Right ventricular-arterial uncoupling independently predicts survival in COVID-19 ARDS.

AIM: To investigate the prevalence and prognostic impact of right heart failure and right ventricular-arterial uncoupling in Corona Virus Infectious Disease 2019 (COVID-19) complicated by an Acute Respiratory Distress Syndrome (ARDS). METHODS: Ninety-four consecutive patients (mean age 64 years) admitted for acute respiratory failure on COVID-19 were enrolled. Coupling of right ventricular function to the pulmonary circulation was evaluated by a comprehensive trans-thoracic echocardiography with focus on the tricuspid annular plane systolic excursion (TAPSE) to systolic pulmonary artery pressure (PASP) ratio RESULTS: The majority of patients needed ventilatory support, which was noninvasive in 22 and invasive in 37. There were 25 deaths, all in the invasively ventilated patients. Survivors were younger (62 ± 13 vs. 68 ± 12 years, p = 0.033), less often overweight or usual smokers, had lower NT-proBNP and interleukin-6, and higher arterial partial pressure of oxygen (PaO2)/fraction of inspired O2 (FIO2) ratio (270 ± 104 vs. 117 ± 57 mmHg, p < 0.001). In the non-survivors, PASP was increased (42 ± 12 vs. 30 ± 7 mmHg, p < 0.001), while TAPSE was decreased (19 ± 4 vs. 25 ± 4 mm, p < 0.001). Accordingly, the TAPSE/PASP ratio was lower than in the survivors (0.51 ± 0.22 vs. 0.89 ± 0.29 mm/mmHg, p < 0.001). At univariate/multivariable analysis, the TAPSE/PASP (HR: 0.026; 95%CI 0.01-0.579; p: 0.019) and PaO2/FIO2 (HR: 0.988; 95%CI 0.988-0.998; p: 0.018) ratios were the only independent predictors of mortality, with ROC-determined cutoff values of 159 mmHg and 0.635 mm/mmHg, respectively. CONCLUSIONS: COVID-19 ARDS is associated with clinically relevant uncoupling of right ventricular function from the pulmonary circulation; bedside echocardiography of TAPSE/PASP adds to the prognostic relevance of PaO2/FIO2 in ARDS on COVID-19.

Accuracy and trending ability of hemoglobin measurement by the Pulse CO-Oximeter during vascular surgery.

Real time information of Hb concentration can guide a tailored patient blood management. The study investigates the accuracy, precision and trending ability of the Pulse CO-Oximeter (SpHb) and blood gas analyzer in measuring the Hb concentration, compared to hematological analysis, in surgery at high risk of hemorrhage. We performed an observational study, involving 48 patients undergoing abdominal aortic open surgery. The primary endpoints of the study were to compare the accuracy in measuring the Hb concentration using non-invasive method (Masimo rainbow SET® Radical 7 Pulse CO-Oximetry™) compared to the values provided by invasive conventional blood gas analyzer and hematological analysis. The secondary endpoint was to compare the differences between the baseline and the final value of the Hb after surgery (Δ-values), as well as the trending ability. Bias (precision) for the SpHb was 1.63 g/dL (± 0.05) with 95% limits of agreement between 0.85 and + 2.4 g/dL, while for the blood gas analyzer was 0.69 g/dL (± 0.04) with 95% limits of agreement between 0.07 and 1.3 g/dL. Δ-values values were not statistically different from the reference values of ΔHb obtained with the hematological analysis. Trending ability was good for both Pulse CO-Oximeter and blood gas analysis. Our results have shown that the SpHb is not precise enough to replace an invasive approach, but the trending ability of SpHb is accurate and may provide important information on the changes in hemoglobin concentration to guide blood management.

Spatial Variation in the Accumulation of Elements in Thalli of the Lichen Pseudevernia furfuracea (L.) Zopf Transplanted Around a Biomass Power Plant in Italy.

