Impact of the environment on the health: From theory to practice.

The Erice 56 Charter titled "Impact of the environment on the health: from theory to practice" was unanimously approved at the end of the 56th course of the "International School of Epidemiology and Preventive Medicine G. D'Alessandro" held from 3rd to November 7, 2019 in Erice - Sicily (Italy) and promoted by the Study Group of "Environment and Health" of the Italian Society of Hygiene, Preventive Medicine and Public Health. The course, that included lectures, open discussions and guided working groups, was aimed to provide a general training on epidemiological and toxicological aspects of the environmental health impact, to be used by public health professionals for risk assessment, without forgetting the risk communications. At the end of the course 12 key points were agreed among teachers and students: they underlined the need of specific training and research, in the perspective of "One Health" and "Global Health", also facing emerging scientific and methodological issues and focusing on communication towards stakeholders. This Discussion highlight the need to improve knowledge of Health and Environment topic in all sectors of health and environmental prevention and management.

Atherosclerosis is associated with a higher risk of hepatic steatosis in HIV-infected patients.

INTRODUCTION: Cardiovascular Diseases (CD) have emerged as a leading cause of morbidity and mortality in HIV population. Some studies have reported higher carotid Intima Media Thickness (c-IMT), a measure of subclinical atherosclerosis (AT), in this cohort of patients. METHODS: Here, we evaluate the role of Hepatic Steatosis (HS) as likely marker for AT in 128 HIV-infected patients without hepatitis C infection. c-IMT has been detected non-invasively by carotid ultrasonography to assess the progression of AT. HS has been evaluated using a process based on vibration-controlled transient elastography (Fibroscan) by a novel ultrasonic controlled attenuation parameter (CAP). The cut-off value for defining the presence of significant HS was CAP > 259 dBm-1. RESULTS: AT has been detected in 26 patients (20.3%), whereas steatosis of grade 2 (S2) in 31 (24.2%). The variables statistically related to AT were age, obesity, diabetes, hypertension and S2. In the multivariate analysis, AT was only associated (p < 0.001) with age and S2. The optimal cut-off value indicated by ROC curve for predicting AT was CAP > 250 dB/m-1. DISCUSSION: Our results highlight the presence of AT in HIVinfected persons and its association with fatty liver disease; therefore, HS assessment in HIV population results crucial to predict AT and CD.

Safety, efficacy, and tolerability of differential treatment to prevent and treat vaginal dryness and vulvovaginitis in diabetic women.

BACKGROUND: Problems affecting the vaginal tract in diabetic women are very often neglected. The efficacy and safety of three gynecological treatments in diabetic women have been assessed. MATERIALS AND METHODS: A single-blind randomized progressive trial on 48 diabetic women affected by vaginal dryness, dyspareunia, and recurrent Candida infections was carried out. The ICIQ Vaginal Symptoms (ICIQ-VS) questionnaire was administered. RESULTS: The analysis of the parameters of ICIQ-VS questionnaire among the three groups showed significant difference only for "dragging pain" (p = 0.0 19) and "soreness" (p = 0.028). In all groups and for all parameters of the questionnaire, improvement of symptoms was observed. In particular, in Group 1 for all symptoms a highly significant difference was observed, to support the already known benefits of the products and of the proposed combination. Significant improvement was also observed in Group 2. CONCLUSIONS: The proposed treatment with DermoXEN® Ultracalming Special for diabetics and DermoXEN® Vitexyl vaginal gel exert effective moisturizing and soothing action. Indeed, the aforementioned products have been proven effective for the main gynecological problems of diabetic women.

Using the cytokinesis-block micronucleus cytome assay to evaluate chromosomal DNA damage in chronic renal patients undergoing bicarbonate haemodialysis and haemodiafiltration.

