"From womb to tomb; we're bound to others": Microbiome in forensic science

Microbiome is a new field of interest in clinical medicine with high potential in forensic medicine. It could be used in several applications, such as post-mortem interval (PMI) estimation, personal identification, differential diagnosis of cause of death and toxicology. Regarding PMI, during the decomposition of a corpse, the passage of time involves changing in microbial population both outside and inside the corpse but also in surrounding soil (cadaver decomposition island). These variations could be hypothetically used as PMI indicators (microbial clock), even thanks to the development of machine learning approach. Another potential use of skin and saliva microbiome is personal identification thanks to its inter-individual variability and tendency to remain unvarying over time. It may also be helpful to link a person to a specific object that has been touched (microbial fingerprint). Furthermore, we could infer some information about health state of human subjects, comparing post-mortem and ante-mortem microbiome, but this field of research is quite new and needs further studies. Moreover, we have to consider the influence of microbiome metabolism in post-mortem toxicological evaluation; microbes could alter substances concentrations - for example of ethanol, gamma-hydroxybutyric acid (GHB) and nitrobenzodiazepines - due to enzymatic degradation and individual microbial metabolism. Finally, integration of microbiome and human being's transcriptomic analysis may be helpful to depict their complex interactions even after death

Patient Involvement in Shared Decision-Making: Do Patients Rate Physicians and Nurses Differently?

Background. Shared decision-making implies that patients and healthcare professionals make decisions together about clinical exams, available treatments, choice of options, and the benefit or downside of every choice. Patients involved in the shared decision-making process are more compliant with treatments and have a reduced risk of complications related to the pathology. In Italy, patient involvement in caring processes is still barely investigated. Aim. To investigate patients’ perceptions about shared decision-making with physicians and nurses, respectively, and to examine the relationship between shared decision-making and patient satisfaction and perceived quality of care/treatment. Methods. The study was performed between March and June 2019 in two wards of one Italian hospital. A questionnaire was administered to inpatients at the time of admission and again at discharge, including demographic information and measurement scales regarding patient involvement in shared decision-making, patient satisfaction, and perceived quality of treatment/care. Results. A total of 151 out of 301 patients completed questionnaires at both admission and discharge. Patients’ scores for shared decision-making (information, patient needs, treatment planning) were significantly different for physicians and nurses. At both admission and discharge, patients rated shared decision-making significantly higher for physicians compared to nurses, while there were no differences in their satisfaction ratings. Patient ratings of physicians did not change from admission (information: mean (M) = 3.50, standard deviation (SD) = 0.81; patient need: M = 3.05, SD = 1.05; treatment planning: M = 2.75, SD = 1.23) to discharge (information: M = 3.50, SD = 0.79; patient need: M = 3.17, SD = 1.02; treatment planning: M = 2.66, SD = 1.23) (p = 0.924, p = 0.098, p = 0.293, respectively), but patients’ ratings of nurses’ behavior increased significantly from admission (information: M = 2.44, SD = 1.23; patient need: M = 2.27, SD = 1.17; treatment planning: M = 2.12, SD = 1.19) to discharge (information: M = 2.62, SD = 1.22; patient need: M = 2.53, SD = 1.24; treatment planning: M = 2.35, SD = 1.21) (p = 0.019, p = 0.001, p = 0.003, respectively). Attention to patients’ needs was the key determinant of both satisfaction with nurses (OR = 3.65, 95% CI = 1.31–10.14, p = 0.013) and perceived quality of care (OR = 3.97, 95% CI = 1.49–10.55, p = 0.006). Providing appropriate information about disease progress and treatments was a key determinant of both satisfaction with physicians (OR = 19.75, 95% CI = 7.29–53.55, p < 0.001) and perceived quality of treatment (OR = 8.03, 95% CI = 3.25–19.81, p < 0.001). Discussion. Nurses should be sensitized to involving patients in the decision-making process, especially upon hospital admission. Specific training about effective communication techniques can be implemented to manage relationships with patients in different caring situations. Practical implications and future directions are discussed

