The Role of Contrast-Enhanced Ultrasound in the Differential Diagnosis of Malignant and Benign Subpleural Lung Lesions.

Background: The application of transthoracic contrast-enhanced ultrasound (CEUS) to the study of peripheral lung lesions is still a topic of debate. The main objective of this review was to evaluate the diagnostic accuracy of CEUS in the diagnosis of malignant subpleural pulmonary consolidations and, therefore, differentiate them from benign ones. Methods: Papers published before December 2023 were detected through a search of PubMed, Cochrane library, and Embase. The pooled specificity and sensitivity, summary receiver operating characteristic (SROC) curve and diagnostic odds ratio (DOR) were used. Results: CEUS is characterized by a pooled sensitivity of 0.95 (95% CI: 0.93-0.97) and a pooled specificity of 0.93 (95% CI: 0.90-0.95) in differentiating benign and malignant subpleural lung diseases; the AUC of SROC was 0.97. Homogeneous CE was characterized by a pooled sensitivity of 0.43 (95% CI: 0.40-0.45) and the pooled specificity of 0.49 (95% CI: 0.46-0.52). Non-homogeneous CE displayed a pooled sensitivity of 0.57 (95% CI: 0.55-0.60) and a pooled specificity of 0.51 (95% CI: 0.48-0.54). The lack of CE displayed a pooled sensitivity of 0.01 (95% CI: 0.00-0.06) and a pooled specificity of 0.76 (95% CI: 0.64-0.85). Marked CE displayed a pooled sensitivity of 0.41 (95% CI: 0.37-0.44) and a pooled specificity of 0.54 (95% CI: 0.50-0.58). Non-marked CE displayed a pooled sensitivity of 0.59 (95% CI: 0.56-0.63) and a pooled specificity of 0.46 (95% CI: 0.42-0.50). The early AT displayed a pooled sensitivity of 0.04 (95% CI: 0.02-0.08) and a pooled specificity of 0.83 (95% CI: 0.77-0.87). The early wash out displayed a pooled sensitivity of 0.61 (95% CI: 0.48-0.72) and a pooled specificity of 0.98 (95% CI: 0.92-1.00). The delayed wash out displayed a pooled sensitivity of 0.15 (95% CI: 0.10-0.20) and a pooled specificity of 0.69 (95% CI: 0.62-0.75). Conclusions: CEUS is characterized by excellent diagnostic accuracy for the diagnosis of the malignancy of subpleural lung lesions. By separately analyzing the CEUS findings, the diagnostic accuracy values are considerably lower and not significant in some cases. The simultaneous evaluation of multiple CEUS features allows us to reach an excellent diagnostic accuracy. Non-homogeneous CE with early wash out are the most indicative features of malignancy of a lung lesion.

Ultrasound diagnosis of a pseudoaneurysm of the internal right mammary artery.

One of the principles of managing trauma patients is that of their continuous re-evaluation over the hours and days. Even if the execution of the computed tomography method is classically recommended, especially in the most serious cases and in polytraumas with major dynamics, the clinician can use or request an ultrasound examination, especially in subsequent re-evaluations. Here we report a clinical case demonstrating how an ultrasound re-evaluation after the acute event can lead to a correct diagnosis of a rare complication of thoracic trauma. The findings were suggestive for a pseudoaneurysm of the internal right mammary artery. Subsequently, an ultrasound-guided injection of thrombin was carried out until complete interruption of the flow within the formation. At subsequent follow-up, no arterial or venous blush was highlighted.

Platelet, Antiplatelet Therapy and Metabolic Dysfunction-Associated Steatotic Liver Disease: A Narrative Review.

