Atraumatic Hepatic Laceration with Hemoperitoneum.

Introduction: A rare case of atraumatic liver laceration associated with hemoperitoneum is presented in a patient with amyloidosis who came to the hospital for abdominal pain. Case Presentation: The imaging findings reveal significant hepatomegaly with finely heterogeneous hepatic density and subcapsular hypo-dense streaks in segments VI and VII, likely representing lesions. Post-contrast enhancement shows a punctiform contrast medium extravasation within the subhepatic fluid collection, visible from the arterial phase and intensifying in subsequent study phases. Discussion: These imaging findings suggest an atraumatic hepatic laceration, a diagnosis confirmed by the presence of hemoperitoneum distributed bilaterally under the diaphragm, in the paracolic gutters, along the mesentery root, and predominantly in the peri-hepatic region. Conclusion: The detailed imaging analysis provided critical insights into the diagnosis and management of this rare clinical presentation.

Assessing 'no evidence of disease activity' status in patients with relapsing-remitting multiple sclerosis: a long-term follow-up.

Introduction: Multiple Sclerosis (MS) is a chronic inflammatory demyelinating disease of the CNS with an autoimmune pathogenesis. Over the years, numerous disease-modifying therapies (DMTs) have proven effective in disease control; to date, there is a need to identify a personalized treatment effective in ensuring disease-free status or no evidence of disease activity (NEDA). Objective: identify clinical, demographic and treatment approach characteristics that affect the maintenance of NEDA-3 and the occurrence of clinical relapses during a 6-years follow-up. Materials and method: a retrospective study was conducted on a cohort of MS patients followed up with six-year period. All participants were treated with first- or second-line MS drugs.Clinical relapse, NEDA-3 at 6 years and sustained EDSS were assessed as disease activity outcomes. Patients with follow-up of less than 6 years and insufficient clinical and radiological data were excluded from the study. Results: Two-hundred-eighty naive patients (mean age was 49.8 years, SD ± 11.35 years, 23-76, F/M 182/98), with MS were followed up for 6 years.The mean age at diagnosis was 34.3 years (SD ±11.5, 14-62 years), the mean EDSS score at the onset was 1.9 (±1.3), 76.8% of patients had an EDSS below or equal to 2.5 at diagnosis.In the cohort 37 (13.2%) directly received second-line treatment, 243 (86.8%) received first-line drugs.The analysis showed that second-line treatment from beginning had a protective effect for the achievement of NEDA-3 (p = 0.029), on the prevention of clinical relapse (p = 0.018) and on number of relapses (p = 0.010); this finding was confirmed by logistic regression analysis (p = 0.04) and Kaplan-Meier analysis (p = 0.034). Conclusion: The results of this study demonstrate the efficacy of targeted and early intervention so as to act in the right time window, ensuring a favorable outcome in both clinical and radiological terms; this could be decisive in reducing clinical relapse, disease progression and related disability. Therefore, prescribing highly effective drug in the early stages of the disease represents a leading strategy with the most favorable cost-benefit ratio.

Peritoneal Carcinosis: What the Radiologist Needs to Know.

Peritoneal carcinosis is a condition characterized by the spread of cancer cells to the peritoneum, which is the thin membrane that lines the abdominal cavity. It is a serious condition that can result from many different types of cancer, including ovarian, colon, stomach, pancreatic, and appendix cancer. The diagnosis and quantification of lesions in peritoneal carcinosis are critical in the management of patients with the condition, and imaging plays a central role in this process. Radiologists play a vital role in the multidisciplinary management of patients with peritoneal carcinosis. They need to have a thorough understanding of the pathophysiology of the condition, the underlying neoplasms, and the typical imaging findings. In addition, they need to be aware of the differential diagnoses and the advantages and disadvantages of the various imaging methods available. Imaging plays a central role in the diagnosis and quantification of lesions, and radiologists play a critical role in this process. Ultrasound, computed tomography, magnetic resonance, and PET/CT scans are used to diagnose peritoneal carcinosis. Each imaging procedure has advantages and disadvantages, and particular imaging techniques are recommended based on patient conditions. Our aim is to provide knowledge to radiologists regarding appropriate techniques, imaging findings, differential diagnoses, and treatment options. With the advent of AI in oncology, the future of precision medicine appears promising, and the interconnection between structured reporting and AI is likely to improve diagnostic accuracy and treatment outcomes for patients with peritoneal carcinosis.

