Is there such a thing as an indispensable skills profile to be a good doctor? "Life skills" as essential capabilities in the medicoforensic professions.

Abstract: This writing aims to convey the essential nature and features of a cultural tool based on a set of skills and capabilities generally referred to as "life skills", which allow for the proper management (in the medical and medical-forensic professional realms) of daily situations in an effective and rewarding fashion. Such a process is based on individual tools such as communication, problem solving, stress management, self-control, the ability to make timely decisions, empathy, creativity and the opportunity to work in a multidisciplinary setting. Life skills include everything the professional should rely on in order to minimize the risks of a professional error, through the acquisition of knowledge and behavioral traits which constitute the fundamental, experience-based starting point. The chief objective of this commentary is to outline the scope of a straightforward discussion by specifically defining such skills; that in turn will make it possible to identify all the technical issues to address during the medical-diagnostic assessment, also from a medico-legal perspective, in order to frame the residual life skills and evaluate the possibilities of recovery and any disabilities, based on observation and interactions with each patient aimed at weighing their psychophysical performance.

Corpses against science death: new Italian law titled 'Rules relating to the directives of one's body and tissues post-mortem for study, training, and scientific research purposes'.

The new Italian Law no. 10 of 2020, titled 'Rules relating to the directives of one's body and tissues post-mortem for study, training, and scientific research purposes' (10 February, 2020), has opened the doors to a new and clearer regimentation on body donation to science, according to the procedure already introduced by Law no. 219/2017 on the 'Rules relating to informed consent and advance directives of treatment'. The authors exposed some concerning regarding the application of the law, such as donation mistrust, also linked to our cultural heritage; the incomplete protection of minor and incompetent people; the complexity of an adequate information, which could undermine the informed consent; and finally, the fees overload for research institutes, with already exiguous budgets. Next, the authors analysed some positive aspects of the law and in primis the central role of corpses in scientifical knowledge and medical training. Moreover, a simple mechanism based on a conscious and pre-stated consent, registered in a database that follows European data protection Regulation, is discussed. Further, the procedure of the restitution of the bodies to their families, which represents a way to guarantee the relatives' commemoration, is also elucidated. In conclusion, the authors proposed a format of informed consent, to try a direct application of the law, thereby fastening the process of standardisation and centralisation of all the living wills. The authors optimistically investigated the opportunities offered by the law and encouraged a conscientious participation by citizens.

Pain in focal dystonias - A focused review to address an important component of the disease.

Focal dystonia is characterized by involuntary muscle contractions that cause abnormal postures and/or twisting movements in a segment of the body. Motor symptoms have a major impact on disability in this condition, but the presence of pain represents an additional source of impairment and poor quality of life. Notwithstanding that pain occurs in up to 70% of patients with cervical dystonia and in a relevant proportion of subjects with focal dystonia of the limbs, it has received very little attention from researchers and controlled trials are scant. The aim of this review is to summarize the current knowledge on the clinical assessment and management of pain in focal dystonias. The search results will inform on the types of pain reported in focal dystonias, on the tools that are used to quantify pain and on the efficacy of pharmacological and non-pharmacological approaches. The collated data will hopefully improve the clinical management of focal dystonia and also stimulate future research on dystonia-associated pain. Optimization of the outcome indeed requires the identification and the management of all the factors that determine disability and hence relies on a multidisciplinary approach.

[Psychoactive drugs and fitness to drive in the occupational field]. / Sostanze voluttuarie e idoneità alla guida in ambito lavorativo.

According to/After the conferences taken place on 30th October and on 18th December 2008, the company doctor functions have been enlarged: at present they include the duty of effectuating toxicological tests in order to find psychotropic and drug substances in some specific working classes, mainly in workers employed in public transports. Company doctors have the duty to report any possible positive matching in these workers'tests. From there, regulations in force are analyzed focusing to critical situations described in the complex and well articulated frame of reference.

[The remodelling of the heart in heart failure: from thoracic radiography to magnetic resonance]. / Il rimodellamento del cuore nell'insufficienza cardiaca: dalla radiografia del torace alla risonanza magnetica.

Congestive heart failure represents the most common medical hospital discharge diagnosis, and can occur in patients with preserved indexes of left ventricular systolic function, even in absence of patent coronary or valvular heart disease. The present review examines the role of imaging techniques in the diagnosis and follow-up of these patients. Imaging of the heart has undergone dramatic advances with the development and refinement of new imaging modalities such as echocardiography, computed tomography, magnetic resonance and radionuclide emission tomography. The role of "low-tech" modalities such as chest roentgenogram is discussed. The possibilities offered by ultrasounds or magnetic resonance in tissue characterization are then compared with the actual capability of cardiac imaging in detecting myocardial tissue alterations (oedema, ischemia, myocarditis, etc.) and/or degeneration (fatty degeneration, fibrosis, amyloidosis, etc.). Finally, the potential use in modern clinical medicine of magnetic resonance spectroscopy and positron emission tomography to study myocardial metabolism and cellular function are discussed.

