Search Results (301)

Chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF) are pathologies that impact mortality and morbidity worldwide. These chronic diseases have multiple causes, and they share some common clinical symptoms, such as diaphragm dysfunction (DD) and cognitive decline (CD), which, in turn, increase the mortality and morbidity rates in patients with COPD and CHF. One of the causes of CD is impaired glymphatic system function, with an accumulation of proteins and metabolites in the central nervous system. The glymphatic system is a structure that has not yet been widely considered by researchers and clinicians. Three key factors stimulate the ongoing physiological function of the glymphatic system: autonomic balance, heart rate, and, most importantly, the diaphragm. All these factors are altered in patients with COPD and CHF. This article reviews the relationship between the importance of the diaphragm, the glymphatic system, and CD, focusing on inspiratory rehabilitation training (IMT). Based on the data reported in this narrative review, we can strongly speculate that a consistent regimen of IMT in patients can improve cognitive status, reducing the cascade of symptoms that follow the diagnosis of CD. Further research is needed to understand whether targeting the glymphatic system with IMT is an effective option for helping patients delay the onset of CD. Full article

Flexible laryngoscopy (FL) is the standard diagnostic tool for vocal cord paralysis (VCP), but it involves patient discomfort, and its interpretation is subjective and operator-dependent. Dynamic digital radiography (DDR) is a novel imaging technique that acquires high-resolution sequential radiographs at a low radiation dose. While DDR has been widely applied in chest and diaphragmatic imaging, its use for laryngeal motion analysis has been poorly investigated. We present the case of a 50-year-old male referred for Computed Tomography (CT) of the neck and chest for suspected vocal cord paralysis. The referring physician did not specify the side of the suspected paralysis. Due to a language barrier and the absence of prior documentation, a detailed history could not be obtained. To assess vocal cord motion, we performed, for the first time in our Institution, a DDR study of the neck. During phonation maneuvers, DDR demonstrated fixation of the left vocal cord in an adducted paramedian position. CT confirmed this finding and did not highlight any further anomaly. This case demonstrates the feasibility of DDR as a low-cost, low-dose, non-invasive technique for functional evaluation of the larynx and may represent a valuable complementary imaging tool in laryngeal functional assessment. Full article

Background: Uncontrolled asthma remains a significant clinical challenge, often linked to impaired lung function and increased diaphragmatic workload. Recent studies have shown promising results using a triple inhaled therapy comprising beclomethasone dipropionate/formoterol fumarate/glycopyrronium (BDP/FF/G). This study assessed the real-world efficacy of BDP/FF/G on lung function and diaphragmatic workload in patients with uncontrolled asthma. Methods: A prospective observational study enrolled 21 adult patients diagnosed with uncontrolled asthma despite high-dose ICS/LABA therapy. Patients underwent lung function tests and right diaphragmatic ultrasound assessments at baseline and after three months of treatment with BDP/FF/G (172/5/9 mcg, administered as two inhalations every 12 h). Results: After three months, significant improvements were observed in FEV₁ (from 57.75 ± 12.30% to 75.10 ± 18.94%, p < 0.001) and FEF_25–75 (from 47.80 ± 19.23% to 75.10 ± 36.06%, p < 0.001). Additionally, during the same period, we recorded significant reductions in residual volume (from 130.10 ± 28.20% to 92.55 ± 21.18%, p < 0.001) and total airway resistance (R_tot) (from 164.60 ± 83.21% to 140.70 ± 83.25%, p < 0.05). The mean asthma control test (ACT) score increased by 5.6 points (p < 0.001), surpassing the established minimal clinically important difference (MCID) of 3 points and raising the cohort mean above the well-controlled threshold. The right diaphragmatic workload was significantly decreased, as shown by a reduction in thickening fraction (TF) (from 63.86 ± 17.67% to 40.29 ± 16.65%, p < 0.01). Correlation analysis indicated significant associations between diaphragmatic function and some lung function parameters (FEV₁, FEF_25–75, and R_tot). Conclusions: In this real-world pilot, triple BDP/FF/G was linked to improvements in airflow, hyperinflation, symptoms, and a reduction in diaphragmatic thickening fraction, indicating potential physiological benefit. Due to the small sample size, single-centre design, and 3-month follow-up, these results should be viewed as hypothesis-generating and need to be confirmed in larger, controlled, multicentre studies with longer follow-up. Full article

