Monaldi Archives for Chest Disease最新文献

We presented a case of a 49-year-old presenting with atypical chest pain and hypertrophic phenotype cardiomyopathy without coronary artery disease. At cardiac magnetic resonance (CMR), the left ventricle was of normal volumes and preserved global ejection fraction with asymmetric wall hypertrophy. The evaluation of native myocardial T1 has been calculated at an average global value of 924 ms, compatible with hypertrophic phenotype cardiomyopathy with reduced native T1 values as observed in Anderson-Fabry disease. The genetic analysis confirmed the Anderson-Fabry disease with a mutation in the exon 5 of the GLA gene, revealing the mutation c.644 A>G. This case report demonstrated that the images obtained in CMR and the analysis of the T1 native mapping, compared with the normal values obtained in the Center, may be considered a gatekeeper in the diagnostic assessment, avoiding redundant examinations, and reducing costs, and radiological exposure.

Differentiation of malignant from benign pleural effusions is challenging in clinical practice due to limitations in the cytologic analysis. The combination of pleural fluid biomarkers has previously been used to predict malignant pleural effusion (MPE). We have conducted a prospective observational study to assess the diagnostic potential of cancer ratio [(CR) serum lactate dehydrogenase (sLDH): pleural fluid adenosine deaminase (pADA)], CR plus (CR: pleural lymphocyte count), sLDH: pleural lymphocyte count, and age: pADA in differentiating malignant effusions from benign ones. Prospective data from patients evaluated for exudative pleural effusions in the pulmonary medicine department at our institute over 12 months were collected. All subjects underwent thoracentesis, and if the results were inconclusive, they underwent invasive diagnostic testing for confirmation. They were divided into MPE and non-MPE groups for analysis. Pleural fluid biomarker ratios were calculated and compared between both groups, and receiver operating characteristic curves were generated. We included 120 subjects: 59 were diagnosed with MPE, and 61 had benign effusion (46 tubercular and 15 parapneumonic). The mean (standard deviation) age of the study population [64 (53.3%) males] was 52.4 (14.5) years. CR, CR plus, and age: pADA were significantly higher in the MPE group compared to the benign group. The sLDH: lymphocyte count was similar between both groups. Age: pADA ratio and CR performed best, with areas under the curve of 0.99 [95% confidence interval (CI), 0.97-1.0] and 0.97 (95% CI, 0.94-1.0), respectively. A higher age: pADA level was associated with a malignant etiology of effusion (adjusted odds ratio 12.27, 95% CI 2.37-63.54) on multivariate analysis. At a cut-off of 2, the age: pADA ratio provided 96.6% sensitivity, 93.4% specificity, with a positive likelihood ratio of 14.7. Age: pADA and CR are promising diagnostic indices for differentiating MPE and non-MPE with high sensitivity and specificity. The diagnostic accuracy of CR plus and sLDH: lymphocyte ratio is inferior to that of CR and age: pADA.

Convalescent plasma therapy (CPT) is one of the treatment modalities used for COVID-19. Initial smaller studies showed the usefulness of CPT in COVID-19, but larger studies showed that it is not effective. This is a retrospective observational study conducted between 1st June 2020 and 31st July 2021 at a tertiary hospital in Noida, India. Our analysis was done on 213 COVID-19 patients, comprising 170 cases who were given convalescent plasma and 43 controls who did not get CPT. Outcomes analyzed were improvement in PaO2:FiO2 ratio (PFR) by day 5 of CPT, 28-day mortality, and level of inflammatory markers. Mean PFR before plasma transfusion was comparable between CPT and control groups (142.11±73.99 vs. 151.11±88.87, p=0.56). There was no significant difference in mean PFR after 5 days of CPT between cases and the control group (187.02±102.34 vs. 160.29±83.39, p=0.206). 28-day mortality was 47.05% in the CPT group and 37.20% in the control group (p=0.246). Mortality among the subgroup of patients on invasive mechanical ventilation was 89.74% in cases and 80% in controls (p=0.518). No significant difference was found in levels of serum ferritin, interleukin-6, and C-reactive protein between the two groups. Convalescent plasma does not have a significant effect on day 5 PFR and 28-day mortality. Our study could not find any subgroup of patients who would benefit from CPT. This study reinforces that CPT does not benefit moderate to severe patients with COVID-19.

