Gingival proteomics reveals the role of TGF beta and YAP/TAZ signaling in Raine syndrome fibrosis.

Raine syndrome (RNS) is a rare autosomal recessive osteosclerotic dysplasia. RNS is caused by loss-of-function disease-causative variants of the FAM20C gene that encodes a kinase that phosphorylates most of the secreted proteins found in the body fluids and extracellular matrix. The most common RNS clinical features are generalized osteosclerosis, facial dysmorphism, intracerebral calcifications and respiratory defects. In non-lethal RNS forms, oral traits include a well-studied hypoplastic amelogenesis imperfecta (AI) and a much less characterized gingival phenotype. We used immunomorphological, biochemical, and siRNA approaches to analyze gingival tissues and primary cultures of gingival fibroblasts of two unrelated, previously reported RNS patients. We showed that fibrosis, pathological gingival calcifications and increased expression of various profibrotic and pro-osteogenic proteins such as POSTN, SPARC and VIM were common findings. Proteomic analysis of differentially expressed proteins demonstrated that proteins involved in extracellular matrix (ECM) regulation and related to the TGFß/SMAD signaling pathway were increased. Functional analyses confirmed the upregulation of TGFß/SMAD signaling and subsequently uncovered the involvement of two closely related transcription cofactors important in fibrogenesis, Yes-associated protein (YAP) and transcriptional coactivator with PDZ-binding motif (TAZ). Knocking down of FAM20C confirmed the TGFß-YAP/TAZ interplay indicating that a profibrotic loop enabled gingival fibrosis in RNS patients. In summary, our in vivo and in vitro data provide a detailed description of the RNS gingival phenotype. They show that gingival fibrosis and calcifications are associated with, and most likely caused by excessed ECM production and disorganization. They furthermore uncover the contribution of increased TGFß-YAP/TAZ signaling in the pathogenesis of the gingival fibrosis.

Accuracy of linear measurements for implant planning based on low-dose cone beam CT protocols: a systematic review and meta-analysis.

OBJECTIVES: The aim of this systematic review was to verify the accuracy of linear measurements performed on low-dose CBCT protocols for implant planning, in comparison with those performed on standard and high-resolution CBCT protocols. METHODS: The literature search included four databases (Pubmed, Web of Science, Embase, and Scopus). Two reviewers independently screened titles/abstracts and full texts according to eligibility criteria, extracted the data, and examined the methodological quality. Risk of bias assessment was performed using the Quality Assessment Tool For In Vitro Studies. Random-effects meta-analysis was used for pooling measurement error data. RESULTS: The initial search yielded 4684 titles. In total, 13 studies were included in the systematic review, representing a total of 81 samples, while 9 studies were included in the meta-analysis. The risk of bias ranged from medium to low. The main results across the studies indicate a strong consistency in linear measurements performed on low-dose images in relation to the reference methods. The overall pooled planning measurement error from low-dose CBCT protocols was -0.24 mm (95% CI, -0.52 to 0.04) with a high level of heterogeneity, showing a tendency for underestimation of real values. Various studies found no significant differences in measurements across different protocols (eg, voxel sizes, mA settings, or dose levels), regions (incisor, premolar, molar) and types (height vs. width). Some studies, however, noted exceptions in measurements performed on the posterior mandible. CONCLUSION: Low-dose CBCT protocols offer adequate precision and accuracy of linear measurements for implant planning. Nevertheless, diagnostic image quality needs must be taken into consideration when choosing a low-dose CBCT protocol.

