Indoor air pollution impacts cardiovascular autonomic control during sleep and the inflammatory profile.

The present study explores the modifications of cardiovascular autonomic control (CAC) during wake and sleep time and the systemic inflammatory profile associated with exposure to indoor air pollution (IAP) in a cohort of healthy subjects. Twenty healthy volunteers were enrolled. Indoor levels of fine particulate matter (PM2.5), nitrogen dioxide (NO2) and volatile organic compounds (VOCs) were monitored using a portable detector for 7 days. Together, a 7-day monitoring was performed through a wireless patch that continuously recorded electrocardiogram, respiratory activity and actigraphy. Indexes of CAC during wake and sleep time were derived from the biosignals: heart rate and low-frequency to high-frequency ratio (LF/HF), index of sympathovagal balance with higher values corresponding to a predominance of the sympathetic branch. Cyclic variation of heart rate index (CVHRI events/hour) during sleep, a proxy for the evaluation of sleep apnea, was assessed for each night. After the monitoring, blood samples were collected to assess the inflammatory profile. Regression and correlation analyses were performed. A positive association between VOC exposure and the CVHRI (Δ% = +0.2% for 1 µg/m3 VOCs, p = 0.008) was found. The CVHRI was also positively associated with LF/HF during sleep, thus higher CVHRI values corresponded to a shift of the sympathovagal balance towards a sympathetic predominance (r = 0.52; p = 0.018). NO2 exposure was positively associated with both the pro-inflammatory biomarker TREM-1 and the anti-inflammatory biomarker IL-10 (Δ% = +1.2% and Δ% = +2.4%, for 1 µg/m3 NO2; p = 0.005 and p = 0.022, respectively). The study highlights a possible causal relationship between IAP exposure and higher risk of sleep apnea events, associated with impaired CAC during sleep, and a pro-inflammatory state counterbalanced by an increased anti-inflammatory response in healthy subjects. This process may be disrupted in vulnerable populations, leading to a harmful chronic pro-inflammatory profile. Thus, IAP may emerge as a critical and often neglected risk factor for the public health that can be addressed through targeted preventive interventions.

Two Decades of Fatal Workplace Accidents in Milan and Monza, Italy: Trends, Work Sectors, and Causes From Autoptic Data.

BACKGROUND: Work-related fatalities represent an important global public health threat, accounting for over 300,000 deaths annually. Despite preventive strategies, fatalities persist, necessitating comprehensive investigations. Autoptic investigations, when ordered, offer comprehensive data on fatal accidents, in particular with detailed information about the type of accident, lesions, and type of work, enabling a thorough analysis of various factors contributing to workplace deaths. This study investigates work-related fatalities in Milan and Monza Brianza, Lombardy, analyzing patterns, industries, and factors leading to death among workers. METHODS: This retrospective study analyzed all fatal work accident data from the Autopsy Database of the Legal Medicine Institute of Milan from January 2000 to December 2022. We also estimated the risk of fatal accidents per 1.00.000 workers using ISTAT data for the different work sectors. RESULTS: Of the 17,841 violent deaths in Milan and Monza Brianza, 308 resulted from work-related accidents. The majority were male (95.1%). The secondary sector showed the higher estimated risk (27 /106 vs. 19/106 in primary and 2.3/106 in tertiary sector) accounted for 78.5% of fatalities, with specialized workers (35.1%) and construction workers (25%) being the most affected. Falls from above were the leading cause of death (36.7%). A decreasing trend in fatal accidents over the study period was observed, with July having the greatest frequency. The most common causes of death were polytrauma (36.4%) and head injuries (19.2%). Non-Italian workers constitute a noteworthy percentage of fatal cases (24%). CONCLUSIONS: The secondary sector has the most fatal accidents at work despite a decrease in accidents over the observed time period. There is a need for rigorous analysis and interventions, using forensic autopsy case data to help understand causes, and collaboration between institutions is encouraged to develop effective preventive policies.

Promoting health and productivity among ageing workers: a longitudinal study on work ability, biological and cognitive age in modern workplaces (PROAGEING study).

