Aim:Pneumothorax is a potentially life-threatening condition whose diagnosis can be challenging. Ultrasound chest examination is generally fast and user-friendly, but in non-expert hands or with uncooperative patients, it may still be difficult and time-consuming. Adding another tool to support the suspicion of pneumothorax might be useful, potentially enhancing the diagnostic accuracy of standard ultrasound chest examination. We evaluated the feasibility of standardized bilateral ultrasound image comparison as a potential new tool for pneumothorax diagnosis. Materials and methods:We enrolled 60 subjects (30 with pneumothorax and 30 controls) and collected bilateral ultrasound images of their chests (each image contained one frame from the left lung and one from the right lung). Ten physicians (eight blinded to diagnosis) divided into five groups according to expertise evaluated the images for potential grayscale differences and/or horizontal artifacts between the two frames. All images were then analyzed with image analysis software for grayscale pixel assessment (one sub-analysis for the entire area under the pleural line, one for a 100-pixel-wide rectangle under the pleural line). Results:All clinicians achieved good results in terms of diagnostic accuracy and inter-operator reliability, even those unexperienced in ultrasound. Mean, range, and median grayscale pixel ratio between the pneumothorax side and the healthy side in a single patient proved to be the most reliable parameters, reaching excellent sensitivity and specificity. Combining these parameters proved to be an excellent diagnostic tool (ROC area under curve = 1.00, p-value = 0.02). Conclusions:Standardized bilateral thoracic ultrasound image comparison may be a potential new tool for the diagnosis of pneumothorax.

BACKGROUND AND OBJECTIVES:Diagnosis of tuberculous pleurisy (TP) may be challenging and it often requires pleural biopsy. A tool able to increase pre-test probability of TP may be helpful to guide diagnostic work-up and enlargement of internal mammary lymph node (IMLN) has been suggested to play a potential role. The aim of the present investigation was to assess role of IMLN involvement in TP in a multi-centric case-control study, by comparing its prevalence and test performance to those observed in patients with infectious, non-tuberculous pleurisy (NTIP), and in controls free from respiratory diseases (CP). METHODS:A total of 419 patients, from 14 Pulmonology Units across Italy were enrolled (127 patients affected by TP, 163 affected by NTIP and 129 CP). Prevalence, accuracy and predictive values of ipsilateral IMLN involvement between cases and control groups were assessed, as well as concordance between chest computed tomography (CT scan) and thoracic ultrasound (TUS) measurements. RESULTS:The prevalence of ipsilateral IMLN involvement in TP was significantly higher than that observed in NTIP and CP groups (respectively 77.2%, 39.3% and 14.7%). Results on test performance, stratified by age, revealed a high positive predictive value in patients aged ≤50 years, while a high negative predictive value in patients aged >50 years. The comparison between CT scan and ultrasound showed moderate agreement (Kappa=0.502). CONCLUSIONS:Evaluation of IMLN involvement plays a relevant role in assessing the pre-test probability of TP. Considering the increasing global prevalence of mycobacterial infections, a tool able to guide diagnostic work-up of suspected TP is crucial, especially where local sources are limited.

Introduction: No studies correlated ultrasonographic evaluation with doppler technique of subglottic stenoses with endoscopic measures. Aims and Objectives: The diagnosis of subglottic stenoses can be challenging and delayed. The gold standard is flexible bronchoscopy, which assesses the mobility of the vocal cords, the location, length and size of the stenosis. Ultrasonography isn’t frequently part of the diagnostic process, least of all doppler technique. Methods: We enrolled 22 patients with subglottic stenoses and 22 control patients. They underwent a bronchoscopic evaluation of the size of the tracheal lumen and subsequent ultrasonographic examination of the neck with doppler technique, both in inspiration and expiration, before and after the treatment. Results: We observed a significant difference between ultrasonographic doppler evaluation before and after the endoscopic treatment (Fig. 1), both in inspiration and expiration (p<0,001). Also, the difference between the tracheal lumen of the two populations was statistically significant. We observed no differences between ultrasonographic and endoscopic measures, both in inspiration (p=0,640) and expiration (p=0,067). Conclusions: Diagnosing and evaluating subglottic stenoses via ultrasounds with doppler technique strongly correlates with endoscopic measures. The use of doppler may ease this process, especially in case of doubt. Figure 1