Thalli of the lichen Pseudevernia furfuracea were transplanted for 3 months at 32 sites located in and around an industrial area of S Italy whose main anthropogenic sources of atmospheric trace elements are a biomass power plant and vehicular emissions. Meteorological stations were deployed at four sites for finer detection of local wind patterns. The station near the biomass power plant showed a significant S-SE wind component not detectable by measurements made at the regional scale or by the other local meteorological stations. Sb, Sn, and Mo showed a very high degree of covariance and a statistically significant correlation with traffic rate. No element concentrations in the exposed thalli were correlated with distance from the biomass power plant, although Ti and Co concentrations showed a significant correlation with the "Potential Number of Times the Winds coming from the biomass power plant Reach each exposure Site" (PNTWRS). This value is calculated dividing the time (minutes) during the experimental trimester that the wind blows from the power plant into each of the four geographical sides by the time (minutes) the winds passing through the power plant take to reach the exposure sites in each of the four geographical sides.) during the period of thalli transplantation. Moreover, there were significant differences among clusters of sites with different levels of enrichment of Ti, Co, Al, V, and Cu and a "local control" group. These results, together with the high covariance of the Al-Ti and V-Co pairs, indicate an association between the biomass power plant and spatial variation of Ti, Co, Al, and V levels in the transplanted lichens. The nature of the fuels used in the biomass power plant explains the spatial variation of As, Cr, Cu, and Zn concentrations.

Assessment of lead pollution in topsoils of a southern Italy area: Analysis of urban and peri-urban environment.

Exposure to lead (Pb) may affect adversely human health. Mapping soil Pb contents is essential to obtain a quantitative estimate of potential risk of Pb contamination. The main aim of this paper was to determine the soil Pb concentrations in the urban and peri-urban area of Cosenza-Rende to map their spatial distribution and assess the probability that soil Pb concentration exceeds a critical threshold that might cause concern for human health. Samples were collected at 149 locations from residual and non-residual topsoil in gardens, parks, flower-beds, and agricultural fields. Fine earth fraction of soil samples was analyzed by X-ray Fluorescence spectrometry. Stochastic images generated by the sequential Gaussian simulation were jointly combined to calculate the probability of exceeding the critical threshold that could be used to delineate the potentially risky areas. Results showed areas in which Pb concentration values were higher to the Italian regulatory values. These polluted areas were quite large and likely, they could create a significant health risk for human beings and vegetation in the near future. The results demonstrated that the proposed approach can be used to study soil contamination to produce geochemical maps, and identify hot-spot areas for soil Pb concentration.

Capnocytophaga canimorsus Meningitis Complicated by Septic Shock: The Use of Extracorporeal Blood Purification Techniques.

Capnocytophaga canimorsus is a Gram-negative bacterium, commonly found as a commensal germ in the oral cavity of dogs and cats. It is an opportunistic pathogen, but, in specific situations, it can cause very severe diseases, including arthritis, pleuritis, endocarditis, sepsis, and, in extremely rare cases, meningoencephalitis. The predisposing situations include immunosuppression, liver cirrhosis, splenectomy, hemochromatosis, beta thalassemia major (Cooley's anemia), and alcohol abuse. In this report, we describe the case of a 48-year-old male patient, with a medical history of several predisposing conditions, who developed a severe case of meningoencephalitis caused by C. canimorsus, following a dog bite on his hand. The patient was successfully treated for his meningitis, but subsequently he developed a hospital-acquired septic shock from Acinetobacter baumannii, which was treated with targeted antibiotic therapy and sequential extracorporeal blood purification therapies using Oxiris™ and Toraymyxin™ hemofilters.

Ultrasound-Guided Regional Anesthesia Using a Mixture of Dexamethasone, Dexmedetomidine, and 0.2% Levobupivacaine for Bilateral Breast Cancer Surgery Under a Spontaneous Breathing Opioid-Free Anesthesia: A Case Report.

