Monaldi Archives for Chest Disease最新文献

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.

Biological drugs have revolutionized the management of severe asthma, and a tailored treatment approach has made it possible to consider remission as an achievable treatment target. The incidence of autoimmune diseases is increasing worldwide. Patients suffering from severe asthma, eligible for or already treated with an asthma-approved biologic agent, may suffer from another immune-mediated inflammatory disease (IMID) that could require the simultaneous use of a second monoclonal antibody. The real-life studies available in the literature describing the concurrent administration of an asthma-approved biologic agent with another biologic for a different immune disease, obtained through a systematic search on online databases based on monoclonal antibodies, were collected and analyzed. In this review, 26 articles were included according to the prespecified inclusion and exclusion criteria. All included papers were retrospective in nature. Study designs were case reports (n=18), case series (n=3), retrospective chart reviews (n=3), retrospective observational studies (n=1), and cohort studies (n=1). The study is intended to present, within the current literature, all the administered combinations of severe asthma-approved biologics with monoclonal antibodies for a different indication. Those were grouped according to the IMID for whom the second biologic agent, with a different mechanism of action, was prescribed. The combinations prescribed to the cohort of patients specifically treating uncontrolled severe asthma were more deeply evaluated in the discussion section, since an analysis of these therapeutic combinations deriving from real-life experiences may be useful to optimize the management of patients with severe asthma, ultimately leading to improved patient care and outcomes. Prospective registries and future studies are required to assess the safety and efficacy of combination therapies for severe asthmatic patients who suffer from an IMID.

Lung carcinoma was the most common cause of cancer deaths globally in 2022, with non-small cell lung carcinoma (NSCLC) accounting for 81% of the burden. Due to promising tyrosine kinase inhibitor (TKI) trials, NSCLC patients harboring EGFR gene mutations are of interest. Our aim was to determine EGFR mutation prevalence in north India and its histologic and demographic correlations. We investigated the frequency of EGFR mutations in 40 patients with histologically confirmed NSCLC using real-time polymerase chain reaction. A 15% mutation frequency was observed in the study sample, involving 32 males and 8 females with a median age of 59 years. Squamous cell carcinoma (SCC) patients had only EXON20 (T790M, exon20 insertion) mutations, while adenocarcinoma patients had mutations in both EXON20 (T790M) and 21 (L858R) with mutation frequencies of 22% and 10%, respectively. 28% of the SCC patients were non-smokers, and 60% of these non-smokers had an EGFR mutation. South Indian and Asian studies have identified EXON19 (19-Del) and EXON21 (L858R) mutations as "common mutations" that account for nearly 80-90% of all mutations and respond well to TKIs. Interestingly, "common mutations" were found seldom in our study population, while the uncommon variants constitute 83% of all mutations, which we assume is due to diverse Indian genetics and ethnicity and co-existing signature mutations that involve the tyrosine kinase domain of EXON20. We suggest future genome-wide association studies to identify plausible genetic polymorphisms responsible for interethnic differences in EGFR mutation, which will contribute to better treatment and prevention of NSCLCs.

Cardiorespiratory physiotherapy (CRP) is an evidence-based process for individuals with both acute and chronic cardiorespiratory health conditions, yet access to center-based CRP in Italy is limited. Home-based and telehealth alternatives remain scarcely explored. This study investigated the status of CRP in the Lombardy region through a cross-sectional online survey distributed to physiotherapists registered with the Interprovincial Professional Register of eight provinces. A total of 388 responses were analyzed: 32 (8.2%) reported performing home-based CRP, and 9 (2.3%) reported telerehabilitation. Peripheral oxygen saturation was the most frequently assessed parameter (86%). Positive expiratory pressure devices were used for airway clearance (75%), and exercise reconditioning was consistently performed (79%). Variation was noted in lung re-expansion techniques, with some outdated methods still in use. Specific training in the use of telehealth facilities was often limited, and technological resources were essential for delivering telerehabilitation. The findings indicate that CRP beyond the clinic is still underutilized in Lombardy. Strengthening training programs and implementing standardized protocols could enhance access to and the quality of care. However, results are preliminary and limited by low representativeness and potential selection bias; therefore, they should not be considered generalizable.

