Quantitative lung ultrasound (LUS) has emerged as a way to improve current LUS data analysis, based on the visual interpretation of imaging patterns. However, most studies on quantitative LUS have neglected dynamic imaging patterns. Among these, pleural sliding is well-known for its clinical relevance, but few studies have focused on its quantitative characterization. Therefore, in this study, we introduce a novel methodology to estimate the velocity of pleural sliding inspired by functional ultrasound (fUS). Additionally, we assessed, through binary classifiers, the potential of this feature in distinguishing between lung pathologies. We applied the methodology to two in-vivo datasets, comprising multifrequency RF data acquired from patients affected by cardiogenic pulmonary edema (CPE), pneumonia, COPD, fibrosis, and exacerbated. Specifically, we analyzed a total of 536 multifrequency LUS videos from 79 patients. The resulting sliding velocity values were within the physiological range (≈0.49 mm/s - ≈ 4.39 mm/s). Among all pathological populations, COPD was characterized by the minimum velocity and pneumonia by the maximum velocity, on average. The statistical analysis highlighted some statistically significant differences, especially when comparing COPD with the other pathologies. These differences were confirmed also with binary classifiers that showed accuracies up to 94.06% (when differentiating between COPD and pneumonia). These results demonstrate the potential of this novel methodology to extract clinically valuable information and highlight its applicability in future diagnostic processes.

Pancreatic cystic lesions (PCLs) are increasingly detected due to the widespread use of cross-sectional imaging and represent a significant diagnostic challenge because of their heterogeneous biological behavior, ranging from benign lesions to neoplasms with malignant potential. Accurate characterization and risk stratification are essential to guide appropriate management and avoid unnecessary surgical interventions. Conventional imaging modalities, including computed tomography (CT), magnetic resonance (MR) imaging, and endoscopic ultrasound (EUS), remain central to the diagnostic work-up; however, their ability to reliably differentiate cyst subtypes and predict malignant transformation remains limited. In recent years, artificial intelligence (AI) and radiomics have emerged as promising approaches for improving the non-invasive characterization of PCLs by extracting quantitative imaging features beyond those appreciable through visual assessment. This narrative review summarizes the current evidence regarding CT- and MR-based radiomics and AI in pancreatic cyst characterization, focusing on their role in differentiating mucinous from non-mucinous cysts, identifying high-risk intraductal papillary mucinous neoplasms (IPMNs), and supporting clinical decision-making. The potential advantages of these techniques are discussed alongside main methodological limitations, including variability in imaging acquisition protocols, segmentation reproducibility, small and often retrospective datasets, limited external validation, and interpretability of AI-based models. Further multicenter studies, standardized radiomic pipelines, and prospective validation are required before these tools can be reliably integrated into routine clinical practice.

BACKGROUND:Sedation has become an essential component of modern interventional pulmonology, accompanying the progressive expansion of bronchoscopic procedures from conventional diagnostic bronchoscopy to advanced diagnostic and therapeutic airway interventions. Despite its increasing relevance, sedation practices remain heterogeneous, and dedicated national recommendations specifically addressing interventional pulmonology are still lacking in many countries. METHODS:A national cross-sectional survey was conducted among physicians involved in interventional pulmonology practice through the Accademia di Ecografia Toracica (ADET) network. The questionnaire consisted of 29 structured items covering organizational models, pharmacological strategies, monitoring approaches, and safety-related aspects of procedural sedation. Responses were analyzed descriptively using proportions, medians, and interquartile ranges. Agreement was operationally defined as a Likert score of 4-5 in at least 70% of responses. RESULTS:Forty-one responses were included in the final analysis. Sedation was routinely integrated into procedural activity in most centers, although relevant variability emerged regarding sedation management, monitoring practices, and anesthesiology involvement. The strongest agreement concerned the need for national recommendations to standardize sedation practices (80.5% agreement), followed by recognition that anesthesiologist presence is required during high-risk interventional procedures (73.2%). Substantial agreement emerged regarding pulmonologist-led moderate sedation in selected settings (68.3%), while capnography did not reach clear consensus (44.7%). Limited anesthesia availability was considered a relevant organizational factor by 63.2% of respondents. CONCLUSIONS:Among participating clinicians, sedation was widely integrated into routine interventional pulmonology practice but remained organizationally heterogeneous. The survey identified broad agreement regarding the need for national harmonization and dedicated anesthesiology support for high-risk procedures. Given the network-based recruitment strategy and the absence of procedural volume data, these findings should be considered exploratory and hypothesis-generating rather than fully representative of national practice.

