Medical Legal Aspects of Telemedicine in Italy: Application Fields, Professional Liability and Focus on Care Services During the COVID-19 Health Emergency

Telemedicine services can be classified into the macro-categories of specialist Telemedicine, Tele-health and Tele-assistance. From a regulatory perspective, in Italy, the first provision dedicated to the implementation of Telemedicine services is represented by the Agreement between the Government and the Regions on the document bearing “Telemedicine—National guidelines,” approved by the General Assembly of the Superior Health Council in the session of 10th July 2012 and by the State Regions Conference in the session of 20th February 2014. Scientifically, several studies in the literature state that information and communication technologies have great potential to reduce the costs of health care services in terms of planning and making appropriate decisions that provide timely tools to patients. Another clear benefit is the equity of access to health care. The evolution of telemedicine poses a series of legal problems ranging from the profiles on the subject of authorization and accreditation to those concerning the protection of patient confidentiality, the definition and solution of which, in the absence of specific regulatory provisions, is mainly left to the assessment of compatibility of the practices adopted so far, with the general regulatory framework. In terms of professional liability, it is necessary to first clarify that the telemedicine service is comparable to any diagnostic-therapeutic health service considering that the telemedicine service does not replace the traditional health service, but integrates the latter to improve its effectiveness, efficiency and appropriateness.

Transfer dynamics of macroplastics in estuaries - New insights from the Seine estuary: Part 2. Short-term dynamics based on GPS-trackers

The dynamics of plastic debris were assessed in the Seine River, especially in the estuary, using plastic bottles equipped with GPS-trackers. In one year, 50 trajectories were recorded, covering a wide range of hydrometeorological conditions. Results show a succession of stranding/remobilization episodes in combination with alternating upstream and downstream transport in the estuary. In the end, 100% of the tracked bottles stranded somewhere, for hours or weeks, from one to several times at different sites. The overall picture shows that different physical phenomena interact with various time scales ranging from hours/days (high/low tides) to weeks/months (spring/neap tides and highest tides) and years (seasonal river flow). Thus, the fate of plastic debris is highly unpredictable, but the consequence of those interactions is that the transfer of debris is chaotic and not straightforward, and its residence time is much longer than the transit time of water.

Ecological Functioning of the Seine River: From Long-Term Modelling Approaches to High-Frequency Data Analysis

At the start of the PIREN-Seine program, organic pollution by the effluent of the Parisian conurbation was responsible for episodic anoxia in the lower Seine River, while nutrients from both point and diffuse sources are used to cause eutrophication, a nuisance for drinking water production from surface water and biodiversity. The implementation of the EU Water Framework Directive led to a drastic decrease of organic carbon, phosphorus and ammonium concentrations in surface waters starting in the early 2000s and to a reduction of the frequency and the amplitude of phytoplankton blooms. However, nitrate contamination from fertiliser-intensive agriculture continued to increase or at best levelled off, threatening groundwater resources and causing unbalanced nutrient ratios at the coastal zone where eutrophication still results in harmful algal blooms. High-frequency O2 data combined with models, which have been developed for 30 years, can help discriminate the contribution of auto- vs. heterotrophic metabolism in the CO2 supersaturation observed in the Seine River. Despite the impressive improvement in water quality of the Seine River, episodic crises such as summer low-flow conditions still threaten the good ecological status of both river and coastal waters. Modelling scenarios, including further wastewater treatments and structural changes in agriculture and future changes in hydrology under climate changes, provide the basis for a future vision of the ecological functioning of the Seine River network.

Successful endovascular treatment of a recurrent giant celiac artery aneurysm

Visceral artery aneurysms are very rare and aneurysms of the celiac trunk are the rarest ones: they are in most cases asymptomatic and their detection is frequently incidental. In this article we report the case of a man affected by severe abdominal pain with a huge aneurysm of the celiac trunk, first successfully treated with coil embolization, but, after 10 months, another endovascular embolization was required for deployment of the metallic coils previously released, ahead into the fund of the sac with recanalization of the aneurysm. A second endovascular treatment was performed with other coils and Amplatzer-Plug. The high risk of rupture makes treatment of such aneurysms mandatory and surgery is still considered the gold standard therapy of VAA, but, due to its high morbidity and mortality risks, in the last years, it has been widely replaced by endovascular embolization. An effective endovascular embolization requires not only the complete filling of the aneurysmal sac, but also the complete vascular exclusion of its in-flow and out-flow tracts, to reduce the risk of its anterograde or retrograde reperfusion.

