Search

Differential mobility spectrometry (DMS) enables the detection and separation of volatile organic compounds, exploiting differences in ion mobility under varying electric fields, which enhance the resolution of complex mixtures. In this study, DMS, upon integration with chemometrics, enabled the differentiation of the botanical origins of Italian honeys. Utilizing a benchtop differential mobility spectrometer connected to pure air, 219 monofloral honeys of five different botanical origins (acacia, chestnut, citrus, eucalyptus, and linden) were simultaneously analyzed in positive and negative ion modes and with the analysis duration of less than 2 min. Repeatability of the resultant volatilomic fingerprints was verified by cosine similarity with the subsequent elimination of the nonrepeatable data. Afterward, the data for both polarities were concatenated, and an exploratory investigation was carried out into the discrimination capabilities of DMS by principal component analysis. The merged data were then submitted to a statistical analysis for classification. The performance of the resultant random forest (RF) classifier was evaluated by repeated cross-validation and resubstitution into the training set, and finally, this classifier was validated on a withheld subset of data. The performances of the classification model for each test were evaluated by calculating the contingency table-derived parameters of accuracy, Matthew's correlation coefficient (MCC), sensitivity, and specificity. The RF classifier produced high-performance values when predicting the botanical origin of the honey in both training (MCC 84.8%, accuracy 88.0%, sensitivity 87.5%, and specificity 96.9%) and validation subsets (MCC 82.6%, accuracy 86.3%, sensitivity 85.7%, and specificity 96.5%). Some limitations, expected to be mitigated by further research, were encountered in the correct classification of acacia honey.

Francesco Livrieri,1 Giulia Ghidoni,1 Roberto Piro,1 Francesco Menzella,1 Alberto Cavazza,2 Claudia Lazzaretti,3 Marco Massari,3 Gloria Montanari,1 Matteo Fontana,1 Nicola Cosimo Facciolongo1 1Department of Medical Specialties, Pneumology Unit, Arcispedale Santa Maria Nuova, Azienda USL di Reggio Emilia- IRCCS, Reggio Emilia 42123, Italy; 2Pathology Unit, Azienda USL/IRCCS di Reggio Emilia, Reggio Emilia 42100, Italy; 3Infectious Diseases, Azienda Unità Sanitaria Locale, IRCCS di Reggio Emilia, Reggio Emilia, ItalyCorrespondence: Francesco LivrieriDepartment of Medical Specialties, Pneumology Unit, Arcispedale Santa Maria Nuova, Azienda USL di Reggio Emilia- IRCCS, Reggio Emilia 42123, ItalyEmail francesco.livrieri@ausl.re.itAbstract: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is causing a massive outbreak throughout the world. In this period, diseases other than coronavirus disease (COVID-19) have not disappeared; however, it is hard for doctors to diagnose diseases that can mimic the clinical, radiological, and laboratory features of COVID-19, especially rare lung diseases such as acute eosinophilic pneumonia (AEP). We report the clinical case of a young patient who presented to the Emergency Department with respiratory failure and clinical symptoms, radiological aspects, and blood tests compatible with COVID-19; two swabs and a serology test for SARS-CoV-2 were performed, both resulted negative, but the respiratory failure worsened. Peripheral eosinophilia guided us to consider the possibility of a rare disease such as AEP, even if radiology findings were not pathognomonic. Therefore, we decided to perform a flexible bronchoscopy with bronchoalveolar lavage (BAL) at the lingula, which showed the presence of eosinophilia greater than 40%. As a consequence, we treated the patient with high-dose corticosteroids that completely resolved the respiratory symptoms. This case report highlights the difficulty of making alternative diagnoses during the COVID-19 pandemic, especially for rare lung diseases such as AEP, which may have initial characteristics similar to COVID-19.Keywords: COVID-19, acute eosinophilic pneumonia, bronchoalveolar lavage, ground glass opacities

Chiara Scelfo,1 Matteo Fontana,1 Eleonora Casalini,1 Francesco Menzella,1 Roberto Piro,1 Alessandro Zerbini,2 Lucia Spaggiari,3 Luca Ghidorsi,1 Giulia Ghidoni,1 Nicola C Facciolongo1 1Department of Medical Specialties, Pneumology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy; 2Unit of Clinical Immunology, Allergy and Advanced Biotechnologies, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy; 3Department of Radiology, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, ItalyCorrespondence: Chiara Scelfo Email chiara.scelfo@ausl.re.itAbstract: The outbreak of the novel severe acute respiratory syndrome coronavirus (SARS-CoV-2) started in China in December 2019. COVID-19 patients at presentation show a wide spectrum of clinical and pathological involvement. We report two cases of respiratory insufficiency due to COVID-19 pneumonia that occurred in adults without a history of respiratory diseases. Although these patients improved and were discharged from the acute ward, during the hospitalization they both progressed with a subsequent clinical and radiological worsening, pointing out one of the main concerns for these patients at discharge: the possibility of developing persistent lung abnormalities also in healthy people not having other risk factors. In conclusion, these cases represent two examples of early lung fibrosis in patients with COVID-19 pneumonia with different severity disease evolution and highlight the need for long-term follow-up strategies. The etiology of this fibrosis is under discussion: we suppose that it could be due to either a possible outcome of natural history of lung damage produced by ARDS, or to the lung injury related to high oxygen level or to the lung damage directly induced by viral infection or finally to the autoimmune response. At this moment, it is not possible to predict how many people will have consequences due to COVID-19 pneumonia, and therefore we believe that careful follow-up should be mandatory.Keywords: COVID-19, pulmonary fibrosis, critical care, viral disease, computed tomography, follow-up