The literature review suggested that the Singla-Richa modified shuttle walk test (SWTSR) was equally reliable and valid when compared to the conventional shuttle walk test. A comparison of SWTSR with the six-minute walk test (6MWT), which is considered the gold standard in walk tests, allowed us to evaluate the SWTSR and determine its validity and reliability as an alternative or supplement to the 6MWT. The objective of this study was to determine the correlation between the distances walked during a SWTSR and the 6MWT in healthy, normal adults. The study recruited 42 healthy normal adults who underwent 6MWT and SWTSR on the same day. The correlation was assessed by Pearson's correlation coefficient, and agreement between the tests was assessed using a Bland-Altman plot. Additionally, the acceptability of the modified test in comparison to the 6MWT was assessed by the Likert scale. The distances walked (mean ± standard deviation) in the 6MWT and SWTSR were 693.8±58.3 and 951.4±139.7 m, respectively (Pearson's correlation coefficient of 0.918). The distance covered by the study participants in the 6MWT and SWTSR showed a strong correlation with spirometry results. The SWTSR induced a greater physiological response compared to the 6MWT. The acceptability of the SWTSR was comparable to that of the 6MWT. The distance walked in the SWTSR shows a strong positive correlation with the 6MWT and has comparable acceptability with the 6MWT. The SWTSR may provide a better index of the patient's ability for his activities of daily living and may be a better measure for studying exercise tolerance than the 6MWT in certain clinical settings.

The N-acetyltransferase 2 (NAT2) gene exhibits substantial genetic diversity, leading to distinct acetylator phenotypes among individuals. In this study, we determine NAT2 gene polymorphisms in tuberculosis (TB) patients and analyze serum isoniazid (INH) concentrations across the various genotypes. An observational prospective cohort study involving 217 patients with pulmonary or extrapulmonary TB was carried out. The NAT2 genotypes were identified using real-time polymerase chain reaction technology. INH concentrations at baseline and 2 hours post-dosing were estimated using high-performance liquid chromatography. The association between the acetylator status and INH concentrations was evaluated using odds ratios (OR), and the occurrence of adverse events across the different patient genotypes was also assessed. The genotype frequency of fast, intermediate, and slow acetylators was 7.37%, 39.17%, and 53.46%, respectively, while allele frequency was 27% for fast acetylators and 73% for slow acetylators. All the alleles followed the Hardy-Weinberg equilibrium. Patients with slow acetylator status had significantly increased serum INH concentrations 2 hours post-drug administration, followed by intermediate acetylators, as compared to fast acetylators. 69 (31.8%) patients developed adverse drug reactions post-therapy. Patients with slow acetylator status had the highest (OR: 9.66) risk of developing drug-induced hepatotoxicity, especially those with raised serum INH concentrations (OR: 1.34). Understanding the correlation between genetics and serum antitubercular drug levels in antitubercular drug-induced hepatotoxicity will provide valuable information to the medical community, minimizing the risk of adverse reactions and hospitalizations.

The management of persistent malignant pleural effusion (MPE) or uremic pleural effusions requires the removal of pleural fluid and the prevention of recurrence through pleurodesis. Pleurodesis involves injecting a sclerosing agent into the pleura to encourage adhesion between the two layers, ultimately obliterating the pleural space. Povidone-iodine is a potential pleurodesing agent. This quasi-experimental study was conducted at the Department of Pulmonology, Shaikh Zayed Hospital, Federal Postgraduate Medical Institute, Lahore, Pakistan, over 1 year (March 2021 - March 2022). A total of 70 patients with MPE, uremic pleural effusions, and secondary spontaneous pneumothorax (SSP) were enrolled after meeting the inclusion criteria. The pleurodesis procedure involved administering a mixture of 20 mL of 10% povidone-iodine solution and 30 mL of normal saline through a chest tube, followed by clamping for 3 hours. Patients were scheduled for follow-up visits at 2, 4, 8, and 12 weeks. Data was analyzed using SPSS version 20.0. The average age of participants was 53.26 years (+13.71). Of the 70 patients, 39 (55.7%) were male and 31 (44.3%) were female. 62 patients (88.57%) had pleural effusion, and 8 patients (11.42%) had pneumothorax. The procedure was successful in 84.3% of patients, with varying success rates by diagnosis: MPE (81%), uremic pleural effusion (92%), and SSP (75%). Statistical analysis revealed significant positive effects of povidone-iodine on procedure outcomes (p=0.048) and effectiveness in preventing pleural effusion recurrence (p=0.028). This study indicates that 10% povidone-iodine can serve as a viable alternative to other pleurodesis agents, yielding standard-quality pleurodesis in 84.3% of patients. It is readily available, cost-effective, and has minimal adverse effects.

