Lung and ultrasound: time to "reflect".

BACKGROUND: Literature concerning lung ultrasonography is largely growing and opening new diagnostic opportunities. The clinical value of the ultrasonographic interstitio-alveolar syndrome, based on artifactual (lung comets or B-lines) rather than real images, in the detection of lung contusion, pneumonia and pulmonary edema, is clearly demonstrated. As clinical echographists, though, we are living the paradox of relying our experience in lung pathology on images whose biophysical and genetic nature is not fully understood. OBJECTIVE AND PERSPECTIVES: A detailed review of the ultimate findings with an analysis of recent and past literature regarding the formation of ultrasonographic artifacts was undertaken with the aim of clarifying what we know and where we are heading in this field. It is important for us to underline how lung ultrasonography is not morphological, as this, along with the study of artifact formation, will be the base for the development of a novel 'view' able to take us from artifact to reality in terms of 'quantification' of lung disease and damage. CONCLUSIONS: Lung ultrasonographic artifacts need to be read in a new light which will privilege biophysical knowledge and research. In this field a gap of basic knowledge clearly exists. A greater understanding of the formation of acoustic artifacts from ultrasound interference on discretely aerated tissues of variable density, would place the practice of lung "ultrasonography" in the correct technological and clinical position.

Physical Mechanisms Providing Clinical Information From Ultrasound Lung Images: Hypotheses and Early Confirmations.

In standard B mode imaging, a set of ultrasound pulses is used to reconstruct a 2-D image even though some of the assumptions needed to do this are not fully satisfied. For this reason, ultrasound medical images show numerous artifacts which physicians recognize and evaluate as part of their diagnosis since even one artifact can provide clinical information. Understanding the physical mechanisms at the basis of the formation of an artifact is important to identify the physiopathological state of the biological medium which generated the artifact. Ultrasound lung images are a significant example of this challenge since everything that is represented beyond the thickness of the chest wall ( ≈ 2 cm) is artifactual information. A convincing physical explanation of the genesis of important ultrasound lung artifacts does not exist yet. Physicians simply base their diagnosis on a correlation observed over the years between the manifestation of some artifacts and the occurrence of particular lung pathologies. In this article, a plausible genesis of some important lung artifacts is suggested.

Ultrasound lung comets for the differential diagnosis of acute cardiogenic dyspnoea: a comparison with natriuretic peptides.

BACKGROUND: Acute dyspnoea as a presenting symptom is a frequent diagnostic challenge for physicians. The main differential diagnosis is between dyspnoea of cardiac and non-cardiac origin. Natriuretic peptides have been shown to be useful in this setting. Ultrasound lung comets (ULCs) are a simple, echographic method which can be used to assess pulmonary congestion. AIM: To evaluate the accuracy of ULCs for predicting dyspnoea of cardiac origin compared to natriuretic peptides. METHODS: We evaluated 149 patients admitted with acute dyspnoea. Chest sonography and NT-proBNP assessments were performed a maximum of 4 h apart and independently analyzed. ULCs were evaluated via cardiac probes placed on the anterior and lateral chest. Two independent physicians, blinded to ULCs and NT-proBNP findings, reviewed all the medical records to establish the aetiologic diagnosis of dyspnoea. RESULTS: Cardiogenic dyspnoea was confirmed in 122 patients and ruled-out in 27 patients. The number of ULCs was significantly correlated to NT-proBNP values (r=.69, p<.0001). Receiver operating characteristic analysis, showed an area under the curve of .893 for ULCs and .978 (p=.001) for NT-proBNP, in predicting the cardiac origin of dyspnoea. CONCLUSIONS: In patients admitted with acute dyspnoea, pulmonary congestion, sonographically imaged as ULCs, is significantly correlated to NT-proBNP values. The accuracy of ULCs in predicting the cardiac origin of dyspnoea is high.

Effects of spontaneous chronic hypoglycemia on central and peripheral nervous system in insulinoma patients before and after surgery: a neurophysiological follow-up.