We comment on the recent observational study by Hopley et al reporting outcomes of 17-year branch duct intraductal papillary mucinous neoplasm surveillance and proposing de-escalation criteria based on cyst stability below 30 mm and serum carbohydrate antigen 19-9 below 43 KU/L after two years of follow-up. While acknowledging the clinical value of these findings, we raise several radiological concerns that deserve further consideration before these criteria can be safely implemented across institutions. Specifically, we discuss the absence of standardised imaging protocols and field strength reporting, the well-documented inter-observer variability in magnetic resonance imaging (MRI)-based cyst size measurement, the evolving radiological definitions of worrisome and high-risk features across guidelines updates, the complementary roles of MRI/ magnetic resonance cholangiopancreatography and endoscopic ultrasound, and the lack of a specified imaging algorithm for the de-escalated surveillance phase. These considerations are intended to help refine the safe implementation of the proposed de-escalation strategy rather than to argue against it.

Introduction: Clinical reasoning in medicine is a complex cognitive process that integrates sensory perception, interpretation, and abductive inference to develop diagnostic hypotheses. Despite the rise of artificial intelligence, the patient-clinician encounter remains rooted in semiotics and a probabilistic approach driven by Bayesian updating. In this context, medical knowledge is viewed as context-dependent and subject to continuous revision based on new clinical signs. Main body: This paper identifies bedside ultrasonography as a transformative "epistemic mediator" that enhances traditional semiotics by uncovering subtle clinical signs often missed by conventional inspection, palpation, percussion, and auscultation. In managing respiratory diseases, ultrasound provides direct, contextualized data that refines the interpretation of findings such as dullness, altered fremitus, and crackles by linking them to specific anatomical correlates. Based on these principles, the AdET-CHEPHEUS initiative proposes a new paradigm for chest physical examination centered on three pillars: 1) Visual inspection; 2) Auscultation integrated with ultrasound; 3) Palpatory ultrasound evaluation Conclusion: By replacing traditional percussion with more informative and reproducible ultrasound-based methods, this model aligns modern technology with classical clinical epistemology. The integration of ultrasound into bedside reasoning represents a vital evolution in chest semiotics, preserving the human element of the diagnostic process while increasing accuracy.

Percutaneous biliary interventions are indicated for both benign or malignant biliary strictures to treat obstructive jaundice and/or biliary leak. Major vascular complications include active bleeding or more frequently pseudoaneurysm formation, bilio-portal, bilio-venous or arterio-biliary fistulae and intra- or peri-hepatic hematoma. Such adverse events can occur during the procedure itself or, more often, several days to weeks after the initial procedure. Major vascular complications frequently manifest with symptoms of hemobilia (jaundice, pain, melena or hemochezia and reduced serum hemoglobin levels), which in some cases lead to life-threatening hemodynamic compromise. Computed tomography angiography is mandatory to diagnose the cause and site of bleeding, while simultaneously depicting the anatomy, in order to plan the treatment. Covered stents, liquid embolic agents and coils are the commonest devices used, depending on the underlying pathology. Although such complications are rare, they are frequently life-threatening, and require prompt treatment. Therefore, interventional radiologists must be proficient in their management. This narrative minireview aims to outline management strategies of the most frequent intra- or post-procedural vascular complications following biliary interventions.

