A case of suicide by double gunshot wounds to the head: the ability to act after the first shot.

A single gunshot (or multiple) does (do) not necessarily lead to immediate loss of consciousness or rapid neurological deficits, so the victim may be able to repeatedly pull the trigger before achieving the lethal effect. Despite multiple gunshot wounds can lead to the suspicious participation of other person to the death of the victim, in the medico-legal literature suicides with multiple gunshot wounds are reported, demonstrating the ability of the victim to act after two or more gunshots. In this case, a 47-years-old man was found dead in a pool of blood in the kitchen of his house. According to findings and analysis, the victim modified a single-shot, pneumatic toy gun branded "Condor" Cal. 7 mm (a gun that is made mainly with "ZAMAK" zinc-based alloy, designed to shoot one soft-polymer bullet at a time, with an initial kinetic energy lower than 1 Joule) into an improvised firearm weapon. With this gun, the victim achieved shooting of two bullets into his head, both entering from the right temporal region of his head, with one stopped in the left occipital lobe and the other one in the left temporal lobe. His death was caused by cranium-meningo-encephalic gunshot wounds. The conditions supporting the hypothesis that the victim was able to fire two shots to his head before the onset of incapacitation (the type of bullets used, the location of injuries and their consequences) and the characteristics that typically allow to distinguish the manner of death (suicide vs homicide) were evaluated. Based on all the collected elements, it was possible to confirm that suicide was the manner of death. This case underlines the importance of evaluating all available elements (post-mortem imaging, autopsy and toxicological findings, ballistics and neuropathological evaluations) to distinguish suicide from homicide and to prevent incorrect conclusions.

Hiperplasia nodular linfoide asociada con colitis ulcerativa: descripción de un caso y revisión de la literatura / Lymphoid Nodular Hyperplasia Associated with Ulcerative Colitis: Case Study and Literature Review

La hiperplasia nodular linfoide es una patología del aparato gastrointestinal, poco frecuente en adultos. Se caracteriza por un crecimiento del tejido linfoide mucoso y submucoso como respuesta a diferentes tipos de estímulos nocivos. Se ha descrito asociada con otras patologías como infección por VIH/ Síndrome de Inmunodeficiencia Adquirida, giardiasis, infección por Helicobacter Pylori, enfermedad celíaca, y en pocos casos con enfermedad inflamatoria intestinal. No tiene una presentación clínica específica y su manejo aún no está claro

Lymphoid nodular hyperplasia is a pathology of the gastrointestinal tract that rarely occurs among adults. It is characterized by growth of submucosal lymphoid tissue and mucosal response to different types of noxious stimuli. It has been described in association with other diseases such as HIV/AIDS, giardiasis, Helicobacter pylori infections, celiac disease, and very rarely with inflammatory bowel disease. At present, there is no specific clinical presentation or treatment

Antimicrobial use and microbiological testing in district general hospital ICUs of the Veneto region of north-east Italy.

International - predominantly American - studies undertaken in the ICUs of teaching centres show that inadequate antibiotic therapy increases mortality and length of stay. We sought to ascertain whether this also pertains to smaller ICUs in the Veneto region of north-east Italy. To the best of our knowledge, this is the first such survey in the Veneto area or in Italy as a whole. A retrospective, observational study was performed across five general-hospital ICUs to examine appropriateness of microbiological sampling, empirical antibiotic adequacy, and outcomes. Among 911 patients (mean age, 65.8 years ± 16.2 SD; median ICU stay, 17.0 days [IQR, 8.0-29.0]), 757 (83.1 %) were given empirical antibiotics. Treatment adequacy could be fully assessed in only 212 patients (28.0 %), who received empirical treatment and who had a relevant clinical sample collected at the initiation of this antibiotic (T0). Many other patients only had delayed microbiological investigation of their infections between day 1 and day 10 of therapy. Mortality was significantly higher among the 34.9 % of patients receiving inadequate treatment (48.6 % vs 18.80 %; p < 0.001). Only 32.5 % of combination regimens comprised a broad-spectrum Gram-negative ß-lactam plus an anti-MRSA agent, and many combinations were irrational. Inadequate treatment was frequent and was strongly associated with mortality; moreover, there was delayed microbiological investigation of many infections, precluding appropriate treatment modification and de-escalation. Improvements in these aspects and in antibiotic stewardship are being sought.

