Telehealth Intervention: A Proposal for a Telemedicine Manual to Ascertain the Civil Disability Status in Italy.

(1) This paper aims to propose a telematic method for assessing the state of disability by a social worker member of the Medico-Legal Commissions of INPS. (2) We have proceeded to delve into and compare the current methods with new strategies to enhance the experience linked to the assessment of the status of disability in terms of timing and accessibility, eliminating the need for a direct visit. (3) The proposed protocol can be applied in cases where patients cannot be physically moved, following a medical visit at home, and when the mere evaluation of documents is sufficient. In both cases, a remote session with the Commission is necessary to fill in the required information about the socio-environmental section. This protocol can be applied to different platforms such as Skype™ since it is free and widely used throughout the country. (4) It should be noted that telemedicine solutions cannot completely replace face-to-face interaction; however, in some limited cases, they can optimize the process and timing, avoiding the need to move or interact only by telephone.

Persistent epigenetic signals propel a senescence-associated secretory phenotype and trained innate immunity in CD34+ hematopoietic stem cells from diabetic patients.

BACKGROUND: Diabetes-induced trained immunity contributes to the development of atherosclerosis and its complications. This study aimed to investigate in humans whether epigenetic signals involved in immune cell activation and inflammation are initiated in hematopoietic stem/progenitor cells (HSPCs) and transferred to differentiated progeny. METHODS AND RESULTS: High glucose (HG)-exposure of cord blood (CB)-derived HSPCs induced a senescent-associated secretory phenotype (SASP) characterized by cell proliferation lowering, ROS production, telomere shortening, up-regulation of p21 and p27genes, upregulation of NFkB-p65 transcription factor and increased secretion of the inflammatory cytokines TNFα and IL6. Chromatin immunoprecipitation assay (ChIP) of p65 promoter revealed that H3K4me1 histone mark accumulation and methyltransferase SetD7 recruitment, along with the reduction of repressive H3K9me3 histone modification, were involved in NFkB-p65 upregulation of HG-HSPCs, as confirmed by increased RNA polymerase II engagement at gene level. The differentiation of HG-HSPCs into myeloid cells generated highly responsive monocytes, mainly composed of intermediate subsets (CD14hiCD16+), that like the cells from which they derive, were characterized by SASP features and similar epigenetic patterns at the p65 promoter. The clinical relevance of our findings was confirmed in sternal BM-derived HSPCs of T2DM patients. In line with our in vitro model, T2DM HSPCs were characterized by SASP profile and SETD7 upregulation. Additionally, they generated, after myeloid differentiation, senescent monocytes mainly composed of proinflammatory intermediates (CD14hiCD16+) characterized by H3K4me1 accumulation at NFkB-p65 promoter. CONCLUSIONS: Hyperglycemia induces marked chromatin modifications in HSPCs, which, once transmitted to the cell progeny, contributes to persistent and pathogenic changes in immune cell function and composition.

Machine-learning prediction of treatment response to stereotactic body radiation therapy in oligometastatic gynecological cancer: A multi-institutional study.

