Working activity of G A Pablo Cirrone Attending the first year of the

Medical School of Catania University Matr. number: L98001091

Presentation 1

The Hospital 1

Blood Tests 1

The medical doctors and their role inside and Hospital 1

Obesity 1

Hyperthension 1

Gastroesophageal reflux 1

Diabetes 1

Classification 1

Type 1 diabetes 1

Type 2 diabetes 1

Gestational diabetes 1

Case History 1

Patient pain rating 1

Living environment 1

Family history 1

General Health 1

Presentation My name Is Pablo Cirrone. I was born in Catania 38 years ago and spend all my life in this beautiful Italian city. In July 1992 I get my high-school degree and I immediately started to attend the courses of Nuclear Physics at the Catania University. In April 1998 I get my master degree in nuclear physics discussing a thesis on the application of scintillating material in medical dosimetry. In 1999 I started to attend the Medical Physics school at the Florence University, getting the 'Medical physics qualification' in July 2000. In September 2011 started to attend the phD course at the Catania University. The main topic of my research, during the PhD, was the use of the Monte Carlo simulations for the reconstruction of a typical eye proton therapy treatment. Finally in February 2004 I get my PhD discussing a thesis on the use of Monte Carlo simulations in the field of cancer radiotherapy with proton beams. In 2005 I get a non permanent researcher position at the Italian Institute for Nuclear physics to perform research in the field of medical physics and related applications. In 2008 I finally get a staff permanent position at the INFN. My actual research activity is focused on the study of laser-generated proton beams for medical applications. In particular I am the National Responsible of the Elimed (MEDical application at the ELI beamlime) project. The main goal of this project is the realization at the ELI facility (In Prague, cz) of a dedicated transport beamlime where laser-generated proton will be used for medical purposes. In September 2012 I started a new adventure: I decided to attend the Medical School of the Catania University, hoping to complete it even if my professional life is really very busy. I will briefly describe now my typical day. I wake up around 7:00 and, after a quick breakfast, take the car to reach my working place around 8:30. Usually I work in a typical physics laboratory: a small room plenty of electronic apparatus and detectors. I and my collaborators performs there experimental measures and characterization of various experimental systems. Very often we irradiate them under high energetic radioactive beams ( especially proton beams of 62 MeV in energy). Usually I have the lunch around 1.30 p.m.. It generally consists of some fruits or a salad. Around 3.00 p.m. I came back to my working place. I generally spend my afternoon working hours not in the experimental laboratory but in my office. These hours are dedicated to various activity: writing of scientific papers, group meetings on our research activity or any other business not related to an experimental activity. I usually complete my working day around 7.00 p.m. Then I came back to home. During the evening, if I have time and not busy with other 'social' activity, I continue my research activity, usually reading some paper or some scientific book chapter.

Some days of my week are slightly different as I have to follow the Medical School lessons at University. In those cases, my morning activity is generally dedicated to attend the lessons or to study the subject of the Medical courses. Finally I have to mention that, in some occasions, I spend long period abroad to perform experiment and/or research activity and conferences talk. Recently I spend more than one month in Prague to work on my project with the Czech colleagues. In the next future I will spend a period in Frascati (Rome) and in Belfast (uk) to perform some experimental campaigns in two different physics laboratories.

The Hospital A hospital is a health care institution providing patient treatment by specialized staff and equipment.

Hospitals are usually funded by the public sector, by health organizations (for profit or nonprofit), health insurance companies, or charities, including direct charitable donations. Historically, hospitals were often founded and funded byreligious orders or charitable individuals and leaders. Today, hospitals are largely staffed by professional physicians,surgeons, and nurses, whereas in the past, this work was usually performed by the founding religious orders or byvolunteers. However, there are various Catholic religious orders, such as the Alexians and the Bon Secours Sisters, which still focus on hospital ministry today.