Breast cancer is unfortunately the most common cancer in women, although survival rates have greatly increased in recent years. Breast surgery can be very aggressive and therefore highly painful, leading to high rates of acute postsurgical pain and chronic pain. In addition to general anesthesia (GA), ultrasound-guided regional anesthesia (RA) is sometimes performed to help reduce acute postoperative pain and consumption of opioids. Although effective, the main limitation of fascial plane blocks is that they require high volumes of local anesthetics, carrying the risk of local anesthetic systemic toxicity. In this article, we present the case of a 41-year-old woman, who refused GA and was successfully operated on for bilateral breast cancer, under a spontaneous breathing opioid-free sedation and ultrasound-guided RA, based on only 0.2% levobupivacaine with the addition of dexamethasone and dexmedetomidine as adjuvants. Despite this, postoperative analgesia lasted for more than 48 hours, and the patient did not require additional analgesia or opioids.

Pharmacokinetic parameters of CAZ-AVI in the normal lung and in models of pneumonia: lessons for treatment optimization in critical care.

The spread of multidrug-resistant Gram-negative bacterial infections is a significant issue for worldwide public health. Gram-negative organisms regularly develop resistance to antibiotics, especially to ß-lactam antimicrobials, which can drastically restrict the number of therapies. A third-generation cephalosporin and the non-ß-lactam ß-lactamase inhibitor avibactam, which exhibits broad-spectrum ß-lactamase inhibition in vitro, are combined to form ceftazidime-avibactam (CAZ-AVI). In this narrative review, we summarize data on pharmacokinetic (PK) parameters for CAZ-AVI in both animal and human models of pneumonia, as well as in healthy individuals. We assessed current literature performing an extensive search of the literature, using as search words 'CAZ-AVI', 'pharmacokinetics', 'pneumonia', 'lung', and 'epithelial lining fluid'. Overall, lung exposure studies of CAZ-AVI revealed that the epithelial lining fluid penetration ranges between 30% and 35% of plasma concentration. Despite the fair lung penetration of CAZ-AVI, this antimicrobial agent has a pivotal role in managing patients with multi-drug resistant Gram-negative pneumonia, however further studies are needed to better assess its PK profile.

The Ephrin tyrosine kinase a3 (EphA3) is a novel mediator of RAGE-prompted motility of breast cancer cells.

BACKGROUND: The receptor for advanced glycation-end products (RAGE) and its ligands have been implicated in obesity and associated inflammatory processes as well as in metabolic alterations like diabetes. In addition, RAGE-mediated signaling has been reported to contribute to the metastatic progression of breast cancer (BC), although mechanistic insights are still required. Here, we provide novel findings regarding the transcriptomic landscape and the molecular events through which RAGE may prompt aggressive features in estrogen receptor (ER)-positive BC. METHODS: MCF7 and T47D BC cells stably overexpressing human RAGE were used as a model system to evaluate important changes like cell protrusions, migration, invasion and colony formation both in vitro through scanning electron microscopy, clonogenic, migration and invasion assays and in vivo through zebrafish xenografts experiments. The whole transcriptome of RAGE-overexpressing BC cells was screened by high-throughput RNA sequencing. Thereafter, Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analyses allowed the prediction of potential functions of differentially expressed genes (DEGs). Flow cytometry, real time-PCR, chromatin immunoprecipitation, immunofluorescence and western blot assays were performed to investigate the molecular network involved in the regulation of a novel RAGE target gene namely EphA3. The clinical significance of EphA3 was explored in the TCGA cohort of patients through the survivALL package, whereas the pro-migratory role of EphA3 signaling was ascertained in both BC cells and cancer-associated fibroblasts (CAFs). Statistical analysis was performed by t-tests. RESULTS: RNA-seq findings and GSEA analysis revealed that RAGE overexpression leads to a motility-related gene signature in ER-positive BC cells. Accordingly, we found that RAGE-overexpressing BC cells exhibit long filopodia-like membrane protrusions as well as an enhanced dissemination potential, as determined by the diverse experimental assays. Mechanistically, we established for the first time that EphA3 signaling may act as a physical mediator of BC cells and CAFs motility through both homotypic and heterotypic interactions. CONCLUSIONS: Our data demonstrate that RAGE up-regulation leads to migratory ability in ER-positive BC cells. Noteworthy, our findings suggest that EphA3 may be considered as a novel RAGE target gene facilitating BC invasion and scattering from the primary tumor mass. Overall, the current results may provide useful insights for more comprehensive therapeutic approaches in BC, particularly in obese and diabetic patients that are characterized by high RAGE levels.