Raw milk cheeses harbor complex microbial communities. Some of these microorganisms are technologically essential, but undesirable microorganisms can also be present. While most of the microbial dynamics and cross-talking studies involving interaction between food-derived bacteria have been carried out on agar plates in laboratory-controlled conditions, the present study evaluated the modulation of the resident microbiota and the changes of metabolite production directly in ripening raw milk cheese inoculated with Listeria innocua strains. Using a proxy of the pathogenic Listeria monocytogenes , we aimed to establish the key microbiota players and chemical signals that characterize Latteria raw milk cheese over 60 days of ripening time. The microbiota of both the control and Listeria -inoculated cheeses was analyzed using 16S rRNA targeted amplicon sequencing, while direct analysis in real time mass spectrometry (DART-HRMS) was applied to investigate the differences in the metabolic profiles of the cheeses. The diversity analysis showed the same microbial diversity trend in both the control cheese and the inoculated cheese, while the taxonomic analysis highlighted the most representative genera of bacteria in both the control and inoculated cheese: Lactobacillus and Streptococcus . On the other hand, the metabolic fingerprints revealed that the complex interactions between resident microbiota and L. innocua were governed by continuously changing chemical signals. Changes in the amounts of small organic acids, hydroxyl fatty acids, and antimicrobial compounds, including pyroglutamic acid, hydroxy-isocaproic acid, malic acid, phenyllactic acid, and lactic acid, were observed over time in the L. innocua -inoculated cheese. In cheese that was inoculated with L. innocua , Streptococcus was significantly correlated with the volatile compounds carboxylbenzaldheyde and cyclohexanecarboxylic acid, while Lactobacillus was positively correlated with some volatile and flavor compounds (cyclohexanecarboxylic acid, pyroxidal acid, aminobenzoic acid, and vanillic acid). Therefore, we determined the metabolic markers that characterize a raw milk cheese inoculated with L. innocua , the changes in these markers with the ripening time, and the positive correlation of flavor and volatile compounds with the resident microbiota. This multi-omics approach could suggest innovative food safety strategies based on the enhanced management of undesirable microorganisms by means of strain selection in raw matrices and the addition of specific antimicrobial metabolites to prevent the growth of undesirable microorganisms.

Untargeted metabolomic profiling, by ambient mass spectrometry and chemometric tools, has made a dramatic impact on human disease detection. In a similar vein, this study attempted the translation of this clinical human disease experience to farmed poultry for precise veterinary diagnosis. As a proof of principle, in this diagnostic/prognostic study, direct analysis in real-time high resolution mass spectrometry (DART-HRMS) was used in an untargeted manner to analyze fresh tissues (abdominal fat, leg skin, liver, and leg muscle) of pigmented and non-pigmented broilers to investigate the causes of lack of pigmentation in an industrial poultry farm. Afterwards, statistical analysis was applied to the DART-HRMS data to retrieve the molecular features that codified for 2 broiler groups, that is, properly pigmented and non-pigmented broilers. Higher abundance of oxidized lipids, high abundance of oxidized bile derivatives, and lower levels of tocopherol isomers (Vitamin E) and retinol (Vitamin A) were captured in nonpigmented than in pigmented broilers. In addition, conventional rapid analyses were used: 1) color parameters of the tissues of pigmented and non-pigmented broilers were measured to rationalize the color differences in abdominal fat, leg skin and leg muscle, and 2) macronutrients were determined in broiler leg muscle, to capture a detailed picture of the pathology and exclude other possible causes. In this study, the DART-HRMS system performed well in retrieving valuable chemical information from broilers that explained the differences between the 2 groups of broilers in absorption of xanthophylls and the subsequent lack of proper broiler pigmentation in affected broilers. The results suggest this technology could be useful in providing near real-time feedback to aid in veterinary decision-making in poultry farming., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Thermal desorption direct analysis in real-time high-resolution mass spectrometry (TD-DART-HRMS) approaches have gained popularity for fast screening of a variety of samples. With rapid volatilization of the sample at increasing temperatures outside the mass spectrometer, this technique can provide a direct readout of the sample content with no sample preparation. In this study, TD-DART-HRMS's utility for establishing spice authenticity was examined. To this aim, we directly analyzed authentic (typical) and adulterated (atypical) samples of ground black pepper and dried oregano in positive and negative ion modes. We analyzed a set of authentic ground black pepper samples (n = 14) originating from Brazil, Sri Lanka, Madagascar, Ecuador, Vietnam, Costa Rica, Indonesia, Cambodia, and adulterated samples (n = 25) consisting of mixtures of ground black pepper with this spice's nonfunctional by-products (pinheads or spent) or with different exogenous materials (olive kernel, green lentils, black mustard seeds, red beans, gypsum plaster, garlic, papaya seeds, chili, green aniseed, or coriander seeds). TD-DART-HRMS facilitated the capture of informative fingerprinting of authentic dried oregano (n = 12) originating from Albania, Turkey, and Italy and those spiked (n = 12) with increasing percentages of olive leaves, sumac, strawberry tree leaves, myrtle, and rock rose. A predictive LASSO classifier was built, after merging by low-level data fusion, the positive and negative datasets for ground black pepper. Fusing multimodal data allowed retrieval of more comprehensive information from both datasets. The resultant classifier achieved on the withheld test set accuracy, sensitivity, and specificity of 100%, 75%, and 90%, respectively. On the contrary, the sole TD-(+)DART-HRMS spectra of the oregano samples allowed construction of a LASSO classifier that predicted the adulteration of the oregano with excellent statistical indicators. This classifier achieved, on the withheld test set, 100% each for accuracy, sensitivity, and specificity., (© 2023 The Authors. Journal of Mass Spectrometry published by John Wiley & Sons Ltd.)

Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Currently, the authentication of ground black pepper is a major concern, creating a need for a rapid, highly sensitive and specific detection tool to prevent the introduction of adulterated batches into the food chain. To this aim, head space gas-chromatography ion mobility spectrometry (HS-GC-IMS), combined with machine learning, is tested in this initial, proof-of-concept study. A broad variety of authentic samples originating from eight countries and three continents were collected and spiked with a range of adulterants, both endogenous sub-products and an assortment of exogenous materials. The method is characterized by no sample preparation and requires 20 min for chromatographic separation and ion mobility data acquisition. After an explorative analysis of the data, those were submitted to two different machine learning algorithms (partial least squared discriminant analysis-PLS-DA and support vector machine-SVM). While the PLS-DA model did not provide fully satisfactory performances, the combination of HS-GC-IMS and SVM successfully classified the samples as authentic, exogenously-adulterated or endogenously-adulterated with an overall accuracy of 90 % and 96 % on withheld test set 1 and withheld test set 2, respectively (at a 95 % confidence level). Some limitations, expected to be mitigated by further research, were encountered in the correct classification of endogenously adulterated ground black pepper. Correct categorization of the ground black pepper samples was not adversely affected by the operator or the time span of data collection (the method development and model challenge were carried out by two operators over 6 months of the study, using ground black pepper harvested between 2015 and 2019). Therefore, HS-GC-IMS, coupled to an intelligent tool, is proposed to: (i) aid in industrial decision-making before utilization of a new batch of ground black pepper in the production chain; (ii) reduce the use of time-consuming conventional analyses and; (iii) increase the number of ground black pepper samples analyzed within an industrial quality control frame., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background: Chemoradiation therapy (CRT) is the treatment of choice for locally advanced non-small cell lung cancer (LA-NSCLC). Several clinical trials that combine programmed cell death 1 (PD1) axis inhibitors with radiotherapy are in development for patients with LA-NSCLC. However, the effect of CRT on tumor cells programmed cell death ligand-1 (PD-L1) expression is unknown., Methods: In this multicentric retrospective study, we analyzed paired NSCLC specimens that had been obtained pre- and post-CRT. PD-L1 expression on tumor cells was studied by immunohistochemistry. The purpose of this study was to evaluate the feasibility, risk of complications, and clinical relevance of performing re-biopsy after CRT in patients with PD-L1 negative LA-NSCLC., Results: Overall, 31 patients from 6 centers with PD-L1 negative LA-NSCLC were analyzed. The percentage of tumor cells with PD-L1 expression significantly increased between pre- and post-CRT specimens in 14 patients (45%). Nine patients had unchanged PD-L1 expression after CRT, in five patients the rebiopsy material was insufficient for PD-L1 analysis and in two patients no tumor cells at rebiopsy were found. The post-rebiopsy complication rate was very low (6%). All patients with positive PD-L1 re-biopsy received Durvalumab maintenance after CRT, except one patient who had a long hospitalization for tuberculosis reactivation. Median PFS of patients with unchanged or increased PD-L1 expression was 10 and 16.9 months, respectively., Conclusion: CRT administration can induce PD-L1 expression in a considerable fraction of PD-L1 negative patients at baseline, allowing them receiving the maintenance Durvalumab in Europe. Hence, after a definitive CRT, PD-L1 redetermination should be considered in patients with LA-NSCLC PD-L1 negative, to have a better selection of maintenance Durvalumab candidates., Competing Interests: MT received speakers’ and consultants’ fee from Astra-Zeneca, Pfizer, Eli-Lilly, BMS, Novartis, Roche, MSD, Boehringer Ingelheim, Otsuka, Takeda, Pierre Fabre, Amgen, Merck, Sanofi. MT received institutional research grants from Astra-Zeneca, Boehringer Ingelheim. The remaining 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 © 2024 Ciammella, Cozzi, Borghetti, Galaverni, Nardone, Ruggieri, Sepulcri, Scotti, Bruni, Zanelli, Piro, Tagliavini, Botti, Iori, Alì, Bennati and Tiseo.)

Background: Awake prone positioning (APP) is broadly implemented in patients with severe acute respiratory syndrome coronavirus 2 related disease [coronavirus disease 2019 (COVID-19)] admitted to hospital with severe respiratory distress syndrome. This prospective observational study aimed to explore the factors influencing the implementation of APP in patients with acute respiratory failure due to COVID-19., Methods: Patients with COVID-19, all hospitalized with positive X-ray findings and oxygen supplementation requirement, in the Respiratory Step-Down Unit of the Peking University Third Hospital between January 6 th , 2023, and January 20 th , 2023, were included in this study. Data regarding basic information, activities of daily living (ADLs) scores, oxygen therapy, vital signs, and duration of APP were collected to investigate the factors influencing prone positioning., Results: Among the 134 patients included, 55.2% showed an improvement in oxygen saturation 1 hour after APP. Logistic regression revealed that the pre-APP heart rate (HR) [odds ratio (OR) =1.032; P=0.046] and peripheral oxygen saturation (SpO 2 ) (OR =0.720; P<0.001) were the associated factors of the improvement in SpO 2 after treatment. Multiple linear regression revealed that the ADL scores and pre-APP respiratory rate (RR) were the associated factors of the duration of prone positioning (P<0.01). The APP technical steering group effectively improved duration of APP., Conclusions: Patients with low SpO 2 and increased HR before treatment showed greater improvement in oxygen saturation. Patients with lower tolerance to ADL but lower RRs were those to demonstrate a longer duration of prone positioning. This is pointing towards establishing the most favorable time window for APP during the course of COVID-19: after the ADLs have already decreased, but before significant tachypnea has appeared., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-23-1441/coif). The authors have no conflicts of interest to declare., (2023 Journal of Thoracic Disease. All rights reserved.)

Background: In cases of suspected animal poisonings or intoxications, there is the need for high-throughput, rapid and accurate analytical tools capable of giving rapid answers and, thus, speeding up the early stages of investigations. Conventional analyses are very precise, but do not meet the need for rapid answers capable of orienting the decisions and the choice of appropriate countermeasures. In this context, the use of ambient mass spectrometry (AMS) screening methods in toxicology laboratories could satisfy the requests of forensic toxicology veterinarians in a timely manner., Results: As a proof of principle, direct analysis in real time high resolution mass spectrometry (DART-HRMS) was applied to a veterinary forensic case in which 12 of a group of 27 sheep and goats died with an acute neurological onset. Because of evidence in the rumen contents, the veterinarians hypothesized an accidental intoxication after ingestion of vegetable materials. The DART-HRMS results showed abundant signals of the alkaloids calycanthine, folicanthidine and calycanthidine, both in the rumen content and at the liver level. The DART-HRMS phytochemical fingerprinting of detached Chimonanthus praecox seeds was also compared with those acquired from the autopsy specimens. Liver, rumen content and seed extracts were then subjected to LC-HRMS/MS analysis to gather additional insights and confirm the putative assignment of calycanthine anticipated by DART-HRMS. HPLC-HRMS/MS confirmed the presence of calycanthine in both rumen contents and liver specimens and allowed its quantification, ranging from 21.3 to 46.9 mg kg -1 in the latter. This is the first report detailing the quantification of calycanthine in liver after a deadly intoxication event., Significance and Novelty: Our study illustrates the potential of DART-HRMS to offer a rapid and complementary alternative to guide the selection of confirmatory chromatography-MS n strategies in the analysis of autopsy specimens from animals with suspected alkaloid intoxication. This method offers the consequent saving of time and resources over those needed for other methods., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:Nicola Pozzato reports financial support, equipment, drugs, or supplies, and writing assistance were provided by Italian Ministery of Health., (Copyright © 2023 Elsevier B.V. All rights reserved.)

