L'emergenza COVID-19 nell'ottica del finanziamento del Servizio Sanitario Nazionale: analisi e proposte.

The COVID-19 pandemic crisis has strongly stressed national health systems and resulted in a global economic crisis. This paper aims to frame and evaluate the funding disbursed and the costs incurred by the National Health Service, in relation to the COVID-19 emergency. It also intends to assess current monetary policies. It aims also to suggest and provide proposals in the context of strengthening the NHS. A narrative review of the grey literature was conducted querying OpenGray, WONDER e Pro-quest's Digital Dissertations e Conference Papers Index and the major institutional websites. The ALTEMS COVID-19 Instant Reports and reports published by regional, national and European institutional bodies were used as main information sources. The discussion begins with the presentation of the economic-health and epidemiological situation, and ends with the proposal of possible initiatives aimed at economic and financial reinforcement of the NHS.

Factors affecting safe and healthy diet in older adults in Italy: results of a preliminary study performed in a community-dwelling sample.

OBJECTIVE: To investigate, through a questionnaire, older adults' demographic and socio-economic characteristics, knowledge, attitudes and practices in terms of food safety and healthy diet; and to develop dietary and hygiene indices able to represent participants' nutritional and food safety behaviour, exploring their association with demographic and socio-economic factors. DESIGN: One-year cross-sectional study. SETTING: Gemelli Teaching Hospital (Rome, Italy). PARTICIPANTS: People aged ≥65 years, Italian speaking, accessing the Centre of Ageing Medicine. RESULTS: Mean age of the sample was 74 (sd 7·7) years. Subjective perception of a safe diet was high: 64·2 % of respondents believed they have a balanced diet. Interviewees got informed about proper nutrition mainly from television, magazines, newspapers, Internet (29·9 %) and from health professionals (34·8 %) such as dietitians, whereas 15·4 % from general practitioners. Regarding food safety, 33·8 % of participants reported to consume expired food, even more than once per month; between 80 and 90 % of participants reported to follow food safety practices during preparation and cooking, even though 49·3 % defrosted food at room temperature. Calculated dietary and hygiene indices showed that the elderly participants were far from having optimal nutritional and food safety behaviours. CONCLUSIONS: These results suggest it is necessary to increase the awareness of older adults in the matter of healthy diet and food safety. Specific and targeted educational interventions for the elderly and their caregivers could improve the adoption of recommended food safety practices and safe nutritional behaviours among older adults.

The Clean Care Contest: promoting hand hygiene among healthcare and medical students.

INTRODUCTION: Despite continuing efforts, compliance rates and knowledge of best practices in hand hygiene remain disappointing. Recognizing that conventional educational tools seem out of touch with young people and that the med and messages contents need refreshing, the Italian Study Group of Hospital Hygiene of the Italian Society of Hygiene, Preventive Medicine and Public Health devised a novel approach to promote the creation of innovative educational tools for improving knowledge of, and compliance with, hand hygiene rules among healthcare and medical students. METHODS: A contest in creating educational material on hand hygiene practices involved university students of nursing and medicine, and of other healthcare degrees. Students from the universities of the GISIO network were invited to create educational material (e.g., videos, posters, presentations, leaflets, and screensavers) to be presented by May 5th 2019 during the World Hand Hygiene Day / Save Lives: Clean Your Hands Global Annual Initiative of the World Health Organization). A local and a national winners were awarded. RESULTS: Three different local and national contests were performed during 2016, 2017 and 2018. During the three-year period, more than 270 educational tools have been developed: 130 (48%) were judged useful for hand hygiene promotion campaigns. The most frequent projects participating in the contests were videos (39%), posters (29%), leaflets (14%), and others (18%) submitted by more than 1,500 students of nursing (40%), medicine (31%), dentistry (7%), and of other healthcare courses in 14 universities. Products were evaluated by a local committee and, subsequently, local winners represented their University in a national contest. CONCLUSIONS: The contest provided a framework for the creation of innovative and potentially effective educational tools via an engaging approach that leveraged student creativity. Given the need to improve compliance rates, this study suggests that new ways can be advantageously explored to teach hand hygiene procedures and increase awareness of the importance of their consistent use among healthcare and medical students.

Epidemiology of intensive care unit-acquired sepsis in Italy: results of the SPIN-UTI network.

