Rhinocerotidae (Mammalia,Perissodactyla) from the middle Pleistocene levels of Grotta Romanelli (Lecce,southern Italy)

The rhinoceros remains collected during the past century in the lower levels XII (= K) and XI (= I) of the famous Pleistocene locality of Grotta Romanelli (Lecce, southern Italy) are described and compared in detail for the first time. Some remains are referred to Stephanorhinus sp. and others are assigned here to the late early-middle Pleistocene European species Stephanorhinus hundsheimensis based on several morphological characters. Based on its olivine-bearing texture, the volcanoclastic ash sampled from some rhinoceros bones can be referred to the first phase of the Monte Vulture activity (around 630 ka). The results of the stable isotope analyses suggest that the climate in the lowest levels of Grotta Romanelli could have been more arid than it was at the time of the upper level IX, which is generally referred to the late Pleistocene. In addition, both recent day δ¹⁸O_ppt values and MAT are very similar to values calculated for levels X and XII, suggesting that the climate at those times may have been close to the Present one, whereas climate in level IX may have been somewhat cooler. The presence of Stephanorhinus hundsheimensis suggests a middle Pleistocene age for the lower levels of Grotta Romanelli, in agreement with the results obtained from the volcanoclastic material.     

Optimising the clinical strategy for autoimmune liver diseases: Principles of value-based medicine

Background

Autoimmune hepatitis, primary biliary cholangitis, and primary sclerosing cholangitis represent the three major autoimmune liver diseases (AILDs). Their management is highly specialized, requires a multidisciplinary approach and often relies on expensive, orphan drugs. Unfortunately, their treatment is often unsatisfactory, and the care pathway heterogeneous across different centers. Disease-specific clinical outcome indicators (COIs) able to evaluate the whole cycle of care are needed to assist both clinicians and administrators in improving quality and value of care. Aim of our study was to generate a set of COIs for the three AILDs. We then prospectively validated these indicators based on a series of consecutive patients recruited at three tertiary clinical centers in Lombardy, Italy.

Lung ultrasound for the diagnosis of pneumonia in children with acute bronchiolitis

Background

Guidelines currently do not recommend the routine use of chest x-ray (CXR) in bronchiolitis. However, CXR is still performed in a high percentage of cases, mainly to diagnose or rule out pneumonia. The inappropriate use of CXR results in children exposure to ionizing radiations and increased medical costs. Lung Ultrasound (LUS) has become an emerging diagnostic tool for diagnosing pneumonia in the last decades. The purpose of this study was to assess the diagnostic accuracy and reliability of LUS for the detection of pneumonia in hospitalized children with bronchiolitis and to evaluate the agreement between LUS and CXR in diagnosing pneumonia in these patients.

Methods

We enrolled children admitted to our hospital in 2016–2017 with a diagnosis of bronchiolitis and undergone CXR because of clinical suspicion of concomitant pneumonia. LUS was performed in each child by a pediatrician blinded to the patient’s clinical, laboratory and CXR findings. An exploratory analysis was done in the first 30 patients to evaluate the inter-observer agreement between a pediatrician and a radiologist who independently performed LUS. The diagnosis of pneumonia was established by an expert clinician based on the recommendations of the British Thoracic Society guidelines.

Results

Eighty seven children with bronchiolitis were investigated. A final diagnosis of concomitant pneumonia was made in 25 patients. Sensitivity and specificity of LUS for the diagnosis of pneumonia were 100% and 83.9% respectively, with an area under-the-curve of 0.92, while CXR showed a sensitivity of 96% and specificity of 87.1%. When only consolidation >?1?cm was considered consistent with pneumonia, the specificity of LUS increased to 98.4% and the sensitivity decreased to 80.0%, with an area under-the-curve of 0.89. Cohen’s kappa between pediatrician and radiologist sonologists in the first 30 patients showed an almost perfect agreement in diagnosing pneumonia by LUS (K 0.93).

Conclusions

This study shows the good accuracy of LUS in diagnosing pneumonia in children with clinical bronchiolitis. When including only consolidation size >?1?cm, specificity of LUS was higher than CXR, avoiding the need to perform CXR in these patients. Added benefit of LUS included high inter-observer agreement.

Trial registration

Identifier: NCT03280732. Registered 12 September 2017 (retrospectively registered).