COPD management as a model for all chronic respiratory conditions: report of the 4th Consensus Conference in Respiratory Medicine.

BACKGROUND: Non-communicable diseases (NCDs) kill 40 million people each year. The management of chronic respiratory NCDs such as chronic obstructive pulmonary disease (COPD) is particularly critical in Italy, where they are widespread and represent a heavy burden on healthcare resources. It is thus important to redefine the role and responsibility of respiratory specialists and their scientific societies, together with that of the whole healthcare system, in order to create a sustainable management of COPD, which could become a model for other chronic respiratory conditions. METHODS: These issues were divided into four main topics (Training, Organization, Responsibilities, and Sustainability) and discussed at a Consensus Conference promoted by the Research Center of the Italian Respiratory Society held in Rome, Italy, 3-4 November 2016. RESULTS AND CONCLUSIONS: Regarding training, important inadequacies emerged regarding specialist training - both the duration of practical training courses and teaching about chronic diseases like COPD. A better integration between university and teaching hospitals would improve the quality of specialization. A better organizational integration between hospital and specialists/general practitioners (GPs) in the local community is essential to improve the diagnostic and therapeutic pathways for chronic respiratory patients. Improving the care pathways is the joint responsibility of respiratory specialists, GPs, patients and their caregivers, and the healthcare system. The sustainability of the entire system depends on a better organization of the diagnostic-therapeutic pathways, in which also other stakeholders such as pharmacists and pharmaceutical companies can play an important role.

Effectiveness of an educational intervention on the management of type 2 diabetic patients hospitalized in Internal Medicine: results from the FADOI-DIAMOND study.

Appropriate management of hyperglycemia is crucial for patients with type 2 diabetes. Aim of the FADOI-DIAMOND study was to evaluate real-world management of type 2 diabetic patients hospitalized in Internal Medicine wards (IMW) and the effects of a standardized educational intervention for IMW staff. DIAMOND has been carried out in 53 Italian IMW, with two cross-sectional surveys interspersed with an educational program (PRE phase and POST phase). In PRE phase, each center reviewed the charts of the last 30 hospitalized patients with known type 2 diabetes. An educational program was conducted in each center by means of the "outreach visit," a face-to-face meeting between IMW staff and a trained external expert. Six months after, each center repeated the data collection (POST phase), specular to the PRE. A total of 3,167 patients were enrolled (1,588 PRE and 1,579 POST). From PRE phase to POST, patients with registered anthropometric data (54.1 vs. 74.9 %, p < 0.001) and in-hospital/recent measurement of glycated hemoglobin (48.2 vs. 61.4 %, p < 0.005) increased significantly. After educational program, more patients received insulin during hospitalization (68.3 vs. 63.6 %, p = 0.005). A more relevant variation in glycemia during hospitalization was observed in POST phase than PRE (-22.2 vs. -15.5 mg/dL, p < 0.001), without differences as for occurrence of hypoglycemia (12.3 vs. 11.9 %). A one-shot educational intervention led to persistent improvement in the management of hospitalized patients with type 2 diabetes and to significant better glycemic control. Further studies might evaluate the effectiveness of a more aggressive educational program, on both management and outcomes.

Magnetism and spin dynamics of novel encapsulated iron oxide superparamagnetic nanoparticles.

Encapsulated Fe3O4 nanoparticles of average diameters d = 12 nm are obtained by coprecipitation, in the presence of 2-methoxyethanol hemiester of poly(maleic anhydride-alt-butyl vinyl ether) 5% grafted with poly(ethylene glycol) (VP-MAG nanoparticles). A complete characterization of nude and encapsulated nanoparticles through structural techniques (namely XRD, TEM, SEM), Raman spectroscopy and magnetic measurements has been performed. These nanoparticles compared with commercial compounds (ENDOREM®) present superparamagnetic behavior and nuclear relaxivities that make them promising as magnetic resonance imaging (MRI) contrast agents (CAs). We found that our nanostructures exhibit r2 relaxivity higher than those of commercial CAs over the whole frequency range. The MRI efficiency of our samples was related to their microstructural and magnetic properties.

Burial of piglet carcasses in cement: a study of macroscopic and microscopic alterations on an animal model.

Scarce experimental data exist describing postmortem effects of burial in cement. The scanty literature presents several case reports, but no experimental study. To perform a pilot study, the following experimental system was designed: 4 piglet corpses, who died of natural causes, were encased in concrete. After 1, 2, 3, and 6 months, a block was opened, and autopsy and microscopic analyses were performed. At the first month, initial putrefaction had started, and hindlegs were partly skeletonized. At the second month, both forelegs and hindlegs were partly skeletonized, and the abdomen and back showed advanced putrefaction. At the third month, the samples showed areas of mummification at the abdomen within a general context of initial putrefaction. At the sixth month, the sample showed wide adipocere formation. Histological findings revealed in some analyzed tissues (epithelium, dermis, adipose, and subcutaneous muscular tissues) a well-defined histological pattern even at 3 months after encasement in concrete: this means that microscopic changes may be delayed in concrete and that it may be worth performing histological analyses even in such kind of decomposed material.