BACKGROUND: Large changes in ageing population and in retirement age are increasing the number of older people in the workforce, raising many challenges for policymakers in promoting employment opportunities and health for older workers. In this respect, longitudinal assessments of workability, well-being perception and cognitive skills over time may allow to detect factors influencing workers' health. Moreover, new available molecular markers permit the measurement of biological age and age-related changes. Most studies analysed one aspect at time (psychological, biological, labour productivity), without considering their interaction. Aims of the study are to evaluate the relationship between workability, cognitive skills, and biological age in a population of ageing workers; to conduct a cross-sectional analysis to assess the impact of occupational exposures on workability, cognitive skills, and biological age; to evaluate inter-individuals changes in a prospective analysis with a re-evaluation of each worker. METHODS: Our study plans to enrol 1000 full-time workers, aged over 50, undergoing the medical surveillance required by the current Italian Legislation. Data collection includes information about: (a) work ability and psychosocial risk factors (work ability index, HSE Management Standard-21 item, Utrecht Work Engagement Scale, World Health Organisation-Five, Well-Being Index, job satisfaction, general well-being, technostress); (b) cognitive skills (Stroop Color and Word test, Simon task, Corsi's block-tapping test, Digit span test); (c) sleep habits and psychological well-being (Pittsburgh Sleep Quality Index, Insomnia Severity Index, Ford Insomnia Response to Stress Test; Symptom Check List 90, Psychological Well-Being Index, Profile of Mood State, Beck Depression Inventory, Beck Anxiety Inventory, Perceived Stress Scale, Brief COPE); (d) biological age (telomere length, DNA methylation) for 500 workers. All workers will repeat the evaluation after one year. DISCUSSION: This study aims to increase our knowledge about interactions between work ability, cognitive ability, well-being perception and psychological status also by including molecular markers, with a longitudinal and multidisciplinary approach. By bringing better insights into the relationship between risk factors and their impact on perceived and biological health, this study also aims at identifying possible interventions and protective measures to ensure aged workers' well-being, consistent with all the eminent calls for actions promoted by key International and European labour organizations.

The burden in palliative care assistance: A comparison of psychosocial risks and burnout between inpatient hospice and home care services workers.

OBJECTIVE: Literature suggests that home care professionals could be at higher risk of burnout than their colleagues in hospital settings, but research on home-based palliative care is still limited. Our study investigates psychosocial risk factors and burnout among workers involved in palliative care, comparing inpatient hospice, and home care settings. METHOD: A cross-sectional study was carried out in a single palliative care organization providing inpatient hospice-based and home care-based assistance in a large urban area of Northern Italy. Participants completed a self-administered questionnaire collecting socio-demographic and occupational data, psychosocial risk factors, and burnout scales (Psychosocial Safety Climate 4; Conflict and Offensive Behavior - COPSOQ II; Work Life Boundaries; Work-home Interaction; Peer Support - HSE; Copenhagen Burnout Inventory). RESULTS: The study sample included 106 subjects (95% of the overall eligible working population) who were predominantly female (68%) and nurses (57%), with a mean age of 41 years. Compared to inpatient hospice staff, home care workers reported more frequent communications with colleagues (p = 0.03) and patients/caregivers (p = 0.01), while there were no differences in the perception of work intrusiveness. Inpatient hospice workers showed lower peer support (p = 0.08) and lower psychosocial safety climate (p = 0.001) than home care colleagues. The experience of aggressive behaviors was rare, and it was relatively more frequent among inpatient hospice workers, female workers, and health assistants. Average scores of burnout scales were similar for both groups except for caregiver-related burnout, which was higher among inpatient hospice workers compared to home care colleagues (p = 0.008). The number of subjects at risk for work-related burnout was similar for both groups. SIGNIFICANCE OF RESULTS: Our study confirms the presence of psychological and physical fatigue in both home-based and inpatient hospice palliative care. Results suggest that home care assistance may not be characterized by higher psychological burden compared to inpatient hospice setting. Given the general tendency to increase home-based care in our aging population, it is essential to broaden the knowledge of psychosocial risks in this specific context to properly protect workers' health.

Still Unanswered Questions About SARS-CoV-2 Mortality and Future Directions for Occupational Medicine.

The article discusses a recent study on mortality attributable to COVID-19 in Italy and the need for further analysis. The study used a reliable methodology to estimate excess deaths due to the pandemic. However, there are still questions about the specific effects of COVID-19 compared to other factors, such as delayed or missing access to treatment for other illnesses. Analyzing the time course of excess deaths could reveal such effects. There are also open questions about how COVID-19 deaths are classified and reported, which could lead to over or under-diagnosing cases. The article notes that occupational physicians have played an important role in preventing the spread of COVID-19 among workers. A recent study found that personal protective equipment (PPE), particularly masks, effectively reduced the risk of infection among healthcare workers. However, it is still unclear whether Occupational Medicine should incorporate infectious diseases as a major concern or return to its historically agnostic attitude toward communicable diseases. More data on mortality from specific diseases will be needed for further analysis and understanding of the pandemic's effects on mortality rates in Italy.