Concerns, Perceived Impact, Preparedness in Coronavirus Disease (COVID-19) Pandemic and Health Outcomes among Italian Physicians: A Cross-Sectional Study

Background: Health care workers (HCWs) are among the professionals at serious risk for the impact of the COVID-19 pandemic on their mental health. In this sense, the next public health challenge globally will be to preserving healthy HCWs during this pandemic. Aim: The present study has the aim of investigating the relationship among concerns, perceived impact, preparedness for the COVID-19 pandemic and the mental health of Italian physicians. Methods: From March 29th to April 15th 2020, we conducted an online survey using snowball sampling techniques through Limesurvey platform. Data were analyzed using descriptive statistics and multiple binary logistic regressions. Results: Multivariate analysis showed that the risk factors for perceived job stress were concerns about catching COVID-19 (OR = 3.18 [95% CI = 2.00-5.05] P <.001), perceived impact on job demands (OR = 1.63 [95% CI = 1.05-2.52] P <.05), perceived impact on job role (OR = 2.50 [95% CI = 1.60-3.90] P <.001), and non-working concerns (OR = 1.86 [95% CI = 1.15-3.03] P <.05). With respect to the risk factors for rumination about the pandemic emerged concerns about catching COVID-19 (OR 1.74, [95% CI = 1.12-2.71] P <.05), perceived impact on job role (OR = 1.68 [95% CI = 1.12-2.52] P <.05), and impact on personal life (OR = 2.04 [95% CI = 1.08-3.86] P <.05). Finally, the risk factors for crying at work were perceived impact on job role (OR = 2.47, [95% CI = 1.20-5.09] P <.05), rumination about the pandemic (OR = 3.027 [95% CI = 1.27-7.19] P <.01), watching colleagues crying at work (OR = 3.82 [95% CI = 1.88-7.77] P <.01), and perceived job stress (OR = 3.53 [95% CI = 1.24-10.07] P <.05). Conclusion: In general, our results highlighted that being concerned about being infected/infecting other people, carrying out new and unusual tasks, and witnessing colleagues crying at work were important risk factors for physicians’ well-being. Additional data are necessary to advance understanding of these risk factors in a long-term perspective

Dealing With COVID-19 Patients: A Moderated Mediation Model of Exposure to Patients' Death and Mental Health of Italian Health Care Workers

Introduction: The COVID-19 pandemic is asking health care workers (HCWs) to meet extraordinary challenges. In turn, HCWs were experiencing tremendous psycho-social crisis as they have had to deal with unexpected emotional requirements (ERs) arising from caring for suffering and dying patients on a daily basis. In that context, recent studies have highlighted how HCWs working during the COVID-19 outbreak manifested extreme emotional and behavioral reactions that may have impacted their mental health, increasing the risk for developing post-traumatic stress symptoms. Purpose: The aim of the study was to investigate post-traumatic stress symptoms, such as intrusion symptoms, as a potential mediator of the link between ERs and crying at work, and whether rumination moderates the relationship between ERs and intrusion-based PTS symptoms among HCWs who have had to deal with patients dying from COVID-19. Methods: An online cross-sectional study design was performed. A total of 543 Italian HCWs (physicians and nurses) participated in the study. Participation was voluntary and anonymous. We used the SPSS version of bootstrap-based PROCESS macro for testing the moderated mediation model. Results: ERs had an indirect effect on crying at work through the mediating role of intrusion symptoms. Results from the moderated mediation model showed that rumination moderated the indirect effect of ERs on crying at work via intrusion symptoms, and this effect was significant only for high rumination. Furthermore, when we tested for an alternative model where rumination moderates the direct effect of ERs on crying at work, this moderation was not significant. Conclusions: As the second wave of the COVID-19 pandemic is ongoing, there is an urgent need for decision-makers to rapidly implement interventions aimed at offering timely psychological support to HCWs, especially in those contexts where the risk of emotional labor associated to patients dying from COVID-19 is higher

