Survival prediction of trauma patients: a study on US National Trauma Data Bank.

BACKGROUND: Exceptional circumstances like major incidents or natural disasters may cause a huge number of victims that might not be immediately and simultaneously saved. In these cases it is important to define priorities avoiding to waste time and resources for not savable victims. Trauma and Injury Severity Score (TRISS) methodology is the well-known and standard system usually used by practitioners to predict the survival probability of trauma patients. However, practitioners have noted that the accuracy of TRISS predictions is unacceptable especially for severely injured patients. Thus, alternative methods should be proposed. METHODS: In this work we evaluate different approaches for predicting whether a patient will survive or not according to simple and easily measurable observations. We conducted a rigorous, comparative study based on the most important prediction techniques using real clinical data of the US National Trauma Data Bank. RESULTS: Empirical results show that well-known Machine Learning classifiers can outperform the TRISS methodology. Based on our findings, we can say that the best approach we evaluated is Random Forest: it has the best accuracy, the best area under the curve, and k-statistic, as well as the second-best sensitivity and specificity. It has also a good calibration curve. Furthermore, its performance monotonically increases as the dataset size grows, meaning that it can be very effective to exploit incoming knowledge. Considering the whole dataset, it is always better than TRISS. Finally, we implemented a new tool to compute the survival of victims. This will help medical practitioners to obtain a better accuracy than the TRISS tools. CONCLUSION: Random Forests may be a good candidate solution for improving the predictions on survival upon the standard TRISS methodology.

[Which legal consequences for those who provoke pain to infants?]. / Quali conseguenze per chi provoca dolore al neonato?

The advances in perinatal care have led to a significant increase in neonatal survival rate but also to the rise of the number of invasive procedures. Several scientific studies show that newborns are able to feel pain more intensely than adults. Despite this evidence, neonatal pain and the right to an appropriate analgesia are systematically underestimated, ignoring ethical and moral principles of beneficence and non-maleficence. Infants are more susceptible to pain and the prolonged exposure to painful sensations can alter the neural development and the response to pain causing hyperalgesia. Anyone who caused pain without using any analgesic procedure due to negligence or incompetence, should be severely punished. The right to analgesia, fundamental principle, is fully incorporated in the Italian code of Medical deontology (article 3). The doctor who does not use analgesia for newborns' treatment can be indicted by the Italian penal code (art.582 and 583), aggravated by being the victim an infant, who is unable to defend himself. To avoid penal consequences, a careful education and attention are needed: "pediatric analgesia" should become a basic teaching in Universities and in specialization schools; analgesic treatments should be mandatory and annotated in the patient's file even for minor potentially painful procedures.

Molecular detection of Leptospira interrogans in human tissues and environmental samples in a lethal case of leptospirosis.

A forensic case of suspected Leptospirosis with fatal course was resolved by the molecular detection of Leptospira interrogans in postmortem human tissues and in environmental samples. Polymerase chain reaction analysis and DNA sequencing confirmed the clinical diagnosis of Weil syndrome, and the death was considered to be an occupational accident with all the legal implications.

Enterocytozoon bieneusi in AIDS: symptomatic relief and parasite changes after furazolidone.

AIMS: To investigate changes in morphology of the developmental stages of Enterocytozoon bieneusi and symptomatic relief observed in AIDS patients after treatment with furazolidone. METHODS: Six AIDS patients with symptomatic E bieneusi infection of the small intestine were treated with a course of furazolidone. All patients had a weekly monitoring of parasite shedding in stool by light microscopy during and after treatment. At the end of the treatment, duodenal biopsy specimens obtained from three patients were studied by transmission electron microscopy by two pathologists who were unaware of the patients' treatment. RESULTS: All patients showed both clinical and parasitological response with transient clearance or decrease of spore shedding in stool. After treatment, alterations in faecal spores were observed in all patients by light microscopy, and ultrastructural changes in E bieneusi at all stages of the life cycle were demonstrated in biopsy specimens of the three patients who underwent post-treatment endoscopy. CONCLUSIONS: The clinical benefit seen after treatment with furazolidone in six AIDS patients with E bieneusi intestinal infection may be due to damage to the developmental stages causing a partial inhibition to reproduction of the parasite.

Morphological injury of the intestinal mucosa and infection in patients with AIDS. The role of combined tissue and stool examination.

AIMS: To define the relationship between morphological injury of the intestinal mucosa and infections in AIDS patients. METHODS: Forty-nine AIDS patients were examined by upper gastrointestinal (GI) endoscopy and 8 of them also by lower GI endoscopy. Biopsy specimens, taken from the lower duodenum, esophagus and rectum, were studied by light (L.M.) and transmission electron microscopy (T.E.M.). Stool examination for microorganisms was routinely performed in all patients. RESULTS: Microorganisms were detected in 37 of the 49 patients (75.5%) by combined tissue and stool examination. The histological study revealed villous atrophy, inter- and intra-enterocyte oedema and epithelial degenerative changes in most of the patients whether or not they had detectable microorganisms. CONCLUSIONS: Combined methods (endoscopy, L.M. and T.E.M., studies of tissue samples, microbiological study of stool samples) may be used to improve the documentation of infections and morphological injury of the intestinal mucosa in AIDS patients.

Disease history in 382 Italian patients with Crohn's disease.

