Feasibility of a new ultrasound guided procedure to ensure the correct position of the central venous catheter tip.

BACKGROUND: Safety of central venous catheter (CVC) placement relies on some general aspects, including selection of the right vessel, correct lumen targeting while inserting the needle, check the position of catheter tip, and post-procedure check for complications. All these four points can be guided by bedside ultrasound, but the best technique to ensure the position of the CVC tip is still uncertain. METHODS: We investigated feasibility of a novel ultrasound technique consisting of focused view of guidewire tip in the cavoatrial junction (CAJ) to calculate the CVC depth in adult patients needing CVC placement in emergency. Direct visualization of the guidewire in the CAJ was used to calculate how deep the CVC needed to be inserted. In those patients without a valid CAJ window, a bubble test in the right atrium was performed to position the CVC tip. In all cases chest radiography confirmed the CVC position. RESULTS: The procedure was performed in 37 patients and CVC was correctly placed in all cases. Within the group, in 25 patients the CVC depth (21.5 ± 6.0 cm) was successfully measured. In other 11 patients the correct CVC tip position was confirmed by the bubble test. In only one case it was not possible to use ultrasound for incomplete CAJ and right atrium views. CONCLUSIONS: This study confirms the feasibility of a new ultrasound method to ensure the correct CVC tip position. This protocol could potentially become a standard method reducing costs, post-procedural irradiation, and time of CVC placement in emergency.

Why do a lung biopsy for benign lesions?

BACKGROUND: Transthoracic needle biopsy of lung lesions is a well-established procedure for the diagnosis of lung lesions. The literature focuses on the diagnosis of malignant lesions with an often reported accuracy rate of more than 90%. Experience showed that biopsy can identify sometimes incidentally, also benign lesions. There are many reasons why a biopsy is performed for a "benign lesion." First of all, it may be an unexpected diagnosis, as some benign pathologies may have misleading presentations, that are very similar to lung cancer, otherwise the reason is only to make a diagnosis of exclusion, which leads to the benign pathology already being considered in the differential diagnosis. METHODS: This study was designed as a retrospective single-center study. We selected from our database all the lung biopsies performed under CT guidance, from 2015 to 2019 and retrospectively analysed the histological data. We selected only benign lesions describing the imaging feature and differential diagnosis with lung malignancy. RESULTS: In our patient population, among the 969 of them that underwent biopsy, we identified 93 benign lesions (10%). Hamartomas, granulomas, slow-resolving pneumonia and cryptogenic organizing pneumonia are the pathologies that most frequently can misinterpratedas lung cancer. CONCLUSIONS: In this brief report we want to show the percentage and type of benign lesions that are found in our lung trans-thoracic biopsy population. Among these, we identified the three most frequent benign lesions that most frequently enter the differential diagnosis with lung malignant lesions describing the classic and atypical imaging findings.

Effects of seasonality in emergency admissions for mental disorders: two years of clinical experience.

OBJECTIVES: This retrospective study, conducted in Turin, Italy, between January 2021 and February 2023, investigates the impact of seasonal heatwaves on emergency department (ED) admissions for mental disorders. METHODS: Through the analysis of data from 2,854 patients, this research found a significant link between the occurrence of heatwaves, especially from June to August, and an elevated rate of ED admissions for psychiatric conditions. RESULTS: The data indicate a clear seasonal pattern, with admissions peaking during the hot months and diminishing in the colder months. Particularly, the study delineates an enhanced correlation between heatwaves and admissions for severe psychiatric disorders, such as bipolar disorder, major depression, personality disorders, and schizophrenia, accounting for 1,868 of the cases examined. This correlation was most pronounced among individuals aged 50-59 years. CONCLUSIONS: The results of this study highlight a critical association between the incidence of seasonal heatwaves and an uptick in ED visits for psychiatric disorders, with a distinct impact on severe cases. It underscores the urgency for healthcare systems to anticipate seasonal fluctuations in psychiatric ED admissions and to allocate resources effectively to support patients during peak periods.

Lung ultrasound: are we diagnosing too much?