BACKGROUND AND PURPOSE: We aimed to develop and validate different machine-learning (ML) prediction models for the complete response of oligometastatic gynecological cancer after SBRT. MATERIAL AND METHODS: One hundred fifty-seven patients with 272 lesions from 14 different institutions and treated with SBRT with radical intent were included. Thirteen datasets including 222 lesions were combined for model training and internal validation purposes, with an 80:20 ratio. The external testing dataset was selected as the fourteenth Institution with 50 lesions. Lesions that achieved complete response (CR) were defined as responders. Prognostic clinical and dosimetric variables were selected using the LASSO algorithm. Six supervised ML models, including logistic regression (LR), classification and regression tree analysis (CART) and support vector machine (SVM) using four different kernels, were trained and tested to predict the complete response of uterine lesions after SBRT. The performance of models was assessed by receiver operating characteristic curves (ROC), area under the curve (AUC) and calibration curves. An explainable approach based on SHapley Additive exPlanations (SHAP) method was deployed to generate individual explanations of the model's decisions. RESULTS: 63.6% of lesions had a complete response and were used as ground truth for the supervised models. LASSO strongly associated complete response with three variables, namely the lesion volume (PTV), the type of lesions (lymph-nodal versus parenchymal), and the biological effective dose (BED10), that were used as input for ML modeling. In the training set, the AUCs for complete response were 0.751 (95% CI: 0.716-0.786), 0.766 (95% CI: 0.729-0.802) and 0.800 (95% CI: 0.742-0.857) for the LR, CART and SVM with a radial basis function kernel, respectively. These models achieve AUC values of 0.727 (95% CI: 0.669-0.795), 0.734 (95% CI: 0.649-0.815) and 0.771 (95% CI: 0.717-0.824) in the external testing set, demonstrating excellent generalizability. CONCLUSION: ML models enable a reliable prediction of the treatment response of oligometastatic lesions receiving SBRT. This approach may assist radiation oncologists to tailor more individualized treatment plans for oligometastatic patients.

The case of Geneviève Lhermitte's euthanasia between psychiatric evaluation, legal aspects and ethical reflection.

A recent euthanasia case in Belgium has garnered attention due to its particularly dramatic aspects, sparking clinical and ethical questions about end-of-life choices in cases of mental suffering. A 56-year-old woman, convicted of the murder of her five minor children and sentenced to life imprisonment, has been granted euthanasia for "irreversible psychological suffering". The clinical and psychodynamic aspects of the case, primarily deduced from press reports, are highly complex and give rise to numerous clinical, medico-legal, and bioethical questions. These include inquiries into the true nature of psychopathology, its actual irreversibility, its impact on the ability to express a euthanasia request with adequate awareness, the preserved capacity for self-determination, and broader issues related to end-of-life requests from patients with mental disorders. These aspects are considered in the context of the legislation in various European countries. The unique details of this case underscore the critical challenges associated with these complex issues.

Psychiatric advance directives (Ulysses Contract): the need for a specific law and a criteria proposal for its introduction.

AIM: Advance healthcare directives in the psychiatric field raise more concerns and controversies compared to their use in other medical branches. We discuss the role of advance directives in this field and suggest a criteria proposal for the settlement of a comprehensive regulation on the matter. METHODS: We analyse the existing law and discuss the ethical points in the Italian context and, in comparison, with the United Kingdom context. RESULTS: Numerous studies have highlighted that psychiatric patients experience advance directives as an instrument to participate in therapeutic decision-making. Regarding the usefulness of advance directives, Italy and the United Kingdom did not approve deontological rules or laws. The United Nations Commission states that, based on the principles of the Convention on the Rights of Persons with Disabilities, it is necessary to respect the spatient's will, even if it is biased by psychic disorders. CONCLUSIONS: The Convention does not consider advance directives; instead, they just suggest using some support to have the patient regain their competence. In case this is unsuccessful, it is necessary to appoint a substitute decision-maker to express, even in the light of the advance directives, the will that the patient would have expressed if he had been competent.

Percutaneous CT-Guided Bone Biopsies: Indications, Feasibility and Diagnostic Yield in the Different Skeletal Sites-From the Skull to the Toe.

CT-guided bone biopsies are currently the diagnostic tool of choice for histopathological (and microbiological) diagnoses of skeletal lesions. Several research works have well-demonstrated their safety and feasibility in almost all skeletal regions. This comprehensive review article aims at summarizing the general concepts in regard to bone biopsy procedures, current clinical indications, the feasibility and the diagnostic yield in different skeletal sites, particularly in the most delicate and difficult-to-reach ones. The choice of the correct imaging guidance and factors affecting the diagnostic rate, as well as possible complications, will also be discussed. Since the diagnostic yield, technical difficulties, and complications risk of a CT-guided bone biopsy significantly vary depending on the different skeletal sites, subdivided analyses of different anatomical sites are provided. The information included in the current review article may be useful for clinicians assisting patients with possible bone neoplasms, as well as radiologists involved in the imaging diagnoses of skeletal lesions and/or in performing bone biopsies.

