Why do a lung biopsy for benign lesions?

BACKGROUND: Transthoracic needle biopsy of lung lesions is a well-established procedure for the diagnosis of lung lesions. The literature focuses on the diagnosis of malignant lesions with an often reported accuracy rate of more than 90%. Experience showed that biopsy can identify sometimes incidentally, also benign lesions. There are many reasons why a biopsy is performed for a "benign lesion." First of all, it may be an unexpected diagnosis, as some benign pathologies may have misleading presentations, that are very similar to lung cancer, otherwise the reason is only to make a diagnosis of exclusion, which leads to the benign pathology already being considered in the differential diagnosis. METHODS: This study was designed as a retrospective single-center study. We selected from our database all the lung biopsies performed under CT guidance, from 2015 to 2019 and retrospectively analysed the histological data. We selected only benign lesions describing the imaging feature and differential diagnosis with lung malignancy. RESULTS: In our patient population, among the 969 of them that underwent biopsy, we identified 93 benign lesions (10%). Hamartomas, granulomas, slow-resolving pneumonia and cryptogenic organizing pneumonia are the pathologies that most frequently can misinterpratedas lung cancer. CONCLUSIONS: In this brief report we want to show the percentage and type of benign lesions that are found in our lung trans-thoracic biopsy population. Among these, we identified the three most frequent benign lesions that most frequently enter the differential diagnosis with lung malignant lesions describing the classic and atypical imaging findings.

Feasibility of a new ultrasound guided procedure to ensure the correct position of the central venous catheter tip.

BACKGROUND: Safety of central venous catheter (CVC) placement relies on some general aspects, including selection of the right vessel, correct lumen targeting while inserting the needle, check the position of catheter tip, and post-procedure check for complications. All these four points can be guided by bedside ultrasound, but the best technique to ensure the position of the CVC tip is still uncertain. METHODS: We investigated feasibility of a novel ultrasound technique consisting of focused view of guidewire tip in the cavoatrial junction (CAJ) to calculate the CVC depth in adult patients needing CVC placement in emergency. Direct visualization of the guidewire in the CAJ was used to calculate how deep the CVC needed to be inserted. In those patients without a valid CAJ window, a bubble test in the right atrium was performed to position the CVC tip. In all cases chest radiography confirmed the CVC position. RESULTS: The procedure was performed in 37 patients and CVC was correctly placed in all cases. Within the group, in 25 patients the CVC depth (21.5 ± 6.0 cm) was successfully measured. In other 11 patients the correct CVC tip position was confirmed by the bubble test. In only one case it was not possible to use ultrasound for incomplete CAJ and right atrium views. CONCLUSIONS: This study confirms the feasibility of a new ultrasound method to ensure the correct CVC tip position. This protocol could potentially become a standard method reducing costs, post-procedural irradiation, and time of CVC placement in emergency.

Effects of seasonality in emergency admissions for mental disorders: two years of clinical experience.

OBJECTIVES: This retrospective study, conducted in Turin, Italy, between January 2021 and February 2023, investigates the impact of seasonal heatwaves on emergency department (ED) admissions for mental disorders. METHODS: Through the analysis of data from 2,854 patients, this research found a significant link between the occurrence of heatwaves, especially from June to August, and an elevated rate of ED admissions for psychiatric conditions. RESULTS: The data indicate a clear seasonal pattern, with admissions peaking during the hot months and diminishing in the colder months. Particularly, the study delineates an enhanced correlation between heatwaves and admissions for severe psychiatric disorders, such as bipolar disorder, major depression, personality disorders, and schizophrenia, accounting for 1,868 of the cases examined. This correlation was most pronounced among individuals aged 50-59 years. CONCLUSIONS: The results of this study highlight a critical association between the incidence of seasonal heatwaves and an uptick in ED visits for psychiatric disorders, with a distinct impact on severe cases. It underscores the urgency for healthcare systems to anticipate seasonal fluctuations in psychiatric ED admissions and to allocate resources effectively to support patients during peak periods.

Lung ultrasound: are we diagnosing too much?