The clinical use of lung ultrasound (LUS) has made more efficient many diagnostic processes at bedside. The great power of LUS is a superior diagnostic sensitivity in many applications, when compared to chest radiography (CXR). The implementation of LUS in emergency is contributing to reveal a growing number of radio-occult pulmonary conditions. In some diseases, the superior sensitivity of LUS is a great advantage, like for pneumothorax and pulmonary edema. Diagnosing at bedside pneumothoraxes, pulmonary congestions, and COVID-19 pneumonia that are visible by LUS but undetected by CXR may be decisive for appropriate management, and even for saving lives. However, in other conditions, like bacterial pneumonia and small peripheral infarctions due to subsegmental pulmonary embolism, the high sensitivity of LUS does not always lead to advantages. Indeed, we doubt that it is always necessary to treat by antibiotics patients suspected of lower respiratory tract infection, who show radio-occult pulmonary consolidations, and to treat by anticoagulation patients with small subsegmental pulmonary embolism. The possibility that we are overtreating radio-occult conditions should be investigated with dedicated clinical trials.

Feasibility of a New Lung Ultrasound Protocol to Determine the Extent of Lung Injury in COVID-19 Pneumonia.

BACKGROUND: Lung ultrasound (LUS) scanning is useful to diagnose and assess the severity of pulmonary lesions during COVID-19-related ARDS (CoARDS). A conventional LUS score is proposed to measure the loss of aeration during CoARDS. However, this score was validated during the pre-COVID-19 era in patients with ARDS in the ICU and does not consider the differences with CoARDS. An alternative LUS method is based on grading the percentage of extension of the typical signs of COVID-19 pneumonia on the lung surface (LUSext). RESEARCH QUESTION: Is LUSext feasible in patients with COVID-19 at the onset of disease, and does it correlate with the volumetric measure of severity of COVID-19 pneumonia lesions at CT scan (CTvol)? STUDY DESIGN AND METHODS: This observational study enrolled a convenience sampling of patients in the ED with confirmed COVID-19 whose condition demonstrated pneumonia at bedside LUS and CT scan. LUSext was visually quantified. All CT scan studies were analyzed retrospectively by a specifically designed software to calculate the CTvol. The correlation between LUSext and CTvol, and the correlations of each score with Pao2/Fio2 ratio were calculated. RESULTS: We analyzed data from 179 patients. Feasibility of LUSext was 100%. Time to perform LUS scan was 5 ± 1.5 mins. LUSext and CTvol were correlated positively (R = 0.67; P < .0001). Both LUSext and CTvol showed negative correlation with Pao2/Fio2 ratio (R = -0.66 and R = -0.54; P < .0001, respectively). INTERPRETATION: LUSext is a valid measure of the severity of the lesions when compared with the CT scan. Not only are LUSext and CTvol correlated, but they also have similar inverse correlation with the severity of respiratory failure. LUSext is a practical and simple bedside measure of the severity of pneumonia in CoARDS, whose clinical and prognostic impact need to be investigated further.

Retrospective analysis of the application of CT scan in the emergency department to screen clinically asymptomatic COVID-19 before hospital admission.

BACKGROUND: The necessity to identify and isolate COVID-19 patients to avoid intrahospital cross infections is particularly felt as a challenge. Clinically occult SARS-CoV-2 infection among patients admitted to the hospital is always considered a risk during the pandemic. The aim of our study is to describe the application of CT scan to reveal unexpected COVID-19 in patients needing hospital admission. METHOD: In our emergency department, we prospectively enrolled adult patients needing hospital admission, without symptoms suspected of COVID-19, and showing negative reverse transcriptase-polymerase chain reaction (RT-PCR) swab test. CT scan was performed to diagnose clinically occult COVID-19 pneumonia. All the exams were read and discussed retrospectively by two expert radiologists and assigned to one of 4 exclusive diagnoses: typical (typCT), indeterminate (indCT), atypical (atyCT), negative (negCT). The clinical characteristics and final diagnoses were described and compared with the results of CT scans. RESULTS: From May 25 to August 18, 2020, we prospectively enrolled 197 patients. They showed 122 negCT, 52 atyCT, 22 indCT, and 1 typCT. Based on the CT imaging, the prevalence of suspected clinically occult COVID-19 pneumonia was 11.6% (23 patients). None had confirmation of SARS-CoV-2 infection after the hospital stay. Nineteen patients had negative serial RT-PCR while in 4 cases, the infection was excluded by clinical follow-up or appearance of positivity of RT-PCR after months. CONCLUSION: Our descriptive analysis confirms that CT scan cannot be considered a valid tool to screen clinically occult COVID-19, when the asymptomatic patients need hospitalization for other conditions. Application of personnel protections and distancing among patients remains the best strategies to limit the possibility of intrahospital cross-infections.