In accord with the original meaning of the word, hospitals were originally "places of hospitality", and this meaning is still preserved in the names of some institutions such as the Royal Hospital Chelsea, established in 1681 as a retirement and nursing home for veteran soldiers. Blood Tests A blood test is a laboratory analysis performed on a blood sample that is usually extracted from a vein in the arm using a needle, or via fingerprick. Blood tests are used to determine physiological and biochemical states, such asdisease, mineral content, drug effectiveness, and organ function. They are also used in drug tests. A basic metabolic panel measures sodium, potassium, chloride, bicarbonate, blood urea nitrogen (BUN), magnesium,creatinine, glucose, and sometimes includes calcium. Blood tests focusing on cholesterol levels can determine LDLand HDL cholesterol levels, as well as triglyceride levels.[5]

Some blood tests, such as those that measure glucose, cholesterol, or for determining the existence or lack of STD, require fasting (or no food consumption) eight to twelve hours prior to the drawing of the blood sample.[6]

For the majority of blood tests, blood is usually obtained from the patient's vein. However, other specialized blood tests, such as the arterial blood gas, require blood extracted from an artery. Blood gas analysis of arterial blood is primarily used to monitor carbon dioxide and oxygen levels related to pulmonary function, but it is also used to measure blood pH and bicarbonate levels for certain metabolic conditions.[7]

While the regular glucose test is taken at a certain point in time, the glucose tolerance test involves repeated testing to determine the rate at which glucose is processed by the body.[8]

Normal ranges

The medical doctors and their role inside and Hospital Doctor of Medicine (M.D., from the Latin Medicinae Doctormeaning "Teacher of Medicine") is a terminal degree for physicians and surgeons. In some countries it is aprofessional doctorate where training is entered after obtaining between 90 and 120 credit hours of university level work (see second entry degree) and in most cases after obtaining a Bachelors Degree. In other countries, such asIndia, Egypt, the United Kingdom, Germany, and Brazil the M.D. is a research degree more similar to a Ph.D.. In Britain,Egypt, Pakistan, India, Ireland, and many Commonwealthnations, the medical degree is instead the MBBS i.e.,Bachelor of Medicine, Bachelor of Surgery (MBChB, MB BChir, BM BCh, MB BCh, MBBS, BMBS, BMed, BM) and M.D. is a higher level of attainment. In particular the physician is a professional who practicesmedicine, which is concerned with promoting, maintaining or restoring human health through the study, diagnosis, and treatment of disease,injury, and other physical and mental impairments. They may focus their practice on certain disease categories, types of patients, or methods of treatment – known as specialist medical practitioners – or assume responsibility for the provision of continuing and comprehensive medical care to individuals, families, and communities – known as general practitioners.[2]

Medical practice properly requires both a detailed knowledge of theacademic disciplines (such as anatomy andphysiology) underlying diseases and their treatment – the science of medicine – and also a decent competence in its applied practice – the art or craft of medicine. Both the role of the physician and the meaning of the word itself vary around the world, including a wide variety of qualifications and degrees, but there are some common elements. For example, the ethics of medicine require that physicians show consideration, compassion and benevolence for their patients.

Regarding the specific activity of the Medical Doctor in an Hospital, we can say that he apply his medical knowledge and his skills to the diagnosis, prevention and management of disease. The work in wards and out-patient clinics, above all in the public sector but in the privat sector, too. They also work with many other health care professionals, including nurses, radiographers, pharmasists and physiotherapists. Hospital medical doctors work within a number of specialities whose most common are: anesthetic, emergency medicine, general medicine, general surgery, obstetrics and gynecology, pediatrics, psychiatry,, rauma and orthopedic. Obesity Obesity is a medical condition in which excess body fat has accumulated to the extent that it may have an adverse effect on health, leading to reduced life expectancy and/or increased health problems.[1][2] People are considered obese when their body mass index (BMI), a measurement obtained by dividing a person's weight in kilograms by the square of the person's height in metres, exceeds 30 kg/m2.[3]

Obesity increases the likelihood of various diseases, particularly heart disease, type 2 diabetes, obstructive sleep apnea, certain types of cancer, and osteoarthritis.[2] Obesity is most commonly caused by a combination of excessivefood energy intake, lack of physical activity, and genetic susceptibility, although a few cases are caused primarily bygenes, endocrine disorders, medications or psychiatric illness. Evidence to support the view that some obese people eat little yet gain weight due to a slow metabolism is limited; on average obese people have a greater energy expenditure than their thin counterparts due to the energy required to maintain an increased body mass.[4][5]