Analysis of Medico-Legal Complaint Data: A Retrospective Study of Three Large Italian University Hospitals.

(1) Background: Identifying hospital-related critical, and excellent, areas represents the main goal of this paper, in both a national and local setting. Information was collected and organized for an internal company's reports, regarding civil litigation that has been affecting the hospital, to relate the obtained results with the phenomenon of medical malpractice on a national scale. This is for the development of targeted improvement strategies, and for investing available resources in a proficient way. (2) Methods: In the present study, data from claims management in Umberto I General Hospital, Agostino Gemelli University Hospital Foundation and Campus Bio-Medico University Hospital Foundation, from 2013 to 2020 were collected. A total of 2098 files were examined, and a set of 13 outcome indicators in the assessment of "quality of care" was proposed. (3) Results: From the total number, only 779 records (37.1%) were attributable to the categories indexable for the present analysis. This data highlights how, following a correct and rigorous categorization of hospital events, it is possible to analyze these medico-legal aspects using a small number of indicators. Furthermore, it is important to consider how a consistent percentage of remaining events was difficult to index, and was also of poor scientific interest. (4) Conclusions: The proposed indicators do not require standards to be compared to, but provide a useful instrument for comparative purposes. In fact, in addition to comparative assessment between different business realities distributed throughout the territory, the use of outcome indicators allows for a longitudinal analysis evaluating the performance of an individual structure over time.

Free access to emergency oral contraceptives (EOCs) in the European Union: A regulatory vacuum to be filled.

BACKGROUND: According to the World Health Organization (WHO), any woman in childbearing age who have decided not to take permanently an oral contraceptive but who are sexually active has the right to access emergency contraception (EC). Despite this, in many European countries there are no specific laws governing the criteria for access to emergency oral contraceptives (EOCs) for girls under 18, especially about the need for third party consent. This normative vacuum is dangerous as it risks creating confusion and entrusting the management of the fundamental right of self-determination to the discretion of others. Moreover, in European Union (EU) countries, there is an inequality in terms of access to contraceptive supplies, reimbursement criteria and the availability of information online. OBJECTIVE: Our article compares the criteria for access to EOCs (Ulipristal Acetate-UPA and Levonorgestrel-LNG) in the various EU countries to highlight possible disparities and consequent inequalities. METHODS: Government and ministerial websites, European agencies websites, and Contraceptive Use by Method 2019 (WHO) have been consulted. RESULTS: There are some differences between the various European countries that could configure inequality in EU countries. CONCLUSIONS: It would be appropriate a definitive levelling of the legislation of the European Union on emergency contraception associated with massive information and awareness campaigns.

Intimate Female Partner Homicide Suicide: demographic and psychopathology aspects of perpetrators and a potential not yet classified diagnostic entityAnalyses of data taken from newspapers in Italy from 2009 to 2019.

INTRODUCTION: The homicide of the female partner followed by suicide of the perpetrator (Intimate Female Partner Homicide Suicide - IFPHS) has been a growing phenomenon over last years, but its psychosocial and psychopathological aspects have not been analyzed in-depth yet. PURPOSE: The aim of this study was to investigate common psychopathological elements in different IFPHS and a specific risk profile for both the couple and the male partner, with the possibility to define a new serial mental condition not classified to date. METHODS: A series of 50 cases of greater media coverage was reconstructed from the Italian newspapers in the period from 2009 to 2019 and information was collected through a predefined form. The characteristics of the perpetrators and the modalities through which the events occurred have been considered. RESULTS: No definite mental disorder is present in the history of almost all cases. A more common psychological profile is found for the homicide/suicide male partner, mainly characterized by jealousy, possessiveness, mood reactivity, rage, and impulsiveness. CONCLUSIONS: It can be hypothesized that such a severe act may express a form of mental disorder not yet classified, with main features of an acute state of mixed depressive mood, emotional discontrol and aggressive impulsiveness, on a personality basis of jealousy and possessiveness, possibly reinforced by previous dependent traits of the female partner. But the methodological limitations of gathering information from the press make it necessary the study in depth, based on more direct and objective methodologies, of such a highly dramatic and heterogeneous phenomenon.