Emergency room comprehensive assessment of demographic, radiological, laboratory and clinical data of patients with COVID-19: determination of its prognostic value for in-hospital mortality.

Mortality risk in COVID-19 patients is determined by several factors. The aim of our study was to adopt an integrated approach based on clinical, laboratory and chest x-ray (CXR) findings collected at the patient's admission to Emergency Room (ER) to identify prognostic factors. Retrospective study on 346 consecutive patients admitted to the ER of two North-Western Italy hospitals between March 9 and April 10, 2020 with clinical suspicion of COVID-19 confirmed by reverse transcriptase-polymerase reaction chain test (RT-PCR), CXR performed within 24 h (analyzed with two different scores) and recorded prognosis. Clinical and laboratory data were collected. Statistical analysis on the features of 83 in-hospital dead vs 263 recovered patients was performed with univariate (uBLR), multivariate binary logistic regression (mBLR) and ROC curve analysis. uBLR identified significant differences for several variables, most of them intertwined by multiple correlations. mBLR recognized as significant independent predictors for in-hospital mortality age > 75 years, C-reactive protein (CRP) > 60 mg/L, PaO2/FiO2 ratio (P/F) < 250 and CXR "Brixia score" > 7. Among the patients with at least two predictors, the in-hospital mortality rate was 58% against 6% for others [p < 0.0001; RR = 7.6 (4.4-13)]. Patients over 75 years had three other predictors in 35% cases against 10% for others [p < 0.0001, RR = 3.5 (1.9-6.4)]. The greatest risk of death from COVID-19 was age above 75 years, worsened by elevated CRP and CXR score and reduced P/F. Prompt determination of these data at admission to the emergency department could improve COVID-19 pretreatment risk stratification.

Are Lung Ultrasound Findings in COVID-19 Pneumonia Typical or Specific?

The application of point-of-care lung ultrasound (LUS) in the first diagnosis and management of Corona Virus Disease 2019 (COVID-19) has gained a great interest during a pandemic that is undermining even the most advanced health systems. LUS demonstrated high sensitivity in the visualization of the interstitial signs of the typical pneumonia complicating the infection. However, although this disease gives typical lung alterations, the same LUS signs observed in COVID-19 pneumonia can be detected in other common pulmonary conditions. While being non-specific when considered separately, the analysis of the distribution of the sonographic typical signs allows the assignment of 4 LUS patterns of probability for COVID-19 pneumonia when the whole chest is examined and attention is paid to the presence of other atypical signs. Moreover, the combination of LUS likelihood with the clinical phenotype at presentation increases the accuracy. This mini-review will analyze the LUS signs of COVID-19 pneumonia and how they can be combined in patterns of probability in the first approach to suspected cases.

Descriptive analysis of a comparison between lung ultrasound and chest radiography in patients suspected of COVID-19.

BACKGROUND: Lung ultrasound (LUS) and chest radiography (CXR) are the most used chest imaging tools in the early diagnosis of COVID-19 associated pneumonia. However, the relationship between LUS and CXR is not clearly defined. The aim of our study was to describe the comparison between LUS interpretation and CXR readings in the first approach to patients suspected of COVID-19. METHODS: In the time of the first COVID-19 pandemic surge, we prospectively evaluated adult patients presenting to an emergency department complaining of symptoms raising suspicion of COVID-19. Patients were studied by LUS and only those performing also CXR were analyzed. All the patients performed viral reverse transcriptase-polymerase chain reaction (RT-PCR). LUS studies were classified in 4 categories of probabilities, based on the presence of typical or alternative signs of COVID-19-associated interstitial pneumonia. Accordingly, the CXR readings were retrospectively adapted by 2 experts in 4 categories following the standard language that describes the computed tomography (CT) findings. Patients were divided in two groups, based on the agreement of the LUS and CXR categories. Results were also compared to RT-PCR and, when available, to CT studies. RESULTS: We analyzed 139 cases (55 women, mean age 59.1 ± 15.5 years old). The LUS vs CXR results disagreed in 60 (43.2%) cases. RT-PCR was positive in 88 (63.3%) cases. In 45 cases, a CT scan was also performed and only 4 disagreed with LUS interpretation versus 24 in the comparison between CT and CXR. In 18 cases, LUS detected signs of COVID-19 pneumonia (high and intermediate probabilities) while CXR reading was negative; in 14 of these cases, a CT scan or a RT-PCR-positive result confirmed the LUS interpretation. In 6 cases, LUS detected signs of alternative diagnoses to COVID-19 pneumonia while CXR was negative; in 4 of these cases, CT scan confirmed atypical findings. CONCLUSION: Our study demonstrated a strong disagreement between LUS interpretation and CXR reading in the early approach to patients suspected of COVID-19. Comparison with CT studies and RT-PCR results seems to confirm the superiority of LUS over a second retrospective reading of CXR.