The study aimed to assess the seasonal variation in raw milk volatile organic compounds (VOCs) from three indoor feeding systems based on maize silage ( n = 31), silages/hay ( n = 19) or hay ( n = 16). After headspace solid-phase microextraction (HS-SPME), VOC profiles were determined by gas chromatography (GC). Chemical and VOC (log 10 transformations of the peak areas) data were submitted to a two-way ANOVA to assess the feeding system (FS) and season (S) effects; an interactive principal component analysis (iPCA) was also performed. The interaction FS × S was never significant. The FS showed the highest ( p < 0.05) protein and casein content for hay-milk samples, while it did not affect any VOCs. Winter milk had higher ( p < 0.05) proportions of protein, casein, fat and some carboxylic acids, while summer milk was higher ( p < 0.05) in urea and 2-pentanol and methyl aldehydes. The iPCA confirmed a seasonal spatial separation. Carboxylic acids might generate from incomplete esterification in the mammary gland and/or milk lipolytic activity, while aldehydes seemed to be correlated with endogenous lipid or amino acid oxidation and/or feed transfer. The outcomes suggested that VOCs could be an operative support to trace raw milk for further mild processing.

The early diagnosis of Mycobacterium avium subsp. paratuberculosis (MAP) is one of the current challenges of farmers and veterinarians. This work aimed to investigate the changes in metabolic levels associated with natural MAP infection in infected and infectious dairy cattle. The study included sera from 23 infectious/seropositive, 10 infected but non-infectious/seronegative, and 26 negative Holstein Fresian cattle. The samples were selected from a collection of samples gathered during a prospective study. The samples were analyzed by quantitative nuclear magnetic resonance (NMR) spectroscopy and routine blood chemistry. The blood indices and the 1 H NMR data were concatenated by low-level data fusion, resulting in a unique global fingerprint. Afterwards, the merged dataset was statistically analyzed by the least absolute shrinkage and selection operator (LASSO), which is a shrinkage and selection method for supervised learning. Finally, pathways analysis was performed to get more insights on the possible dysregulated metabolic pathways. The LASSO model achieved, in a 10 time repeated 5-fold cross-validation, an overall accuracy of 91.5% with high values of sensitivity and specificity in classifying correctly the negative, infected, and infectious animals. The pathway analysis revealed MAP-infected cattle have increased tyrosine metabolism and enhanced phenylalanine, tyrosine and tryptophan biosynthesis. The enhanced synthesis and degradation of ketone bodies was observed both in infected and infectious cattle. In conclusion, fusing data from multiple sources has proved to be useful in exploring the altered metabolic pathways in MAP infection and potentially diagnosing negative animals within paratuberculosis-infected herds., 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 Massaro, Tata, Pallante, Bertazzo, Bottazzari, Paganini, Dall'Ava, Stefani, De Buck, Piro and Pozzato.)

This study developed and validated a method, based on the coupling of Fourier-transform infrared spectroscopy (FT-IR) and machine learning, for the automated serotyping of Legionella pneumophila serogroup 1, Legionella pneumophila serogroups 2-15 as well as their successful discrimination from Legionella non- pneumophila . As Legionella presents significant intra- and inter-species heterogeneities, careful data validation strategies were applied to minimize late-stage performance variations of the method across a large microbial population. A total of 244 isolates were analyzed. In details, the method was validated with a multi-centric approach with isolates from Italian thermal and drinking water ( n  = 82) as well as with samples from German, Italian, French, and British collections ( n  = 162). Specifically, robustness of the method was verified over the time-span of 1 year with multiple operators and two different FT-IR instruments located in Italy and Germany. Moreover, different production procedures for the solid culture medium (in-house or commercial) and different culture conditions (with and without 2.5% CO 2 ) were tested. The method achieved an overall accuracy of 100, 98.5, and 93.9% on the Italian test set of Legionella , an independent batch of Legionella from multiple European culture collections, and an extra set of rare Legionella non- pneumophila, respectively., Competing Interests: MC was employed by Bruker Daltonic GmbH (the manufacturer of IR-Biotyper R). The remaining 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 Tata, Marzoli, Cordovana, Tiengo, Zacometti, Massaro, Barco, Belluco and Piro.)

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a safe and accurate diagnostic procedure used for investigating mediastinal pathologies. It is usually performed using an oral approach. The nasal route has been proposed but not extensively investigated. With the aim to report the use of linear EBUS through the nasal route and compare its accuracy and safety with the oral one, we conducted a retrospective analysis of the subjects who underwent an EBUS-TBNA procedure at our center. From January 2020 to December 2021, 464 subjects underwent an EBUS-TBNA, and in 417 patients, EBUS was performed through the nose or mouth. Nasal insertion of the EBUS bronchoscope was performed in 58.5% of the patients. No difference between the two insertion routes was observed in terms of location or number of stations sampled per subject. Procedure complications were mild and similar between the two groups (10.2% for the nasal group vs. 9.8% for the oral group). Minor epistaxis occurred in five subjects in the nasal group. Comparing the two groups, the rates of adequate specimens were similar (95.1% vs. 94.8%), as were the proportions of diagnostic specimens (84% vs. 82%). In conclusion, the nasal route for EBUS-TBNA is a valid alternative to the oral one.

