National Recovery and Resilience Plan and Health: qualitative analysis on the sustainability of the interventions on healthcare.

Background: Sars-CoV2 epidemic was the cause of death of more than 180,000 Italian citizens. The sever-ity of this disease showed to policymakers how easily Italian health services, and particularly hospitals, could be overwhelmed by requests and needs from patients and the general population. As a consequence of the clogging of health services, the government decided to allocate a consistent investment to the com-munity and proximity assistance with a specific section (Mission 6) of the so called "National Recovery and Resilience Plan". Objective: The aim of this study is to analyse the economic and social impact of the Mission 6 of the National Recovery and Resilience Plan, with particular regard to the most relevant interventions (Community Homes, Community Hospitals, Integrated Home Care), in order to understand its future sustainability. Material and methods: A qualitative research methodology was chosen. Documents containing all the relevant information regarding the sustainability of the plan (called in short "Sustainability Plan") were taken into consideration. In case of missing data regarding the potential costs or expenditure of the afore-mentioned structures, estimates will be made reviewing literature for similar healthcare services, already implemented and active in Italy. Direct content analysis was chosen as the methodology for data analysis and final reporting of results. Results: The National Recovery and Resilience Plan states that it will create savings of up to €1.18 bil-lion thanks to the re-organization of healthcare facilities, the reduction of hospitalizations, the reduction of inappropriate access to the emergency room, and the containment of pharmaceutical expenditure. This amount will be used to cover the salaries for the healthcare professionals employed in the newly planned healthcare structures. The analysis of this study has taken into account the number of healthcare profes-sionals that will be needed to operationalize the new facilities, as described in the plan and compared them with the reference salaries for each category (doctors, nurses, other healthcare workers). The annual cost for healthcare professionals has been stratified for each structure, with the following results: € 540 million for the personnel of the Community Hospitals ("Ospedali di Comunità"); € 1.1 billion for the personnel of Integrated Home Care Assistance ("Assistenza Domiciliare Integrata"); and € 540 million for the personnel of Community Homes ("Case della Comunità"). Discussion: The expected € 1.18 billion expenditure is implausible to be sufficient to cover the cost for salaries of all the healthcare professionals needed, which is expected to be around € 2 billion. The National Agency for the Regional Healthcare Services ("Agenzia nazionale per i servizi sanitari regionali") calculated that in Emilia-Romagna (the only region in Italy to have already implemented a healthcare structure based on the one described in the National Recovery and Resilience Plan), the activation of Community Hospitals and Community Homes reduced the rate of inappropriate access to emergency rooms by 26% (while in the National Recovery and Resilience Plan expectation is a reduction of at least by 90% for "white codes", the identified code for stable and not urgent patients). Moreover, the hypothesis for the daily cost of stay in the Community Hospital is roughly € 106, while the average current cost in the active Community Hospitals in Italy is € 132 (much higher than the National Recovery and Resilience Plan estimate). Conclusion: The underlying principle of the National Recovery and Resilience Plan is highly valuable since it strives to enhance the quality and the quantity of the healthcare services in the country that are too often left out of national investments and programs. Nevertheless, the National Recovery and Resilience Plan has critical issues due to the superficial prevision of cost. The success of the reform appears to be established by decision makers and by their long-term prospective, oriented to overcome the resistance to change.

Laparoscopic sleeve gastrectomy modifies cholesterol synthesis but not cholesterol absorption.

