To be or not to be: the patient's view of thrombophilia testing

INTRODUCTION

The literature on the psychological effects of thrombophilia testing is unclear. Little is known about the complex world of significance subjects construct around the test.

OBJECTIVE

The study explored the peculiar network of implicit meanings that may be linked to the experience of being tested.

MATERIALS AND METHODS

The research was designed according to Interpretative Phenomenological Analysis (IPA). 19 patients were interviewed. Integral verbatim reports of the interviews were analyzed through an inductive process aimed at gaining a holistic understanding of the narratives.

RESULTS

Two main issues were identified, each with sub-issues: (1) the clinical problem: (1.1) unhealthy blood and (1.2) the family issue; (2) the test: (2.1) knowing for the sake of knowing; (2.2) knowing for the sake of doing; (2.3) not knowing.

CONCLUSIONS

The thrombophilia test is part of a larger network of meanings, where information about the test and its results seem to be lost.

PRACTICE IMPLICATION

The study suggests the importance of paying greater attention to the process of doctor-patient communication at the time of the test. The theme of being informed is important for patients, yet often they are not able to understand or retain the information they receive, increasing the risk of misunderstandings.

Development of clinical signs in low risk term born infants with neonatal hyperexcitability

BACKGROUND

Several studies have reported on neonatal tremors or "jitteriness" or, as described by Precthl "hyperexcitability syndrome" including tremors and increased resistance to passive movement.

AIM

To describe the evolution of signs and the outcome at one year in low risk term born infants with neonatal tremors persisting beyond 10 days.

SUBJECTS

84 low risk term born neonates with tremors at birth and persisting after 10 days, underwent a longitudinal neurological assessment paying attention to the evolution of tremors and increased resistance to passive movement.

RESULTS

At 1 month 74 of the 84 infants had persistent tremors, isolated in 27 or associated with increased resistance to passive movement in the other 47. The remaining 10 had isolated increased resistance to passive movement and none had a normal assessment. The percentage of infants with a normal assessment progressively increased at 6, 9 and 12 months (34.5%, 77%, 93% respectively).

CONCLUSION

Our data suggest that neonatal tremors can have a variable evolution and rate of resolution, with 70% of recovery by 9 months with a normal outcome at 24 months in all. The risk of persistence of signs (at 12 months) in infants with either isolated tremors or increased resistance to passive movements is lower than in the subgroup with both signs at one month.

Hb Treviso [α91(FG3)Leu→Phe (α2)]: a new slightly unstable hemoglobin variant with moderately decreased oxygen affinity

We report a new hemoglobin (Hb) variant, found in a North-East Italian family living in the city of Treviso. The proband, a non anemic 60-year-old male with a history of chronic rhinitis, allergy to Parietaria and suspected obstructive sleep apnea syndrome, was referred for blood gas analysis. Determination of the oxygen affinity revealed a p50 of 32.5 mmHg (control 27.5 mmHg) indicating a moderate decrease in oxygen affinity. An abnormal pattern compatible with an α Hb variant was observed on high performance liquid chromatography (HPLC); direct sequencing revealed a transition at codon 91 of the α2 gene (HBA2: c.274C>T) changing leucine into phenylalanine. Characterization and phenotype studies are reported.

Simulation of phoswich detectors using MCNPX and EGSNRC

The in vivo monitoring Lab at KIT uses two phoswich detectors for routine lung counting. A simplified model of one of them has been implemented in the two Monte Carlo codes EGSnrc and MCNPX. The active part of the detector consists of a crystal of NaI(Tl) and one of CsI(Tl): the energy deposited in both the crystals have been studied to consider the effect of the anticoincidence logic, present in the read-out electronics of the detectors and not yet studied with Monte Carlo simulations. Only the NaI(Tl) crystal has then been used to study the escape peaks at several energies, which are more prominent at low energies. The results from the two codes have been compared. The comparison of the codes predictions for the escape peaks has been then extended using the model of a germanium detector.

How Italian students learn to become physicians: a qualitative study of the hidden curriculum

BACKGROUND

A great deal of what medical students learn in terms of behaviors, values, and attitudes related to their profession is conveyed by the hidden curriculum.

AIM

To explore the messages conveyed by the hidden curriculum as perceived by third-year students of the Milan School of Medicine, Italy, following their first clinical internship.

METHOD

Three group interviews were conducted. Students were asked to reflect on values, attitudes, and implicit rules they noticed during their internship experiences. Verbatim transcripts of the group interviews were analyzed through content analysis using Nvivo8.

RESULTS

Of the 81 students, 57 (70%) participated in the group interviews. Six themes were identified within the hidden curriculum: Physicians reassure and protect patients; power differential between physicians and patients; variable respect for patients; disease-centered medicine; respect for hierarchies; and delegation of patients' emotional needs to nurses.

CONCLUSIONS

Our findings suggest that the hidden curriculum has a strong cultural component. In our students' experience, the hidden curriculum conveyed a paternalistic model of physician-patient relationships. Some of the messages conveyed by the actual hidden curriculum may compromise the standards formally taught in medical schools about doctor-patient relationships. Organizational culture change and student empowerment could be fostered to counteract the negative effects of the hidden curriculum.