A new method for quantitation of mitral regurgitation based on color flow Doppler imaging of flow convergence proximal to regurgitant orifice.

BACKGROUND: Imaging of the flow convergence region (FCR) proximal to a regurgitant orifice has been shown to provide a method for quantifying the regurgitant flow rate. According to the continuity principle, the FCR is constituted by concentric hemispheric isovelocity surfaces centered at the orifice. The flow rate is constant across all isovelocity surfaces and equals the flow rate through the orifice. For any isovelocity surface the flow rate (Q) is given by: Q = 2 pi r2 Vr, where 2 pi r2 is the area of the hemisphere and Vr is the velocity at the radial distance (r) from the orifice. METHODS AND RESULTS: We studied 52 consecutive patients with mitral regurgitation (mean age, 49 years; age range, 21-66 years) verified by left ventricular angiography using color flow mapping. The FCR r was measured as the distance between the first aliasing limit--at a Nyquist limit obtained by zero-shifting the velocity cutoff to 38 cm/sec--and the regurgitant orifice. Seven patients without evidence of an FCR had only grade 1+ mitral regurgitation angiographically. There was a significant relation between the Doppler-derived maximal instantaneous regurgitant flow rate and the angiographic degree of mitral regurgitation in the other patients (rs = 0.91, p less than 0.001). The regurgitant flow rate by Doppler also correlated with the angiographic regurgitant volume (r = 0.93, SEE = 123 ml/sec) in the 15 patients in normal sinus rhythm and without other regurgitant lesions in whom it could be measured. The correlation between regurgitant jet area within the left atrium and the angiographic grade was only fair (rs = 0.75, p less than 0.001). CONCLUSIONS: Color flow Doppler provides new velocity information about the proximal FCR in patients with mitral regurgitation. According to the continuity principle, the maximal instantaneous regurgitant flow rate, obtained with the FCR method, may provide a quantitative estimate of the severity of mitral regurgitation, which is relatively independent of technical factors.

[Doppler estimation of the stenotic mitral valve area. Direct application of the continuity equation to the flow convergence region]. / Stima mediante Doppler dell'area mitralica stenotica. Applicazione diretta dell'equazione di continuità alla regione di convergenza del flusso.

The continuity equation, applied to the flow convergence region (FCR), fournishes a simple alternative to calculate stenotic valve area. The flow rate in the FCR can be calculated by multiplying the hemispheric isovelocity surface area by the velocity of the isovelocity surface. Since according to the continuity principle the flow rate through any isovelocity surface equals the flow rate through the stenotic orifice, the stenotic orifice area can be calculated as: 2 pi r2Vr/Vm, where 2 pi r2 is the hemispheric isovelocity area, Vr is the velocity at the radial distance r from the orifice and Vm is the peak jet velocity. This study was designed to analyze the validity of application of the continuity equation to the FCR for estimating mitral orifice area by Dopler ultrasound. We studied 35 consecutive patients with rheumatic mitral stenosis. Three patients were excluded; the final study population consisted of 32 patients (8 men and 24 women; mean age 56 years). Nine patients were in normal sinus rhythm and 23 in atrial fibrillation. Doppler examination was performed from the apical approach within 24 hours of cardiac catheterization. On color Doppler image Vr was defined as the first aliasing limit (lowered to 38 cm/s to increase FCR r); r represented the maximal early diastolic distance between the first alias and the stenotic orifice in a direction parallel to that of the transducer; Vm was the early diastolic peak jet velocity by continuous wave Doppler.(ABSTRACT TRUNCATED AT 250 WORDS)

Color Doppler diagnosis of mechanical prosthetic mitral regurgitation: usefulness of the flow convergence region proximal to the regurgitant orifice.

In prosthetic or paravalvular prosthetic mitral regurgitation, transthoracic color Doppler flow mapping can sometimes fail to detect the regurgitant jet within the left atrium because of the shadowing by the prosthetic valve. To overcome this limitation, we assessed the utility of color Doppler visualization of the flow convergence region (FCR) proximal to the regurgitant orifice in 20 consecutive patients with mechanical prosthetic mitral regurgitation documented by surgery and cardiac catheterization (13 of 20 patients). In addition, we studied 33 patients with normally functioning mitral prostheses. Doppler studies were performed in the apical, subcostal, and parasternal long-axis views. An FCR was detected in 95% (19 of 20) of patients with prosthetic mitral regurgitation. A jet area in the left atrium was detected in 60% (12 of 20) of patients. In 18 of 19 patients with Doppler-detected FCR, the site of the leak was correctly identified by observing the location of the FCR. A trivial jet area was detected in eight patients with a normally functioning mitral prosthesis; in none was an FCR identified. Thus color Doppler visualization of the FCR proximal to the regurgitant orifice is superior to the jet area in the diagnosis of mechanical prosthetic mitral regurgitation. Moreover, FCR permits localization of the site of the leak with good accuracy.