Management of Non-Melanoma Skin Cancer: Radiologists Challenging and Risk Assessment.

Basal cell carcinoma, squamous cell carcinoma, and Merkel cell carcinoma are the three main types of nonmelanoma skin cancers and their rates of occurrence and mortality have been steadily rising over the past few decades. For radiologists, it is still difficult to treat patients with advanced nonmelanoma skin cancer. Nonmelanoma skin cancer patients would benefit greatly from an improved diagnostic imaging-based risk stratification and staging method that takes into account patient characteristics. The risk is especially elevated among those who previously received systemic treatment or phototherapy. Systemic treatments, including biologic therapies and methotrexate (MTX), are effective in managing immune-mediated diseases; however, they may increase susceptibility to NMSC due to immunosuppression or other factors. Risk stratification and staging tools are crucial in treatment planning and prognostic evaluation. PET/CT appears more sensitive and superior to CT and MRI for nodal and distant metastasis as well as in surveillance after surgery. The patient treatment response improved with advent and utilization of immunotherapy and different immune-specific criteria are established to standardized evaluation criteria of clinical trials but none of them have been utilized routinely with immunotherapy. The advent of immunotherapy has also arisen new critical issues for radiologists, such as atypical response pattern, pseudo-progression, as well as immune-related adverse events that require early identification to optimize and improve patient prognosis and management. It is important for radiologists to have knowledge of the radiologic features site of the tumor, clinical stage, histological subtype, and any high-risk features to assess immunotherapy treatment response and immune-related adverse events.

Role of Cardiac Biomarkers in Non-Small Cell Lung Cancer Patients.

Treatment-induced cardiac toxicity represents an important issue in non-small cell lung cancer (NSCLC) patients, and no biomarkers are currently available in clinical practice. A novel and easy-to-calculate marker is the quantitative analysis of calcium plaque in the coronary, calculated on CT. It is called the Agatston score (or CAD score). At the same time, other potential predictors include cardiac ultrasonography and anamnesis of the patients. Our work aimed to correlate cardiac biomarkers with overall survival (OS) in NSCLC patients. We retrospectively analyzed patients with NSCLC discussed in the Multidisciplinary Tumor Board of our Institute for the present analysis between January 2018 and July 2022. Inclusion criteria were the availability of basal CT imaging of the thorax, cardiac ultrasonography with the calculation of ejection fraction (EF), and complete anamnesis, including assessment of co-pathologies and pharmacological drugs. The clinical data of the patients were retrospectively collected, and the CAD scores was calculated on a CT scan. All of these parameters were correlated with overall survival (OS) with univariate analysis (Kaplan-Meier analysis) and multivariate analysis (Cox regression analysis). Following the above-mentioned inclusion criteria, 173 patients were included in the present analysis. Of those, 120 patients died in the follow-up period (69.6%), and the median overall survival (OS) was 28 months (mean 47.2 months, 95% CI, 36-57 months). In univariate analysis, several parameters that significantly correlated with lower OS were the stage (p < 0.001), the CAD grading (p < 0.001), history of ischemic heart disease (p: 0.034), use of beta blocker drugs (p: 0.036), and cardiac ejection fraction (p: 0.005). In multivariate analysis, the only parameters that remained significant were as follows: CAD score (p: 0.014, OR 1.56, 95% CI: 1.04-1.83), stage (p: 0.016, OR: 1.26, 95% CI: 1.05-1.53), and cardiac ejection fraction (p: 0.011, OR 0.46, 95% CI: 0.25-0.84). Both CAD score and ejection fraction are correlated with survival in NSCLC patients at all stages of the disease. Independently from the treatment choice, a cardiological evaluation is mandatory for patients with NSCLC.