Resolución de múltiples nódulos pulmonares cavitados con el abandono del hábito tabáquico como único tratamiento / Resolution of multiple cavitated lung nodules with smoking cessation as the only treatment

El término histiocitosis hace referencia a un grupo heterogéneo de enfermedades caracterizadas por la infiltración de células de Langerhans (CL) en diferentes órganos. La histiocitosis pulmonar (HP) es una enfermedad poco frecuente que afecta típicamente a adultos jóvenes. Su patogenia no es bien conocida, aunque se ha observado una relación con el tabaquismo, por lo que la primera medida de tratamiento que se debe realizar es el abandono de éste. Presentamos un caso de histiocitosis pulmonar que evolucionó en seis meses de forma favorable, clínica, funcional y radiológicamente como consecuencia del abandono del tabaco como único tratamiento (AU)

The term histiocytosis refers to a heterogeneous group of diseases characterized by the infiltration of Langerhans cells (LC) in different organs. Pulmonary Histiocytosis (PH) is anuncommon disease that typically affects young adults. Its pathogeny is not well known, although a relationship with smoking has been observed. Thus, the first treatment measure should be smoking cessation. We present a case of pulmonary histiocytosis that showed a favorable clinical, functional and radiological course in six months as a consequence of using smoking cessation as the only treatment (AU)

p16INK4a como predictor de evolución clínica en pacientes con neoplasia intraepitelial cervical de bajo grado (NIC-I): serie de casos / p16INK4a as a predictor of clinical outcome in patients with low grade-cervical intraepithelial neoplasia

El diagnóstico morfológico de neoplasia intraepitelial cervical de bajo grado (NIC-I) no permite determinar su real riesgo de progresión a cáncer de cérvix, llevando a seguimiento estricto a un alto número de pacientes cuyas lesiones, en su mayoría, regresarán espontáneamente. La detección de p16INK4A se ha propuesto como biomarcador que permite diferenciar entre infección productiva-autolimitada por virus del papiloma humano (VPH) y transformación celular inducida por cepas oncogénicas del VPH, sin embargo, es necesario aportar evidencias de su capacidad predictiva. Se presenta una serie de 14 casos de NIC-I con detección inmunohistoquímica de p16INK4a en biopsia de cérvix (8 positivos y 6 negativos), cuya revisión retrospectiva de historial clínico de más de 12 meses de seguimiento cito-histopatológico, permite describir regresión espontánea en todos los casos p16INK4a negativo y en 3 casos p16INK4a positivo (37,5 por ciento). Los hallazgos en esta serie coinciden con lo descrito en estudios previos en los que se ha demostrado el valor predictivo negativo del marcador para descartar riesgo de progresión-persistencia y evitar seguimientos y tratamientos innecesarios. Además señalan debilidades a evaluar respecto al valor predictivo positivo de la prueba, al no discriminar algunos factores independientes de la transformación celular, determinantes en la progresión-persistencia de la NIC-I, como lo son variables genéticas y/o inmunológicas del huésped.

The morphological diagnosis of low grade-cervical intraepithelial neoplasia (CIN-1) can not determine its true risk of progression to cervical cancer, leading to strict adherence to a high number of patients whose lesions, most will return spontaneously. The detection of p16INK4a has been proposed as biomarker to differentiate between productive infection self-limiting by human papillomavirus (HPV) and cell transformation induced by oncogenic strains of HPV, however, it is necessary provide evidence of its predictive capacity. We present a series of 14 cases of CIN-1 with immunohistochemical detection of p16INK4a in cervical biopsy (8 positive and 6 negative), whose retrospective review of medical records of more than 12 months of cyto-histopathological follow, can describe spontaneous regression in all cases p16INK4a negative and in 3 cases p16INK4a positive (37.5 percent). The findings in this series of cases coincide with that described in previous studies that has been demonstrated the negative predictive value of the marker to exclude risk of progression-persistence and avoid follow-ups and unnecessary treatments. Additionally, these indicates weaknesses to evaluate about the positive predictive value of the test, by not discriminating factors independent of cellular transformation, determining the progression-persistent CIN-1, such as genetic and / or immunologic variables of the host.

MALT-linfoma de cérvix: reporte de caso / MALT-lymphomas of cervix: a case report

Los linfomas MALT de cérvix son de muy rara presentación. Se reporta el caso de una paciente de 38 años con neoplasia linfoproliferativa detectada incidentalmente en los cortes de rutina, durante el estudio anátomo-patológico de espécimen de resección producto de histerectomía total, motivada por hallazgos ecográficos compatibles con miomatosis en cuerpo uterino. La etiología de esta neoplasia está asociada a procesos infecciosos o autoinmunes, se ha descrito alta radiosensibilidad y quimiosensibilidad a la biotera-pia contra anticuerpos CD20.