The Shanti De Corte case: euthanasia for mental disorder between clinic and bioethics, between law and medico-legal implications.

INTRODUCTION: In recent months, a great uproar has been aroused by the case of a 23-year-old Belgian woman who requested and obtained euthanasia because she was suffering from a mental disorder, in the absence of any somatic pathology. The news raises some questions and stimulates some reflections both on the general theme of euthanasia carried out for the simple presence of a mental disorder, and for the indefiniteness of the clinical information on the case in question, as well as on the ethical and medico-legal questions connected to such indefiniteness. CASE PRESENTATION: The information on the case was derived essentially from the press and from websites, with no specific access to actual clinical documentation and without in-depth knowledge of case details. One wonders what the real clinical diagnosis of the patient was, only hypothetically identifiable in a Post-traumatic Stress Disorder associated with Major or Chronic Depressive Disorder, probably on the basis of a possible Personality Disorder. One wonders if all the necessary therapeutic interventions had been implemented, in a clinical case that did not theoretically have the characteristics of incurability. One wonders why the death request was considered valid, in a subject perhaps suffering from a mental disorder of such severity as to alter the ability to express valid consent to medical treatment. One wonders why the death request was not considered as an indicator of the severity of the disease, rather than simply being considered as a free choice of a subject capable of self-determination. One wonders why the negative opinion of the patient's family members was not considered. CONCLUSIONS: Belgian legislation provides for euthanasia for patients suffering from mental disorders who, like those suffering from somatic disorders, experience a condition of constant, unbearable and incurable suffering. But the case in question raises numerous perplexities both on the clinical and ethical coherence of Belgian legislation and on the ways in which the rules of this legislation have been observed in this specific situation.

Clinical Application of Diffusion Tensor Imaging for a Brachial Plexus Injury.

Brachial plexus injuries are commonly diagnosed clinically, as conventional imaging has a low sensitivity. In recent years, diffusion tensor imaging has established a clinical role in the study of the central nervous system and, while still presenting some limitations due to the technical complexity of the acquisition method, is showing promising results when applied to peripheral nerves. Moreover, deterministic fiber tracking with the Euler's method and multishell acquisition are two novel advances in the field which contribute to enhancing the reliability of the technique reducing the respiratory and inhomogeneity artifacts in this "magnetically complex" region, and better isolating the fibers in a heterogeneous territory. Here, we report a case of brachial plexus traumatic injury, a healthy reference subject, and details on the acquisition protocol of the reconstruction algorithm.

Liraglutide preserves CD34+ stem cells from dysfunction Induced by high glucose exposure.