Extravascular lung water index, pulmonary vascular permeability index, and global end-diastolic volume index in mechanically ventilated COVID-19 patients requiring prone position ventilation: a preliminary retrospective study.

BACKGROUND: There is a lack of data on extravascular lung water index (EVLWi), pulmonary vascular permeability index (PVPi), and global end-diastolic volume index (GEDVi) during prone position ventilation (PPV) in coronavirus disease 2019 (COVID-19) patients. The objectives of this study were to analyze trends in EVLWi, PVPi, and GEDVi during PPV and the relationships between these parameters and PaO2/FiO2. METHODS: In this preliminary retrospective observational study, we performed transpulmonary thermodilution (TPTD) in seven mechanically ventilated COVID-19 patients without cardiac and pulmonary comorbidities requiring PPV for 18 hours, at specific times (30 minutes pre-PPV, 18 hours after PPV, and 3 hours after supination). EVLWi, PVPi and GEDVi were measured. The relationships between PaO2/FiO2 and EVLWi, and PVPi and GEDVi values, in the supine position were analyzed by linear regression. Correlation and determination coefficients were calculated. RESULTS: EVLWi was significantly different between three time points (analysis of variance, P=0.004). After 18 hours in PPV, EVLWi was lower compared with values before PPV (12.7±0.9 ml/kg vs. 15.3±1.5 ml/kg, P=0.002). Linear regression showed that only EVLWi was correlated with PaO2/FiO2 (ß =-5.757; 95% confidence interval, -10.835 to -0.679; r=-0.58; R2 =0.34; F-test P=0.029). CONCLUSIONS: EVLWi was significantly reduced after 18 hours in PPV and values measured in supine positions were correlated with PaO2/FiO2. This relationship can help clinicians discriminate whether deterioration in gas exchange is related to fluid overload or disease progression. Further clinical research should evaluate the role of TPTD parameters as markers to stratify disease severity and guide clinical management.

Catching the Main Ethiopian Rift evolving towards plate divergence.

Magmatism accompanies rifting along divergent plate boundaries, although its role before continental breakup remains poorly understood. For example, the magma-assisted Northern Main Ethiopian Rift (NMER) lacks current volcanism and clear tectono-magmatic relationships with its contiguous rift portions. Here we define its magmatic behaviour, identifying the most recent eruptive fissures (EF) whose aphyric basalts have a higher Ti content than those of older monogenetic scoria cones (MSC), which are porphyritic and plagioclase-dominated. Despite these differences, calculations highlight a similar parental melt for EF and MSC products, suggesting only a different evolutionary history after melt generation. While MSC magmas underwent a further step of storage at intermediate crustal levels, EF magmas rose directly from the base of the crust without contamination, even below older polygenetic volcanoes, suggesting rapid propagation of transcrustal dikes across solidified magma chambers. Whether this recent condition in the NMER is stable or transient, it indicates a transition from central polygenetic to linear fissure volcanism, indicative of increased tensile conditions and volcanism directly fed from the base of the crust, suggesting transition towards mature rifting.

Shallow conduit dynamics fuel the unexpected paroxysms of Stromboli volcano during the summer 2019.

