XI. STRATEGIES FOR IMPROVING DIABETES CARE D iabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed. For more detailed information, refer to Bode (Ed.): Medical Management of Type 1 Diabetes (1), Burant (Ed): Medical Management of Type 2 Diabetes (2), and Klingensmith (Ed): Intensive Diabetes Management (3). The recommendations included are diagnostic and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E.

Standards of Medical Care in Diabetes

This review focuses on recent developments in forensic DNA typing. It highlights important recent advances and issues in forensic human identification and identifies representative papers. It is not intended to be comprehensive. The review is divided into several important topic areas. These include developments in forensic serology using RNA, proteomic, and Epigenetic markers, and methods for human identification using short tandem repeats, single nucleotide polymorphisms, and insertion deletions. Sequencing methods for autosomal DNA, sex linked DNA, and mitochondrial DNA are included as well as for the human microbiome. New technologies are also featured, such as real time PCR, microfluidics, integrated rapid PCR systems, and massively parallel sequencing. Expert systems have also been developed to assist with the analysis of data from these complex analytical tools.

Forensic DNA Analysis

This review paper covers the forensic-relevant literature in fingerprint and bodily impression sciences from 2016 to 2019 as a part of the 19th Interpol International Forensic Science Managers Symposium. The review papers are also available at the Interpol website at: https://www.interpol.int/content/download/14458/file/Interpol%20 Review%20 Papers%202019. pdf.

Interpol review of fingermarks and other body impressions 2016-2019.

Traces of body fluids can be present at a variety of crime scenes. It is important that forensic investigators have a reliable and nondestructive method of identifying these traces. Of equal importance is establishing the limitations of any method in use, including its detection limit. We have previously reported on the use of Raman microspectroscopy and multivariate data analysis to identify and differentiate body fluids. While many studies use serial dilutions to establish limits of detection, we utilized a different approach and demonstrated that a single red blood cell is sufficient to be correctly identified as blood. The experimental Raman spectra of individual red blood cells were loaded into the previously reported models for body fluid identification, and all were correctly classified as peripheral blood. These results demonstrate that our model can be used to identify peripheral blood, even if there is only a single red blood cell present. Furthermore, a single red blood cell is 5000× smaller than the amount of peripheral blood required to perform DNA analysis in a modern crime laboratory. This means that if a bloodstain is large enough for DNA analysis, Raman microspectroscopy should be able to make a positive identification. Considering that the sample analysis reported here was carried out with a different instrument, not the one used for the previously reported method development, these results also represent a form of method validation. The model's ability to correctly classify spectra acquired on a different instrumental platform is crucial in preparing it for practical application. Graphical Abstract Peripheral blood is of great interest in forensic sciences. While many tests are available for the identification of peripheral blood at a crime scene, most are presumptive and destructive. Here we present results that show our new, nondestructive method can identify peripheral blood using as little as a single red blood cell.

Identification of individual red blood cells by Raman microspectroscopy for forensic purposes: in search of a limit of detection

A high-performance liquid chromatographic method with ultraviolet (UV) and fluorescence detection was developed for the analysis of one indandione and four hydroxycoumarin anticoagulant rodenticides in human serum. The superwarfarin rodenticides, chlorophacinone, bromadiolone, difenacoum, brodifacoum, and difethialone, can be identified and quantitated simultaneously with this method. After adding a buffer (pH 5.5), the anticoagulants were extracted from serum with chloroform-acetone. The organic phase was separated and evaporated to dryness, and the residue was subjected to chromatographic analysis. The anticoagulants were separated by reversed-phase chromatography and detected by UV absorption at 285 nm and by fluorescence at an excitation wavelength of 265 nm and an emission wavelength of 400 nm. Extraction efficiencies from 55 to 131% were obtained. The within-run precision ranged from 2.0 to 7.1% for UV detection and from 0.0 to 4.8% for fluorescence detection. Between-run precision ranged from 1.3 to 16.0% for UV detection and from 1.8 to 9.0% for fluorescence detection. The anticoagulants can be quantitated at serum concentrations down to 3-12 ng/mL for fluorescence detection and down to 20-75 ng/mL for UV detection. No interferences were observed with the related compounds warfarin and vitamin K1.