Dieting and physical exercise are the mainstays of treatment for obesity. Diet quality can be improved by reducing the consumption of energy-dense foods such as those high in fat and sugars, and by increasing the intake of dietary fiber. Anti-

obesity drugs may be taken to reduce appetite or inhibit fat absorption together with a suitable diet. If diet, exercise and medication are not effective, a gastric balloon may assist with weight loss, or surgery may be performed to reduce stomach volume and/or bowel length, leading to earlier satiation and reduced ability to absorb nutrients from food.[6][7]

Obesity is a leading preventable cause of death worldwide, with increasing prevalence in adults andchildren, and authorities view it as one of the most serious public health problems of the 21st century.[8]Obesity is stigmatized in much of the modern world (particularly in the Western world), though it was widely perceived as a symbol of wealth and fertility at other times in history, and still is in some parts of the world.[2][9]

Hyperthension Hypertension (HTN) or high blood pressure, sometimes called arterial hypertension, is a chronic medical conditionin which the blood pressure in the arteries is elevated.[1]This requires the heart to work harder than normal to circulate blood through the blood vessels. Blood pressure is summarised by two measurements, systolic and diastolic, which depend on whether the heart muscle is contracting (systole) or relaxed between beats (diastole) and equate to a maximum and minimum pressure, respectively. Normal blood pressure at rest is within the range of 100-140mmHg systolic (top reading) and 60-90mmHg diastolic (bottom reading). High blood pressure is said to be present if it is persistently at or above 140/90 mmHg.

Hypertension is classified as either primary (essential) hypertension or secondary hypertension; about 90–95% of cases are categorized as "primary hypertension" which means high blood pressure with no obvious underlying medical cause.[2] The remaining 5–10% of cases (secondary hypertension) are caused by other conditions that affect the kidneys, arteries, heart or endocrine system.

Hypertension is a major risk factor for stroke, myocardial infarction (heart attacks), heart failure, aneurysms of the arteries (e.g. aortic aneurysm), peripheral arterial diseaseand is a cause of chronic kidney disease. Even moderate elevation of arterial blood pressure is associated with a shortened life expectancy. Dietary and lifestyle changes can improve blood pressure control and decrease the risk of associated health complications, although drug treatment is often necessary in people for whom lifestyle changes prove ineffective or insufficient.

Hypertension is rarely accompanied by any symptoms, and its identification is usually through screening, or when seeking healthcare for an unrelated problem. A

proportion of people with high blood pressure reportheadaches (particularly at the back of the head and in the morning), as well as lightheadedness, vertigo,tinnitus (buzzing or hissing in the ears), altered vision or fainting episodes.[3] These symptoms however are more likely to be related to associated anxiety than the high blood pressure itself.[4]

On physical examination, hypertension may be suspected on the basis of the presence of hypertensive retinopathy detected by examination of the optic fundus found in the back of the eye usingophthalmoscopy.[5] Classically, the severity of the hypertensive retinopathy changes is graded from grade I–IV, although the milder types may be difficult to distinguish from each other.[5] Ophthalmoscopy findings may also give some indication as to how long a person has been hypertensive.[3]

Gastroesophageal reflux Gastroesophageal reflux disease (GERD), gastro-oesophageal reflux disease (GORD), gastric reflux disease, or acid reflux disease is a chronic symptom ofmucosal damage caused by stomach acid coming up from the stomach into the esophagus.[1]

GERD is usually caused by changes in the barrier between the stomach and the esophagus, including abnormal relaxation of the lower esophageal sphincter, which normally holds the top of the stomach closed, impaired expulsion of gastric reflux from the esophagus, or a hiatal hernia. These changes may be permanent or temporary.

Treatment is typically via lifestyle changes and medications such as proton pump inhibitors, H2 receptor blockers orantacids with or without alginic acid.[2] Surgery may be an option in those who do not improve. In the Western world between 10 and 20% of the population is affected.