Open conduit basaltic volcanoes can be potentially hazardous as the eruptive activity may turn suddenly from a steady state to highly explosive. Unexpected changes in explosion intensity are recurrent at Stromboli volcano, where major explosions and large-scale paroxysms sometimes break off the ordinary, Strombolian activity with little or no warning. Two powerful paroxysmal eruptions took place at Stromboli volcano during the summer 2019, causing widespread fires, consistent damages across the island, injuries and one fatality. Prediction of similar events is really challenging for the modern volcanology, though models propaedeutic to early-warning monitoring systems are not properly assessed yet in many volcanoes worldwide. Here, we present a multi-parametric study that combines petrological and geophysical data to investigate processes generating the two paroxysms. The time information derived by Li enrichments in plagioclase crystals correlates with tilt time series derived by seismometers installed on the island, highlighting the dominant role of shallow conduit processes in triggering the 2019 paroxysmal activity. Our dataset conceives a mechanism of gas slug formation and fast upward migration that finally triggered the eruptions in very limited times. The proposed model questions our capability to forecast such kind of paroxysms in times that are rapid enough to allow mitigation of the associated risk.

Multidrug-Resistant Infections and Outcome of Critically Ill Patients with Coronavirus Disease 2019: A Single Center Experience.

Background: The aim of this study was to assess the drivers of multidrug-resistant (MDR) bacterial infection development in coronavirus disease 2019 (COVID-19) and its impact on patient outcome. Methods: Retrospective analysis on data from 32 consecutive patients with COVID-19, admitted to our intensive care unit (ICU) from March to May 2020. Outcomes considered were MDR infection and ICU mortality. Results: Fifty percent of patients developed an MDR infection during ICU stay after a median time of 8 [4-11] days. Most common MDR pathogens were carbapenem-resistant Klebsiella pneumoniae and Acinetobacter baumannii, causing bloodstream infections and pneumonia. MDR infections were linked to a higher length of ICU stay (p = 0.002), steroid therapy (p = 0.011), and associated with a lower ICU mortality (odds ratio: 0.439, 95% confidence interval: 0.251-0.763; p < 0.001). Low-dose aspirin intake was associated with both MDR infection (p = 0.043) and survival (p = 0.015). Among MDR patients, mortality was related with piperacillin-tazobactam use (p = 0.035) and an earlier onset of MDR infection (p = 0.042). Conclusions: MDR infections were a common complication in critically ill COVID-19 patients at our center. MDR risk was higher among those dwelling longer in the ICU and receiving steroids. However, MDR infections were not associated with a worse outcome.

Mobility of REE from a hyperacid brine to secondary minerals precipitated in a volcanic hydrothermal system: Kawah Ijen crater lake (Java, Indonesia).

Rare Earth Elements (REE; lanthanides and yttrium) are elements with high economic interest because they are critical elements for modern technologies. This study mainly focuses on the geochemical behavior of REE in hyperacid sulphate brines in volcanic-hydrothermal systems, where the precipitation of sulphate minerals occurs. Kawah Ijen lake, a hyperacid brine hosted in the Ijen caldera (Indonesia), was used as natural laboratory. ∑REE concentration in the lake water is high, ranging from 5.86 to 6.52 mg kg-1. The REE pattern of lake waters normalized to the average local volcanic rock is flat, suggesting isochemical dissolution. Minerals spontaneously precipitated in laboratory at 25 °C from water samples of Kawah Ijen were identified by XRD as gypsum. Microprobe analyses and the chemical composition of major constituents allow to identify possible other minerals precipitated: jarosite, Al-sulphate and Sr, Ba-sulphate. ∑REE concentration in minerals precipitated (mainly gypsum) range from 59.53 to 78.64 mg kg-1. The REE patterns of minerals precipitated normalized to the average local magmatic rock show enrichment in LREE. The REE distribution coefficient (KD), obtained from a ratio of its concentration in the minerals precipitated (mainly gypsum) and the lake water, shows higher values for LREE than HREE. KD-LREE/KD-HREE increases in the studied samples when the concentrations of BaO, MgO, Fe2O3, Al2O3, Na2O and the sum of total oxides (except SO3 and CaO) decrease in the solid phase. The presence of secondary minerals different than gypsum can be the cause of the distribution coefficient variations. High concentrations of REE in Kawah Ijen volcanic lake have to enhance the interest on these environments as possible REE reservoir, stimulating future investigations. The comparison of the KD calculated for REE after mineral precipitation (mainly gypsum) from Kawah Ijen and Poás hyperacid volcanic lakes allow to generalize that the gypsum precipitation removes the LREE from water.