9 a method for the simultaneous identification and quantification of five superwarfarin rodenticides in human serum

The aim of this study was to develop chemical improvements to the original Weber protocol, in order to increase the intensity and time length of light emission and to eliminate false-positive reactions. The intensity and duration of light were measured on serial blood dilutions using a plate reader chemiluminometer. Blood stains of various concentrations were impregnated in pure cellulose, dried, and luminol solution was added with/without the potential enhancers. An in silico study was also conducted, aiming to demonstrate the enhancing mechanism of hemoglobin denaturation using 8 M urea. The luminol blood detection test revealed important improvements after urea pretreatment or in the presence of monochloro-triazinyl-β-cyclodextrin. This approach also eliminated the false-positive reaction from sodium hypochlorite. These improvements could provide a higher sensitivity under particular circumstances such as old or washed blood stains, leading to a better localization for further DNA typing and higher quality photographic analysis.

Improving Luminol Blood Detection in Forensics

The aim of the study is to analyze how the patient’s rights are respected in Romanian hospitals and how important is communication for the medical staff. During this study, we have analyzed the results of an application form with 152 indicators, from Reference no. 6 “Patient’s rights and communication”, from Accreditation Standards, used by The National Authority of Quality Management in Healthcare, in 146 Romanian hospitals, from a total of 433 medical units. The study revealed that there are some recurrent problems related to patient’s rights and communication, such as: access in hospitals of people with disabilities, aspects related to informed consent, or communication between medical staff and patients or caregivers.

Patient’s rights and communication in the hospital accreditation process

The determination of the sexual cohabitation capacity may be required by the legal authorities in cases where persons suspected of committing sexual crimes declare themselves as being impotent, alleging their preexisting sexual impotence. In such cases it is compulsory to scientifically evaluate the existence or absence of the sexual impotence at the time of the presumed sexual offense. In this sense, various diagnostic tests are used, the intracavernous injection of papaverine (ICIP) being accepted by the judiciary system in Romania. During our forensic activity carried out at the Institute of Legal Medicine Cluj-Napoca we have applied this diagnostic test to a number of four male inmates in Gherla Penitentiary. The results obtained allowed us to evaluate the status of the inmates’ impotence at the time we had performed those tests. However, the ICIP, as assessor of the cohabitation capacity in men raises numerous diagnostic and nonetheless ethical issues. Among the most significant we might mention the following: difficulties in assessing the state of impotence depending upon the degree of the erection, the association of the test with sexual stimuli, the value of test according to the specific type of impotence diagnosed, the psychiatric aspect regarding the possibil ity of existence of a degree of needle phobia, the risk of complications.

Ethical and diagnostic difficulties of the cohabitation tests in the forensic expertise

In this paper, the authors want to introduce the concept of responsibility of an alive person to the values and rights of the deceased person through the ethical professional-personal model introduced, which will help us to make a decision when it comes to issues of morality and ethics in the forensic practice.

Ethical professional-personal model of making decisions in forensic medicine

The rationale of this paper is based on a deep fascination with the nature of identification, not only from a scientific point of view, but also from an existential and ethical perspective. In the field of Forensic Medicine the identification get extreme significance for a living person, being a proof of his or her existence. Especially in the modern society where everything has to be identified in order to be proved, identification is crucial. This paper is an attempt to make a philosophical approach to some identification methods, which are claimed by their supporters to be based on the theory of “uniqueness”. It is a challenging claim which is counteracted in an argumentative discussion. The conclusions of these paper are: uniqueness should not be used in forensic science, as it belongs to the realm of a pure philosophy because the “uniqueness” is impossible to prove.

Diana Bulgaru-Iliescu

Papers

Improving Luminol Blood Detection in Forensics

Patient’s rights and communication in the hospital accreditation process

Ethical and diagnostic difficulties of the cohabitation tests in the forensic expertise

Ethical professional-personal model of making decisions in forensic medicine

Claims of “uniqueness” in forensic medicine