GERD is caused by a failure of the lower esophageal sphincter. In healthy patients, the "Angle of His"—the angle at which the esophagus enters the stomach—creates a valve that prevents duodenal bile, enzymes, and stomach acid from traveling back into the esophagus where they can cause burning and inflammation of sensitive esophageal tissue.

Factors that can contribute to GERD:

• Hiatal hernia, which increases the likelihood of GERD due to mechanical and motility factors.[9][10]

• Obesity: increasing body mass index is associated with more severe GERD.[11] In a large series of 2000 patients with symptomatic reflux disease,

it has been shown that 13% of changes in esophageal acid exposure is attributable to changes in body mass index.[12]

• Zollinger-Ellison syndrome, which can be present with increased gastric acidity due to gastrinproduction.

• Hypercalcemia, which can increase gastrin production, leading to increased acidity.

• Scleroderma and systemic sclerosis, which can feature esophageal dysmotility.

• The use of medicines such as prednisolone. • Visceroptosis or Glénard syndrome, in which the stomach has sunk in the

abdomen upsetting the motility and acid secretion of the stomach. • Yeast infection

GERD has been linked to a variety of respiratory and laryngeal complaints such as laryngitis, chronic cough, pulmonary fibrosis, earache, and asthma, even when not clinically apparent. These atypical manifestations of GERD is commonly referred to as laryngo pharyngeal reflux or as extra esophageal reflux disease (EERD).

Factors that have been linked with GERD, but not conclusively:

• Obstructive sleep apnea[13][14] • Gallstones, which can impede the flow of bile into the Duodenum, which can

affect the ability to neutralize gastric acid In 1999, a review of existing studies found that, on average, 40% of GERD patients also had H. pyloriinfection.[15] The eradication of H. pylori can lead to an increase in acid secretion, leading to the question of whether H. pylori-infected GERD patients are any different than non-infected GERD patients. Adouble-blind study, reported in 2004, found no clinically significant difference between these two types of patients with regard to the subjective or objective measures of disease severity.

X-ray showing radiocontrast agent injected into the stomach entering the esophagus due to severe reflux

The diagnosis of GERD is usually made when typical symptoms are present.[18] Reflux can be present in people without symptoms and the diagnosis requires both symptoms or complications and reflux of stomach content.[19]

Other investigations may include esophagogastroduodenoscopy (EGD). Barium swallow X-raysshould not be used for diagnosis.[18] Esophageal manometryis not recommended for use in diagnosis being recommended only prior to surgery.[18] Ambulatory esophageal pH monitoring may be useful in those who do not improve after PPIs and is not needed in those in whom Barrett's esophagus is seen.[18] Investigations for H. pylori is not usually needed.[18]

The current gold standard for diagnosis of GERD is esophageal pH monitoring. It is the most objective test to diagnose the reflux disease and allows monitoring GERD patients in their response to medical or surgical treatment. One practice for diagnosis of GERD is a short-term treatment with proton-pump inhibitors, with improvement in symptoms suggesting a positive diagnosis. Short-term treatment with proton-pump inhibitors may help predict abnormal 24-hr pH monitoring results among patients with symptoms suggestive of GERD.

Diabetes Diabetes mellitus, or simply diabetes, is a group of metabolic diseases in which a person has high blood sugar, either because the pancreas does not produce enoughinsulin, or because cells do not respond to the insulin that is produced.[2] This high blood sugar produces the classical symptoms of polyuria (frequent urination), polydipsia(increased thirst) and polyphagia (increased hunger).

There are three main types of diabetes mellitus (DM).

• Type 1 DM results from the body's failure to produce insulin, and currently requires the person to inject insulin or wear an insulin pump. This form was previously referred to as "insulin-dependent diabetes mellitus" (IDDM) or "juvenile diabetes".

• Type 2 DM results from insulin resistance, a condition in which cells fail to use insulin properly, sometimes combined with an absolute insulin deficiency. This form was previously referred to as non insulin-dependent diabetes mellitus (NIDDM) or "adult-onset diabetes".

• The third main form, gestational diabetes occurs when pregnant women without a previous diagnosis of diabetes develop a high blood glucose level. It may precede development of type 2 DM.