BACKGROUND: Sepsis is the major cause of mortality from any infectious disease worldwide. Sepsis may be the result of a healthcare associated infection (HAI): the most frequent adverse events during care delivery especially in Intensive Care Units (ICUs). The main aim of the present study was to describe the epidemiology of ICU-acquired sepsis and related outcomes among patients enrolled in the framework of the Italian Nosocomial Infections Surveillance in ICUs - SPIN-UTI project. STUDY DESIGN: Prospective multicenter study. METHODS: The SPIN-UTI network adopted the European protocols for patient-based HAI surveillance. RESULTS: During the five editions of the SPIN-UTI project, from 2008 to 2017, 47.0% of HAIs has led to sepsis in 832 patients. Overall, 57.0% episodes were classified as sepsis, 20.5% as severe sepsis and 22.5% as septic shock. The most common isolated microorganisms from sepsis episodes were Acinetobacter baumannii, Klebsiella pneumoniae and Pseudomonas aeruginosa. The case fatality rate increased with the severity of sepsis and the mean length of ICU-stay was significantly higher in patients with ICU-acquired sepsis than in patients without. CONCLUSION: Our study provides evidence that ICU-acquired sepsis occurs frequently in Italian ICU patients and is associated with a high case fatality rate and increased length of stay. However, in order to explain these findings further analyses are needed in this population of ICU patients.

Hospital hygiene in Italy: the GISIO-SItI survey.

BACKGROUND: In Italy there are no rules concerning the establishment of a hospital hygiene structure in hospitals and other healthcare settings, and the hospital organization plans vary widely. The aim of the survey, carried out by the Italian Study Group of Hospital Hygiene of the Italian Society of Hygiene, Preventive medicine and Public health, was to evaluate the presence in the hospital organization plan of a structure referred to as Hospital hygiene, or including in its denomination the words "hygiene" or "hospital hygiene", the activities carried out, the relation to other areas, like patient safety, the type and quantity of professionals involved, the strengths and the critical aspects. METHODS: A semi-structured questionnaire was administered to Healthcare Trusts representing all Italian Regions through the members of the above Study Group. RESULTS: 35 Trusts, 13 in Northern, 8 in Central, 14 in Southern Italy (including Sicily and Sardinia), completed the questionnaire. In 19 Trusts (54.3%) a structure whose denomination included the words "hospital hygiene" or "hygiene" was present. The activities related to the management of infectious risk were most represented, carried out autonomously or in collaboration, but many other activities were covered. In all hospitals the activities of the Hospital Hygiene Unit inter-linked with those of the clinical risk, with different forms of collaboration. CONCLUSION: This survey, even though on a limited sample, provided a picture of hospital hygiene at a national level, showing a considerable heterogeneity and highlighting critical issues but also strengths. It is essential to share organizational and management models that enhance and promote hospital hygiene, to ensure the appropriateness of healthcare practices offered in a safe and comfortable environment to patients, operators, and visitors.

Food supplements: survey of the ASL TO3.

