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Severe left outflow tract obstruction (LVOTO) is not always associated with hypoplastic left heart syndrome (HLHS). Aortic valvar atresia or complex LVOTO in the presence of a large ventricular septal defect (VSD) are a rare group of lesions that offer the possibility of biventricular repair. The Yasui procedure is the commonest surgical approach which can be performed as a primary neonatal correction or as a staged procedure with a Norwood followed by a subsequent Rastelli. This article reviews the surgical outcomes and decision-making process. Both strategies are reasonable with the trend toward staged procedure in the setting of the additional interrupted arch, with neonatal survival of > 90% in the modern era and excellent long-term survival. Re-intervention is mostly related to conduit revision and the need for re-operation for LVOTO is rare. Deciding between conventional repair and the Yasui in cases of LVOTO/VSD can be difficult and there are no uniform accepted criteria. In a typical neonate, an aortic annulus < 4.5 mm is generally the limit of acceptability for a conventional repair. In selected cases of LVOTO/VSD, an alternative to the Yasui is the Ross-Konno. Retrospective comparisons between the 2 techniques are difficult due to differing patient characteristics (especially associated with mitral valve disease) but the neonatal Ross has been associated with higher early mortality.

Italian “Gelli–Bianco” law (law n. 24 enacted by the Italian Government on 8 March 2017) introduced innovative changes and regulations regarding patient safety and healthcare workers’ (HCWs) liability. We promoted a national survey to evaluate the effect of the law on HCWs. The questionnaire was edited and distributed using the free online tool “Google Forms” (Google LLC). The mode of administration chosen for the questionnaire was telematic self-completion. In particular, the questionnaire was sent to several portals of information, websites, in the scientific and medical sectors. Four hundred forty-five subjects participated in the survey. The differences in categorical variables for Gelli–Bianco Law reading with professional variables were analyzed in a univariate analysis using the Chi-square test and Fisher’s exact test. Reading the law is significantly and positively related to knowledge and communication of adverse events and sentinel events, checklist adoption, and participation in educational activities on risk management. The law’s implementation and promotion is a reliable educational tool for increasing patient safety culture and involving HCWs in risk management activities. Knowledge of the law, related education, and understanding of its application are still inadequate; therefore, educational programs regarding patient safety, risk management, and the contents of the law itself must be vigorously promoted to achieve clinical governance goals.

The concept of autoerotic asphyxiation refers to the use of devices or substances intended to enhance one's arousal by inducing cerebral hypoxia, which can involuntarily lead to death. Although in most cases death occurs accidentally, it is nonetheless true that the same devices might be used by the practitioners in order to attempt suicide. The case of a 34-year-old practitioner of autoerotic asphyxiation found dead in his apartment with bondage-like ligatures and masking is reported here. The case raised some issues concerning the accidental or suicidal nature of the act. The aspects taken into account in the management of the case are discussed, along with a compared approach to the data provided by literature.

In recent years, the mode of alcoholic intake known as binge drinking (BD) has become a common practice, especially among adolescents who, due to socio-environmental motives, tend to reach a rapid state of drunkenness. This drunkeness leads to alterations in brain areas responsible for executive functions and cognitive processes, as well as to the genesis of factors that predispose to lasting addiction. Likewise, nicotine leads to a comparable degree of addiction. On this basis, the aim of this research was to evaluate, on a cohort of 349 high school students (15–17 years old) in the province of Palermo, the following: (I) the drinking model of alcoholic beverages; (II) the use of nicotine and the degree of dependence; (III) the correlation between the consumption of alcoholic beverages and the use of nicotine. We employed the AUDIT-C test and the Fagerström test, two valid and standard instruments, in order to assess alcohol and nicotine use, respectively. Statistical analysis of the data showed that male and female students consumed alcohol prominently in a BD mode (77.2%, audit score (AS) 3.497, confidence interval (CI) 3.206–3.788; 69.6%, AS 2.793, CI 2.412–3.274) and nicotine (41.5%, Fagerström score (FS) 3.882, CI 3.519–4.245; 28%, FS 3.286, CI 2.547–4.024). Furthermore, a positive correlation between alcohol consumption and nicotine use was found for male (r = 0.6798, p < 0.0001) and female (r = 0.6572, p < 0.0001) students. This study provided further insights into the use of legal substances of abuse in adolescents, evidencing the obvious need for the promotion of specific school educational programs aimed at the wellbeing of youth populations.

The Covid-19 pandemic has completely modified the Healthcare organization. This review aims to analyze the evolution of the different Telemedicine areas during pandemic. Electronic Health Records allows accelerating the study of patients suffering from Covid-19 disease, supporting their clinical assistance. The decreasing rehabilitation programs have determined a deterioration of the patient quality of life. Teleradiology was necessary to discard the increased requests and dab the shortage of staff, and to guarantee the interaction between specialist and patient. Telecardiology was fundamental determining a reduced of secondary mortality for cardiological complications of the infection. Teledermatology has permitted an early identification of the patients affected through diagnoses of cutaneous signs, reducing clinical visits. Telelegal-medicine changed through a law, that was introduced allowing a remarkable use of videoconferencing in the different stages of judicial and extrajudicial process. The digital consultations and home drug delivery were implemented in telepharmacy area. Artificial Intelligence allows an early diagnosis of the infection, monitoring the treatment through an intelligent platform. Robotic assisted telemedicine minimizes the risk of exposure allowing the disinfection of the places, drugs and meals delivery, the measurement of vital signs. Mobile Health facilitated the collection and the automatic transfer of the patient's parameters. Telemedicine would constitute still today as complementary but not substitutive to the traditional medicine. During the pandemic telemedicine has resulted important to guarantee continuity cures. Radiology and Dermatology showed a major telemedicine application.

Hearing loss standards depend on noise power and duration but are incomplete when the noise is primarily impulsive in nature rather than maintaining a continuous power level. Calculating the kurtosis of a noise exposure captures information about its impulsivity, and high kurtosis values cause additional hearing damage. In this paper, a method for measuring the reduction of noise kurtosis through hearing protection is outlined, and measurements demonstrate that spectral insertion loss is independent of the noise kurtosis and that kurtosis loss is not related to either the mean or standard deviation of spectral attenuation.