Psychometric Evaluation of GHQ-12 as a Screening Tool for Psychological Impairment of Healthcare Workers Facing COVID-19 Pandemic.

BACKGROUND: The General Health Questionnaire (GHQ) is a widely used tool, both in clinical and research settings, due to its brevity and easy administration. Researchers often adopt a dichotomous measurement method, considering a total score above or below a certain threshold. This leads to an extreme simplification of the gathered data and therefore to the loss of clinical details. In a multi-step evaluation study aimed at assessing health care workers' mental health during the Covid-19 pandemic, GHQ-12 proved to be the most effective tool to detect psychological distress compared to other scales adopted. These results led to deepen the understanding of GHQ-12 properties through a statistical study by focusing on items' properties and characteristics. METHODS: GHQ-12 responses were analyzed using Item Response Theory (IRT), a suitable method for scale assessment. Instead of considering the single overall score, in which each item accounts equally, it focuses on individual items' characteristics. Moreover, IRT models were applied combined with the latent class (LC) analysis, aiming to the determination of subgroups of individuals according to their level of psychological distress. RESULTS: GHQ-12 was administered to 990 health-care workers and responses were scored using the binary method (0-0-1-1). We applied the two-parameter logistic (2-PL) model, finding that the items showed different ways of responses and features. The latent class analysis classified subjects into three sub-groups according to their responses to GHQ-12 only: 47% of individuals with general well-being, 38% expressing signs of discomfort without severity and 15% of subjects with a high level of impairment. This result almost reproduces subjects' classification obtained after administering the six questionnaires of the study protocol. CONCLUSIONS: Accurate statistical techniques and a deep understanding of the latent factors underlying the GHQ-12 resulted in a more effective usage of such psychometric questionnaire - i.e. a more refined gathering of data and a significant time and resource efficiency. We underlined the need to maximize the extraction of data from questionnaires and the necessity of them being less lengthy and repetitive.

Towards a toxic-free environment: perspectives for chemical risk assessment approaches.

Regulatory frameworks to control chemical exposure in general living and occupational environments have changed exposure scenarios towards a widely spread contamination at relatively low doses in developed countries. In such evolving context, some critical aspects should be considered to update risk assessment and management strategies. Risk assessment in low-dose chemical exposure scenarios should take advantage of: toxicological investigations on emerging substances of interest, like those recognised as endocrine disruptors or increasingly employed nanoscale materials; human biological monitoring studies aimed to identify innovative biomarkers for known chemical exposure; "omic" technologies useful to identify hazards of chemicals and their modes of action. For updated risk assessment models, suitable toxicological studies, analyses of dose-responses at low-concentrations, environmental and biological monitoring of exposure, together with exposome studies, and the proper definition of susceptible populations may all provide helpful contributions. These may guide defining preventive measures to control the exposure and develop safe and sustainable chemicals by design. Occupational medicine can offer know-how and instruments to understand and manage such evolution towards a toxic-free environment to protect the safety and health of the workforce and, in turn, that of the general population.

Incidence Rates and Case-Fatality Rates of Cerebral Vein Thrombosis: A Population-Based Study.

Background and Purpose: Cerebral vein thrombosis (CVT) incidence is estimated to be >10 per 1 000 000 per year. Few population-based studies investigating case-fatality rates (CFRs) and pyogenic/nonpyogenic CVT incidence are available. We assessed trends in CVT incidence between 2002 and 2012, as well as adjusted in-hospital CFRs and incidence of hospital admissions for pyogenic/nonpyogenic CVT in a large Northwestern Italian epidemiological study. Methods: Primary and secondary discharge diagnoses of pyogenic/nonpyogenic CVT were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes 325, 671.5, and 437.6. Age, sex, vital status at discharge, length of hospital stay, and up to 5 secondary discharge diagnoses were collected. Concomitant presence of intracerebral hemorrhage (ICH) was registered, and comorbidities were assessed through the Charlson comorbidity index. Results: A total of 1718 patients were hospitalized for CVT (1147 females­66.8%; 810 pyogenic and 908 nonpyogenic CVT, 47.1% and 52.9%, respectively), with 134 patients (7.8%) experiencing a concomitant ICH. The overall incidence rate for CVT was 11.6 per 1 000 000 inhabitants with a sex-specific rate of 15.1 and 7.8 per 1 000 000 in females and males, respectively. CVT incidence significantly increased in women during time of observation (P=0.007), with the highest incidence being at 40 to 44 years (27.0 cases per 1 000 000). In-hospital CFR was 3%, with no difference between pyogenic/nonpyogenic CVT. Patients with concomitant ICH had a higher in-hospital CFR compared with patients without ICH (7.5% versus 2.7%; odds ratio, 2.96 [95% CI, 1.45­6.04]). In-hospital CFR progressively increased with increasing Charlson comorbidity index (P=0.003). Age (odds ratio, 1.03 [95% CI, 1.02­1.05]), Charlson comorbidity index ≥4 (odds ratio, 4.33 [95% CI, 1.29­14.52]), and ICH (odds ratio, 3.05 [95% CI, 1.40­6.62]) were independent predictors of in-hospital mortality. Conclusions: In a large epidemiological study, CVT incidence was found to be comparable to the one registered in population-based studies reported after the year 2000. CVT incidence increased among women over time. In-hospital CFR was low, but not negligible, in patients with concomitant ICH. Age, ICH, and a high number of comorbidities were independent predictors of in-hospital mortality. Pyogenic CVT was not a predictor of in-hospital CFR, although its high proportion was not confirmed by internal validation.

