Applications to augment patient care for Internal Medicine specialists: a position paper from the EFIM working group on telemedicine, innovative technologies & digital health.

Telemedicine applications present virtually limitless prospects for innovating and enhancing established and new models of patient care in the field of Internal Medicine. Although there is a wide range of innovative technological solutions in Europe, there are overarching elements associated with such technologies when applied to the practices of Internal Medicine specialists. The European Federation of Internal Medicine (EFIM) strongly advocates for active leadership and influence from the Internal Medicine societies and specialist physicians across Europe in the development and application of telemedicine and digital technologies in healthcare. This position paper's conclusions were drawn via Delphi method, which was developed collaboratively from July 2021 to December 2023. The panel, consisting of experts in clinical medicine, public health, health economics and statistics, assessed various aspects related to telemedicine. Participants assigned scores on a Likert scale reflecting perceived value and potential risks. The findings were consolidated in a comprehensive checklist aligning with relevant literature and a SWOT analysis. Specifically, key issues that need to be addressed include promoting the professional development of e-health competencies in the healthcare and medical workforce, using educational campaigns to promote digital literacy among patients and caregivers, designing and implementing telemedicine applications tailored to local conditions and needs and considering the ethical and legal contexts under which these applications are employed. Importantly, there is currently no consensus on care models or standardized protocols among European Internal Medicine specialists regarding the utilization of telemedicine. This position paper aims to outline the opportunities and challenges associated with the application of telemedicine in Internal Medical practice in Europe.

Hybrid Raman/Brillouin-optical-time-domain-analysis-distributed optical fiber sensors based on cyclic pulse coding.

We experimentally demonstrate the use of cyclic pulse coding for distributed strain and temperature measurements in hybrid Raman/Brillouin optical time-domain analysis (BOTDA) optical fiber sensors. The highly integrated proposed solution effectively addresses the strain/temperature cross-sensitivity issue affecting standard BOTDA sensors, allowing for simultaneous meter-scale strain and temperature measurements over 10 km of standard single mode fiber using a single narrowband laser source only.

High-performance hybrid Raman/fiber Bragg grating fiber-optic sensor based on simplex cyclic pulse coding.

We propose and experimentally demonstrate the use of cyclic pulse coding to improve the performance of hybrid Raman/fiber Bragg grating (FBG) fiber-optic sensors, for simultaneous measurement of distributed static temperature and discrete dynamic strain over the same sensing fiber. Effective noise reduction is achieved in both Raman optical time-domain reflectometry and dynamic interrogation of time-division-multiplexed fiber FBG sensors, enhancing the sensing range resolution and providing real-time point dynamic strain measurement capabilities. The highly integrated sensor scheme employs broadband apodized low-reflectivity FBGs, a single narrowband optical source, and a shared receiver block.

Cyclic pulse coding for fast BOTDA fiber sensors.

A cyclic pulse coding technique is proposed and experimentally demonstrated for fast implementation of long-range Brillouin optical time-domain analysis (BOTDA). The proposed technique allows for accurate temperature and strain measurements with meter-scale spatial resolution over kilometers of standard single-mode fiber, with subsecond measurement times.

Cognitive Digital Biomarkers from Automated Transcription of Spoken Language.

BACKGROUND: Although patients with Alzheimer's disease and other cognitive-related neurodegenerative disorders may benefit from early detection, development of a reliable diagnostic test has remained elusive. The penetration of digital voice-recording technologies and multiple cognitive processes deployed when constructing spoken responses might offer an opportunity to predict cognitive status. OBJECTIVE: To determine whether cognitive status might be predicted from voice recordings of neuropsychological testing. DESIGN: Comparison of acoustic and (para)linguistic variables from low-quality automated transcriptions of neuropsychological testing (n = 200) versus variables from high-quality manual transcriptions (n = 127). We trained a logistic regression classifier to predict cognitive status, which was tested against actual diagnoses. SETTING: Observational cohort study. PARTICIPANTS: 146 participants in the Framingham Heart Study. MEASUREMENTS: Acoustic and either paralinguistic variables (e.g., speaking time) from automated transcriptions or linguistic variables (e.g., phrase complexity) from manual transcriptions. RESULTS: Models based on demographic features alone were not robust (area under the receiver-operator characteristic curve [AUROC] 0.60). Addition of clinical and standard acoustic features boosted the AUROC to 0.81. Additional inclusion of transcription-related features yielded an AUROC of 0.90. CONCLUSIONS: The use of voice-based digital biomarkers derived from automated processing methods, combined with standard patient screening, might constitute a scalable way to enable early detection of dementia.