Secondary Complications in COVID-19 Patients: A Case Series.

INTRODUCTION: Coronavirus SARS-CoV-2, the causative agent of COVID-19, primarily causes a respiratory tract infection that is not limited to respiratory distress syndrome, but it is also implicated in other body systems. Systemic complications were reported due to an exaggerated inflammatory response, which involves severe alveolar damage in the lungs and exacerbates the hypercoagulation that leads to venous thrombosis, ischemic attack, vascular dysfunction and infarction of visceral abdominal organs. Some complications are related to anticoagulant drugs that are administrated to stabilize hypercoagulability, but increase the risk of bleeding, hematoma and hemorrhage. The aim of this study is to report the diagnostic role of CT in the early diagnosis and management of patients with severe COVID-19 complications through the most interesting cases in our experience. MATERIAL AND METHODS: The retrospective analysis of patients studied for COVID-19 in our institution and hospitals, which are part of the university training network, was performed. CASES: Pneumomediastinum, cortical kidney necrosis, splenic infarction, cerebral ischemic stroke, thrombosis of the lower limb and hematomas are the most major complications that are reviewed in this study. CONCLUSIONS: Since the onset of the COVID-19 pandemic, the CT imaging modality with its high sensitivity and specificity remains the preferred imaging choice to diagnose early the different complications associated with COVID-19, such as thrombosis, ischemic stroke, infarction and pneumomediastinum, and their management, which significantly improved the outcomes.

Clinical literature on postoperative delirium and neurocognitive disorders: a historical systematic review.

BACKGROUND: Since the appearance of the first report on postoperative cognitive impairment in 1955, the number of papers focusing on perioperative neurocognitive disorders (PND) has constantly increased, both in the field of basic science and clinical research. A critical comprehensive review may explore the perception of how noteworthy PND is for physicians and clinical researchers. The aim of this systematic review is to describe how the clinical papers published to date with PND as primary or secondary outcome have changed over time in terms of editorial characteristics. RESULTS: A literature search was performed on PubMed, Embase, CINAHL, Cochrane, Scopus, and Web of Science databases, up to March 2021. Human prospective or retrospective clinical studies in which incidence, risk factors, treatments, or outcomes associated with PND are described among primary or secondary outcomes were included. A total of 2109 articles were considered. CONCLUSIONS: The bibliometric analysis suggests a stable increase in attention towards PND, particularly in general surgery adult-elderly patients, and underlines the importance for the clinicians not to underestimate this specific field.

Universal Access to Advanced Imaging and Healthcare Protection: UHC and Diagnostic Imaging.

Universal Health Coverage (UHC) is a set of principles adopted by the World Health Organization (WHO) aimed to guarantee access to primary care for the entire world population through a range of essential health services without neglecting the diagnostic aspect. Italy is one of the signatory states, which means that diagnostic services should be appropriated and exigible throughout the national territory equally. Our research analyzed and identified the main criticalities in terms of age, territorial distribution, and technological and health appropriateness of installed Computed Tomography (CT) needed to meet the principles of UHC. Data analyzed in our study were published by Assobiomedica at the end of 2016 and by COCIR, which included and investigated the installed fleet of diagnostic equipment in the Italian sanitary system and in various European countries. The 6th point of the Alma Ata Declaration defines the concept of "primary health care", which includes the importance of the diagnostic phase in the Italian health care system to provide Essential Levels of Assistance (LEA). It is clear from our studies that the technology at the national level is not adequate to satisfy the UHC principles or the European criteria, with negative effects on the diagnostic standards and on advanced screenings. This study conducted on the installed CTs in Italy at the end of 2016 confirms the persistence of progressive aging that has been recorded for several years in the health facilities of the country and suggests incentive policies for the replacement of obsolete equipment, which represent a form of investment rather than a cost, due to the nature of the expenditure itself, one-off and amortizable over time.

Usefulness of High-Frequency Ultrasonography in the Diagnosis of Melanoma: Mini Review.