One of the most recently debated topics worldwide is the mass vaccination of children against coronavirus disease 2019 (COVID-19). Next, the risk/benefit ratio of COVID-19 vaccination and infection in children are compared. Nonetheless, the real question in this debate is as follows: Does the vaccine represent a necessary tool or is it an obstacle in protecting the right to health? From a public health point of view, the Supreme Court of Nova Scotia, in Canada, recommends COVID-19 vaccination in the pediatric population. Based on Article 25 of the Draft Articles on State responsibility, vaccination can be considered a social act necessary for protecting the individual's right to health. The 1989 New York Convention on the Rights of the Child and the European Regulation number 219/1111 state that the opinion of a minor aged >12 years is considerable. However, this validity of opinion is related to age and degree of discernment. The onset of adverse events following the administration of the COVID-19 vaccine may lead to compensation in the near future. Recent studies have identified a new COVID-19-related pediatric pathology, known as multisystem inflammatory syndrome. Other studies have demonstrated that myocarditis in the pediatric population might occur following COVID-19 vaccine administration. In June 2021 in the USA, the Center for Control and Prevention of Infectious Diseases Advisory Committee on Immunization Practices declared that the benefits of vaccination against COVID-19 in the pediatric population outweighed the risks. In the meantime, whereas the bioethical debate remains open, monitoring the real risk/benefit ratio of vaccination in the pediatric population is crucial.

BACKGROUND: Glioblastoma multiforme (GBM) is the most common and malignant primary brain tumor in adults. Novel treatments are needed to counteract the molecular mechanisms of GBM growth and drug resistance. The chaperone system (CS) members are typically cytoprotective but some, termed Hsp, can become pathogenic and participate in carcinogenesis, along with the vascular endothelial growth factor (VEGF), and we investigated them in GBM biopsies and derived cell lines. The objectives were to identify diagnostic-prognostic biomarkers and gather information for developing chaperonotherapy. METHODS: Cell lines from GBMs were established, characterized (morphology, growth characteristics, and specific markers), and stored. Chaperones and angiogenic factors [Hsp10, Hsp27, Hsp60, Hsp70, Hsp90, FLT-1 (VEGFR-1), FLK1 (KDR, VEGFR-2), and FLT-4 (VEGFR-3)] were observed in cells by immunofluorescence while the chaperones were measured in tumor tissue by immunohistochemistry. RESULTS: Four cell lines were derived from four different GBMs; the cells were spindle shaped or polygonal and grew at high rates as adherent monolayers or clusters without evidence of contact inhibition. The astrocyte-specific glial fibrillary acidic protein (GFAP); and the neuronal NSE, malignancy VIM, and proliferation PCNA, markers were determined. The cells expressed GFAP but no NSE, indicating that they were primary glioblastoma cell lines, with high levels of Hsp10, Hsp27, Hsp60, Hsp90, and Flk1; and low levels of Hsp70, Flt1, and Flt4. CONCLUSIONS: Four cell lines were established derived from four out of ten GBM tumors studied. The cell lines showed intense positivity for chaperones studied and factors connected to malignancy and the tumors showed increased levels of chaperones, making them potential diagnostic-prognostic biomarkers and targets for anti-cancer compounds.

Violence against women breaches women’s human rights and is a global public health issue that can cause devastating life-long damage. This study considers the characters of victims, abusers and traumatic bonding in heterosexual couples from a medico-legal and psycological standpoint. After considering the devastating effects on women’s health, and with the objective of preventing future violence, it illustrates the weaknesses and strengths of new Italian guidelines related to violence against women in emergency departments including the use of “Brief Risk Assessment for IPV in the Emergency Department – DA5”.

Background Studies have revealed a higher incidence of injury and illness among elite adaptive athletes when compared to non-disabled athletes in the Paralympics and Olympics. However, sport-specific health care incidence rates and patterns outside of the Paralympics have been poorly described. To date, there are no prospective studies focused on injury or illness rates among intercollegiate wheelchair basketball players. Objective To determine the incidence of sports-related injuries and illnesses among men's and women's intercollegiate wheelchair basketball teams throughout a season. We hypothesized that injury rates among the intercollegiate wheelchair basketball players would be similar to or greater than those of previously published National Collegiate Athletic Association (NCAA) nondisabled basketball players and that injuries would most commonly affect the upper extremities. Design Prospective surveillance study. Setting Men's and women's intercollegiate wheelchair basketball teams in Arlington, Texas. Participants Twenty-eight (14 male, 14 female) of the 29 (15 male, 14 female) eligible adult athletes playing on an intercollegiate men's or women's wheelchair basketball team during the 2018-2019 season. Interventions Completion of a repeatable, electronic, web-app injury and illness survey during the season, as well as separate pre- and post-season injury and illness surveys. Main outcome measures Injury rates throughout the season based on athlete-exposures and relative risk (RR) of injury of intercollegiate wheelchair basketball players compared to NCAA nondisabled basketball players. Description of onset, location, diagnosis, medical evaluation, and missed time from sport related to injuries and illnesses. Results Sixty-two health-related incidents, including 48 injuries and 14 illnesses, were prospectively reported during the season. Overall injury incidence rates were 12.2 (95% confidence interval [95% CI] 7.4 to 17.4) and 13.1 (95% CI 7.8 to 18.4) injuries per 1000 athlete-exposures among male and female athletes, respectively. These equated to RRs of 1.53 (95% CI 1.03 to 2.27) (male) and 2.01 (95% CI 1.34 to 3.02) (female) when compared to the rates published previously on NCAA nondisabled basketball players, indicating a statistically significant increase in injury risk. Injuries most commonly involved the upper extremities (56.3%). Illnesses commonly involved the gastrointestinal (35.7%) or respiratory (21.4%) systems. Conclusions This is the first prospective study to report incidence of sports-related injuries and illnesses throughout an intercollegiate wheelchair basketball season. Overall injury rates reported were higher than prior NCAA nondisabled intercollegiate basketball reports. This reinforces the need to establish an accessible network of health care support and injury prevention strategies for these athletes.

