1%), although there were no significant variations with the double sugar test. CONCLUSIONS: The results obtained showed a correlation between the damage of the gastrointestinal mucosa, subsequent increased permeability, E coli bacteremia, and the activation of a self-limited inflammatory response in the absence of significant macrocirculatory changes and postoperative complications.

[Hibernating and stunned myocardium. Pathogenetic mechanisms during and after myocardial ischemia]. / Miocardio ibernato e stordito. Meccanismi patogenetici durante e dopo ischemia miocardica.

In this paper the Authors consider the concept of stunning/hibernating myocardium, analizing the most recent articles and reviews in literature, until April 2002 (database PubMed). Dysfunctional segments with normal perfusion and normal glucose utilization are considered to be "stunned", and dysfunctional segments with reduced perfusion and preserved glucose utilization are considered to be "hibernated". Together with the two major hypothesis (generation of oxygen-derived free radicals and transient calcium overload) in developing of dysfunctional myocardium after ischaemia, recent studies have demonstrated an important role in down-regulation of beta-adrenergic receptors both in the stunned and in the hibernated segments. Moreover, the increase of negatively inotropic cytokines TNF-alpha and NOS2 has been observed in dysfunctional segments. The number of copies of mRNA has been quantified by reverse transcription-polymerase chain reaction (reverse-PCR).