The MALT-lymphomas of cervix are of very rare presentation. This is the case of a 38 years old patient in which this linfoproliferative disorder was detected incidentally in the routine cuts, during the anatomo-pathological study of a resection specimen product of total hysterectomy motivated by ecographic findings that were compatible with myomatosis of the uterine corpus. The etiology of these tumors is associated with infectious or autoimmune processes, and high radiosensitivity and chemosensitivity to biotherapy against antibodies CD20 (rituximab) has been described.

Septic shock, pneumonia, and soft tissue infection due to Myroides odoratimimus: report of a case and review of Myroides infections.

The genus Myroides comprises aerobic, yellow-pigmented, non-motile, non-fermenting gram-negative rods formerly classified as Flavobacterium odoratum. Members of the genus are widely distributed in the environment, especially in water, and usually behave as low-grade opportunistic pathogens, having been found to cause urinary tract infection, endocarditis, ventriculitis, and cutaneous infections in severely immunocompromised patients. We report a case of soft tissue infection, septic shock, and pneumonia due to M. odoratimimus in an immunocompetent male. To our knowledge, this is the first description of life-threatening infection caused by this organism in an immunocompetent host. We have also reviewed the medical literature on the genus Myroides.

Non-invasive identification of organic materials in wall paintings by fiber optic reflectance infrared spectroscopy: a statistical multivariate approach.

The aim of this study is to develop a method for the non-invasive and in situ identification of organic binders in wall paintings by fiber optic mid-FTIR reflectance spectroscopy. The non-invasive point analysis methodology was set-up working on a wide set of wall painting replicas of known composition and using statistical multivariate methods, in particular principal component analysis (PCA), for the interpretation, understanding, and management of data acquired with reflectance mid-FTIR spectroscopy. Results show that PCA can be helpful in managing and preliminary sorting of the large amount of spectra typically collected during non-invasive measurement campaigns and highlight further avenues for research. The developed PCA model was finally applied to the case of a Renaissance wall painting by Perugino assessing it predictability as compared to the interpretation of the single spectrum.

Prevalence and risk factors for nosocomial infections in hospitals of the Veneto region, north-eastern Italy.

OBJECTIVE: The study aimed to assess prevalence and risk factors for nosocomial infection (NI) in 21 hospitals of the Veneto Region (Italy). METHODS: In May 2003, a one-week-period prevalence study of NI was carried out in 21 hospitals, representing 63% of all hospital beds for acute patients of the Veneto Region. Intensive care units represented 84% of all intensive care beds of the Region. Long term care, neonatal intensive care, burn, psychiatric and dermatology units were excluded. RESULTS: Overall, 6,352 patients were surveyed. The prevalence of NI was 7.6% (range 2.6%-17.7%), while 6.9% of patients (range 2.6%-15.5%) were affected by at least one NI. The prevalence of patients with NI in medical, surgical and intensive care areas was 6.6%, 5.0% and 25.8%, respectively. The sites most frequently affected were the following: urinary tract (28.4%), surgical site (20.3%), blood stream (19.3%), pulmonary and lower respiratory tract (17.6%). At multivariate analysis risk factors independently associated to NI were: Charlson index score >1, severity of underlying disease, exposure to antibiotics, surgical intervention, trauma at admission, presence of central venous catheter >24 h, urinary catheter, intubation, tracheostomy, and duration since admission >15 days. CONCLUSION: The study provided baseline data of NI in the Veneto Region hospitals. It showed that NI are frequent, and display a wide inter-hospital variability of rates. The highest prevalence has been reported in intensive care units. The unusual high frequency of blood stream infections and the relatively lower prevalence rate of surgical site infections highlighted the limits of prevalence studies.

[Off-label antibiotic use: malpractice or good clinical practice?]. / La prescrizione off-label di antibiotici: malpractice o buona pratica clinica?

In Italy, off-label drug use has been forbidden since 1998. However, Italian law allows off-label treatment for single cases only if treatment is considered irreplaceable, and completely under physician responsibility. To assess the consequences of such regulations for the infectious diseases specialist, we listed the indications of intravenous and oral antibiotics available in our hospital pharmacy service, and discussed them in a pool of nine infectious diseases specialists. Indications were compared with the recommended treatment of major bacterial syndromes as suggested by the major guidelines and textbooks. We found that standard treatment for several bacterial infections is off-label. The pool of specialists concluded that some off-label use of antibiotics is vital to daily practice in infectious diseases. Scientific societies should promote guidelines as the standard reference for good clinical practice, which should not be based only on the respect of drug labels.