INTRODUCTION: Chronic Renal Failure (CRF) patients are considered to show genomic instability and are associated with a high risk of both cardiovascular diseases and cancer. We explored DNA damage due to two dialysis treatments in 20 patients undergoing bicarbonate haemodialysis (BD), 20 undergoing haemodiafiltration (HDF) and 40 healthy subjects. METHODS: The cytokinesis-block micronucleus (MN) assay was performed on peripheral blood lymphocytes to evaluate genetic damage. RESULTS: A higher frequency of MN in the dialysis groups compared with controls was found. The results do not show a relationship between genetic instability and the type, frequency and duration of haemodialysis. The average BD and HDF treatment time was respectively 3.8 ± 6.3 and 3.7 ± 3.9 yrs. CAT and scintigraphy was independently correlated with high levels of MN. CONCLUSIONS: Overall, the frequency of MN in CRF patients undergoing dialysis therapy was observed to be higher. Further studies need to be performed on a larger number of patients and for a longer period.

Are 6-8 year old Italian children moving away from the Mediterranean diet?

BACKGROUND: The Mediterranean diet (MD) is considered one of the healthiest dietary models, as it decreases the risk of chronic diseases and may modulate the organism's early response to environmental pollution. In recent decades, Mediterranean countries have been replacing their traditional diet with other less healthy eating habits, especially among children and teenagers. OBJECTIVE: The aim of this study was to evaluate the MD and the level of adherence to it in 6-8 year old Italian children, in relation to residence, lifestyle, and social and family contexts. METHODS: A questionnaire was administered to the children's parents in two seasons in 5 Italian towns. The diet section contained 116 questions investigating the frequency of consumption of different types of food. The Italian Mediterranean Index (IMI) was calculated according to the intake of 6 typical Mediterranean and 4 non-Mediterranean foods. On the basis of IMI score, MD adherence was classified as low (≤ 3 IMI score), medium (4-5) and high (≥ 6). Total energy load and diet composition in micro- and macronutrients were calculated from consumption frequency. RESULTS: Diet analysis was computed on 1164 subjects with two complete questionnaires. Body mass index, calculated for each subject, showed that 28.9% of the children were overweight, the figure varying slightly with area of residence. Our findings showed that 59.0% of the children had a low score for MD adherence. CONCLUSIONS: The results of this study showed that most Italian children did not follow the MD and socio-economic characteristics appeared not to be associated with type of diet.

Feasibility and reliability of a questionnaire for evaluation of the exposure to indoor and outdoor air pollutants, diet and physical activity in 6-8-year-old children.

INTRODUCTION: The MAPEC-Life project aims to study the biological effects of early exposure to air pollutants on the oral mucosa cells of school-age children in five Italian cities. A questionnaire was created to evaluate the association between outdoor and indoor airborne pollutants, lifestyle, diet and biomarker effects. The feasibility and reliability of the questionnaire were evaluated. METHODS: A questionnaire was drawn up to be filled in by the parents of 6-8-year-old children. It consisted of 148 questions on the children's health, physical activity, environmental exposures and the frequency of food consumption at the main meals. First we conducted a questionnaire feasibility study involving 53 volunteer parents. We then performed a reliability study by administering the questionnaire to a further 156 parents and again one month later (test/retest method). The correlations between answers at the first and second administration of the questionnaire were evaluated using the Kappa statistic and Spearman's coefficient. RESULTS: After verifying the feasibility of the questionnaire, we conducted a reliability analysis on 132 completed questionnaires. The percentage of agreement between the first and the second responses given was over 70%, all K values being greater than 0.6. The analysis of calories and macronutrients also showed good agreement. CONCLUSIONS: The questionnaire drawn up for the study proved to be sufficiently reliable for gathering information about the factors of interest in our study of the relationship between air pollution and early biological effects in children.

Surveillance of human influenza A(H3N2) virus from 1999 to 2009 in southern Italy.

The aim of this study was to evaluate the presence of influenza virus co-infections in humans and changes in the genetic variability of A(H3N2) virus strains in southern Italy from 1999 to 2009. A partial sequence of the haemagglutinin (HA) gene by human influenza H3N2 strains identified in oropharyngeal swabs from patients with influenza-like illness was analysed by DNA sequencing and a phylogenetic analysis was performed. During the seasons 1999-2000, 2002-2003, 2004-2005 and 2008-2009, the influenza viruses circulating belonged to subtype H3N2. However, A(H1N1) subtype virus and B type were respectively prevalent during the 2000-2001, 2006-2007, 2007-2008 and 2001-2002, 2003-2004, 2005-2006 seasons. The HA sequences appeared to be closely related to the sequence of the influenza A vaccine strain. Only the 2002-2003 season was characterized by co-circulation of two viral lineages: A/New York/55/01(H3N2)-like virus of the previous season and A/Fujian/411/02(H3N2)-like virus, a new H3 variant. In this study, over the decade analysed, no significant change was seen in the sequences of the HA gene of H3 viruses isolated.