Reducing marine eutrophication may require a paradigmatic change

Marine eutrophication in the North-East Atlantic (NEA) strongly relies on nutrient enrichment at the river outlets, which is linked to human activities and land use in the watersheds. The question is whether human society can reduce its nutrient emissions by changing land use without compromising food security. A new version of Riverstrahler model (pyNuts-Riverstrahler) was designed to estimate the point and diffuse nutrient emissions (N, P, Si) to the rivers depending on land use in the watersheds across a large domain (Western Europe agro-food systems, waste water treatment). The loads from the river model have been used as inputs to three marine ecological models (PCOMS, ECO-MARS3D, MIRO&CO) covering together a large part of the NEA from the Iberian shelf to the Southern North Sea. The modelling of the land-ocean continuum allowed quantifying the impact of changes in land use on marine eutrophication. Pristine conditions were tested to scale the current eutrophication with respect to a "natural background" (sensu WFD), i.e. forested watersheds without any anthropogenic impact. Three scenarios representing potential management options were also tested to propose future perspectives in mitigating eutrophication. This study shows that a significant decrease in nitrogen fluxes from land to sea is possible by adapting human activities in the watersheds, preventing part of the eutrophication symptoms in the NEA rivers and adjacent coastal zones. It is also shown that any significant achievement in that direction would very likely require paradigmatic changes at social, economic and agricultural levels. This requires reshaping the connections between crop production and livestock farming, and between agriculture and local human food consumption. It also involves cultural changes such as less waste production and a shift towards lower-impact and healthier diets where half of the animal products consumption is replaced by vegetal proteins consumption, known as a demitarian diet (http://www.nine-esf.org/node/281/index.html).

Depression and Hepatitis C

Combination therapy of peginterferon and ribavirin for HCV has been recommended as a first choice for chronic hepatitis C. INF therapy has been associated with various IFN-related adverse events, such as psychological disturbances. Beyond that preexisting mental disorders are considered risk factors for INF-alfa-induced severe psychiatric side effects such as depression and/or suicidality, consequently many of these patients remain untreated even tough they fulfil the medical criteria for antiviral treatment of chronic hepatitis C.

The authors relate the case of a patient, 56 year's old, sent to infecciology consultation because she had alterations in abnormal liver function tests. She had a previous history of mental disorder with neurotic personality traits and she was treated with psychiatric medication.

She had treatment for chronic hepatitis C with peginterferon and ribavirin as well psychiatric and psychotherapeutic support.

A low sustained virologic response was obtained however the depressive picture has been difficult to handle so she had had already had a psychiatric hospitalization. There were several adverse life events that can not be forgotten as they certainly trigger and exacerbate the depressive symptomatology.

We assume that psychiatric patients have more depressive symptoms before and during treatment compared with patients without no psychiatric history. This shows that this patients have an increase need for treatment with antidepressants and that a close cooperation with a psychiatrist is always needed.

Activated sludge respirometry to assess solar detoxification of a metal finishing effluent

Inhibition of the respiration of activated sludge has been tested as a convenient method to estimate toxicity of aqueous solutions containing copper and cyanide, such as metal finishing effluents; according to this method, an EC50 of 0.5 mg/l was determined for CN(-) and 3.0 mg/l for copper. Solar detoxification of cyanide-containing solutions was studied using TiO2, but this process was unfavourable because of the inhibitory role that plays the copper ions present in real effluents on the oxidation of cyanide. On the other hand, the oxidative effect of hydrogen peroxide was greatly enhanced by Cu2+ and solar irradiation, as complete elimination of free and complexed cyanide could be accomplished, together with precipitation of copper, in experiments carried out at pilot plant scale with real metal finishing effluents. Under these conditions, total detoxification was achieved according to respirometric measurements although some remaining toxicity was determined by more sensitive Vibrio fischeri luminescent assay.

