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Antiretroviral therapy (ART) significantly reduced Human Immunodeficiency Virus (HIV) morbidity and mortality; nevertheless, stigma still characterises the living with this condition. This study explored patients’ coping experience by integrating narrative medicine (NM) in a non-interventional clinical trial. From June 2018 to September 2020 the study involved 18 centres across Italy; enrolled patients were both D/C/F/TAF naïve and previously ART-treated. Narratives were collected at enrolment (V1) and last visit (V4) and then independently analysed by three NM specialist researchers through content analysis. One-hundred and fourteen patients completed both V1 and V4 narratives. Supportive relationships with clinicians and undetectable viral load facilitated coping. Conversely, lack of disclosure of HIV-positive status, HIV metaphors, and unwillingness to narrate the life before the diagnosis indicated internalised stigma. This is the first non-interventional study to include narratives as patient reported outcomes (PROs). Improving HIV awareness and reducing the sense of guilt experienced by patients helps to overcome stigma and foster coping.

Eleonora Volpato,1– 3 Stefano Centanni,4 Paolo Banfi,3 Salvatore D’Antonio,5 Enrico Peterle,6 Filomena Bugliaro,7 Ignazio Grattagliano,8 Alessio Piraino,9 Luca Cavalieri,9 Alfio Pennisi,10 Gianluca Danesi,11 Luigi Santoiemma,12 Maria Giulia Marini1 1Healthcare Area, ISTUD Foundation, Milan, Italy; 2Department of Psychology, Università Cattolica del Sacro Cuore, Milan, Italy; 3Heart-Respiratory Rehabilitation Unit, IRCCS Fondazione Don Carlo Gnocchi, Milan, Italy; 4Department of Health Sciences Università degli Studi di Milano - Respiratory UnitASST Santi Paolo e Carlo, Milan, Italy; 5Associazione ONLUS BPCO, Rome, Italy; 6General Practitioner, Local Health Department 3 Serenissima, Venezia, Italy; 7Federasma e Allergie-Federazione Italiana Pazienti OdV, Prato, Italy; 8Italian College of General Practitioners, Bari, Italy; 9Chiesi Farmaceutici S.p.A, Parma, italy; 10Rehabilitation Clinic Monsignor Calaciura Biancavilla, Catania, Italy; 11Local Health Department Romagna Pulmonology Ravenna, Ravenna, Italy; 12General Practitioner, Local Health Department Bari, Bari, ItalyCorrespondence: Eleonora Volpato Email evolpato@istud.itPurpose: The COVID-19 pandemic has disrupted many lives, including those of people suffering from chronic obstructive pulmonary disease (COPD) and their caregivers. The main aim of this study was to use narrative medicine, a validated approach promoting quality of care to explore how the COVID-19 pandemic impacted the quality of care, quality of life, psychological factors and social factors of people affected by COPD and their caregivers and healthcare professionals (HCPs). A secondary aim was to explore the role of telemedicine in combating isolation and providing access to care.Methods: A cross-sectional observational narrative medicine study was conducted between July and November 2020 across Italy. An online semi-structured questionnaire with a narrative plot was completed by 146 participants (79 COPD patients, 24 caregivers, and 43 HCPs). Narrations were analyzed with descriptive statistics and evaluated using NVivo 11 software to break down the text and identify recurring themes and major semantic clusters.Results: During the first lockdown, 58.22% of responses from COPD patients indicated terror, fear and/or apprehension; at reopening, this figure was 35.44%. Among caregivers, these figures were 100% at first lockdown and 45.83% at reopening. The metaphors most commonly used by patients to describe COPD and COVID-19 were monster and murderer, respectively. Patients described their homes more often as clean and lonely than as offering no shelter. The narratives of 42 COPD patients (45.2%) described coping. Only 12.6% of COPD patients reported regular access to medical visits during lockdown, while 59.1% of general practitioners and pulmonologists reported using telemedicine, which was perceived as satisfactory by both patients and caregivers.Conclusion: It is relevant to aim for a multidisciplinary and multilevel system of care that empowers telemedicine and integrates specific psychological support programs for COPD patients and their caregivers.Keywords: chronic obstructive pulmonary disease, COPD, COVID-19, narrative medicine, quality of life

Background: There is paucity of data on the potential value of early palliative home care for patients with hematologic malignancies. Objective: To compare costs, use of resources, and clinical out...