Comparative use of aqueous humour 1H NMR metabolomics and potassium concentration for PMI estimation in an animal model

Estimation of the post-mortem interval (PMI) remains a matter of concern in the forensic scenario. Traditional and novel approaches are not yet able to fully address this issue, which relies on complex biological phenomena triggered by death. For this purpose, eye compartments may be chosen for experimental studies because they are more resistant to post-mortem modifications. Vitreous humour, in particular, has been extensively investigated, with potassium concentration ([K+]) being the marker that is better correlated with PMI estimation. Recently, a 1H nuclear magnetic resonance (NMR) metabolomic approach based on aqueous humour (AH) from an animal model was proposed for PMI estimation, resulting in a robust and validated regression model. Here we studied the variation in [K+] in the same experimental setup. [K+] was determined through capillary ion analysis (CIA) and a regression analysis was performed. Moreover, it was investigated whether the PMI information related to potassium could improve the metabolome predictive power in estimating the PMI. Interestingly, we found that a part of the metabolomic profile is able to explain most of the information carried by potassium, suggesting that the rise in both potassium and metabolite concentrations relies on a similar biological mechanism. In the first 24-h PMI window, the AH metabolomic profile shows greater predictive power than [K+] behaviour, suggesting its potential use as an additional tool for estimating the time since death

Worries, Preparedness, and Perceived Impact of Covid-19 Pandemic on Nurses' Mental Health

Background: In times of global public health emergency, such as the COVID-19 pandemic, nurses stand at the front line, working in close contact with infected individuals. Being actively engaged in fighting against COVID-19 exposes nurses to a high risk of being infected but can also have a serious impact on their mental health, as they are faced with excessive workload and emotional burden in many front-line operating contexts. Purpose: The aim of the study is to analyze how risk factors such as perceived impact, preparedness to the pandemic, and worries were associated with mental health outcomes (crying, rumination and stress) in nurses. Methods: A cross-sectional study design was performed via an online questionnaire survey. Participants included 894 registered nurses from Italy. Participation was voluntary and anonymous. Multiple binary logistic regression was carried out to analyze the relationship between risk factors and health outcomes. Results: Increased job stress was related to higher levels of rumination about the pandemic (OR = 4.04, p < 0.001), job demand (OR = 2.00, p < 0.001), impact on job role (OR = 2.56, p < 0.001), watching coworkers crying at work (OR = 1.50, p < 0.05), non-work-related concerns (OR = 2.28, p < 0.001), and fear of getting infected (OR = 2.05, p < 0.001). Job stress (OR = 2.52, p < 0.01), rumination (OR = 2.28, p < 0.001), and watching colleagues crying (OR = 7.92, p < 0.001) were associated with crying at work. Rumination was associated with caring for patients who died of COVID-19 (OR = 1.54, p < 0.05), job demand (OR = 1.70, p < 0.01), watching colleagues crying (OR = 1.81, p < 0.001), non-work-related worries (OR = 1.57, p < 0.05), and fear of getting infected (OR = 2.02, p < 0.001). Conclusions: The psychological impact that this pandemic may cause in the medium/long term could be greater than the economical one. This is the main challenge that health organizations will have to face in the future. This study highlights that the perceived impact and worries about the pandemic affect nurses' mental health and can impact on their overall effectiveness during the pandemic. Measures to enhance nurses' protection and to lessen the risk of depressive symptoms and post-traumatic stress should be planned promptly

Blood Biomarkers and Metabolomic Profiling for the Early Diagnosis of Vancomycin-Associated Acute Kidney Injury: A Systematic Review and Meta-Analysis of Experimental Studies