The clinical use of lung ultrasound (LUS) has made more efficient many diagnostic processes at bedside. The great power of LUS is a superior diagnostic sensitivity in many applications, when compared to chest radiography (CXR). The implementation of LUS in emergency is contributing to reveal a growing number of radio-occult pulmonary conditions. In some diseases, the superior sensitivity of LUS is a great advantage, like for pneumothorax and pulmonary edema. Diagnosing at bedside pneumothoraxes, pulmonary congestions, and COVID-19 pneumonia that are visible by LUS but undetected by CXR may be decisive for appropriate management, and even for saving lives. However, in other conditions, like bacterial pneumonia and small peripheral infarctions due to subsegmental pulmonary embolism, the high sensitivity of LUS does not always lead to advantages. Indeed, we doubt that it is always necessary to treat by antibiotics patients suspected of lower respiratory tract infection, who show radio-occult pulmonary consolidations, and to treat by anticoagulation patients with small subsegmental pulmonary embolism. The possibility that we are overtreating radio-occult conditions should be investigated with dedicated clinical trials.

Feasibility of a New Lung Ultrasound Protocol to Determine the Extent of Lung Injury in COVID-19 Pneumonia.

BACKGROUND: Lung ultrasound (LUS) scanning is useful to diagnose and assess the severity of pulmonary lesions during COVID-19-related ARDS (CoARDS). A conventional LUS score is proposed to measure the loss of aeration during CoARDS. However, this score was validated during the pre-COVID-19 era in patients with ARDS in the ICU and does not consider the differences with CoARDS. An alternative LUS method is based on grading the percentage of extension of the typical signs of COVID-19 pneumonia on the lung surface (LUSext). RESEARCH QUESTION: Is LUSext feasible in patients with COVID-19 at the onset of disease, and does it correlate with the volumetric measure of severity of COVID-19 pneumonia lesions at CT scan (CTvol)? STUDY DESIGN AND METHODS: This observational study enrolled a convenience sampling of patients in the ED with confirmed COVID-19 whose condition demonstrated pneumonia at bedside LUS and CT scan. LUSext was visually quantified. All CT scan studies were analyzed retrospectively by a specifically designed software to calculate the CTvol. The correlation between LUSext and CTvol, and the correlations of each score with Pao2/Fio2 ratio were calculated. RESULTS: We analyzed data from 179 patients. Feasibility of LUSext was 100%. Time to perform LUS scan was 5 ± 1.5 mins. LUSext and CTvol were correlated positively (R = 0.67; P < .0001). Both LUSext and CTvol showed negative correlation with Pao2/Fio2 ratio (R = -0.66 and R = -0.54; P < .0001, respectively). INTERPRETATION: LUSext is a valid measure of the severity of the lesions when compared with the CT scan. Not only are LUSext and CTvol correlated, but they also have similar inverse correlation with the severity of respiratory failure. LUSext is a practical and simple bedside measure of the severity of pneumonia in CoARDS, whose clinical and prognostic impact need to be investigated further.

Retrospective analysis of the diagnostic accuracy of lung ultrasound for pulmonary embolism in patients with and without pleuritic chest pain.

BACKGROUND: Lung ultrasound (LUS) has a role in the diagnosis of pulmonary embolism (PE) mainly based on the visualization of pulmonary infarctions. However, examining the whole chest to detect small peripheral infarctions by LUS may be challenging. Pleuritic pain, a frequent presenting symptom in patients with PE, is usually localized in a restricted chest area identified by the patient itself. Our hypothesis is that sensitivity of LUS for PE in patients with pleuritic chest pain may be higher due to the possibility of focusing the examination in the painful area. We combined data from three prospective studies on LUS in patients suspected of PE and extracted data regarding patients with and without pleuritic pain at presentation to compare the performances of LUS. RESULTS: Out of 872 patients suspected of PE, 217 (24.9%) presented with pleuritic pain and 279 patients (32%) were diagnosed with PE. Pooled sensitivity of LUS for PE in patients with and without pleuritic chest pain was 81.5% (95% CI 70-90.1%) and 49.5% (95% CI 42.7-56.4%) (p < 0.001), respectively. Specificity of LUS was similar in the two groups, respectively 95.4% (95% CI 90.7-98.1%) and 94.8% (95% CI 92.3-97.7%) (p = 0.86). In patients with pleuritic pain, a diagnostic strategy combining Wells score with LUS performed better both in terms of sensitivity (93%, 95% CI 80.9-98.5% vs 90.7%, 95% CI 77.9-97.4%) and negative predictive value (96.2%, 95% CI 89.6-98.7% vs 93.3%, 95% CI 84.4-97.3%). Efficiency of Wells score + LUS outperformed the conventional strategy based on Wells score + d-dimer (56.7%, 95% CI 48.5-65% vs 42.5%, 95% CI 34.3-51.2%, p = 0.02). CONCLUSIONS: In a population of patients suspected of PE, LUS showed better sensitivity for the diagnosis of PE when applied to the subgroup with pleuritic chest pain. In these patients, a diagnostic strategy based on Wells score and LUS performed better to exclude PE than the conventional strategy combining Wells score and d-dimer.

