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Overall, these courses are not only well settled and familiar to physicians and nurses: they usually provide an excellent training opportunity, improving both knowledge specific to the field of interest and technical skills, through clinical scenarios, high fidelity simulations and hands-on sessions with medical devices. [...]the standardization of the training and of the evaluation process—both for students and for instructors—and a solid groundwork of constantly updated international best practice guidelines ensure not only the quality of the educational intervention but also the building of a common language that can be easily shared among colleagues across the world. Sharing a common ground of daily exposure to clinical cases, passion for clinical ethics and end-of-life care, and a few years’ experience in studying and teaching ethical issues in different settings, a couple of years ago, we started developing an “ELS—Ethical Life Support” project: a short but comprehensive manual and a 1-day highly interactive course (Fig. 1). Fig. 1 Fig. 1 Fig. 1 ELS logo Obviously, our aim has never been to compress a full ethics program in a short reading and a single-day course, rather to provide basic ethical reasoning abilities and vocabulary, some practical communication skills and basic conflict management strategies. [...]of individual participants’ values, the focus is on the importance of end-of-life shared decision-making, taking into account the best available scientific evidence as well as the best reconstruction of the patient’s preferences [8].

ImportanceDuring the SARS-CoV-2 pandemic, a complete physical isolation has been worldwide introduced. The impossibility of visiting their loved ones during the hospital stay causes additional distress for families: in addition to the worries about clinical recovery, they may feel exclusion and powerlessness, anxiety, depression, mistrust in the care team and post-traumatic stress disorder. The impossibility of conducting the daily meetings with families poses a challenge for healthcare professionals.ObjectiveThis paper aims to delineate and share consensus statements in order to enable healthcare team to provide by telephone or video calls an optimal level of communication with patient’s relatives under circumstances of complete isolation.Evidence reviewPubMed, Cochrane Database of Systematic Reviews, Database of Abstracts and Reviews of Effectiveness and the AHCPR Clinical Guidelines and Evidence Reports were explored from 1999 to 2019. Exclusion criteria were: poor or absent relevance regarding the aim of the consensus statements, studies prior to 1999, non-English language. Since the present pandemic context is completely new, unexpected and unexplored, there are not randomised controlled trials regarding clinical communication in a setting of complete isolation. Thus, a multiprofessional taskforce of physicians, nurses, psychologists and legal experts, together with some family members and former intensive care unit patients was established by four Italian national scientific societies. Using an e-Delphi methodology, general and specific questions were posed, relevant topics were argumented, until arriving to delineate position statements and practical checklist, which were set and evaluated through an evidence-based consensus procedure.FindingsTen statements and two practical checklists for phone or video calls were drafted and evaluated; they are related to who, when, why and how family members must be given clinical information under circumstances of complete isolation.Conclusions and relevanceThe statements and the checklists offer a structured methodology in order to ensure a good-quality communication between healthcare team and family members even in isolation, confirming that time dedicated to communication has to be intended as a time of care.