Associations of sickness absence for pain in the low back, neck and shoulders with wider propensity to pain.

OBJECTIVES: To explore the association of sickness absence ascribed to pain at specific anatomical sites with wider propensity to musculoskeletal pain. METHODS: As part of the CUPID (Cultural and Psychosocial Influences on Disability) study, potential risk factors for sickness absence from musculoskeletal pain were determined for 11 922 participants from 45 occupational groups in 18 countries. After approximately 14 months, 9119 (78%) provided follow-up information about sickness in the past month because of musculoskeletal pain, including 8610 who were still in the same job. Associations with absence for pain at specific anatomical sites were assessed by logistic regression and summarised by ORs with 95% CIs. RESULTS: 861 participants (10%) reported absence from work because of musculoskeletal pain during the month before follow-up. After allowance for potential confounders, risk of absence ascribed entirely to low back pain (n=235) increased with the number of anatomical sites other than low back that had been reported as painful in the year before baseline (ORs 1.6 to 1.7 for ≥4 vs 0 painful sites). Similarly, associations with wider propensity to pain were observed for absence attributed entirely to pain in the neck (ORs up to 2.0) and shoulders (ORs up to 3.4). CONCLUSIONS: Sickness absence for pain at specific anatomical sites is importantly associated with wider propensity to pain, the determinants of which extend beyond established risk factors such as somatising tendency and low mood. Better understanding of why some individuals are generally more prone to musculoskeletal pain might point to useful opportunities for prevention.

Cancer risk in oil refinery workers: a pooled mortality study in Italy.

BACKGROUND: Oil refinery workers are exposed to several well-established carcinogens and working in this type of industry has been classified by IARC as probable carcinogen to humans (Group 2A). OBJECTIVES: To examine the mortality experience of workers employed in four Italian oil refineries. METHODS: The cohort included 5112 male workers ever employed between 1949 and 2011. The average follow-up period was 49 years. Standardized mortality ratios (SMR) and 95% Confidence Intervals (CI) were calculated using as reference age-gender-calendar specific regional rates. Analyses by duration of employment and latency were performed. RESULTS: In the whole cohort, pleural cancer (6 deaths, SMR 1.59; 95% CI 0.71-3.53), brain cancer (14 deaths, SMR 1.47; 95% CI 0.87-2.49) and lymphatic leukemia (LL) (8 deaths, SMR 1.81; 95% CI 0.91-3.62) showed increased risks. All pleural cancers occurred after 10 years of latency and the highest risk was observed among workers with duration ≥20 years; the brain cancer excess was confined in the shortest duration and latency. The LL (and chronic lymphatic leukemia in particular) excess regarded workers with latency and duration longer than 20 years. Four deaths from acute myeloid leukemia (AML) were observed and all occurred after 20 years of latency (SMR 1.55, 95% CI 0.58-4.12); a two-fold-increased risk was observed in the longest duration. No increased risk for skin cancer has been observed in our study population. CONCLUSION: Our findings are consistent with recent evidence of an increased mortality from pleural and hematopoietic malignancies (AML and LL) among oil refinery workers. However, the lack of individual quantitative exposure data and the small number of observed events prevent the identification of the possible causal role of individual chemicals, including benzene, especially at the current very low exposure levels.

Development and validation of a score to predict life expectancy after carotid endarterectomy in asymptomatic patients.