Long-term mortality in anorexia nervosa: a report after an 8-year follow-up and a review of the most recent literature.

OBJECTIVE: To evaluate long-term mortality rate of anorexia nervosa (AN) patients in a southern Italy population compared to the most recent literature. DESIGN: Retrospective and review setting. PATIENTS AND INTERVENTIONS: One hundred and forty-seven female AN patients, consecutively admitted from 1994 to 1997 to the Outpatient Unit, were re-examined between June and November 2003. Our data are compared with 10 other studies published since 1988. RESULTS: One hundred and twenty-three deaths in 2240 patients, amounting to a total mortality rate of 5.25% were reported in the literature. Deaths due to suicide, AN-related and AN-unrelated diseases were 1.20, 3.07 and 0.98%, respectively. After correcting for unrelated deaths, mortality rate was 4.27%. In our 8-year follow-up, we found a mortality rate of 2.72% (1.82% after correcting for unrelated deaths). Standardized mortality ratio was 9.7. CONCLUSION: We interpret our favourable findings as a consequence of an integrated, clinical-nutritional and psychiatric approach. Finally, considering AN demographic characteristics, that is young female subjects in Westernized societies, mortality rate is confirmed to be dramatically high.

Comparison of verapamil versus felodipine on heart rate variability in hypertensive patients.

OBJECTIVE: We evaluated the effect of two calcium channel blockers, verapamil and felodipine, on heart rate variability in hypertensive patients. DESIGN: Time and frequency domain measures of heart rate variability were obtained from 24 h Holter recording in 25 previously untreated hypertensive patients without left ventricular hypertrophy, before and after 3 months of verapamil slow-release treatment (240 mg once daily) or felodipine extended-release treatment (10 mg once daily). RESULTS: Blood pressure values decreased with both drugs. Measures of heart rate variability, comparable at baseline in the two groups, were unchanged after felodipine. After verapamil, the average RR interval, the square root of the mean of the squared differences between all adjacent normal RR intervals (r-MSSD) and the percentage of differences between all adjacent normal RR intervals > 50 ms (pNN50), measures of vagal modulation of heart rate, increased (from 735 +/- 67 to 827 +/- 84 ms, P < 0.001; from 30 +/- 10 to 44 +/- 15 ms, P < 0.001; and from 3 +/- 2 to 7 +/- 6%, P < 0.01, respectively) and were higher than after felodipine. The coefficient of variation, a measure that compensates for heart rate effects, increased only after verapamil (from 5.8 +/- 1.3% to 6.6 +/- 1.0%; P < 0.05). High frequency power and its coefficient of component variance, both representing the vagal modulation of heart rate, increased after verapamil (from 5.33 +/- 0.29 to 5.80 +/- 0.27 In units, P < 0.001 and from 1.9 +/- 0.3 to 2.2 +/- 0.25%; P < 0.05). Finally, the low to high frequency power ratio, an indicator of sympathovagal balance, with a high value suggesting a sympathetic predominance, decreased after verapamil (from 2.16 +/- 0.41 to 1.36 +/- 0.35; P < 0.001), confirming the improvement in vagal modulation of heart rate. CONCLUSION: In hypertensive patients, despite a comparable anti-hypertensive effect, verapamil, but not felodipine, has favourable effect on cardiac autonomic control.