The study retraces the healthcare pathway of patients affected by diabetic macular edema (DME) through the direct voice of patients and caregivers by using a “patient journey” and narrative method approach. The mapping of the patient’s journey was developed by a multidisciplinary board of health professionals and involved four Italian retina centers. DME patients on intravitreal injection therapy and caregivers were interviewed according to the narrative medicine approach. Narratives were analyzed through a quali-quantitative tool, as set by the narrative medicine method. The study involved four specialized retina centers in Italy and collected a total of 106 narratives, 82 from DME patients and 24 from caregivers. The narratives reported their difficulty in identifying the correct pathway of care because of a limited awareness of diabetes and its complications. Patients experienced reduced autonomy due to ocular complications. In the treatment of diabetes and its complications, a multidisciplinary approach currently appears to be missing. DME reduces the quality of life of affected patients. The narrative medicine approach offers qualitative and emotional patient-guided information. The patient journey provides all of those involved in the management of DME with flowcharts to refer to, identifying the critical points in the healthcare journey of DME patients to improve the management of the disease.

Background The The Roadmap Using Story Telling project used a narrative medicine (NM) framework to assess the perspectives of people with heart failure (HF), their informal caregivers and HF specialists of the impact of HF on the daily life of patients and their carers. Methods Italian HF specialists participated on a voluntary basis, completing their own narratives, and inviting patients and their caregivers to write anonymously about their experiences, all on a dedicated online platform. The narratives were analyzed according to standard NM methodology. Results 82 narratives were collected from patients, 61 from caregivers, and 104 from HF specialists. Analysis of the three points of view revealed the extent of the burden of illness on the entire family, particularly that of the caregiver. The impact was mainly experienced as emotional and social limitations in patients’ and their caregivers’ daily lives. The analysis of all three points of view highlighted a strong difference between how HF is perceived by patients, caregivers, and HF specialists. Conclusions This NM project illustrates the complex issues of living with HF and gave insights to integrate three different perspectives into the HF pathway of care.

ObjectiveThis research aimed to investigate the experience of major depression by integrating the perspectives of patients, caregivers and healthcare providers through narrative-based medicine (NBM) to provide new insights to improve care relationships.Design and settingThe research was conducted in 2019 and involved five Italian psychiatric centres and targeted adult patients, their caregivers and healthcare providers to address data source triangulation. A sociodemographic survey and a narrative plot, based on Natural Semantic Metalanguage were collected. Narratives were analysed through NBM classifications, NVivo software and interpretative coding.ParticipantsThirty-six patients with a diagnosis of major depression, 27 caregivers and 33 healthcare providers participated in the research.ResultsAmong the 96 collected narratives, ‘lonely’ was the word patients used most frequently, while ‘sad’ and ‘lifeless’ were used most respectively by caregivers and healthcare providers. A positive care relationship was crucial for 84% of patients in relation to their care pathway, and nature (36%) and the arts (28%) were the most frequent resources. Caregivers expressed feelings of powerlessness and inadequacy, and 21% of them reported a declining social life while providing care to a loved one with depression. Thirty-one percent of mental health professionals experienced difficulties in their first encounter with patients; however, their emotions progressively moved towards trust and satisfaction. Furthermore, 89% of patients and healthcare providers and 58% of caregivers evaluated writing the narrative to be a positive experience.ConclusionFindings suggested the possible role for language in understanding major depression, thereby improving care relationships between patients and physicians. Care pathways might also be more attentive to caregivers, to reduce their risk of burnout. Finally, narrative medicine could be integrated with the care pathway as an additional space of expression, dialogue, reflection and development of empathy.