Metabolic dysfunction-associated steatotic liver disease (MASLD) is not only related to traditional cardiovascular risk factors like type 2 diabetes mellitus and obesity, but it is also an independent risk factor for the development of cardiovascular disease. MASLD has been shown to be independently related to endothelial dysfunction and atherosclerosis. MASLD is characterized by a chronic proinflammatory response that, in turn, may induce a prothrombotic state. Several mechanisms such as endothelial and platelet dysfunction, changes in the coagulative factors, lower fibrinolytic activity can contribute to induce the prothrombotic state. Platelets are players and addresses of metabolic dysregulation; obesity and insulin resistance are related to platelet hyperactivation. Furthermore, platelets can exert a direct effect on liver cells, particularly through the release of mediators from granules. Growing data in literature support the use of antiplatelet agent as a treatment for MASLD. The use of antiplatelets drugs seems to exert beneficial effects on hepatocellular carcinoma prevention in patients with MASLD, since platelets contribute to fibrosis progression and cancer development. This review aims to summarize the main data on the role of platelets in the pathogenesis of MASLD and its main complications such as cardiovascular events and the development of liver fibrosis. Furthermore, we will examine the role of antiplatelet therapy not only in the prevention and treatment of cardiovascular events but also as a possible anti-fibrotic and anti-tumor agent.

Perioperative Management of Antithrombotic Therapy in Patients Who Undergo Dental Procedures: A Systematic Review of the Literature and Network Meta-Analysis.

BACKGROUND: The surgical dental treatment of subjects admitted for anticoagulants therapy represents a consistent risk for peri-operative bleeding. The aim of the present study was to investigate the clinical findings of dental surgery operative management of the patients under anticoagulants drugs protocol. METHODS: The literature screening was performed using Pubmed/Medline, EMBASE and Cochrane library, considering only randomized clinical trials (RCTs) papers. No limitations about the publication's period, follow-up time or clinical parameters were considered. RESULTS: A total of eight RCTs were included for the qualitative synthesis. No thromboembolic complications were reported in any studies. Several bleeding episodes associated with anticoagulant drugs in dental surgery were mild and generally happened on the first day after the treatment. CONCLUSIONS: The use of local haemostatic measures is generally effective for bleeding control with no further pharmacological drug management or suspension.

Infectious Pneumonia and Lung Ultrasound: A Review.

The application of thoracic ultrasound examination has not long been developed because ultrasound's interaction with the lung does not generate an anatomical image but an artifactual one. Subsequently, the evaluation of pulmonary artifacts and their correlation to specific diseases allowed the development of ultrasound semantics. Currently, pneumonia still represents one of the main causes of hospitalization and mortality. Several studies in the literature have demonstrated the ultrasound features of pneumonia. Although ultrasound cannot be considered the diagnostic gold standard for the study of all lung diseases, it has experienced an extraordinary development and growth of interest due to the SARS-CoV-2 pandemic. This review aims to provide essential information on the application of lung ultrasound to the study of infectious pneumonia and to discuss the differential diagnosis.

The case of a liver adenoma that looked like a hemangioma.

Benign focal liver lesions are among the most frequent findings on ultrasound. Liver hemangiomas are often easily recognizable on ultrasound examination and are characterized by a clear benign prognosis. In some cases, hemangiomas display an atypical appearance both on B-mode and on contrast-enhanced ultrasound, thus raising concerns for differential diagnosis both with adenomas and with lesions of malignant nature. We report here the case of a patient who presented with a liver lesion with all signs suggestive for hemangioma on B-mode, but it showed atypical features on contrast-enhanced ultrasound examination and final diagnosis of liver adenoma.

Non-Alcoholic Fatty Liver Disease and Metabolic Syndrome in Women: Effects of Lifestyle Modifications.