Diffuse alveolar hemorrhage (DAH) is characterized by a syndrome of alveolar bleeding, a fall in hemoglobin, and respiratory failure. It can occur because of various immunologic and non-immunologic conditions. The etiology of DAH is important, as treatment varies with the etiology. This retrospective observational study evaluates the diverse etiologies, time to diagnosis from symptom onset, management strategies, and outcome of DAH in a span of 12 months at our tertiary care center. A total of 8 patients were identified with 8 different etiologies. 6/8 (75%) patients had immunologic causes, and 2/8 (25%) had non-immunologic causes of DAH. 6/8 (75%) patients were females, the mean time to DAH diagnosis was 4.25 months from symptom onset, 6/8 (75%) patients improved, and 2/8 (25%) died due to complications. It is necessary to differentiate between the etiologies of DAH and establish an early diagnosis to plan management and improve outcomes.

An 18-year-old male presented with syncope during a training break. Post-syncope, he developed effort dyspnea, which he associated with the Pfizer-BioNTech COVID-19 vaccine received a week earlier. The electrocardiogram showed T inversion in V1-V3, III, and aVF, while 24-hour Holter monitoring revealed frequent ventricular premature beats. A transthoracic echocardiogram showed severe biventricular dilation and mild left ventricular (LV) dysfunction. Cardiac magnetic resonance (CMR) imaging confirmed these findings, showing moderate right ventricular (RV) systolic dysfunction with akinesia of the inferior and inferolateral walls. T2 hypersignal in the middle segment of the inferior interventricular septum suggested myocardial edema. Extensive transmural late gadolinium enhancement was noted in the RV and LV walls. An implantable loop recorder was implanted. Three months later, the patient was admitted with palpitations, fever, and a positive SARS-CoV-2 test. Sustained ventricular tachycardia (VT) episodes were documented and managed with amiodarone and β-blockers. Follow-up CMR showed a slight improvement in LV ejection fraction and resolution of edema. A single-chamber implantable cardioverter-defibrillator (ICD) was implanted. Genetic testing for arrhythmogenic RV cardiomyopathy (ARVC) was negative, and family screening was normal. Two years later, pre-syncope episodes occurred, and ICD interrogation revealed nonsustained VT. The patient is awaiting VT ablation. This case highlights the diagnostic and therapeutic challenges of ARVC, particularly in differentiating it from myocarditis. The "hot-phase" presentation, vaccine association, and subsequent SARS-CoV-2 infection added complexity. CMR was crucial for diagnosis, and VT management required a combination of medical therapy and invasive procedures.

Asthma is a prevalent chronic respiratory disease affecting all age groups globally, causing significant morbidity and mortality. Small airway involvement, often undetected by traditional spirometry, has emerged as a critical aspect of asthma pathophysiology, especially in severe cases. This retrospective observational study aimed to assess small airway dysfunction using impulse oscillometry (IOS) in 94 severe asthma patients. Results indicated that 27.3% of patients had small airway obstruction. While spirometry showed no statistical differences between groups, IOS parameters were significantly different, highlighting its sensitivity in detecting small airway disease. Patients with small airway involvement exhibited poorer asthma control, emphasizing the clinical relevance of identifying and addressing small airway dysfunction. The study underscores the need for comprehensive evaluation tools like IOS alongside spirometry, especially in severe asthma management. Further large-scale studies are warranted to validate IOS's utility in optimizing therapeutic strategies and improving asthma control, particularly in resource-limited settings. Recognizing and addressing small airway involvement could lead to individualized management approaches and better outcomes in severe asthma patients.

In this prospective study, we evaluated the diagnostic yield and safety of two endobronchial ultrasound (EBUS) biopsy techniques - mediastinal cryobiopsy (EBUS-MCB) and Franseen tip needle biopsy (EBUS-ANB) - in patients with undiagnosed mediastinal lymphadenopathy. The study included 30 patients who underwent both EBUS-MCB and EBUS-ANB, with four biopsies taken from each patient using both methods. The results demonstrated that EBUS-MCB provided a higher diagnostic yield (96.4%) compared to EBUS-ANB (73.3%). Specimens from EBUS-MCB showed fewer artifacts and a higher density of granulomas and were adequate for ancillary studies in all cases. The most common complication observed was minor bleeding, which was more common with EBUS-MCB (36.6% vs. 13.3%, p=0.04). This study demonstrates that EBUS-guided cryobiopsy has a higher diagnostic yield when compared to EBUS-ANB and that both biopsy techniques have an acceptable safety profile. Larger studies comparing these two techniques are necessary to confirm the findings of the current study.