Background: Noninfectious complications of peritoneal dialysis (PD) are common in infants. Mechanical dysfunctions with abdominal compartment syndrome, hydrothorax with respiratory failure, and medication-induced chyloperitoneum are rare during PD. In this case report, we aim to present several life-threatening events and the timely management of a PD infant. Case Presentation: This male infant is a case of infantile nephronophthisis, NPHP3/renal-hepatic–pancreatic dysplasia type 1, with end-stage kidney disease, and he received PD therapy at 4 months of age. Because of the young age with low body weight and hepatosplenomegaly with a limited abdominal cavity, intra-abdominal pressure-associated noninfectious complications frequently occurred. Acute respiratory failure with abdominal dullness was detected at 5 months of age. Abdominal compartment syndrome caused by PD catheter outflow obstruction from omental wrapping was diagnosed via laparoscopic revision surgery. Hyperkalemia, decreased PD drainage volume, and sudden respiratory distress occurred at 10 months old. Hydrothorax due to pleuroperitoneal communication was confirmed by scintigraphy. After thoracoscopic diaphragmatic bleb repair and plication surgery were performed, no recurrence of hydrothorax was observed. Calcium channel blocker-induced chyloperitoneum was observed at 13 months of age. Chylous ascites disappeared after tapering off the calcium channel blocker in 3 days. After the patient grew up with a larger peritoneal cavity, no more pressure-associated complications of PD occurred. Conclusions: The key to successful treatment of rare and life-threatening noninfectious complications of PD in young infants lies in early detection and timely intervention. A limited abdominal cavity is not a contraindication for PD therapy, especially in very young infants with low body weight, because hemodialysis is not a choice of long-term dialysis modality. Full article

Early prediction of weaning outcomes in mechanically ventilated patients has significant potential to influence the duration of treatment as well as associated morbidity and mortality. This study aimed to investigate the utility of signal analysis using electromyographic diaphragm (EMG) and electrocardiography (ECG) signals to classify the success or failure of weaning in mechanically ventilated patients. Electromyographic signals of 40 subjects were recorded using 5-channel surface electrodes placed around the diaphragm muscle, along with an ECG recording through a 3-lead Holter system during extubation. EMG and ECG signals were recorded from mechanically ventilated patients undergoing weaning trials. Linear and nonlinear signal analysis techniques were used to assess the interaction between diaphragm muscle activity and cardiac activity. Supervised machine learning algorithms were then used to classify the weaning outcomes. The study revealed clear differences in diaphragmatic and cardiac patterns between patients who succeeded and failed in the weaning trials. Successful weaning was characterised by a higher ECG-derived respiration amplitude, whereas failed weaning was characterised by an elevated EMG amplitude. Furthermore, successful weaning exhibited greater oscillations in diaphragmatic muscle activity. Spectral analysis and parameter extraction identified 320 parameters, of which 43 were significant predictors of weaning outcomes. Using seven of these parameters, the Naive Bayes classifier demonstrated high accuracy in classifying weaning outcomes. Surface electromyographic and electrocardiographic signal analyses can predict weaning outcomes in mechanically ventilated patients. This approach could facilitate the early identification of patients at risk of weaning failure, allowing for improved clinical management. Full article