Non-alcoholic fatty liver disease (NAFLD) is the most widespread liver disease, characterized by fatty acids liver accumulation and subsequent fibrosis. NAFLD prevalence ranges from 80% to 90% in obese subjects and is estimated to be around 50% in patients with metabolic syndrome. In this clinical scenario, diet and lifestyle modifications can play an important role. There are several imaging techniques that can accurately diagnose fatty liver. Recently, ultrasound has acquired a leading role in the diagnosis and follow-up of fatty liver disease. Furthermore, elastosonography represents a valid alternative to liver biopsy. Shear wave elastosonography evaluates the elastic and mechanical properties of liver tissue. The aim is to evaluate the effects of lifestyle and nutritional interventions and a loss of body weight during hepatic steatosis through ultrasonographic and elastosonographic techniques. Thirty-two female subjects with metabolic syndrome were subjected to clinical, anthropometric, and laboratory assessments, as well as abdominal ultrasonographic/elastosonographic measurements taken from enrollment time (T0) and after 3 months (T1) of lifestyle modifications. After 3 months of lifestyle changes, significant weight loss was observed, with a marked improvement in all adiposity indices. The laboratory parameters at T1 showed significant decreases in total and LDL cholesterol, triglycerides, basal blood glucose, 120 min glycaemia, basal insulin and HOMA Index (p < 0.001). A similar improvement was observed at T1 for steatosis degree (p < 0.01) and elastosonographic measurements (Kpa p < 0.001). The linear regression analysis of the baseline conditions documented that the size of the liver positively correlated with body weight, BMI, neck and waist circumferences, waist to height ratio (WhtR), insulin and HOMA Index, fat mass and visceral fat, and steatosis grade. After 3 months, the liver size showed improvement with positive correlations to all previous variables. Hepatic stiffness (Kpa) positively correlated with neck circumference, visceral fat, and ALT, with basal insulin, gamma-GT, and AST, and with waist circumference, WhtR, and fat mass. The degree of steatosis was positively correlated with more variables and with greater statistical significance at T1 with respect to T0. Particularly, the positive correlations between the degree of steatosis and neck circumference (p < 0.001), HOMA Index, and triglycerides (p < 0.001) appeared to be very significant. NAFLD management in women with metabolic syndrome should be focused on lifestyle modifications. Moreover, liver involvement and improvement at follow-up could be evaluated in a non-invasive manner through ultrasonographic and elastosonographic techniques.

Disentangling the Association of Hydroxychloroquine Treatment with Mortality in Covid-19 Hospitalized Patients through Hierarchical Clustering.

The efficacy of hydroxychloroquine (HCQ) in treating SARS-CoV-2 infection is harshly debated, with observational and experimental studies reporting contrasting results. To clarify the role of HCQ in Covid-19 patients, we carried out a retrospective observational study of 4,396 unselected patients hospitalized for Covid-19 in Italy (February-May 2020). Patients' characteristics were collected at entry, including age, sex, obesity, smoking status, blood parameters, history of diabetes, cancer, cardiovascular and chronic pulmonary diseases, and medications in use. These were used to identify subtypes of patients with similar characteristics through hierarchical clustering based on Gower distance. Using multivariable Cox regressions, these clusters were then tested for association with mortality and modification of effect by treatment with HCQ. We identified two clusters, one of 3,913 younger patients with lower circulating inflammation levels and better renal function, and one of 483 generally older and more comorbid subjects, more prevalently men and smokers. The latter group was at increased death risk adjusted by HCQ (HR[CI95%] = 3.80[3.08-4.67]), while HCQ showed an independent inverse association (0.51[0.43-0.61]), as well as a significant influence of cluster∗HCQ interaction (p < 0.001). This was driven by a differential association of HCQ with mortality between the high (0.89[0.65-1.22]) and the low risk cluster (0.46[0.39-0.54]). These effects survived adjustments for additional medications in use and were concordant with associations with disease severity and outcome. These findings suggest a particularly beneficial effect of HCQ within low risk Covid-19 patients and may contribute to clarifying the current controversy on HCQ efficacy in Covid-19 treatment.

Delirium in COVID-19 patients: a multicentric observational study in Italy.