BACKGROUND AND AIMS: Each bariatric surgery procedure impacts differently on cholesterol synthesis and absorption. Although a restrictive procedure, sleeve gastrectomy resolves diabetes mellitus and, like mixed-type procedures, induces early changes in gastrointestinal hormones. To our knowledge the present study is the first to assess the effects of sleeve gastrectomy on cholesterol synthesis and absorption. METHODS AND RESULTS: 42 consecutive subjects with obesity and sleeve gastrectomy candidates were included in the study together with a control group of 20 subjects without obesity. Before sleeve gastrectomy and 10 months afterwards, all subjects underwent a clinical examination, blood tests, ultrasound visceral fat area estimation and determination of plasma lathosterol, campesterol and sitosterol concentrations. After sleeve gastrectomy, significant decreases were observed in BMI, waist circumference, visceral and subcutaneous fat, blood pressure, triglycerides, insulin and glucose levels, lathosterol and HOMA-IR. HDL-C and apolipoprotein AI levels increased significantly. No significant differences emerged in LDL-C, apolipoprotein B levels or cholesterol absorption markers. Lathosterol levels correlated significantly with BMI, visceral fat area and HOMA-IR. Differences in cholesterol intake after surgery were not significantly associated with differences in lathosterol, campesterol and sitosterol concentrations. CONCLUSIONS: Sleeve gastrectomy reduced the markers of cholesterol synthesis but did not modify cholesterol absorption. Changes in cholesterol synthesis and absorption were independent of variations in cholesterol intake, suggesting a specific sleeve gastrectomy-related effect.

Circulating Levels of the Adipokines Monocyte Chemotactic Protein-4 (MCP-4), Macrophage Inflammatory Protein-1ß (MIP-1ß), and Eotaxin-3 in Severe Obesity and Following Bariatric Surgery.

The aim of the study was to investigate the involvement of the adipokines eotaxin-3, MIP-1ß, and MCP-4 in obesity and related comorbidities and the modification of their circulating levels after bariatric surgery. Eighty severely obese subjects and 20 normal-weight controls were included in the study. Circulating levels of MCP-4, MIP-1ß, and eotaxin-3, and the main clinical, biochemical, and instrumental parameters for the evaluation of cardiovascular and metabolic profile were determined in controls and in obese subjects at baseline and 10 months after surgery. Within the obese group at baseline, eotaxin-3 levels were higher in males than females and in smokers than non-smokers and showed a positive correlation with LDL-cholesterol, apolipoprotein B, and leptin. MIP-1ß showed a positive correlation with age and leptin and a negative correlation with adiponectin and was an independent predictor of increased carotid artery intima-media thickness. MCP-4 levels were higher in obese subjects than controls and showed a positive correlation with body mass index, eotaxin-3, and MIP-1ß. Bariatric surgery induced a marked decrease in all the 3 adipokines. MCP-4 is a novel biomarker of severe obesity and could have an indirect role in favoring sub-clinical atherosclerosis in obese patients by influencing the circulating levels of eotaxin-3 and MIP-1ß, which are directly related to the main atherosclerosis markers and risk factors. The reduction of circulating levels of MCP-4, eotaxin-3, and MIP-1ß could be one of the mechanisms by which bariatric surgery contributes to the reduction of cardiovascular risk in these patients.

Evaluation of oxidized buckypaper as material for the solid phase extraction of cobalamins from milk: Its efficacy as individual and support sorbent of a hydrophilic-lipophilic balance copolymer.

This work describes a new analytical method for the determination of four cobalamins (adenosylcobalamin (AdoCbl), methylcobalamin (MeCbl), hydroxocobalamin (OHCbl) and cyanocobalamin (CNCbl)) in cow's milk. The extraction procedure is fast and based on dilution/protein precipitation of a milk sample with 50mM sodium acetate buffer (pH 4.6), followed by solid phase extraction (SPE) of the filtered supernatant. Relative recoveries higher than 60% have been obtained for all the cobalamins by combining two different types of sorbents in the same SPE cartridge: two disks of buckypaper (BP), a nanoporous felt composed of oxidized multiwalled carbon nanotubes (MWCNTs), separated by a Teflon frit from OASIS HLB (500mg), a hydrophilic-lipophilic balance copolymer. Before its use as sorbent, BP was characterized in terms of porosity, permeability, surface area, specific adsorption capacity and tested for a potential reuse after adequate chemical regeneration. The analysis of the extracts was performed by liquid chromatography (LC) coupled to tandem mass spectrometry (MS/MS) on an analytical C18 column in less than 10min. After validation, the method was applied to the determination of the natural content of the four B12 homologues in cow's milk samples, providing data lacking in the literature.

Predictive outcome indexes in neonatal Congenital Diaphragmatic Hernia.