Objective We developed interim guidance for the care of patients with cognitive impairment in hospital during the COVID‐19 pandemic. Methods A Guidance Committee and Readers Group were recruited. The content was identified by the Committee and content‐specific subgroups, resulting in a draft document, which was sent to the Readers for review. People with dementia and care partners were involved in all aspects of the process. Results Infection control measures can lead to an escalation of distress. In an environment where visiting bans are applied to care partners/advocates, hospitals need to ensure care partners can continue to provide decision‐making support. Health‐care professionals can proactively engage care partners using videoconferencing technologies. Developing models of care that proactively support best practice can minimise the risk of delirium, mitigate escalating symptoms and guide the use of non‐pharmacological, pharmacological (start low, go slow) or physical restraint in managing behavioural and psychological symptoms.

Laparoscopy has emerged as a common alternative to the open approach for colorectal operations. Robotic surgery has many advantages, but cost and outcomes are an area of study. There are no randomized-controlled trials of all techniques. The present study evaluated a cohort of veterans undergoing (procto-) colectomy for benign or malignant colorectal disease. This is a single-institution retrospective review. We compared open, laparoscopic, and robotic colectomies. The primary outcome was 30-day mortality. The secondary endpoints included morbidity, operative times, estimated blood loss (EBL), length of stay (LOS), conversion rate, and the learning curve (LC). Subgroup analyses were undertaken for: (1) right hemicolectomies (RHC) and (2) by specific surgeons most familiar with each approach. The cohort included 390 patients (men = 95%, White = 70.8%, BMI = 29.3 ± 6.4 kg/m2, age = 63.7 ± 10.2 years) undergoing (open = 117, laparoscopic = 168, and robotic = 105), colorectal operations for colorectal adenocarcinoma (52.8%) and benign disease. Thirty-day morbidity was similar across all techniques (open = 46.2%, laparoscopic = 42.9%, and robotic = 38.1%; NS). EBL and LOS were decreased with minimally invasive techniques compared to open. Operative time was longer in robotic, but equalized to laparoscopic after 90 cases. The learning curve was reduced to 20 when performed by the surgeon most familiar with the robot. EBL and operative time independently predicted complications for the entire cohort. The best technique for colorectal operations rests on the surgeon’s experience, but minimally invasive techniques are gaining momentum over open colectomies. Robotic colectomy is emerging as a non-inferior approach to laparoscopy in terms of outcomes, while maintaining all its technical advantages.

Hypoxic ischemic encephalopathy is one of the major causes of neonatal death and neurological disability in the child, and represents the most common birth injury claim. Intrapartum asphyxia often leads to several long-term sequalae, such as cerebral palsy and/or developmental delay, epilepsy. Through the neuroimaging it's possible to identify and define the different lesioned pictures and provide useful elements to establish the moment in which the damage occurred; indeed, timing of injury is a key element in the legal arena. Magnetic resonance imaging (MRI) is emerging as one of the most important tools in identifying the etiologic of neonatal encephalopathy as well as in predicting long-term outcomes. The aim of this study is to evaluate all MRI tests performed in a group of infants and young patients with possible neonatal encephalopathy, in order to determine the role of MRI in perinatal hypoxic-ischemic damage and the specific patterns that can point towards a diagnosis of the time of the damage's onset. Another goal is to assess the role of MRI in cases subject to legal-medical ligation. Since the advent of hypothermic neuroprotection, new malpractice allegations have arisen, including the failure to initiate cooling in a timely manner. In all cases, documentation of the status of the baby at birth, including a thorough neurologic exam, can be extremely helpful to the later defence of a malpractice claim, which might occur years later.

Introduction. Water intoxication is a well-recognized cause of symptomatic hyponatremia, whose often fatal consequences are described in a wide variety of conditions such as psychiatric disorders, metabolic dysfunctions, child abuse, drug abuse and several medical procedures. The case. We here report a rare case of a 67-year-old woman with severe acute hyponatremia due to an excessive voluntary water intake – 14 litres in two days – following a chiropractic prescription. The patient developed sudden severe symptoms, including water retention, sensory alteration, altered mental status and tonic-clonic seizures. She was thus admitted to the Intensive Care Unit with a diagnosis of coma due to electrolyte alterations following water intoxication. Conclusion. The evaluation, in the present case, of the medicolegal implications related to malpractice involving a practitioner of Complementary and Alternative Medicine, led to the admission of a professional liability of the chiropractor.

Despite the benefits of the implantation of cardiac rhythm management devices cardiac implantable electronic device (CIED) infection is an emerging problem New debate emerged about the unclear role of the pre-operative alteration of pro-inflammatory parameters, such as leukocytosis, in the development CIED infection and/or heart failure, and its consequent impact on the timing of ICD implantation/reimplantation.A 65 years old patient with a history of Diabetes Mellitus (DM) type II, ventricular and supraventricular arrhythmias, chronic myocardial ischemia, heart failure was admitted to hospital. Healthcare workers opted for ICD implantation despite the presence of a persistent leukocytosis with normothermia. Five days later the implantation, patient showed fever and heart failure; blood culture resulted positive for Staphylococcus Aureus. Patient died for sepsis syndrome due to a cardiac device-related infection after a few days, despite the device extraction.Cardiac device implantation remains a necessary surgi-cal procedure in order to reduce sudden cardiac death's rate in patients with heart failure. Leukocytosis is a new potential poor prognosis risk factor. The relationship between pro-inflammatory markers', such as CRP and white blood cell count, and device implantation is still not entirely clear. Pro-inflammatory markers could facilitate an infection development; recent study hypothesized that these markers could promote the development of heart failure.Leukocytosis could represent a poor prognosis risk factor favoring the development of CIED infection and/or heart failure.