Hypophosphatemia, defined as serum phosphate levels below 2.5 mg/dL, is a common yet underrecognized electrolyte disturbance in critically ill patients, with prevalence estimates reaching up to 80%. This review explores the intricate bidirectional relationship between hypophosphatemia and hyperventilation, emphasizing its profound implications for respiratory function and critical care management. Hypophosphatemia impairs oxygen delivery by depleting 2,3-diphosphoglycerate (2,3-DPG), disrupts central respiratory drive, and weakens respiratory muscles, leading to hyperventilation, ventilatory failure, and prolonged mechanical ventilation. Conversely, hyperventilation exacerbates hypophosphatemia through respiratory alkalosis, triggering intracellular phosphate shifts and metabolic cascades that rapidly deplete serum levels. This cycle creates significant challenges for ventilator weaning and increases morbidity and mortality. Underlying mechanisms include impaired ATP synthesis, altered chemoreceptor sensitivity, and systemic inflammatory responses. Hypophosphatemia-induced hyperventilation manifests as unexplained tachypnea and respiratory alkalosis, often misdiagnosed as anxiety or pain, while hyperventilation-induced hypophosphatemia contributes to diaphragmatic dysfunction and poor ventilatory performance. Common precipitating factors include refeeding syndrome, diabetic ketoacidosis, continuous renal replacement therapy, and malnutrition. Complications extend beyond respiratory dysfunction to include cardiac depression, immune dysfunction, prolonged ICU stays, and increased healthcare costs. Current diagnostic approaches rely on serum phosphate measurements, which poorly reflect total body stores due to significant intracellular shifts. Emerging biomarkers such as fibroblast growth factor 23 (FGF23) and advanced monitoring technologies, including continuous phosphate tracking, may enhance recognition. Treatment strategies emphasize targeted phosphate repletion based on severity, with intravenous supplementation and ventilatory support tailored to minimize complications. Preventive measures, including risk stratification, prophylactic supplementation, and ventilator management, are critical for high-risk populations. Despite advances, knowledge gaps persist in optimizing monitoring and repletion protocols, understanding genetic variations, and identifying ideal phosphate targets for improved respiratory outcomes. This review provides a comprehensive framework for recognizing and managing hypophosphatemia’s impact on respiratory dysfunction in critically ill patients. Adopting evidence-based interventions and leveraging emerging technologies can significantly improve clinical outcomes, reduce ICU complications, and enhance recovery in this vulnerable population. Full article

Background/Objectives: Amyotrophic Lateral Sclerosis (ALS) is a progressive and fatal neurodegenerative disease characterized by motor neuron loss, muscle weakness, and respiratory dysfunction, often culminating in ventilatory failure. Evidence suggests that High-Definition Transcranial Direct Current Stimulation (HD-tDCS) may modulate motor cortical excitability and potentially influence motor and respiratory function in ALS. This study aims to evaluate the effects of home-based HD-tDCS applied over the primary diaphragmatic motor cortex on respiratory parameters and disease progression in individuals with ALS. Methods: This is a multicenter, randomized, controlled clinical trial. Eligible participants (aged 18–80, both sexes, diagnosed with ALS) will be randomized into an active HD-tDCS group (gTDCS) or a sham group (gSham). The intervention consists of 30 min daily HD-tDCS sessions (3 mA) applied for two weeks (5 days/week), using a 4 × 1 ring configuration targeting the diaphragmatic motor cortex. Sham stimulation includes an identical setup but only delivers ramp currents (30 s) with a minimal ongoing current (0.1 mA). Results: Pre-, intra-, and post-intervention evaluations will include measures of cortical excitability, cerebral and tissue perfusion, surface electromyography, respiratory and pulmonary function, fatigue, sleep quality, pain, motor performance, dyspnea, quality of life, and adverse effects. All procedures will be conducted at participants’ homes with appropriate safety monitoring. Conclusions: This study will investigate the effects of HD-tDCS on respiratory and motor function in ALS and explore the feasibility of a home-based neuromodulation intervention. The outcomes may provide insight into non-pharmacological strategies for respiratory management in ALS. Full article