INTRODUCTION: In recent years, the increase of the consumption of supplements reveals problems concerning the safety of use. Current legislation states that supplements must be free of any therapeutic purpose and must have quality guarantees for the users' safety. The operators of the of Hygiene, Food and Nutrition Service (SIAN) of ASL TO 3 (province of Turin) conducted a surveillance in order to asses the situation on the territory, to know the use and consumption in local gyms. During the official control at the manufacturers / packers of supplements, located on the territory of the ASL TO 3, labels of supplement produced / packed were acquired, to analyze the components indicated, to carry out a deep evaluation of the individual product . METHODS: Updating of the register of companies located in the territory of the ASL TO 3 was carried out; and during the period October 2011-March 2013 the labels of the products of these companies have been found and analyzed. The detailed content of the labels (ingredients, dose, method of recruitment, composition, etc. ..) was written in a database. It was also checked how many local gyms marketed supplements, and, in a small sample, a questionnaire was administered to visitors, in order to assess consumption. RESULTS: 355 labels were acquired and loaded on the database. 80% of them falls within the category of supplements based on ingredients derived from plants or similar. For these products was evaluated the presence on the label of not allowed plant extracts (according to the Ministerial Decree of 9 July 2012): only 2 products (of the same company) contained an ingredient not allowed. In all the examined labels was evaluated the presence of the substances for which there are specific warnings: 97% of the label is compliant and 3% are not in compliance. In the analyzed products the indications for use mainly found on the labels are related to increased demand and/or reduced intake, followed by antioxidant action. The study also evaluated the sale of supplements at gyms located on the territory of ASLTO3: 59 gyms are available on territory, but only in one of them supplements are sold. Some customers of these gyms have filled a questionnaire concerning the consumption of supplements. The processing of the questionnaires showed that 27% of respondents in the past 2 years used only occasionally food supplements. For 42% of the subjects the use of these products was to achieve weight loss, for 33% for athletes and 17% have used specific products in the case of particular physiological situations such as pregnancy and lactation. The reasons that lead to the use of dietary supplements, in all cases, are attributed to the improvement of health status. In addition, in 50% of cases the pharmacist has led to the use of these products or, alternatively, friends and relatives. The general practitioner is often not informed even in case of disturbances introduced after their use (seen in 8% of our sample). The majority of the sample (58%) said that they had benefited from the use of supplements and they are aware (68%) that there could be contraindications. CONCLUSIONS: A greater knowledge of the topic, with attention focused on the entire supply chain of the product, is essential to ensure the safety of consumers in the use of food supplements. For these reasons a more detailed check on the procedure is essential: selection and verification of suppliers (especially for raw materials coming from Eastern countries, because they are not subjected to a thorough inspection); traceability of products marketed; correspondence between manufactured and authorized products. Finally, promote an awareness campaign at all levels is necessary, including general practitioners for a conscious purchase.

Pilot randomized experimental study evaluating isopropyl alcohol and ultraviolet-C radiation in the disinfection of healthcare workers' smartphones.

BACKGROUND: Smartphones in medical settings pose infection risks due to harbouring pathogenic bacteria. AIM: This pilot study assessed the effectiveness duration of sanitization methods, focusing on 70% isopropyl alcohol wipes and ultraviolet-C (UVC) boxes, aiming to obtain preliminary data on the reduction in total bacterial load 3 h post-sanitization. METHODS: A randomized monocentric trial with two intervention arms (wipes and UVC boxes) was designed. As participants, healthcare workers from three wards at Fondazione Policlinico Universitario 'A. Gemelli' IRCCS Hospital were recruited, stratified by ward, and block randomized within each ward to control confounders. FINDINGS: Seventy-one healthcare workers, mostly nurses (62%) were included in the study. Initial bacterial load reduction was significant with both disinfection techniques, but after 3 h both methods showed increased bacterial levels, with wipes displaying potentially higher residual efficacy (P=0.056). To adequately size a trial (89% power, significance level 0.05) for assessing the residual efficacy of alcohol-impregnated wipes compared with UVC boxes at 3 h post-sanitization, 503 professionals per group were required. CONCLUSION: This study highlights the necessity for guidelines on hospital smartphone sanitization and educational initiatives for healthcare workers and patients. Further studies, adequately sized, are necessary to determine optimal sanitization intervals and assess pathogen transmission risks.

Development of a checklist as self-assessment tool to evaluate the reprocessing of endoscopic instruments in an Italian teaching hospital.

OBJECTIVE: The present study aims to develop a checklist, as a self-assessment tool, for evaluating all the items involved in the endoscope reprocessing that could be useful for the improvement and/or development of a safety endoscope reprocessing system. MATERIALS AND METHODS: A three-step modified Delphi method, with an embedded qualitative component, was adopted to develop the checklist. According to it, corrective actions were performed before its further re-administration. Contextually, the microbiological surveillance of the endoscopes and of the wash disinfector machine was carried out. RESULTS: Five areas were included in the checklist. After the 1st checklist application, only one of three wards reached the excellent scores in all the items. The other two wards showed an improvement in the Traceability and Endoscope Reprocessing areas after corrective actions. The McNemar's test reported significant difference in the proportion of satisfactory results before and after the 1st and 2nd checklist application. The microbiological surveillance, conducted after the 1st administration, showed unsatisfactory results for the 2 bronchoscopes available in the Intensive Care Unit and for 2 automated endoscope reprocessors. The analysis performed after the 2nd administration showed good results. CONCLUSIONS: The periodic administration of the checklist is functional for a self-assessment of quality reprocessing procedures carried out in the large endoscopic services and in the wards occasionally providing those services, according to the good practice guidelines and for any corrective actions to increase the safety.