Invasive Meningococcal Disease is a severe disease mainly affecting infants and young children. Most infections are caused by serogroups A, B, C, W, X, and Y. In the last 10 years, serogroup B has been the main cause of Invasive Meningococcal Disease in Europe. Recent data resulting from an observational study conducted in Italy show a significant reduction in the number of Invasive Meningococcal Disease cases due to Neisseria meningitidis B after the introduction of vaccine 4CMenB. Thus, the Naples Team of Federation of Italian Primary Care Pediatricians and the Public Health Department started an active collaboration focused on vaccination process management (named "Progetto Via") with the aim of increasing Meningococcal B vaccination coverage.Source of data is the regional platform "GE.VA.". Every Primary care Pediatrician uses daily to record vaccination activity. This platform is integrated with data entered by operators of the District/Vaccination Center.Time: January 2019 - December 2019. The Federation of Italian Primary Care Pediatricians/Naples organized a meeting to identify six coordinators. The pediatricians could choose to counsel in their own offices and send children to the vaccination center or to counsel and vaccinate directly in their own clinics.A total of 78 pediatricians took part in the project: 46 did only counseling and 32 did both counseling and vaccination in their medical clinic. Data obtained show an overall average vaccination coverage growth of about 13% in the first 4 months of the survey, and a further growth of about 11% in the following seven months, with a total growth in the entire period of 24%. The pediatricians' counseling is essential to recover non-compliant subjects, considering both the relationship of trust with the families and the visits already scheduled as an ideal moment for vaccinations' status check.The project highlights how an effective collaboration between family pediatricians and the Local Health Authority becomes valuable in getting closer to reach the Ministerial goal of 95%. Vaccination coverage increased significantly when family pediatricians supported the activity of vaccine centers in distress in many regional situations. The trust relationship, the hourly availability and the capillary network of family pediatricians' clinics were key elements for the success of this project and were also recognized by parents.

Native biodiversity decline and non-native species spread are major features of the Anthropocene. Both processes can drive biotic homogenization by reducing trait and phylogenetic differences in species assemblages between regions, thus diminishing the regional distinctiveness of biotas and likely have negative impacts on key ecosystem functions. However, a global assessment of this phenomenon is lacking. Here, using a dataset of >200,000 plant species, we demonstrate widespread and temporal decreases in species and phylogenetic turnover across grain sizes and spatial extents. The extent of homogenization within major biomes is pronounced and is overwhelmingly explained by non-native species naturalizations. Asia and North America are major sources of non-native species; however, the species they export tend to be phylogenetically close to recipient floras. Australia, the Pacific and Europe, in contrast, contribute fewer species to the global pool of non-natives, but represent a disproportionate amount of phylogenetic diversity. The timeline of most naturalisations coincides with widespread human migration within the last ~500 years, and demonstrates the profound influence humans exert on regional biotas beyond changes in species richness., Human-driven movements and extinctions of species have made plant communities across biomes more homogenous. Here the authors quantify plant vascular species and phylogenetic homogenization across the globe, finding that non-native species naturalisations have been a major driver.

Intimate partner violence against women (IPVAW) is the most pervasive violation of women’s rights worldwide, causing devastating lifelong damage. Victims can suffer physical, emotional or mental health problems, and experience detrimental effects in social, psychological and relational health with their families, especially children. Due to the complexity regarding violence against women in heterosexual couples, it is important to make a clear distinction between psychological and physical mistreatment, which also includes psychological violence. This differentiation is important in determining different emotional and psychological aspects of mistreatment in order to understand the reasons why some women stay in such relationships and to explain the personality profiles of victims and perpetrators. In this short narrative review, we have combined perspectives of depth psychology and attachment theory from studies on trauma, traumatic bonds and the perpetrator/victim complex in gender violence. We have also considered the growing literature on IPVAW as it relates to the medico-legal field. Our search strategy included intimate partner violence, attachment styles, risk factors and the victim/perpetrator relationship. Distinguishing the different types of IPVAW is a necessary step in understanding the complexity, causes, correlations and consequences of this issue. Above all, it enables the implementation of effective prevention and intervention strategies.

The Covid-19 pandemic caused a marked increase in admissions to intensive care units. The critically ill patients’ condition from the infection resulted in their deaths. The healthcare facilities have got into trouble because of the pandemic. In fact, they had to create additional beds in a very short time and to protect health workers with personal protective equipment. Healthcare professionals fear that there will be an increase in complaints and medico-legal malpractice claims and hence they have urged politicians to discuss this. The Italian Parliament recently debated the topic of medical liability and passed the Decree-Law no. 18 of 17 March 2020 (DL – so called Cura Italia) by which they want to extend the concept of “gross negligence” to healthcare facilities. Several Extended Care Units have suffered from outbreaks of Covid-19, so the Prosecutor’s Office of several cities initiated investigations against them. This situation has reached Sicily, where the Prosecutor’s Office of Palermo has opened an inquiry against an Extended Care Unit. Simultaneously, the Covid-19 pandemic may change patients’ attitudes towards healthcare professionals, who are risking their lives daily. So the Italian medico-legal community is debating these questions, with one last pending question remaining: is the number of medico-legal claims likely to increase or trend down?

The applications of forensic radiology involve both Virtopsy both studies on living people - to demonstrate bone age, search for foreign bodies, such as voluntary injection of drug ovules or surgical sponges accidentally forgotten, to assess gunshot wounds, to evaluate injuries by road accidents, and cases of violence or abuse (both in adults and in children). Computed tomography is the most used imaging tool used in forensic pathology and its indications are mainly focused on cases of unnatural deaths or when a crime is suspected. It is preferred over the standard autopsy in selected cases, such as in putrefied, carbonized or badly damaged bodies; or as a preliminary evaluation in mass disasters.

Myocardial bridging is a congenital coronary pathology described as a segment of coronary artery which courses through the myocardial wall under the muscle bridge. Although the prognosis of myocardial bridging is benign, sports medicine recognises myocardial bridging as a leading cause of sudden death among young basketball, football and soccer players. The authors report a case of a 42-year-old man who collapsed while playing football. He died notwithstanding prompt medical assistance and cardiopulmonary resuscitation. At autopsy, gross examination of the heart revealed the intramural course of the left anterior descending coronary artery to be 2 cm from its coronary ostial origin. Histological examination of ventricular septal and left myocardium showed early signs of ischaemic injury without disease of small coronary vessels and hypertrophic cardiomyopathy. The cause of the death was due to malignant ventricular arrhythmia during intense physical activity.