Background: Since February 2021 active screening of COVID-19-associated pulmonary aspergillosis (CAPA) has been implemented in our institution., Objectives: To evaluate CAPA incidence in our centre and evaluate performance of our screening protocol., Methods: We screened once per week, collecting endotracheal aspirates for fungal culture and galactomannan (GM) and serum for 1,3-ß-D-glucan (BG). In case of positivity (GM more than 4.5, platelia assay, and/or BG >7 pg/ml, wako and/or positive fungal culture), second-level investigations were performed to pursue CAPA diagnosis according to ECMM/ISHAM criteria: bronchoalveolar lavage (BAL) fungal culture and GM, chest computed tomography (CT), serum GM., Results: A total of 102 patients were screened (median age 64 years, range 39-79; 28 (27.4%) females). Twenty-two patients were diagnosed with CAPA (21%). 12 patients were positive for serum BG, 17 patients were positive for endotracheal aspirates GM and 27 patients were positive for endotracheal aspirates fungal culture. Thirty-two BALs were performed, and 26 patients underwent CT chest. Following the second level investigations 61% of the patients with positive screening tests were diagnosed with CAPA. Serum BG above 20 pg/ml or positive serum GM were always associated with typical CT chest signs of aspergillosis. Compared with 1 single positive test, having 2 positive screening test was significantly more associated with CAPA diagnosis (p = .0004)., Conclusions: Active CAPA screening with serum 1,3-ß-D-glucan and endotracheal aspirates galactomannan and fungal cultures and consequent second level investigations led to high number of CAPA diagnosis. Combining more positive fungal biomarkers was more predictive of CAPA diagnosis., (© 2022 Wiley-VCH GmbH.)

Organizing pneumonia (OP) is a pulmonary disease histopathologically characterized by plugs of loose connective tissue in distal airways. The clinical and radiological presentations are not specific and they usually require a biopsy confirmation. This paper presents the case of a patient with a pulmonary opacity sampled with a combined technique of ultrathin bronchoscopy and cone-beam CT. A 64-year-old female, a former smoker, was admitted to the hospital of Reggio Emilia (Italy) for exertional dyspnea and a dry cough without a fever. The history of the patient included primary Sjögren Syndrome interstitial lung disease (pSS-ILD) characterized by a non-specific interstitial pneumonia (NSIP) radiological pattern; this condition was successfully treated up to 18 months before the new admission. The CT scan showed the appearance of a right lower lobe pulmonary opacity of an uncertain origin that required a histological exam for the diagnosis. The lung lesion was difficult to reach with traditional bronchoscopy and a percutaneous approach was excluded. Thus, cone-beam CT, augmented fluoroscopy and ultrathin bronchoscopy were chosen to collect a tissue sample. The histopathological exam was suggestive of OP, a condition occurring in 4-11% of primary Sjögren Syndrome cases. This case showed that, in the correct clinical and radiological context, even biopsies taken with small forceps can lead to a diagnosis of OP. Moreover, it underlined that the combination of multiple advanced technologies in the same procedure can help to reach difficult target lesions, providing proper samples for a histological diagnosis.

The lung is a frequent site of secondary malignancies. Melanoma is a malignant tumor originating from melanocytes, that accounts for the majority of death related to skin cancers. In advanced stages, it can also present with intrathoracic metastasis, particularly in the lungs, but infrequent intrathoracic manifestations are possible. A retrospective analysis of the cases referred to the pulmonary endoscopy unit of the hospital of Reggio Emilia in the last 10 years (since December 2012) was carried out, discovering 17 cases of melanoma metastasis with thoracic localizations, either with or without a diagnosis of primary melanoma. Four repetitive patterns of clinical-radiological presentation have been identified and described through the same number of paradigmatic clinical cases: nodal involvement (35%), lung mass(es) (41%), diffuse pulmonary involvement (12%), and pleural involvement (12%). These different presentations imply the use of different diagnostic techniques, with an overall high diagnostic yield (87.5%). Finally, a brief analysis of survival based on the pattern of presentation has been performed, finding no statistically significant differences between the four groups at metastasis diagnosis ( p -value = 0.06, median survival of respectively 54, 8, 9, and 26 months from metastasis diagnosis), while there is a significant difference considering patients with lung involvement versus nodal/pleural involvement ( p = 0.01).

Animal poisoning and dissemination of baits in the environment have public health and ethological implications, which can be followed by criminal sanctions for those responsible. The reference methods for the analysis of suspect baits and autopsy specimens are founded on chromatographic-based techniques. They are extremely robust and sensitive, but also very expensive and laborious. For this reason, we developed an ambient mass spectrometry (AMS) method able to screen for 40 toxicants including carbamates, organophosphate and chlorinated pesticides, coumarins, metaldehyde, and strychnine. Spiked samples were firstly purified and extracted by dispersive solid phase extraction (QuEChERS) and then analyzed by direct analysis in real time high-resolution mass spectrometry (DART-HRMS). To verify the performance of this new approach, 115 authentic baits ( n = 59) and necropsy specimens (gastrointestinal content and liver, n = 56) were assessed by the official reference methods and combined QuEChERS-DART-HRMS. The agreement between the results allowed evaluation of the performances of the new screening method for a variety of analytes and calculation of the resultant statistical indicators (the new method had overall accuracy 89.57%, sensitivity of 88.24%, and a specificity of 91.49%). Taking into account only the baits, 96.61% of overall accuracy was achieved with 57/59 samples correctly identified (statistical sensitivity 97.50%, statistical specificity 94.74%). Successful identification of the bitter compound, denatonium benzoate, in all the samples that contained rodenticides (28/28) was also achieved. We believe initial screening of suspect poison baits could guide the choice of reference confirmatory methods, reduce the load in official laboratories, and help the early stages of investigations into cases of animal poisoning., 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. The reviewer BM declared a past co-authorship with the authors AT, IP, NP, and RP to the handling editor., (Copyright © 2022 Tata, Pallante, Zacometti, Moressa, Bragolusi, Negro, Massaro, Binato, Gallocchio, Angeletti, Pozzato and Piro.)

This feasibility study reports the use of direct analysis in real-time high-resolution mass spectrometry (DART-HRMS) in profiling the powders from edible insects, as well as the potential for the identification of different insect species by classification modeling. The basis of this study is the revolution that has occurred in the field of analytical chemistry, with the improved capability of ambient mass spectrometry to authenticate food matrices. In this study, we applied DART-HRMS, coupled with mid-level data fusion and a learning method, to discriminate between Acheta domesticus (house cricket), Tenebrio molitor (yellow mealworm), Locusta migratoria (migratory locust), and Bombyx mori (silk moth). A distinct metabolic fingerprint was observed for each edible insect species, while the Bombyx mori fingerprint was characterized by highly abundant linolenic acid and quinic acid; palmitic and oleic acids are the statistically predominant fatty acids in black soldier fly ( Hermetia illucens ). Our chemometrics also revealed that the amino acid proline is a discriminant molecule in Tenebrio molitor , whereas palmitic and linoleic acids are the most informative molecular features of the house cricket ( Acheta domesticus ). Good separation between the four different insect species was achieved, and cross-validation gave 100% correct identification for all training samples. The performance of the random forest classifier was examined on a test set and produced excellent results, in terms of overall accuracy, sensitivity, and specificity. These results demonstrate the reliability of the DART-HRMS as a screening method in a future quality control scenario to detect complete substitution of insect powders.