Residual β-Cell Function and Male/Female Ratio Are Higher in Incident Young Adults Than in Children The registry of type 1 diabetes of the province of Turin, Italy, 1984–2000 Graziella Bruno , MD 1 , Franco Cerutti , MD 2 , Franco Merletti , MD 3 , Paolo Cavallo-Perin , MD 1 , Enrico Gandolfo , MD 1 , Marina Rivetti , MD 1 , Cristina Runzo , MD 1 , Silvia Pinach , PHD 1 , Gianfranco Pagano , MD 1 and The Piedmont Study Group for Diabetes Epidemiology * 1 Department of Internal Medicine, University of Turin, Turin, Italy 2 Department of Pediatrics, University of Turin, Turin, Italy 3 Unit of Cancer Epidemiology, CERMS and Center for Oncologic Prevention, University of Turin, Turin, Italy Address correspondence and reprint requests to Graziella Bruno, MD, Department of Internal Medicine, University of Turin, corso Dogliotti 14, I-10126 Turin, Italy. E-mail: graziella.bruno{at}katamail.com Abstract OBJECTIVE — The hypothesis of age-dependent variations in epidemiologic and clinical features at onset of type 1 diabetes has been assessed in the registry of the province of Turin, Italy. RESEARCH DESIGN AND METHODS — The study base is the population 0–29 years of age of the province of Turin, in the period from 1984 to 2000. Islet cell antibody (ICA), GAD antibody (GADA), antibodies to protein tyrosine phosphatase (IA2), and C-peptide were measured in subgroups of the cohort. RESULTS — One thousand fifty-six incident cases have been identified (completeness of ascertainment 98.1%). Rates per 100,000 person-years were similar in males and females in the age-group 0–14 years (10.7, 95% CI 9.5–12.0 vs. 9.8, 8.6–11.1). In the age-group 15–29 years, males had higher risk than females (7.7, 6.9–8.6 vs. 5.3, 4.6–6.1; rate ratio, 1.46, 95% CI 1.23–1.74; P = 0.00002). Fasting plasma C-peptide values ( n = 575) were twofold lower in the age-group 0–14 years than in the age-group 15–29 years (0.10 vs. 0.23 nmol/l; P < 0.0001). Frequencies of ICA and IA2 positivities ( n = 183) decreased with increasing age, whereas frequency of GADA positivity increased. Idiopathic cases were 12.6% and had higher mean values of fasting (0.28 vs. 0.14 nmol/l; P = 0.043) and stimulated C-peptide (0.59 vs. 0.34 nmol/l; P = 0.05). In logistic regression analyses, subjects with fasting C-peptide values in the upper quartile had higher likelihood of being older (odds ratio 1.20 for year, 95% CI 1.11–1.28), ICA negative (0.26, 0.10–0.70), and female (1.29, 0.48–3.42). CONCLUSIONS — This study shows 1 ) sex differences in incidence rates in young adults; 2 ) better preserved β-cell function in young adults, in idiopathic cases (12%), and in ICA-negative cases; and 3 ) lower frequencies of ICA and IA2 positivities and higher frequency of GADA positivity in young adults than in children. GADA, GAD antibody IA2, antibodies to protein tyrosine phosphatase ICA, islet cell antibody Footnotes A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances. ↵ *A list of members of the Piedmont Study Group for Diabetes Epidemiology can be found in the APPENDIX. Accepted October 31, 2004. Received June 14, 2004. DIABETES CARE

Background: Use of the antiepileptic drug vigabatrin is associated with an elevated risk of visual field loss. Objective: To determine the frequency of, and risk factors for, vigabatrin-attributed visual field loss (VAVFL) in the setting of a large-scale, multinational, prospective, observational study. Study design: A comparative, open-label, parallel-group, multicentre study. Setting: Hospital outpatient clinics at 46 centres in five countries. Patients: 734 patients with refractory partial epilepsy, divided into three groups and stratified by age (8–12 years; >12 years) and exposure to vigabatrin. Group I comprised patients treated with vigabatrin for ≥6 months. Group II comprised patients previously treated with vigabatrin for ≥6 months who had withdrawn from the drug for ≥6 months. Group III comprised patients never treated with vigabatrin. Patients underwent perimetry at either 4- or 6-month intervals, for up to 36 months. Visual field outcome was evaluated masked to drug exposure. Intervention: Perimetry. Main outcome measure: The visual field outcome at each of four analysis points: (i) at enrolment (i.e. baseline, all patients); (ii) for patients exhibiting a conclusive outcome at the initial visual field examination; (iii) for patients exhibiting at least one conclusive outcome to the visual field examinations; and (iv) at the last conclusive outcome to the visual field examinations. Results: Of the 734 patients, 524 yielded one or more conclusive visual field examinations. For Group I, the frequency of VAVFL at the last conclusive examination was 10/38 (26.3%) for those aged 8–12 years and 65/150 (43.3%) for those aged >12 years. For Group II, the respective frequencies were 7/47 (14.9%) and 37/151 (24.5%). One case resembling VAVFL was present amongst the 186 patients in Group III at the last conclusive examination. The frequency of VAVFL in Groups I and II combined was 20.0% for those aged 8–12 years and 33.9% for those aged >12 years. VAVFL was associated with duration of vigabatrin therapy (odds ratio [OR] up to 15.2; 95% CI 4.4, 51.7), mean daily dose of vigabatrin (OR up to 26.4; 95% CI 2.4, 291.7) and male gender (OR 2.51; 95% CI 1.5, 4.1). VAVFL was more frequently detected with static than with kinetic perimetry (OR up to 0.43; 95% CI 0.24, 0.75). Conclusions: Since the probability of VAVFL is positively associated with treatment duration, careful assessment of the risk-benefit ratio of continuing treatment with vigabatrin is recommended in patients currently receiving this drug. All patients continuing to receive vigabatrin should undergo visual field examination at least every 6 months for the duration of treatment. We recommend two-level (three-zone), gradient-adapted, suprathreshold static perimetry of the peripheral field together with threshold perimetry of the central field out to 30° from fixation. The frequency of ophthalmological and perimetric examinations should be increased in the presence of VAVFL.