People who live and work or are detained inside restricted communities (including prisons) need to be considered as they are at a high risk of becoming infected with Covid-19 during this pandemic.1 InItaly, the spread of Covid-19 has provoked numerous riots within the prisons and local detention centres, and there is a consequent increase in requests for inmates to be released and detained at home

Introduction and objectives Liver transplantation candidates are among the most comorbid patients awaiting lifesaving intervention. Health related quality of life (HRQOL) measured by instruments that incorporate dynamic computerized adaptive testing, could improve their assessment. We aimed to determine the feasibility of administration of the Patient-Reported Outcomes Measurement Information System (PROMIS-CAT) in liver transplant candidates. Materials and methods Liver transplantation candidates were prospectively enrolled following a review of their available medical history. Subjects were given a tablet computer (iPad) to access the pre-loaded PROMIS CAT. Results 109 candidates with mean age 55.6 ± 8.6 years were enrolled in this pilot study. Mean MELD-Na score was 16.3 ± 6.3; 92.6% had decompensated liver disease. Leading etiologies of cirrhosis included hepatitis C (34.8%), nonalcoholic steatohepatitis (25.7%) and alcohol (21.1%). Subjects with MELD-Na score > 20 had the most significant impairment in HRQOL (anxiety/fear + 5.9 ± 2.7, p = 0.0289, depression + 5.1 ± 2.5, p = 0.0428, fatigue + 4.3 ± 2.6, p = 0.0973) and physical impairment (−7.8 ± 2.5, p = 0.0022). Stage of cirrhosis and decompensated liver disease were predictive of impaired HRQOL but Child–Pugh Turcotte score was not. Hepatic encephalopathy was the strongest independent predictor of impaired HRQOL, with significant impairment across all domains of health. Conclusions Liver transplant candidates have significantly impaired HRQOL across multiple domains of health as measured by PROMIS-CAT. HRQOL impairment parallels disease severity. Future study is needed to determine how best HRQOL could be systematically included in liver transplantation listing policy, especially in those candidates with hepatic encephalopathy.

Background IDH1 mutation shows diagnostic, prognostic, and predictive value in gliomas. Direct Sanger sequencing is considered the gold standard to detect IDH1 mutation. However, this technology is not available in most neuropathological centers in developing countries such as Indonesia. Immunohistochemistry (IHC) and polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) have also been used to detect IDH1 mutation. This study aimed to compare DNA sequencing, IHC, and PCR-RFLP in detecting IDH1 mutations in gliomas. Methods Research subjects were recruited from Dr. Sardjito Hospital. Genomic DNA was extracted from fresh or formalin-fixed paraffin-embedded samples of tumor tissue. DNA sequencing, PCR-RFLP and IHC were performed to detect IDH1 mutation. Sensitivity, specificity, and accuracy of PCR-RFLP and IHC were calculated by comparing them to DNA sequencing as the gold standard. Results Among 61 recruited patients, 13 (21.3%) of them carried a mutation in codon 132 of the IDH1 gene, as shown by DNA sequencing. PCR-RFLP and DNA sequencing have a concordance value of 100%. Meanwhile, the concordance value between IDH1 R132H IHC and DNA sequencing was 96.7%. The sensitivity, specificity, positive predictive values, negative predictive values, and accuracy for PCR-RFLP were all 100%. On the other hand, the sensitivity, specificity, and accuracy of IHC were 92.3%, 97.9%, and 96.7%, respectively. Conclusion This study showed that both PCR-RFLP and IHC have high accuracy in detecting IDH1 mutation. We recommend a combination of PCR-RFLP and IHC to detect IDH1 mutation in resource-limited settings. .

Introduction and Aim: Hemostatic disorders in chronic liver disease and cirrhosis show continued expansion of research efforts. However, clinical decision making is often practiced on an individual patient level as consensus guidelines are lacking. We aimed to better assess individual day-to-day clinical practice through gauging clinicians’ responses to common clinical scenarios. Materials and Methods: A series of ten clinical scenarios (seven procedural coagulation and three thrombosis management) were posed to conference attendees utilizing real-time polling software (Poll Everywhere). Responses were binomial and were submitted as “Agree” or “Disagree.” Results were displayed real time following a standardized response period and an open-forum discussion ensued between conference faculty and attendees following response submission. Results: Twenty conference attendees participated in the clinical scenario plenary session. In general, agreement rates were high. All but one of the ten clinical scenarios had ≥ 70% agreement. Agreement was based both on procedural risk, with greatest agreement seen for low-risk procedures (80–93%), and on peri-procedural coagulation parameters of platelet count and fibrinogen level where > 50,000μ/L and 120 mg/dL were the most agreed upon thresholds, respectively. 75–95% agreement was reached when surveying the need for anticoagulation for mesenteric vein thrombosis in liver transplant candidates; slightly less (71%) agreement was found when deciding to proceed with anticoagulation in non-liver transplant candidates with mesenteric vein thrombosis. Conclusions: While large-scale, methodologically rigorous randomized controlled trials are lacking to guide clinical decision making in patients with coagulation disorders and chronic liver disease, consensus expert opinion regarding mitigating peri-procedural bleeding risk and treatment of thrombosis appears consistent and strong.

The robotic approach to an inguinal hernia has not been compared head to head with the open and laparoscopic techniques in randomized controlled trials. Furthermore, long-term outcomes for robotic inguinal hernia repair (RHR) are lacking. In this study, we compared laparoscopic inguinal hernia repair (LHR) and RHR with open inguinal hernia repair (OHR) in veteran patients performed by surgeons most familiar with each approach.A retrospective single-institution analysis of 1299 inguinal hernia repairs performed at the VA North Texas Health Care System between 2005 and 2017 was undertaken. Three surgeons performed the operations, each an expert in one approach, and there was no crossover in techniques. A total of 1100 OHRs, 128 LHRs, and 71 RHRs were performed. Univariable analysis was undertaken to determine associations between techniques and outcomes (OHR versus LHR; OHR versus RHR; LHR versus RHR). Setting complications as a dependent variable, multivariable analyses were undertaken to determine an association with complications as well as independent predictors of complications.Patient demographics were similar among groups except for age that was higher in the OHR cohort. The average follow-up was 5.2 ± 3.4 y. In the present report, recurrence was associated with a higher rate in the RHR versus OHR (5.6% versus 1.7%; P 0.02), but not in the LHR versus OHR (3.9% versus 1.9%; P = 0.09). Inguinodynia was more likely to occur in both the LHR and RHR compared with the OHR (9.4% and 14.1 versus 1.5%; both P's 0.001). Urinary retention was also more common in the LHR and RHR than in the OHR (5.5% and 5.6% versus 1.8%, both P's 0.05) as was the rate of overall complications (34.4% and 38.0% versus 11.2%, both P's 0.001). Multivariable regression analysis showed femoral hernias, ASA, serum albumin, operative room time, a recurrent hernia, and the minimally invasive approaches were independent predictors of overall complications.Outcomes in the OHR cohort were, in general, superior compared with both the LHR and RHR. However, these strategies should be viewed as complementary. The best approach to an inguinal hernia repair rests on the specific expertise of the surgeon.