OBJECTIVE: We examined the reliability of the main prenatal and postnatal prognosis-related indexes that can be used to evaluate congenital diaphragmatic hernia (CDH) outcome. METHODS: Seventy-seven neonates with CDH were analyzed according to CDH prognosis-related factors, divided into prenatal findings, postnatal clinical values and postnatal predictive outcome scores applied at birth and within the first 12-24 h. The data are compared between two groups: survivors and non-survivors. RESULTS: During prenatal age, major associated anomalies, intrathoracic stomach, diagnosis prior to 25 weeks of gestational age and lung-to-head ratio < 0.6 were statistically significant, demonstrating their greater incidence in non-survivors. The majority of postnatal values at PICU admission were found to be reliable in identifying the CDH outcome: paO2/FiO2, oxygenation index, alveolar-arterial-O2 gradient, arterial-alveolar-O2 tension ratio, pH, mean blood pressure, body temperature. All the postnatal predictive outcome scores (Apgar 1' and 5', CDH-Study-Group equation, Score for Neonatal-Acute-Physiology II, SNAP-Perinatal-Extension II, Pediatric Risk of Mortality III and Wilford-Hall/Santa-Rosa formula) were statistically significant with more favorable values for prognosis in the survivors group. CONCLUSION: The chances of predicting CDH outcome are fairly high. During prenatal age, only a few findings may be obtained. Conversely, many postnatal indexes and scores can reliably predict such outcome.

Preoperative evaluation in infants and children: recommendations of the Italian Society of Pediatric and Neonatal Anesthesia and Intensive Care (SARNePI).

BACKGROUND: The preoperative assessment involves the process of evaluating the patient's clinical condition, which is intended to define the physical status classification, eligibility for anesthesia and the risks associated with it, thus providing elements to select the most appropriate and individualized anesthetic plan. The aim of this recommendation was provide a framework reference for the preoperative evaluation assessment of pediatric patients undergoing elective surgery or diagnostic/therapeutic procedures. METHODS: We obtained evidence concerning pediatric preoperative evaluation from a systematic search of the electronic databases MEDLINE and Embase between January 1998 and February 2012. We used the format developed by the Italian Center for Evaluation of the Effectiveness of Health Care's scoring system for assessing the level of evidence and strength of recommendations. RESULTS: We produce a set of consensus guidelines on the preoperative assessment and on the request for preoperative tests. A review of the existing literature supporting these recommendations is provided. In reaching consensus, emphasis was placed on the level of evidence, clinical relevance and the risk/benefit ratio. CONCLUSION: Preoperative evaluation is mandatory before any diagnostic or therapeutic procedure that requires the use of anesthesia or sedation. The systematic prescription of complementary tests in children should be abandoned, and replaced by a selective and rational prescription, based on the patient history and clinical examination performed during the preoperative evaluation.

Neonatal congenital diaphragmatic hernia: respiratory and blood-gas derived indices in choosing surgical timing.

BACKGROUND: Congenital diaphragmatic hernia (CDH) still has a high mortality despite advanced assistance techniques. The aim of this study is to verify the validity of five respiratory and blood-gas-derived indices in defining presurgical stabilization: the oxygenation index (OI), the alveolar-arterial O(2) gradient (A-aDO(2)), the arterial-alveolar O(2) tension ratio (a/AO(2)), the arterial pH and the PaCO(2). METHODS: The study involved 73 neonates with CDH where the accuracy of stabilization was assessed through the survival percentage and the contemporary behaviour of mean arterial pressure (MAP), ductal shunting, urine output and lactate levels. The trend of the indices was compared in two groups (stable/fit for surgery vs unstable/unfit for surgery) at five times (PICU admission, 6, 12, 24 hours after admission, assessment of clinical stabilization). RESULTS: Fifty-five neonates were defined stabilized on the basis of the indices and underwent surgery with a 100% survival rate; 18 patients died before surgery, having never achieved clinical stabilization. MAP, ductal shunting, urine output and lactate levels were normal in the stabilized patients and altered in the non stabilized. Of the five parameters considered, all three oxygenation-linked indices (OI, A-aDO(2), a/AO(2)) are very powerful, whereas pH and PaCO(2) appears valid but more tardive. Their progressive improvement (OI<10, A-aDO(2)<250 mmHg, a/AO(2)>0.50, PaCO(2)<55 mmHg, pH>7.35) defined presurgical stabilization, thus allowing CDH surgical correction. CONCLUSION: The study confirms the validity of these indices as a guide to the treatment of neonates with CDH, showing a good reliability in identifying presurgical stabilization.