Sharps Accidents: Occurrence and Knowledge Level among Brazilian Dental Students

ABSTRACT Objective: To evaluate the prevalence of sharps accidents among dental students in southwest Goiás state, Brazil, and further survey their knowledge of biosafety and post-injury management. Material and Methods: A cross-sectional analytical observational study was carried out in 2018 following the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. The study population included dental students in the 4th and 10th course semester. A pre-formulated self-administered questionnaire containing 14 objective questions was used for data collection. Mean and standard deviation values were calculated. Results: A total of 308 responses were obtained. Overall, 15.9% of the respondents reported having previously experienced accidents with sharps. Most dental students who claimed to know the biological risks to which they are exposed were in the 5th and 8th course semesters, and 67.2% of them reported knowing how to proceed in the event of a sharp accident. Conclusion: A low prevalence of sharps accidents has been reported, and dental students are considered to have a good knowledge of biosafety.

The solute carrier SLC25A17 sustains peroxisomal redox homeostasis in diverse mammalian cell lines.

Despite the crucial role of peroxisomes in cellular redox maintenance, little is known about how these organelles transport redox metabolites across their membrane. In this study, we sought to assess potential associations between the cellular redox landscape and the human peroxisomal solute carrier SLC25A17, also known as PMP34. This carrier has been reported to function as a counter-exchanger of adenine-containing cofactors such as coenzyme A (CoA), dephospho-CoA, flavin adenine dinucleotide, nicotinamide adenine dinucleotide (NAD+), adenosine 3',5'-diphosphate, flavin mononucleotide, and adenosine monophosphate. We found that inactivation of SLC25A17 resulted in a shift toward a more reductive state in the glutathione redox couple (GSSG/GSH) across HEK-293 cells, HeLa cells, and SV40-transformed mouse embryonic fibroblasts, with variable impact on the NADPH levels and the NAD+/NADH redox couple. This phenotype could be rescued by the expression of Candida boidinii Pmp47, a putative SLC25A17 orthologue reported to be essential for the metabolism of medium-chain fatty acids in yeast peroxisomes. In addition, we provide evidence that the alterations in the redox state are not caused by changes in peroxisomal antioxidant enzyme expression, catalase activity, H2O2 membrane permeability, or mitochondrial fitness. Furthermore, treating control and ΔSLC25A17 cells with dehydroepiandrosterone, a commonly used glucose-6-phosphate dehydrogenase inhibitor affecting NADPH regeneration, revealed a kinetic disconnection between the peroxisomal and cytosolic glutathione pools. Additionally, these experiments underscored the impact of SLC25A17 loss on peroxisomal NADPH metabolism. The relevance of these findings is discussed in the context of the still ambiguous substrate specificity of SLC25A17 and the recent observation that the mammalian peroxisomal membrane is readily permeable to both GSH and GSSG.

[The resignations among nurses in the Veneto healthcare institutions. A retrospective study]. / Il fenomeno delle dimissioni tra gli infermieri nelle Aziende Sanitarie del Veneto. Uno studio retrospettivo.

. The resignations among nurses in the Veneto healthcare institutions. A retrospective study. INTRODUCTION: The phenomenon of large-scale resignations is complex, heterogeneous and cannot be attributed solely to the pandemic crisis, during which many people reconsidered the role of work in their lives. The health system was particularly exposed to the shocks caused by the pandemic. AIMS: To describe the turnover and analyse the resignations of nurses in the NHS hospitals and districts of the Veneto Region. METHODS: The hospitals were categorised into 4 types: Hub and Spoke of level 1 and 2. The positions of nurses with permanent contracts between 1 January 2016 and 31 December 2022 were analysed, considering active, nurses on duty for at least one day. The data were extracted from the human resource management database of the Region. Unexpected resignations were considered those occurring before the retirement date (59 years for women and 60 for men). Negative and overall turnover rates were calculated. RESULTS: The risk of unexpected resignations was increased for nurses not resident in Veneto, of male gender and employed at a Hub hospital. CONCLUSIONS: The flight from the NHS is in addition to the physiological flow of retirements, due to increase in the coming years. It is necessary to: act on the retention capacity and attractiveness of the profession; implement organisational models based on task sharing and shifting; implement digital tools; favour flexibility and mobility to improve the balance between work and personal life; efficiently integrate professionals quali-fied abroad.