Impact of calcium intake on body mass index in Venezuelan adolescents

The prevalence of overweight and obesity is increasing worldwide, affecting approximately 15% of adolescents in Venezuela, 17% in United States, and more than 30% in Mexico and Puerto Rico. Recent studies have shown that dietary calcium and dairy intake are associated with body fat. These studies show that a high calcium intake results in low body mass index (BMI). Therefore, the objective of the present study is to relate calcium intake from foods rich in calcium-rich foods to body weight and BMI in a random sample of 100 adolescents, aged 13-18 years. Anthropometric measurements (weight and height) were obtained for each participant, who also completed a food frequency questionnaire (FFQ), modified with calcium-rich foods. Dietary calcium consumption was 1076+/-534 mg/d among the adolescents, which represented an adequacy of 90%. A negative and significant association was found between calcium intake and BMI in the boys aged 13-15 years (r=-0.39, p<0.05). This population subgroup exhibited the widest range of BMI values among all groups evaluated. This correlation was not found among the older boys (aged 16-18 years) or girls, in which BMI was in the normal range and with relatively high calcium intake. In conclusion, we found that high calcium intake in younger boys was related to a lower BMI. A high calcium intake, not only helps to maintain a healthy body weight, but also is essential for acquiring peak bone mass in this crucial stage of life.

Fiber-optic fourier transform mid-infrared reflectance spectroscopy: a suitable technique for in situ studies of mural paintings.

A prototypical in situ noninvasive study of ancient mural painting materials has been carried out using an easily manageable fiber-optic Fourier transform mid-infrared (mid-FT-IR) reflectance spectrophotometer. The reported object of the study is the Renaissance fresco by Pietro Vannucci, called il Perugino, located in the church of Santa Maria delle Lacrime (1521, Trevi, Perugia Italy). For the first classification and interpretation of infrared spectra, principal components analysis was used. Spectral artifacts due to lacunas, restoration materials, or alteration products have been identified, as well as two different secco refinements bound in a tempera medium. For the characterization of inorganic pigments, mid-FT-IR spectra have been integrated with other data obtained through in situ X-ray fluorescence (XRF) elemental analysis. This complementary noninvasive approach led to the characterization of Perugino's pigments, even in the presence of complex mixtures. The mid-FT-IR noninvasive technique, in combination with XRF, is thus recommended as a valuable first approach for the examination of mural paintings, permitting the assessment of the execution technique as well as contributing to the evaluation of the conservation state.

Resolving surface details with reflection and fluorescence video-confocal profilometry.

Video-confocal profilometry has been exploited to characterize reflecting and non-reflecting surfaces in materials with tilted and corrugated areas. An alternative method based on fluorescence detection has been developed and tested to characterize metal surfaces modified by intense laser irradiation. Combined representations of surface topography have been obtained on the basis of both reflectance and fluorescence signals. A discussion of results and problems encountered in reflection and fluorescence based techniques is provided.

Leptospirosis following a flood in the Veneto area, North-east Italy.

In August 2002, an exceptional flood devastated a suburban area in the surroundings of Vicenza, North-east Italy. A fatal case of haemorrhagic pneumonia, which was presumptively diagnosed as leptospirosis, was observed as a consequence of the inundation. A local seroepidemiological survey was activated thereafter, with the principal aim of evaluating the risk of infection with Leptospirae in the population exposed to the flood. A 6.8% seroconversion rate was found in the population studied; however, the case previously observed remained unique, since an overt outbreak of leptospirosis did not occur.

Towards many colors in FISH on 3D-preserved interphase nuclei.

The article reviews the existing methods of multicolor FISH on nuclear targets, first of all, interphase chromosomes. FISH proper and image acquisition are considered as two related components of a single process. We discuss (1) M-FISH (combinatorial labeling + deconvolution + wide-field microscopy); (2) multicolor labeling + SIM (structured illumination microscopy); (3) the standard approach to multicolor FISH + CLSM (confocal laser scanning microscopy; one fluorochrome - one color channel); (4) combinatorial labeling + CLSM; (5) non-combinatorial labeling + CLSM + linear unmixing. Two related issues, deconvolution of images acquired with CLSM and correction of data for chromatic Z-shift, are also discussed. All methods are illustrated with practical examples. Finally, several rules of thumb helping to choose an optimal labeling + microscopy combination for the planned experiment are suggested.