The hypothesis of age-dependent variations in epidemiologic and clinical features at onset of type 1 diabetes has been assessed in the registry of the province of Turin, Italy. The study base is the population 0-29 years of age of the province of Turin, in the period from 1984 to 2000. Islet cell antibody (ICA), GAD antibody (GADA), antibodies to protein tyrosine phosphatase (IA2), and C-peptide were measured in subgroups of the cohort. One thousand fifty-six incident cases have been identified (completeness of ascertainment 98.1%). Rates per 100,000 person-years were similar in males and females in the age-group 0-14 years (10.7, 95% CI 9.5-12.0 vs. 9.8, 8.6-11.1). In the age-group 15-29 years, males had higher risk than females (7.7, 6.9-8.6 vs. 5.3, 4.6-6.1; rate ratio, 1.46, 95% CI 1.23-1.74; P = 0.00002). Fasting plasma C-peptide values (n = 575) were twofold lower in the age-group 0-14 years than in the age-group 15-29 years (0.10 vs. 0.23 nmol/l; P < 0.0001). Frequencies of ICA and IA2 positivities (n = 183) decreased with increasing age, whereas frequency of GADA positivity increased. Idiopathic cases were 12.6% and had higher mean values of fasting (0.28 vs. 0.14 nmol/l; P = 0.043) and stimulated C-peptide (0.59 vs. 0.34 nmol/l; P = 0.05). In logistic regression analyses, subjects with fasting C-peptide values in the upper quartile had higher likelihood of being older (odds ratio 1.20 for year, 95% CI 1.11-1.28), ICA negative (0.26, 0.10-0.70), and female (1.29, 0.48-3.42). This study shows 1) sex differences in incidence rates in young adults; 2) better preserved beta-cell function in young adults, in idiopathic cases (12%), and in ICA-negative cases; and 3) lower frequencies of ICA and IA2 positivities and higher frequency of GADA positivity in young adults than in children.

OBJECTIVE:-- The hypothesis of age-dependent variations in epidemiologic and clinical features at onset of type 1 diabetes has been assessed in the registry of the province of Turin, Italy. RESEARCH DESIGN AND METHODS-- The study base is the population 0-29 years of age of the province of Turin, in the period from 1984 to 2000. Islet cell antibody (ICA), GAD antibody (GADA), antibodies to protein tyrosine phosphatase (IA2), and C-peptide were measured in subgroups of the cohort. RESULTS:-- One thousand fifty-six incident cases have been identified (completeness of ascertainment 98.1%). Rates per 100,000 person-years were similar in males and females in the age-group 0-14 years (10.7, 95% CI 9.5-12.0 vs. 9.8, 8.6-11.1). In the age-group 15-29 years, males had higher risk than females (7.7, 6.9-8.6 vs. 5.3, 4.6-6.1; rate ratio, 1.46, 95% CI 1.23-1.74; P = 0.00002). Fasting plasma C-peptide values (n = 575) were twofold lower in the age-group 0-14 years than in the age-group 15-29 years (0.10 vs. 0.23 nmol/l; P < 0.0001). Frequencies of ICA and IA2 positivities (n = 183) decreased with increasing age, whereas frequency of GADA positivity increased. Idiopathic cases were 12.6% and had higher mean values of fasting (0.28 vs. 0.14 nmol/l; P = 0.043) and stimulated C-peptide (0.59 vs. 0.34 nmol/l; P = 0.05). In logistic regression analyses, subjects with fasting C-peptide values in the upper quartile had higher likelihood of being older (odds ratio 1.20 for year, 95% CI 1.11-1.28), ICA negative (0.26, 0.10-0.70), and female (1.29, 0.48-3.42). CONCLUSIONS:-- This study shows 1) sex differences in incidence rates in young adults; 2) better preserved {szligbeta}-cell function in young adults, in idiopathic cases (12%), and in ICA-negative cases; and 3) lower frequencies of ICA and IA2 positivities and higher frequency of GADA positivity in young adults than in children.