Gemelli decision tree Algorithm to Predict the need for home monitoring or hospitalization of confirmed and unconfirmed COVID-19 patients (GAP-Covid19): preliminary results from a retrospective cohort study.

OBJECTIVE: To develop a deep learning-based decision tree for the primary care setting, to stratify adult patients with confirmed and unconfirmed coronavirus disease 2019 (COVID-19), and to predict the need for hospitalization or home monitoring. PATIENTS AND METHODS: We performed a retrospective cohort study on data from patients admitted to a COVID hospital in Rome, Italy, between 5 March 2020 and 5 June 2020. A confirmed case was defined as a patient with a positive nasopharyngeal RT-PCR test result, while an unconfirmed case had negative results on repeated swabs. Patients' medical history and clinical, laboratory and radiological findings were collected, and the dataset was used to train a predictive model for COVID-19 severity. RESULTS: Data of 198 patients were included in the study. Twenty-eight (14.14%) had mild disease, 62 (31.31%) had moderate disease, 64 (32.32%) had severe disease, and 44 (22.22%) had critical disease. The G2 value assessed the contribution of each collected value to decision tree building. On this basis, SpO2 (%) with a cut point at 92 was chosen for the optimal first split. Therefore, the decision tree was built using values maximizing G2 and LogWorth. After the tree was built, the correspondence between inputs and outcomes was validated. CONCLUSIONS: We developed a machine learning-based tool that is easy to understand and apply. It provides good discrimination in stratifying confirmed and unconfirmed COVID-19 patients with different prognoses in every context. Our tool might allow general practitioners visiting patients at home to decide whether the patient needs to be hospitalized.

Low divergence in Dlx gene expression between dentitions of the medaka (Oryzias latipes) versus high level of expression shuffling in osteichtyans.

Serially homologous structures are believed to originate from the redeployment of a genetic cascade in different locations of the body. Serial homologs may diverge at the genetic and morphological level and acquire developmental independency (individualization). Teeth are repeated units that form dentitions found on different bones of the oral-pharyngeal cavity in gnathostomes and provide a good model to study such processes. Previous comparisons of dlx gene expression patterns between mouse oral teeth and zebrafish pharyngeal teeth showed a high level of divergence. Furthermore, these genes are differentially expressed in different teeth of the zebrafish, and in the mouse they are responsible for tooth identity (incisors vs. molars). We examined the potential divergence of dlx gene expression between oral and pharyngeal teeth by examining the expression pattern in the development of the first generation teeth of the medaka and comparing it with data from the zebrafish and the mouse. Out of the seven medaka dlx genes, five are expressed during odontogenesis compared with six in both the zebrafish and the mouse. The only difference observed between oral and pharyngeal teeth in the medaka is an earlier expression of dlx5a in the oral dental epithelium. The subset of dlx genes expressed in the medaka, zebrafish, and mouse is slightly different but their detailed expression patterns are highly divergent. Our results demonstrate a low constraint on dlx gene expression shuffling in the odontogenic cascade within osteichtyans but the non-individualization of oral and pharyngeal dentitions in the medaka.

Prospective 3-year surveillance for nosocomial and environmental Legionella pneumophila: implications for infection control.

OBJECTIVES: To perform a 3-year, prospective surveillance program for legionnaires disease (LD) in a large university hospital in Rome, and to assess the usefulness of the hospital water monitoring program in predicting the risk of nosocomial LD. METHODS: Samples from patients with new cases of nosocomial pneumonia were sent for legionella laboratory investigations. Meanwhile, water samples for bacteriological analysis were collected every 6 months from high- and medium-risk hospital wards (10 in total). Legionella pneumophila isolates collected were serotyped and analyzed by pulsed-field gel electrophoresis. RESULTS: From June 2001 through May 2004, the pneumonia surveillance identified one case of nosocomial LD among 43 cases of nosocomial pneumonia (2.3%). Environmental investigations detected L. pneumophila in 12 (18.7%) of the 64 water samples, of which 50% belonged to serogroup 1. The L. pneumophila count and the percentage of positive locations never exceeded 10(2) colony-forming units/L and 20%, respectively, except when the LD nosocomial case occurred (positive water samples, 40%; L. pneumophila count, <10(2) colony-forming units/L). Genotyping showed 3 prevalent clones of L. pneumophila in the water distribution network, of which one persisted over the 3 years. One clone contained 3 different L. pneumophila serogroups (2, 4, and 6). CONCLUSIONS: The low incidence of nosocomial cases of LD appears to be associated with a low percentage (<20%) of positive water samples per semester and with a low contamination level (<10(2) colony-forming units/L). An infection control system for nosocomial LD should, therefore, be based on both environmental and clinical surveillance, together with the appropriate maintenance of the hospital water distribution system.