To investigate the effects of spontaneous chronic hypoglycemia on the peripheral and central nervous system, a multimodal neurophysiological evaluation [median somatosensory (mSEP), brain stem auditory (BAEP), and visual (VEP) evoked potentials recordings] was performed in seven insulinoma patients before and 3 and 6 months after surgical removal of tumor. Before surgery, mSEP findings showed abnormal reduction in peripheral wrist-Erb conduction velocity in three patients as well as a pathological increase in Erb-N13, N13-N20, and Erb-N20 conduction times in five cases. BAEP and VEP recordings gave pathological results in two patients. Moreover, during hypoglycemia, the III-V and I-V interpeak latencies of BAEPs were significantly prolonged (P < 0.01 and P < 0.005, respectively) compared to recordings in euglycemia. After 6 months, a mSEP recovery, even if partial was noted in four patients, BAEPs were normalized in one case, and VEPs were unmodified. Compared to presurgery data, these recordings showed a significant (P < 0.05), but incomplete, shortening of BAEPs (III-V and I-V interpeak latencies) and mSEPs (Erb-N13 and Erb-N20 conduction times). Our findings demonstrate that multiple and selective neurophysiological abnormalities are present in insulinoma patients, confirm that hypoglycemia impairs suddenly brain stem function, and show that after tumor removal, long recovery times for improvement of some neurophysiological anomalies are requested.

Partial purification of lymphoblasts after in vitro immunization increases the yield in Ig-producing hybridomas.

Using in vitro immunization with a human plasma protein (apolipoprotein-A1) as antigen, we have shown that it is possible to prepare more monoclonal antibodies using a ten-fold lower concentration of antigen compared to in vivo immunization procedures (Weech et al., 1985). In addition, we can increase the number of Ig-producing hybridomas after in vitro immunization by a simple one-step separation of the lymphoblasts on a Percoll gradient before the fusion procedure. In order to apply this procedure to in vivo immunization techniques, it is necessary to expand the B-blast/plasma cell population by culturing the spleen cells for 4-6 days before fusion. Only antibodies of the IgM class were produced with the in vitro technique. However, by combining in vivo priming with in vitro immunization, it is possible to produce specific antibodies to both IgG and IgM classes.

Effect of volumetric mixtures of peritoneal and follicular fluid from the same woman on sperm motility and acrosomal reactivity in vitro.

OBJECTIVE: To study the effect of peritoneal (PF) and follicular fluids (FF from the same woman) as well as of given volumetric combinations thereof on sperm motility and acrosomal reactivity. DESIGN: Prospective. Peritoneal fluid and FF were incubated separately or in given volumetric combinations (PF/FF = 100/0, 75/25, 50/50, 25/75, 0/100; vol/vol) with swim-up sperm suspensions. SETTING: In vitro fertilization and general infertility clinic and laboratories. PATIENTS, PARTICIPANTS: Women participants of the gamete intrafallopian transfer program (motility study, n = 20; acrosomal reaction study, n = 14). Sperm donors of the artificial insemination program and men with given sperm parameters. INTERVENTIONS: Hormonal stimulation. Laparoscopy. MAIN OUTCOME MEASURES: Progressive velocity and percentage of motile gametes measured with multiple-exposure photography. Acrosomal reactivity measured by an immunofluorescent technique. RESULTS: Follicular fluid always influenced progressive motility and also sustained the number of motile gametes, as function of time, better than PF or the PF/FF mixtures (P less than 0.05). The acrosomal reactivity of sperm incubated in the various PF/FF combinations was low; after 5 hours only the FF-sperm suspensions showed a significant enhancement of acrosomally reacted gametes. CONCLUSION: At ovulation, FF transmit positive (motility- and acrosomal reactivity-enhancing) signals to sperm, whereas PF may transmit positive, neutral, or negative signals (noise signals). The volumetric combination of FF and PF in the tubal environment, which may differ from cycle to cycle and from woman to woman, could therefore result in synergic (or antagonistic) effects on the sperm fertility potential.