Cardiocirculatory intraoperative assessment during single-shot caudal anaesthesia in children: comparison between levobupivacaine and ropivacaine.

BACKGROUND: Caudal block with levobupivacaine or ropivacaine is the most commonly used regional anaesthesia in children. METHODS: The aim of study was to compare the cardiocirculatory profile induced in two matched groups of young patients, submitted to caudal anaesthesia with levobupivacaine or ropivacaine for an elective subumbilical surgery. Sixty children were enrolled: thirty received levopubivacaine 0.25% and thirty ropivacaine 0.2%. Intraoperative heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP) were monitored at following times: Ta0 (after anaesthesia induction), Tal (after caudal anaesthesia), Ta2 (five minutes later), Ta3 (ten minutes later), Ts1 (at surgical incision), Ts2, Ts3, Ts4, Ts5 (every 10 minutes during surgery), Taw (at the awakening). RESULTS: In both groups the cardiocirculatory trend remained within normal ranges at all times considered, demonstrating the safety of the method with both drugs. Both groups showed a similar trend at the different monitoring times: low decrease in HR, SBP and DBP after caudal block, slight increase in parameters after skin incision, slight decrease during surgery, increase at awakening. Regarding SBP and DBP, the levobupivacaine group children generally showed higher levels compared to the ropivacaine group, especially for DBP. CONCLUSIONS: Paediatric caudal anaesthesia is an effective method with an very infrequent complication rate. Possible hypotheses for differing haemodynamic behaviour could include a stronger vasoconstriction reflex of innervated areas during caudal anaesthesia with levobupivacaine and a lower levobupivacaine induced block of the sympathetic fibers, related to different pharmacokinetic profile of low concentrations of the local anaesthetics used in paediatric epidural space.

First interlaboratory exercise on non-steroidal anti-inflammatory drugs analysis in environmental samples.

Comparability of monitoring data are essential for any meaningful assessment and for the management of environmental risks of emerging pollutants. The reliability and comparability of data at European level is often limited, because analytical methods for emerging pollutants are often not fully validated, not harmonized or not suitable for all relevant matrices. This paper describes a collaborative interlaboratory exercise for the analysis of non-steroidal anti-inflammatory drugs (NSAIDs) residues in freshwater and wastewater, held in the framework of the EU project "Network of reference laboratories for monitoring of emerging environmental pollutants" (NORMAN). The NSAID compounds selected in this study were ketoprofen, naproxen, ibuprofen and diclofenac. Thirteen laboratories distributed along nine European Countries (Austria, France, Germany, Greece, Italy, Slovak Republic, Slovenia, Spain, and Switzerland) took part in this exercise, 126 samples were analyzed and a total number of 473 values in duplicate were collected. Samples selected in this study include environmental water (river water and waste water) and artificial water (fortified environmental and distilled water) with different ranges of complexity. Two analytical methods were proposed by the organiser; one is based on the use of solid phase extraction (SPE) followed by liquid chromatography-tandem mass spectrometry (LC-MS/MS) and the second one is based on SPE followed by gas-chromatography-mass spectrometry (GC-MS), however, in the first round some different approaches were also admitted. The main goals of this interlaboratory comparison were to evaluate the available analytical schemes for NSAID analysis in natural waters, to evaluate the repeatability (r) and reproducibility (R) between participating laboratories, and to evaluate the influence of the analytical method and sample matrices on the results.

[Clinical spectrum and management of congenital pulmonary cystic lesions].