Bodies in sequestered and non-sequestered aquatic environments: a comparative taphonomic study using decompositional scoring system.

The study of decomposition by using accumulated degree days (ADDs) has been suggested not only in terrestrial decay but also for water-related deaths. Previous studies have demonstrated that the accumulation of thermal energy as a function of the post-mortem submersion interval (PMSI) can be derived from a descriptive decompositional scoring system (DSS). In order to verify how useful can the total aquatic decomposition score (TADS) for ADD prediction be, a comparative taphonomic study has been performed between two series of bodies: 16 corpses found floating in shallower waters with a presumptive PMSI from 3 to 118 days and exposed to water temperatures (Tw) between 10.5 and 20.3 °C approximately equating from a minimum of 46 to 1.392 ADD; 52 bodies, all victims of a single shipwreck, found in sequestered environments and subjected to constant Tw of 4 °C for 210 days approximately equating to 840 ADD. The two series of bodies have revealed different stages of decay and a large DSS variability. In most of bodies, freshly formed adipocere was able to delay the appearance of later decompositional stages explaining why most of the bodies were in relatively good condition. Although promising, the accuracy of the TADS model can be affected by adipocere and animal activity. The TADS model suffers of the same limitations for ADD calculations as they can give a false perception of accuracy due to the complexity of integrating all changing factors affecting human decay in sequestered and non-sequestered marine environments (currents, animal activity, water temperatures, depth of submersion).

Identification of HEV in symptom-free migrants and environmental samples in Italy.

Hepatitis E virus (HEV) is considered an emerging pathogen in industrialized countries. The occurrence of HEV genotypes in samples of faeces from asymptomatic migrants arriving on the coasts of South Italy and environmental samples was investigated. Analyses of sequences were used to compare human and environmental genotypes. A total of 40 stool specimens, 12 samples of untreated urban sewage, 12 samples of treated urban sewage and 12 samples of surface water were analysed. Viruses were concentrated from water samples by the tangential flow ultrafiltration technique. The presence of HEV RNA was detected by nested RT-PCR. Viral isolates were sequenced and phylogenetically characterized. Two (5%) of the 40 faecal samples tested were found to be positive for HEV RNA (G1 and G3 genotypes). The virus was detected in 25% (3/12) of the untreated sewage samples and 25% (3/12) of the surface water samples: all isolates belonged to G3 genotype. None of the treated sewage samples were found to be HEV RNA positive. The virus was detected in the faeces of two asymptomatic subjects, suggesting a potential role for symptom-free HEV carriers as a human reservoir. G3 HEV strains were detected in the untreated sewage, as observed in similar studies conducted in other European countries but differing from another study conducted in Italy recently. Moreover, our results show the first case of HEV isolated from fresh surface waters.

Sequence analysis of human rotavirus strains: comparison of clinical isolates from Northern and Southern Italy.

The surveillance and monitoring of rotavirus (RV)-related diseases, preferably through the establishment of sentinel surveillance sites, are essential for assessing the need for vaccination and the projected results of the vaccine in terms of reducing the burden of disease. The objective of the present study was to compare RV strains isolated in Northern (Ferrara) and Southern (Galatina-LE) Italy. During 2007-2008, 115 RV-positive stool samples were collected from children with diarrhea admitted to the hospitals of Ferrara and Galatina. The specimens were genotyped for VP7 (G-type) and VP4 (P-type) gene by reverse transcription (RT) and multiplex polymerase chain reaction (PCR). A subset of 21 RV strains was randomly selected and characterized by sequence analysis of the VP7 genes. In total, seven G/P combinations (G1P[8], G2P[4], G4P[8], G9P[8], G2P[8], G1P[9], and G2P[10]) were identified. Phylogenetic comparison of the VP7 encoding gene of selected strains showed that there was similarity among RV strains circulating in Northern and Southern Italy. The observation of nucleotide sequence diversity contributes to a better understanding of RV spreading and helps to characterize the various antigenic shifts that could have an impact on vaccine effectiveness.