OBJECTIVE: Recent improvement of best medical treatment for carotid stenosis has sparked a debate on the role of surgery-identification of patients who may benefit from carotid endarterectomy (CEA) is crucial to avoid overtreatment. An expected 5-year postoperative survival is one of the main selection criteria. The aim of this study was the development of a score for predicting survival of asymptomatic patients after CEA. METHODS: Our score was derived from a retrospective analysis of 648 consecutive asymptomatic patients from a single hospital. External validation of the score was then performed on a second cohort of 334 asymptomatic patients from two different hospitals in the same area. Factors associated with reduced postoperative survival within the derivation cohort (DC) were identified and tested for statistical significance. Each selected factor was assigned a score proportional to its ß coefficient: 1 point for chronic obstructive pulmonary disease, diabetes mellitus, coronary artery disease, and lack of statin treatment; 4 points for age 70 to 79 years and creatinine concentration ≥1.5 mg/dL; 8 points for age ≥80 years and dialysis. The DC was divided into four groups based on individual scores: group 1, 0 to 3 points; group 2, 4 to 7 points; group 3, 8 to 11 points; and group 4, ≥12 points. Group-specific survival curves were calculated. The validation cohort (VC) was stratified according to the score. Survival of each of the four risk groups within the VC was compared with its analogue from the DC. RESULTS: Median follow-up of the DC and VC was, respectively, 56 and 65 months. Intercohort comparison of 5-year survival was 84.7% ± 1.7% vs 85.2% ± 2% (P = .41). Group-specific 5-year survival within the DC was 97% ± 1.5% (group 1), 88.4% ± 2.2% (group 2), 69.6% ± 4.7% (group 3), and 48.1% ± 13.5% (group 4; P < .0001). Five-year survival within the VC was 95.5% ± 2% (group 1), 89.5% ± 2.7% (group 2), 65% ± 6.1% (group 3), and 44.8% ± 14.1% (group 4; P < .0001). Intercohort comparison of group-specific survival curves showed close similarity throughout the groups. CONCLUSIONS: Our score is a simple clinical tool that allows a quick and reliable prediction of survival in asymptomatic patients who are candidates for CEA. This selective approach is crucial to avoid unnecessary surgery on patients who are less likely to survive long enough to experience the benefits of this preventive procedure.

PM10 exposure is associated with increased hospitalizations for respiratory syncytial virus bronchiolitis among infants in Lombardy, Italy.

Respiratory syncytial virus (RSV) is the primary cause of acute lower respiratory infections in children, bronchiolitis in particular. Airborne particulate matter (PM) may influence the children's immune system and foster the spread of RSV infection. We aimed to verify whether PM10 exposure is associated with hospitalization due to RSV bronchiolitis. We selected hospital discharge records (HRD) with ICD-9-CM code 466.11 of infants < 1 year of age, occurring in the epidemic seasons of two years (2012-2013) in Lombardy, Italy. Cases were assigned daily PM10 and apparent temperature levels of the capital city of their residential province. Different exposure windows were considered: single days preceding hospitalization (lag 0 to 30), their average estimates (lag 0-1 to 0-30), and the four weeks preceding hospitalization (week 1 to 4). Negative binomial regression models adjusted for apparent temperature and season were applied to the daily counts of hospitalizations in each province. Results were expressed as incidence rate ratios (IRR) and 95% confidence intervals (95%CI) per 10 µg/m3 increase in PM10 concentration. Random effects meta-analyses of province-specific IRR were performed to obtain regional estimates. 2814 HRD met our inclusion criteria; males represented about 55% of the cases. A 6% increased risk of hospitalization (95%CI: 1.03-1.10) was found at lag 0 and an almost overlapping 7% increase at lag 1. IRR ranged from 1.03 to 1.05 between lags 2 and 11. No increased risk was observed from lag 12. When considering averaged daily lags, risk estimates gradually increased in the two weeks preceding hospitalization from 1.08 (1.04-1.12) at lag 0-1 to 1.15 (1.08-1.23) between lags 0-11 and 0-13. Analyses on weekly lags showed a risk increase of 6% (1.01-1.12) during week 1 and of 7% (1.02-1.13) during week 2. Our study found a clear association between short- and medium-term PM10 exposures and increased risk of hospitalization due to RSV bronchiolitis among infants.

Short-term particulate matter exposure influences nasal microbiota in a population of healthy subjects.