Zebrafish evx1 is dynamically expressed during embryogenesis in subsets of interneurones, posterior gut and urogenital system.

The even-skipped-related homeobox genes (evx) are widely distributed through animal kingdom and are thought to play key role in posterior body patterning and neurogenesis. We have cloned and analyzed the expression of evx1 in zebrafish (see also Borday et al. (Dev. Dyn. 220 (2001) in press) which displays a dynamic and restricted expression pattern during neurogenesis. In spinal cord, rhombencephalon, and epiphysis, evx1 is expressed in several subsets of emerging interneurones prior to their axonal outgrowth, identified as primary interneurones and a subset of Pax2.1(+) commissural interneurones. In the hindbrain, evx1 is expressed in reticulospinal interneurones of rhombomeres 5 and 6 as well as in rhombomere 7 interneurones. The latest emerging evx1(+) interneurones in the hindbrain correspond to commissural interneurones. evx1 is also dynamically transcribed during the formation of the posterior gut and the uro-genital system in mesenchymal cells that border the pronephric ducts, the wall of the pronephric duct, and later in the posterior gut and the wall of the uro-genital opening. In larvae, the ano-rectal epithelium and the muscular layer that surrounds the analia-genitalia region remain stained up to 27 days. In contrast other vertebrates, evx1displays no early nor caudal expression in zebrafish.

Genetic and molecular analysis of terminal deletions of chromosome 3R of Drosophila melanogaster.

Terminal deletions of chromosome 3R are induced at a high frequency (3.2 x 10(-3)) by irradiating 45-4 Drosophila melanogaster females with a low dose of X-rays. The 45-4 line carries a white transgene inserted at 16 kb from the terminus and is homozygous for the mu-2 mutation, a gene involved in the repair of double-strand DNA breaks. Four of the 51 recovered deleted strains have lost modulo, the distalmost essential gene on chromosome 3R. Breakpoints of 22 deletions have been localised in a single hybridisation step, using pulsed-field gel electrophoresis to separate genomic DNA fragments obtained from digestion with a rare-cutter restriction enzyme. Breaks do not occur at random, but are rather clustered in three susceptible chromosomal domains. Backcross experiments resulting in transheterozygous (deleted chromosome/45-4) animals indicate that the activity of the white transgene is enhanced when the DNA break has occurred proximal to a critical position. This suggests that homologous chromosomal pairing distal to the critical position results in the definition of a more compact chromatin structure and, due to position effect, in the silencing of white.

A molecular typing approach for evaluating bioaerosol exposure in wastewater treatment plant workers.

Bioaerosols associated with wastewater treatment process may represent a health risk for occupationally exposed personnel. To evaluate microbial contamination in plant workers, we compared oral cavity isolates against isolates collected from aerosol surrounding the aeration basin. Typing was performed by metabolic profile and arbitrarily primed-polymerase chain reaction. The latter is more sensitive and rapid than conventional tests. After comparison, isolates from the air samples were not related to those obtained from the exposed workers. This molecular approach can support bioaerosol risk evaluation .

[Efficacy and critical implications of food handlers' professional training: analysis of an experience]. / Efficacia e aspetti critici della formazione degli operatori alimentari: analisi di un'esperienza.