Molecular approaches in the diagnosis of sepsis in neutropenic patients with haematological malignances.

INTRODUCTION: Sepsis is a major cause of significant morbidity and mortality in neutropenic patients. Blood culture remains the gold standard in the microbiological diagnosis of bacterial or fungal bloodstream infections, but it has clear limits of rapidity and sensitivity. The objective of the study was to compare the real-time polymerase chain reaction (RT-PCR) with automated blood cultures (BC) method in detection in whole blood of pathogens in febrile neutropenic patients with hematological malignancies. METHODS: A total of 166 consecutive febrile neutropenic patients were enrolled. Blood samples for cultures and SeptiFast testing were obtained at the onset of fever, before the implementation of empirical antibiotic therapy. RESULTS: Forty (24.1%) samples out of the 166 blood samples tested, were positive by at least one method. Twenty-three (13.9%) samples were positive by blood culture and 38 (22.9%) by multiplex real-time PCR. The analysis of concordance evidenced a low correlation between the two methods (n = 21; 52.5%), mainly due to samples found negative by culture but positive with the Septi-Fast assay. Sensitivity, specificity, and positive and negative predictive values of RT-PCR were 91.3%, 88.1%, 55.3%, and 98.4%, respectively, compared with BC. DISCUSSION: Multiplex real-time PCR assay improved detection of the most bacteria associated with febrile neutropenia episodes. Further studies are needed to assess the real advantages and clinical benefits that molecular biology tests can add in diagnosis of sepsis.

Facial approximation for identification purposes: soft tissue thickness in a Caucasian population. Sex and age-related variations.

The aim of this study was to collect soft tissue thickness (STT) values of an Italian population from 12 bone landmarks, to improve the facial approximation process for identification purposes. 100 Italian adults (50 males and 50 females), who had undergone head CT for clinical purposes, were analysed in order to expand the database of the Italian population. Average values, standard deviation and range were collected according to gender and age and the obtained values were statistically analysed in order to evaluate any possible significant difference. Only one landmark was statistically significant associated with sex, females showed significantly higher values for para-zygomaxillary. Two landmarks were statistically significant associated with age, upper incisor and pogonion. The obtained results were compared with the existing literature. Such information can be useful in the forensic craniofacial reconstruction process and can facilitate choosing the most suitable STT values according to osteological analysis of the human remains.

Widespread microbiological groundwater contamination in the South-eastern Salento (Puglia-Italy).

In the Salento peninsula (Puglia Region, South-East Italy), underground waters are a fundamental resource for the population because they constitute the principal reservoir for drinking water and irrigation. They are, however, affected by overexploitation. The risk factors in the Salento arise mainly from anthropic activities, especially tourism and agriculture (leaking wells, sewage and inadequate waste disposal procedures). The Southern Salento is recognized to be at high risk of pathologies characterised by oral-faecal transmission. From 2001 to 2009 the incidence of typhoid fever in the Salento was 12.11/100,000 inhabitants as against 2.91 in Italy. Enteritis caused by rotaviruses is an important cause of hospitalization of paediatric-aged children in the Salento, with high social costs. An effective monitoring system for the conservation and management of water bodies and the protection of public health is therefore fundamental. The present study sought to determine the microbiological and chemical-physical quality of groundwater in the Salento and to analyse the factors associated with contamination. The results indicated widespread pollution from salt and microbial contamination. Contamination from faecal microorganisms posed a significant risk of human infection in 100% of samples. Furthermore, the water was unsuitable even for irrigation in a high percentage of cases (31.8%), which is of considerable significance given that agriculture is one of the most important economic activities in the area under study. The high salt concentration was probably due to excessive extraction of water for intensive irrigation, especially in summer. Under these circumstances, some of mitigation activity is necessary. Furthermore, it would be advisable to decrease the pollution load from anthropic activities in the territory and to reduce water consumption in order to conserve groundwater resources especially.