A new method for estimating left ventricular dP/dt by continuous wave Doppler-echocardiography. Validation studies at cardiac catheterization.

In this study, we explored the use of continuous wave Doppler-echocardiography guided by color Doppler flow-mapping as a method for noninvasively calculating the rate of pressure rise (RPR) in the left ventricle. Continuous wave Doppler determination of the velocities in mitral regurgitant jets allows calculation of instantaneous pressure gradients between the left ventricle and the left atrium. Left atrial pressure variations in early systole can be considered negligible; therefore, the rising segment of the mitral regurgitation velocity curve should reflect left ventricular pressure increase. We studied 50 patients (mean age, 51 years; range, 25-66 years) in normal sinus rhythm with color Doppler-proven mitral regurgitation and compared the Doppler-derived left ventricular RPR with peak dP/dt obtained at cardiac catheterization. Doppler studies were performed simultaneously with cardiac catheterization in 11 patients and immediately before in the remaining cases. Two points were arbitrarily selected on the steepest rising segment of the continuous wave mitral regurgitation velocity curve (point A, 1 m/sec, point B, 3 m/sec), and the time interval (t) between them was measured. Following the Bernoulli relation, the pressure rise between points A and B is 32 mm Hg (4vB2-4vA2) and the RPR is 32 mm Hg/t. Results showed a linear correlation between the Doppler RPR and peak dP/dt (r = 0.87, SEE = 316 mm Hg/sec). The RPR in the left ventricle can be derived from the continuous wave Doppler mitral regurgitation velocity curve.

[Doppler evaluation of the Sorin and Medtronic-Hall prostheses in the aortic position]. / Valutazione Doppler delle protesi Sorin e Medtronic-Hall in posizione aortica.

Doppler characteristics of normally functioning tilting disk prostheses in aortic position were studied in 55 patients (30 Medtronic-Hall and 25 Sorin) whose valvular function was considered normal using clinical and echocardiographic evaluation. Peak gradients, mean gradients and effective orifice area were estimated for different sizes of prostheses. The peak gradient calculated from maximal aortic velocity was 27.3 +/- 11.1 mmHg in Sorin and 21.1 +/- 9.7 mmHg in Medtronic-Hall valves; the mean gradients were 12.9 +/- 6.2 mmHg and 10.8 +/- 5.7 mmHg in Sorin and Medtronic-Hall valves respectively. The effective orifice area calculated by the continuity equation was 1.4 +/- 0.5 cm2 in Sorin and 1.5 +/- 0.57 cm2 in Medtronic-Hall prostheses; the performance index calculated as the ratio between functional area and manufactured area was 0.4-0.6 for Medtronic-Hall and 0.45-0.52 for Sorin prostheses. Prosthetic regurgitation was found in 64% of Sorin valves and 80% of Medtronic-Hall valves; prosthetic regurgitation was mild in 81% and moderate in 19% of cases. Doppler echocardiography is a reliable method for the characterization of the normal function of prosthetic aortic valves and provides information similar to cardiac catheterization.

[The role of echocardiography and pulsed Doppler in the congenital absence of the pericardium. Description of 2 cases]. / Il ruolo dell'ecocardiografia e del Doppler pulsato nell'assenza congenita del pericardio. Descrizione di due casi.

Congenital absence of the left pericardium, partial or complete, is an uncommon cardiac defect. Most patients affected by this abnormality are asymptomatic. Usually it is suspected on the basis of a chest X-ray showing a normal sized cardiac shadow projecting entirely to the left of the spine. Computed axial tomography confirmed the absence of the left pericardium detecting the interposition of the left lung between the ascending aorta and main pulmonary artery. The M-mode, two-dimensional, and Doppler-cardiographic findings of complete congenital absence of the left pericardium are described in two cases. Imaging seems to be not specific for this abnormality; however in both cases pulsed Doppler detected mild tricuspid and pulmonic valve regurgitation.

Ventricular septal rupture after myocardial infarction: diagnosis by two-dimensional and pulsed Doppler echocardiography.

Rupture of the ventricular septum in the acute phase of myocardial infarction (MI) requires prompt recognition for correct management. The 2-dimensional and pulsed Doppler echocardiographic findings are reported from 11 patients with ventricular septal (VS) rupture. VS rupture was confirmed by cardiac catheterization in 9 patients, surgery in 4 patients and necropsy examination in 3 patients. Two-dimensional echocardiography (echo) directly visualized the rupture in 7 patients and assessed the size and location of an associated aneurysm in 10. In all patients, M-mode pulsed Doppler echo allowed detection of the left-to-right shunting due to VS rupture, but failed to indicate the rupture site. M-mode pulsed Doppler echo was reliable for detecting VS rupture after MI. Conversely, 2-dimensional echo was less effective in the direct visualization of the rupture, but provided anatomic and functional information that was useful in medical and surgical management. Thus, the techniques are complementary and should be used in combination for the assessment of VS rupture in acute MI.