Other forms of diabetes mellitus include congenital diabetes, which is due to genetic defects of insulin secretion, cystic fibrosis-related diabetes, steroid diabetes induced by high doses of glucocorticoids, and several forms of monogenic diabetes.

Untreated, diabetes can cause many complications. Acute complications include diabetic ketoacidosis andnonketotic hyperosmolar coma. Serious long-term complications include cardiovascular disease, chronic renal failure, and diabetic retinopathy (retinal damage). Adequate treatment of diabetes is thus important, as well as blood pressure control and lifestyle factors such as stopping smoking and maintaining a healthybody weight.

All forms of diabetes have been treatable since insulin became available in 1921, and type 2 diabetes may be controlled with medications. Insulin and some oral medications can cause hypoglycemia (low blood sugars), which can be dangerous if severe. Both types 1 and 2 are chronic conditions that cannot be cured.Pancreas transplants have been tried with limited success in type 1 DM; gastric bypass surgery has been successful in many with morbid obesity and type 2 DM. Gestational diabetes usually resolves after delivery.

Classification Diabetes mellitus is classified into four broad categories: type 1, type 2,gestational diabetes and "other specific types".[2] The "other specific types" are a collection of a few dozen individual causes.[2] The term "diabetes", without qualification, usually refers to diabetes mellitus. The rare disease diabetes insipidus has similar symptoms as diabetes mellitus, but without disturbances in the sugar metabolism (insipidus means "without taste" in Latin) and does not involve the same disease mechanisms.

The term "type 1 diabetes" has replaced several former terms, including childhood-onset diabetes, juvenile diabetes, and insulin-dependent diabetes mellitus (IDDM). Likewise, the term "type 2 diabetes" has replaced several former terms, including adult-onset diabetes, obesity-related diabetes, and noninsulin-dependent diabetes mellitus (NIDDM). Beyond these two types, there is no agreed-upon standard nomenclature. Type 1 diabetes Type 1 diabetes mellitus is characterized by loss of the insulin-producing beta cells of the islets of Langerhans in the pancreas, leading to insulin deficiency. This type can be further classified as immune-mediated or idiopathic. The majority of type 1 diabetes is of the immune-mediated nature, in which beta cell loss is a T-cell-mediated autoimmune attack.[5] There is no known preventive measure against type 1 diabetes, which causes approximately 10% of diabetes mellitus cases in North America and Europe. Most affected people are otherwise healthy and of a healthy weight when onset occurs. Sensitivity and responsiveness to insulin are usually normal, especially in the early stages. Type 1 diabetes can affect children or adults, but was traditionally termed "juvenile diabetes" because a majority of these diabetes cases were in children.

"Brittle" diabetes, also known as unstable diabetes or labile diabetes, is a term that was traditionally used to describe to dramatic and recurrent swings in glucose levels, often occurring for no apparent reason ininsulin-dependent diabetes. This term, however, has no biologic basis and should not be used.[6] There are many reasons for type 1 diabetes to be accompanied by irregular and unpredictable hyperglycemias, frequently with ketosis, and sometimes serious hypoglycemias, including an impaired counterregulatory response to hypoglycemia, occult infection,

gastroparesis (which leads to erratic absorption of dietary carbohydrates), and endocrinopathies (e.g., Addison's disease).[6] These phenomena are believed to occur no more frequently than in 1% to 2% of persons with type 1 diabetes.[7] Type 2 diabetes Type 2 diabetes mellitus is characterized by insulin resistance, which may be combined with relatively reduced insulin secretion.[2] The defective responsiveness of body tissues to insulin is believed to involve the insulin receptor. However, the specific defects are not known. Diabetes mellitus cases due to a known defect are classified separately. Type 2 diabetes is the most common type.

In the early stage of type 2, the predominant abnormality is reduced insulin sensitivity. At this stage, hyperglycemia can be reversed by a variety of measures and medications that improve insulin sensitivity or reduce glucose production by the liver. Gestational diabetes Gestational diabetes mellitus (GDM) resembles type 2 diabetes in several respects, involving a combination of relatively inadequate insulin secretion and responsiveness. It occurs in about 2%–5% of allpregnancies and may improve or disappear after delivery. Gestational diabetes is fully treatable, but requires careful medical supervision throughout the pregnancy. About 20%–50% of affected women develop type 2 diabetes later in life.