In patients with non-small-cell lung cancer (NSCLC), the use of postoperative radiotherapy (PORT) has been controversial since 1998, because of one meta-analysis showing a deleterious effect on survival in patients with pN0 and pN1, but with an unclear effect in patients with pN2 NSCLC. Because many changes have occurred in the management of patients with NSCLC, the role of three-dimensional (3D) conformal PORT warrants further investigation in patients with stage IIIAN2 NSCLC. The aim of this study was to establish whether PORT should be part of their standard treatment.Lung ART is an open-label, randomised, phase 3, superiority trial comparing mediastinal PORT to no PORT in patients with NSCLC with complete resection, nodal exploration, and cytologically or histologically proven N2 involvement. Previous neoadjuvant or adjuvant chemotherapy was allowed. Patients aged 18 years or older, with an WHO performance status of 0-2, were recruited from 64 hospitals and cancer centres in five countries (France, UK, Germany, Switzerland, and Belgium). Patients were randomly assigned (1:1) to either the PORT or no PORT (control) groups via a web randomisation system, and minimisation factors were the institution, administration of chemotherapy, number of mediastinal lymph node stations involved, histology, and use of pre-treatment PET scan. Patients received PORT at a dose of 54 Gy in 27 or 30 daily fractions, on five consecutive days a week. Three dimensional conformal radiotherapy was mandatory, and intensity-modulated radiotherapy was permitted in centres with expertise. The primary endpoint was disease-free survival, analysed by intention to treat at 3 years; patients from the PORT group who did not receive radiotherapy and patients from the control group with no follow-up were excluded from the safety analyses. This trial is now closed. This trial is registered with ClinicalTrials.gov number, NCT00410683.Between Aug 7, 2007, and July 17, 2018, 501 patients, predominantly staged withLung ART evaluated 3D conformal PORT after complete resection in patients who predominantly had been staged using (French National Cancer Institute, Programme Hospitalier de Recherche Clinique from the French Health Ministry, Gustave Roussy, Cancer Research UK, Swiss State Secretary for Education, Research, and Innovation, Swiss Cancer Research Foundation, Swiss Cancer League.

Caroline McGregor Argo argues that the new vet school at SRUC will not just be 'more of the same', and that instead it will have a clear remit to produce vets with attributes aligned with society's priority needs.

Maximizing liver graft volume benefits the living donor liver recipient. Whether maximizing graft volume negatively impacts living donor recovery and outcomes remains controversial. Patient randomization between right and left hepatectomy has not been possible due to anatomic constraints; however, a number of published, nonrandomized observational studies summarize donor outcomes between 2 anatomic living donor hepatectomies. This meta-analysis compares donor-specific outcomes after right versus left living donor hepatectomy. Systematic searches were performed via PubMed, Cochrane, ResearchGate, and Google Scholar databases to identify relevant studies between January 2005 and November 2019. The primary outcomes compared overall morbidity and incidence of severe complications (Clavien-Dindo >III) between right and left hepatectomy in donors after liver donation. Random effects meta-analysis was performed to derive summary risk estimates of outcomes. A total of 33 studies (3 prospective and 30 retrospective cohort) were used to identify 7649 pooled patients (5993 right hepatectomy and 1027 left hepatectomy). Proportion of donors who developed postoperative complications did not significantly differ after right hepatectomy (0.33; 95% confidence interval [CI], 0.27-0.40) and left hepatectomy (0.23; 95% CI, 0.17-0.29; P = 0.19). The overall risk ratio (RR) did not differ between right and left hepatectomy (RR, 1.16; 95% CI, 0.83-1.63; P = 0.36). The relative risk for a donor to develop severe complications showed no differences by hepatectomy side (Incidence rate ratio, 0.97; 95% CI, 0.67-1.40; P = 0.86). There is no evidence that the overall morbidity differs between right and left lobe donors. Publication bias reflects institutional and surgeon variation. A prospective, standardized, multi-institutional study would help quantify the burden of donor complications after liver donation.

The most common cause of sudden death during sexual intercourse in adults is heart disease, and it is usually the male, whereas the death of the woman is unusual. Generally, in these cases, death occurs as a result of cardiovascular disease. The authors report an unusual case of the sudden death of a young woman during sexual intercourse. The post-mortem investigations (autopsy, cardiac nuclear magnetic resonance and cardiac histology) demonstrated a previously undiagnosed arrhythmogenic right ventricular cardiomyopathy. The terminal cause of death was a malignant arrhythmia from arrhythmogenic right ventricular cardiomyopathy. This is the first report of a case in which sexual activity can be regarded as the triggering factor combined with cardiac disease to the woman’s death.

Diagnosis of death by electrocution may be difficult when electric marking is not visible or unclear. Accordingly, the body of a man who appeared to have died from accidental electrocution was carefully forensically analysed. Macroscopic and microscopic analysis of the current mark was carried out using a variable-pressure scanning electron microscope equipped with energy dispersive X-ray microanalyser to highlight skin metallisation, indicating the presence of iron and zinc. The histological findings of electrocution myocardial damage were supported by the results of biochemical analysis which demonstrated the creatine kinase-MB and cardiac troponin I elevation. The effects of electric current flow were also highlighted by perforations of endothelial surface of a pulmonary artery using scanning electron microscope, and all the results were analysed by the main tools suggested in the literature.