Human peroxisomal NAD+/NADH homeostasis is regulated by two independent NAD(H) shuttle systems.

Reduced (NADH) and oxidized (NAD+) nicotinamide adenine dinucleotides are ubiquitous hydride-donating/accepting cofactors that are essential for cellular bioenergetics. Peroxisomes are single-membrane-bounded organelles that are involved in multiple lipid metabolism pathways, including beta-oxidation of fatty acids, and which contain several NAD(H)-dependent enzymes. Although maintenance of NAD(H) homeostasis in peroxisomes is considered essential for peroxisomal beta-oxidation, little is known about the regulation thereof. To resolve this issue, we have developed methods to specifically measure intraperoxisomal NADH levels in human cells using peroxisome-targeted NADH biosensors. By targeted CRISPR-Cas9-mediated genome editing of human cells, we showed with these sensors that the NAD+/NADH ratio in cytosol and peroxisomes are closely connected and that this crosstalk is mediated by intraperoxisomal lactate and malate dehydrogenases, generated via translational stop codon readthrough of the LDHB and MDH1 mRNAs. Our study provides evidence for the existence of two independent redox shuttle systems in human peroxisomes that regulate peroxisomal NAD+/NADH homeostasis. This is the first study that shows a specific metabolic function of protein isoforms generated by translational stop codon readthrough in humans.

Functional Analysis of GSTK1 in Peroxisomal Redox Homeostasis in HEK-293 Cells.

Peroxisomes serve as important centers for cellular redox metabolism and communication. However, fundamental gaps remain in our understanding of how the peroxisomal redox equilibrium is maintained. In particular, very little is known about the function of the nonenzymatic antioxidant glutathione in the peroxisome interior and how the glutathione antioxidant system balances with peroxisomal protein thiols. So far, only one human peroxisomal glutathione-consuming enzyme has been identified: glutathione S-transferase 1 kappa (GSTK1). To study the role of this enzyme in peroxisomal glutathione regulation and function, a GSTK1-deficient HEK-293 cell line was generated and fluorescent redox sensors were used to monitor the intraperoxisomal GSSG/GSH and NAD+/NADH redox couples and NADPH levels. We provide evidence that ablation of GSTK1 does not change the basal intraperoxisomal redox state but significantly extends the recovery period of the peroxisomal glutathione redox sensor po-roGFP2 upon treatment of the cells with thiol-specific oxidants. Given that this delay (i) can be rescued by reintroduction of GSTK1, but not its S16A active site mutant, and (ii) is not observed with a glutaredoxin-tagged version of po-roGFP2, our findings demonstrate that GSTK1 contains GSH-dependent disulfide bond oxidoreductase activity.

Enhanced Levels of Peroxisome-Derived H2O2 Do Not Induce Pexophagy but Impair Autophagic Flux in HEK-293 and HeLa Cells.

Peroxisomes are functionally specialized organelles that harbor multiple hydrogen peroxide (H2O2)-producing and -degrading enzymes. Given that this oxidant functions as a major redox signaling agent, peroxisomes have the intrinsic ability to mediate and modulate H2O2-driven processes, including autophagy. However, it remains unclear whether changes in peroxisomal H2O2 (po-H2O2) emission impact the autophagic process and to which extent peroxisomes with a disturbed H2O2 metabolism are selectively eliminated through a process called "pexophagy". To address these issues, we generated and validated HEK-293 and HeLa pexophagy reporter cell lines in which the production of po-H2O2 can be modulated. We demonstrate that (i) po-H2O2 can oxidatively modify multiple selective autophagy receptors and core autophagy proteins, (ii) neither modest nor robust levels of po-H2O2 emission act as a prime determinant of pexophagy, and (iii) high levels of po-H2O2 impair autophagic flux by oxidative inhibition of enzymes involved in LC3II formation. Unexpectedly, our analyses also revealed that the autophagy receptor optineurin can be recruited to peroxisomes, thereby triggering pexophagy. In summary, these findings lend support to the idea that, during cellular and organismal aging, peroxisomes with enhanced H2O2 release can escape pexophagy and downregulate autophagic activity, thereby perpetuating the accumulation of damaged and toxic cellular debris.