Correlation between CT findings and thoracoscopic diagnosis in diffuse pleural disease.

OBJECTIVE: Computed Tomography (CT) is considered part of the routine diagnostic workup for pleural malignancy. The definitive diagnosis of pleural malignancy depends upon histological confirmation by pleural biopsy. The aim of this study is to assess the sensitivity and specificity of CT, in view of the latest imaging technologies, in detecting pleural malignancy compared to definitive histology achieved via thoracoscopy (VATS). MATERIALS AND METHODS: We included in this retrospective study 90 patients (36 F, 54 M) with suspected pleural malignancy  evaluated in our Institution with CT scan who received a definitive diagnosis after VATS biopsy. Unaware of histopathologic diagnoses CT scans were evaluated by a junior and two experts thoracic radiologist. Conclusions were reached by consensus. RESULTS: We evaluated all CT signs suggestive for malignant pleural diseases: pleural thickening > 10 mm (Se 0,41 , Sp 0,79); nodular thickening (Se 0,86, Sp 0,75); circumferential thickening (Se 0,79, Sp 0,69); irregular pleural thickening (Se 0,77, Sp 0,91); mediastinal involvement (Se 0,88, Sp 0,64); costal involvement (Se 0,89, Sp 0,60); diaphragmatic involvement (Se 0,88, Sp 0,53). Furthermore, the diagnostic performance of additional CT features was evaluated: concomitant costal, mediastinal and diaphragmatic pleura lesions (Se 0,84, Sp 0,69); nodular/irregular thickening with mediastinal pleural involvement (Se 0,83, Sp 0,90); nodular/irregular thickening with diaphragmatic pleural involvement (Se 0,81, Sp 0,90). CONCLUSIONS: CT confirms its central role in the pleura malignancy. The high sensibility, respect to previous studies, especially in the presence of nodular pleural thickening, may lead to reconsider at least partly the diagnostic pathway of diffuse pleural disease, avoiding the use of VATS in patients not eligible for surgery, in favor of US or CT guided core biopsy.

"Sigmoid diverticulitis mimicking cholecystitis" a clinical challenge.

Diverticular disease is a common disorder and its incidence increases with ageing. Pathophysiology is multifactorial. Lifestyle, including smoking, alcohol intake, decreased dietary fibres and lack of physical activity, plays a predominant role. Genetics seems also to contribute specifically for right-sided diverticular disease (RSD). The majority of the patients with diverticular disease are asymptomatic. Diverticulitis is the inflammation of the diverticula usually presenting with abdominal pain associated to nausea, vomiting, rectal bleeding, diarrhoea and fever. When the inflammation process affects the diverticula in the ascending colon, the condition represents a clinical challenge as it can be easily misdiagnosed with other acute abdominal emergencies. We reported a case of a 70-year-old female who presented to our Emergency Department (ED) with right upper quadrant pain and an initial clinical suspicion of cholecystitis. Ultrasound (US) and Computed Tomography (CT) demonstrated an anatomical variation of the sigmoid colon diverticulitis. This clinical report demonstrates that ultrasound plays a relevant part as first-step approach to the acute abdominal conditions and its accuracy increases together with other diagnostic tools such as Computer Tomography.

[Pulmonary tuberculosis in diagnostic imaging: the great mime.] / La tubercolosi polmonare nella diagnostica per immagini: il grande mimo.

Pulmonary tuberculosis (TB) is nowadays one of the most common causes of infectious disease-related morbility and mortality worldwide. The differential diagnosis between TB and some others conditions is an emerging problem, particularly challenging when TB imaging mimicks sarcoidosis, lymphoproliferative disorders and pulmonary neoplasms. In these cases, the correct diagnoses can be made with certainty only with trans-bronchial or CT guided biopsy.