Caesarean section in the world: a new ecological approach.

INTRODUCTION: This study aimed to estimate the most recent caesarean section rates in the world and examine the association between these rates and old and new indicators of health care. METHODS: Authors analyzed the Caesarean Section (CS) rates, also in geo-economic and economic groups, and correlated them to maternal and neonatal mortality, to births attended by skilled health personnel and to births among adolescents. Analysis of covariance and piecewise regressions were used for the statistical analysis. RESULTS: In 47.2% of the countries, the CS rate exceeded 15%. Countries of Latin America and the Caribbean along with Europe, North America and Oceania had the highest values. The analysis showed an inverse association between CS rates and Maternal Mortality (MMR) and Neonatal Mortality (NMR) for all geographical areas except for Europe. The greatest association was observed in lower-middle-income countries. In developing countries only 50% of cases, occur in medical facilities and only half of these are seen by medical, nursing and obstetrical staff. Age of the mother appears to influence the outcome and choice of delivery type. Countries where an high ABR rate is present have low CS use. CONCLUSIONS: To best evaluate the consequences of the increasing rate of CS, it would be useful to identify the most sensitive outcome indicators.

Phlegmasia Cerulea Dolens: a sudden unexpected death with hypothesis of medical malpractice.

ABSTRACT: Phlegmasia Cerulea Dolens (PCD) is a severe and rare form of venous thrombosis of the lower extremities, caused by a subtotal or complete occlusion of venous outflow by a thrombus. PCD should be considered a real medical emergency; complications include necrosis and gangrene of the affected limb, amputation, massive pulmonary embolism and, in extreme cases, the death of the patient. Case Report. A 63-years-old man was admitted to the Emergency room with localized pain on the right calf, hyperthermia, cold sweating and vomiting episodes. Five days prior he developed flu-like symptoms, joint pain and cold sensation unresponsive to treatment. Ultrasound examination showed a deep venous thrombosis of the lower right limb with partial occlusion of common iliac and femoral veins. The patient was treated with low molecular weight heparin given twice daily. He began to develop severe hypotension and metabolic acidosis, with tachycardia and atrial fibrillation. Despite the treatment, there was no improvement and he developed severe sinus node dysfunction. He failed to respond to all resuscitative efforts and died. Family members complained Authority, assuming it was a medical error. The clinical-forensic investigation is essential to determine the causes and manner of death and to assess medical responsibility and liability.

Age estimation from dry bone measurements: evidence from a sample of soldiers exiled in two concentration camps in Bari.

The mandible undergoes remodelling and morphological alterations throughout the life of an individual, and it is subjected to sex- and age-related structural changes. Personal identification from skeletal remains represents one of the most difficult challenges for a forensic anthropologist. The study of mandibular morphology is an important aid in determining the sex and age of skeletal remains. The objective of this study was to evaluate the age-related changes of three mandibular dimensions through dry bone measurements: bigonial width, ramus height and gonial angle. A total of 93 skeletal remains were included in this study, from a group of soldiers of Yugoslav origin who lived in two concentration camps in Bari (southern Italy) during World War II. These are included in the collection of the Forensic Anthropology Laboratory of the Institute of Forensic Medicine of Bari. The measurements were recorded after comprehensive examination by a forensic anthropologist and a forensic odonto-stomatologist. The data obtained were analysed statistically using a bivariate test and a multivariate linear regression model, using the Statal 13MP software. The results indicate that the bigonial width and gonial angle vary significantly according to age. In conclusion, this study confirms that the mandible is useful for age estimation in the identification of skeletal remains using these specific mandibular measurements when performed on dry bone without radiological distortion.

Methadone overdose in patients following methadone mainte- nance treatment:A three years overview in the district of Bari (South-Italy).

