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Background : Pneumothorax (PNX) represents a common clinical condition in emergency departments (EDs), requiring prompt recognition and treatment. The role of transthoracic ultrasounds (TUSs) in the diagnosis of PNX is still debated. We aimed to prospectively evaluate the accuracy of TUSs in the detection of spontaneous PNX in EDs. Methods : A total of 637 consecutive adult patients who presented to the EDs of four Italian hospitals complaining of acutely onset chest pain and dyspnoea were included in the study. Exclusion criteria were previous traumatic events, cardiogenic causes of pain/dyspnoea and suspected tension PNX. The absence of "lung sliding" (B-mode) and the "bar-code" sign (M-mode) were considered indicative of PNX in a TUS. Accuracy, sensitivity, specificity, and positive and negative predictive values (PPVs, NPVs) were calculated using a chest CT scan as reference. Results : Spontaneous PNX occurred in 93 patients: of those, 83 (89.2%) were correctly identified by TUSs. However, 306 patients with suspected PNX at TUS were not confirmed by chest CTs. The diagnostic accuracy of both the absence of "lung sliding" and "bar-code" sign during TUS was 50.4% (95% CI: 46.4-54.3), sensitivity was 89.2% (95% CI: 81.1-94.7), specificity was 43.8% (95% CI: 39.5-48.0), the PPV was 21.3% (95% CI: 19.7-23.1) and the NPV was 96.0% (95% CI: 92.9-97.7). Conclusions : TUS showed high sensitivity but low specificity in the identification of PNX in EDs. Relying exclusively on TUSs results for patients' management in ED settings is neither suitable nor recommendable. TUS examination can be useful to strengthen the clinical suspicion of PNX, but its results should be confirmed by a chest X-ray or CT scan.

In this case report, real-time neuropsychological testing (RTNT) and music listening were applied for resections in the left temporal-parietal lobe during awake surgery (AS). The case is based on a 66-year-old with glioblastoma and alterations in expressive language and memory deficit. Neuropsychological assessment was run at baseline (2-3 days before surgery), discharge from hospital (2-3 days after surgery), and follow-up (1 month and 3 months). RTNT was started before beginning the anesthetic approach (T0) and during tumor excision (T1 and T2). At T0, T1, and T2 (before performing neuropsychological tests), music listening was applied. Before AS and after music listening, the patient reported a decrease in depression and anxiety. During AS, an improvement was shown in all cognitive parameters collected at T0, T1, and T2. After the excision and music listening, the patient reported a further decrease in depression and anxiety. Three days post surgery, and at follow-ups of one month and three months, the patient reported a further improvement in cognitive aspects, the absence of depression, and a reduction in anxiety symptoms. In conclusion, RTNT has been useful in detecting cognitive function levels during tumor excision. Music listening during AS decreased the patient's anxiety and depression symptoms.