High-frequency equipment is characterized by ultrasound probes with frequencies of over 10 MHz. At higher frequencies, the wavelength decreases, which determines a lower penetration of the ultrasound beam so as to offer a better evaluation of the surface structures. This explains the growing interest in ultrasound in dermatology. This review examines the state of the art of high-frequency ultrasound (HFUS) in the assessment of skin cancer to ensure the high clinical approach and provide the best standard of evidence on which to base clinical and policy decisions.

Personality Traits and Cardiotoxicity Arising From Cancer Treatments: An Hypothesized Relationship.

Thanks to the evolution in medical and pharmaceutical research, to date, the number of cancer treatments is increasingly on the rise. Despite this, several side effects related to cancer treatments can exacerbate patients' physical and psychological conditions, such as cardiotoxicity. Over the years, researchers have explored the possible relationship between psychological variables and physical diseases. Even though some authors examined the relationship between personality and specific diseases, no scientific attention has been paid to the role of personality in the development of cardiotoxicity arising from cancer treatments. Yet this is an important objective, given that determining whether personality influences cardiac toxicity of anticancer treatments could inform the processes by which stable psychological factors influence health. This contribution summarizes and analyzes the available scientific evidence about the association between personality and main cardiotoxicity-related-diseases of anticancer therapies, including cancer and cardiovascular diseases, in order to sketch a hypothetical model of the relationship between personality traits and cardiotoxicity.

Coronavirus Disease 2019 (COVID-19) in Italy: Double Reading of Chest CT Examination.

To assess the performance of the second reading of chest compute tomography (CT) examinations by expert radiologists in patients with discordance between the reverse transcription real-time fluorescence polymerase chain reaction (RT-PCR) test for COVID-19 viral pneumonia and the CT report. Three hundred and seventy-eight patients were included in this retrospective study (121 women and 257 men; 71 years median age, with a range of 29-93 years) and subjected to RT-PCR tests for suspicious COVID-19 infection. All patients were subjected to CT examination in order to evaluate the pulmonary disease involvement by COVID-19. CT images were reviewed first by two radiologists who identified COVID-19 typical CT patterns and then reanalyzed by another two radiologists using a CT structured report for COVID-19 diagnosis. Weighted к values were used to evaluate the inter-reader agreement. The median temporal window between RT-PCRs execution and CT scan was zero days with a range of (-9,11) days. The RT-PCR test was positive in 328/378 (86.8%). Discordance between RT-PCR and CT findings for viral pneumonia was revealed in 60 cases. The second reading changed the CT diagnosis in 16/60 (26.7%) cases contributing to an increase the concordance with the RT-PCR. Among these 60 cases, eight were false negative with positive RT-PCR, and 36 were false positive with negative RT-PCR. Sensitivity, specificity, positive predictive value and negative predictive value of CT were respectively of 97.3%, 53.8%, 89.0%, and 88.4%. Double reading of CT scans and expert second readers could increase the diagnostic confidence of radiological interpretation in COVID-19 patients.

MRI Radiomics in Prostate Cancer: A Reliability Study.