Increasing the antibacterial effect of lysozyme by immobilization on multi-walled carbon nanotubes.

We report a facile strategy to obtain multiwalled carbon nanotubes (MWCNTs) functionalized with covalently bonded lysozyme. The functionalization procedure has been investigated by means of several techniques, including thermogravimetry, Raman spectroscopy, transmission electron microscopy, and cyclic voltammetry. A functionalization of about 1 lysozyme molecule every 4000 carbon atoms is obtained. The modified lysozyme-CNTs nanocomposite shows a significant increase of the antibacterial activity towards the Gram-positive S. aureus if compared with lysozyme in solution.

Detection of blunt, sharp force and gunshot lesions on burnt remains: a cautionary note.

The study of skin and bone lesions may give information concerning type and manner of production, but in burnt material modification of tissues by the high temperatures may considerably change the morphological characteristics of the lesions. This study aims at pointing out the effects of burning head of pigs with several types of lesions (blunt trauma, sharp force, and gunshot lesions) on soft tissues and bones, both from a morphological and chemical point of view. Results show that the charring process does not completely destroy signs of lesions on bones, which can often be recovered by cleaning bone surface from charred soft-tissue residues. Furthermore, neutron activation analysis test proved that antimony may be detectable also on gunshot entry wounds at the final stages of charring process.

Macroscopic, microscopic, and chemical assessment of gunshot lesions on decomposed pig skin.

Very little literature exists on gunshot wounds on decomposed material. In this study, seven pig heads underwent a shooting test. Entrance wounds from the first head underwent neutron activation analysis (NAA) and histological testing immediately after the firing test; the other six heads were exposed to two different environments (open air and soil) and analyzed by radiochemical and histological tests every 15 days. Gunshot wounds in air maintained their morphological characteristics, and those in soil showed severe alteration after 5 weeks. Microscopic testing verified positive results for lead in all gunshot wounds in open air, whereas in most of those in soil lead could not be detected. Radiochemical analysis performed by NAA yielded for all gunshot wounds but one antimony quantities in the range of 0.07-13.89 microg. In conclusion, it may be possible to detect residues of antimony even in degraded tissues.

Identification from chest x-rays: reliability of bone density patterns of the humerus.

A critical review of Kahana and Hiss' study on identification from bone trabecular pattern and a test of their method conducted on the humerus are presented. Bone trabecular pattern was studied through the generation of a numerical file representing the gray scale. Using the correlation coefficient, several pairwise comparisons between numerical files were performed. The test gave nearly 30% of incorrect exclusions (the method did not recognize couples of radiographs belonging to the same subject) and 50% of misidentifications (the method recognized couples of radiographs belonging to different subjects, as belonging to the same subject); therefore, this research shows that at the present time, it is not possible to safely quantify identification through bone density patterns, of the proximal humerus taken from thoracic X-rays. Thus, an "easy"-but dangerous-use of trabecular density patterns on this specific type of radiogram as an identification method should be currently avoided.

Micro-Raman study of the role of sterilization on carbon nanotubes for biomedical applications.

AIM: We investigate the effect of four different types of sterilization procedures on the structural properties and morphological features of single-wall carbon nanotube samples approachable by micro-Raman spectroscopy. Sterilization procedures (treatment in humid heat autoclave or ethylene oxide and irradiation with gamma-rays or UV light) are necessary in view of the use of carbon nanotube sterile samples in in vivo toxicity tests on laboratory rats. Micro-Raman spectroscopy allows us to estimate several details about the morphology of the single-wall carbon nanotube mixture (mainly the presence of disorder and diameter distribution) before and after the sterilization treatment. RESULTS: The best of these treatments, in other words, the one that least affected the morphology and structural properties of carbon nanotubes, was found to be UV irradiation and has thus been selected for future in vivo tests on rats.

Immersion of piglet carcasses in water--the applicability of microscopic analysis and limits of diatom testing on an animal model.