INTRODUCTION: Congenital cystic lesions of the lung in children are uncommon but potentially life-threatening and warrant an urgent diagnostic work-up. Pulmonary sequestration (PS), congenital cystic adenomatoid malformation (CCAM), congenital lobar emphysema (CLE), and bronchogenic cyst (BC) are the four major congenital cystic lesions, but they share similar embryologic and clinical characteristics. The purpose of this study is to review our institutional experience with congenital cystic lung disease emphasizing on diagnosis and management. PATIENTS AND METHODS: Between January 1975 and October 2007, 109 patients have been treated, of which 57 males and 52 females, the age ranged from the birth to 13 years. 104 patients presented solitary lesions: CCAM (47), CLE (16), PS (22), BC (19). The remainders 5 patients presented two simultaneous lesions: intralobar PS and CCAM (2), CLE and CCAM (3). RESULTS: All the lesions have been treated surgically: in the first cases, only symptomatic patients underwent surgery, while in the last years, patients have systematically been submitted operated. CONCLUSIONS: A meaningful percentage of CCAM joins to PS and CLE; instead the BC are generally isolated, probably deriving by a more precocious embryogenetic defect. The treatment of these lesions is surgical: CCAM (type I-II) and CLE should be treated promptly in newborns for respiratory distress and pneumothorax; CCAM (type II) and BC generally become symptomatic gradually and expose to degenerative risk; intralobar PS generally becomes symptomatic and surgery prevents the risk of infections. Extralobar PS and the asymptomatic BC are not exempted by surgical approach whenever accidentally described as masses of uncertain nature. Asymptomatic cysts in children should be resected, to avoid later complications of the cysts, which could make operation more difficult. Conservative anatomic resections should be attempted to preserve functional lung tissue. Careful histologic examination of the resection specimen is mandatory to identify occult malignancy. In conclusion a correct embryogenetic organization and a clinical evaluation of the congenital cystic lung diseases allow a precocious and effective surgical timing.

Rhabdomyolysis and respiratory failure: rare presentation of carnitine palmityl-transferase II deficiency.

Carnitine palmityl-transferase (CPT) II deficiency is a rare disorder of the fatty acid beta-oxidation cycle. CPT II deficiency can be associated with rhabdomyolysis in particular conditions that increase the requirement for fatty acid oxidation, such as low-carbohydrate and high-fat diet, fasting, exposure to excessive cold, lack of sleep and prolonged exercise. The best known CPT II deficiency is the muscular form with episodic muscle necrosis and paroxysmal myoglobinuria after prolonged exercise. We report a case of a four-year-old male child, who, after one day of hyperthermia and fasting, developed a massive rhabdomyolysis beginning with acute respiratory failure and later complicated by acute renal failure. Appropriate management in Pediatric Intensive Care Unit (PICU) (mechanical ventilatory support, fluid supply combined with mannitol and bicarbonate infusions, administration of acetaminophen and antibiotics, and continuous venovenous haemofiltration) brought about complete resolution with an excellent outcome. Biochemical investigation of muscle biopsy and genetic analysis showed a deficiency of CPT II. The onset of CPT II deficiency with respiratory failure is extremely rare, but a correct and early diagnosis of rhabdomyolysis is the key to successful treatment. A metabolic myopathy such as CPT II deficiency should be suspected in children affected by rhabdomyolysis if trauma, crash, infections, drugs or extreme exertion can be excluded.

Increase of plasmatic beta-endorphin immunoreactive material in children in the perioperative period: the influence of the site of surgery.

BACKGROUND: The primary aim of the study was to confirm the increase of plasmatic IR beta-endorphin material during the perioperative period in children. The second was to search for the factors responsible for this increment. METHODS: Seventy-two consecutive children undergoing a surgical procedure were recruited. Pre-anaesthesia and anaesthesia were standardised. Plasmatic IR beta-endorphin material was measured at three timepoints: at baseline (t (0)), before induction (t (1)), and at the end of anaesthesia (t (2)). Two general linear models were set up to analyse the influence of demographics and clinics on the IR beta-endorphin variation between t (0) and t (1). A third model was established to process the possible surgical factors contributing to the IR beta-endorphin variation between t (1) and t (2). RESULTS: ANOVA showed that IR beta-endorphin concentrations increased significantly across the three timepoints (p < 0.0001). Wilcoxon test proved that the difference was significant both for t (0) vs. t (1) and for t (1) vs. t (2). None of the factors taken into account in the pre-operative period influenced the increase in IR beta-endorphin between t (0) and t (1). Of the factors taken into account in the surgical period, only the type of procedure was significant (p = 0.005). The t-test showed that IR beta-endorphin significantly increased during spermatic and epigastric anastomosis (p = 0.000), orchidopexy (p = 0.02), Van der Meulen urethroplasty (p = 0.004), and Duckett urethroplasty (p = 0.003). CONCLUSION: Plasmatic beta-endorphin increases during the perioperative period in children. The site of surgery is responsible for this increment during intervention.