BACKGROUND: Radiomics can provide quantitative features from medical imaging that can be correlated to clinical endpoints. The challenges relevant to robustness of radiomics features have been analyzed by many researchers, as it seems to be influenced by acquisition and reconstruction protocols, as well as by the segmentation of the region of interest (ROI). Prostate cancer (PCa) represents a difficult playground for this technique, due to discrepancies in the identification of the cancer lesion and the heterogeneity of the acquisition protocols. The aim of this study was to investigate the reliability of radiomics in PCa magnetic resonance imaging (MRI). METHODS: A homogeneous cohort of patients with a PSA rise that underwent multiparametric MRI imaging of the prostate before biopsy was tested in this study. All the patients were acquired with the same MRI scanner, with a standardized protocol. The identification and the contouring of the region of interest (ROI) of an MRI suspicious cancer lesion were done by two radiologists with great experience in prostate cancer (>10 years). After the segmentation, the texture features were extracted with LIFEx. Texture features were then tested with intraclass coefficient correlation (ICC) analysis to analyze the reliability of the segmentation. RESULTS: Forty-four consecutive patients were included in the present analysis. In 26 patients (59.1%), the prostate biopsy confirmed the presence of prostate cancer, which was scored as Gleason 6 in 6 patients (13.6%), Gleason 3 + 4 in 8 patients (18.2%), and Gleason 4 + 3 in 12 patients (27.3%). The reliability analysis conversely showed poor reliability in the majority of the MRI acquisition (61% in T2, 89% in DWI50, 44% in DWI400, and 83% in DWI1,500), with ADC acquisition only showing better reliability (poor reliability in only 33% of the texture features). CONCLUSIONS: The low ratio of reliability in a monoinstitutional homogeneous cohort represents a significant alarm bell for the application of MRI radiomics in the field of prostate cancer. More work is needed in a clinical setting to further study the potential of MRI radiomics in prostate cancer.

Clinical and laboratory data, radiological structured report findings and quantitative evaluation of lung involvement on baseline chest CT in COVID-19 patients to predict prognosis.

OBJECTIVE: To evaluate by means of regression models the relationships between baseline clinical and laboratory data and lung involvement on baseline chest CT and to quantify the thoracic disease using an artificial intelligence tool and a visual scoring system to predict prognosis in patients with COVID-19 pneumonia. MATERIALS AND METHODS: This study included 103 (41 women and 62 men; 68.8 years of mean age-range, 29-93 years) with suspicious COVID-19 viral infection evaluated by reverse transcription real-time fluorescence polymerase chain reaction (RT-PCR) test. All patients underwent CT examinations at the time of admission in addition to clinical and laboratory findings recording. All chest CT examinations were reviewed using a structured report. Moreover, using an artificial intelligence tool we performed an automatic segmentation on CT images based on Hounsfield unit to calculate residual healthy lung parenchyma, ground-glass opacities (GGO), consolidations and emphysema volumes for both right and left lungs. Two expert radiologists, in consensus, attributed at the CT pulmonary disease involvement a severity score using a scale of 5 levels; the score was attributed for GGO and consolidation for each lung, and then, an overall radiological severity visual score was obtained summing the single score. Univariate and multivariate regression analysis was performed. RESULTS: Symptoms and comorbidities did not show differences statistically significant in terms of patient outcome. Instead, SpO2 was significantly lower in patients hospitalized in critical conditions or died while age, HS CRP, leukocyte count, neutrophils, LDH, d-dimer, troponin, creatinine and azotemia, ALT, AST and bilirubin values were significantly higher. GGO and consolidations were the main CT patterns (a variable combination of GGO and consolidations was found in 87.8% of patients). CT COVID-19 disease was prevalently bilateral (77.6%) with peripheral distribution (74.5%) and multiple lobes localizations (52.0%). Consolidation, emphysema and residual healthy lung parenchyma volumes showed statistically significant differences in the three groups of patients based on outcome (patients discharged at home, patients hospitalized in stable conditions and patient hospitalized in critical conditions or died) while GGO volume did not affect the patient's outcome. Moreover, the overall radiological severity visual score (cutoff ≥ 8) was a predictor of patient outcome. The highest value of R-squared (R2 = 0.93) was obtained by the model that combines clinical/laboratory findings at CT volumes. The highest accuracy was obtained by clinical/laboratory and CT findings model with a sensitivity, specificity and accuracy, respectively, of 88%, 78% and 81% to predict discharged/stable patients versus critical/died patients. CONCLUSION: In conclusion, both CT visual score and computerized software-based quantification of the consolidation, emphysema and residual healthy lung parenchyma on chest CT images were independent predictors of outcome in patients with COVID-19 pneumonia.

Exploring public attitude toward biofeedback technologies: Knowledge, preferences and personality tendencies.