Background Although migraine is widespread and disabling, stigmatisation and poor awareness of the condition still represent barriers to effective care; furthermore, research on migraine individual and social impact must be enhanced to unveil neglected issues, such as caregiving burden. The project investigated the migraine illness experience through Narrative Medicine (NM) to understand daily life, needs and personal resources of migraneurs, their caregivers and clinicians, and to provide insights for clinical practice. Methods The project involved 13 Italian headache centres and targeted migraneurs, their caregivers and migraine specialists at these centres. Written narratives, composed by a sociodemographic survey and illness plot or parallel chart, were collected through the project’s webpage. Illness plots and parallel charts employed open words to encourage participants’ expression. Narratives were analysed through Nvivo software, interpretive coding and NM classifications. Results One hundred and seven narratives were collected from patients and 26 from caregivers, as well as 45 parallel charts from clinicians. The analysis revealed migraine perception in social, domestic and work life within the care pathway evolution and a bond between chaos narratives and day loss due to migraine; furthermore, narratives suggested the extent of the caregiving burden and a risk of underestimation of migraine burden in patients’ and caregivers’ life. Conclusion The project represents the first investigation on migraine illness experience through NM simultaneously considering migraneurs’, caregivers’ and clinicians’ perspectives. Comparing narratives and parallel charts allowed to obtain suggestions for clinical practice, while NM emerged as able to foster the pursuing of migraine knowledge and awareness.

Objectives To investigate the real-life experience of patients affected by neovascular age-related macular degeneration (nAMD), in the healthcare pathway for the management of the disease, using a "patient journey" and narrative method approach. Methods The patient journey of subjects affected by nAMD was designed using a process-mapping methodology involving a team from 11 Italian centres. Subsequently, narratives were collected from nAMD patients and family members. The interviews were analyzed using the narrative medicine methodology. Results Eleven specialized retina centres across Italy were involved and 205 narratives collected. In 29% of cases, patients underestimated their symptoms or attributed them to non-pathological causes, thus delaying the specialist consultation. The delay in accessing to care was due to a lack of awareness of this disease (50% of the participants didn't know what nAMD is) and to critical issues faced at first visit (long waiting lists, failed diagnosis, underestimation of the problem). Despite anti-VEGF therapies were perceived as effective in improving or stabilizing vision in 91% of narratives collected, 77% of patients still reduced or ceased daily activities such as reading and driving. Within the pathway of care there was not a multidisciplinary approach, and the patients were treated just by the ophthalmologist. Conclusions nAMD may significantly affect the quality of life of affected patients, both from a functional and psychological point of view. The narrative medicine approach highlights some critical points in the healthcare journey of nAMD patients and represents a useful background in implementing patient management algorithms and pathways of care.

Acute bacterial skin and skin structures infections (ABSSSIs) are associated with high morbidity, costs and mortality in patients with diabetes mellitus. Their appropriate management should include several figures and a well-organized approach. This review aims to highlight the interplay between diabetes and ABSSSIs and bring out the unmet clinical needs in this area. Pathogenetic mechanisms underlying the increased risk of ABSSSIs in diabetes mellitus are multifactorial: high glucose levels play a crucial pathogenetic role in the tissue damage and delayed clinical cure. Moreover, the presence of diabetes complications (neuropathy, vasculopathy) further complicates the management of ABSSSIs in patients with diabetes. Multidrug resistance organisms should be considered in this population based on patient risk factors and local epidemiology and etiological diagnosis should be obtained whenever possible. Moreover, drug-drug interactions and drug-related adverse events (such as nephrotoxicity) should be considered in the choice of antibiotic therapy. Reducing unnecessary hospitalizations and prolonged length of hospital stay is of primary importance now, more than ever. To achieve these objectives, a better knowledge of the interplay between acute and chronic hyperglycemia, multidrug resistant etiology, and short and long-term outcome is needed. Of importance, a multidisciplinary approach is crucial to achieve full recovery of these patients.