Effect of peritoneal fluid on sperm motility and velocity distribution using objective measurements.

The aim of this study was to analyze in vitro the effect(s) of peritoneal fluid (PF) on sperm motility. Seventy PFs obtained during laparoscopy were tested on motile-rich sperm suspensions. Proportion of motile sperm and velocity distribution were evaluated by multiple-exposure photography technique. At time (t) = 0, PFs increased both sperm parameters as compared with control (P less than 0.01). Maximum effect was observed at t = 5 hours: 32 (45%) PFs increased and 5 (7%) decreased the proportion of motile sperm, while 8 (11%) PFs increased and 4 (6%) decreased sperm velocity. No correlation was found between a particular infertile group and a definite negative effect. However, 70% of PFs from fertile women maintained or increased the proportion of motile sperm at t = 5 hours, compared with 36% in the total infertile group. Comparison of the sperm motility effect(s) of a given PF on different ejaculates revealed that the effects observed also were influenced by the sperm sample tested. In conclusion, PFs can maintain or increase the motility of spermatozoa as function of time. However, some PFs can inhibit sperm motility and these effect(s) can be influenced by the sperm sample.

Preprogramming and control activity of bimanual self-paced motor task in Parkinson's disease.

OBJECTIVE: The authors investigated programming (Bereitschaftspotential or BP) and control activity (Skilled Performance Positivity or SPP) of a bimanual, sequential, skilled motor act in off-therapy Parkinson's disease (PD) patients. METHODS: We recorded Movement Related Potentials (MRPs) in 12, non-demented, off-therapy parkinsonian patients and in 17 control subjects who were performing a skilled, time-locked motor act, which was not routine in their everyday life but had to be learned: the Skilled Performance Task (SPT). BP, SPP and correct performances were evaluated in grand average waveforms and in sequential blocks. RESULTS: The analysis of correct performances showed that accuracy in PD patients was significantly lower than in the control group and this accuracy did not improve throughout the blocks. A significantly low level of performances was associated with an increased BP amplitude (P<0.05) and decreased SPP amplitude (P<0.05) in PD patients. CONCLUSION: Our findings suggest that skill motor learning is impaired in non-demented unmedicated PD patients. We discuss the view that PD patients may allocate more attentional resources, as suggested by the increased BP amplitude, the decreased SPP amplitude and the low correct performances, in order to perform a new skilled motor act.

Homocysteine, vitamins and gene mutations in peripheral arterial disease.

A case-control study was undertaken involving 51 consecutive patients with peripheral artery obstructive disease (PAOD) scheduled for angioplasty. Blood samples of these patients were analysed for plasma homocysteine (tHcy) and levels of vitamin B12 and folate, and the MTHFR gene was assessed for mutation. Patients were compared with age- and sex-matched controls who did not present with cardiovascular risk factors. Mean tHcy did not differ between cases and controls (13.3 +/- 5.7 and 12.6 +/- 4.9 micromol/l, P = 0.49). More patients were above the 95th percentile as determined from the data in the control group with an odds ratio (OR) that almost reached statistical significance [OR, 2.8; 95% confidence interval (CI), 0.9-8.7], but on separate analyses only female patients showed higher tHcy than female controls (15.6 versus 12.0 micromol/l, P = 0.05), with an odds ratio for tHcy above the 95th percentile of 10.5 (95% CI, 1.1-96.6). The TT genotype of the MTHFR gene was found in 24% of the patients and in 12% of the controls (OR, 2.3; 95% CI, 0.8-6.7). Our findings point to a modest association between tHcy and PAOD, with a difference between cases and controls restricted to the highest percentile in female patients. A weak but not significant association was also found for the TT genotype of the MTHFR gene.

New compounds: addition products of heterocyclic chalcones.

