Home respiratory muscle training in patients with chronic obstructive pulmonary disease

The benefits of inspiratory muscle strength training in decreasing symptoms, disability or handicap of patients affected by COPD are not well established. The objective of this study was to assess the efficacy of the constant use of a new flow-volumetric inspiratory exerciser, named Respivol™, in improving respiratory functional parameters in COPD patients. Twenty consecutive ambulatory patients affected by COPD were enrolled. Each patient was assessed, before and after 3 and 6 months inspiratory exercise with Respivol™, for the following clinical parameters: maximal inspiratory pressure, maximal expiratory pressure, dyspnoea grade, quality of life by a self-administered St George questionnaire and a 6-min walking test. After a brief progressive ambulatory training programme, inspiratory exercise with Respivol™ was performed at home for 6 months. All patients used Respivol™ together with medical treatment. Maximal inspiratory pressure and maximal expiratory pressure values were significantly increased after 3 and 6 months of exercise. Dyspnoea grade was significantly reduced and the 6-min walking test showed an increase in effort tolerance, after 6 months of home training. Quality of life assessment showed an improvement, associated with a decrease of respiratory disease symptoms. Inspiratory muscle strength training with Respivol™ seems to be efficient in reducing symptoms and improving quality of life in adults with COPD

Renin-Angiotensin-Aldosterone System Inhibitors, Statins, and Beta-Blockers in Diabetic Patients With Critical Limb Ischemia and Foot Lesions

Medical therapy for secondary prevention is known to be under-used in patients with peripheral artery disease (PAD). Few data are available on the subgroup with critical limb ischemia (CLI). Prescription of cardiovascular preventive therapies was recorded at discharge in a large, prospective cohort of patients admitted for treatment of CLI and foot lesions, stratified for coronary artery disease (CAD) diagnosis. All patients were followed up for at least 1 year. The primary endpoint was major adverse cardiovascular events (MACE). 618 patients were observed for a median follow-up of 981 days. Renin-angiotensin-aldosterone system (RAAS) inhibitors, statins, beta-blockers, and antithrombotic drugs were prescribed in 52%, 80%, 51%, and 99% of patients, respectively. However, only 43% of patients received optimal medical therapy (OMT), defined as the combination of RAAS inhibitor plus statin plus at least one antithrombotic drug. It was observed that the prescription of OMT was not affected by the presence of a CAD diagnosis. On the other hand, it was noticed that the renal function affected the prescription of OMT. OMT was independently associated with MACE (HR 0.688, 95%CI 0.475-0.995, P = .047) and, after propensity matching, also with all-cause mortality (HR 0.626, 95%CI 0.409-0.958, P = .031). Beta-blockers prescription was not associated with any outcome. In conclusion, patients with critical limb ischemia are under-treated with cardiovascular preventive therapies, irrespective of a CAD diagnosis. This has consequences on their prognosis

Effect of surgical experience and spine subspecialty on the reliability of the {AO} Spine Upper Cervical Injury Classification System

OBJECTIVE The objective of this paper was to determine the interobserver reliability and intraobserver reproducibility of the AO Spine Upper Cervical Injury Classification System based on surgeon experience (< 5 years, 5–10 years, 10–20 years, and > 20 years) and surgical subspecialty (orthopedic spine surgery, neurosurgery, and "other" surgery). METHODS A total of 11,601 assessments of upper cervical spine injuries were evaluated based on the AO Spine Upper Cervical Injury Classification System. Reliability and reproducibility scores were obtained twice, with a 3-week time interval. Descriptive statistics were utilized to examine the percentage of accurately classified injuries, and Pearson’s chi-square or Fisher’s exact test was used to screen for potentially relevant differences between study participants. Kappa coefficients (κ) determined the interobserver reliability and intraobserver reproducibility. RESULTS The intraobserver reproducibility was substantial for surgeon experience level (< 5 years: 0.74 vs 5–10 years: 0.69 vs 10–20 years: 0.69 vs > 20 years: 0.70) and surgical subspecialty (orthopedic spine: 0.71 vs neurosurgery: 0.69 vs other: 0.68). Furthermore, the interobserver reliability was substantial for all surgical experience groups on assessment 1 (< 5 years: 0.67 vs 5–10 years: 0.62 vs 10–20 years: 0.61 vs > 20 years: 0.62), and only surgeons with > 20 years of experience did not have substantial reliability on assessment 2 (< 5 years: 0.62 vs 5–10 years: 0.61 vs 10–20 years: 0.61 vs > 20 years: 0.59). Orthopedic spine surgeons and neurosurgeons had substantial intraobserver reproducibility on both assessment 1 (0.64 vs 0.63) and assessment 2 (0.62 vs 0.63), while other surgeons had moderate reliability on assessment 1 (0.43) and fair reliability on assessment 2 (0.36). CONCLUSIONS The international reliability and reproducibility scores for the AO Spine Upper Cervical Injury Classification System demonstrated substantial intraobserver reproducibility and interobserver reliability regardless of surgical experience and spine subspecialty. These results support the global application of this classification system