Symptomatic Aberrant Right Subclavian Artery: Advantages of a Less Invasive Surgical Approach.

We present the case of a 33-year-old woman with a non-aneurysmal, symptomatic aberrant right subclavian artery (ARSA) traveling posterior to the esophagus, as demonstrated on chest computed tomography (CT) scans. She was treated with a less invasive surgical approach: closure of the anomalous vessel close to its origin from the aortic arch, through a left thoracoscopic procedure, followed by right common carotid-subclavian artery transposition via an open right supraclavicular approach. This method avoids the postoperative morbidity associated with open thoracic surgery and allows a clear identification of the anatomic structures minimizing possible procedure-related complications as a long residual arterial stump.

Outcomes and biomarker analyses among patients with COVID-19 treated with interleukin 6 (IL-6) receptor antagonist sarilumab at a single institution in Italy.

BACKGROUND: The inflammatory pathology observed in severe COVID-19 disease caused by the 2019 novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is characterized by elevated serum levels of C reactive protein (CRP) and cytokines, including interferon gamma, interleukin 8 (IL-8), and interleukin 6 (IL-6). Initial reports from the outbreak in Italy, China and the USA have provided anecdotal evidence of improved outcomes with the administration of anti-IL-6 agents, and large-scale trials evaluating these therapies are ongoing. STUDY DESCRIPTION: In this retrospective case series, clinical outcomes and correlates of response to treatment with the IL-6 receptor antagonist sarilumab are described for 15 patients with COVID-19 from a single institution in Southern Italy. Among 10 patients whose symptoms improved after sarilumab treatment, rapid decreases in CRP levels corresponded with clinical improvement. Lower levels of IL-6 at baseline as well as lower neutrophil to lymphocyte ratio as compared with patients whose COVID-19 did not improve with treatment were associated with sarilumab-responsive disease. CONCLUSIONS: This observation may reflect a possible clinical benefit regarding early intervention with IL-6-modulatory therapies for COVID-19 and that CRP could be a potential biomarker of response to treatment.

Release and fate of Cr(VI) in the ophiolitic aquifers of Italy: the role of Fe(III) as a potential oxidant of Cr(III) supported by reaction path modelling.

Reaction path modelling of serpentinite dissolution in meteoric water was performed, varying Fe2O3/(FeO + Fe2O3) weight ratios of serpentine and reproducing the analytical concentrations of relevant solutes, including Cr(VI), in the Mg-HCO3 groundwaters hosted in the ophiolitic aquifers of Italy. The occurrence of geogenic Cr(VI) in these groundwaters appears to be potentially controlled by the oxidation of trivalent Cr to the hexavalent redox state, driven by the reduction of trivalent Fe to the divalent redox state. In fact, trivalent Fe is the only oxidant present in suitable amounts in serpentinite rock, and even serpentine contains a high content of trivalent Fe as proven by recent studies. In contrast, the generally accepted hypothesis that geogenic Cr(VI) in waters interacting with serpentinites is driven by the reduction of trivalent and tetravalent Mn is questionable, since serpentinite rock has a low Mn content and it is necessary to invoke adsorption of trivalent Cr ions onto the surface of Mn oxides, which are oxidised as a surface complex to hexavalent Cr. Moreover, Mn oxides are present in the aqueous solution as suspended particles or in rocks as coatings or nodules.

Ultra-trace determination of total mercury in Italian bottled waters.