Background The TRUST (The Roadmap Using Story Telling) project used a Narrative Medicine (NM) framework to assess the impressions of people with heart failure (HF), their informal caregivers and HF specialists of the impact of heart failure (HF) on the daily life of patients and their carers. Methods Italian HF specialists participated on a voluntary basis, completing their own narratives, and inviting patients and their caregivers to write anonymously about their experiences, all on a dedicated online platform. The narratives were analyzed according to standard NM methodology. Results 82 narratives were collected from patients, 61 from caregivers, and 104 from HF specialists. Analysis of the three points of view revealed the extent of the burden of illness on the entire family, particularly that of the caregiver. The impact was mainly experienced as emotional and social limitations in patients’ and their caregivers’ daily lives. The analysis of all three points of view highlighted a strong difference between how HF is perceived by patients, caregivers, and HF specialists. Conclusions This NM project illustrates the complex issues of living with HF and gave new insight into integrating three different perspectives into the HF pathway of care.

Purpose of review Previous studies suggest an association between depression and increased risk of various type of infections, including acute bacterial skin and skin structure infections (ABSSSI). Here, we review the latest advancement in our understanding of immunity in patients with depression and its relevance to disease management and diagnosis, with a special focus on patients suffering from ABSSSI. Recent findings Recent studies have highlighted the role of hypothalamic-pituitary-adrenal axis, neuro-endocrine stress signaling pathways and behavioral attitudes (substance abuse and homelessness) in the pathogenesis of infections in depressed patients. Furthermore, acute bacterial infections, in turn, have emerged as a possible risk for depression development because of different mechanisms including antibiotic-driven changes in the microbiota. Summary Recent evidences have emphasized the threat that comanagement of depression and infection pose to infectious disease physician and psychiatrist. Depressed patients with ABSSSI must be closely monitored for drug side-effects, drug-drug interactions, toxicity, and adequate compliance. New management strategies including new long-acting antibiotics (e.g., dalbavancin) are welcome.

Valeria Gatti,1 Paolo Banfi,2 Stefano Centanni,3 Salvatore D’Antonio,4 Saffi Giustini,5 Alessio Piraino,6 Marco Zibellini,1 Maria Giulia Marini1 1Health Care Area, Fondazione ISTUD, Milan, Italy; 2Fondazione Don Carlo Gnocchi IRCCS, Milan, Italy; 3Respiratory Unit, ASST San Paolo e San Carlo, Department of Health Sciences, University of Milan, Milan, Italy; 4Italian Patient’s Association “BPCO ONLUS”, Rome, Italy; 5Italian General Practitioners’ Association “SIMG”, Florence, Local Health Unit of Montale, Pistoia, Italy; 6Chiesi Farmaceutici S.p.A, Parma, Italy Purpose: The primary aim of this research was to raise awareness for COPD through real narratives of patients, caregivers, and pulmonologists. The second objective includes providing clinicians new means of caring for and treating patients with COPD.Methods: Using narrative medicine, testimonies from patients, their caregivers, and clinicians were collected through an online questionnaire enriched by a narrative plot. Narrations were analyzed throughout descriptive statistics and an elaboration of recurring words and expressions.Results: Throughout the project, 350 narratives were collected from 235 patients, 55 caregivers, and 60 physicians. Though a generally neutral reaction had been observed upon diagnosis, COPD had been found to have a high impact on the patients’ and caregivers’ lives. Metaphors utilized by patients and caregivers were suggestive of fear and panic unlike those utilized by clinicians who usually had a more technical approach. Smoking was a significant concern for not only patients and caregivers but also clinicians.Conclusion: Physicians are therefore challenged to find new ways of communicating COPD to raise awareness on this pathology and encourage corrective habits. An important social objective should be the implementation of a health system that is able to optimize patients’ and caregivers’ lives.Keywords: COPD, quality of life, narrative medicine, communication