Computed tomography of solitary fibrous tumor of the pleura abutting the mediastinum: A diagnostic challenge.

BACKGROUND: Solitary fibrous tumor of the pleura (SFTP) arising from the mediastinal pleura may be confused with primary mediastinal tumors. We studied the computerized tomographic (CT) findings of patients with SFTP that could suggest a diagnosis of SFTP. MATERIALS AND METHODS: At our hospital from January 1995 to June 2012, 39 patients with histologically confirmed SFTP were surgically treated; seven of them abutting the mediastinal pleura. The study group included seven patients aged between 53 and 81 years. Baseline CT scans were retrospectively reviewed to identify radiological findings suggestive of SFTP including: (1) smooth and sharply delineated contours; (2) obtuse, acute, or tapering angles between the lesion and the mediastinum depending on the size; (3) homogeneous soft-tissue attenuation; (4) "geographic pattern" due to the contemporary presence of large vessels, necrosis, and calcifications; (5) displacement of the lung parenchyma; (6) presence of a cleavage plane; and (7) absence of lymphadenopathy or pleural methastasis. RESULTS: All tumors formed acute angles with the pleura. Six out of the seven presented smoothly tapering margins, three had a "geographic pattern" of attenuation and displaced the anterior junction line; one showed an outside junction line development. Four cases had a clear pleural origin. CONCLUSIONS: The possibility of SFTP should be taken into account when a mass abuts the mediastinum projecting inside the thoracic cavity in the presence of an intense and "geographical pattern" of enhancement without lymphoadenopathy or pleural metastasis. These findings assume greater significance in the presence of discrepancy between the size of the lesion and the clinical presentation.

Structured reporting for fibrosing lung disease: a model shared by radiologist and pulmonologist.

OBJECTIVES: To apply the Delphi exercise with iterative involvement of radiologists and pulmonologists with the aim of defining a structured reporting template for high-resolution computed tomography (HRCT) of patients with fibrosing lung disease (FLD). METHODS: The writing committee selected the HRCT criteria-the Delphi items-for rating from both radiology panelists (RP) and pulmonology panelists (PP). The Delphi items were first rated by RPs as "essential", "optional", or "not relevant". The items rated "essential" by < 80% of the RP were selected for the PP rating. The format of reporting was rated by both RP and PP. RESULTS: A total of 42 RPs and 12 PPs participated to the survey. In both Delphi round 1 and 2, 10/27 (37.7%) items were rated "essential" by more than 80% of RP. The remaining 17/27 (63.3%) items were rated by the PP in round 3, with 2/17 items (11.7%) rated "essential" by the PP. PP proposed additional items for conclusion domain, which were rated by RPs in the fourth round. Poor consensus was observed for the format of reporting. CONCLUSIONS: This study provides a template for structured report of FLD that features essential items as agreed by expert thoracic radiologists and pulmonologists.

Diagnostic Imaging and workup of Malignant Pleural Mesothelioma.

Malignant pleural mesothelioma is the most frequent primary neoplasm of the pleura and its incidence is still increasing.This tumor has a strong association with exposure to occupational or environmental asbestos, often after a long latent period of 30-40 years.Plain chest radiography (CXR) is usually the first-line radiologic examination, but the radiographic findings are nonspecific due to its limited contrast resolution and they need to be complemented by other imaging modalities such as computed tomography (CT), magnetic resonance Imaging (MRI), Positron emission tomography-computed tomography (PET-CT) and ultrasound (US).The aim of this paper is to describe the imaging  features of this malignancy, underlining the peculiarity of CXR, CT, MRI, PET-CT and US and also focusing on diagnostic workup, based on the literature evidence and according to our experience.

Radiological contribution to the diagnosis of early postoperative complications after lung resection for primary tumor: a revisional study.

In the post-operative course of the interventions of lung resection for primary tumor, complications of different nature and severity can arise, recognizing different pathogenetic mechanisms and differing according to the type of resection performed and to the time elapsed after surgery. The low diagnostic accuracy of chest radiography requires a thorough knowledge of the radiologist about all radiographic findings, both normal and pathological, which can be found in the immediate post-operative period (within 30 days after surgery). This article aims to describe the incidence, the clinical features and the radiological aspects of immediate complications following pulmonary resections, with specific reference to those in which the diagnostic imaging provides a fundamental contribution.