Critical comparison of nine different self-administered questionnaires for the evaluation of disability caused by low back pain.

AIM: The aim of this study was to critically compare 9 self-administered questionnaires designed to evaluate disability caused by back pain. METHODS: The questionnaires were analyzed considering and comparing their psychometric characteristics (reliability, validity, responsiveness, minimal clinically relevant difference), together with other practical and technical aspects (number of items, number and kind of domains, scaling of items, scoring, time to complete, validated translations, etc.). Data were obtained from scientific literature. RESULTS: Only 3 out of 9 analyzed instruments (i.e., the Oswestry Low Back Pain Disability Questionnaire, the Quebec Back Pain Disability Scale, and the Roland-Morris Low Back Pain Disability Questionnaire) appear fully validated from a psychometric standpoint. CONCLUSIONS: On the basis of psychometric evaluations as well as feasibility considerations, the authors suggest using either the Roland-Morris or Oswestry questionnaire as the best assessment of the level of disability caused by back pain.

Outbreak of African tick-bite fever in six Italian tourists returning from South Africa.

In May 1999, a cluster of cases of African tick-bite fever was detected in six Italian tourists who had returned from South Africa. All of the patients had moderate fever and cutaneous eschars. Regional lymphangitis was observed in three of the patients and skin rash in two. By comparing the number of eschars with the number of detectable bite sites it was suggested that at least two-thirds of the biting vectors were capable of transmitting Rickettsia africae. The clinical course of disease was mild in all cases, and all but one of the patients recovered spontaneously before antibiotic treatment was initiated. The diagnosis of African tick-bite fever was confirmed serologically using both microimmunofluorescence and Western blot tests.

Electrostatic analysis and Brownian dynamics simulation of the association of plastocyanin and cytochrome f.

The oxidation of cytochrome f by the soluble cupredoxin plastocyanin is a central reaction in the photosynthetic electron transfer chain of all oxygenic organisms. Here, two different computational approaches are used to gain new insights into the role of molecular recognition and protein-protein association processes in this redox reaction. First, a comparative analysis of the computed molecular electrostatic potentials of seven single and multiple point mutants of spinach plastocyanin (D42N, E43K, E43N, E43Q/D44N, E59K/E60Q, E59K/E60Q/E43N, Q88E) and the wt protein was carried out. The experimentally determined relative rates (k(2)) for the set of plastocyanin mutants are found to correlate well (r(2) = 0.90 - 0.97) with the computed measure of the similarity of the plastocyanin electrostatic potentials. Second, the effects on the plastocyanin/cytochrome f association rate of these mutations in the plastocyanin "eastern site" were evaluated by simulating the association of the wild type and mutant plastocyanins with cytochrome f by Brownian dynamics. Good agreement between the computed and experimental relative rates (k(2)) (r(2) = 0.89 - 0.92) was achieved for the plastocyanin mutants. The results obtained by applying both computational techniques provide support for the fundamental role of the acidic residues at the plastocyanin eastern site in the association with cytochrome f and in the overall electron-transfer process.

Deep tissue biopsy vs. superficial swab culture monitoring in the microbiological assessment of limb-threatening diabetic foot infection.

AIMS: The results of ulcer swabbing vs. deep tissue biopsy have been compared prospectively in 29 diabetic patients with limb-threatening foot infection, to investigate the effectiveness and reliability of each method, and to evaluate whether any of the two could be more suitable for the microbiological follow-up of severe lesions. METHODS: Microbiological samples were collected by using both methods at fixed intervals after therapy commencement (i.e. at day 0, 7, 14, and 30). Statistical comparison was performed between the results of each sampling procedure after the end of follow-up. RESULTS: At enrolment, the mean number of isolates per patient was 2.34 by swabbing and 2.07 by tissue biopsy sampling; the rate of isolation for anaerobes with the two methods was 35% and 25%, respectively; no statistical differences could be observed between the two procedures in terms of either species or frequency of isolation. Anaerobic species were never detected after the first 2 weeks of appropriate treatment, and those ulcers which were still active at day 30 yielded almost exclusively Gram-positive bacteria. At the end of follow-up, deep tissue cultures appeared to exhibit a higher diagnostic sensitivity with respect to swabs. CONCLUSIONS: Swabbing and deep tissue cultures appear to be equally reliable for the initial monitoring of antimicrobial treatment in severe diabetic foot infection. However, our experience seems to suggest that deep tissue might be more sensitive than swabbing for monitoring those isolates that have been selected for antibiotic resistance, i.e. those from ulcers that are still active after 30 days of treatment.