Diagnostic role of internal mammary lymph node involvement in tuberculous pleurisy: a multicenter study.

BACKGROUND AND OBJECTIVES: Diagnosis of tuberculous pleurisy (TP) may be challenging and it often requires pleural biopsy. A tool able to increase pre-test probability of TP may be helpful to guide diagnostic work-up and enlargement of internal mammary lymph node (IMLN) has been suggested to play a potential role. The aim of the present investigation was to assess role of IMLN involvement in TP in a multi-centric case-control study, by comparing its prevalence and test performance to those observed in patients with infectious, non-tuberculous pleurisy (NTIP), and in controls free from respiratory diseases (CP). METHODS: A total of 419 patients, from 14 Pulmonology Units across Italy were enrolled (127 patients affected by TP, 163 affected by NTIP and 129 CP). Prevalence, accuracy and predictive values of ipsilateral IMLN involvement between cases and control groups were assessed, as well as concordance between chest computed tomography (CT scan) and thoracic ultrasound (TUS) measurements. RESULTS: The prevalence of ipsilateral IMLN involvement in TP was significantly higher than that observed in NTIP and CP groups (respectively 77.2%, 39.3% and 14.7%). Results on test performance, stratified by age, revealed a high positive predictive value in patients aged ≤50 years, while a high negative predictive value in patients aged >50 years. The comparison between CT scan and ultrasound showed moderate agreement (Kappa=0.502). CONCLUSIONS: Evaluation of IMLN involvement plays a relevant role in assessing the pre-test probability of TP. Considering the increasing global prevalence of mycobacterial infections, a tool able to guide diagnostic work-up of suspected TP is crucial, especially where local sources are limited.

Evolving concepts and management of endoleaks after endovascular aneurysm repair: where do we stand in 2019?

In recent years, there has been tremendous progress in endovascular aneurysm repair (EVAR) techniques and devices. This process has seen a change in incidence, risk factors, and treatment of endoleaks as well as in follow-up protocols after EVAR. In particular, recent literature has highlighted new concepts in the evaluation and prevention/treatment of type I and II endoleak after standard EVAR. There is also recent evidence regarding new imaging protocols for follow-up after EVAR, which include magnetic resonance imaging and contrast-enhanced ultrasound. This comprehensive review aims to outline the most recent concepts on imaging follow-up, pathophysiology/risk factors, and management of endoleaks.

Immuno-oncology and interventional oncology: a winning combination. The latest scientific evidence.

OBJECTIVE: Interventional oncology (IO) is an emergent field in interventional radiology that can be considered the fourth pillar of oncology. Interventional oncology has the unique capability to treat malignancy in a loco-regional fashion enabling curative (percutaneous ablation), disease stabilization (intra-arterial chemo/radioembolization), and palliative treatment (such as biliary drainage or nephrostomy). The whole arsenal of IO acts by inducing necrosis and apoptosis, with interactions with the tumour's microenvironment potentially crucial for oncological outcomes. Considering that tumour's microenvironment is a pivotal target for both immuno-oncology and interventional-oncology, the interactions between these two anti-tumour weapons must be investigated to understand their synergy. Interestingly, substantial efforts have been directed to understand which technique combinations are best for specific tumours. This review article summarizes the latest scientific evidence highlighting the future prospective of this winning combination, integrating evidence-reported literature and experience-based perceptions.

Analysis of CT features and quantitative texture analysis in patients with lung adenocarcinoma: a correlation with EGFR mutations and survival rates.

AIM: To investigate the correlation between conventional computed tomography (CT) features, quantitative texture analysis (QTA), epidermal growth factor receptor (EGFR) mutations, and survival rates in patients with lung adenocarcinoma. MATERIALS AND METHODS: Sixty-eight patients were evaluated for conventional CT features and QTA in this retrospective study. A multiple logistic regression analysis and receiver operating characteristics (ROC) curve analysis versus death and EGFR status was performed for CT features and QTA in order to assess correlation between CT features, QTA, EGFR mutations, and survival rates. A p-value <0.05 was regarded to indicate a statistically significant association. RESULTS: An EGFR mutation was identified in 26/68 tumours (38.2%). A negative association was found between EGFR mutation and emphysema (p < 0.0001) whereas a positive correlation was found with necrosis (p=0.017), air bronchogram (p=0.0304), and locoregional infiltration (p=0.0018). Mean, standard deviation, and skewness were found to have significant correlation with EGFR mutation (p=0.0001; p=0.0001; p=0.0459; Fig 3). The only parameter correlated with the event death was entropy (r=0.2708; p=0.0329). CONCLUSION: Both qualitative and quantitative analysis disclosed potential associations between CT features and QTA parameters, EGFR mutations and prognosis; these correlations need to be confirmed in larger studies to be used as imaging biomarkers in the management of patients affected by lung adenocarcinoma.