Covid-19 in immunocompromised patients shows a prolonged course and may lead to a poor prognosis. Although data on hyperimmune plasma for treatment of Covid-19 suggest an improved outcome in immunocompetent patients, limited data are currently available in immunocompromised patients. We present the case of a 62-year-old Caucasian woman, who was previously treated with obinutuzumab and bendamustine for follicular lymphoma and showed a prolonged positive test for Covid-19. Since no improvement was observed with standard of care (including remdesivir), the possibility of hyperimmune plasma infusion was discussed. A first dose of hyperimmune plasma was administered, with subsequent onset of fever, increasing inflammatory indexes and worsening radiological findings. Three days later a second dose of plasma was administered. Within twelve hours cough and fever disappeared, and oxygen at rest was discontinued. The patient was discharged 5 days later, and nasopharyngeal swabs resulted negative 16 days after discharge.

Angiosarcoma is a rare malignancy of vascular origin, mostly originating from skin, soft tissues, and breast, but rarely also from the pleura. We present the case of a 55-year-old man who referred to our hospital for a spontaneous bilateral hemothorax. The CT angiography did not show any source of active bleeding; plus, no pleural or lung masses were observable. Cytological and microbiological analyses made on a sample of pleural fluid resulted negative. Despite numerous blood transfusions and thoracenteses, the patient deceased from hemorrhagic shock ten days later and the diagnosis of primary pleural epithelioid angiosarcoma was obtained only by autopsy. Additionally, we present a review of the literature about primary pleural angiosarcomas.

Introduction: Diagnosing pneumothorax (PTX) is often compared with a potentially poor prognosis, leading clinicians to find new ultrasound (US) signs to obtain a more confident diagnosis. Aims and objectives: To assess the diagnostic yield of a potential new US sign for PTX diagnosis. Methods: We designed a prospective case-control study; patients were evaluated with chest US in supine position, collecting a double-view image with two frames: one from the left lung and one from the right lung. An objective analysis, relying on an image-editing program, compared selected areas of 100-pixel width on both sides, whereas a subjective one included 10 different physicians, divided into 5 groups (4 blinded), answering whether the two sides differed by greyscale and/or horizontal artifacts. Results: 60 patients were enrolled (30 cases). The objective analysis showed a significant difference between the PTX side and the contralateral one, as opposed to the control group. We focused on the ROC curves with the higher area under curve (AUC). The combination of mean ratio (AUC 0.98), range ratio (AUC 0.89) and median ratio (AUC 0.95) resulted in a perfect curve (AUC=1.0). No significant differences were observed among the 5 different groups of physicians. Conclusions: Our results suggest this may be a potential new tool for diagnosing PTX; it could lead to new US software development, allowing physicians to obtain a much more confident diagnosis.