Toremifene as a substitute for adjuvant tamoxifen in breast cancer patients.

BACKGROUND: Toremifene is a new antiestrogen, which in nonclinical studies appears less carcinogenic than tamoxifen. Clinical trials of adjuvant toremifene vs. tamoxifen in breast cancer patients are ongoing. This study aimed to evaluate the short-term effects of changing from adjuvant tamoxifen to toremifene. PATIENTS AND METHODS: Twenty postmenopausal breast cancer patients receiving adjuvant tamoxifen, 20 mg/day, were switched to toremifene 60 mg/day. The effects on the uterus were evaluated prospectively by transvaginal ultrasound; tolerability was assessed clinically. RESULTS: In 14 patients who had uterine abnormalities (endometrial thickening or polyps) under tamoxifen, no significant changes occurred during a median of 18 months (range 7-24) of toremifene treatment. Out of six patients who had entered the study due to intolerance to tamoxifen, however, 3 tolerated toremifene well. CONCLUSION: Toremifene does not modify previous uterine changes induced by tamoxifen. For some patients who do not tolerate tamoxifen, however, switching to toremifene may allow the continuation of adjuvant antiestrogenic therapy.

Microtubule assembly in Friend erythroleukemia cells spread on fibronectin- and lectin-coated substrates.

A comparison was carried out between parental Friend Erythroleukemia cells (FLC, 745 A clone) and highly fibronectin (FN)-sensitive clones of FLC for their ability to adhere, spread and organize microtubular (MT) apparatus, when seeded on FN- or lectin-coated plastic substrates. While FN was able to induce the spreading only in the FN-sensitive FLC clones (further referred to as FF clones) and not in the parental 745 A cells, the lectins Concanavalin A (ConA) and Leukoagglutinin (LeuA) promoted the spreading of both 745 A and FF cells, with no differences between the two cell lines. Wheat germ agglutinin (WGA), instead, is almost ineffective in triggering cell spreading in both cell clones. The spreading of FLC, either 745 A or FF, on any of the ligands tested, is always accompanied by a massive reorganization of the MT apparatus of the cell. Possible mechanisms involved in the selective spreading effect, exerted by FN, are discussed.

Wavelet transform analysis of heart rate variability during dipyridamole-induced myocardial ischemia: relation to angiographic severity and echocardiographic dyssynergy.

BACKGROUND: Analysis of heart rate variability (HRV) is a valuable noninvasive method for quantifying autonomic cardiac control in humans and has been utilized during dipyridamole echocardiographic test to differentiate positive from negative test results. HYPOTHESIS: We aimed to evaluate, by means of HRV analysis, the influence of the angiographic severity of coronary artery disease on cardiac autonomic control during dipyridamole-induced myocardial ischemia. METHODS: We analyzed RR interval variability changes during dipyridamole-induced myocardial ischemia in 31 selected patients (mean age 54 +/- 9 years) with available coronary angiography and positive dipyridamole echocardiographic test. Spectral components of HRV were assessed by means of wavelet transform analysis for the last 5 min before the beginning of the test (baseline) and for 5 min after the onset of ischemia-related events (peak dipyridamole effect). RESULTS: Patients were divided into three groups according to the number of coronary diseased vessels (Group A, single-vessel disease; Group B, double-vessel disease; Group C, triple-vessel disease). No difference was detectable at baseline among the three groups. After dipyridamole, low-frequency power, a measure of sympathetic modulation of heart rate, increased and echocardiographic wall motion score index worsened in all groups (p < 0.001). The increase in low-frequency power was more evident in Group C patients than in the other two groups (p < 0.005). Furthermore, after dipyridamole, a direct correlation was found between low-frequency power and wall motion score index (r = 0.59; p < 0.001). CONCLUSIONS: These data suggest that HRV analysis performed during dipyridamole echocardiographic test provides useful information to assess the severity of coronary artery disease.

Insulin formulations--a review.