MR appearance of parathyroid adenomas at 3 T in patients with primary hyperparathyroidism: what radiologists need to know for pre-operative localization.

OBJECTIVES: To identify frequent MRI features of parathyroid adenomas (PTAs) in patients with primary hyperparathyroidism (PHPT) using a fast protocol with a 3 T magnet. METHODS: Thirty-eight patients with PHPT underwent a 3 T-MR. All patients had positive US and Tc-99 sestamibi, for a total number of 46 PTAs. T2-weighted IDEAL-FSE and T1 IDEAL-sequences, before and after contrast, were performed. Five features of PTAs were recognised: hyperintensity, homogeneous or "marbled" appearance and elongated morphology on T2-sequences; cleavage plane from thyroid gland on T2-outphase; rapid enhancement in post-contrast T1. Image quality for T2-weighted IDEAL FSE and usefulness for IDEAL post-contrast T1-weighted and T2-outphase sequences were also graded. RESULTS: PTAs were hyperintense in T2-sequences in 44/46 (95.7%), "marbled" in 30/46 (65.2%) and elongated in 38/46 (82.6%) patients. Cleavage plane was observed in 36/46 (78.3%), and rapid enhancement in 20/46 (43.5%) patients. T2-sequences showed both excellent fat suppression and image quality (average scores of 3.2 and 3.1). T2-outphase images demonstrated to be quite useful (score 2.8), whereas, post-contrast T1 images showed a lower degree of utility (score 2.4). CONCLUSIONS: A fast protocol with 3.0-T MRI, recognising most common features of PTAs, may be used as a second-line method in the preoperative detection of PTAs. KEY POINTS: 3 T MRI protocol based on T2-weighted IDEAL FSE sequences was used. T2-hyperintensity and elongated morphology are common features of PTAs. 3 T MRI could be used in the preoperative detection of PTAs.

Emphysema: coiling up the lungs, trick or treat?

Lung volume reduction coil (LVRC) treatment is a minimally-invasive technique planned to achieve an improvement of exercise capacity and pulmonary function in subjects with advanced emphysema and hyperinflation. It has been proposed together with other bronchoscopic lung volume reduction approaches to reduce lung hyperinflation in emphysema as less invasive alternatives to LVRS and are currently under clinical investigation. Following the successful early experiences in previous pilot trials, recent studies allow further investigation into the feasibility, safety and efficacy of LVR coil treatment in a multi-center setting in a larger group of patients. According to this studies we can state that LVR coil treatment results in significant clinical improvements in patients with severe emphysema, in multicenter analysis, with a good safety profile and sustained results for up to 1 year. The literature on endobronchial coils continues to look promising with an acceptable safety profile, and positive long-term follow-up data are certainly more and more available. However, further well-designed, blinded, placebo (or sham) controlled trials, and even randomized trials against LVRS (lung volume reduction surgery), are needed before routine clinical use can be recommended. This is true not only for endobronchial coils, but also for the whole field of bronchoscopic lung volume reduction.

Evaluation of image quality, radiation dose and diagnostic performance of dual-energy CT datasets in patients with hepatocellular carcinoma.

AIM: To evaluate image quality and diagnostic accuracy of different dual-energy computed tomography (DECT) datasets for identification of hepatocellular carcinoma (HCC), assess the reliability of virtual unenhanced (VU) images in replacing standard unenhanced (SU) images, and quantify effective dose (ED) at different tube voltages. MATERIAL AND METHODS: Thirty cirrhotic patients underwent liver contrast-enhanced DECT. Two blinded observers retrospectively evaluated conventional unenhanced and VU images, 140 kVp/80 kVp/mixed tube potential arterial datasets and conventional portal-venous/late phases in consensus. Final diagnosis was based on pathological proof or imaging criteria. Image quality, ED, sensitivity, and specificity of arterial datasets were calculated. RESULTS: Thirty-eight HCC and 18 benign lesions were detected at 80 kVp, 33 HCC and 22 benign lesions were detected at 140 kVp, and 36 HCC and 20 benign lesions were detected at mixed tube potentials. Final diagnosis confirmed 37 HCC and 20 benign lesions. There was no significant difference in diagnostic confidence between 80 kVp, 140 kVp, and mixed tube potential arterial datasets (p>0.05). Image quality was adequate for all datasets, with increased quality at higher tube potential (80 versus 140 kVp, p=0.001; mixed versus 140 kVp, p=0.001; 80 kVp versus mixed, p=0.0024). Significant ED reduction was observed between 140 and 80 kVp datasets (p<0.001). CONCLUSIONS: The 140 kVp dataset provided higher image quality. The 80 kVp images were more sensitive in detecting HCC. VU images are adequate in replacing SU images. The ED of the 80 kVp dataset was significantly lower.