Paolo Banfi,1 Antonietta Cappuccio,2 Maura E Latella,3 Luigi Reale,2 Elisa Muscianisi,3 Maria Giulia Marini2 1Pneumological Rehabilitation, IRCCS Fondazione Don Gnocchi Onlus, Milan, Italy; 2Healthcare Area, Fondazione ISTUD, Milan, Italy; 3Medical Department, Novartis Farma Spa, Origgio, Italy Purpose: Poor adherence to therapy and the failure of current smoking cessation programs demonstrate that the current management of COPD can be improved, and it is necessary to educate physicians about new approaches for taking care of patients. Parallel chart is a narrative medicine tool that improves the doctor–patient relationship by asking physicians to write about their patients’ lives, thereby encouraging reflective thoughts on care. Patients and methods: Between October 2015 and March 2016, 50 Italian pulmonologists were involved in the collection of parallel charts of anonymous patients with COPD. The narratives were analyzed according to the Grounded Theory methodology. Results: In the 243 parallel charts collected, the patients (mean age 69 years, 68% men) are described as still active and as a resource for their families (71%). The doctor–patient relationship started as difficult in 50% of cases, and younger age and smoking were the main risk factors. The conversations turned positive in 78% of narratives, displaying deeper mutual knowledge, trust for the clinicians’ ability to establish effective therapy (92%), support efforts to quit smoking (63%), or restore patients’ activities (78%).Conclusion: All the physicians concurred that the adoption of innovative parallel charts was useful for improving clinical care and worthy of official inclusion in protocols for the management of COPD. Keywords: narrative medicine, COPD, doctor–patient relationship, quality of life

Nobody ever seems to have enough time: there are only 24 h in a day, and yet, we continue to struggle to squeeze countless things into our already busy schedules. Healthcare professionals are no different, and as everyone else in this ever more efficiency-driven society, they are asked to push their limits constantly further. Time, or rather shortage of time, is a constant mantra. The shorter the visits are, the larger the productivity. So how is it feasible to even consider embracing a new activity like the practice of NM? Where could they possibly find the time to practise the art of listening, the tools for reflective writing, the moving forwards from disease to illness and giving each patient a central role and so right time as proposed by NM? Time is finite.

Emotions are debated daily in scientific and social literature, social media and media in general. In the narrative turn, described by John Launer (2007) in our postmodern age, emotions are playing a dominant role. This is illustrated in Inside Out, a movie produced by Disney Pixar in 2015, which aimed at familiarising young children, teenagers, parents and relatives regarding the functioning and importance of emotions beyond our ‘decision free will’ based on reason (Dacher and Paul 2015). The main characters are five emotions, joy, sadness, disgust, anger and fear that live in the minds (somewhere in imaginary control stations) of a family who recently moved from Minnesota to San Francisco. In this family, the adventures of Riley, a girl aged 11 years, in coping with the difficulty of the new environment are demonstrated. Inside Out had the expert input of the psychologist Dacher Keltner, Berkeley University, California, who says that emotions are really critical as to how we look at the world—our perception, our attention, our memories and our judgement.

The topic of trauma and coping is a complex one. In this chapter, we approach them starting from a broader context of symbolisms and patients’ narratives and then discuss them in light of current clinical evidence. Specifically, we start by analysing the myth of the Minotaur in the Labyrinth and the Beauty and the Beast as examples of diverse patient journeys. The first represents the patient’s approach to illness passing through the maze of healthcare, with its closed ends, tortuous paths and eventually its exit; the second represents the patient’s coping with the beast of illness.