Background: Biofeedback is increasingly used in the clinical area and in daily health monitoring through wearable devices (e.g. smart watches). Nevertheless, it remains rather unknown. This study aimed to assess, in a sample of Italian citizens, the level of knowledge, attitudes, perceived efficacy and personality tendencies which could affect the uptake of biofeedback technologies. Design and Methods: Participants were recruited by advertising the survey on the social networks, from March to May 2019. 160 subjects filled in an ad hoc online questionnaire assessing socio-demographic variables, clinical status, physical activity, knowledge and attitude towards biofeedback, psychological tendencies toward health. Results: Data showed a good level of interest in biofeedback training in spite of poor knowledge about such technologies. Sport and chronic diseases were not correlated to a greater use of biofeedback. People informed about biofeedback technologies were more interested in undergoing biofeedback training and had higher scores in the Health Locus of Control. Finally, people who showed a positive perception of their own health (Health Esteem) did not rely on these technologies. Discussion: Despite the huge spread of biofeedback technologies, our results disconfirmed the expectation that people having an active lifestyle or a disease were more familiar with biofeedback systems. The attitude toward such technologies seems to depend on individual tendencies. Conclusions: This study suggests the importance to improve general public literacy on biofeedback technologies, tailor tools on their needs and characteristics, empower people's sense of internal health control for promoting a valid use and a proper knowledge of biofeedback.

Extranodal Lymphomas: a pictorial review for CT and MRI classification.

Extranodal lymphomas represent an extranodal location of both non-Hodgkin and Hodgkin lymphomas. This study aims to evaluate the role of CT and MRI in the assessment of relationships of extranodal lymphomas with surrounding tissues and in the characterization of the lesion. We selected and reviewed ten recent studies among the most recent ones present in literature exclusively about CT and MRI imaging of extranodal lymphomas. Contrast-enhanced computed tomography (CT) is usually the first-line imaging modality in the evaluation of extranodal lymphomas, according to Lugano classification. However, MRI has a crucial role thanks to the superior soft-tissue contrast resolution, particularly in the anatomical region as head and neck.

Chest CT Computerized Aided Quantification of PNEUMONIA Lesions in COVID-19 Infection: A Comparison among Three Commercial Software.

PURPOSE: To compare different commercial software in the quantification of Pneumonia Lesions in COVID-19 infection and to stratify the patients based on the disease severity using on chest computed tomography (CT) images. MATERIALS AND METHODS: We retrospectively examined 162 patients with confirmed COVID-19 infection by reverse transcriptase-polymerase chain reaction (RT-PCR) test. All cases were evaluated separately by radiologists (visually) and by using three computer software programs: (1) Thoracic VCAR software, GE Healthcare, United States; (2) Myrian, Intrasense, France; (3) InferRead, InferVision Europe, Wiesbaden, Germany. The degree of lesions was visually scored by the radiologist using a score on 5 levels (none, mild, moderate, severe, and critic). The parameters obtained using the computer tools included healthy residual lung parenchyma, ground-glass opacity area, and consolidation volume. Intraclass coefficient (ICC), Spearman correlation analysis, and non-parametric tests were performed. RESULTS: Thoracic VCAR software was not able to perform volumes segmentation in 26/162 (16.0%) cases, Myrian software in 12/162 (7.4%) patients while InferRead software in 61/162 (37.7%) patients. A great variability (ICC ranged for 0.17 to 0.51) was detected among the quantitative measurements of the residual healthy lung parenchyma volume, GGO, and consolidations volumes calculated by different computer tools. The overall radiological severity score was moderately correlated with the residual healthy lung parenchyma volume obtained by ThoracicVCAR or Myrian software, with the GGO area obtained by the ThoracicVCAR tool and with consolidation volume obtained by Myrian software. Quantified volumes by InferRead software had a low correlation with the overall radiological severity score. CONCLUSIONS: Computer-aided pneumonia quantification could be an easy and feasible way to stratify COVID-19 cases according to severity; however, a great variability among quantitative measurements provided by computer tools should be considered.

Bond-Slip Behavior between Stainless Steel Rebars and Concrete.