Valvular heart disease (VHD) remains a significant global health concern, with mortality rates ranging from 1% to 15%. In Indonesia, the most prevalent form of VHD is rheumatic heart disease, which is associated with a hospital mortality rate of 6.5% following valve surgery. Previous studies have shown that, post-surgery, morbidity rates remain high: 30.8% of patients experience prolonged intensive care unit stays (>96 hours), 30.67% require extended mechanical ventilation (>24 hours), and 52% need prolonged use of inotropic agents (≥14 days). Right ventricular (RV) dysfunction is closely associated with these three morbidity parameters, as well as with 30-day postoperative mortality. However, limited research in Indonesia has explored the most effective parameters for evaluating RV function as a predictor of postoperative morbidity and mortality following heart valve surgery. This prospective cohort study was conducted at the Department of Cardiology and Vascular Medicine, Universitas Indonesia, and the National Cardiovascular Center Harapan Kita (NCCHK) from October 2023 to July 2024. During this period, 174 patients with VHD who underwent surgical valve replacement were enrolled. After applying exclusion criteria, 26 patients were excluded, resulting in a final study population of 148 patients. All participants underwent preoperative echocardiographic assessment of RV function, performed by two operators within 1 week prior to surgery. Among the 148 subjects, females comprised the majority (60.1%). Atrial fibrillation (AF) was the most common comorbidity, affecting 62.8% of the cohort. The most frequent morbidity outcome was prolonged mechanical ventilation, observed in 27.7% of cases. Of the total mortality events, 70% were cardiac-related, while the remaining 30% were due to non-cardiac causes. Multivariate analysis revealed that a preoperative S'<10 cm/s was significantly associated with cardiac-related mortality [odds ratio (OR) 3.46; 95% confidence interval (CI) 1.01-11.87; p=0.049]. Additionally, a preoperative S'<11 cm/s was significantly associated with overall clinical outcomes, including both morbidity and all-cause mortality (OR 3.08; 95% CI 1.43-6.65; p=0.004). In conclusion, S', an echocardiographic parameter reflecting RV function, demonstrates potential as a predictive marker for postoperative morbidity and mortality in patients undergoing heart valve surgery.

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Diaphragm dysfunction during exacerbation of chronic obstructive pulmonary disease (COPD) has prognostic and therapeutic implications. The utility of the latter in predicting continued need for respiratory support at the time of discharge is worth exploring. The present study was carried out in a tertiary care teaching hospital with patients who were admitted to the ward or intensive care unit with exacerbations of COPD. The association between diaphragm function and the need for respiratory support at the time of discharge was assessed. All included participants underwent diaphragm ultrasound within 48-72 hours of admission. Diaphragm ultrasound was performed using the standard protocol wherein diaphragm excursion (DE), measured as the displacement of the diaphragm during inspiration and expiration; diaphragm thickening fraction (DTf), the fractional change of diaphragm thickness between inspiration and expiration; and ratio of inspiratory and expiratory diaphragm thickness (TR) were measured. The need for respiratory support [oxygen alone or oxygen and home non-invasive ventilation (NIV)] at the time of discharge was the outcome measured. Differences between various groups of respiratory support were analyzed using analysis of variance, Kruskal-Wallis, or Chi-square test, as appropriate. A total of 56 patients with exacerbation of COPD were included in the study. The median DE was 2.43 cm (interquartile range: 1.24, 3.33). The mean DTf (in %) was 52.25±34. On comparing the diaphragm function between the three outcome groups, patients requiring both oxygen and NIV at the time of discharge had a lower DTf and TR (p=0.05). Patients with an acute exacerbation of COPD requiring home oxygen and NIV support at discharge had a lower DTf and TR compared to those who were discharged without any respiratory support.

This narrative review explores parental knowledge, attitudes, and practices (KAP) toward childhood asthma in India, covering aspects of disease etiology, stigma, trigger avoidance, and management, and their overall impact on asthma control and outcomes. A total of 17 studies from 2014 to 2024 focusing on parental KAP were analyzed, excluding those centered on healthcare providers or lacking KAP-compliance correlation. This review reveals widespread parental misconceptions, stigma, and poor knowledge about childhood asthma in India, influenced by regional and socioeconomic factors. Fear of inhalers, use of alternative therapies, and cost barriers to treatment are common. Improved, culturally tailored education and policy efforts are needed to enhance asthma care and outcomes. Parental KAP significantly influences asthma control, with gaps caused by misconceptions, cultural beliefs, and poor practices. Regional disparities highlight the need for context-specific strategies. Despite various global and national asthma guidelines, parental knowledge and practices in India remain poor. Culturally tailored education, community engagement, and policy support are essential to improve parental compliance and childhood asthma outcomes, particularly in underserved regions.