Repeatability and reproducibility of distraction indices in PennHIP examinations of the hip joint in dogs

Repeatability and reproducibility of Distraction Index (DI) measurements in the PennHIP method were evaluated in 100 dogs. The PennHIP distraction views sent to the PennHIP Analysis Center (PAC) were duplicated, digitalised, and identified with a code, and an adequate computer software was used for DI measurements. One examiner performed two DI measurement sessions, evaluating individually 200 hip joints. The scoring repeatability and reproducibility were estimated calculating the Intraclass Correlation Coefficient (ICC) between the two DI measurement sessions and between the second DI measurement session and the DI in PAC reports, respectively. The ICC for repeatability was 0.97 [95% confidence interval (CI), 0.96 to 0.98], and the ICC for reproducibility was 0.95 (95% CI, 0.93 to 0.96). The results suggest that the DI measurement method described is repeatable and can reproduce the PAC reports with confidence. Distraction indices measured in different PennHIP studies, using this DI measurement method and performed by trained researchers, can be considered interchangeable.

Human immunodeficiency virus type 1 recombinant B/G subtypes circulating in Coimbra, Portugal

An increasing prevalence of HIV-1 non-B variants is being noticed in several European regions, particularly in countries such as Portugal, which have closer contacts with African endemic areas, where multiple HIV subtypes cocirculate. HIV-1 subtyping by phylogenetic analyses of reverse transcriptase, protease and env (C2-V3) genomic regions was carried out in plasma collected from 18 HIV-1-infected subjects living in Coimbra, Portugal, and suspected to be infected with non-B variants. Three (16.7%) subjects carried recombinant B/G viruses (BV3/BRT/Gpro; GV3/URT/Bpro; AV3/GRT/Bpro), whereas all the remaining individuals were infected with HIV-1 subtype B. This is the first report of recombinant B/G subtypes in Portugal.

Small dose of recombinant factor VIIa (rFVIIa) to perform percutaneous liver biopsies in cirrhotic patients

Low levels of vitamin K-dependent coagulation factors, synthesized in the liver, play a key role in the hypocoagulable state of end-stage liver disease patients. Recombinant factor VII (rFVIIa) has been developed for, and currently is used in the treatment of patients with hemophilia A and B with inhibitors. Some experience was gained with rFVIIa in liver diseases since 1995. We used a low dose of rFVIIa to perform percutaneous liver biopsy in three patients, all of them with abnormal coagulation, impeditive of the percutaneous liver biopsy. The first one was a 29 years old man with alcoholic cirrhosis and a liver nodule; the second was a 32 years old man with post hepatitis C cirrhosis and excessive alcohol intake; the third was a 53 years old man with chronic hepatitis C and a congenital deficit of factor VII. A single dose of 5 micrograms/Kg of rFVII administered before liver biopsies raised levels of factor VII to acceptable values during more than 5 hours in the first two patients. We conclude that a small dose of rFVIIa can be enough to correct the abnormal coagulation of cirrhotic patients, permits percutaneous liver biopsy, and is cost-effective, compared to transjugular access.

Maternal hypercholesterolemia and treatment during pregnancy influence the long-term progression of atherosclerosis in offspring of rabbits

Maternal hypercholesterolemia during pregnancy is associated with enhanced fatty streak formation in human fetuses and faster progression of atherosclerosis during childhood even under normocholesterolemic conditions. A causal role of maternal hypercholesterolemia in lesion formation during fetal development has previously been established in rabbits. The same experimental model is now used to establish that maternal hypercholesterolemia or ensuing pathogenic events in fetal arteries enhance atherogenesis later in life. Five groups of rabbit mothers were fed chow, cholesterol-enriched chow, or cholesterol-enriched chow plus 1000 IU vitamin E, 3% cholestyramine, or both during pregnancy. Offspring of all groups (n=136) were fed a mildly hypercholesterolemic diet for up to a year and had similar cholesterol levels. Aortic lesion sizes and lipid peroxidation products in plasma and lesions in offspring were determined at birth, 6 months, or 12 months. Lesion progression in offspring of hypercholesterolemic mothers was greater than in all other groups. At each time point, offspring of hypercholesterolemic mothers had 1.5- to 3-fold larger lesions than offspring of normocholesterolemic mothers (P<0.01), with the greatest absolute differences at 12 months. Maternal treatment reduced lesions by 19% to 53%, compared with offspring of untreated hypercholesterolemic mothers (P<0.01), with the greatest effect in the vitamin E groups. At 12 months, lesions in offspring of all vitamin E and cholestyramine-treated mothers were similar to those of normocholesterolemic mothers. Lipid peroxidation end-products in lesions and plasma showed analogous differences between groups as lesions (P<0.01). Thus, pathogenic programming in utero increases the susceptibility to atherogenic risk factors later in life and maternal intervention with cholesterol-lowering drugs or antioxidants reduce postnatal lipid peroxidation and atherosclerosis in their offspring.