UNLABELLED: Our study aimed at both assessing the efficacy of the same training course in different contexts and training course repeated in the same context. We examined the most critical aspects, on which to develop further aimed course. In 1998 the Laboratory of Environmental Microbiology of the Institute of Hygiene (UCSC) has implemented 2 professional training courses both for food handlers of a refectory (course A) and of a hospital canteen (course B). Two years after a following course (C) in the hospital canteen. At the beginning and at the end of every course a questionnaire of 25 questions has been gathered in five areas. The data drawn by the questionnaires have been compared using the percentage of exact answers before and after the course. Correct answers beginning and end course: A 89% and 94%, B 68% and 77%, C 76% and 78%. The correct answers beginning course C and end course B are not significatively different (p = 0.1963). Critical areas of the C and B courses have been "microbiological risks" and "correct temperatures"; at the end of the training both the areas had sensitive improvements (C 40% to 59%, 60% to 78%-B 31% to 69%, 45% to 78%). CONCLUSION: Food handlers professional training have been effective both in the same context and in a different context; the training should be based on both the operator's knowledge and difficulties met during the training; knowledge obtained by training is kept unchanged for some years, and it is supposed to repeat the course after one or two years; the analysis of the areas has confirmed the existence of critical problems, common causes of epidemics in collective catering services.

[Environmental diffusion of Legionella spp and legionellosis frequency among patients with pneumonia: preliminary results of a multicentric Italian survey]. / Diffusione ambientale di Legionella spp e frequenza di legionellosi in pazienti affetti da polmonite: primi risultatidi uno studio multicentrico italiano.

A multicentric Italian investigation on legionnaires' disease is in course to clarify host factors as well as pathogen associated characteristics involved in the infection/disease. The main goal of the research plan is to account for some critical aspects concerning identification and prevention of legionellosis. To improve knowledge on factors associated with Legionella spp colonisation in hot waters, to detect cases and to characterize risk factors in subjects which develop pneumonia are specific objectives of the research programme. Preliminary results show that hot waters of houses and hotels are frequently contaminated (22.6% and 54.6%, respectively), mainly by L. pneumophila. Microbial concentrations were low in domestic waters (<1.000 ufc/l), but higher in samples from the hotels (geom. mean 1.85 x 10(3) ufc/l). Warming system, age of the plant, type of building were risk factors significantly associated with Legionella spp positivity. The active surveillance on patients affected by pneumonia with search for Legionella urinary antigen allowed the identification of 34 cases, 3 of which of nosocomial origin, corresponding to 4.2% of the screened pneumonia. After informed consent, 26 subjects were recruited for a case-control-study to clarify risk factors for the disease.

The modifier of variegation modulo gene acts downstream of dorsoventral and HOM-C genes and is required for morphogenesis in Drosophila.

Growing evidence involves chromatin structural flexibility in gene regulation during development. modulo is a dominant suppressor of position effect variegation, suggesting the participation of its product in the assembly of higher order chromatin structures. Here we report the patterns of modulo expression and regulation during embryogenesis, analyzed in correlation with phenotypical defects resulting from the amorphic mutation of the gene. Zygotic expression of modulo depends on the activity of genes which pattern the embryo along dorsoventral and anteroposterior axes and specify diversified morphogenesis, dorsal and the mesoderm-specific genes twist and snail direct modulo expression in the presumptive mesoderm. The homeotic genes Sex combs reduced and Ultrabithorax positively regulate the gene in the ectoderm of parasegment 2 and abdominal mesoderm, respectively, modulo mutants exhibit aberrant morphogenesis of tissues originating from those embryonic primordia which normally express the gene, but do not show defect in cell fate specification. We propose that down-stream of pattern-forming genes modulo controls, via chromatin structural changes, genes critical for the process of morphogenesis of several tissue types.

Homeotic control in Drosophila; the scabrous gene is an in vivo target of Ultrabithorax proteins.

The regulatory functions of transcription factors encoded by the Ultrabithorax (Ubx) gene initiate genetic programmes essential for segmental identity and morphogenesis in Drosophila. Based on the formation of DNA-protein adducts in intact nuclei and immunoselection procedure, we cloned genomic targets for Ubx proteins. One clone was studied in detail. It encompasses parts of the last intron and exon of the scabrous (sca) gene, which encodes a secreted protein involved in cellular communication during neurogenesis. Five motifs, presenting the ATTA core, which is shared by most homeodomain binding sites, were found in the nucleotide sequence of this clone. We detail here the dynamic pattern of sca transcript accumulation during embryogenesis and show that mutation of Ubx results in the ectopic transcription of sca in the first abdominal segment. We propose that a direct interaction of Ubx with cis-acting elements in sca negatively regulates the gene. Transcript localization in several combinations of deficiencies in the Bithorax complex (BX-C) indicates that sca is downregulated by abdominal A (abdA) and Abdominal B (AbdB), and suggests that it is a common target of the three genes of BX-C.