Emphysema: coiling up the lungs, trick or treat?

Lung volume reduction coil (LVRC) treatment is a minimally-invasive technique planned to achieve an improvement of exercise capacity and pulmonary function in subjects with advanced emphysema and hyperinflation. It has been proposed together with other bronchoscopic lung volume reduction approaches to reduce lung hyperinflation in emphysema as less invasive alternatives to LVRS and are currently under clinical investigation. Following the successful early experiences in previous pilot trials, recent studies allow further investigation into the feasibility, safety and efficacy of LVR coil treatment in a multi-center setting in a larger group of patients. According to this studies we can state that LVR coil treatment results in significant clinical improvements in patients with severe emphysema, in multicenter analysis, with a good safety profile and sustained results for up to 1 year. The literature on endobronchial coils continues to look promising with an acceptable safety profile, and positive long-term follow-up data are certainly more and more available. However, further well-designed, blinded, placebo (or sham) controlled trials, and even randomized trials against LVRS (lung volume reduction surgery), are needed before routine clinical use can be recommended. This is true not only for endobronchial coils, but also for the whole field of bronchoscopic lung volume reduction.

Perineal and pelvic aggressive angiomyxoma: spontaneous regression after hormonal replacement therapy withdrawal assessed by 3T magnetic resonance.

Aggressive angiomyxoma (AA) is a rare mesenchymal tumour which mainly arises in the soft tissue of the pelvis and perineum in women of reproductive age. AA usually shows an aggressive behaviour, with a high rate of incomplete surgical excision and post-surgical recurrence. Most cases of AA exhibit oestrogen and/or progesterone receptors; in these cases, maintenance of a hypo-oestrogenic state can be helpful in the medical management of this tumour. We describe a case of spontaneous reduction in size of an AA during a 6-month period of hormonal replacement therapy withdrawal, assessed by MRI using a 3T magnet.

Clinical applications of diaphragm ultrasound: moving forward.

Establishing the correct time of weaning from mechanical ventilation is a crucial issue in the clinical practice. The difficult process of weaning can be due to pathological conditions that result in an imbalance between respiratory-muscle strength and respiratory load. Recently it has been suggested that ultrasound measurements of diaphragm muscle thickening in inspiration during weaning could provide an estimation of extubation success. Bedside ultrasonography, particularly sonographic evaluation of the diaphragm by measuring the percentage variation of diaphragm thickness (tdi) between end-inspiration and end-expiration (Δtdi%), has become a valuable tool in the management of intensive care unit patients. This non-invasive, low-cost and fast to perform technique seems to predict with a good accuracy the extubation failure. Some limitations derive from the difficulty to determine the maximum (end inspiratory) and minimum (end expiratory) tdi observing a dynamic image in B-mode, in particular in non-collaborating patients. In addition, some dynamic situations causing extubation failure could not be predicted by an ultrasound measure performed at the beginning of the weaning trial. Nowadays the technique proposed remains a useful tool for helping the prediction of extubation failure. It would be useful in the future to set up multicentric studies with a standardised description of the procedure and serial measurements in different timing during the weaning trial. Furthermore, randomized controlled trials to evaluate the efficiency of Δtdi% versus other indexes in predicting extubation failure are needed.

Bronchial thermoplasty in severe asthma: food for thoughts.