Cross-cultural adaptation of an innovative approach to learning about difficult conversations in healthcare

BACKGROUND

The Program to Enhance Relational and Communication Skills (PERCS) was developed at a large hospital in the United States to enhance clinicians' preparedness to engage in difficult conversations.

AIM

To describe the implementation of PERCS in an Italian hospital and assess the program's efficacy.

METHODS

The Italian PERCS program featured 4-h experiential workshops enrolling 10-15 interdisciplinary participants. The workshops were organized around the enactment and debriefing of realistic case scenarios portrayed by actors and volunteer clinicians. Before and after the workshop, participants rated their perceived preparation, communication and relational skills, confidence, and anxiety on 5-point Likert scales. Open-ended questions explored their reflections on the learning. T-tests and content analysis were used to analyze the quantitative and qualitative data, respectively.

RESULTS

146 clinicians attended 13 workshops. Participants reported better preparation, confidence, and communication skills (p < 0.001) after the workshops. The program had a different impact depending on the discipline. Participants valued the emphasis on group feedback, experiential and interdisciplinary learning, and the patient's perspective, and acquired: new communication skills, self-reflective attitude, reframed perspective, and interdisciplinary teamwork.

CONCLUSION

PERCS proved culturally adaptable to the Italian context and effective in improving participants' sense of preparation, communication skills, and confidence.

Cortical visual function in preterm infants in the first year

OBJECTIVE

To assess visual function in low-risk preterm infants at 3, 5, and 12 months corrected age to determine whether the maturation of visual function in the first year is similar to that reported in term-born infants.

STUDY DESIGN

Seventy-five low-risk infants (25.0-30.9 weeks gestation) underwent ophthalmological examinations and a battery of tests (fix and follow, visual fields, acuity, attention at distance, and fixation shift) designed to assess various aspects of visual function at 3, 5, and 12 months corrected age.

RESULTS

The results were comparable with normative data from term-born infants in all tests but fixation shift, suggesting that maturation of most aspects of visual function is not significantly affected by preterm birth. In contrast, >25% of preterm infants failed the fixation shift test at 3 months, with a higher percentage of failing at 5 and 12 months.

CONCLUSIONS

There is a specific profile of early visual behavior in low-risk preterm infants, with a high percentage of infants failing a test that specifically assesses visual attention and provides a measure of cortical processing.

Erroneously low continuous ScvO2 reading due to red blood cells transfusion

Hemoglobin oxygen saturation in superior vena cava (ScvO(2)) is used as a parameter to guide hemodynamic management in shock patients and it can be continuously read through a central venous catheter equipped with a fiberoptic spectrophotometric probe (Edwards PreSep catheter) connected to a specific monitor (Edwards Vigileo). We report of an episode of erroneous ScvO(2) reading by this technology in a patient with septic shock who was receiving an erythrocytes transfusion through the PreSep catheter main lumen. We think this artifact should be known by intensivists since it can lead to ScvO(2) misinterpretation and subsequent erroneous therapeutic decisions.

[Difficult conversations in medicine: an experiential, optional course with medical students]

A 24 hrs optional course was realized with 15 students at the Medical School of Milan, with the aim of undertaking the management of the emotional aspects in a difficult communication in medicine. The course was realized through the use of active teaching tools; issues resulted from what literature consider as "difficult communication". Photolangage was used as pre-post test to assess the effects of the course; a satisfaction questionnaire was also used. From the content analysis of the data the course resulted effective both for the students' satisfaction and for the enhancing of their self reflective skills.

Application of a neonatal assessment of visual function in a population of low risk full-term newborn

BACKGROUND

We have previously developed and described a battery of 9 items suitable for assessing different clinical aspects of visual function in newborn infants.

AIM OF THE STUDY

Application of the test battery to a cohort of low risk term-born infants at 48 and 72 h after birth 1) to define the normative distribution of results for each item and 2) to document any effect of postnatal age.

STUDY DESIGN AND SUBJECTS

124 term-born low risk infants were assessed at 48 h; fifty of them were re-assessed 24 h later at 72 h.

RESULTS

The visual test battery was successfully completed in 110 of the 124 infants assessed at 48 h and in all the 50 infants assessed at 72 h after birth. For 3 of the 9 items (fixation on a black/white target of concentric circles, on a coloured (red/yellow) face and horizontal tracking), the findings were very similar at both ages. For the remaining 6 items the range of findings was wider. There was a statistical difference in the responses obtained at 48 and 72 h for vertical and arc tracking (p<0.05) and the ability to discriminate stripes and attention at distance (p<0.001).

CONCLUSION

Our results provide information on the visual abilities in a low risk population of term-born infants and the distribution of frequency of their visual responses to our battery of visual tests. These findings may be used as reference data when using our visual test battery in both clinical and research settings.

