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.

Clinical research on point-of-care lung ultrasound: misconceptions and limitations.

Over the last 20 years, advances in point-of-care lung ultrasound (PoCLUS) have been consistent. The clinical application of PoCLUS has drastically changed the diagnosis of some respiratory conditions mainly in the acute setting. Despite these improvements, misconceptions regarding the current scientific evidence and errors in the direction given to the latest research are delaying the implementation of PoCLUS in the clinical field. The diagnostic power of PoCLUS is still under-evaluated in many settings and there is a generalized yet unjustified feeling that further evidence is needed before introducing PoCLUS as a standard of care. In the effort to build up further evidence by new studies, the role of randomized clinical trials is over-emphasized and gold standards used to investigate diagnostic accuracy of PoCLUS are sometimes not appropriate. Moreover, the sonographic patterns and techniques used to confirm the diagnoses not always are adapted to the patients' clinical condition, which limit the scientific value of those clinical studies. Finally, there is a recurrent confusion in the role of PoCLUS scoring techniques, which should be only applied to quantify and monitor injury severity and not to diagnose lung diseases. Awareness of these misconceptions and errors could help the researchers when approaching new study projects on PoCLUS.

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.

International consensus conference recommendations on ultrasound education for undergraduate medical students.

OBJECTIVES: The purpose of this study is to provide expert consensus recommendations to establish a global ultrasound curriculum for undergraduate medical students. METHODS: 64 multi-disciplinary ultrasound experts from 16 countries, 50 multi-disciplinary ultrasound consultants, and 21 medical students and residents contributed to these recommendations. A modified Delphi consensus method was used that included a systematic literature search, evaluation of the quality of literature by the GRADE system, and the RAND appropriateness method for panel judgment and consensus decisions. The process included four in-person international discussion sessions and two rounds of online voting. RESULTS: A total of 332 consensus conference statements in four curricular domains were considered: (1) curricular scope (4 statements), (2) curricular rationale (10 statements), (3) curricular characteristics (14 statements), and (4) curricular content (304 statements). Of these 332 statements, 145 were recommended, 126 were strongly recommended, and 61 were not recommended. Important aspects of an undergraduate ultrasound curriculum identified include curricular integration across the basic and clinical sciences and a competency and entrustable professional activity-based model. The curriculum should form the foundation of a life-long continuum of ultrasound education that prepares students for advanced training and patient care. In addition, the curriculum should complement and support the medical school curriculum as a whole with enhanced understanding of anatomy, physiology, pathophysiological processes and clinical practice without displacing other important undergraduate learning. The content of the curriculum should be appropriate for the medical student level of training, evidence and expert opinion based, and include ongoing collaborative research and development to ensure optimum educational value and patient care. CONCLUSIONS: The international consensus conference has provided the first comprehensive document of recommendations for a basic ultrasound curriculum. The document reflects the opinion of a diverse and representative group of international expert ultrasound practitioners, educators, and learners. These recommendations can standardize undergraduate medical student ultrasound education while serving as a basis for additional research in medical education and the application of ultrasound in clinical practice.

Lung ultrasound in blunt chest trauma: A clinical review.

INTRODUCTION: Bedside lung sonography is recognized as a reliable diagnostic modality in trauma settings due to its ability to detect alterations both in lung parenchyma and in pleural cavities. In severe blunt chest trauma, lung ultrasound can identify promptly life-threatening conditions which may need direct intervention, whereas in minor trauma, lung ultrasound contributes to detection of acute pathologies which are often initially radio-occult and helps in the selection of those patients that might need further investigation. TOPIC DESCRIPTION: We did a literature search on databases EMBASE, PubMed, SCOPUS and Google Scholar using the terms 'trauma', 'lung contusion', 'pneumothorax', 'hemothorax' and 'lung ultrasound'. The latest articles were reviewed and this article was written using the most current and validated information. DISCUSSION: Lung ultrasound is quite accurate in diagnosing pneumothorax by using a combination of four sonographic signs; absence of lung sliding, B-lines, lung pulse and presence of lung point. It provides a rapid diagnosis in hemodynamically unstable patients. Lung contusions and hemothorax can be diagnosed and assessed with lung ultrasound. Ultrasound is also very useful for evaluating rib and sternal fractures and for imaging the pericardium for effusion and tamponade. CONCLUSION: Bedside lung ultrasound can lead to rapid and accurate diagnosis of major life-threatening pathologies in blunt chest trauma patients.