Transvaginal ultrasonography and hysteroscopy in postmenopausal bleeding: a prospective study

OBJECTIVE

To determine the diagnostic value of transvaginal ultrasonography and hysteroscopy in patients with postmenopausal bleeding.

MATERIAL AND METHODS

Between January 1, 1998 and June 30, 1999, 88 outpatient women with postmenopausal bleeding were enrolled in a prospective study. They underwent transvaginal ultrasonography and hysteroscopy, and were submitted to directed biopsy during hysteroscopy. Findings were classified as normal endometrium, suggestive of atrophy, focal abnormality (benign or suspicious), and diffuse thickness (benign or suspicious). Data was compared with the final diagnosis, established by histological examination, as atrophy, benign pathology, atypical hyperplasia and endometrial carcinoma.

RESULTS

Among 88 women enrolled, 15 were excluded because hysteroscopy was impossible, and four had abandoned the study. The histological findings were scanty material in 12 (17.4%), atrophy in 24 (34.8%), cystic atrophy in one (1.4%), normal endometrium in five (7.2%), tuberculous endometritis in one (1.4%), polyps in 12 (17.4%), leiomyoma in one (1.4%), non-atypical hyperplasia in three (4.3%), atypical hyperplasia in one (1.4%) and endometrial carcinoma in nine cases (13.0%). For the assessment of endometrial carcinoma, ultrasonography revealed sensitivity 77.8%, specificity 93.3%, positive predictive value 63.6%, negative predictive value 96.6%; and hysteroscopy revealed sensitivity of 88.9%, specificity 98.3%, positive predictive value 88.9%, negative predictive value 98.3%. The combined use of both methods revealed sensitivity 100%, specificity 91.7%, positive predictive value 64.3%, negative predictive value 100%.

CONCLUSIONS

Both imagiological methods were found to be useful screening tests for endometrial carcinoma. Hysteroscopy was a superior diagnostic procedure.

Spontaneous plaque rupture and secondary thrombosis in apolipoprotein E-deficient and LDL receptor-deficient mice

Apolipoprotein E-deficient (apoE(-/-)) and LDL receptor-deficient (LDLR(-/-)) mice develop extensive atherosclerosis, but the occurrence of spontaneous plaque rupture and secondary thrombosis in these models has not been established. The goal of this study was to provide histological evidence of acute complications of atherosclerotic lesions in these mice and to assess their prevalence. Complications of atherosclerosis were initially studied in aortas of control mice which died during previous intervention studies. Coronary arteries and the aortic origin were then systematically assessed in serial sections through the heart of apoE(-/-) and LDLR(-/-) mice. Aortic plaque rupture and/or thrombi were seen in 3 of 82 untreated mice from past intervention studies. Screening of heart sections of 33 older apoE(-/-) mice (age 9-20 months) showed extensive atherosclerosis in one or more coronary arteries of 18 animals. In three coronary arteries, the presence of blood-filled channels within advanced atherosclerotic lesions suggested previous plaque disruption/thrombotic events followed by recanalization. In the aortic origin of the same mice, four deep plaque ruptures (or erosions reaching necrotic core areas) and a large thrombus originating from the core of a disrupted atherosclerotic lesion were observed. Although plaque ruptures/deep erosions were far less frequent than in human populations, these observations demonstrate that spontaneous plaque rupture and secondary thrombosis do occur in apoE(-/-) and LDLR(-/-) mice. These mice may therefore be suitable for studying factors contributing to thrombotic complications of atherosclerosis. However, the frequent absence of a clearly defined single fibrous cap in murine coronary lesions limits their usefulness as a model of fibrous cap rupture.