BACKGROUND: Exposure to air pollutants, such as particulate matter (PM), represents a growing health problem. The aim of our study was to investigate whether PM could induce a dysbiosis in the nasal microbiota in terms of α-diversity and taxonomic composition. METHODS: We investigated structure and characteristics of the microbiota of 40 healthy subjects through metabarcoding analysis of the V3-V4 regions of the 16s rRNA gene. Exposure to PM10 and PM2.5 was assessed with a personal sampler worn for 24h before sample collection (Day -1) and with measurements from monitoring stations (from Day -2 to Day -7). RESULTS: We found an inverse association between PM10 and PM2.5 levels of the 3rd day preceding sampling (Day -3) and α-diversity indices (Chao1, Shannon and PD_whole_tree). Day -3 PM was inversely associated also with the majority of analyzed taxa, except for Moraxella, which showed a positive association. In addition, subjects showed different structural profiles identifying two groups: one characterized by an even community and another widely dominated by the Moraxella genus. CONCLUSIONS: Our findings support the role of PM exposure in influencing microbiota and altering the normal homeostasis within the bacterial community. Whether these alterations could have a role in disease development and/or exacerbation needs further research.

Sentinel node biopsy in ductal carcinoma in situ of the breast: Never justified?

Sentinel lymph node biopsy for ductal carcinoma in situ (DCIS) of the breast is not standard of care. However, nodal involvement for DCIS patients is reported. Aim of our study was to identify preoperative features predictive of nodal involvement in DCIS patients. We have retrospectively reviewed 175 patients with a preoperative diagnosis of DCIS following a vacuum-assisted breast biopsy, and undergoing surgery with sentinel node biopsy. Variables distribution was compared between patients upstaged to invasive cancer at final pathology and patients with a confirmed DCIS, and between positive vs negative sentinel node patients. Univariate and multivariate analyses were performed for risk of a positive node. Lymph node biopsy was positive in 13 (7.4%) patients, with 8 (61.5%) macrometastases and 5 (38.5%) micrometastases. In these patients, Breast Imaging Reporting and Data System (BI-RADS) index >4 (OR 4.69, 95% CI 1.282-17.224, P = .02), lesion extension ≥20 mm (OR 4.25, 95% CI 1.255-14.447, P = .02), multifocal disease (OR 4.12, 95% CI 0.987-17.174, P = .05), comedo type (OR 3.54, 95% CI 1.044-11.969, P = .04), and upstaging (OR 4.56, 95% CI 1.080-19.249, P = .04) were all predictive of nodal involvement, although upstaging could not be predicted preoperatively. By multivariate analysis, the only independent factor predictive for positive sentinel node was multifocal disease (OR 5.14, 95% CI 1.015-26.066, P < .05). A preoperative diagnosis of DCIS, also including advanced biopsy systems such as vacuum-assisted breast biopsy, may be not always sufficient to exclude patients from sentinel node biopsy. DCIS patients with associated BI-RADS >4, lesion extension ≥20 mm, comedo type, and above all multifocal disease should be considered for axillary evaluation.

Cavity Shaving Reduces Involved Margins and Reinterventions Without Increasing Costs in Breast-Conserving Surgery: A Propensity Score-Matched Study.

BACKGROUND: Currently, reinterventions for involved margins after breast-conserving surgery remain common. The aim of this study was to assess the capability of the cavity shave margins (CSM) technique to reduce positive margin rates and reoperations compared with simple lumpectomy (SL). The impact of CSM on the various biological portraits of breast cancer and costs were also investigated. METHODS: A retrospective review of 976 consecutive patients from a single center was performed; 164 patients underwent SL and 812 received CSM. All patients were treated with an oncoplastic approach. and involved margins and reoperations were compared for each group. To avoid selection bias, propensity score-matched analysis was performed before applying a logistic regression model. Main outcomes were reanalyzed for each biological portrait, and surgery and hospitalization costs for SL and CSM were compared. RESULTS: Clear margins were found in 98.3% of patients in the CSM group versus 74.4% of patients in the SL group (p < 0.001). The reoperation rate was 18.9% in the SL group and 1.9% in the CSM group (p < 0.001). After propensity score-matched logistic regression, odds ratio (OR) for positive final margin status was 6.2 (95% confidence interval [CI] 2.85-13.46; p < 0.001) without CSM, while OR for reintervention was 5.46 (95% CI 2.21-13.46; p < 0.001). CSM significantly reduced positive margins and reexcisions for Luminal A, Luminal B, and triple-negative breast cancers (p < 0.001, p < 0.001, and p = 0.0137, respectively). SL had higher global costs compared with CSM: €193,630.6 versus €177,830 for 100 treated patients (p = 0.009). CONCLUSIONS: CSM reduces reexcisions, mainly in luminal breast cancers, without increasing costs.

The effect of a uterine manipulator on the recurrence and mortality of endometrial cancer: a multi-centric study by the Italian Society of Gynecological Endoscopy.