[The incidence of dental caries during childhood. A clinical and epidemiologic study in Matera (Southern Italy)]

AIM

The aim of the present study is to obtain comprehensive epidemiological data of the incidence of oral and dental health conditions in an Italian homogeneous population of schoolchildren.

MATERIALS AND METHODS

The study has been performed on schoolchildren born, living and attending the primary school in Matera, Basilicata, Southern Italy. Such data have been compared with the alimentary habits of the participants to the study, as well as with the social-economic family situations and with the social-environmental data.

RESULTS

The data show a marked difference in the habits of oral hygiene, and in the health status of the oral structures also, based on both the sex and the environment of life.

CONCLUSIONS

Such differences in the prevalence of caries among various urban areas and the behavioural habits related to sex and age ratios may be very useful findings for future regional prevention programs.

Antenatal post-hemorrhagic ventriculomegaly: a prospective follow-up study

OBJECTIVE

The aim of this study was to evaluate the presence and the severity of neurological and cognitive impairment at 2 years of age in 16 infants (9 term born, 7 preterm of mean gestation 33.6 weeks) with cerebral ventriculomegaly of antenatal onset associated with intraventricular haemorrhage.

METHODS

Ventricular dilatation, with or without associated lesions, was, with one exception, not identified on the antenatal routine scan at approximately 22 weeks but was obvious on the scans performed between weeks 27 and 33. In 8 of the 16 cases there were signs of parenchymal involvement or of abnormalities of the corpus callosum or cerebellum. In all patients the diagnosis of antenatal IVH was confirmed by early neonatal imaging. Outcome was measured using the Hammersmith infant neurological examination and the Griffiths developmental scales at 2 years.

RESULTS AND CONCLUSIONS

At 2 years, 8 infants had normal motor outcome and 8 had cerebral palsy. The presence and severity of cerebral palsy or neurodevelopmental delay was not always related to the magnitude or symmetry of the ventricular dilatation per se. The presence of associated lesions was a negative prognostic marker. The early development of epilepsy was also associated with an abnormal outcome.

Neurological examination at 6 to 9 months in infants with cystic periventricular leukomalacia

The Hammersmith Infant Neurological Examination was performed in 24 infants with cystic periventricular leukomalacia whose gestational age ranged between 26-38 weeks. The infants were examined between 6 and 9.5 months corrected age. The aim of the study was to establish the different patterns of neurological abnormality as well as the optimality scores that predict the severity of motor sequelae at 2 years. Increased neck and trunk extensor tone, and a posture of flexed arms and extended legs between 6 and 9 months were always associated with the inability to sit unsupported at 2 years, whilst truncal hypotonia and extended arms and legs were associated with unsupported sitting but not walking. Optimality scores between 41 and 60 were generally associated with sitting but not walking at 2 years whilst scores below 40 were always associated with the inability to sit independently at 2 years. All infants who did not develop cerebral palsy at 2 years had scores > 60. Our results suggest that the pattern of findings on neurological examination performed between 6 and 9 months as well as the calculated optimality score helps to predict motor impairment in infants with PVL.

[Nutritional problems in the surgical patients with head and neck tumours. Literature review and personal experience]

During the last years the importance of the correct nutritional assessment as a part of the therapeutic process of the human pathologies has a greatly increased relevance. Still more in oncology, such relationship among nutritional assessment and good result of the therapeutic treatment have a fundamental importance. Among the neoplastic diseases those of the head and the neck result to be particularly aggressive, both for their nature and for the particular anatomical organization of such body areas, and the affected patients also need a precise evaluation of the nutritional assessment to obtain an optimal therapeutic result. On the basis of such premises and to their own clinical experience, the authors describe the main nutritional problems of the patients with tumours of the head and the neck and the possible therapeutic solutions.

[Drug/food interactions: an actual therapeutic outcome]

The biological effects of specific interactions occurring between drugs and foods may greatly vary, determining severe side effects in some people. A lot of factors may influence such interactions, i.e. age, sex, dietary composition, and so. In addition, further interaction may be determined by cigarette smoking, alcohol abuse and coffee consumption. Older people, as well as children, chronic ill and malnourished people seems to be most commonly affected by side effects due to food/drugs interaction. The aim of this review is to give a synopsis of the drug/food interactions most commonly occurring in clinical practice.

Hb Trento: an elongated C-terminal beta chain due to a new frameshift mutation [beta144 (-A)]

An elongated C-terminal hemoglobin variant, due to the deletion of nucleotide A in codon 144 (nucleotide 63600 GenBank entry UO1317) was found in a 31-year-old woman from Trento (northeastern Italy). This deletion led to the replacement of lysine at beta144 by a serine residue, the disappearance of the stop codon at position 147, and the presence of 12 additional residues, identical to those observed in Hbs Saveme, Tak and Cranston, which result from a similar mechanism. Hb Trento, amounting to 29% of the total hemoglobin, was unstable and had, as the other variants of this group, an increased oxygen affinity. It led to a mild compensated hemolytic anemia with red cell inclusion bodies. Functional studies of the isolated abnormal hemoglobin were difficult to perform because of autoxidation, precipitation, and formation of hybrids with Hb A.