Telemedicine offers a support to traditional medicine, delivering clinical services when distance is a critical factor. Although this tool does not replace a medical examination, during Covid-19 pandemic, it reduces the spread of infection and avoids the need for a patient’s visit. It is useful in the management of chronic disorders or for patients undergoing palliative treatment. The University Hospital of Palermo has applied this in cases of chronic illness caring for patients who cannot stop their treatment, such as Department of Onco-Haematology, Internal Medicine, Dermatology, etc. The Department of Legal Medicine of Palermo, in particular, is also using telemedicine to manage medico-legal sudden natural death investigations and dealing with the Public Prosecutor’s office of Palermo. Even after the Covid-19 emergency, telemedicine will be essential to streamline outpatient visits, while at the same time limiting costs, with significant benefits for the Italian National Public Health Service budget. In conclusion, telemedicine can offer a valuable support to the doctor’s activity by streamlining and facilitating their work. In this sense, the Covid-19 pandemic represents a positive input for the acceleration and enhancement of these tools.

Our institute, in collaboration with the Public Prosecutor’s Office, arranges for cadaveric inspections during a judicial inspection, jointly with the police. With the advent of the Covid-19 pandemic, operating methods have changed. Specifically, we now discuss the cases individually before attending to guarantee the health of operators and citizens

The aim of this case report is to share with the forensic science community the experience of a rare complication of sickle cell anemia: acute chest syndrome. In October 2016, at the port of the city of Trapani (Sicily, Italy), the landing of an ONG "Médecins Sans Frontières" ship took place with 548 non-EU citizens and a corpse on board. The man, in the hours before his death, complained of severe chest pain and respiratory difficulties, and, despite of the therapeutic aids and resuscitation maneuvers, lastly died. The Public Prosecutor ordered that autopsy be executed on the corpse of the young Ghanaian, and it was to be supplemented by histological, toxicological, genetic investigations, and the dating of the biological age. The autoptic examination findings were indicative of bilateral bronchopneumonia, and were also confirmed by the histological findings, which identified a condition of massive adipose pulmonary embolism, due to the presence of extramedullary hematopoietic tissue, site of endovascular thrombosis secondary to hemolysis of sickle cells. The spleen appeared of small volume, with fibrotic phenomena. The predisposition to infections, thrombosis, extramedullary hematopoiesis are all complications of sickle cell anemia. The severe pulmonary condition characterized by vaso-occlusive findings and pulmonary inflammation with infiltrate, symptoms like fever, chest pain and severe systemic hypoxia allowed to ascribe the plausible cause of death as acute chest syndrome, a rare complication of sickle cell anemia. The peculiarity of this clinical case is also related to the methods of medical intervention (boat with non-governmental medical support for assistance to migrants).

The Covid-19 pandemic and the resulting fear, quarantine and lockdown measures implemented in Italy and other countries to contain the risk of contagion have seriously impacted the mental health of a large number of people. The need to offer psychological and psychotherapeutic support to these people, while respecting the government’s pressing calls to “stay home”, have led many psychologists and psychotherapists, both in the public and private sectors, to provide their professional services via teleconference, telephone, smartphone, etc. The aim of this work is to highlight some critical issues related to the sudden switch from the traditional method of providing psychological services to the digital one in Italy.

The authors evaluate the importance of prevention measures and health care from their own experience and briefly analyse the factors that may have contributed to the rapid spread of Covid-19 in Italy, and hope this will feed into appropriate and new and improved health policies.

Local anaesthetics (LAs) are commonly used in surgery, especially in dentistry. They cause a transitory inhibition of nerve signal due to the blockade of the voltage-gated sodium channels. LAs are administrated alone or with vasoconstriction agents, such as adrenaline. Toxicity of LAs is associated to neurological and cardiovascular alterations. Tachycardia, arrhythmia, tremors, tonic-clonic seizure and respiratory depression (at high doses) are the main symptoms of intoxication by LAs. Lidocaine, articaine and mepivacaine are among the most used anaesthetics. This study aimed to fully validated a new method for the simultaneous detection of articaine and mepivacaine in whole blood. Sample treatment consisted in a liquid-liquid extraction with phosphate buffer (pH 8, 0.1 M) and ethyl-acetate. Analysis was performed by liquid chromatography-tandem mass spectrometry in multiple reaction monitoring mode (transitions: articaine, 285→8658 m/z; mepivacaine, 247→9870 m/z; lidocaine - internal standard -, 235→8658 m/z). The method proved to be highly sensitive with limit of quantifications for articaine and mepivacaine of 0.8 and 0.1 ng/mL, respectively. Accuracy and precision were always within the acceptance criteria. The new procedure was also successfully applied to a preliminary pharmacokinetics study.

The dismemberment of a corpse is comparatively rare in forensic medicine and usually performed with different types of sharp tools. The victim is always the victim of a homicide. Dismemberment usually occurs where the killing took place without prior planning by the perpetrator. We report a case of homicide with post mortem mutilation of the victim’s body with previous amputation of right lower limb in which the perpetrator was not identified. At autopsy, several fractures were detected on the cranial vault, and the cause of death was due to skull and brain injuries from multiple blunt force traumas.

Background Gliomas remain one of the most common primary brain tumors. Mutations in the isocitrate dehydrogenase (IDH) gene are associated with a distinct set of clinicopathological profiles. However, the distribution and significance of these mutations have never been studied in the Indonesian population. This study aimed to elucidate the association between IDH mutations and clinicopathological as well as prognostic profiles of Indonesian patients with gliomas. Methods In total, 106 patients with gliomas were recruited from a tertiary academic medical center in Yogyakarta, Indonesia. Formalin-fixed paraffin-embedded and fresh tissue specimens were obtained and sectioned for hematoxylin-eosin staining and immunohistochemical examinations. Genomic DNA was isolated and analyzed for the presence of IDH mutations using standard polymerase chain reaction and nucleotide sequencing methods. Clinicopathological data were collected from medical records. Results Although no IDH2 mutation was identified, IDH1 mutations were found in 23 (21.7%) of the patients. Patients with IDH1 mutations tended to have a history of smoking and a shorter interval between onset of symptoms and initial surgical interventions. Frontal lobe involvement, oligodendroglial histology, lower Ki67 expression, WHO grades II and III gliomas, and methylated O6-methylguanine-DNA methyltransferase (MGMT) promoters were significantly associated with the presence of IDH1 mutations. Compared with patients with IDH1-wild-type, patients with IDH1 mutation were observed to have a longer overall survival. Conclusions IDH1 mutations are associated with certain clinicopathological and prognostic profiles in Indonesian patients with gliomas. This finding demonstrates the importance of identifying IDH mutations as part of the management of patients with glioma in Indonesia. .

