The role of point-of-care ultrasound in the management of neonates with congenital diaphragmatic hernia.

In the last few years, current evidence has supported the use of point-of-care ultrasound (POCUS) for a number of diagnostic and procedural applications. Considering the valuable information that POCUS can give, we propose a standardized protocol for the management of neonates with a congenital diaphragmatic hernia (CDH-POCUS protocol) in the neonatal intensive care unit. Indeed, POCUS could be a valid tool for the neonatologist through the evaluation of 1) cardiac function and pulmonary hypertension; 2) lung volumes, postoperative pleural effusion or pneumothorax; 3) splanchnic and renal perfusion, malrotations, and/or signs of necrotizing enterocolitis; 4) cerebral perfusion and eventual brain lesions that could contribute to neurodevelopmental impairment. In this article, we discuss the state-of-the-art in neonatal POCUS for which concerns congenital diaphragmatic hernia (CDH), and we provide suggestions to improve its use. IMPACT: This review shows how point-of-care ultrasound (POCUS) could be a valid tool for managing neonates with congenital diaphragmatic hernia (CDH) after birth. Our manuscript underscores the importance of standardized protocols in neonates with CDH. Beyond the well-known role of echocardiography, ultrasound of lungs, splanchnic organs, and brain can be useful. The use of POCUS should be encouraged to improve ventilation strategies, systemic perfusion, and enteral feeding, and to intercept any early signs related to future neurodevelopmental impairment.

Aggregatibacter actinomycetemcomitans infection in a 15-year-old boy with pulmonary empyema: a case report and review of literature.

BACKGROUND: Aggregatibacter actinomycetemcomitans (Aa), previously known as Actinobacillus actinomycetemcomitans, is a slow-growing Gram-negative coccobacillus, member of the HACEK group of bacteria colonizing oral flora. Besides causing infectious diseases in the oral cavity such as dental caries and periodontitis, it is responsible for severe extra-oral infections secondary to hematogenous spread or aspiration, such as endocarditis, soft tissue abscesses and osteomyelitis. The diagnosis depends on prolonged bacterial culture of biological material obtained through biopsy. Aa is susceptible to most antibiotics but complete eradication often requires a long term treatment. CASE PRESENTATION: We report the case of a 15-year-old previously healthy boy diagnosed with both pulmonary empyema and subphrenic chest wall abscess caused by Aa. He was admitted to our Pediatric Emergency department for evaluation of a right mass associated with marked asthenia and dry cough. After radiological findings etiological diagnosis was made by culture of fluid drainage of pleural empyema. He started empirical antibiotic therapy with intravenous piperacillin/tazobactam, whose sensibility was confirmed by the antibiogram, then, for occurrance of hepatopathy it was switched to ciprofloxacin: the patient almost completely recovered after 6-month therapy. CONCLUSIONS: Extra-oral infections caused by Aa are extremely rare, especially in children, and not well described yet. To our knowledge, there is only another similar case described in literature. However, the case described in our manuscript represents the only one presenting with pulmonary empyema without involvement of lung parenchyma in children. We also conducted a brief review of published cases of Aa infection in the pediatric population. This case report reminds us the importance of an accurate inspection of the oral cavity during the examination of pediatric patients.

Long-term survival and phenotypic spectrum in heterotaxy syndrome: A 25-year follow-up experience.

BACKGROUND: Heterotaxy syndrome (HS) is a group of congenital disorders characterized by abnormal arrangement of thoraco-abdominal organs across the left-right axis of the body, classified as right (RAI) and left atrial isomerism (LAI)·We investigated the long-term survival and phenotypic spectrum in our HS cohort. Results are compared to literature data. METHODS: This is a single centre, observational, both retro and prospective study. Cardiac features, surgical management and abdominal ultrasound (US) of all HS patients were reviewed or investigated if missing. We evaluated all anatomical data and their clinical impact on survival, arrhythmias, infections, and heart transplant (HT). RESULTS: 136 patients were classified as RAI (81) and LAI (55). Long-term survival and freedom from HT reached 69.8% and 87.8% at 40 years in RAI and LAI, respectively. Multivariate analysis showed that LAI is an independent predictor for pacemaker implantation (p = 0.019). Splenic status varied in both groups: in RAI, abdominal US showed asplenia, polysplenia and normal spleen in 48%, 4% and 32% of patients, respectively, whereas in LAI polysplenia, asplenia and normal spleen occurred in 64%, 4% and 16% of cases, respectively. CONCLUSIONS: Mortality was significantly lower (9%) compared to literature (50%). Although patients with RAI experienced a higher mortality, no independent predictors were found. We demonstrated that the obsolete cardiac definition of "asplenia" and "polysplenia" instead of RAI and LAI is misleading, because of the high variability of the splenic phenotype among patients of both groups.

Radiological patterns of childhood thoracic tuberculosis in a developed country: a single institution's experience on 217/255 cases.

The incidence of tuberculosis is increasing in the developed world and children in particular represent a high-risk group for developing the disease. The aim of this review is to analyse the spectrum of radiological signs as reported in the recent literature, in light of our series over a 15-year period, to pinpoint the most common radiological patterns in a developed country and to determine the role played by the different chest imaging techniques in diagnosis improvement. Lung TB was present in 217 out of 255 patients (85 %): 146 patients were under 5 years of age (76 under 2 years) and 71 over 5 years (41 over 10 years). We describe different patterns differentiating adolescents and young adults from infants and children. Adolescents and young adult tuberculosis are apical and cavitary. Thoracic TB in infants and children is characterized by lymph node and parenchymal disease. In 21 cases with lymphadenopathies without lymph-bronchial diffusion (age range 2 months-7 years), CT identified the Ghon focus in 16/21 cases; chest X-ray never identified the Ghon focus. In our series, pleural TB was present in 8 cases out of 146 under 5 years of age, 5 cases out of 76 under 2 years, and 18 cases out of 71 over 5 years. Radiologists should be aware of typical patterns of tuberculosis, to provide an early diagnosis.