Asthma is a complex inflammatory disorder of the airways characterized by airway hyper-responsiveness and variable, reversible, airflow obstruction. Bronchial thermoplasty (BT) is a new modality for treating asthma. It targets airway smooth muscles (ASM) by delivering a controlled specific amount of thermal energy (radiofrequency ablation) to the airway wall through a dedicated catheter. The use of bronchial thermoplasty has been widely discussed for its potential in the treatment of asthma, since it seems to be able to reduce the symptoms of asthma. The definitive study for BT (AIR2 trial) employed a randomized, double-blind, sham-controlled design and enrolled 288 subjects with severe persistent asthma from 30 US and international centers. The results of the AIR2 trial demonstrated clinically significant benefits of BT compared with the sham group at one year post-treatment, including an improvement in asthma-related quality of life, 32% reduction in severe exacerbations, 84% reduction in emergency department visits for asthma symptoms, and a 66% reduction in time lost from work/school/other daily activities because of asthma symptoms. Preclinical work showed that ASM is reduced after BT by at least 3 years after treatment. The recent article from the ARI2 trial study group analyses the long-term safety and effectiveness of BT in patients with severe persistent asthma and demonstrates the 5-year durability of the benefits of BT in the control of symptoms and safety. It supports the evidence that reduction in asthma attacks, ER visits, and hospitalizations for respiratory symptoms are maintained for at least 5 years. There is a pressing need to understand the underlying mechanism(s) of BT and how the delivered heat is translated into clinical benefit. This necessitates additional investigation to identify disease and patient characteristics that would enable accurate phenotyping of positive responders to avoid unnecessary procedures and risks.

Are benzodiazepines and opioids really safe in patients with severe COPD?

Breathlessness is a key symptom in chronic obstructive pulmonary disease (COPD) with prognostic implications on health status and survival. Since most conditions underlying chronic refractory breathlessness in COPD are not modifiable, the use of opioids and benzodiazepines has been proposed to relieve it. However, respiratory depression is a known adverse event of these drugs, and concerns have been raised on their use in patients with chronic respiratory failure. Despite safety-related concerns, benzodiazepines are frequently prescribed for a variety of reasons, including treatment of insomnia, depression and anxiety, as well as to relieve refractory dyspnea in patients with COPD. The key role of opioids in the end-of-life and in the management of dyspnea that is unresponsive to best-possible disease management is recognized. Moreover, the use of low dose opioids to treat dyspnea, discomfort or refusal for patient undergoing non-invasive ventilation is still debated. In the current review, we aim at discussing and analyzing recently published findings on the use of benzodiazepines and opioids in patients with COPD and at reviewing the literature on this topic. Recent observations favor the use of lower doses of opioids (≤30 mg oral morphine equivalents/day) for reduction of symptoms in those patients with severe COPD receiving long-term oxygen therapy. Low dose opioids are not associated with an increased risk of hospital admission or death in cohorts of COPD patients on long term oxygen therapy. On the contrary, benzodiazepines and opioids at higher doses might increase mortality.

Retirada de la cánula de traqueostomía. Revisión bibliográfica / Removal of the cannula from tracheostomy Review bibliographic

En la Unidad de Terapia Intensiva, la traqueostomía se utiliza en pacientes que requieren ventilación mecánica prolongada o en aquellos con mal manejo de las secreciones u obstrucción de la vía aérea. Una vez superado el proceso que obligó al procedimiento, se debe intentar el retiro de la cánula de traqueostomía. La decanulación de la traqueostomía debe considerarse un proceso que implica la evaluación de competencia de múltiples variables, y si bien no existen consensos ni protocolos que hayan demostrado ser útiles en el momento de realizar el proceso, consideramos necesario que el paciente esté liberado de la ventilación mecánica (salvo casos especiales), que tenga una vía aérea permeable y que logre un correcto manejo de sus secreciones bronquiales. Cada institución debe contar con un protocolo preciso y adecuado a su ambiente de trabajo. La decisión final debe tomarse de común acuerdo entre el equipo tratante.(AU)

Tracheostomy is commonly used in patients with prolonged mechanical ventilation in the intensive care units, and it is also indicated in those with poor management of secretions or airway obstruction. Once the process that generated the procedure is resolved, an attempt for removal of the tracheostomy tube should be made. The tracheostomy tube decannulation should be considered a process that involves the evaluation of competence of multiple variables, for example, the patient must be without mechanical ventilation requirement (except in special cases), with airway patency and with a correct bronchial secretions management. Each institution should have a precise protocol appropriate to their work environment. The final decision should be taken in agreement with all the health care team.(AU)

Incisional hernia surgery: report on 283 cases.