Identification of Peroxisome-Derived Hydrogen Peroxide-Sensitive Target Proteins Using a YAP1C-Based Genetic Probe.

As the reversible oxidation of protein cysteine thiols is an important mechanism in signal transduction, it is essential to have access to experimental approaches that allow for spatiotemporal indexing of the cellular sulfenome in response to local changes in H2O2 levels. Here, we provide a step-by-step guide for enriching and identifying the sulfenome of mammalian cells at the subcellular level in response to peroxisome-derived H2O2 by the combined use of (i) a previously developed cell line in which peroxisomal H2O2 production can be induced in a time- and dose-dependent manner; (ii) YAP1C, a genetically encoded yeast AP-1-like transcription factor-based probe that specifically reacts with S-sulfenylated cysteines and traps them through mixed disulfide bonds; and (iii) mass spectrometry. Given that this approach includes differential labeling of reduced and reversibly oxidized cysteine residues, it can also provide additional information on the positions of the modified cysteines. Gaining more in-depth insight into the complex nature of how alterations in peroxisomal H2O2 metabolism modulate the cellular sulfenome is key to our understanding of how these organelles act as redox signaling hubs in health and disease.

Assessment of the Peroxisomal Redox State in Living Cells Using NADPH- and NAD+/NADH-Specific Fluorescent Protein Sensors.

The pyridine nucleotides NAD(H) and NADP(H) are key molecules in cellular metabolism, and measuring their levels and oxidation states with spatiotemporal precision is of great value in biomedical research. Traditional methods to assess the redox state of these metabolites are intrusive and prohibit live-cell quantifications. This obstacle was surpassed by the development of genetically encoded fluorescent biosensors enabling dynamic measurements with subcellular resolution in living cells. Here, we provide step-by-step protocols to monitor the intraperoxisomal NADPH levels and NAD+/NADH redox state in cellulo by using targeted variants of iNAP1 and SoNar, respectively.

Quantitative and qualitative comparisons of pulp cavity volumes produced by cone beam computed tomography and micro-computed tomography through semiautomatic segmentation: An ex vivo investigation.

OBJECTIVE: The aim of this study was to measure the volume and visually assess 3-dimensional (3D) virtual models of pulp cavities obtained through semiautomatic segmentation on images from 6 cone beam computed tomography (CBCT) units compared with the reference standard of micro-CT. STUDY DESIGN: Fifteen mandibular premolar teeth were scanned with 6 CBCT units: Prexion 3D Elite, i-CAT Next Generation, NewTom 5G, Cranex 3D, 3Shape X1, and Orthophos SL 3D, using the smallest available field of view and highest resolution settings. Pulp cavity volumes were quantitatively assessed by 2 calibrated examiners. The volumes from each CBCT unit were compared with micro-CT. Qualitative assessment of the 3D reconstructions was also performed. Repeated-measures analysis of variance and the Friedman test compared the CBCT reconstructions to micro-CT. Intra- and interexaminer agreements were calculated with the intraclass correlation coefficient and kappa statistic. RESULTS: The CBCT-based volumes were all significantly larger than micro-CT (P ≤ .0061). Prexion, X1, and Orthophos provided the segmentations that most closely resembled the reference standard. Intra- and interexaminer agreements ranged from good to excellent for quantitative measurements. Interexaminer agreement for qualitative evaluation was substantial. CONCLUSIONS: Semiautomatic segmentation of CBCT images is a feasible method to produce virtual 3D models of the pulp cavity. Prexion, X1, and Orthophos were the CBCT units that resulted in 3D reconstructions most similar to the reference standard.

[The education of specialized nurses' aides: current scenario and future perspectives]. / La formazione dell'operatore sociosanitario con formazionecomplementare in assistenza sanitaria: scenario attuale e prospettive future.