Though it may be transient, untreated gestational diabetes can damage the health of the fetus or mother. Risks to the baby include macrosomia (high birth weight), congenital cardiac and central nervous system anomalies, and skeletal muscle malformations. Increased fetal insulin may inhibit fetal surfactant production and cause respiratory distress syndrome. Hyperbilirubinemia may result from red blood cell destruction. In severe cases, perinatal death may occur, most commonly as a result of poor placental perfusion due to vascular impairment. Labor induction may be indicated with decreased placental function. A Caesarean section may be performed if there is marked fetal distress or an increased risk of injury associated withmacrosomia, such as shoulder dystocia.

A 2008 study completed in the U.S. found the number of American women entering pregnancy with pre-existing diabetes is increasing. In fact, the rate of diabetes in expectant mothers has more than doubled in the past six years.[8] This is particularly problematic as diabetes raises the risk of complications during pregnancy, as well as increasing the potential for the children of diabetic mothers to become diabetic in the future.

Case History Full name: Francesco Rossi Address: 944 5th Ave, New York, NY 10021 Home Phone: (212) 650-9269 Mobile (917) 555-5555 e-mail Francesco.Rossi@email.com sex: Male Date of Birth: 1974.08.20 Marital status: Married Emergency contact name: Ludovico Rossi Address: 25 E 77th St, New York, N Home phone (212) 650-9132 Mobile (917) 324-2234 Date Patient Signature

X

Describe the problem for which you now require treatment: Lack of visus on the left eye Date of onset January 23, 2013 Symptoms I cannot read small letters and often I am affected by a generalized pain to the head. Are you seeing anyone else for this problem? yes, my family doctor Referring Doctor Giovanni Cannizzaro Describe any other treatment you have received or are receiving for this injury: Nothing, at moment. Please, answer to the following questions regarding your pain symptoms: Do you have pain all the time: No, absolutely no pain. Pain is worse: // Pain intensity: // What activities make your pain or symptoms worse? Symptoms are worse when I start to read or what the television What activities relieve your pain or symptoms? Closing the eyes my symptoms are disappear.

Patient pain rating Please mark on the diagram the location and type of pain you are experiencing. Use the following symbols to represent the type of pain: Burning >>> Sharp xxx

Shooting +++

X

Living environment Where do you line? In an independent house. With whom do you live? I live with my wife and my daughter. Does your home have any of the following? Stairs, no lift assistive device. Employment status Staff researcher at a Public Physics research Institute

Have you ever had, or been told tat you have, any of the following? Diabetes No

Low Blood Sugar No

High Blood Pressure No

Hearth Disease No

Angina and chest pain No

Shortness of Breath Yes

Anemia No

Brocken Bone fractures No

Lung problems No

Multiple sclerosis No

Parkinson’s No

Allergies Yes

Cancer No

Kidney problems No

Ulcer Stomach problems No

Depression No

Arthritis No

Osteoporosis No

Thyroid problems No

Polio No

Stroke No

Circulation No

Blood disorders No

Head injury Yes

Muscular Dystrophy No

Seizures/Epilepsy No

Development/Grow problems No

Infection disease No

Repeated infections No

Skin disease Yes

Have you ever had surgery? No. Describe any other medical problems that you have had. During childhood I suffered from ear infections. Moreover, many times I had the the head bone broken. Family history Indicate if Mother, Father, Brother, Sister, Grandmother, Grandfather, Aunt or Uncle and age of onset if known. Heart disease: Grandfather Hypertension: Father Skin problems: Grandfather Osteoporosis: Mother Arthritis: Grandmother General Health Do you smoke or chew tobacco? No. Do you drink alcoholic beverages? Yes. On average, how many drinks per week? Five/Six. Do you have a pacemaker, transplanted organs or metal implants? No. How many time do you exercise per week? No exercises.