BACKGROUND AND OBJECTIVES: Despite the improvement of the surgical technique and several experiences reported in literature about prosthetic incisional hernioplasty, the prevalence rate of recurrence and of the classic complications has not changed over the years. We analyze our caseload, establishing some technical cornerstones in order to reduce their occurrence. PATIENTS AND METHODS: 283 patients underwent incisional hernioplasty in our Department of Surgery in the decade 1999-2008. They were retrospectively divided into four groups (A-D) according to the surgical technique adopted for a comparative analysis: A, 37 primary direct closure; B, 207 Rives-Stoppa procedures; C, 9 Chevrel procedures; D, 30 intraperitoneal repairs. The outcomes were considered in terms of postoperative surgical complications. RESULTS: In total, we observed 11 cases of hernia recurrence (3.9%), 13 cases of infections (4.6%), 7 cases of seroma/hematoma (2.4%) and one case of acute respiratory insufficiency. DISCUSSION: The Rives-Stoppa procedure is, among all those practised, the treatment of choice in incisional hernioplasty. Thanks to the introduction of some simple modifications to this technique and preventing the postoperative infections, we obtained excellent results in terms of recurrence rate (only 1 case on 207 patients, 0.48%) and morbidity.

Total fundoplication without division of the short gastric vessels: functional evaluation at one year and review of literature.

AIM: Gastro-esophageal reflux disease (GERD) has emerged as one of the most common diseases in modern civilization. We investigated functional evaluation after total fundoplication without division of short gastric vessels and review of literature. METHODS: From January 2007 to June 2008 43 patients with chronic gastroesophageal reflux underwent laparoscopic Nissen-Rossetti fundoplication, 7 were lost during the follow-up. Patients underwent endoscopy, 24 hours pH-Metry, preoperatively, 6 months and 12 months after surgery. Articles were sourced from PubMed and Medline, using the MeSH terms "gastroesophageal reflux disease" and "laparoscopic surgery" and "fundoplication technique". Selection of articles were based on peer review, journal, relevance and English language. RESULTS: Endoscopic findings revealed complete healing of esophagitis in all patients. Barrett esophagus was still present. Six patients reported persistence of symptoms but postoperative pH-metry and endoscopy showed the absence of reflux; two patients (5.5%) were still on PPI therapy at 12 months. Seven patients (19.4%) reported dysphagia for solid for at least three months. Re-admission for dysphagia was required for two (5.5%) and one patient underwent to endoscopic dilatation. At six and 12 months no dysphagia was reported. During the follow-up no gas-bloat syndrome was referred. The Johnsson and DeMeester's score reduction from six months to 12 months was statistically significant. Randomized and non-randomized studies seem to point out in a precise way that a division of short gastric vessels is unnecessary to perform a "short and floppy" placation. CONCLUSION: Nissen-Rossetti fundoplication is safe and effective for treatment of GERD, with minimal post-operative side effects.

Is contrast-enhanced US alternative to spiral CT in the assessment of treatment outcome of radiofrequency ablation in hepatocellular carcinoma?

PURPOSE: The present study was conducted to assess the efficacy of contrast-enhanced ultrasound with low mechanical index in evaluating the response of percutaneous radiofrequency ablation treatment of hepatocellular carcinoma by comparing it with 4-row spiral computed tomography. MATERIALS AND METHODS: 100 consecutive patients (65 men and 35 women; age range: 62 - 76 years) with solitary hepatocellular carcinomas (mean lesion diameter: 3.7 cm +/- 1.1 cm SD) underwent internally cooled radiofrequency ablation. Therapeutic response was evaluated at one month after the treatment with triple-phasic contrast-enhanced spiral CT and low-mechanical index contrast-enhanced ultrasound following bolus injection of 2.4 ml of Sonovue (Bracco, Milan). 60 out of 100 patients were followed up for another 3 months. Contrast-enhanced sonographic studies were reviewed by two blinded radiologists in consensus. Sensitivity, specificity, NPV and PPV of contrast-enhanced ultrasound examination were determined. RESULTS: After treatment, contrast-enhanced ultrasound identified persistent signal enhancement in 24 patients (24 %), whereas no intratumoral enhancement was detected in the remaining 76 patients (76 %). Using CT imaging as gold standard, the sensitivity, specificity, NPV, and PPV of contrast enhanced ultrasound were 92.3 % (95 % CI = 75.9 - 97.9 %), 100 % (95 % CI = 95.2 - 100 %), 97.4 % (95 % CI = 91.1 - 99.3 %), and 100 % (95 % CI = 86.2 - 100 %). CONCLUSION: Contrast-enhanced ultrasound with low mechanical index using Sonovue is a feasible tool in evaluating the response of hepatocellular carcinoma to radiofrequency ablation. Accuracy is comparable to 4-row spiral CT.