Background/Objectives: Blunt trauma injury of the diaphragm is uncommon. Even after imaging examination, accurate diagnosis remains difficult. We sought to identify clinical factors that raise suspicion of such injuries, which can be applied during the initial evaluation of trauma patients. Methods: We retrospectively analyzed patients with blunt trauma who were diagnosed with diaphragmatic injury between January 2015 and July 2025. Demographic variables, clinical findings, operative records, and imaging findings were reviewed. Results: The most common mechanism of injury in patients with diaphragmatic injury was traffic accidents (64.2%), and 77.4% were identified as severe injuries with an Injury Severity Score (ISS) ≥ 16. Computed tomography (CT) scans of these patients frequently showed hemothorax, hemoperitoneum, and pneumothorax, but 49.1% of cases did not show diaphragmatic injury on preoperative imaging. In these patients, pneumothorax, lower rib fractures, and liver injury were more common. Notably, pneumothorax strongly suggested the possibility of diaphragmatic injury in patients where intrathoracic herniation was not clear. Conclusions: In patients with polytrauma and unstable vital signs, CT evaluation of torso injuries and careful interpretation are essential. Even when CT does not reveal diaphragmatic injury, suspicion should be elevated in cases with high ISS accompanied by pneumothorax, hemoperitoneum, hemothorax, lower rib fractures, or extremity injuries. If the injury mechanism further raises clinical suspicion, repeated physical examinations and imaging studies should be performed. When suspicion remains high, surgical intervention should be considered to confirm the diagnosis. Full article

Background: In congenital diaphragmatic hernia (CDH), pulmonary hypoplasia and pulmonary hypertension are major causes of morbidity and mortality. Antenatal treatment with sildenafil has shown some promising protective effects in experimental CDH, but no systematic review has yet evaluated the preclinical evidence on this topic. Methods: PubMed and EMBASE databases were searched for studies using antenatal sildenafil in animal models of CDH. Bayesian model-averaged (BMA) meta-analysis was used to calculate Bayes factors (BFs). The BF₁₀ is the ratio of the probability of the data under the alternative hypothesis (presence of effect) over the probability of the data under the null hypothesis (absence of effect). Risk of bias was assessed by the SYRCLE tool. Results: We included 18 studies (14 nitrofen and 4 surgical CDH). The BMA analysis showed inconclusive evidence (BF₁₀ between 0.33 and 3) for the presence of an effect of sildenafil in fetal survival (7 studies, BF₁₀ = 1.25) or in lung hypoplasia as assessed by the lung-to-body weight ratio (16 studies, BF₁₀ = 2.04). In contrast, the BMA analysis showed conclusive evidence (BF₁₀ > 3) in favor of a positive effect of sildenafil on small pulmonary arteries medial wall thickness (12 studies, BF₁₀ = 1499), radial alveolar count (6 studies, BF₁₀ = 167.57), interalveolar septa thickness (4 studies, BF₁₀ = 56.86), distal airway complexity (3 studies, BF₁₀ = 7.95), mean saccular airspace diameter (2 studies, BF₁₀ = 7.61), total lung capacity (2 studies, BF₁₀ = 6.91), lung compliance (2 studies, BF₁₀ = 5.19), and VEGF expression (5 studies, BF₁₀ = 10.62). Conclusions: In preclinical models of CDH, antenatal sildenafil rescues pulmonary vascular remodeling and airway/airspace morphometric alterations. Full article

Background/Objectives: The etiology of congenital diaphragmatic hernia (CDH) remains unknown in over 50% of cases, although multiple heterogeneous causative defects have been identified. Emerging evidence suggests that specific genes and molecular pathways involved in connective tissue biology may contribute to CDH development. Associations between CDH and connective tissue disorders have been reported, including cases in Marfan syndrome and a prevalence of CDH in 34% of patients with arterial tortuosity syndrome. Noticing joint laxity in several CDH patients, we aimed to investigate the presence of genetic variants linked to connective tissue disorders in this subgroup, focusing on patients enrolled in the follow-up program at Bambino Gesù Children’s Hospital. Methods: We selected patients diagnosed with CDH who also exhibited joint laxity based on a positive Beighton scale. These individuals underwent molecular analysis targeting genes known to be associated with heritable connective tissue disorders. Results: Genetic testing revealed variants in several genes across our patient series. These included mutations in FBN1, FBN2, ZNF469, VEGFA, NOTCH1, ELN, MCTP2, and SMAD6. In some cases, the variants were inherited paternally, while others appeared de novo. Most of these variants were classified as of unknown significance according to ACMG guidelines. Conclusions: (1) Several “variants of unknown significance” in different genes causative for connective tissue disorders have been detected in half of the present series of patients with CDH and joint laxity; (2) although the majority of the variants are classified accordingly to the ACMG as “variants of unknown significance”, a role of predisposition or susceptibility to CDH cannot be excluded; (3) a precise clinical evaluation for features of connective disorders should be recommended in the diagnostic workflow of patients with CDH. Full article