Objectives: We validated a screening protocol in which thoracic ultrasound (TUS) acts as a first-line complementary imaging technique in selecting patients which may deserve a second-line low-dose high resolution computed tomography (HRCT) scan among a population of asymptomatic high-risk subjects for interstitial lung abnormalities (ILA) and lung cancer. Due to heavy environmental pollution burden, the district Tamburi of Taranto has been chosen as "case study" for this purpose., Methods: From July 2018 to October 2020, 677 patients aged between 45 and 65 year and who had been living in the Tamburi district of Taranto for at least 10 years were included in the study. After demographic, clinical and risk factor exposition data were collected, each participant underwent a complete TUS examination. These subjects were then asked to know if they agreed to perform a second-level examination by low-dose HRCT scan., Results: On a total of 167 subjects (24.7%) who agreed to undergo a second-level HRCT, 85 patients (50.9%) actually showed pleuro-pulmonary abnormalities. Interstitial abnormalities were detected in a total of 36 patients on HRCT scan. In particular, 34 participants presented subpleural ILAs, that were classified in the fibrotic subtype in 7 cases. The remaining 2 patients showed non-subpleural interstitial abnormalities. Subpleural nodules were observed in 46 patients. TUS showed an overall diagnostic accuracy of 88.6% in detecting pleuro-pulmonary abnormalities in comparison with HRCT scan, with a sensitivity of 95.3%, a specificity of 81.7%, a positive predictive value of 84.4% and a negative predictive value of 94.4%. The matched evaluation of specific pulmonary abnormalities on HRTC scan (i.e., interstitial abnormalities or pulmonary nodules) with determinate sonographic findings revealed a reduction in both TUS sensibility and specificity. Focusing TUS evaluation on the assessment of interstitial abnormalities, a thickened pleural line showed a sensitivity of 63.9% and a specificity of 69.5%, hypoechoic striae showed a sensitivity of 38.9% and a specificity of 90.1% and subpleural nodules showed a sensitivity of 58.3% and a specificity of 77.1%. Regarding to the assessment of subpleural nodules, TUS showed a sensitivity of 60.9% and a specificity of 81.0%. However, the combined employment of TUS examination and HRCT scans allowed to identify 34 patients with early subpleural ILA and to detect three suspicious pulmonary nodules (of which two were intraparenchymal and one was a large subpleural mass), which revealed to be lung cancers on further investigations., Conclusion: A first-line TUS examination might aid the identification of subjects highly exposed to environmental pollution, who could benefit of a second-line low-dose HRCT scan to find early interstitial lung diseases as well as lung cancer., Protocol Registration Code: PLEURO-SCREENING-V1.0_15 Feb, 17., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Quarato, Dama, Maggi, Feragalli, Borelli, Del Colle, Taurchini, Maiello, De Cosmo, Lacedonia, Barbaro, Carpagnano, Scioscia, Graziano, Termine, Frongillo, Santamaria, Venuti, Grimaldi, Notarangelo, Saponara, Copetti, Colangelo, Cuttano, Macrodimitris, Mazzarelli, Talia, Mirijello, Pazienza, Perna, Simeone, Vergara, Varriale, Carella, Bianchi and Sperandeo.)

Abdominal pain represents a frequent symptom for referral to emergency departments and/or internal medicine outpatient setting. Similarly, fever, fatigue and weight loss are non-specific manifestations of disease. The present case describes the diagnostic process in a patient with abdominal pain and a palpable abdominal mass. Abdominal ultrasonography confirmed the presence of a mass in the mesogastrium. Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) scans oriented toward calcific lymphadenopathies with increased metabolism in the positron emission tomography-computed tomography (PET-CT) scan. Laboratory examinations were inconclusive, although serology for Brucella and the Quantiferon test were positive. After multidisciplinary discussion, the patient underwent surgical excision of the abdominal mass. Histological examination excluded malignancies and oriented toward brucellosis in a patient with latent tuberculosis. The patient was treated with rifampin 600 mg qd and doxycycline 100 mg bid for 6 weeks with resolution of the symptoms. In addition, rifampin was continued for a total of 6 months in order to treat latent tuberculosis. This case underlines the need for a multidisciplinary approach in the diagnostic approach to abdominal lymphadenopathies.

(1) Background: Despite the high accuracy of CT-guided transthoracic biopsy for diagnosis of pulmonary lesions, in a certain amount of cases biopsy results may indicate the presence of nonspecific findings or insufficient material. We aimed to investigate the effectiveness of CT-guided transthoracic biopsy of pulmonary lesions in providing a specific diagnosis and to analyze the variables affecting biopsy results. (2) Methods: In this retrospective study, a total of 170 patients undergoing 183 CT-guided transthoracic biopsies of pulmonary lesions were included. The clinical, radiological and pathological data were reviewed to classify biopsy results as diagnostic or nondiagnostic and to identify which variables were associated with the two groups. (3) Results: The biopsy results were diagnostic in 150 cases (82.0%), of which 131 (87.3%) positive for malignancy and 19 (12.7%) with specific benign lesions, and nondiagnostic in 33 cases (18.0%). Twenty-two of the thirty-three (66.7%) nondiagnostic cases were finally determined as malignancies and eleven (33.3%) as benign lesions. In the diagnostic group, all the 131 biopsies positive for malignancy were confirmed to be malignant at final diagnosis (87.3%); of 19 biopsies with specific benign lesions, 13 cases were confirmed to be benign (8.7%), whereas six cases had a final diagnosis of malignancy (4%). Multivariate analysis showed increased risk of nondiagnostic biopsy for lesions ≤ 20 mm ( p = 0.006) and lesions with final diagnosis of benignity ( p = 0.001). (4) Conclusions: CT-guided transthoracic lung biopsy is an effective technique for the specific diagnosis of pulmonary lesions, with a relatively acceptable proportion of nondiagnostic cases. Small lesion size and final benign diagnosis are risk factors for nondiagnostic biopsy results.