INTRODUCTION: Although recent data show that SARS-CoV-2 infection seems to affect the central nervous system (CNS), little is known about the neuropsychiatric effects resulting from this condition. In addition to the well-known neurotrophism of coronaviruses, recent evidence shows also that the "cytokine storm" induced by the infection is at the basis of the neuroinflammation of the CNS. Furthermore, prolonged hospitalization, polypharmacotherapy, and isolation could be at the basis of the onset of delirium in hospitalized COVID patients. This multicentric observational study explores the incidence of the onset of delirium in an Italian cohort of SARS-CoV-2 positive inpatients. METHODS: Data were collected in the COVIDhospitals of Brescia, Bergamo, Chieti, and Genova. Different socio-demographic, medical, neurological, and pharmacological parameters were collected. As a rapid screening for delirium, the 4AT scale was used. Eighty COVID-19 inpatients (mean age 74.7 ± 14.5 years) met the inclusion criteria (confirmed positivity to the SARS-CoV-2 virus; the presence of delirium and/or psychomotor agitation and/or new onset of other neuropsychiatric symptoms during hospitalization). RESULTS: The majority of these patients (68.8%) had "hyperactive delirium" subtype. Polypharmacotherapy, current treatment with corticosteroids, and higher age were associated with delirium severity. CONCLUSION: These data provide an insight into the onset of delirium among COVID-19 patients underlining the need for monitoring, especially in elderly patients, the neuropsychiatric symptoms, and the therapy in order to have shorter hospitalization times and better outcomes.

Common cardiovascular risk factors and in-hospital mortality in 3,894 patients with COVID-19: survival analysis and machine learning-based findings from the multicentre Italian CORIST Study.

BACKGROUND AND AIMS: There is poor knowledge on characteristics, comorbidities and laboratory measures associated with risk for adverse outcomes and in-hospital mortality in European Countries. We aimed at identifying baseline characteristics predisposing COVID-19 patients to in-hospital death. METHODS AND RESULTS: Retrospective observational study on 3894 patients with SARS-CoV-2 infection hospitalized from February 19th to May 23rd, 2020 and recruited in 30 clinical centres distributed throughout Italy. Machine learning (random forest)-based and Cox survival analysis. 61.7% of participants were men (median age 67 years), followed up for a median of 13 days. In-hospital mortality exhibited a geographical gradient, Northern Italian regions featuring more than twofold higher death rates as compared to Central/Southern areas (15.6% vs 6.4%, respectively). Machine learning analysis revealed that the most important features in death classification were impaired renal function, elevated C reactive protein and advanced age. These findings were confirmed by multivariable Cox survival analysis (hazard ratio (HR): 8.2; 95% confidence interval (CI) 4.6-14.7 for age ≥85 vs 18-44 y); HR = 4.7; 2.9-7.7 for estimated glomerular filtration rate levels <15 vs ≥ 90 mL/min/1.73 m2; HR = 2.3; 1.5-3.6 for C-reactive protein levels ≥10 vs ≤ 3 mg/L). No relation was found with obesity, tobacco use, cardiovascular disease and related-comorbidities. The associations between these variables and mortality were substantially homogenous across all sub-groups analyses. CONCLUSIONS: Impaired renal function, elevated C-reactive protein and advanced age were major predictors of in-hospital death in a large cohort of unselected patients with COVID-19, admitted to 30 different clinical centres all over Italy.

Sonography of abdominal wall vascular malformation: a case report and review of the literature.

Vascular anomalies are classified as vascular tumors (VT) and vascular malformations (VM). VTs are divided according to their clinical behavior, while VMs are classified according to their flow characteristics, histopathologic features, and associations with other anomalies. Sonography emerges as the diagnostic imaging method of first choice for assessing abdominal wall disorders and masses, thus representing a valuable tool for the diagnosis and follow-up of abdominal wall VMs. In this review, we report a case of abdominal wall arteriovenous malformation (AVM) in a 17-year old and briefly discuss the cases of abdominal wall VMs.

From an abdominal ultrasound to a lung disease passing through the diaphragm: a case of idiopathic pulmonary fibrosis.