Epilepsy and syncope - A case report and narrative review of arrhythmias connected to temporal lobe epilepsy.

We present the case of a 28-years-old male presenting to the Emergency Department for relapsing episodes of "déjà vu" and syncope. After a diagnostic workup by a multidisciplinary team, the simultaneous EEG and ECG monitoring showed an asystole associated with EEG anomalies in right fronto-temporal region of the brain. The brain MRI revealed an ischemic lesion concordant with EEG anomalies. In the suspicion of an ictal asystole, we decided not to implant a permanent pacemaker as the first line therapy but started a targeted anti-epileptic therapy. No more syncopal episodes nor dysrhythmias occurred during recovery and almost two years follow-up.

Retrospective analysis of the application of CT scan in the emergency department to screen clinically asymptomatic COVID-19 before hospital admission.

BACKGROUND: The necessity to identify and isolate COVID-19 patients to avoid intrahospital cross infections is particularly felt as a challenge. Clinically occult SARS-CoV-2 infection among patients admitted to the hospital is always considered a risk during the pandemic. The aim of our study is to describe the application of CT scan to reveal unexpected COVID-19 in patients needing hospital admission. METHOD: In our emergency department, we prospectively enrolled adult patients needing hospital admission, without symptoms suspected of COVID-19, and showing negative reverse transcriptase-polymerase chain reaction (RT-PCR) swab test. CT scan was performed to diagnose clinically occult COVID-19 pneumonia. All the exams were read and discussed retrospectively by two expert radiologists and assigned to one of 4 exclusive diagnoses: typical (typCT), indeterminate (indCT), atypical (atyCT), negative (negCT). The clinical characteristics and final diagnoses were described and compared with the results of CT scans. RESULTS: From May 25 to August 18, 2020, we prospectively enrolled 197 patients. They showed 122 negCT, 52 atyCT, 22 indCT, and 1 typCT. Based on the CT imaging, the prevalence of suspected clinically occult COVID-19 pneumonia was 11.6% (23 patients). None had confirmation of SARS-CoV-2 infection after the hospital stay. Nineteen patients had negative serial RT-PCR while in 4 cases, the infection was excluded by clinical follow-up or appearance of positivity of RT-PCR after months. CONCLUSION: Our descriptive analysis confirms that CT scan cannot be considered a valid tool to screen clinically occult COVID-19, when the asymptomatic patients need hospitalization for other conditions. Application of personnel protections and distancing among patients remains the best strategies to limit the possibility of intrahospital cross-infections.

Are Lung Ultrasound Findings in COVID-19 Pneumonia Typical or Specific?

The application of point-of-care lung ultrasound (LUS) in the first diagnosis and management of Corona Virus Disease 2019 (COVID-19) has gained a great interest during a pandemic that is undermining even the most advanced health systems. LUS demonstrated high sensitivity in the visualization of the interstitial signs of the typical pneumonia complicating the infection. However, although this disease gives typical lung alterations, the same LUS signs observed in COVID-19 pneumonia can be detected in other common pulmonary conditions. While being non-specific when considered separately, the analysis of the distribution of the sonographic typical signs allows the assignment of 4 LUS patterns of probability for COVID-19 pneumonia when the whole chest is examined and attention is paid to the presence of other atypical signs. Moreover, the combination of LUS likelihood with the clinical phenotype at presentation increases the accuracy. This mini-review will analyze the LUS signs of COVID-19 pneumonia and how they can be combined in patterns of probability in the first approach to suspected cases.

Descriptive analysis of a comparison between lung ultrasound and chest radiography in patients suspected of COVID-19.