One of the aims of NM is to remove the background ‘noise’ from healthcare communication to capture the authentic signal feelings, hopes and thoughts of the patient. The noise we refer to here is related to the excessive use of technology. Certainly, the application of technology in medicine has been beneficial; however, it is being used when not required, diverting the physicians’ attention from other more appropriate tools available for understanding the human nature and illness. Whenever healthcare providers are unable to listen to their patients and speak to them in a constructive manner, technology creeps up time and again as if it were a Pavlovian automatism. In fact, when we analyse the language spoken by physicians during medical consultations, we most often encounter technical jargon made up of complex terms, which the patient can rarely comprehend or relate to.

In 2014, the Lancet published a landmark report entitled Culture and health (Napier et al. 2014). In the report, the authors defined culture as ‘a set of practices and behaviours defined by customs, habits, language and geography that groups of individuals share’. Accordingly, they acknowledged that although much progress in medicine was made through epidemiological and basic science research, a significant shortcoming was the lack of systematic attention to culture. They made several recommendations: they suggested that medicine should accommodate the cultural construction of wellbeing, culture should be incorporated in health and healthcare provision and there should be a better understanding of agency (i.e. human intention and action) in light of cultural imprint. This led to the inception of the ‘cultural context for health’ taskforce. This taskforce was entitled to write a document on the research concerning healthcare improvement by adopting the methodology of narrative medicine (NM) in 2016.

Narratives can be collected in various ways: orally, through an open interview (with no fixed questions letting the speakers follow their stream of consciousness) or through written text using either under the form of free narrative without prompts. These can also be collected using semi-structured illness plots (related to the broader meaning of illness, i.e. of disruption from a previous state of wellbeing), with prompts that follow the diachronic unfolding (past, present, future) of illness. Nonetheless, our experience shows that those who narrate eventually develop their narrations by spontaneously following what is identified as the mental illness plot, which unfolds from past to present to future. Using free narratives and a semi-structured illness plot, we found no major differences. This is probably because most of us live with the ‘continuity of the self’, i.e. a consciousness of continuity in time, with memories of the past, here and now of the present time, and the uncertainties of the future (Ramachandran 2012).

NM is based on real stories in the healthcare ecosystem, whereas storytelling is based on fiction, inspiring artistic re-elaboration/movies/literature and entertainment based on true facts. Storytelling and NM in the education and training of healthcare providers change their mindset and behaviour for providing care.

In ancient Greece, the concepts of beauty (kalos) and good (agathos) were considered as one: beauty implied goodness, and, vice versa, the individual virtue spreads charm. Ethics and aesthetics blend, and in the so-called kalokagathia, the ideal of the evolution of the human people could not be separated. Likewise, the term ‘aesthetic’, which comes from the word ‘aesthesis’—sensorial perception—includes more than just the visual perception: it stands for a global perception with all given senses (Online Etymology Dictionary n.d.), encompassing the impression left by what is perceived. In the original meaning of the concept, tactile and visual perception constitutes a whole, together with hearing and feeling. Even scent is part of the aesthesis, as well discernment, which is part of the aesthetic experience. If we think about something very familiar to the medical world, we might refer to the ‘anaesthesia’, i.e. simply the blocking of the body’s sensorial perception either at a general or a local level. As an oxymoron, anaesthesia seems quite to block the aesthesis, the aesthetic experience. We are definitely grateful to a group of researchers and physicians in Boston who discovered the anaesthetic gas in surgery at the end on the nineteenth century. They were not the first: probably, many centuries ago, anaesthetics herbs were used both for healing and for sacrifice. Calling in action the meaning of anaesthesia, I thought it to be powerful enough to explain deeply the roots of an aesthetic experience, something perceived by the whole body, and this something produces something good just by the fact of the engagement of our sensorial and logical system with the world around, the people around and the air around the body.