RATIONALE: Idiopathic pulmonary fibrosis (IPF) is a chronic lung disease characterized by abnormal and excessive deposition of collagen in the pulmonary interstitium (fibrosis) with minimal associated inflammation evolving into progressive and irreversible decline in lung function. PATIENT CONCERNS: Patient referred discomfort, bilateral upper quadrant abdominal pain, and progressive exertional dyspnea (shortness of breath with exercise). DIAGNOSIS: Exertional dyspnea due to idiopathic pulmonary fibrosis (IPF). INTERVENTION: Sonographic evaluation demonstrated an alteration of diaphragm excursion together with a relevant alteration of the pleural line and multiple irregular and confluent B lines. CONCLUSIONS: Lung and diaphragm ultrasound could be employed as a screening or first-line diagnostic tool in the suspicion of interstitial lung disease.

Homocysteine and education but not lipoprotein (a) predict estimated 10-year risk of cardiovascular disease in blood donors: a community based cross-sectional study.

BACKGROUND: With aging of the population, screening and prevention health programs for blood donors will increasingly be a priority. We aimed at: assessing the 10 year-cardiovascular disease (CVD) risk in blood donors, according to Italian CUORE risk score (CRS); determining the association of homocysteine (Hcy), lipoprotein (Lp)(a) and socio-demographic or lifestyle variables with estimated 10-year CVD risk. METHODS: Between June 2015 and July 2017, 1,447 (61.2% men) unselected blood donors (aged 18-69 years) were enrolled at the Blood Transfusion Service of the Pescara General Hospital, Italy. The project entailed evaluation of unalterable (age and gender) and modifiable CV risk factors (total cholesterol, HDL, LDL, triglycerides, fasting glucose, smoking, hypertension). The educational attainment, socio-demographic and lifestyle behavior information were obtained through a structured self-report questionnaire, and Health-related quality of life (HRQoL) through the Short Form Survey (SF-12). Plasma Hcy and Lp(a) were determined in the fasting state. RESULTS: A CRS within the moderate-high risk range was reported in 21.7% donors. Multivariate logistic regression, after adjustment for clinical and demographic variables, showed that Hcy [OR (95% CI): 1.09 (1.04-1.13); p < 0.001) and low educational attainment [1.71 (1.09-2.73); p = 0.019] are independent risk factors for moderate-to-high CVD risk. Instead, Lp(a), evaluated in 774 donors, was > 30 mg/dL in 22.4% of the examined population, but without any significant correlation with CRS. CONCLUSIONS: Our study highlights a previously unappreciated need for CV risk assessment in blood donors, which may include evaluation of educational attainment as a non-traditional risk marker.

Oxidative stress in chronic vascular disease: From prediction to prevention.

This review article is intended to describe the strong relationship between oxidative stress and vascular disease. Reactive oxygen species (ROS) play an important role in the pathogenesis of vascular disease: oxidative stress is intimately linked to atherosclerosis, through oxidation of LDL and endothelial dysfunction, to diabetes, mainly through advanced glycation end-products (AGEs)/receptor for AGE (RAGE) axis impairment, protein kinase C (PKC), aldose reductase (AR) and NADPH oxidase (NOX) dysfunction, and to hypertension, through renin­angiotensin system(RAS) dysfunction. Several oxidative stress biomarkers have been proposed to detect oxidative stress levels and to improve our current understanding of the mechanisms underlying vascular disease. These biomarkers include ROS-generating and quenching molecules, and ROS-modified compounds, such as F2-isoprostanes. An efficient therapeutic approach to vascular diseases cannot exclude evaluation and treatment of oxidative stress. In fact, oxidative stress represents an important target of several drugs and nutraceuticals, including antidiabetic agents, statins, renin-angiotensin system blockers, polyphenols and other antioxidants. A better understanding of the relations between atherosclerosis, diabetes, hypertension and ROS and the discovery of new oxidative stress targets will translate into consistent benefits for effective vascular disease treatment and prevention.