BACKGROUND:Cryoablation is a specific minimally invasive thermal ablation technique that destroys tumor targets using low temperatures, freezing the pathological tissue and forming an "ice ball" around it. The aim of this study is to analyze how the reduction in freezing intensity during a cryoablation procedure affects the size of the ice ball. MATERIALS AND METHODS:The experimentation was conducted on room-temperature ultrasound gel, using the ICEfx™ cryoablation system with IceSphere™ needles in single and multiple configurations (double, triple, and quadruple). Each configuration was studied using a freezing intensity of 100%, 70%, 50%, and 20%, with a single 10-minute freezing cycle. CT scans of the gel cubes were performed at the end of each freezing cycle to measure the dimensions of the individual ice balls. RESULTS:Results show that the reduction in freezing intensity affects the size of the ice balls in a nonlinear but exponentially decreasing manner. Furthermore, the calculation of the decrement factors for each dimension, for every configuration and intensity level, highlighted that the width and depth of the ice ball are the most reduced dimensions, while the height values undergo minimal variation. CONCLUSION:This study provides the operator with a practical guide for customizing and optimizing in vivo cryoablation. This enables careful selection of the best configuration and freezing intensity to ensure the exclusion of adjacent sensitive anatomical structures that need to be preserved from freezing.

Interstitial lung diseases (ILDs) encompass a heterogeneous group of disorders characterized by varying degrees of inflammation and fibrosis. Despite advances in understanding the pathogenesis, therapeutic options remain limited, particularly for patients with progressive phenotypes. Current international guidelines for idiopathic pulmonary fibrosis (IPF) and progressive pulmonary fibrosis (PPF) emphasize the need for antifibrotic strategies and call for novel pharmacological interventions targeting key molecular pathways involved in fibrogenesis. This review provides a comprehensive overview of the most promising emerging pharmacological agents for ILDs, with particular attention to their mechanisms of action, efficacy, and safety profiles as reported in recent preclinical and clinical studies. The recent approval of Nerandomilast and the ongoing phase III trials of other agents mark a pivotal transition toward a new generation of antifibrotic therapies, aiming to achieve more effective disease control and improved patient outcomes. In view of an enlargement of active drugs aiming at controlling the disease with different mechanisms, the Authors underline the need for a "precision medicine" model to be applied to each ILD phenotyped patient, mirroring what already happens for other respiratory diseases.

Small-airway disease (SAD) is a key feature of severe asthma and is associated with poor symptom control and frequent exacerbations. Dupilumab has demonstrated efficacy in improving lung function and reducing exacerbations, but real-world evidence on its effects in SAD remains limited. The aim of this study is to evaluate the impact of 12 months of dupilumab treatment on SAD, clinical outcomes, and type 2 inflammation. We included 21 patients. Small-airway function was assessed by impulse oscillometry (R5-R20) and spirometry FEF25-75% predicted at baseline (T0) and after 3 (T3), 6 (T6), and 12 (T12) months of treatment. Additional assessments included FEV1, the Asthma Control Test (ACT), exacerbation frequency, oral corticosteroid (OCS) use, the blood eosinophil count (BEC), and fractional exhaled nitric oxide (FeNO). At baseline, 62% of patients exhibited SAD (R5-R20 > 0.07 kPa/L/s). Dupilumab treatment led to a significant and sustained improvement in small-airway function: mean R5-R20 decreased from 0.18 ± 0.17 kPa/L/s to 0.09 ± 0.07 at T12 (p = 0.04), while predicted FEF25-75% increased from 29.5 ± 20.8% to 47.0 ± 21.1% (p < 0.001). ACT scores improved from 13.1 ± 4.9 to 19.6 ± 3.8 (p < 0.001). FeNO levels declined from 64.1 ± 50.7 ppb to 24.8 ± 20.9 ppb (p = 0.01). Improvements in R5-R20 correlated with better ACT and FeNO reductions. In this real-world cohort, dupilumab significantly improved SAD, lung function, and asthma control, while reducing exacerbations, OCS dependence, and type 2 inflammation over 12 months.

Respiratory distress is the main reason for the admission of infants to the neonatal intensive care unit (NICU). Rapid identification of the causes of respiratory distress and selection of appropriate and effective treatment strategies are important to optimise favourable short- and long-term patient outcomes. Lung ultrasound (LUS) technology has become increasingly important in this field. According to the scientific literature, LUS has high sensitivity (92–99

BACKGROUND:Chest physical exam (CPE) is based on the four pillars of classical semiotics. However, CPE's sensitivity and specificity are low, and is affected by operators' skills. The aim of this work was to explore the contribution of chest ultrasound (US) to the traditional CPE. METHODS:For this purpose, a survey was submitted to US users. They were asked to rate the usefulness of classical semiotics and chest US in evaluating each item of CPE pillars. The study was conducted and described according to the STROBE checklist. The study used the freely available online survey cloud-web application (Google Forms, Google Ireland Ltd, Mountain View, CA, USA). RESULTS:The results showed a tendency to prefer chest US to palpation and percussion, suggesting a possible -future approach based on inspection, auscultation and palpatory ultrasound evaluation. CONCLUSION:The results of our survey introduce, for the first time, the role of ultrasound as a pillar of physical examination. Our project CHEPHEUS has the aim to study and propose a new way of performing the physical exam in the future.