Investigation of bodies recovered in water comprises an important proportion of medico-legal cases, but is affected by relevant limits concerning the specific decomposition processes and the cause of death. Few indications are provided by literature concerning the post mortem modification of corpses in water, but for a general variability in decomposition degree, and only few experimental projects have been performed in order to verify the influence of water on the decomposition process. On the other hand, in order to reconstruct the cause of death, at present, the diatom test is considered as the "golden standard" for the diagnosis of drowning, although recent literature has pointed out its relative reliability and the frequent problems of contamination. This pilot study was performed to observe the changes of animal remains in aquatic environments. The following experimental system was set up: three piglet corpses, who died by natural causes independent from the study, were immerged in water rich in diatoms (Navicola, Order Pennales) in a tank exposed to the open air; macroscopic, histochemical and diatoms analysis were performed after 1, 2 and 3 months. Decomposition effects were fast: since the first month the skin appeared colliquated with exposure of the underlying bone surface, whereas at the second and third month the inner viscera were no longer recognizable; histology revealed that the skin was well preserved at 1 month, but morphology was completely altered at the second month, whereas at the third month epidermis was no longer visible. Diatom testing showed the presence of contamination both in the first and second piglet; the finding of a sea-diatom, on the other hand, was completely unexpected. This study performed for the first time histochemical testing on animal models submerged in water: although the results became negative after the second month, some microscopic structure could still be recognized at the end of the experimental project; on the other hand, the search for diatoms in the samples proved the high possibility of post mortem contamination.

The detection of microscopic markers of hemorrhaging and wound age on dry bone: a pilot study.

An example of the barriers and conceptual differences between forensic anthropology and pathology can be seen in determining the vitality of a wound. Pathology can make use of skin color and microscopic techniques; anthropology (as concerns the study of dry bone) needs different criteria. The diagnosis of the vitality of a wound (whether it is produced antemortem or postmortem) as well as determination of the time elapsed between the production of the wound and death is a crucial issue in forensic pathology. In fresh skin, the red-purplish coloration of a cut or bruise will reveal its vitality, whereas the change in coloration, from a macroscopic perspective, will reveal the time of survival. In more difficult cases, microscopic analyses can be performed. Bone follows similar "laws" as concerns the evolution of the histologic picture, but even if the beginning of healing processes (periosteal bone production and callus formation) can be detected macroscopically and radiologically, these processes require a long time.The scope of this pilot study was therefore to collect bone fractures from cadavers with a known time of survival, have them undergo a simulated putrefaction procedure until they became "dry or macerated bone" and perform macroscopic and microscopic analysis to verify the potential of histology in identifying "vital" processes in putrefied soft-tissue-free bone.A total of 6 samples of fractured bone (cranium, rib, and tibia) were taken from cadavers with known time of survival between trauma and death. Time intervals ranged from a few seconds after the bone fracture had been inflicted, to several hours, days, and weeks. A negative control was included (postmortem fracture). The bone was decalcified and stained with hematoxylin and eosin, Perls' (for the demonstration of hemosiderin deposits), Periodic Acid Schiff, phosphotungstic acid-hematoxylin, and Weigert (for the demonstration of fibrin). Immunohistochemistry was performed using a monoclonal antibody antihuman Glycophorin A.Results show the presence of clots and red blood cell residues on the fractured margins, strongly indicative of vital reaction.This study, though certainly not conclusive, shows that it may be worth pursuing the study of bone fractures from a histopathological point of view even on "dry bone" to verify whether the fracture is vital or not, and, if so, if its time of production can be verified.

The difficult issue of age assessment on pedo-pornographic material.

The issue of juvenile pornography has seen an increase in the past few years of the number of expert opinions requested to forensic pathologists, paediatricians and other various experts within the forensic and medical fields concerning the age of represented individuals. Regardless of the entity of the problem, no actual method exists which can allow us to give an objective and scientific answer, particularly in the postpubertal stage. Using parameters related to sexual maturation can be very dangerous. Nonetheless some experts still insist with similar types of "expertises". This study aims at verifying the ability of different experts in assessing age of postpubertal individuals represented in pornographic material. Results underline the difficulties and major uncertainties of age evaluation by visual observation of photographic material particularly when the subjects have reached the sexual maturation stage - and therefore in verifying whether the individual is above or below 18 years of age (an important age limit for most European countries as far as this type of crime is concerned). Furthermore the study stresses the need both to search for an alternate approach and to apply extreme caution in judicial evaluation.

A new computer-assisted technique to aid personal identification.

The paper describes a procedure aimed at identification from two-dimensional (2D) images (video-surveillance tapes, for example) by comparison with a three-dimensional (3D) facial model of a suspect. The application is intended to provide a tool which can help in analyzing compatibility or incompatibility between a criminal and a suspect's facial traits. The authors apply the concept of "geometrically compatible images". The idea is to use a scanner to reconstruct a 3D facial model of a suspect and to compare it to a frame extracted from the video-surveillance sequence which shows the face of the perpetrator. Repositioning and reorientation of the 3D model according to subject's face framed in the crime scene photo are manually accomplished, after automatic resizing. Repositioning and reorientation are performed in correspondence of anthropometric landmarks, distinctive for that person and detected both on the 2D face and on the 3D model. In this way, the superimposition between the original two-dimensional facial image and the three-dimensional one is obtained and a judgment is formulated by an expert on the basis of the fit between the anatomical facial districts of the two subjects. The procedure reduces the influence of face orientation and may be a useful tool in identification.