BACKGROUND: Glucagon like peptide-1 receptor agonists (GLP-1RAs) have shown to reduce mortality and cardiovascular events in patients with type 2 diabetes mellitus (T2DM). Since the impairment in number and function of vasculotrophic circulating CD34+ hematopoietic stem progenitor cells (HSPCs) in T2D has been reported to increase cardiovascular (CV) risk, we hypothesized that one of the mechanisms whereby GLP-1 RAs exert CV protective effects may be related to the ability to improve CD34+ HSPC function. METHODS: In cord blood (CB)-derived CD34+ HSPC, the expression of GLP-1 receptor (GLP-1R) mRNA, receptor protein and intracellular signaling was evaluated by RT-qPCR and Western Blot respectively. CD34+ HSPCs were exposed to high glucose (HG) condition and GLP-1RA liraglutide (LIRA) was added before as well as after functional impairment. Proliferation, CXCR4/SDF-1α axis activity and intracellular ROS production of CD34+ HSPC were evaluated. RESULTS: CD34+ HSPCs express GLP-1R at transcriptional and protein level. LIRA treatment prevented and rescued HSPC proliferation, CXCR4/SDF-1α axis activity and metabolic imbalance from HG-induced impairment. LIRA stimulation promoted intracellular cAMP accumulation as well as ERK1/2 and AKT signaling activation. The selective GLP-1R antagonist exendin (9-39) abrogated LIRA-dependent ERK1/2 and AKT phosphorylation along with the related protective effects. CONCLUSION: We provided the first evidence that CD34+ HSPC express GLP-1R and that LIRA can favorably impact on cell dysfunction due to HG exposure. These findings open new perspectives on the favorable CV effects of GLP-1 RAs in T2DM patients.

Abortion in Europe: Recent legislative changes and risk of inequality.

BACKGROUND: Induced abortion is a medical practice that has always been much discussed all over the world. Abortion is allowed in most European countries at the request of the woman with limitations that are imposed mainly by the gestational age. However, there are legislative differences between European countries which impose stringent limits on the use of induced abortion. OBJECTIVE: This article analyzes the European legislation on abortion, with a particular focus on countries in which there have been recent legislative changes in recent years, and the possible consequent risk of inequality among European women. METHODS: Government and ministerial websites of the countries analyzed have been consulted to investigate abortion laws in Europe. In addition, the Global Abortion Policies Database of the World Health Organization was also consulted for a regulatory comparison. RESULTS: The differences between the various European countries are considerable. Although guaranteed by most legislation, abortion remains a fragile right in some European countries. CONCLUSION: Different legislation in the various countries of Europe causes difficulties for women who want to have an abortion but who reside in states where there are strict limits to abortion. In addressing the issue of induced abortion, we must not forget that the center of this practice is the woman. For this reason, it is essential to apply a reasoning based on respect for women's rights: freedom, health, and self-determination.

Ultrasound-guided Treatments for the Painful Shoulder.

Shoulder pain is an extremely common condition. The painful shoulder may be the result of a wide spectrum of underlying pathological conditions, including calcific tendinopathy of the rotator cuff, subacromial-subdeltoid bursitis, acromioclavicular or glenohumeral arthritis, tenosynovitis of the long biceps tendon, rotator cuff lesions, and many other less common conditions. Ultrasound imaging is an effective tool for the diagnosis and also for the image guidance of treatment of the majority of these conditions. Several ultrasound-guided procedures are effective for pain relief, such as percutaneous irrigation, intra-bursal or intra-articular drugs injection, fluid aspiration, neural block. This review article aims to summarize and discuss the most common treatment possibilities with ultrasound guidance for the painful shoulder.

The Long Telling Story of "Endothelial Progenitor Cells": Where Are We at Now?

Endothelial progenitor cells (EPCs): The name embodies years of research and clinical expectations, but where are we now? Do these cells really represent the El Dorado of regenerative medicine? Here, past and recent literature about this eclectic, still unknown and therefore fascinating cell population will be discussed. This review will take the reader through a temporal journey that, from the first discovery, will pass through years of research devoted to attempts at their definition and understanding their biology in health and disease, ending with the most recent evidence about their pathobiological role in cardiovascular disease and their recent applications in regenerative medicine.

Reflections about abortion limitation.

The debate on abortion has not yet found a clear solution. In fact, there is still discussion about what the limits of this procedure should be. This uncertainty is related to the lack of a clear definition of human life: when can the product of conception be defined as a human being with full medical-legal rights? Based on the answer to this question, the various world governments have drafted more or less restrictive laws regulating abortion. Since May 2019, some American states have considerably restricted the possibility of carrying out abortion on their territory. Alabama has practically banned abortion in any circumstance (including incest and rape). Obviously, these restrictive policies have had a significant impact on the social, bioethical and legal debate, concerning abortion, globally. This paper analyses the implications of these policies with a focus on women's fundamental rights: the right to health and the right to self-determination.