Fenofibrate and rosiglitazone lower serum triglycerides with opposing effects on body weight

Activators of peroxisome proliferator activated receptors (PPARs) are effective drugs to improve the metabolic abnormalities linking hypertriglyceridemia to diabetes, hyperglycemia, insulin-resistance, and atherosclerosis. We compared the pharmacological profile of a PPARalpha activator, fenofibrate, and a PPARgamma activator, rosiglitazone, on serum parameters, target gene expression, and body weight gain in (fa/fa) fatty Zucker rats and db/db mice as well as their association in db/db mice. Fenofibrate faithfully modified the expression of PPARalpha responsive genes. Rosiglitazone increased adipose tissue aP2 mRNA in both models while increasing liver acyl CoA oxidase mRNA in db/db mice but not in fatty Zucker rats. Both drugs lowered serum triglycerides yet rosiglitazone markedly increased body weight gain while fenofibrate decreased body weight gain in fatty Zucker rats. KRP 297, which has been reported to be a PPARalpha and gamma co-activator, also affected serum triglycerides and insulin in fatty Zucker rats although no change in body weight gain was noted. These results serve to clearly differentiate the metabolic finality of two distinct classes of drugs, as well as their corresponding nuclear receptors, having similar effects on serum triglycerides.

Effect of aging on aortic expression of the vascular cell adhesion molecule-1 and atherosclerosis in murine models of atherosclerosis

Although age is a strong risk factor for atherosclerosis, it is unclear whether age may directly influence the process of atherogenesis. We, therefore, performed several studies in young (2-4 months old), mature (10-14 months old), and old (20-22 months old) mice to determine if the rate of aortic lesion formation increases with age, and whether this is related to increases in oxidative stress or vascular cell adhesion molecule (VCAM-1) expression in the aortic wall. In chow-fed low-density lipoprotein receptor-deficient (LDLR-/-) mice, plasma total cholesterol levels increased with age (250 +/- 52 mg/dl in young, 276 +/- 58 in mature, and 314 +/- 101 mg/dl in old mice). In contrast, the extent of atherosclerosis rose more rapidly, increasing from 3.6 +/- 2.7% of the aortic surface in mature mice to 18.2 +/- 8% in old mice. Plasma and tissue levels of antioxidant enzymes and molecules, as well as plasma thiobarbituric acid reactive substances and low-density lipoprotein susceptibility to oxidation, did not change with age. In a second study, VCAM-1 expression in the aortic arch and the extent of atherosclerosis in the aortic origin were significantly greater in old LDLR-/- mice than in young LDLR-/- mice. Additionally, after 1 month of a high-fat diet, which induced equally elevated plasma cholesterol levels in both young and old LDLR-/- mice, VCAM-1 expression and aortic lesion formation were still greater in old mice. The extent of atherosclerosis correlated well (r = .65,p <.01) with the expression of VCAM-1 in the aortic origin. In a final study, we measured VCAM-1 expression and atherosclerosis in young, mature, and old C57BL/6 mice, which have low plasma cholesterol levels (< or =100 mg/dl) when fed a standard chow diet. Although plasma cholesterol levels did not increase with age, old C57BL/6 mice had significantly more VCAM-1 expression in the aortic arch than did young mice. However, no lesions were observed in the aortic origin in either group. These data demonstrate that plasma cholesterol levels and VCAM-1 expression increase with age and suggest that this may contribute to the increased rate of atherosclerotic lesion formation in LDLR-/- mice. Importantly, the age-dependent increase in VCAM-1 expression does not appear to be related to plasma cholesterol levels. This study also suggests that in the absence of elevated plasma cholesterol, an increased expression of VCAM-1 alone is not sufficient for lesion formation.

