Multifractal Heart Rate Value Analysis: A Novel Approach for Diabetic Neuropathy Diagnosis.

Type 2 diabetes mellitus (T2DM) is characterized by several complications, such as retinopathy, renal failure, cardiovascular disease, and diabetic neuropathy. Among these, neuropathy is the most severe complication, due to the challenging nature of its early detection. The linear Hearth Rate Variability (HRV) analysis is the most common diagnosis technique for diabetic neuropathy, and it is characterized by the determination of the sympathetic-parasympathetic balance on the peripheral nerves through a linear analysis of the tachogram obtained using photoplethysmography. We aimed to perform a multifractal analysis to identify autonomic neuropathy, which was not yet manifest and not detectable with the linear HRV analysis. We enrolled 10 healthy controls, 10 T2DM-diagnosed patients with not-full-blown neuropathy, and 10 T2DM diagnosed patients with full-blown neuropathy. The tachograms for the HRV analysis were obtained using finger photoplethysmography and a linear and/or multifractal analysis was performed. Our preliminary results showed that the linear analysis could effectively differentiate between healthy patients and T2DM patients with full-blown neuropathy; nevertheless, no differences were revealed comparing the full-blown to not-full-blown neuropathic diabetic patients. Conversely, the multifractal HRV analysis was effective for discriminating between full-blown and not-full-blown neuropathic T2DM patients. The multifractal analysis can represent a powerful strategy to determine neuropathic onset, even without clinical diagnostic evidence.

A retrospective study of endobronchial ultrasound transbronchial needle aspiration versus conventional transbronchial needle aspiration in diagnosis/staging of hilar/mediastinal lymph node in lung cancer: Which role in clinical practice?

The conventional-trans bronchial needle aspiration (c-TBNA) has been the first procedure for sampling hilar/mediastinal lymph node for the diagnosis/staging of lung cancer. In the last decade the endobronchial ultrasound trans bronchial needle aspiration (EBUS-TBNA) was introduced in clinical practice and became the first-choice exam in diagnosis and staging of lung cancer. The aim of this study was to compare the diagnostic accuracy (DA), sensitivity and adequacy of c-TBNA and EBUS-TBNA. It was a retrospective and observational multicenter study. The first endpoint was diagnostic accuracy of EBUS-TBNA versus c-TBNA. The secondary end-points were sensitivity and adequacy. Two hundred and nine consecutive patients underwent the procedure, 99 EBUS-TBNA and 110 c-TBNA. When lymph nodes with short axis <2 cm the diagnostic accuracy for correct diagnosis was 94.2% in EBUS-TBNA group and 89.7% in c-TBNA group (p=0.01); the sample adequacy was 70.3% and 42%, respectively (p=0.01); the sensitivity was 93% (95% CI, 82-98%) and 86.4% (95% CI, 67.6-95.6%), respectively (p=0.002). In lymph nodes with short axis ≥2 cm the diagnostic accuracy was 95.7% in EBUS-TBNA group and 93% in c-TBNA group (p=0.939); the sample adequacy was 68.7% and 68.3%, respectively (p=0.889); the sensitivity was 95.1% (95% CI, 83-99%) and 92.1%, respectively (95% CI, 78.7-97.7%) (p=0.898). The EBUS-TBNA in patients with lymph nodes size <2 cm presented a statistically significant difference in the DA, adequacy and sensitivity compared to c-TBNA procedure, while there were no significant differences in the DA, adequacy and sensitivity between EBUS-TBNA and c-TBNA in patients with lymph node size ≥2 cm. The results of our study indicated that the EBUS-TBNA should be the first-choice procedure for the diagnosis/staging in lung cancer patients with lymph node size <2 cm. In patients with lymph node size ≥2 cm, instead, both procedures can be used for the diagnosis/staging of lung cancer.

Deep sedation versus minimal sedation during endobronchial ultrasound transbronchial needle aspiration.

The sedation plays an important role in the endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) procedure. The sedation can be Minimal (anxiolysis), Moderate (conscious sedation) or Deep. The ACCP guidelines suggest that moderate or deep sedation (DS) is an acceptable approach. In fact, several studies compare moderate versus deep sedation, but no study has been carried out to compare deep sedation versus minimal. We carried out a retrospective study to compare the Deep versus Minimal sedation (MiS) in patients undergoing EBUS-TBNA.  The primary end point was the diagnostic accuracy. The secondary end points were adequacy and sensitivity. We evaluated the LN size sampling, procedural time, complications and patient tolerance. Thirty-six patients underwent EBUS-TBNA, 16 under DS and 20 under MiS. The overall diagnostic accuracy for correct diagnosis was 92.9% in DS group and 94.1% in MiS group (p=0.554). Sample adequacy, defined as the percentage of patients with a specific diagnosis by EBUS-TBNA, was 87.5% (14 of 16) and 85% (17 of 20) for the DS group and MiS group, respectively, (p=0.788); the sensitivity was 92.9% in the DS group (95% CI, 73-100%) and 92.9% in the MiS group (95% CI, 77-100%) (p=0.463). There were no major complications in either group. Minor complications were 4 in MiS and 1 in DS (p=0.355).  The patients in the MiS group recalled the procedure more often compared to the other group (p=0.041). The majority of the patients would agree to undergo the same procedure again in the future in both groups (p=0.766).  In our experience EBUS-TBNA performed under MiS has comparable accuracy, adequacy, sensitivity, complications and patient satisfaction to DS, even if the sample was small.  Future prospective multicenter studies are needed to confirm our results.

Aspiration of tracheoesophageal prosthesis in a laryngectomized patient.

BACKGROUND: The voice prosthesis inserted into a tracheoesophageal fistula has become the most widely used device for voice rehabilitation in patients with total laryngectomy. CASE PRESENTATION: We describe a case of tracheoesophageal prosthesis' (TEP) aspiration in a laryngectomized patient, with permanent tracheal stoma, that appeared during standard cleaning procedure, despite a programme of training for the safe management of patients with voice prosthesis. CONCLUSIONS: The definitive diagnosis and treatment were performed by flexible bronchoscopy, that may be considered the procedure of choice in these cases, also on the basis of the literature.

Pseudossarcoma inflamatório primário de bexiga: relato de caso / Primary inflammatory pseudossarcoma of the bladder: case report

O pseudossarcoma inflamatório primário de bexiga é um tumor raro, com apenas 50 casos na literatura. Clinicamente e pelos exames de imagem, ele é indistinguível de tumores malignos, sendo que apenas a histologia consegue diferenciá-lo, mesmo assim com dificuldade. O tratamento é cirúrgico, havendo recidivas apenas quando ele não é completamente ressecado. Os autores relatam um caso de pseudossarcoma inflamatório de bexiga em paciente feminina de 40 anos, que apresentou recidiva após ressecção inicial e boa evolução após nova intervenção cirúrgica