Is the Right to Abortion at Risk in Times of COVID-19? The Italian State of Affairs within the European Context.

The COVID-19 health emergency has thrown the health systems of most European countries into a deep crisis, forcing them to call off and postpone all interventions deemed not essential or life-saving in order to focus most resources on the treatment of COVID-19 patients. To facilitate women who are experiencing difficulties in terminating their pregnancies in Italy, the Ministry of Health has adapted to the regulations in force in most European countries and issued new guidelines that allow medical abortion up to 63 days, i.e., 9 weeks of gestational age, without mandatory hospitalization. This decision was met with some controversy, based on the assumption that the abortion pill could "incentivize" women to resort to abortion more easily. In fact, statistical data show that in countries that have been using medical abortion for some time, the number of abortions has not increased. The authors expect that even in Italy, as is the case in other European countries, the use of telemedicine is likely to gradually increase as a safe and valuable option in the third phase of the health emergency. The authors argue that there is a need to favor pharmacological abortion by setting up adequately equipped counseling centers, as is the case in other European countries, limiting hospitalization to only a few particularly complex cases.

Trauma- and stressor-related disorders in survivors from a shipwreck: a short report on forensic implications.

On January 2012 the Costa Concordia cruise ship sank after hitting an underwater rock off Isola del Giglio, in Tuscany, this resulting in a number of deaths and injuries. After the disaster, several survivors developed psychological disturbances. This led to medico-legal evaluations aimed at assessing the psychiatric sequelae of the accident in order to quantify the permanent biological impairment and the related compensations. In the present manuscript we provide an overview of the results of clinical and medico-legal evaluations performed between 2013 and 2019 on 177 survivors complaining psychological disturbances. The most frequently diagnosed condition was Post-Traumatic Stress Disorder (PTSD; n=90), followed by Acute Stress Disorder (n=37), Adjustment Disorders (n=29) and Generalized Anxiety Disorder (n=5). The results of such evaluations are consistent with evidence indicating the risk of developing PTSD and other trauma- and stressor-related disorders among disaster survivors; further, they highlight the potential relevance in the forensic context of individual elements increasing or decreasing the possibility to develop PTSD among subjects exposed to similar life threatening experiences.

Two sides of the same coin: educational and professional pathway for surgical residents.

AIM: To provide a review of medical malpractice cases ruled by the Italian Supreme Court with the aims at identifying lawsuits targeting involved with surgical residents. MATERIAL AND METHODS: Legal cases ruled by the Italian Supreme Court, from September 2020 to October 2020, pertaining to medical claims involving surgical residents were examined, using the main online databases. RESULTS: Of a total of eleven (n=11; 100%) cases identified, four (n= 4; 36,4%) cases addressed the standard of care pertaining to the surgical residents' medical activity. The legal reasoning of the Italian Supreme Court does not focus on the manual skill in the resident's medical performance, but rather on the choice to accept to treat the patient, regardless of the participation of the tutor. CONCLUSIONS: The performance of the surgical residents is made more difficult due to their peculiar nature, characterized by the complex interactions between the directives given by the tutor and the need to guarantee patients' needs. KEY WORDS: Surgical Residents, Tutor, Educational Pathway, Medical Malpractice, Standard of Care.

Does an occupational physician have a duty to carry out general clinical assessments?

An occupational physician is employed to be responsible for the overall assessment of workers' health risks and all work-related pathological situations which creates an unusual doctor-patient relationship. The duties of the occupational physician are also very limited as is their professional responsibility. However, the boundaries of the occupational physician's duties and responsibilities are not always clear. The purpose of this article is to answer the following question: Does the occupational doctor have a duty to carry out general clinical evaluations (not work-related) of the patient?