Language has a tremendous impact on our wellbeing (Newberg and Waldme 2012). This chapter analyses the power of spoken language, music and sound together and as single elements: first, we will take out the words and leave the music, and then we will take out music and leave sound eventually until reaching silence. These elements are vital to our wellbeing and affect the functioning of our brains, inducing the release of neurotransmitters involved in building our sense of belonging and approaching problems (Newberg and Waldme 2012).

As we know, NM, or better narrative healthcare, focuses on the interaction between patients and healthcare professionals, especially across moments of disease starting from when the disease first manifested. It gives voice and meanings to the way the patient lives the disease, how the disease and the patient are treated and to critical aspects that might suggest unmet needs in healthcare pathways (Greenhalgh and Hurwitz 1999). Narratives can be collected either through reflective writing (which itself elicits a therapeutic effect on the person writing) or through verbal testimony. The narratives we collect are authentic and do not belong to the fiction or literature. The aim of NM is to create an aligned relationship between carers and patients to allow patients to find the factors for coping, i.e. to master the stress induced by the disease, the rupture of a previous status of wellbeing, with its partial loss.

Narrative medicine is an approach to medicine which seeks to combine with and enhance conventional evidence-based medicine by adding perspectives and experience in medical humanities. The chapter expounds on the importance of effective communication with patients and in particular on the importance of having some structured protocols (scripts, interview prompts, and the like) to encourage more comprehensive and effective patient narratives and to allow for increased comparability between them. It tells the story of an emerging collaboration with Minimal English and an international pilot study applying Minimal English to such protocols.

Introduction: The severity of asthma varies individually and the main factors leading to such differences are resignation towards the symptoms, stress and physical activity. Narrative medicine is a medical approach that allows the accommodation of both patients’ and physicians’ cultural construction, including emotions and values on the illness and the pathways of care. Objective: The aims were to evaluate risk factors and positive triggers in doctor-patient relationships and to give clinicians new strategies to improve quality of care. Methods: In 2016 Italian pulmonologists, allergists and paediatricians narrated their relationship with people living with severe asthma (5 each). The collected narratives were analysed according to the Grounded Theory approach. Results: Out of the 314 narratives written by 66 clinicians (246 adult and 68 paediatric patients), the most frequent risk factors for difficult relationships are physicians’ moral judgment (73%), frustration about treatments previously prescribed (60%) and patients’ anger (50%), followed by smoking, independent internet researches, homeopathy and obesity. Difficult relationship lead patients to refuse a therapy change in half of the cases (50%) and to a lower rate of restored activities. On the other hand, physicians could master, beyond acceptance and listening, difficult emotions as fear and sadness, providing reassurance and comfort. This last behaviour improved the patients’ alliance and the effectiveness of treatments. Conclusions: The clinicians learnt to pay more attention to the cultural mindset of patients. The results are positive when dialogue, scientific expertise and effective therapies, as biological drugs, are there.

Fibromyalgia, a possible hypochondriac condition, is considered more psychological than clinical, since many symptoms are “invisible”. In this study, a narrative medicine approach was used to explore the needs of both patients and physicians. Fibromyalgic patients were asked to write their illness narrative in a diary. The clinician also kept a journal of his reflections on treating these patients by the clinician. At the start of the study, patients wrote of their doubt about their treatment, and scepticism about their physician. At the end, sharing the journals fostered greater self-awareness amongst all participants, as well as improved trust and comprehension between both provider and patient. Narrative Medicine was found to be an effective tool to align care between patients and their clinician.