Acute liver failure associated with a prolonged course of acetaminophen at recommended dosages in paediatric age.

Acetaminophen is considered as a safe analgesic and antipyretic drug in paediatric age. The main problem in the use of acetaminophen is acute liver failure after an overdose or an acute intoxication. We report a case of fulminant liver failure and spontaneous recovery in a patient treated with a prolonged course of acetaminophen at recommended dosages.

[Laparoscopic surgery in Hirschsprung's disease]. / Trattamento laparoscopico nel megacolon agangliare.

The laparoscopic treatment of benign conditions of the colon represents only one of the numerous application fields of the modern laparoscopic techniques in pediatric surgery. Until the half of the 1990's, the surgical treatment of choice for Hirschsprung's disease has been the procedure ideated by Soave in the early 1960's. Nowadays, the optimal treatment in the classic forms of aganglionic megacolon consists in performing, in neonatal age or in the first months of life, a transanal extramucous pull-through. This approach can be integrated by a laparoscopic step. From September 2000, at the Department of Pediatric Surgery, Bologna University, we have operated 21 cases of congenital aganglionic megacolon with this technique.

[Thoracoscopic treatment of oesophageal atresia]. / Correzione toracoscopica dell'atresia esofagea.

BACKGROUND: Advancements in minimally invasive surgery in newborns have allowed even the most complex neonatal procedures to be approached using these techniques. Other authors have demonstrated its efficacy in the treatment of the esophageal atresia with distal fistula. METHODS: We report our experience based on the thoracoscopic repair of esophageal atresia with distal fistula in two newborns. Birth weights were 2.800 g and 2.300 g respectively. The patients were intubated endotracheally and placed in a left prone position. Four trocars were inserted: the first one of 5 mm was positioned in the fifth intercostal space for the camera, the other two of 3 mm were positioned in the fourth intercostal space on the anterior and posterior axillary line respectively for the operative instruments. The last trocar of 3 mm was inserted in the third intercostal space on the anterior axillary line for the lung retractor. CO2 was insufflated at a pressure of 8 mm Hg and a flow of 0.5 L/min. The fistula was first isolated then ligated and cut with scissors. The proximal esophagus was opened and an anastomosis was made over a 6F or 8F nasogastric tube with interrupted 4-0 Vicryl sutures. A tube chest was placed through the lower trocar site with the tip near the anastomosis. RESULTS: These two procedures were free of neither intraoperative nor post-operative complications. Feeding by nasogastric tube was started after a mean of 4 days. Barium swallow made on day 7 demonstrated no leakage and no stenosis of the anastomosis. Total oral feeding was possible after 8 days. Mean hospitalization was 14 days. CONCLUSION: This initial report shows, as demonstrated by the experience since 1999 by other authors, that the thoracoscopic esophageal repair in the newborns is technically feasible and, thanks to a magnified vision, it allows to abtain a good isolation of the esophagus and of the tracheo-esophageal fistula respecting the anatomical structures. Moreover the advantages are in terms of exposure and esophageal length, avoiding the significant short and long-term morbidity associated with thoracotomy.

Cattle breeding: A fast screening procedure to control the bovine fodder contamination.

The European Commission has adopted a large number of emergency measures to prevent the spread of the Bovine spongiform encephalopathy (BSE) in the Member States, and among them, a European Regulation prohibits the feeding to ruminants of animal protein and animal feed containing such protein. Aim of this work has been to propose the thermal analysis as a new rapid and sensitive screening tool for a preliminary determination of possible contamination in products destined to bovine growth, since the possibility to screen the samples by a rapid and sensitive tool could reduce the time of analysis required by the actual methodology and could allow the systematic surveillance of bovine feeding, with the official EU methods applied only to positive samples.