Objective (1) To determine the reliability of the King-Devick (KD) test among wheelchair basketball athletes across a season and (2) to compare the KD test time changes among those with and without a clinically suspected concussion. Design Prospective, observational study. Setting Division 3 college athletics department. Participants Twenty-nine intercollegiate wheelchair basketball athletes. Interventions Athletes were prospectively monitored for concussions throughout the 2018 to 2019 season. King-Devick testing was completed preseason, midseason, postseason, and after clinically suspected concussions. Main outcome measures Two-way random effects intraclass correlation coefficient (ICC) was calculated. Friedman's test and pairwise comparison with Bonferroni correction were used to compare for change over time. Mean KD times and changes were compared between athletes with and without suspected concussion. Results The KD test demonstrated good test-retest reliability (ICC = 0.826). Among participants without a concussion, there was a significant decrease in the mean KD test time from preseason to midseason (-3.3 seconds; P = 0.0167) and preseason to postseason (-3.3 seconds; P = 0.0167). No change was seen from mid-to-post season. Six athletes had 7 suspected concussions. Each demonstrated an increase in the KD test time, with a mean increase from 44.3 ± 9.5 seconds to 53.7 ± 12.8 seconds. King-Devick test times returned to or below baseline by postseason. Conclusions The KD test shows good reliability among wheelchair basketball athletes without a concussion. A learning effect is demonstrated initially but plateaus on subsequent testing. Unlike athletes without a concussion, players with a clinically suspected concussion showed an increase in the KD test time.

The British Mandate in Palestine ended abruptly in 1948. The British departure engendered a complex situation which affected all areas of life, and the country’s health system was no exception. Gradual transition of the infrastructure was almost impossible owing to the ineffectiveness of the committee appointed by the United Nations. The situation was further complicated by the outbreak of the Arab–Israeli War. We relate for the first time the story of 75 Jewish patients who were left in a former British mental hospital in Bethlehem – deep behind the front lines. Despite the hostilities, there were complex negotiations about relocating those patients. This episode sheds light on the Jewish and Arab relationship as it pertained to mental institutions during and immediately after the British Mandate.

BACKGROUND Clostridium difficile is a bacterial pathogen associated with significant morbidity and mortality in patients with cirrhosis. GOALS Our primary aim is to identify variables that are predictive of poor outcomes in cirrhosis patients with C. difficile infection (CDI). We also aim to further characterize the risk factors for developing CDI and risk of mortality in this patient population. STUDY A total of 200 subjects with a diagnosis of cirrhosis and CDI were matched to 200 cirrhosis inpatients without CDI. The groups were compared to evaluate variables associated with decreased survival for cirrhosis inpatients with CDI as well as risk factors for developing CDI. RESULTS Cirrhosis patients with CDI were more frequently prescribed antibiotics during their hospitalization (P=0.002) and cared for in an intensive care unit (ICU) (P

INTRODUCTION: Injuries to the peripheral auditory system are among the most common results of high intensity impulsive acoustic exposure. Prior studies of high intensity sound transmission by the ossicular chain have relied upon measurements in animal models, measurements at more moderate sound levels (i.e. < 130 dB SPL), and/or measured responses to steady-state noise. Here, we directly measure intracochlear pressure in human cadaveric temporal bones, with fiber optic pressure sensors placed in scala vestibuli (SV) and tympani (ST), during exposure to shock waves with peak positive pressures between ~7–83 kPa. METHODS: Eight full-cephalic human cadaver heads were exposed, face-on, to acoustic shock waves in a 45 cm diameter shock tube. Specimens were exposed to impulses with nominal peak overpressures of 7, 28, 55, & 83 kPa (171, 183, 189, & 192 dB pSPL), measured in the free field adjacent to the forehead. Specimens were prepared bilaterally by mastoidectomy and extended facial recess to expose the ossicular chain. Ear canal (EAC), middle ear, and intracochlear sound pressure levels were measured with fiber-optic pressure sensors. Surface-mounted sensors measured SPL and skull strain near the opening of each EAC and at the forehead. RESULTS: Measurements on the forehead showed incident peak pressures approximately twice that measured by adjacent free-field and EAC entrance sensors, as expected based on the sensor orientation (normal vs tangential to the shock wave propagation). At 7 kPa, EAC pressure showed gain, calculated from the frequency spectra, consistent with the ear canal resonance, and gain in the intracochlear pressures (normalized to the EAC pressure) were consistent with (though somewhat lower than) previously reported middle ear transfer functions. Responses to higher intensity impulses tended to show lower intracochlear gain relative to EAC, suggesting sound transmission efficiency along the ossicular chain is reduced at high intensities. Tympanic membrane (TM) rupture was observed following nearly every exposure 55 kPa or higher. CONCLUSIONS: Intracochlear pressures reveal lower middle-ear transfer function magnitudes (i.e. reduced gain relative to the ear canal) for high sound pressure levels, thus revealing lower than expected cochlear exposure based on extrapolation from cochlear pressures measured at more moderate sound levels. These results are consistent with lowered transmissivity of the ossicular chain at high intensities, and are consistent with our prior report measuring middle ear transfer functions in human cadaveric temporal bones with high intensity tone pips.

Early detection of oral cancer improves survival after treatment and the quality of life. The adoption of standardized methodological protocols of screening has increased the possibilities for early identification and appropriate treatment. The informed consent must be obtained by patients before any treatment and/or surgical procedure. The clinical and surgical details must be discussed with the patient, as well as potential risks and benefits. Consent must be documented in the medical record and consent forms may serve to document the physician's discussion with the patient. Objectives. all dentists are trained to detect the early signs of oral cancer. The health professional have a key role in identify the early signs of oral cancer in order to plan the treatment and management of the disease. The work aims to provide simple practical information to collect the patient's consent and encouraging him to improve healthy behaviors. Materials and Methods. are analyzed the critical issues of clinical practice in order to improve the management of oral cancer Results and conclusions. identify effective information approaches documented in the medical record as a tool of close communication between the patient and the physician.