Maintenance of reinforced concrete structures is a prevailing topic, especially with regard to lifeline structures and bridges, many of which are now designed with a service life beyond 100 years. Reinforcement made of ordinary (carbon) steel may corrode in aggressive environments. Stainless steel, being much more resistant to corrosion, is a valid solution to facilitate the protection of the works, increasing the service life and reducing the need for repair and maintenance. Despite the potential for stainless steel to reduce maintenance costs, studies investigating the influence of stainless steel on the behavior of reinforced concrete structures are limited. This study investigated the bond behavior of stainless steel rebars by means of experimental tests on reinforced concrete specimens with different concrete cover thicknesses, concrete strengths, and bar diameters. In each case, identical specimens with carbon steel reinforcement were tested for comparison. The failure modes of the specimens were examined, and a bond stress-slip relationship for stainless steel bars was established. This research shows that the bond behavior of stainless steel rebars is comparable to that of carbon steel bars.

Corticosteroid-related central nervous system side effects.

Corticosteroids have been used since the 50s as anti-inflammatory and immunosuppressive drugs for the treatment of several pathologies such as asthma, allergy, rheumatoid arthritis, and dermatological disorders. Corticosteroids have three principal mechanisms of action: 1) inhibit the synthesis of inflammatory proteins blocking NF-kB, 2) induce the expression of anti-inflammatory proteins by IkB and MAPK phosphatase I, and 3) inhibit 5-lipoxygenase and cyclooxygenase-2. The efficacy of glucocorticoids in alleviating inflammatory disorders results from the pleiotropic effects of the glucocorticoid receptors on multiple signaling pathways. However, they have adverse effects: Growth retardation in children, immunosuppression, hypertension, hyperglycemia, inhibition of wound repair, osteoporosis, metabolic disturbances, glaucoma, and cataracts. Less is known about psychiatric or side effects on central nervous system, as catatonia, decreased concentration, agitation, insomnia, and abnormal behaviors, which are also often underestimated in clinical practice. The aim of this review is to highlight the correlation between the administration of corticosteroids and CNS adverse effects, giving a useful guide for prescribers including a more careful assessment of risk factors and encourage the use of safer doses of this class of drugs.

Brugada syndrome (BS) and syncope: a complex therapeutic issue.

A 66 year-old man was brought to the emergency room (ER) for syncope and sphincter incontinence; syncope duration was about 15 min. Similar short duration episodes had been referred by his relatives during the last months, following small traumas; no seizures had been registered. Patient told he was affected with BS, having already been diagnosed 5 years before, after performing an electrocardiogram (ECG) highly suggestive for it. He had performed an electrophysiologic study, which had not shown any sustained ventricular arrhythmias after scheduled stimulation. This finding together to the lack of symptoms had suggested a conservative treatment, notwithstanding that familiar history documented his father's sudden death. Patient was also affected with hypertension and gastroesophageal reflux disease. Clinical examination did not suggest any significant findings. Laboratory tests, supra aortic Doppler ultrasound, electroencephalogram (EEG) and brain CT were normal. ECG showed sinus rhythm with a heart frequency of 82 bpm, QRS axis was normal, as well as atrioventricular conduction. ST coved-type elevation with right bundle branch block pattern and repolarization abnormalities were found. Holter ECG and Doppler echocardiography were also performed. The onset of syncope in presence of BS suggested the evaluation of this case report together with electrophysiolgists and neurologists. Therefore, an implantable cardioverter defibrillator (ICD) was implanted through left subclavian vein. He was discharged eight days after hospitalization, diagnosis was "Syncope in patient affected with BS, hypertension". Arrhythmogenic risk stratification is necessary; the indication for implanting this device is obvious in symptomatic patients, whereas it is controversial in patients presenting only ECG patterns of BS. In conclusion, the above mentioned case report rises remarkable diagnostic and therapeutic issues. The finding of BS in a patient with syncope indicates the opportunity of implanting a defibrillator and only clinical experience and common opinions may help doctors in taking the most appropriated, often difficult, decisions.