Three-dimensional (3D) modeling and printing technologies are increasingly used in pediatric surgery, offering improved anatomical visualization, surgical planning, and personalized approaches to complex conditions. Compared to standard imaging, patient-specific 3D models—virtual or printed—provide a more intuitive spatial understanding of congenital anomalies, tumors, and vascular anomalies. This review compiles evidence from pediatric surgical fields including oncology, abdominal, and thoracic surgery, highlighting the clinical relevance of 3D applications. The technological workflow—from image segmentation to computer-aided design (CAD) modeling and multimaterial printing—is described, emphasizing accuracy, reproducibility, and integration into hospital systems. Several clinical cases are presented: neuroblastoma, cloacal malformation, conjoined twins, and two cases of congenital diaphragmatic hernia (one with congenital pulmonary airway malformation, CPAM). In each, 3D modeling enhanced anatomical clarity, increased surgeon confidence, and supported safer intraoperative decision-making. Models also improved communication with families and enabled effective multidisciplinary planning. Despite these advantages, challenges remain, such as production time, cost variability, and lack of standardization. Future directions include artificial intelligence-based automation, expanded use of virtual and mixed reality, and prospective validation studies in pediatric cohorts. Overall, 3D modeling represents a significant advance in pediatric precision surgery, with growing evidence supporting its safety, clinical utility, and educational value. Full article

Background: Endometriosis is a chronic disease defined by the presence of endometrial-like tissue outside the uterine cavity. While typically confined to the pelvis, extrapelvic manifestations—including thoracic endometriosis—can occur. Although rare, thoracic endometriosis is the most common extragenital form. In clinical practice, this presentation is often described as thoracic endometriosis syndrome (TES), a constellation of cyclic thoracic symptoms temporally associated with menstruation but not always histologically confirmed. Its atypical symptoms and limited clinical awareness frequently lead to delayed diagnosis, mismanagement and increased patient burden. Methods: In accordance with the CARE guidelines, we present a case report of a female patient with thoracic endometriosis syndrome, emphasizing the prolonged interval between symptom onset and final diagnosis. Case Report: We describe a 42-year-old woman with a longstanding history of dysmenorrhea and menorrhagia, who developed cyclical chest pain and dyspnea in 2019. Despite multiple thoracoscopic procedures, her symptoms persisted and were repeatedly misattributed to anxiety or infection. Thoracic endometriosis syndrome (TES) was suspected in 2022, and although histopathological confirmation was lacking, intraoperative visualization revealed diaphragmatic fenestrations. In 2025, a second laparoscopic intervention targeting the abdominal surface of the diaphragm resulted in significant symptom relief. The patient is currently continuing hormonal therapy with Dienogest and has reported a marked improvement in quality of life. Nevertheless, the protracted diagnostic and therapeutic process—marked by chronic pain and repeated hospitalizations—had a profound psychosocial impact, culminating in a suicide attempt. Conclusions: This case illustrates the substantial burden associated with the delayed recognition of thoracic endometriosis syndrome and the consequences of fragmented care. The patient’s experience underscores the urgent need for coordinated, multidisciplinary management and psychological support, particularly for patients with extrapelvic manifestations. Early multidisciplinary evaluation, with readiness to consider surgical intervention alongside individualized hormonal therapy, may support improved outcomes, provided they are reinforced by increased clinical awareness and systemic improvement in diagnostic pathways. Full article