BACKGROUND: Lung ultrasound (LUS) and chest radiography (CXR) are the most used chest imaging tools in the early diagnosis of COVID-19 associated pneumonia. However, the relationship between LUS and CXR is not clearly defined. The aim of our study was to describe the comparison between LUS interpretation and CXR readings in the first approach to patients suspected of COVID-19. METHODS: In the time of the first COVID-19 pandemic surge, we prospectively evaluated adult patients presenting to an emergency department complaining of symptoms raising suspicion of COVID-19. Patients were studied by LUS and only those performing also CXR were analyzed. All the patients performed viral reverse transcriptase-polymerase chain reaction (RT-PCR). LUS studies were classified in 4 categories of probabilities, based on the presence of typical or alternative signs of COVID-19-associated interstitial pneumonia. Accordingly, the CXR readings were retrospectively adapted by 2 experts in 4 categories following the standard language that describes the computed tomography (CT) findings. Patients were divided in two groups, based on the agreement of the LUS and CXR categories. Results were also compared to RT-PCR and, when available, to CT studies. RESULTS: We analyzed 139 cases (55 women, mean age 59.1 ± 15.5 years old). The LUS vs CXR results disagreed in 60 (43.2%) cases. RT-PCR was positive in 88 (63.3%) cases. In 45 cases, a CT scan was also performed and only 4 disagreed with LUS interpretation versus 24 in the comparison between CT and CXR. In 18 cases, LUS detected signs of COVID-19 pneumonia (high and intermediate probabilities) while CXR reading was negative; in 14 of these cases, a CT scan or a RT-PCR-positive result confirmed the LUS interpretation. In 6 cases, LUS detected signs of alternative diagnoses to COVID-19 pneumonia while CXR was negative; in 4 of these cases, CT scan confirmed atypical findings. CONCLUSION: Our study demonstrated a strong disagreement between LUS interpretation and CXR reading in the early approach to patients suspected of COVID-19. Comparison with CT studies and RT-PCR results seems to confirm the superiority of LUS over a second retrospective reading of CXR.

Neuroendocrine immunity in patients with Alzheimer's disease: toward translational epigenetics.

The emerging domain of epigenetics in molecular medicine finds application for a variety of patient populations. Here, we present fundamental neuroendocrine immune evidence obtained in patients with senile dementia of the Alzheimer's type (sDAT), and discuss the implications of these data from the viewpoint of translational epigenetics of Alzheimer's disease. We followed 18 subjects with mild sDAT treated with acetylcholinesterase inhibitors, and 10 control subjects matched for age in a repeated measure design every six months for 18 months. We monitored psychosocial profile (Mini-Mental State Examination, Functional Assessment Staging, Independence in Activities of Daily Living, Depression, Profile of Moods States) in parallel to immunophenotypic parameters of T cell subpopulations by flow cytometry. Based on change in the mini-mental state score at entry and at 18 months, patients with sDAT were assigned to a "fast progression" (delta greater than 2 points) or to a "slow progression" group (delta less than or equal to 2 points). The change in circulating activated T cells (CD3+Dr+) with time in patients with sDAT was significantly inversely correlated with the change in time in natural killer (NK) cytotoxic activity to cortisol modulation in these patients, which was greater in patients with fast progression, compared to slow progression sDAT. These data indicate underlying neuroendocrine immune processes during progression of sDAT. Our observations suggest that psychoimmune measures such as those we have monitored in this study provide relevant information about the evolving physiological modulation in patients with sDAT during progression of Alzheimer's disease, and point to new or improved translational epigenetic treatment interventions.

Physiologic modulation of natural killer cell activity as an index of Alzheimer's disease progression.

Patients with Alzheimer's disease (AD) are characterized by an altered sensitivity to cortisol-mediated modulation of circulating lymphocytes. Longitudinal studies are needed to address the clinical applicability of these abnormalities as prognostic factors. Therefore, we designed a longitudinal study to address the clinical applicability of physiologic modulation of Natural Killer (NK) cell activity as a prognostic factor in AD. NK activity was assessed as baseline measurement and in response to modulation by cortisol at 10(-6)M. To verify the immunophysiological integrity of the NK cell population, we tested augmentation of NK cytotoxicity by human recombinant interleukin (IL)-2 (100 IU/ml) as control. The response to modulation by cortisol or by IL-2 was significantly greater in patients with AD. Based on change in the Mini-Mental State score at entry and at 18 months, patients with AD could be assigned to a "fast progression" (Delta > 2 points) or to a "slow progression" group (Delta