Background: Bronchial thermoplasty (BT) is an effective treatment in severe asthma. How to select patients who more likely benefit from BT is an unmet clinical need. Moreover, mechanisms of BT efficacy are still largely unknown. We sought to determine BT efficacy and to identify potential mechanisms of response., Methods: This retrospective cohort study evaluated clinical outcomes in 27 patients with severe asthma: 13 with T2-high and 14 with T2-low endotype. Expression levels of 20 genes were compared by real-time PCR in bronchial biopsies performed at the third BT session versus baseline. Clinical response was measured based on Asthma Control Questionnaire (ACQ) score < 1.5, asthma exacerbations < 2, oral corticosteroids reduction of at least 50% at 12 months post-BT. Patients were classified as responders when they had at least 2 of 3 outcome measures., Results: 81% of patients were defined as responders. BT induced a reduction in alpha smooth muscle actin (ACTA2) and an increase in CD68, fibroblast activation protein-alpha (FAP), alpha-1 and alpha-2 type I collagen (COL1A1, COL1A2) gene expression in the majority of patients. A higher reduction in ubiquitin carboxy-terminal-hydrolase L1 (PGP9.5) mRNA correlated with a better response based on Asthma Quality of Life Questionnaire (AQLQ). Lower changes in CD68 and FAP mRNAs correlated with a better response based on ACQ. Lower levels of occludin (OCLN), CD68, connective tissue growth factor (CTGF), higher levels of secretory leukocyte protease inhibitor (SLPI) and lower changes in CD68 and CTGF mRNAs were observed in patients who had less than 2 exacerbations post-BT. Lower levels of COL1A2 at baseline were observed in patients who had ACQ < 1.5 at 12 months post-BT., Conclusions: BT is effective irrespective of the asthma endotypes and seems associated with airway remodelling. Quantification of OCLN, CD68, CTGF, SLPI, COL1A2 mRNAs could be useful to identify patients with better results., Trial Registration: The study protocol was approved by the Local Ethics Committee (Azienda USL-IRCCS of Reggio Emilia-Comitato Etico Area Vasta Nord of Emilia Romagna; protocol number: 2019/0014076) and all the patients provided written informed consent before participating in the study., (© 2022. The Author(s).)

Metabolomics approaches, such as direct analysis in real time-high resolution mass spectrometry (DART-HRMS), allow characterising many polar and non-polar compounds useful as authentication biomarkers of dairy chains. By using both a partial least squares discriminant analysis (PLS-DA) and a linear discriminant analysis (LDA), this study aimed to assess the capability of DART-HRMS, coupled with a low-level data fusion, discriminate among milk samples from lowland (silages vs. hay) and Alpine (grazing; APS) systems and identify the most informative biomarkers associated with the main dietary forage. As confirmed also by the LDA performed against the test set, DART-HRMS analysis provided an accurate discrimination of Alpine samples; meanwhile, there was a limited capacity to correctly recognise silage- vs. hay-milks. Supervised multivariate statistics followed by metabolomics hierarchical cluster analysis allowed extrapolating the most significant metabolites. Lowland milk was characterised by a pool of energetic compounds, ketoacid derivates, amines and organic acids. Seven informative DART-HRMS molecular features, mainly monoacylglycerols, could strongly explain the metabolomic variation of Alpine grazing milk and contributed to its classification. The misclassification between the two lowland groups confirmed that the intensive dairy systems would be characterised by a small variation in milk composition., (© 2022. The Author(s).)

Aims: The efficacy of ambient mass spectrometry to identify and serotype Legionella pneumophila was assessed. To this aim, isolated waterborne colonies were submitted to a rapid extraction method and analysed by direct analysis in real-time mass spectrometry (DART-HRMS)., Methods and Results: The DART-HRMS profiles, coupled with partial least squares discriminant analysis (PLS-DA), were first evaluated for their ability to differentiate Legionella spp. from other bacteria. The resultant classification model achieved an accuracy of 98.1% on validation. Capitalising on these encouraging results, DART-HRMS profiling was explored as an alternative approach for the identification of L. pneumophila sg. 1, L. pneumophila sg. 2-15 and L. non-pneumophila; therefore, a different PLS-DA classifier was built. When tested on a validation set, this second classifier reached an overall accuracy of 95.93%. It identified the harmful L. pneumophila sg. 1 with an impressive specificity (100%) and slightly lower sensitivity (91.7%), and similar performances were reached in the classification of L. pneumophila sg. 2-15 and L. non-pneumophila., Conclusions: The results of this study show the DART-HMRS method has good accuracy, and it is an effective method for Legionella serogroup profiling., Significance and Impact of the Study: These preliminary findings could open a new avenue for the rapid identification and quick epidemiologic tracing of L. pneumophila, with a consequent improvement to risk assessment., (© 2021 The Society for Applied Microbiology.)