Respiratory effort is a critical parameter for assessing respiratory function in various pathological conditions such as obstructive sleep apnea (OSA), as well as in patients undergoing respiratory ventilation. Currently, the gold-standard method for measuring it is esophageal pressure (Pes), which is obtrusive and uncomfortable for patients. An alternative approach is using diaphragmatic electromyography (dEMG), a non-obtrusive method that directly reflects the electrical drive triggering respiratory effort, holding potential for quantifying effort. Despite progress in this area, there is still no clear agreement on the best features for assessing respiratory effort from dEMG. This feasibility study considers several time, frequency, and statistical domain features, providing a comparative analysis to determine their performance in estimating respiratory effort. In particular, we evaluate the correlation of the different features with Pes using overnight recordings from 10 OSA patients and assess their robustness across different signal quality levels with the Kruskal–Wallis test. Our results support that time-domain dEMG features such as the filtered envelope, root mean square, and waveform length (WL) exhibit moderately strong correlations (R > 0.6) with respiratory effort. In terms of robustness to noise, the best features were WL, the area under the curve, and the slope sign change, demonstrating moderately strong to fair correlations (R > 0.5) even in low- to very low-quality signals. In contrast, features like skewness, the mean frequency, and the median frequency performed poorly (R < 0.3), regardless of signal quality, likely because they focus on overall signal characteristics rather than the dynamic and transient changes associated with respiratory effort by temporal features. These findings highlight the importance of selecting optimal features to obtain a reliable estimation of respiratory effort, providing a foundation for future research on non-intrusive methods. Full article

The effectiveness of breathing interventions on postural alignment, pain reduction, and functional improvement in patients with forward head posture (FHP) and chronic neck pain remains uncertain. Previously conducted randomized controlled trials (RCTs) that involved breathing interventions were identified through searches of the PubMed, Cochrane Library, Web of Science, and Scopus databases. Studies were included if they applied diaphragmatic breathing, breathing muscle training, or feedback breathing exercises for at least 2 weeks to chronic neck pain (duration ≥ 3 months) and/or forward head posture. The craniovertebral angle (CVA), the visual analog scale (VAS), and the neck disability index (NDI) were the primary outcome measures. The results showed that breathing interventions had a moderate effect size in terms of improving the CVA. Limited effects were observed for pain reduction, and improvements in neck disability approached statistical significance. However, despite these positive findings, the overall evidence was rated as ‘very low certainty’ in the GRADE assessment, primarily due to high heterogeneity among studies, limited sample sizes, and the potential for unit-of-analysis errors in diagnosis-based subgroup analyses. Consequently, their overall effectiveness in chronic neck pain was limited. Future research is needed to explore a multidisciplinary approach to neck pain using standardized protocols and larger samples. Full article

This study aimed to explore prognostic factors for mortality in dogs and cats following traumatic diaphragmatic herniorrhaphy using both multivariable logistic regression, a traditional statistical method, and the random forest algorithm, a machine learning approach. Associations between demographic and clinical variables and mortality were examined. Overall survival was 78.8% (149/189), 77% (97/126) in cats and 82.5% (52/63) in dogs. Key findings revealed that chronic diaphragmatic hernia (DH) significantly increased the odds of death compared to acute cases (adjusted odds ratio (OR) = 4.01, 95% confidence interval (CI): 1.69–9.53). Elevated blood urea nitrogen (BUN) increased mortality (adjusted OR = 3.24, 95% CI: 1.22–8.57). Cox proportional hazards analysis revealed that chronic DH (adjusted hazard ratio (HR) = 3.31, 95% CI: 1.51–7.30) and elevated BUN (HR = 2.88, 95% CI: 1.23–6.77) were associated with increased one-year mortality risk. The random forest analysis reinforced these findings, identifying hernia duration (Gini importance: 1.90) and BUN (Gini importance: 0.94) as the most crucial predictors. Among chronic DH patients, 55% of those with elevated BUN experienced fatal outcomes based on classification and regression tree (CART) analysis. The consistency of random forest results with logistic regression strengthens the reliability of these prognostic insights for DH patients. Full article