AIMS: This large-scale study was aimed at evaluating the long-term history of Crohn's disease in a cohort of consecutive patients referred to the Careggi Hospital in Florence from January 1973 to June 1996. PATIENTS: A total of 382 patients (187 females, 195 males; mean age of 47 years) were included in our study. The median follow-up was more than 11 years and only 46 patients (12%) had a follow-up of less than 1 year. The main endpoints evaluated in these patients included mortality for any cause, disease-specific mortality, recurrences, and need for surgery. Furthermore, in a subgroup of 130 patients observed during the last 6 months of our study, a more detailed assessment of the disease was carried out in which the distribution of inflammatory, fibrostenosing and fistulizing forms was determined. RESULTS: Our results showed that the disease-specific mortality rate was extremely low (around 3% at 10 years and 5% at 20 years), but the rate of recurrence was approximately 50% at 3 years and more than 60% at 6 years. Surgery was needed in more than 50% of the patients over the 10 years following diagnosis, and the risk of a second operation was of a further 30% within 4 years of the first operation. CONCLUSIONS: These epidemiological data emerging from our study are interesting since a large patient population was evaluated and the duration of the follow-up is extremely long.

[Pseudomonas aeruginosa antibodies in patients with cystic fibrosis: clinical implications]. / Anticorpi anti-Pseudomonas aeruginosa in pazienti con fibrosi cistica: implicazioni cliniche.

Patients chronically colonised by P. aeruginosa develop a pronounced antibody response against P. aeruginosa that can be used to discriminate between superficial colonization and chronic infection. Anti-P. aeruginosa antibodies fail to afford protection against this pathogen; moreover high levels of antibodies are correlated with a poor prognosis. We investigated the significance of anti-P. aeruginosa antibodies (precipitins) by crossed immunoelectrophoresis (CIE) in 94 patients attending the Cystic Fibrosis Center of Florence. The highest numbers of precipitins were found in serum from patients chronically colonized in comparison to those patients who were transiently or not colonized. A negative correlation was found between the number of precipitin peaks and clinical conditions, evaluated with Schwachman score, and the number of precipitins and pulmonary functions. In summary, anti-P. aeruginosa antibodies fail to protect against P. aeruginosa bronchopulmonary infections, and are correlated to a more severe disease. Based on our experience, P. aeruginosa antibodies can be considered a reliable index of lung damage.

Mitotic activity in colorectal mucosa of healthy subjects in two Italian areas with different dietary habits.

The proliferative activity was evaluated in colorectal biopsies of 39 healthy subjects living in two distinct geographical areas, Trieste in northern and Florence in central Italy. Subjects living in Trieste had a significantly higher mitotic activity compared with subjects living in Florence (mitoses/cells counted x 100 were 0.17 +/- 0.04 in Trieste and 0.089 +/- 0.02 in Florence). The results of a dietary questionnaire also showed that subjects in Trieste consumed significantly fewer starches, fibers, nitrites, and proteins. However, no correlation was evident between the consumption of these nutrients and intestinal proliferation.

[Isosporiasis and sarcocystosis. The current findings]. / Isosporiasi e sarcocistosi. Acquisizioni attuali.

A review on infections by Isospora belli and Sarcocystis spp. both in healthy and in AIDS patients is done on the basis of literature and personal data. In this view a special focus is made on isospora belli infection in AIDS because of its high recurrence after successful attack therapy. Consequently the most recent protocols for maintenance and attack therapy in these patients are reported. At the end, concerning ultrastructural pathology, the features of some Isospora belli developing stages are described by means of electron microscopy on duodenal biopsy specimens from a patient.

[Proctocolitis caused by Schistosoma mansoni in AIDS. A clinical and immunohistochemical study of a case]. / Proctocolite da Schistosoma mansoni in AIDS. Studio clinico ed immunoistochimico di un caso.

An imported case of intestinal schistosomiasis in AIDS is analysed by the relationships between immune response, diagnostic methods, pathogenetic mechanisms. The inconclusiveness of negative results from both serology and stool parasitology is remarked whereas the efficacy of associated histological, histochemical and immunohistochemical methods is emphasized in order to get better data on aetiological diagnosis and on cell types and size of reactive granulomas. In the case studied, negative serology, absent fecal egg excretion and uneffective granulomatous response with scarcity of T and B lymphocytes have been documented by means of the above methods.

[Intestinal microbial pathology in AIDS. A clinical case series]. / La patologia microbica intestinale in AIDS. Contributo casistico.

Microbial isolates from 60 diarrheic AIDS patients hospitalized to the Infectious Disease Division of Careggi hospital (Florence) are described. Clinical, microbiological and diagnostic features of each case are discussed with emphasis to some rare or underestimated entities in Europe: Campylobacter laridis bacteremia, Whipple-like disease by atypical Mycobacteria, Schistosoma mansoni proctocolitis. Results regarding newly AIDS-related microorganisms are also stressed.

[Pseudo-Whipple disease caused by atypical mycobacteriosis in AIDS: a clinical and electron microscopic study of 2 cases]. / Pseudo-malattia di Whipple da mycobatteriosi atipica in AIDS: studio clinico ed elettromicroscopico di due casi.

The Authors focus on two cases, studied by electron and light microscopy, of Whipple-like disease caused by atypical mycobacteria in AIDS. Differential characteristics between the cases and classical Whipple's disease are analyzed with regard to the diagnostic and therapeutical peculiarities of Mycobacterium avium-intracellulare infection which accounts for over 80% of atypical mycobacterial infections in AIDS. In this regard the Authors stress the role of histological findings of pale blue striated histiocytes as a marker of Mycobacterium avium-intracellulare infection.

[New Campylobacters in human pathology. Current findings and research contributions]. / Nuovi campylobacter in patologia umana. Attuali acquisizioni e contributi di ricerca.

The Authors focused on the new isolates' important role in human infections (particularly pylori, laridis, hyointestinalis and Campylobacters like- organisms) by clinical, microbiological and research data. Recent knowledge about pathogenetic mechanisms of classical Campylobacters is also reported.