Although the improvement on insulin therapy since it was first conceived, it is still far from mimicking physiological secretion of pancreatic b-cells and research to find new insulin formulations and new routes of administration continues. Human biosynthetic insulin (rapid-acting, intermediate-acting and long-acting), produced by recombinant DNA technique, is currently available. The pharmacokinetic profile of rapid-acting insulin (regular) does not adequately reproduce the physiological post-prandial insulin response. This has led to the development of molecular analogues with slight modifications that prevent the spontaneous polymerisation underlying delayed absorption. Fast-acting analogues such as Lyspro and Aspart can be injected immediately before the meal, inducing a very fast and substantial peak of insulin, similar to that produced by b-cells, but have the disadvantage of short duration of action. For this reason, and because of the difficulty of obtaining sufficient basal insulin concentrations to control preprandial blood glucose levels with current long-acting insulins, analogues known as Glargine and Detemir have been synthesized. They have virtually no plasma peak and acts for about 24 h. These characteristics make it ideal to cover basal insulin requirement. With insulin analogues, it also seems possible to overcome the problem of intra- and inter-individual variability in absorption after subcutaneous injection. This variability is directly proportional to the duration of insulin action. Research into new routes of administration has led to production of inhaled insulin powder, soon to become commercially available. Insulin is absorbed through the lung alveoli. Trials to evaluate efficacy and toleration have shown that inhaled insulin has a similar kinetic profile to the fast-acting injected analogue and can therefore be used for mealtime requirement, combined with a single daily injection of long-acting insulin. Oral insulin is currently being studied in type 1 diabetes prevention with promising results.

A scientific reappraisal of the 'principle of similarity'.

In the history of therapeutics, the 'principle of similarity'--the treatment of 'same by same' or of 'like by like'--may be traced back to a number of medical traditions, including the systems of Hippocrates, Paracelsus and Hahnemann. Although in recent years we have witnessed a renaissance of interest in traditional medicines and 'holistic' medical practices, the reliability of the principle of similarity has still to be demonstrated on experimental grounds, and very few studies have been conducted to understand the underlying mechanism(s). Acceptance of this phenomenon requires supporting evidence of possible mechanisms and high-quality studies exploring its effectiveness in clinical medicine. The aim of this work is to provide a rational approach to the analysis of the various aspects of this historical yet also modern medical principle, in order to construct a plausible framework of ideas capable of facilitating further basic and clinical research into this field.

[Clinical study of the therapeutic effect of Mefoxine]. / Osservazioni cliniche sull'azione terapeutica del Mefoxin.

The therapeutic efficacy of cefoxitin was studied in 15 patients with pulmonary or urinary infections, after other unsuccessful antibiotic treatment. The drug determined a total regression of clinical picture within 10 days of therapy. Our results show that brief periods of treatment are sufficient in order to obtain recovery and to avoid selection of resistant germs. Patients treated with cefoxitin did not present any intolerance. The conclusion is drawn that "Mefoxin" is useful in patients affected by infections resistant to common antibiotics.

[Effects of ticlopidine on the plasma levels of beta-thromboglobulin and thromboxane B2 in types 1 and 2 diabetics]. / Effetti della ticlopidina sui valori plasmatici della beta-tromboglobulina e del trombossano B2 rilevati in diabetici tipo 1 e 2.

11 insulin-dependent and 19 non insulin-dependent diabetics with varying degrees of metabolic compensation and with high plasma levels of beta-thromboglobulin and thromboxane B2 were selected. Depending on the type of diabetes and the degree of glycaemia, control plasma levels of beta-thromboglobulin and thromboxane B2 were progressively lower after 14, 28 and 42 days of treatment with ticlopidine (500 mg/per day orally), than those encountered at the start of the study. It is concluded that ticlopidine influences plasma levels of beta-thromboglobulin and thromboxane B2 independently of the type and degree of metabolic compensation in diabetes mellitus.