Wandering spleen in children: a report of 3 cases and a brief literature review underlining the importance of diagnostic imaging.

BACKGROUND: Wandering spleen is a rare condition in children that is often caused by loss or weakening of the splenic ligaments. Its clinical presentation is variable; 64% of children with wandering spleen have splenic torsion as a complication. OBJECTIVE: To provide up-to-date information on the diagnosis, clinical management and diagnostic imaging approaches for wandering spleen in infants and children and to underline the importance of color Doppler US and CT in providing important information for patient management. MATERIALS AND METHODS: We report a series of three children with wandering spleen treated at our children's hospital over the last 6 years. All three underwent clinical evaluation, color Doppler US and CT and were surgically treated. We also reviewed 40 articles that included 55 patients younger than 18 years reported in the Medline database from 2002 to 2012. RESULTS: We correlated pathological data with imaging findings. Color Doppler US, the first imaging modality in investigating abdominal symptoms in children with suspected wandering spleen, yielded a diagnostic sensitivity of 54.9%, whereas CT achieved about 71.7%. CONCLUSION: Radiologic evaluation has a major role in confirming the diagnosis of a suspected wandering spleen and avoiding potentially life-threatening complications requiring immediate surgery.

Characterization of solid breast masses: use of the sonographic breast imaging reporting and data system lexicon.

OBJECTIVE: The purpose of this study was to determine the reliability of sonographic American College of Radiology Breast Imaging Reporting And Data System (BI-RADS) classification in differentiating benign from malignant breast masses. METHODS: One hundred seventy-eight breast masses studied by sonography with a known diagnosis were reviewed. All lesions were classified according to the sonographic BI-RADS lexicon. Pathologic results were compared with sonographic features. Sensitivity, specificity, accuracy, and positive predictive value (PPV) and negative predictive value (NPV) for the sonographic BI-RADS lexicon were calculated. RESULTS: Twenty-six cases were assigned to class 3, 73 to class 4, and 79 to class 5. Pathologic results revealed 105 malignant and 73 benign lesions. The sonographic BI-RADS lexicon showed 71.3% accuracy, 98.1% sensitivity, 32.9% specificity, 67.8% PPV, and 92.3% NPV. The NPV for class 3 was 92.3%. The PPVs for classes 4 and 5 were 46.6% and 87.3%. Typical signs of malignancy were irregular shape, antiparallel orientation, noncircumscribed margin, echogenic halo, and decreased sound transmission. Typical signs of benignity were oval shape and circumscribed margin. CONCLUSIONS: The sonographic BI-RADS lexicon is an important system for describing and classifying breast lesions.

Combined diagnostic approach in a breast unit: a case of minimal sign.

The case of a 57-year old woman, apparently in good health, in menopause with familial incidence of breast cancer is discussed. The patient came to the Senology Unit for annual control mammography. For diagnostic completion US was performed: it showed the presence of a hypoechoic neoformation highly suggestive of malignancy (class V BI-RADS). Therefore, US-guided needle aspiration biopsy was performed. It confirmed the malignant nature of the neoformation and surgery was planned. At definitive histological examination a small invasive ductal carcinoma, 6 mm in diameter, was diagnosed.

Combined diagnostic imaging and management of a breast tumor in a young woman.

The typical presentation of breast cancer in a young woman is discussed. Diagnostic imaging of the breast showed the presence of an extensive pathological area, approximately 5 cm in size, at the level of the upper quadrants of left breast. On mammography the pathological sign was represented by numerous regional granular microcalcifications. On sonography an inhomogeneously hypoechoic area with intralesional hyperechoic spots was identified. On MRI a large area of pathological enhancement was visualized. For the tumor extent and the patient's young age neoadjuvant chemotherapy was performed. Post-treatment assessment showed good response to therapy, suggestive of possible better prognosis.

[An experience with health education for high school students]. / Un'esperienza di educazione alla salute per i giovani della scuola media superiore.

In Italy, measures for the prevention of drug addiction have often been directed solely towards providing information and creating greater awareness. Fisher and Fisher (1992), instead, propose a model based on three factors, Information-Motivation-Behavioural Skills, for the planning of programs for the prevention of health risk behaviour. This model provided the basis for the pilot experience of a health education course for the prevention of drug use, which involved 417 students in two high schools in Rome. This experience shows that efforts to prevent drug use in young people, if focused only on content, risk failure because young people already seem to possess the basic information concerning the risks connected to substance abuse. For this reason, there is a need for the organization of encounters for confrontation and debate in order to favour the acquisition of the capabilities needed to confront a potential problem of substance abuse.

Suspected cup syndrome. Diagnostic imaging of a misunderstood breast tumor for its uncommon location.

The case of a 41-year-old female patient with axillary lymphadenopathies and negative clinical and mammographic examinations is discussed. In the suspicion of a cup syndrome of breast origin, breast sonography was performed. While the absence of alterations was confirmed, a right parasternal swelling was highly suggestive of malignancy. On histology, a malignant parasternal nodule was diagnosed. Breast MRI was performed and an ipsilateral malignant focal lesion was visualized. Chemotherapy was administered but after a disease-free interval leptomeningeal and cerebral metastases appeared.