Mercury (Hg) is a widespread, highly toxic persistent pollutant with adverse health effects on humans. So far, concentrations below the method detection limit have always been reported by studies on the concentration of mercury in bottled water when determined using instrumental analytical methods. These are often very expensive and are unaffordable for many laboratories. In this work, a less expensive method based on cold vapour atomic fluorescence spectrometry has been employed to determine total mercury (HgT) concentrations in bottled natural mineral waters. In all, 255 waters representing 164 different typologies were analysed. They came from 136 springs located in 18 Italian regions. In all samples, HgT concentrations were found in the range of sub-nanogram to a few nanograms per litre, well below the National and European regulatory limit (1 µg L-1). Differences in HgT concentrations were related not only to the environmental characteristics of the springs but also to the extent and impact of human activities. Higher concentrations were found in waters coming from regions with former mining and/or natural thermal and volcanic activity. These data allowed us to estimate the mercury intake by population (adults, children and toddlers) from drinkable mineral waters consumption. The mean mercury daily intake was found to be remarkably lower, not only than the provisional tolerable value (1 µg L-1 according to European and Italian legislation) but also than the estimated provisional tolerable weekly intake (PTWI) value (4 µg kg-1 body weight) recommended by the Joint FAO/WHO Expert Committee on Food Additives (JECFA).

Clinical guidelines for perioperative hemodynamic management of non cardiac surgical adult patients.

Perioperative hemodynamic management, through monitoring and intervention on physiological parameters to improve cardiac output and oxygen delivery (goal-directed therapy, GDT), may improve outcome. However, an Italian survey has revealed that hemodynamic protocols are applied by only 29.1% of anesthesiologists. Aim of this paper is to provide clinical guidelines for a rationale use of perioperative hemodynamic management in non cardiac surgical adult patients, oriented for Italy and updated with most recent studies. Guidelines were elaborated according to NICE (National Institute for Health and Care Excellence) and GRADE system (Grading of Recommendations of Assessment Development and Evaluations). Key questions were formulated according to PICO system (Population, Intervention, Comparators, Outcome). Guidelines and systematic reviews were identified on main research databases and strategy was updated to June 2018. There is not enough good quality evidence to support the adoption of a GDT protocol in order to reduce mortality, although it may be useful in high risk patients. Perioperative GDT protocol to guide fluid therapy is recommended to reduce morbidity. Continuous monitoring of arterial pressure may help to identify short periods of hemodynamic instability and hypotension. Fluid strategy should aim to a near zero balance in normovolemic patients at the beginning of surgery, and a slight positive fluid balance may be allowed to protect renal function. Drugs such as inotropes, vasocostrictors, and vasodilatator should be used only when fluids alone are not sufficient to optimize hemodynamics. Perioperative GDT protocols are associated with a reduction in costs, although no economic study has been performed in Italy.

Effects of source rocks, soil features and climate on natural gamma radioactivity in the Crati valley (Calabria, Southern Italy).

The study, which represents an innovative scientific strategy to approach the study of natural radioactivity in terms of spatial and temporal variability, was aimed to characterize the background levels of natural radionuclides in soil and rock in the urban and peri-urban soil of a southern Italy area; to quantify their variations due to radionuclide bearing minerals and soil properties, taking into account nature and extent of seasonality influence. Its main novelty is taking into account the effect of climate in controlling natural gamma radioactivity as well as analysing soil radioactivity in terms of soil properties and pedogenetic processes. In different bedrocks and soils, activities of natural radionuclides ((238)U, (232)Th (4) K) and total radioactivity were measured at 181 locations by means of scintillation γ-ray spectrometry. In addition, selected rocks samples were collected and analysed, using a Scanning Electron Microscope (SEM) equipped with an Energy Dispersive Spectrometer (EDS) and an X-Ray Powder Diffraction (XRPD), to assess the main sources of radionuclides. The natural-gamma background is intimately related to differing petrologic features of crystalline source rocks and to peculiar pedogenetic features and processes. The radioactivity survey was conducted during two different seasons with marked changes in the main climatic characteristics, namely dry summer and moist winter, to evaluate possible effects of seasonal climatic variations and soil properties on radioactivity measurements. Seasonal variations of radionuclides activities show their peak values in summer. The activities of (238)U, (232)Th and (4) K exhibit a positive correlation with the air temperature and are negatively correlated with precipitations.