Background: According to the guidelines, endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) is the technique of choice for the diagnosis of mediastinal involvement in lung cancer; it is also useful for other mediastinal malignancies and benign pathology. Nevertheless, there is still discussion about whether to perform it under general anesthesia or under conscious sedation., Methods: We retrospectively analyzed the data of all patients who underwent EBUS-TBNA under conscious sedation with up to 1 mg/kg of meperidine and up to 0.15 mg/kg of midazolam in the Interventional Pulmonology Unit of the Azienda USL-IRCCS Santa Maria Nuova of Reggio Emilia during 2 consecutive years. Demographic data, indication for the procedure, duration, number of lymph node sampled, number of passes per station, diagnostic yield, drugs dosage, questionnaire score, and complications were collected., Results: A total of 302 patients underwent EBUS-TBNA, and 68% of the patients were males and the mean age was 65 ± 13 years old. The average duration of procedures was 24.4 minutes and the mean dosage of drugs was 4.32 ± 1.52 mg for midazolam and 50.86 ± 13.71 mg for meperidine. The mean number of lymph nodes sampled per patient was 1.75 ± 0.82, and each patient received an average of 4.71 ± 1.78 passes. A total of 90.7% of patients completed the procedures, 85% had adequate samples, and 94.4% of patients declared with Likert's questionnaire that they strongly agree to repeat the test if necessary., Conclusion: EBUS-TBNA performed under conscious sedation with meperidine and midazolam is feasible and well-tolerated and has a similar diagnostic yield of that reported in literature., (© 2021 The Authors. Thoracic Cancer published by China Lung Oncology Group and John Wiley & Sons Australia, Ltd.)

Why are some dreams of the deceased experienced as comforting, while others are distressing? We propose that there are different types of dreams serving diverse functions. In particular, we considered three: processing trauma, maintaining a continuing bond, and regulating emotion. We also examined the impact of post-dream reactions on the bereaved's experience of their dreams. Participants were 216 individuals whose romantic partner or spouse had died. They provided reports of dreams of the deceased that were content analyzed and completed measures of grief intensity, posttraumatic symptoms, attachment style, internalized versus externalized continuing bonds, as well as questions about the death, and ratings of how they experienced the dream after awakening. Support was found for the three proposed functions, suggesting dreams of the deceased can actively facilitate adjustment to bereavement. In addition, there was evidence that post-dream reactions can impact both the perception of the dream and grief.

Background: Surgery for non-small cell lung cancer is proven to be the most effective treatment in early stages, although concerns exist on its negative impact on patients' overall fitness., Aim: To establish whether intensive pulmonary rehabilitation, preoperative and postoperative, improves exercise capacity in patients undergoing lung resection., Design: Single center, unblinded, designed for superiority, 1:1 randomized controlled trial with two parallel arms., Setting: S. Maria Nuova Hospital of Reggio Emilia (Reggio Emilia, Italy)., Population: Patients referred from local lung cancer multidisciplinary team for lung resection., Methods: Patients were randomized to either standard of care (SC) or SC + intensive perioperative pulmonary rehabilitation (SC+PR). The primary aim was to investigate the effectiveness of pulmonary rehabilitation in improving exercise capacity six months after surgery. Additionally, we wanted to investigate the same effect shortly after surgery (at one month), as well as the overall impact of rehabilitation on lung function, postoperative complications and length of stay, quality of life, mood disturbances and pain. Sample was sized based on the primary outcome assuming a minimal clinically significant difference of 25 meters in exercise tolerance, measured with 6 minutes walking test., Results: The exercise tolerance at 6 months after surgery was significantly higher in patients undertaking PR compared to SC (+48.9 meters vs. -7.5 meters respectively, difference: +56.4 meters, 95% CI: 29.6-83.0, P<0.001) and it showed significantly lower impairment at 1 month after surgery in the intervention group (-3.0 meters vs. -30.1 meters difference: +27.1 meters, 95% CI: 3.4-50.8, P=0.025). No other significant differences between groups were found., Conclusions: Comparison between groups showed that pulmonary rehabilitation, administered pre and postoperatively, significantly improved exercise capacity at 6 months in patients undergoing lung resection; it also significantly reduced the decrease in exercise tolerance observed 1 month after surgery., Clinical Rehabilitation Impact: The PUREAIR trial highlights the importance of combined preoperative and postoperative rehabilitation in reducing physical deconditioning in lung cancer patients undergoing surgery. Comprehensive pulmonary rehabilitation improves exercise capacity at 1 and 6 months after surgery. The PUREAIR trial results increase knowledge on comprehensive rehabilitation's outcomes in the first six months after surgery.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has changed bronchoscopy practices worldwide. Bronchoscopy is a high-risk aerosol-generating procedure with a potential for direct SARS-CoV-2 exposure and hospital-acquired infection. Current guidelines about personal protective equipment and environment considerations represent key competencies to minimize droplets dispersion and reduce the risk of transmission. Different measures should be put in field based on setting, patient's clinical characteristics, urgency and indications of bronchoscopy. The use of this technique in SARS-CoV-2 patients is reported primarily for removal of airway plugs and for obtaining microbiological culture samples. In mechanically ventilated patients with SARS-CoV-2, bronchoscopy is commonly used to manage complications such as hemoptysis, atelectasis or lung collapse when prone positioning, physiotherapy or recruitment maneuvers have failed. Further indications are represented by assistance during percutaneous tracheostomy. Continuous positive airway pressure, non-invasive ventilation support and high flow nasal cannula oxygen are frequently used in patient affected by Coronavirus disease 2019 (COVID-19): management of patients' airways and ventilation strategies differs from bronchoscopy indications, patient's clinical status and in course or required ventilatory support. Sedation is usually administered by the pulmonologist (performing the bronchoscopy) or by the anesthetist depending on the complexity of the procedure and the level of sedation required. Lastly, elective bronchoscopy for diagnostic indications during COVID-19 pandemic should be carried on respecting rigid standards which allow to minimize potential viral transmission, independently from patient's COVID-19 status. This narrative review aims to evaluate the indications, procedural measures and ventilatory strategies of bronchoscopy performed in different settings during COVID-19 pandemic.