Philemon and Baucis deaths: A case of two siblings and state of the art

The simultaneous discovery of two corpses at the same scene obliges the forensic pathologist to consider many circumstances. First, the hypothesis of homicide/crime has to be investigated. However, when the circumstances, autopsy, histological data and toxicological and biochemical analyses suggest a natural cause of death, Philemon and Baucis syndrome should be considered. While a few cases of Philemon and Baucis deaths involving couples of spouses have been reported in the literature, only one paper describes the simultaneous deaths of two siblings. The case presented here concerns the death of two siblings who were found in an advanced stage of decomposition in their apartment, which had been allocated to them by social services. The victims were known to be living in conditions of social and economic deprivation and to be suffering from psychiatric disorders. The first suspected cause of death was malnutrition. However, this was excluded by complete autopsy, histological studies and, especially, biochemical investigations, which excluded starvation ketoacidosis. Moreover, no evidence of trauma or poisoning was found in either of the bodies. Despite the advanced stage of decomposition, one of the bodies presented with histological signs of myocardial sclerosis, left ventricular hypertrophy and contraction band necrosis, suggesting that the mechanism of death involved a fatal arrhythmia. The circumstances and the post-mortem findings were highly suggestive of Philemon and Baucis syndrome

Aspetti medico-legali nella gestione del contenzioso nelle infezioni nosocomiali: l'esperienza dell'IRCSS AOU SAN MARTINO - IST nel quadriennio 2012-2015

Le infezioni nosocomiali rappresentano una delle principali complicanze correlate all\u2019assistenza sanitaria, la cui diffusione ha ripercussioni sulla salute pubblica a causa degli ingenti costi economici e sociali connessi. I costi sono considerati sempre in relazione al prolungamento delle degenze e delle cure e mai messi in relazione ai risarcimenti richiesti in sede civile. La creazione di un Fondo Regionale Ligure per il risarcimento diretto dei danni da responsabilit\ue0 professionale medica ha reso necessaria l\u2019elaborazione di un indirizzo di valutazione comune anche nei casi di infezioni nosocomiali. Lo scopo principale \ue8 di pervenire, ove possibile, ad una risoluzione extra-giudiziale della istanze risarcitorie in tempi brevi, permettendo, allo stesso tempo, il contenimento dei costi. In tale cornice, sono state analizzate le richieste risarcitorie per presunte infezioni nosocomiali, verificatesi presso l\u2019IRCCS San Martino - IST nel quadriennio 2012- 2015. In totale, 81 casi. Attraverso la definizione della possibile posizione soccombente della Struttura, si \ue8 formulata una proposta risarcitoria in sede stragiudiziale, riducendo i costi derivanti da un\u2019azione legale esercitata in un Tribunale ordinario. Questa tempestiva gestione ha portato ad un sensibile contenimento delle spese

Optimal fiducial configuration in image-guided neurosurgery using a genetic algorithm

Image Guided Neurosurgery allows surgeons to navigate and localize lesion through the patient's cranium with a 3D image guidance. The model of the head is reconstructed using pre-operative Computed Tomography or Magnetic Resonance images and real and virtual spaces are aligned by means of fiducial markers placed on the patient. In the paper a new method for the optimal placement of the fiducial markers in order to reduce misalignment is presented. Using routine diagnostic images a customized 3D model of the patient's cranium is reconstructed. A genetic algorithm calculates optimal positions of the marker in order to minimize the Target Registration Error. The fiducial set is shown to the surgeons on the 3D model to help him/her in placement of the