SESSION TITLE: Late-breaking Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: The aim of the study was to assess the presence of small airways dysfunction and the potential correlation with the presence of Z-AAT polymers obtained by Exhaled Breath Condensate (EBC) collection in PiZZ subjects, comparing with matched healthy PiMM subjects. METHODS: We enrolled 17 asymptomatic non-smoker subjects: 9 PiZZ and 8 PiMM as controls, without obstructive ventilatory defect (i.e.: normal FEV1/VC ratio). All subjects underwent complete pulmonary function tests (PFT). EBC was collected in PiZZ patients. ELISA test was applied to search for Z-AAT polymers. RESULTS: The PiZZ subjects showed normal lung volumes and DLCO values. However, In comparison with PiMM subjects, the single breath test N2 wash-out revealed significant differences regarding the phase III slope (1.5±0.4 N2/L vs 1.1±0.3 N2/L) and the closing volume/vital capacity ratio (14.3±4.5 % vs 9.5±5.3 %) (p<0.05) in the PiZZ subjects. The ELISA test detected the presence of Z-AAT polymers in 4 PiZZ patients. No correlations were found between polymers levels and any functional respiratory parameter. CONCLUSIONS: PiZZ subjects showed small airways dysfunction when compared to PiMM subjects. Surprisingly, Z-AAT polymers were found only in 4 PiZZ subjects; this is probably due to the sample methodology. New studies are needed to evaluate the correlation between bronchial Z-AAT polymers and small airway impairment in subjects with Z-AAT deficiency. CLINICAL IMPLICATIONS: The presence of Alpha1-Antitrypsin (AAT) polymers that are pro-inflammatory has been previously demonstrated in bronchial biopsies of subjects with Z-AAT deficiency (Respir Res, 2014 Sep 14;15:112), suggesting a possible role in the development of COPD. DISCLOSURES: No relevant relationships by Marianna Arici, source=Web Response No relevant relationships by Jordan Franz Giordani, source=Web Response No relevant relationships by Guido Levi, source=Web Response No relevant relationships by Laura Pini, source=Web Response No relevant relationships by Chiara Rocchetti, source=Web Response No relevant relationships by Claudio Tantucci, source=Web Response No relevant relationships by Laura Tiberio, source=Web Response

TYPE: Abstract Publication TOPIC: Diffuse Lung Disease PURPOSE: Analyze the natural history of AATD subjects identified during the twenty-five years’ experience of the Referral Center of Spedali Civili, Brescia (Italy). METHODS: Retrospective clinical analysis of patients referred to our Center since January 1996 up to January 2020. The inclusion criterion was a diagnosis of AATD via genotyping or protein phenotyping. RESULTS: 1021 patients were included (53% males). At the time of diagnosis, mean AAT serum level was 79±27 mg/dL. We diagnosed 825 simple heterozygotes (genotype PiMZ 65%), 117 compound heterozygotes (genotype PiSZ 54%) and 79 homozygotes (genotype PiZZ 82%); 151 (15%) patients were carriers of rare variants, especially Mmalton (35). Index cases (diagnosed due to diseases correlated with AATD) were 223 (22%), 70 of them suffered from emphysema. Among non-index cases, family history for AATD was the most common cause of diagnosis (70%). Augmentation therapy was prescribed in 38 patients; no adverse drug reactions were observed. FEV1 annual decline (mL/year) and the annual trend of blood transaminases have been evaluated. CONCLUSIONS: Z-AAT resulted the most common variant, although many rarer ones are present. Experienced Referral Centers are crucial for AATD correct management and to carry out a timely diagnosis. Our final data regarding natural history of AATD will let clinicians better understand the prognosis of AATD, supporting them to make the better medical decision. CLINICAL IMPLICATIONS: This research increases the knowledge on AATD natural history and its optimal management. DISCLOSURE: No significant relationships. KEYWORDS: Alpha1-Antitrypsin deficiency, Retrospective Analysis, AATD