Background: several blood-based biomarkers have been proposed for predicting vancomycin-associated kidney injury (VIKI). However, no systematic analysis has compared their prognostic value. Objective: this systematic review and meta-analysis was designed to investigate the role of blood biomarkers and metabolomic profiling as diagnostic and prognostic predictors in pre-clinical studies of VIKI. Methods: a systematic search of PubMed was conducted for relevant articles from January 2000 to May 2022. Animal studies that administered vancomycin and studied VIKI were eligible for inclusion. Clinical studies, reviews, and non-English literature were excluded. The primary outcome was to investigate the relationship between the extent of VIKI as measured by blood biomarkers and metabolomic profiling. Risk of bias was assessed with the CAMARADES checklist the SYRCLE's risk of bias tool. Standard meta-analysis methods (random-effects models) were used. Results: there were four studies for the same species, dosage, duration of vancomycin administration and measurement only for serum creatine and blood urea nitrogen in rats. A statistically significant increase was observed between serum creatinine in the vancomycin group compared to controls (pooled p = 0.037; Standardized Mean Difference: 2.93; 95% CI: 0.17 to 5.69; I-2 = 92.11%). Serum BUN levels were not significantly different between control and vancomycin groups (pooled p = 0.11; SMD: 3.05; 95% CI: 0.69 to 6.8; I-2 = 94.84%). We did not identify experimental studies using metabolomic analyses in animals with VIKI. Conclusions: a total of four studies in rodents only described outcomes of kidney injury as defined by blood biomarkers. Blood biomarkers represented included serum creatinine and BUN. Novel blood biomarkers have not been explored

Ethical issues of unrelated hematopoietic stem cell transplantation in adult thalassemia patients

Background: Beta thalassemia major is a severe inherited form of hemolytic anemia that results from ineffective erythropoiesis. Allogenic hematopoietic stem cell transplantation (HSCT) remains the only potentially curative therapy. Unfortunately, the subgroup of adult thalassemia patients with hepatomegaly, portal fibrosis and a history of irregular iron chelation have an elevated risk for transplantation-related mortality that is currently estimated to be about 29 percent. Discussion: Thalassemia patients may be faced with a difficult choice: they can either continue conventional transfusion and iron chelation therapy or accept the high mortality risk of HSCT in the hope of obtaining complete recovery. Throughout the decision making process, every effort should be made to sustain and enhance autonomous choice. The concept of conscious consent becomes particularly important. The patient must be made fully aware of the favourable and adverse outcomes of HSCT. Although it is the physician's duty to illustrate the possibility of completely restoring health, considerable emphasis should be put on the adverse effects of the procedure. The physician also needs to decide whether the patient is eligible for HSCT according to the "rule of descending order". The patient must be given full details on self-care and fundamental lifestyle changes and be fully aware that he/she will be partly responsible for the outcome. Summary: Only if all the aforesaid conditions are satisfied can it be considered reasonable to propose unrelated HSCT as a potential cure for high risk thalassemia patients

Metabolomics improves the histopathological diagnosis of asphyxial deaths: an animal proof-of-concept model

The diagnosis of mechanical asphyxia remains one of the most difficult issues in forensic pathology. Asphyxia ultimately results in cardiac arrest (CA) and, as there are no specific markers, the differential diagnosis of primitive CA and CA secondary to asphyxiation relies on circumstantial details and on the pathologist experience, lacking objective evidence. Histological examination is currently considered the gold standard for CA post-mortem diagnosis. Here we present the comparative results of histopathology versus those previously obtained by 1H nuclear magnetic resonance (NMR) metabolomics in a swine model, originally designed for clinical purposes, exposed to two different CA causes, namely ventricular fibrillation and asphyxia. While heart and brain microscopical analysis could identify the damage induced by CA without providing any additional information on the CA cause, metabolomics allowed the identification of clearly different profiles between the two groups and showed major differences between asphyxiated animals with good and poor outcomes. Minute-by-minute plasma sampling allowed to associate these modifications to the pre-arrest asphyxial phase showing a clear correlation to the cellular effect of mechanical asphyxia reproduced in the experiment. The results suggest that metabolomics provides additional evidence beyond that obtained by histology and immunohistochemistry in the differential diagnosis of CA