A new method of reproduction of fingerprints from corpses in a bad state of preservation using latex.

In view of the problems arising while fingerprinting corpses in a bad state of preservation, especially in case of mummification and carbonization, the authors propose an innovative technique which uses latex film. To better illustrate the potential of the method, two cases where the latex technique was applied successfully are reported: the first one is a mummified body discovered in a shack on the outskirts of Milan and the second one is the case of a burnt corpse found in a car boot. Such a technique is versatile, easy to apply, and allows the operator to work quickly on cadavers without amputating parts, except in rare cases (i.e., burnt bodies with muscle retraction). By the latex technique, a perfect and enduring negative copy of the fingerprint is obtained, ready to be inked and photographed. The numerous copies produced this way can be inked several times allowing for the repeatability of the procedure and this is crucial in cases of problematic legal identification of corpses. In both the cases illustrated, the fingerprints obtained by the latex technique were useful for identification. The quality was good enough for the automatic fingerprint identification system research system to be applied.

New method for height estimation of subjects represented in photograms taken from video surveillance systems.

The article describes a method developed and applied by the authors for the purpose of determining the height of subjects taped on video surveillance systems. The determination of height is obtained by developing a virtual telecamera having the same characteristics of the video surveillance system with which the images have been shot. The results demonstrate that height is a parameter that can be accurately estimated with the method proposed, in the experimental conditions described, and consequently, can be utilized in probatory inquiry.

The assessment of complexity in internal medicine patients. The FADOI Medicomplex Study.

BACKGROUND: Although the number of elderly people is progressively increasing in the world, old and very old patients have been under-represented and understudied in trials evaluating the efficacy of chronic illness management models. The usual hospital indicators and practice guidelines do not consider the effects of complexity - co-morbidity, social support, functional and cognitive status, patient adherence to therapy, risk of adverse drug reactions - in these subjects. The aim of this observational, multi-centric cohort study was to carefully assess factors contributing to the complexity of care for patients admitted to internal medicine wards. This was done by evaluating the severity of disease and degree of stability at admission, co-morbidity, age-related impairments, and the need for discharge planning plus post-discharge support. METHODS: A total of 386 patients from 11 internal medicine wards in Emilia-Romagna and Marche, Italy, enrolled in a given week were evaluated. At admission, the following variables were recorded: demographic characteristics, medical history, global clinical-social prognostic evaluation, co-morbidity, severity of illness, presence of shock or hemodynamic instability, coma, and frequencies and causes of unscheduled hospital re-admission. RESULTS: Cancer, congestive heart failure, pneumonia, stroke, and chronic obstructive pulmonary disease were the most frequent primary diagnoses. The complexity of our case study was characterized by several concomitant diseases. Over 50% of the patients were considered severe or more than severe, and over 20% extremely severe, with very high co-morbidity indices and illness severity scores. Some 55% of our patients were in need of partial or total care; 10% had some speech impairment, and 63% needed in-home health care after hospital discharge. CONCLUSIONS: The increasing numbers of elderly patients admitted to internal medicine departments suggests the need for a chronic illness management model, integrating gerontological and geriatric care to improve outcomes. For effective care, future protocols need to take a multi-dimensional, interdisciplinary approach to these patients and to develop a coordinated, integrated plan for treatment and long-term follow-up.

Progressive supranuclear gaze palsy without parkinsonism: a case of neuro-Whipple.

We report the case of a 69-year-old man with a 7-month history of severe progressive supranuclear gaze palsy associated with mild cognitive decline and sleep disturbances, but not parkinsonism. After a period spent consulting a range of different specialists, the appearance of brachial myoclonus prompted his referral to a movement disorders specialist. Duodenum biopsy confirmed the suspicion of neuro-Whipple disease. Antibiotic therapy was started but the delay in the diagnosis proved fatal to this patient. This noteworthy case shows unusual neurological features of a rare but treatable disease, often misdiagnosed as progressive supranuclear palsy.

Dental amalgam and mercury levels in autopsy tissues: food for thought.

Eighteen cadavers from routine autopsy casework were subject to a study of tissue levels of total mercury in brain, thyroid, and kidney samples by atomic absorption. On these same cadavers, all dental amalgam fillings (the most important source of inorganic mercury exposure in the general population, according to the World Health Organization (WHO) were charted. Total mercury levels were significantly higher in subjects with a greater number of occlusal amalgam surfaces (>12) compared with those with fewer occlusal amalgams (0-3) in all types of tissue (all P < or = 0.04). Mercury levels were significantly higher in brain tissues compared with thyroid and kidney tissues in subjects with more than 12 occlusal amalgam fillings (all P < or = 0.01) but not in subjects with 3 or less occlusal amalgams (all P > or = 0.07).