The template-directed synthesis of RNA played an important role in the transition from prebiotic chemistry to the beginnings of RNA based life, but the mechanism of RNA copying chemistry is incompletely understood. We measured the kinetics of template copying with a set of primers with modified 3'-nucleotides and determined the crystal structures of these modified nucleotides in the context of a primer/template/substrate-analog complex. pH-rate profiles and solvent isotope effects show that deprotonation of the primer 3'-hydroxyl occurs prior to the rate limiting step, the attack of the alkoxide on the activated phosphate of the incoming nucleotide. The analogs with a 3 E ribose conformation show the fastest formation of 3'-5' phosphodiester bonds. Among those derivatives, the reaction rate is strongly correlated with the electronegativity of the 2'-substituent. We interpret our results in terms of differences in steric bulk and charge distribution in the ground vs. transition states., (© 2021 Wiley-VCH GmbH.)

Before the advent of polymerase enzymes, the copying of genetic material during the origin of life may have involved the nonenzymatic polymerization of RNA monomers that are more reactive than the biological nucleoside triphosphates. Activated RNA monomers such as nucleotide 5'-phosphoro-2-aminoimidazolides spontaneously form an imidazolium-bridged dinucleotide intermediate that undergoes rapid nonenzymatic template-directed primer extension. However, it is unknown whether the intermediate can form on the template or only in solution and whether the intermediate is prone to hydrolysis when bound to the template or reacts preferentially with the primer. Here we show that an activated monomer can first bind the template and then form an imidazolium-bridged intermediate by reacting with a 2-aminoimidazole-activated downstream oligonucleotide. We have also characterized the partition of the template-bound intermediate between hydrolysis and primer extension. In the presence of the catalytic metal ion Mg 2+ , >90% of the template-bound intermediate reacts with the adjacent primer to generate the primer extension product while less than 10% reacts with competing water. Our results indicate that an RNA template can catalyze a multistep phosphodiester bond formation pathway while minimizing hydrolysis with a specificity reminiscent of an enzyme-catalyzed reaction.

Malignant melanoma development in gastrointestinal (GI) tract may be primary or secondary. Although small bowel, colon and stomach represent common GI sites affected from metastatic cutaneous malignant melanoma (cMM), more than 90% of the cases are identified only during autoptic examinations. Therefore, the diagnosis in a living patient of gallbladder metastasis from cMM is considered extremely rare. We aimed to describe a case of metastatic melanoma involving the gallbladder, the stomach and the small bowel in a 78-year-old male with diffuse abdominal pain and a history of cMM of the back, which was radically resected 4 years before. Abdominal ultrasound showed intracholecystic multiple nodulations. CT, besides confirming the gallbladder nodules, revealed multiple masses in the stomach, duodenum and ileum. Malignant melanoma lesions were confirmed by histopathological and immunohistochemical analyses of bioptic material obtained from endoscopic examination. In patients with history of melanoma, careful inspection of GI tract should be prompted adopting adequate imaging techniques and endoscopy in order to better influence treatment planning and prognosis.