Deep learning approaches in lung ultrasound (LUS) imaging classification traditionally focus on the frame-level prediction, employing a severity score system ranging from score 0 to score 3. In clinical practice, LUS patterns are evaluated at the video level. Current threshold-based method aggregates scores from frame to video level by finding a single optimal threshold across all score levels. To better align with clinical evaluation practices, we proposed the first hierarchical binary classification (HBC) algorithm to find optimal thresholds for each score level. Top-to-bottom (score 3 to 0) and bottom-to-top (score 0 to 3) approaches are explored, where optimal thresholds serve as binary classifiers to separate videos of current score from non-current score groups. We evaluated the generalization capability of the HBC approach on 2 LUS datasets that contain different patient populations. Results show that hierarchical binary classification algorithm performs comparably to state-of-the-art, demonstrating its strong generalization ability across different patient populations.

Severe asthma exacerbations have high morbidity and mortality. The management can be challenging, and the optimal strategy for patients admitted to the intensive care unit (ICU) with life-threatening and near-fatal asthma has not been fully defined. An interesting area of research is represented by the rescue or compassionate use of biological drugs when all treatments fail, including advanced interventions such as extracorporeal membrane oxygenation. This systematic review analyzes the cases described in the literature and discusses characteristics, treatments, and outcomes of patients who received asthma-approved monoclonal antibodies as rescue therapy following admission to the ICU due to near-fatal asthma exacerbations or status asthmaticus refractory to conventional treatments. A total of 14 studies (13 case reports and 1 case series) were included according to the prespecified inclusion and exclusion criteria. Various monoclonal antibodies were administered, most commonly benralizumab and omalizumab. Treatment was generally initiated within the first week of ICU admission, with nearly half of the patients receiving therapy within 5 days. Further research, including randomized controlled trials, is required to assess if this therapeutic option impacts ICU outcomes, which specific biologics could be used, and their eventual optimal timing and dosage.

BACKGROUND:Tuberculosis (TB) prevention is a major goal in teaching hospital setting. Because of the possible progression or reactivation of latent disease, the screening of both health-care workers (HCWs) and students is an important issue in the TB control program. OBJECTIVE:to deploy a web-based platform interoperating health surveillance systems from different hospitals to define models based on the highlighted risk factors to predict the occurrence of Latent Tuberculosis Infection (LTBI) and to define prevention strategies and interventions. METHODS:This is a cross-sectional ambispective observational study without drug and device. The primary endpoint is the prevalence of LTBI. The secondary endpoint is the identification of possible risk factors of LTBI in a large cohort of HCWs and students. CONCLUSIONS:This study aims to enrich the primary prevention measures against TB, having a high socio-economic-health impact in high-risk populations (HCWs and students) through an interoperable digital approach based on data obtained in three large Italian teaching hospitals. ClinicalTrials.gov: NCT05756582.

Tuberculous pleural effusion (TPE) is currently the most common form of extrapulmonary tuberculosis and remains a significant cause of pleural disease worldwide, particularly in endemic regions. It often presents with non-specific clinical symptoms, such as fever, chest pain, cough and weight loss, thereby complicating the diagnostic process. This narrative review provides an expert comprehensive clinical practice overview covering the following issues correlated with diagnosis and management of TPE: 1- epidemiology, clinical presentation and underlying pathophysiology; 2- limitations of conventional diagnostic procedures on pleural fluid; 3- usefulness of thoracic ultrasound (TUS) in the stepwise pathway 4- role of thoracoscopy as a golden diagnostic tool, with the proposal of a step by step algorithm. A large iconography enriches the review from the educational point of view by presenting a pictorial series of characteristic sonographic and thoracoscopic findings.