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.

Specification and guideline for technical aspects and scanning parameter settings of neonatal lung ultrasound examination.

Lung ultrasound (LUS) is now widely used in the diagnosis and monitor of neonatal lung diseases. Nevertheless, in the published literatures, the LUS images may display a significant variation in technical execution, while scanning parameters may influence diagnostic accuracy. The inter- and intra-observer reliabilities of ultrasound exam have been extensively studied in general and in LUS. As expected, the reliability declines in the hands of novices when they perform the point-of-care ultrasound (POC US). Consequently, having appropriate guidelines regarding to technical aspects of neonatal LUS exam is very important especially because diagnosis is mainly based on interpretation of artifacts produced by the pleural line and the lungs. The present work aimed to create an instrument operation specification and parameter setting guidelines for neonatal LUS. Technical aspects and scanning parameter settings that allow for standardization in obtaining LUS images include (1) select a high-end equipment with high-frequency linear array transducer (12-14 MHz). (2) Choose preset suitable for lung examination or small organs. (3) Keep the probe perpendicular to the ribs or parallel to the intercostal space. (4) Set the scanning depth at 4-5 cm. (5) Set 1-2 focal zones and adjust them close to the pleural line. (6) Use fundamental frequency with speckle reduction 2-3 or similar techniques. (7) Turn off spatial compounding imaging. (8) Adjust the time-gain compensation to get uniform image from the near-to far-field.

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.

Quantitative Lung Ultrasound: Technical Aspects and Clinical Applications.

Lung ultrasound is increasingly used in emergency departments, medical wards, and critical care units-adult, pediatric, and neonatal. In vitro and in vivo studies show that the number and type of artifacts visualized change with lung density. This has led to the idea of a quantitative lung ultrasound approach, opening up new prospects for use not only as a diagnostic but also as a monitoring tool. Consequently, the multiple scoring systems proposed in the last few years have different technical approaches and specific clinical indications, adaptable for more or less time-dependent patients. However, multiple scoring systems may generate confusion among physicians aiming at introducing lung ultrasound in their clinical practice. This review describes the various lung ultrasound scoring systems and aims to clarify their use in different settings, focusing on technical aspects, validation with reference techniques, and clinical applications.

Feasibility, usability and acceptability of paediatric lung ultrasound among healthcare providers and caregivers for the diagnosis of childhood pneumonia in resource-constrained settings: a qualitative study.

OBJECTIVES: Paediatric pneumonia burden and mortality are highest in low-income and middle-income countries (LMIC). Paediatric lung ultrasound (LUS) has emerged as a promising diagnostic tool for pneumonia in LMIC. Despite a growing evidence base for LUS use in paediatric pneumonia diagnosis, little is known about its potential for successful implementation in LMIC. Our objectives were to evaluate the feasibility, usability and acceptability of LUS in the diagnosis of paediatric pneumonia. DESIGN: Prospective qualitative study using semistructured interviews SETTING: Two referral hospitals in Mozambique and Pakistan PARTICIPANTS: A total of 21 healthcare providers (HCPs) and 20 caregivers were enrolled. RESULTS: HCPs highlighted themes of limited resource availability for the feasibility of LUS implementation, including perceived high cost of equipment, maintenance demands, time constraints and limited trained staff. HCPs emphasised the importance of policymaker support and caregiver acceptance for long-term success. HCP perspectives of usability highlighted ease of use and integration into existing workflow. HCPs and caregivers had positive attitudes towards LUS with few exceptions. Both HCPs and caregivers emphasised the potential for rapid, improved diagnosis of paediatric respiratory conditions using LUS. CONCLUSIONS: This was the first study to evaluate HCP and caregiver perspectives of paediatric LUS through qualitative analysis. Critical components impacting feasibility, usability and acceptability of LUS for paediatric pneumonia diagnosis in LMIC were identified for initial deployment. Future research should explore LUS sustainability, with a particular focus on quality control, device maintenance and functionality and adoption of the new technology within the health system. This study highlights the need to engage both users and recipients of new technology early in order to adapt future interventions to the local context for successful implementation. TRIAL REGISTRATION NUMBER: NCT03187067.