Background: Thrombocytosis can follow surgery and has occasionally been observed after major orthopaedic surgery. The aim of the present study was to ascertain the platelet count (PLTC) change in patients admitted to a rehabilitation unit after major joint surgery and whether deep venous thrombosis (DVT) and poor outcomes occurred in those who had thrombocytosis., Method: PLTC, red blood cells (RBC), haemoglobin (Hb), fibrinogen, and D-dimers were assessed in patients on admission and at discharge after major joint surgery. Functional outcomes were ascertained using the Barthel Scale (BS), the Functional Independence Measure (FIM) and gait evaluation. Thrombocytosis was considered to have occurred when PLTC was greater than or equal to 500 × 100(9)/L. All subjects with thrombocytosis had ultrasonography to assess DVT occurrence. The patients were divided into "young" and "old" groups according to an age cut-off of 75 years to investigate potential age-related differences., Results: Two hundred and seventy-five patients were identified and 142 (36 M and 106 F, mean age 77.2 ± 10.7) were enrolled. Seventy-six (53.5%) underwent total hip arthroplasty (THA), 40 (51.1%) underwent hip internal fixation and 26 (18.3%) subjects underwent total knee arthroplasty (TKA). The young and old groups included 60 and 82 patients, respectively. Fifty-nine (42.4%) patients had PLTC above 400 × 100(9)/L. Of these, 28 (20.1%) had thrombocytosis with PLTC above 500 × 100(9)/L, and 15 of them (10.7%) had very high values above 600 × 100(9)/L. Increased levels of fibrinogen and D-dimers were also detected. No subject with thrombocytosis had DVT. Outcome was not affected by PLTC. At discharge, significant improvement in all functional assessments was observed in young compared to old people; gait: 2.9 ± 0.2 vs. 2.2 ± 0.8; BS: 97 ± 6.9 vs. 70.5 ± 25.6; and FIM: 116.4 ± 10.9 vs. 83.6 ± 31.2 (p < 0.004), respectively. BS and FIM mean scores were positively correlated with Hb level., Conclusion: Elevated PLTC and thrombocytosis were not uncommon in patients after major joint surgery, but no subject developed DVT. Platelet count change did not affect the outcome. Higher age and lower haemoglobin level correlated with poorer functional recovery.

Background: Spasticity can be a severe disabling disorder requiring high-dose injections of botulinum toxin type A (BoNT-A). Efficacy and safety of high BoNT-A doses in reducing multi-level spasticity of subjects with brain injury and cerebral palsy were investigated. Pain and functional outcome were also assessed., Method: High doses (up to 840 IU) of incobotulinumtoxinA were injected in adult subjects with severe spasticity of the upper and lower limbs due to brain injury (BI) and cerebral palsy (CP). The Modified Ashworth Scale, Visual Analogue scale, Glasgow Outcome Scale, Franchay Arm Test (FAT) and Barthel Scale were employed to assess spasticity, pain and functional outcome at baseline, and 4 and 16 weeks after BoNT-A injection., Results: Twenty-two (12 M, 10 F; mean age 38.1 ± 13.7 years) subjects - 16 subjects with BI and 6 with CP - were enrolled. Elbow, wrist, fingers and ankle muscles showed significant spasticity reduction after BoNT-A injections. The mean FAT score improved, but the benefit was not significant. Three (13.6%) subjects complained of mild adverse events., Conclusion: High-dose BoNT-A injections were effective and safe in reducing spasticity of BI and CP subjects. A significant reduction of the pain was also observed, but global functionality and arm dexterity were unchanged.

The population is getting older. Rehabilitation can play an essential strategic role to counteract impairments and disability which characterize the elderly. Correct rehabilitative programmes have to be approached on the functional limitation and residual abilities of elders. Leading a more active lifestyle and regular physical activity including aerobic and resistance exercises have been demonstrated to improve cardiovascular, respiratory, musculoskeletal, and cognitive wellbeing in older adults. Occupational therapy, prescription of assistive devices, environmental, and home living adaptation, and family or caregiver educational training represent an essential rehabilitative strategy in elders developing disability. In these people, falls are dramatic events that lead to hospitalization, functional decline, decreased social activity, and poor quality of life. Rehabilitation incorporating balance, gait, and strength training exercise interventions can reduce the risk of falls. Frailty refers to a condition characterized by a gradual physiologic decline in multiple body systems, loss of physiologic reserve, and increased vulnerability to disease and death. Several therapeutic strategies have been proposed including exercises, multi-component training and approaches, all aimed at decreasing the need for nursing home placement, hospitalization, and reducing dependence and death. In these subjects, geriatric comprehensive assessment and the multi-disciplinary team have recently been demonstrated to be more effective than usual care.