BACKGROUND: Although widely adopted, the use of a uterine manipulator during laparoscopic treatment of endometrial cancer represents a debated issue, and some authors hypothesize that it potentially may cause an increased risk of relapse, particularly at specific sites. OBJECTIVE: Our aim was to evaluate the risk and site of disease recurrence, overall survival, and disease-specific survival in women who had laparoscopic surgery with and without the use of a uterine manipulator. STUDY DESIGN: Data were reviewed from consecutive patients who had laparoscopic surgery for endometrial cancer staging in 7 Italian centers. Subjects were stratified according to whether a uterine manipulator was used during surgery; if so, the type of manipulator was identified. Multivariable analysis to correct for possible confounders and propensity score that matched the minimize selection bias were utilized. The primary outcome was the risk of disease recurrence. Secondary outcomes were disease-specific and overall survival and the site of recurrence, according to the use or no use of the uterine manipulator and to the different types of manipulators used. RESULTS: We included 951 patients: 579 patients in the manipulator group and 372 patients in the no manipulator group. After a median follow-up period of 46 months (range,12-163 months), the rate of recurrence was 13.5% and 11.6% in the manipulator and no manipulator groups, respectively (P=.37). Positive lymph nodes and myometrial invasion of >50% were associated independently with the risk of recurrence after adjustment for possible confounders. The use of a uterine manipulator did not affect the risk of recurrence, both at univariate (odds ratio, 1.18; 95% confidence interval, 0.80-1.77) and multivariable analysis (odds ratio, 1.00; 95% confidence interval, 0.60-1.70). Disease-free, disease-specific, and overall survivals were similar between groups. Propensity-matched analysis confirmed these findings. The site of recurrence was comparable between groups. In addition, the type of uterine manipulator and the presence or not of a balloon at the tip of the device were not associated significantly with the risk of recurrence. CONCLUSION: The use of a uterine manipulator during laparoscopic surgery does not affect the risk of recurrence and has no impact on disease-specific or overall survival and on the site of recurrence in women affected by endometrial cancer.

Histone 3 modifications and blood pressure in the Beijing Truck Driver Air Pollution Study.

CONTEXT: Histone modifications regulate gene expression; dysregulation has been linked with cardiovascular diseases. Associations between histone modification levels and blood pressure in humans are unclear. OBJECTIVE: We examine the relationship between global histone concentrations and various markers of blood pressure. MATERIALS AND METHODS: Using the Beijing Truck Driver Air Pollution Study, we investigated global peripheral white blood cell histone modifications (H3K9ac, H3K9me3, H3K27me3, and H3K36me3) associations with pre- and post-work measurements of systolic (SBP) and diastolic (DBP) blood pressure, mean arterial pressure (MAP), and pulse pressure (PP) using multivariable mixed-effect models. RESULTS: H3K9ac was negatively associated with pre-work SBP and MAP; H3K9me3 was negatively associated with pre-work SBP, DBP, and MAP; and H3K27me3 was negatively associated with pre-work SBP. Among office workers, H3K9me3 was negatively associated with pre-work SBP, DBP, and MAP. Among truck drivers, H3K9ac and H3K27me were negatively associated with pre-work SBP, and H3K27me3 was positively associated with post-work PP. DISCUSSION AND CONCLUSION: Epigenome-wide H3K9ac, H3K9me3, and H3K27me3 were negatively associated with multiple pre-work blood pressure measures. These associations substantially changed during the day, suggesting an influence of daily activities. Blood-based histone modification biomarkers are potential candidates for studies requiring estimations of morning/pre-work blood pressure.

Particulate matter exposure is associated with inflammatory gene methylation in obese subjects.

BACKGROUND: Overweight and obesity are becoming more widespread with alarming projections for the coming years. Obesity may increase susceptibility to the adverse effects of PM exposure, exacerbating the effects on cardiovascular diseases and altering the biomarkers of vascular inflammation. The associated biological mechanisms have not been fully understood yet; the common denominator in the pathogenesis of the co-morbidities of obesity is the presence of an active, low-grade inflammatory process. DNA methylation has been shown to regulate inflammatory pathways that are responsible for the development of cardiovascular diseases. OBJECTIVES: The aim of the study was to investigate, in a population of overweight/obese subjects, the effects of PM on blood DNA methylation in genes associated to inflammatory response. METHODS: Using bisulfite pyrosequencing, we measured DNA methylation in peripheral blood mononuclear cells from 186 overweighted/obese subjects. In particular, we quantified DNA methylation in a set of 3 candidate genes, including CD14, TLR4 and TNF-α, because of the important roles that these genes play in the inflammatory pathway. Personal exposure to PM10 was estimated for each subject based on the local PM10 concentrations, measured by monitoring stations at residential address. Repeated measure models were used to evaluate the association of PM10 with each genes, accounting for possible correlations among the genes that regulate the same inflammatory pathway. RESULTS: We found an inverse association between the daily PM10 exposure and the DNA methylation of inflammatory genes, measured in peripheral blood of healthy overweight/obese subjects. Considering different exposure time-windows, the effect on CD14 and TLR4 methylation was observed, respectively, in days 4-5-6, and days 6-7-8. TNF-α methylation was not associated to PM10. CONCLUSIONS: Our findings support a picture in which PM10 exposure and transcriptional regulation of inflammatory gene pathway in obese subjects are associated.