Aim: To report on the use of a combined intra-ocular tamponade with silicone oil and perfluorohexyloctane (F 6 H 8 ) in the treatment of complex retinal detachment. Design: A prospective consecutive interventional case series from seven study centres. Participants: 69 patients presenting a retinal detachment with proliferative vitreoretinopathy (PVR) and retinal breaks of the inferior two quadrants of the fundus. Method: Patients were divided into two groups: (1) 28 eyes which had not been operated on before; (2) 41 eyes affected by recurrent retinal detachment that had had unsuccessful previous surgery with silicone oil or gas tamponade. A pars plana vitrectomy, membrane peeling and – when necessary – a retinotomy were performed; the vitreous cavity was filled with two thirds of F 6 H 8 and one third of silicone oil 1,000 mPas (double filling, DF). The endotamponade was removed after 30–45 days (median 38) and replaced by balanced salt solution or silicone oil according to the condition of the retina. Results: Retinal reattachment was achieved in 52 out of 69 cases (75%) 6 months after removal of the DF without any endotamponade. Conclusion: The DF with F 6 H 8 and silicone oil allows a good endotamponading to the inferior retina and the posterior pole. The DF appeared to be well tolerated. Further studies are necessary to evaluate whether a DF is advantageous in respect to silicone oil filling alone in case of retinal breaks and PVR of the inferior retina.

Purpose  To assess corneal penetration of naproxen sodium and its efficacy in maintaining intraoperative mydriasis during cataract surgery. Methods  Two double blind studies have been performed comparing the efficacy of naproxen ophthalmic solution to that of placebo or diclofenac in inhibiting pre-operative miosis. Study No. 1 was a placebo-controlled study and involved 194 patients undergoing extracapsular cataract extraction. Study No. 2 was an active-controlled study ( vs diclofenac) concerning 214 patients undergoing phacoemulsification. In both studies treatment started the day before surgery. A balanced salt solution containing adrenaline was used in all patients. Pupil size was measured prior to the corneal section and at the end of surgery. An aqueous humor sample was taken immediately before corneal incision in a subset of 20 patients to measure naproxen aqueous concentration. Results  In both studies the pupillary diameter decreased during surgery within each treatment group in a statistically significant manner ( P < 0.001). Naproxen was more effective than placebo ( P < 0.01) and as effective as diclofenac in controlling pupil diameter regression during cataract. Mean concentration level of naproxen in the aqueous humor was 372.3 ng/ml. Conclusions  Naproxen sodium ophthalmic solution penetrates the cornea and it is effective in maintaining intraoperative mydriasis.

The process of forming an information resource of recording solid-state structures is considered. A criterion is proposed for the information efficiency of transducers and systems.[PUBLICATION ABSTRACT]

Spondyloarthritis (SpA) is characterized by the infiltration of innate and adaptive immune cells into entheses and bone marrow. Molecular, cellular and imaging evidence demonstrates the presence of bone marrow inflammation, a hallmark of SpA. In the spine and the peripheral joints, bone marrow is critically involved in the pathogenesis of SpA. Evidence suggests that bone marrow inflammation is associated with enthesitis and that there are roles for mechano-inflammation and intestinal inflammation in bone marrow involvement in SpA. Specific cell types (including mesenchymal stem cells, innate lymphoid cells and γδ T cells) and mediators (Toll-like receptors and cytokines such as TNF, IL-17A, IL-22, IL-23, GM-CSF and TGFβ) are involved in these processes. Using this evidence to demonstrate a bone marrow rather than an entheseal origin for SpA could change our understanding of the disease pathogenesis and the relevant therapeutic approach.In this Perspective, the authors discuss molecular, cellular and imaging evidence in spondyloarthritis that supports a bone marrow rather than an entheseal origin. Focusing on immune cells and dysfunction in the bone marrow niche could redirect the therapeutic approach to spondyloarthritis.