Purpose: To demonstrate the greater accuracy of B- and M-probe ultrasound (US) compared to traditional examinations in the evaluation of diseases of the lung-base, a frequent localisation of pathology in patients undergoing orthotopic liver transplantation (OLT)., Material and Methods: Twenty-one patients, 13 males and 8 females aged 24 to 63, awaiting OLT were examined using the three modalities. B-mode US was performed as a preliminary study to identify the districts of interest and the profile of the diaphragm wall, searching for any related alterations. This was followed by M-mode US, with an approach along the left and right posterior axillary lines during spontaneous and forced maximal expiration, to calculate and document the curve representing diaphragm mobility. All patients were also studied pre- and postoperatively by standard chest X-ray double projections. The parameters evaluated by US were diaphragmatic inspiratory slant and diaphragm range while the standard chest X-ray was used to assess hypoventilation, diaphragm range and pleural effusion., Results: For each parameter considered we obtained the following results: presence or absence of pleural effusion (sensitivity: 100% with US vs 64% with chest X-ray) and diaphragmatic hypomobility with related hypoventilatory phenomena (sensitivity: 85% with US, with 15% false negatives). In 15 cases the chest X-ray revealed a clear elevation of the diaphragm, a finding supported by US in 11 cases. In 7 cases US showed a reduction in the diaphragm range curve without, however, any radiological evidence of any ventilatory dysfunction of the lung base and/or elevation of the corresponding hemidiaphragm., Conclusion: Our results suggest that radiology, B-mode US and color Doppler US, which are widely used for monitoring OLT patients, can be usefully integrated by M-mode US to evaluate diaphragmatic mobility both pre- and post-operatively. This method is fast, easy to use and widely available.

Purpose: We reassessed the incidence of mucocele of the residual cystic duct in our series of orthotopic liver transplantation (OLT) patients., Material and Methods: We examined a series of 283 liver transplants with end-to-end choledocho-choledocal anastomosis (263 patients, 163 men and 80 women, 24-65 years old), performed at the II Surgical Department of the University of Bologna from May 1986 to April 1999 and subsequently followed-up in our Institute. All patients were examined with gray-scale and color Doppler US and some also underwent CT and CT cholangiography., Results: An anechoic ovoidal structure just before the portal vein and in proximity of the main bile duct was found in 13 patients. US and CT findings, the latter when available, led us to make a diagnosis of nonobstructive mucocele of the cystic duct. The radiological diagnosis was eventually confirmed by clinical and surgical findings., Discussion and Conclusions: In our series the incidence of this complication was 4.5%, a slightly higher value than those reported in the literature. Cystic duct mucocele cannot be considered an uncommon complication and should thus be more carefully searched for by operators. In our experience this complication never required reoperation for cholestasis.

The contribution of the sn-glycerol-3-phosphate (G-3-P) shuttle in the control of energy metabolism is well established. It is also known that its activity may be modulated by hormones involved in thermogenesis, such as thyroid hormones or dehydroepiandrosterone and its metabolites, that act by inducing de novo synthesis of mitochondrial G-3-P dehydrogenase (mGPDH). However, little is known as to the factors that may influence the activity without enzyme induction. In the present study we investigated the possible role of the G-3-P shuttle in the thermogenic response to different hypothermic stresses. It was found that a decrease of body temperature causes the liver rapidly to enhance mGPDH activity and G-3-P-dependent respiration. The enhancement, which does not result from de novo synthesis of enzymes, has the potential of increasing heat production both by decreased ATP synthesis during the oxidation of G-3-P and by activation of the glycolytic pathway., (Copyright 2000 Academic Press.)

The adoption of an erect posture was an important step in human evolution for its consequent redimensioning of organisms and functions, in addition to its strictly evolutionary results. Formation of the sole to provide three-point support and better support of the front of the body--this being now deprived of direct support and thus compelled to rest on low-set, rear supports--was accompanied by the release and upward shift of the front limbs for use in tasks, such as gripping and carrying, formerly performed by the jaws; the latter, moreover, regressed so as to cause a variation in favour of the neural as opposed to the facial cranium and an increase in brain capacity, available nerve circuits, and so-called "higher faculties". Intelligence, in the classic sense of "Umschaltungsfähigkeit" is included among the latter. The present study sets a more rational background for flat feet and talipes equinus. These ase seen as signs of a single process, flat feet being a form of extreme hypo-evolution in three orthopaedic degrees, and equinus a manifestation of excessive development in the opposite direction. This contention is supported by comparative evidence, using data from other animal species. In man, various stages involve different races and are dependent on both habits and habitat, or indeed on the need for survival. Extensive references are made to the literature and the subject is updated and viewed as an example of "reasoned evolution".