Michael-type adducts, 1,3-heterocyclic-3-mercaptopropan-1-ones, were prepared by the base-catalyzed reaction of heterocyclic chalcones with thiols. These new compounds were found to be active as fungicides.

Synthesis of anticholinergic agents: N-methyl-4-piperidinyl alpha-benzoyloxy-alpha-cyclopentylphenylacetate salts.

The synthesis of a new anticholinergic agent, N-methyl-4-piperidinyl alpha-benzoyloxy-alpha-cyclopentylphenylacetate, obtained by reacting N-methyl-4-piperidinyl alpha-cyclopentylmandelate with benzoyl chloride in the presence of methyllithium, is reported. This material may be useful as an antiperspirant.

Electrophysiological study (VEP, BAEP) in HIV-1 seropositive patients with and without AIDS.

One hundred-twenty nine HIV-1 seropositive patients (39 females, 90 males) were studied by means of pattern visual evoked potential (VEP) and brainstem auditory evoked potential (BAEP) recording. Utilizing the criteria of the Centers for Disease Control the patients were clinically defined and then subdivided into four groups: group A included patients of category II (n:11); group B patients of category III (n:29); group C patients of category IVa and IVc2 (n:55) and group D patients belonging to the other subgroups of category IV (n:34). EP were altered in 26.35% of the entire group with a marked prevalence of BAEP alterations (21.7%) rather than of VEP (4.65%). A considerable amount of BAEP abnormalities (24.13%) were found in patients with persistent generalized lymphadenopathy (group B). A significant increase of BAEP mean interpeak latencies were observed in group B, C, D patients when compared with those of the control group. On the whole, EP were altered in 20.65% of the neurologically asymptomatic patients. EP alterations may precede any clinical manifestation and can be found during the earlier phases of HIV-1 infection.

Clinical and pathological characterisation of primary pulmonary hypertension in a dog.

Primary pulmonary hypertension was diagnosed in an eight-year-old labrador retriever on the basis of echocardiographic findings of severe right ventricular eccentric hypertrophy, abnormally high systolic and diastolic pulmonary arterial pressures calculated by applying the modified Bernoulli equation to the tricuspid and pulmonary insufficiency peak velocities, and the absence of any underlying disease known to cause secondary pulmonary hypertension. The clinical abnormalities developed gradually, from exercise intolerance starting early in life to terminal right-sided congestive heart failure. Consistent histopathological findings were severe intimal and medial thickening of small arteries and arterioles that led to vascular obliteration.

[Boerhaave syndrome. A case report and review of the literature]. / La sindrome di Boerhaave. Descrizione di un caso e revisione della Letteratura.

Spontaneous esophageal perforation (Boerhaave's syndrome) remains a difficult diagnostic and management problem with controversial recommendations regarding its treatment. The clinical manifestations of the disease are variable, and may be misleading, thus delaying accurate recognition. On the other hand, in view of the rapid onset of severe complications, particularly mediastinitis, a prompt diagnosis is essential to a better prognosis, successful operative outcome and potential survival. A case of spontaneous perforation of the thoracic esophagus penetrating the left pleural space treated within 4 hours from admission to the Emergency Room, with minimal surgical intervention is presented. Despite negative chest X-ray, a thoracic TC showed a small right sided effusion with left sided hydropneumothorax, and the definitive diagnosis was obtained by contrast study with a water soluble medium which showed the leak communicating freely with the left pleural space. The patient underwent repair by thoracic approach, the rupture was closed with a primary suture without flap reinforcement and the pleural space drained with the placement of single chest thoracostomy tube. The recovery was uneventful. The analysis of this case report and of the appropriate literature reveals that a poor prognosis is correlated with the time elapsed between the perforation and treatment. In conclusion the importance of an early aggressive surgical treatment for the Boerhaave's syndrome is emphasized, because any perforation treated more than 24 hours after the onset of symptoms, irrespective of the procedure used, is associated with a significantly higher morbility and mortality.