Effects of metal-rich particulate matter exposure on exogenous and endogenous viral sequence methylation in healthy steel-workers.

BACKGROUND: Inhaled particles have been shown to produce systemic changes in DNA methylation. Global hypomethylation has been associated to viral sequence reactivation, possibly linked to the activation of pro-inflammatory pathways occurring after exposure. This observation provides a rationale to investigate viral sequence (both exogenous and endogenous) methylation in association to metal-rich particulate matter exposure. To verify this hypothesis, we chose the Wp promoter of the Epstein-Barr Virus (EBV-Wp) and the promoter of the human-endogenous-retrovirus w (HERV-w), respectively as a paradigm of an exogenous and an endogenous retroviral sequence, to be investigated by bisulfite PCR Pyrosequencing. We enrolled 63 male workers in an electric furnace steel plant, exposed to high level of metal-rich particulate matter. RESULTS: Comparing samples obtained in the first day of a work week (time 0-baseline, after 2 days off work) and the samples obtained after 3 days of work (time 1-post exposure), the mean methylation of EBV-Wp was significantly higher at baseline compared to post-exposure (meanbaseline = 56.7%5mC; meanpost-exposure = 47.9%5mC; p-value = 0.009), whereas the mean methylation of HERV-w did not significantly differ. Individual exposure to inhalable particles and metals was estimated based on measures in all working areas and time spent by the study subjects in each area. In a regression model adjusted for age, body mass index and smoking, PM and metal components had a positive association with EBV-Wp methylation (i.e. PM10: ß = 5.99, p-value < 0.038; nickel: ß = 17.82, p-value = 0.02; arsenic: ß = 13.59, p-value < 0.015). CONCLUSIONS: The difference observed comparing baseline and post-exposure samples may be suggestive of a rapid change in EBV methylation induced by air particles, while correlation between EBV methylation and PM/metal exposure may represent a more stable adaptive mechanism. Future studies investigating a larger panel of viral sequences could better elucidate possible mechanisms and their role in pro-inflammatory pathways leading to systemic health effects.

Short-term particulate matter exposure induces extracellular vesicle release in overweight subjects.

BACKGROUND: Extracellular vesicles (EVs) represent a plausible molecular mechanism linking particulate matter (PM) inhalation to its systemic effects. Microvesicles (MVs) are released from many cell types in response to various stimuli. Increased body mass index (BMI) could modify the response to PM exposure due to enhanced PM uptake and/or an underlying pro-oxidative state. We investigated the relationship between EV release and PM10/PM2.5 exposure in a cohort of 51 volunteers. Subjects were stratified based on their BMI to evaluate whether overweight BMI is a determinant of hypersusceptibility to PM effects. RESULTS: Exposure to PM10/PM2.5 was assessed with a personal sampler worn for 24hours before plasma collection and confirmed with monitoring station data. Size and cellular origin of plasma EVs were characterized by Nanosight analysis and flow cytometry, respectively. Multivariate regression models were run after log-transformation, stratifying subjects based on BMI (≥ or <25kg/m2). PM exposure resulted in increased release of EVs, with the maximum observed effect for endothelial MVs. For PM10 and PM2.5, the adjusted geometric mean ratio and 95% confidence interval were 3.47 (1.30, 9.27) and 3.14 (1.23, 8.02), respectively. Compared to those in normal subjects, PM-induced EV alterations in overweight subjects were more pronounced, with visibly effect in all MV subtypes, particularly endothelial MVs. CONCLUSIONS: Our findings emphasize the role of EV release after PM exposure and the susceptibility of overweight subjects. Larger studies with accurate exposure assessment and complete EVs characterization/content analysis, could further clarify the molecular mechanism responsible for PM effects and of hypersusceptibility of overweight subjects.