Background: Detection of small peripheral lung nodules is constantly increasing with the development of low dose computed tomography lung cancer screening programs. A tissue diagnosis is often required to confirm malignity, with endobronchial biopsies being associated with a lower pneumothorax rate than percutaneous approaches. Endoscopic diagnosis of peripheral small size lung nodules is however often challenging using traditional bronchoscopy and endobronchial ultrasound alone. New virtual bronchoscopic navigation techniques such as electromagnetic navigational bronchoscopy (ENB) have developed to improve peripheral navigation, with diagnostic yield however remaining in the 30-50% range for small lesions. Recent studies have shown the benefits of combining Cone beam computed tomography (CBCT) with ENB to improve diagnostic yield to up to 83%. The use of ENB however remains limited by disposable cost, bronchus sign dependency and inaccuracies due to CT to body divergence., Case Presentation: This case report highlights the feasibility and usefulness of CBCT-guided bronchoscopy for the sampling of lung nodules difficult to reach through traditional bronchoscopy because of nodule size and peripheral position. Procedure was scheduled in a mobile robotic hybrid operating room with patient under general anaesthesia. CBCT acquisition was performed to localize the target lesion and plan the best path to reach it into bronchial tree. A dedicated software was used to segment the lesion and the bronchial path which 3D outlines were automatically fused in real time on the fluoroscopic images to augment live guidance. Navigation to the lesion was guided with bronchoscopy and augmented fluoroscopy alone. Before the sampling, CBCT imaging was repeated to confirm the proper position of the instrument into the lesion. Four transbronchial needle aspirations (TBNA) were performed and the tissue analysis showed a primary lung adenocarcinoma., Conclusions: CBCT and augmented fluoroscopy technique is a safe and effective and has potential to improve early stage peripheral lesions endobronchial diagnostic yield without ENB. Additional studies are warranted to confirm its safety, efficacy and technical benefits, both for diagnosis of oncological and non-oncological disease and for endobronchial treatment of inoperable patients., (© 2021. The Author(s).)

Background: Transbronchial lung cryobiopsy is a safe technique increasingly used in the study of lung diseases. Until now, only a case of pneumatocele was described but this interesting condition is probably underestimated because CT scan is routinely not performed after transbronchial lung cryobiopsies., Case Presentation: We report a case of a woman presenting two pneumatoceles after lung cryobiopsies performed for the study of an interstitial lung disease. The finding was obtained with a CT scan performed because of the appearance of hemoptysis, four days after the biopsies., Conclusions: Small cavitations could develop after cryobiopsies in the absence of an active infection. Studies that prospectively perform CT scan of the chest in patients who have undergone these samplings could be useful to know the incidence of iatrogenic lesions., (© 2021. The Author(s).)

The current pandemic caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has led people to implement preventive measures, including surface disinfection and use of alcohol-based hand gel, in order to avoid viral transmission via fomites. However, the role of surface transmission is still debated. The present systematic review aims to summarize all the evidence on surface survival of coronaviruses infecting humans. The analysis of 18 studies showed the longest coronavirus survival time is 28 days at room temperature (RT) on different surfaces: polymer banknotes, vinyl, steel, glass, and paper banknotes. Concerning SARS-CoV-2 human infection from contaminated surfaces, dangerous viral load on surfaces for up to 21 days was determined on polymer banknotes, steel, glass and paper banknotes. For viruses other than SARS-CoV-2, the longest period of survival was 14 days, recorded on glass. Environmental conditions can affect virus survival, and indeed, low temperatures and low humidity support prolonged survival of viruses on contaminated surfaces independently of surface type. Furthermore, it has been shown that exposure to sunlight significantly reduces the risk of surface transmission. Although studies are increasingly investigating the topic of coronavirus survival, it is difficult to compare them, given the methodology differences. For this reason, it is advisable to define a reference working protocol for virus survival trials, but, as an immediate measure, there is also a need for further investigations of coronavirus survival on surfaces., Competing Interests: Declaration of competing interest The authors have no competing interests to declare., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Coronavirus disease (COVID-19) is a respiratory disease affecting many people and able to be transmitted through direct and perhaps indirect contact. Direct contact transmission, mediated by aerosols or droplets, is widely demonstrated, whereas indirect transmission is only supported by collateral evidence such as virus persistence on inanimate surfaces and data from other similar viruses. The present systematic review aims to estimate SARS-CoV-2 prevalence on inanimate surfaces, identifying risk levels according to surface characteristics. Data were obtained from studies in published papers collected from two databases (PubMed and Embase) with the last search on 1 September 2020. Included studies had to be papers in English, had to deal with coronavirus and had to consider inanimate surfaces in real settings. Studies were coded according to our assessment of the risk that the investigated surfaces could be contaminated by SARS-CoV-2. A meta-analysis and a metaregression were carried out to quantify virus RNA prevalence and to identify important factors driving differences among studies. Thirty-nine out of forty retrieved paper reported studies carried out in healthcare settings on the prevalence of virus RNA, five studies carry out also analyses through cell culture and six tested the viability of isolated viruses. Overall prevalences of SARS-CoV-2 RNA on high-, medium- and low-risk surfaces were 0.22 (CI 95 [0.152-0.296]), 0.04 (CI 95 [0.007-0.090]), and 0.00 (CI 95 [0.00-0.019]), respectively. The duration surfaces were exposed to virus sources (patients) was the main factor explaining differences in prevalence., (© 2021. Springer Nature B.V.)

Introduction: During this long COVID-19 pandemic outbreak, continuous positive airway pressure (CPAP) and noninvasive ventilation (NIV) are being widely used to treat patients with moderate to severe acute respiratory failure (ARF). As for now, data on the efficacy of NIV in COVID-19 acute respiratory distress syndrome (ARDS) are lacking, and for this reason it is extremely important to accurately determine the outcomes of this strategy. This study aimed to evaluate clinical data and outcomes of NIV in patients with COVID-19 ARDS., Matherials and Methods: Seventy-nine consecutive patients with sudden worsening of respiratory failure were evaluated. All patients (71% male) had a confirmed SARS-CoV-2 infection and signs, symptoms and radiological findings compatible with COVID-19 pneumonia and all of them underwent a trial of NIV. Primary outcomes were NIV success and failure defined by intubation and mortality rate. Secondary outcome was the duration of NIV., Results: NIV was successful in 38 (48.1%) patients (Table 1). EOT was necessary in 21 patients (26.6%). Death occurred in 20 patients (25.3%). In the group of patients having failed a trial with NIV and then being intubated, compared to those who continued NIV, there was no higher mortality rate. By evaluating the ICU survival outcome of the subgroup of patients intubated after NIV, 57% of the patients were discharged and 43% died., Conclusion: Previous studies conducted on patients undergoing invasive mechanical ventilation showed higher mortality rate than the present study. Our data showed that NIV can avoid intubation in almost half of the patients. Therefore, this data could reassure clinicians who would consider using NIV in COVID-19 ARDS-related treatment., (© 2021 John Wiley & Sons Ltd.)