BACKGROUND: Methadone maintenance treatment (MMT) is reco-gnized as a reference treatment for opioid dependence. According to Italian Law, at the beginning of the treatment patients must receive medication under the supervision of a physician, to avoid overdose. After a period of stability, patients could be allowed to take methadone at home in pre-arranged and personalized concentrations, in order to empower their self-responsibility. The aim of the present investigation is to underline the presence of a "glitch in the system" of the MMT. METHODS: In the last three years, 7 forensic autopsies and toxi-cological analysis on corpses of regular opioid users were performed into the Institute of Legal Medicine of Bari. CONCLUSION: Therefor an improvement of the MMT's guideline is needed to reduce methadone overdose deaths in future. RESULTS: In all these cases very high methadone concentration in blood were found. All the 7 subjects were following a MMT in a Public Health Institute and the cause of death was respiratory depression by overdose of methadone in 6 cases.

Study of the correlation between microfauna and the macrostructure of activated sludge and the efficiency of biological wastewater treatment plants.

Assessment of protozoan populations is an important tool in evaluating the efficiency of activated sludge in the treatment of wastewater. In this process, protozoa play a significant role by grazing on dispersed bacteria, supporting a healthy food web in activated sludge artificial ecosystems. The objective of this study was to verify how the success of the purification process in activated sludge plants, mainly in terms of TSS, BOD, and COD, is related to ciliate protozoa communities and the presence of filamentous bacteria. Samples were collected from five water treatment plants in the Puglia region, in the period May 2007 - April 2008. Microfauna and filamentous bacteria were identified and quantified, and the sludge biotic index calculated. The data show a correlation between the biological components of activated sludge and traditional chemical parameters. Our results indicate that biological analyses represent a valid alternative to traditional chemical testing in assessing the performance of activated sludge systems.

Microbial and nutritional aspects on the production of live feeds in a fish farming industry.

Aquaculture is an enterprise in constant development, in particular relating to its effect on the environment and also the quality of its products. It represents a valid alternative to traditional fishing, facing the increasing demand for fish products. To guarantee to the consumer a product of high nutritional, organoleptic and hygienic quality, it is fundamental to monitor every phase of the fish farming industry, isolating the potential risk points. For this reason there has been a rapid evolution of productive technique, particularly in the technology, artificial reproduction and feed sectors. The aim of this research has been the monitoring of the evolution of certain microbial and nutritional quality indexes (total microbial counts and lipid analysis on suspensions of Rotifers and Artemia, used as live feed) in the larval phase of the productive cycle of the farm raised fish, in an intensive system. The study has shown an increment in the total microbial counts in the fish farming industry within the production of Rotifers and Artemia, more evident in the suspensions of Rotifers. In addition the study has demonstrated that the maintenance phase, in the enrichment protocol, can reduce the EPA and DHA content. The results confirm the importance of microbial and nutritional control of the live feeds before they get supplied to fish larvae.

Evaluation of radon exposure risk and lung cancer incidence/mortality in South-eastern Italy.

INTRODUCTION: Radon and its decay products may cause substantial health damage after long-term exposure. The aim of the study was to perform a spatial analysis of radon concentration in the Salento peninsula, province of Lecce (South-eastern Italy) in order to better characterize possible risk for human health, with specific focus on lung cancer. METHODS: Based on previous radon monitoring campaigns carried out in 2006 on behalf of the Local Health Authority (ASL Lecce) involving 419 schools and through the application of kriging estimation method, a radon risk map was obtained for the province of Lecce, in order to determine if areas with higher radon concentrations were overlapping with those characterized by the highest pulmonary cancer incidence and mortality rates. RESULTS: According to our data, areas at higher radon concentrations seem to overlap with those characterized by the highest pulmonary cancer mortality and incidence rates, thus indicating that human exposure to radon could possibly enhance other individual or environmental pro-carcinogenic risk factors (i.e. cigarette smoking, air pollution and other exposures). CONCLUSIONS: The radon risk should be further assessed in the evaluation of the causes resulting in higher mortality and incidence rates for pulmonary cancer in Salento area vs Italian average national data. For these reasons, ASL Lecce in cooperation with ARPA Puglia and CNR-IFC has included the monitoring of individual indoor radon concentrations in the protocol of PROTOS case-control Study, aimed at investigating the role of different personal and environmental risk factors for lung cancer in Salento.