[Prolactin secretion in patients with essential obesity]. / Aspetti della secrezione prolattinica in pazienti affete da obesità essenziale.

17 women affected by essential obesity were examined, 9 of whom had become obese as adults (group A) and 8 had been obese since childhood (group B). In group A, fasting and after TRH, the PRL presented higher plasmatic levels than those found in the controls. In group B the hormone showed basal values and global secretory areas higher than those observed in the controls and in group A, while incremental areas did not result different from those found in the other groups examined. In no case did IRI, GH and glycaemia undergo changes in relation to TRH. In conclusion we think that the behaviour of prolactin can be an important physiopathological characteristic, expression of the different neuroendocrine hypothalamic homeostasis existent in the heterogeneous obese population.

[Rationale for the building of a new hospital]. / Perché costruire un nuovo ospedale.

The "Azienda Ospedaliera Ospedali Riuniti di Bergamo" has completed the preliminary planning of the building of a new, great hospital, after a long and deep debate about the role and the significance of a modern hospital, thought to support, during the next century, the activity of a "hospital of national relevance and high specialization". The main aspects about the number of beds in the new hospital are debated and considered in the new conditions following the new programming acts of health planning in Italy and Lombardy and the needs of demography and emerging health demands The choice between new building or restructuring the existing hospital is discussed and the debate is referred to international scientific bibliography. Risk management is also considered as a must in a new hospital building.

[Theory of training and quality of safety in health]. / Teoria della formazione e qualità della sicurezza in Sanità.

This article aims to define the concept of security, particularly in relation to concepts of risk, error, danger and adverse events. The authors go on to analyse the latest theory of adult training, applying it to healthcare safety whilst recognising that this is a complex facility. By using tools such as guidelines and risk management, the authors propose a new kind of corporate culture that enables certain initiatives, such as clinical governance and therefore learning organisation, to develop. This strategic organisation the company allows vital knowledge and experience, which lead to problem-solving and an increased guarantee of security for both internal and external clients, to become the common knowledge and property of the company as a whole and of all who operate in and around it.

Neurobehavioral functions in operating theatre personnel exposed to anesthetic gases.

Neurobehavioral functions in paramedical operating theatre personnel were assessed in a cross-sectional survey. Sixty-two subjects (40 males and 22 females) occupationally exposed to anesthetic gases were examined and compared to 46 unexposed hospital workers (18 males and 28 females). The Simple Reaction Time (SRT) test was selected from the MANS battery (Milan Automated Neurobehavioural System). In order to evaluate acute and subacute types of effects on performance, the test was administered before and after the work shift, at the beginning and at the end of the working week. In addition, the complete battery was administered during one working day without exposure to anesthetic gases. On the last day of the working week, atmospheric nitrous oxide (N2Oa) ranged from 7 to 553 ppm (geometric mean 62.6), atmospheric ethrane (ETHa) ranged from 0.1 to 18.8 ppm (geometric mean 1.3), and urinary N2O (N2Ou) ranged from 4 to 297 micrograms/l (geometric mean 26.8). An impairment of performance on the SRT test was observed at the end of the working week in subjects exposed to anesthetic gases compared to controls. This alteration was observed also considering only the subjects exposed to less than 55 micrograms/l (which is the Italian exposure limit for N2Ou, equivalent to 100 ppm for N2Oa). No significant differences were observed for the other psychometric tests. No dose-effect relationships where found between SRT test score and the indicators of exposure (N2Oa, ETHa, N2Ou).(ABSTRACT TRUNCATED AT 250 WORDS)

[Organization of health and safety activities in health care centers]. / Organizzazione delle attività di prevenzione e sicurezza nelle aziende sanitarie.

The paper proposes a model for health and safety organization in health care units and hospitals which takes account of the risk assessment procedures required by law and the quality assessment of the measures thus taken. A redefinition is given of the role of Medical Director and of the functions, aims and standards on which health and safety service and the services of an authorized occupational health physicians must be based.