Inhibition of VCAM-1 expression in the arterial wall is shared by structurally different antioxidants that reduce early atherosclerosis in NZW rabbits

We previously established that probucol decreases basal expression of VCAM-1 in the aorta of WHHL rabbits and inhibits the up-regulation of VCAM-1 expression that normally accompanies atherogenesis. To determine whether this effect is shared by other antioxidants in vivo, we now investigated whether a structurally unrelated antioxidant, vitamin E, also inhibits arterial VCAM-1 expression and whether the degree of VCAM-1 inhibition correlates with the reduction of atherosclerosis or the antioxidant protection of LDL. Atherogenesis and VCAM-1 mRNA and protein were determined in four groups of NZW rabbits (n = 6;-8) fed 0.5% cholesterol alone or supplemented with 0.1% vitamin E, a low dose (0.04;-0.075%) of probucol yielding the same degree of antioxidant protection of plasma LDL as vitamin E, or a high dose (0.5%) of probucol, and in normocholesterolemic rabbits. After 81 days, extensive atherosclerosis and a greater than 4-fold up-regulation of VCAM-1 mRNA was seen in rabbits on high cholesterol diet, mostly in the intima. Treatment with vitamin E, high-dose probucol, and low-dose probucol significantly decreased VCAM-1 mRNA by 49.0, 74.9, and 57. 5%, respectively, and reduced atherosclerosis in adjacent segments of the thoracic aorta to a similar degree as reported by previous studies. Immunocytochemistry confirmed that lesions of antioxidant-treated animals also contained less VCAM-1 protein. Neither the degree of VCAM-1 inhibition nor the extent of atherosclerosis correlated with the degree of antioxidant protection of plasma LDL.In summary, treatment with structurally unrelated antioxidants conveyed different degrees of antioxidant protection to plasma LDL but significantly reduced VCAM-1 expression in vivo and inhibited atherogenesis. This is consistent with the assumption that antiatherogenic effects of antioxidants may in part be mediated by interference with oxidation-dependent intracellular signaling.

Effect of probucol treatment on gene expression of VCAM-1, MCP-1, and M-CSF in the aortic wall of LDL receptor-deficient rabbits during early atherogenesis

Probucol is a potent inhibitor of atherosclerosis in animal models. However, the mechanism of its antiatherogenic effect is not known. To investigate the effects of probucol on gene expression of VCAM-1, MCP-1, and M-CSF in vivo during the early stages of atherogenesis, we determined gene expression in 12 control WHHL rabbits and 12 WHHL rabbits fed 1% probucol from age 3 weeks. Three animals from each group were killed at 6, 9, 12, and 18 weeks of age. Two intimal/medial segments of the thoracic aorta, each comprising the orifices of a pair of intercostal arteries, were analyzed by semiquantitative RT-PCR using GAPDH as an internal standard. A third segment located between these two segments was studied by immunocytochemistry. A basal level of VCAM-1 gene expression was observed in lesion-free aortas of both treated and untreated WHHL rabbits (and in normal NZW aortas). Immunocytochemistry showed some VCAM-1 protein in normal arteries and confirmed that VCAM-1 protein expression generally correlated with gene expression. In the untreated WHHL rabbits, a marked upregulation of VCAM-1 expression was observed at 18 weeks. To correlate gene expression with intimal monocyte/macrophages in each animal, the macrophage area was determined by morphometry of immunostained sections. In addition, a scoring system of lesions was used. VCAM-1 expression showed a highly significant correlation with the extent of intimal macrophage presence (P < .001). A lesser degree of correlation between gene expression and macrophage accumulation was also seen for MCP-1. In contrast, M-CSF expression remained constant over the entire study period and showed no correlation with the intimal macrophage accumulation. Probucol treatment completely prevented lesion formation in all animals up to 18 weeks of age. Probucol reduced the level of basal VCAM-1 expression and prevented its upregulation. MCP-1 expression was not affected by probucol treatment, whereas M-CSF expression was significantly lowered by probucol. Our results support the idea that VCAM-1 plays an important role in early atherogenesis and suggest that the antiatherogenic effect of probucol may in part be due to a downregulation of VCAM-1. Reduction of the basal level of M-CSF gene expression by probucol treatment may also contribute to its ability to inhibit atherogenesis.