The objective of the research was to understand the experience of families living a premature birth and to outline the current care plan in Italy. The survey was addressed to 150 parents of children born under the 34

PURPOSE We aimed to verify whether combination of specific signs improves magnetic resonance imaging (MRI) accuracy in morbidly adherent placenta (MAP). METHODS MRI findings for MAP were retrospectively evaluated in 27 women. Histopathology was the reference standard, showing MAP in eight of 27 cases. Specificity, sensitivity, positive predictive value, and negative predictive value were calculated for all MRI signs. Two skilled radiologists analyzed MRI findings, resolving discrepancies by consensus, using three alternative diagnostic criteria during three consecutive sections. First criterion: at least one of reported MRI signs indicates MAP and the absence of any sign is normal; second criterion: at least one statistically significant sign indicates MAP and no sign or nonsignificant sign is normal; third criterion: at least two statistically significant signs indicate MAP and no sign, nonsignificant sign, or only one significant sign is normal. RESULTS Using the first criterion yielded an unacceptable rate of false positive results (78.9%). Using the second criterion there were less false positive results (31.5%), and diagnostic accuracy of the second criterion was significantly higher than the first; the third criterion correctly classified 100% of cases. CONCLUSION Only specific MRI signs can correctly predict MAP at histopathology, particularly when multiple (at least two) specific signs are observed together.

SUMMARY Until 2010 pain management in Italy was only partially covered and no structural and qualitative mapping had ever been realized. The VEDUTA project was designed to provide a tool to unite pain therapists in national cooperation. Quantitative questionnaires and narrative plots were sent to 350 Italian specialists; 184 therapists completed the first section and 87 also wrote their stories. Narratives were analyzed through transactional analysis and emotional intelligence. Overall, results show that a patient-centered approach is common in daily practice, but that bureaucracy is endangering quality of care. This cultural analysis, through both the application of quantitative assessment and narrative plots, provides a useful tool to improve those aspects of the system detrimental to the appropriate management of pain in Italy.

Uterine malignancies account for the majority of gynaecologic cancers. Different treatment options are available depending on histology, disease grade and stage. Hysterectomy is the most frequent surgical procedure. Chemotherapy and radiation therapy (CRT) represents the preferred therapeutic choice for locally advanced uterine and cervical malignancies. Imaging of the female pelvis following these treatments is particularly challenging due to alteration of the normal anatomy. Radiologists should be familiar with both the expected post-treatment imaging findings and the imaging features of possible complications to make the correct interpretation and avoid possible pitfalls. The purpose of this review is to show the expected computed tomography (CT) and Magnetic Resonance Imaging (MRI) appearances of the female pelvis following surgery and CRT for uterine and cervical cancer, to illustrate the imaging findings of early and delayed most common complications after surgery and CRT, describing the suitable imaging modalities and protocols for evaluation of patients treated for gynaecologic malignancies.

Background: Lack of adherence to treatment accounts for up to 50% in Italian patients with COPD, being the possible cause the lack of efficacious understanding of illness, as already assessed in other countries (Leiva-Fernandez, J. et al. BMC Pulm Med 2014 25;14:70). The parallel chart is a narrative medicine tool that improves doctor–patient relationship (Charon R. Oxford University Press 2006), by asking physicians to write about patients9 life, bringing out reflective thoughts on care. Aims and Objectives: The aim of the project was to evaluate if the use of parallel chart could change the reciprocal relationship between physicians and patients with COPD and consequently the quality and the alliance of care. Methods: Between October 2015 and March 2016, 50 Italian pulmonologists were involved in the collection of parallel charts of anonymous patients with COPD. The narratives were analysed according to the Grounded Theory and using semantic software (NVivo 10). Results: In the 244 parallel charts collected, the patients (mean age 69 years, 68% men) are described as still active and as a resource for their families (71%). Doctor patient relationship started as difficult in 50% of cases, being young age (78%) and smoking (86%) main conditioning factors. The conversations turned positive in 78% of narratives, leveraging onto a deeper mutual knowledge, on the trust for the clinicians establishing the effective therapy (92%), or supporting in smoke quitting (63%), or restoring patients9 activities (78%). Conclusions: All physicians, on a consensus basis, stated the adoption of innovative parallel charts was useful to improve clinical care and worth to be included officially in protocols for COPD patients9 management.