Introduction: The presence of Alpha1-Antitrypsin (AAT) polymers that are pro-inflammatory has been previously demonstrated in bronchial biopsies of subjects with Z-AAT deficiency (Respir Res, 2014 Sep 14;15:112), suggesting a possible role in the development of COPD. Aim: The aim of the study was to assess the presence of small airways dysfunction and the potential correlation with the presence of Z-AAT polymers obtained by Exhaled Breath Condensate (EBC) collection in PiZZ subjects, comparing with matched healthy PiMM subjects. Methods: We enrolled 17 asymptomatic non-smoker subjects: 9 PiZZ and 8 PiMM as controls, without obstructive ventilatory defect (i.e.: normal FEV1/VC ratio). All subjects underwent complete pulmonary function tests (PFT). EBC was collected in PiZZ patients. ELISA test was applied to search for Z-AAT polymers. Results: The PiZZ subjects showed normal lung volumes and DLCO values. However, In comparison with PiMM subjects, the single breath test N2 wash-out revealed significant differences regarding the phase III slope (1.5±0.4 N2/L vs 1.1±0.3 N2/L) and the closing volume/vital capacity ratio (14.3±4.5 % vs 9.5±5.3 %) (p<0.05) in the PiZZ subjects. The ELISA test detected the presence of Z-AAT polymers in 4 PiZZ patients. No correlations were found between polymers levels and any functional respiratory parameter. Conclusions: PiZZ subjects showed small airways dysfunction when compared to PiMM subjects. Surprisingly, Z-AAT polymers were found only in 4 PiZZ subjects; this is probably due to the sample methodology. New studies are needed to evaluate the correlation between bronchial Z-AAT polymers and small airway impairment in subjects with Z-AAT deficiency.

Background Undifferentiated connective tissue disease (UCTD) is a group of systemic autoimmune conditions not fulfilling the classification criteria for a definite connective tissue disease (CTD). While an average of 20–40% of UCTD patients develop a defined CTD during follow-up, the remaining patients maintain an undefined diseases. Objectives The objective was to assess flare or differentiation into well-defined CTD of UCTD newly diagnosed during pregnancy and to evaluate the prevalence of obstetric complications in the context of the new diagnosis. Methods We examined 54 patients with UCTD newly diagnosed during pregnancy, followed during pregnancy and after delivery at our rheumatologic unit. Diagnosis of UCTD was made at the time of pregnancy. Women in their first trimester (T0) were screened using a two-step approach using a self-administered 10-item questionnaire, a subsequent testing for rheumatic autoantibodies (ANA, anti-dsDNA, ENA, anticardiolipin antibodies, anti-β2-glycoprotein I antibodies and lupus anticoagulant) and evaluation by a rheumatologist, who made the final diagnosis. The same questionnaire was re-administered at least one year after delivery (T1) and the same rheumatic autoantibodies were tested at the same time. Results Fourty-two patients (77.77%) showed persistence or worsening of symptoms and 45 (83.33%) had at least one positivity for autoantibodies at T1. The diagnosis of UCTD was confirmed in 29 patients (53.70%). Sixteen (16/54) women (29.62%) received a final diagnosis of another rheumatic disease: 12 patients with systemic lupus erythematosus (22.22%), 2 (3.70%) antiphospholipid syndrome, 1 (1.85%) spondyloarthritis and 1 (1.85%) Behçet disease. Amelioration of symptoms with a resulting unconfirmed diagnosis was seen among 9/54 (16.67%) of them. We then focused on the pregnancy that was ongoing at T0. We observed some obstetrical complications: 3 miscarriages, 3 fetal loss, 6 hypertensive disorders, 4 intrauterine growth restriction, 6 preterm deliveries and 8 small for gestational age babies. These major obstetrical complications were not significantly different in the three different groups of new diagnoses. Also in the univariate analysis performed through Fisher9s test for each single obstetric complication there was no significant difference between groups. Conclusions The questionnaire is an optimal screening method to detect undiagnosed rheumatic diseases in pregnancy, in particular UCTDs. Furthermore, in spite of their evolution or remission, UCTDs are always associated with negative effects on the outcome of pregnancy. References Spinillo A, Beneventi F, Epis OM, Montanari L, Mammoliti D, Ramoni V, et al. Prevalence of undiagnosed autoimmune rheumatic diseases in the first trimester of 87 pregnancy. Results of a two-steps strategy using a self-administered questionnaire and autoantibody testing. BJOG An Int J Obstet Gynaecol 2008;115:51–7. Spinillo A, Beneventi F, Ramoni V, Caporali R, Locatelli E, Simonetta M, et al. Prevalence and significance of previously undiagnosed rheumatic diseases in pregnancy. Ann Rheum Dis 2012;71:918–23. Disclosure of Interest None declared