. The education of specialized nurses' aides: current scenario and future perspectives. INTRODUCTION: The complementary training in health care of the nurse aides (NAs), launched in Italy in 2003, has little impact on health care organisations. OBJECTIVE: To analyse, through the regional provisions issued in the last three years, the current state of complementary training in health care and propose some recommendations for the nursing profession with respect to the inclusion of this figure in care teams. METHODS: A documentary content analysis was conducted with respect to six main topics: recipients and admission to the courses, organisation and characteristics of the courses, learning evaluation, responsibilities of the new NAs, expected competences and skills. RESULTS: There is a clear need to update and standardise the contents of the courses, with a focus on current social and health problems and future scenarios, and to render more homogeneous the structure of the courses, to guarantee high standards at national level. The need of increasing the skills of the NAs is associated with the implementation of innovative care and organisational models that require the ability to care for populations whose needs have changed profoundly over the last twenty years. CONCLUSIONS: Health care teams with professionals with different skill-mix guarantee safe, appropriate, effective and efficient care: the organization should enable nurses to free up time to act out their competences in care planning, health promotion, therapeutic education, transition management and specialist functions.

Peroxisome-Derived Hydrogen Peroxide Modulates the Sulfenylation Profiles of Key Redox Signaling Proteins in Flp-In T-REx 293 Cells.

The involvement of peroxisomes in cellular hydrogen peroxide (H2O2) metabolism has been a central theme since their first biochemical characterization by Christian de Duve in 1965. While the role of H2O2 substantially changed from an exclusively toxic molecule to a signaling messenger, the regulatory role of peroxisomes in these signaling events is still largely underappreciated. This is mainly because the number of known protein targets of peroxisome-derived H2O2 is rather limited and testing of specific targets is predominantly based on knowledge previously gathered in related fields of research. To gain a broader and more systematic insight into the role of peroxisomes in redox signaling, new approaches are urgently needed. In this study, we have combined a previously developed Flp-In T-REx 293 cell system in which peroxisomal H2O2 production can be modulated with a yeast AP-1-like-based sulfenome mining strategy to inventory protein thiol targets of peroxisome-derived H2O2 in different subcellular compartments. By using this approach, we identified more than 400 targets of peroxisome-derived H2O2 in peroxisomes, the cytosol, and mitochondria. We also observed that the sulfenylation kinetics profiles of key targets belonging to different protein families (e.g., peroxiredoxins, annexins, and tubulins) can vary considerably. In addition, we obtained compelling but indirect evidence that peroxisome-derived H2O2 may oxidize at least some of its targets (e.g., transcription factors) through a redox relay mechanism. In conclusion, given that sulfenic acids function as key intermediates in H2O2 signaling, the findings presented in this study provide valuable insight into how peroxisomes may be integrated into the cellular H2O2 signaling network.

Mitochondrial and metabolic remodelling in human skin fibroblasts in response to glucose availability.

Cell culture conditions highly influence cell metabolism in vitro. This is relevant for preclinical assays, for which fibroblasts are an interesting cell model, with applications in regenerative medicine, diagnostics and therapeutic development for personalized medicine, and the validation of ingredients for cosmetics. Given these cells' short lifespan in culture, we aimed to identify the best cell culture conditions and promising markers to study mitochondrial health and stress in normal human dermal fibroblasts (NHDF). We tested the effect of reducing glucose concentration in the cell medium from high glucose (HGm) to a more physiological level [low glucose medium (LGm)], or its complete removal and replacement by galactose [medium that forces oxidative phosphorylation (OXPHOSm)], always in the presence of glutamine and pyruvate. We have demonstrated that only with OXPHOSm was it possible to observe the selective inhibition of mitochondrial adenosine triphosphate (ATP) production. This reliance on mitochondrial ATP was accompanied by changes in oxygen consumption rate and extracellular acidification rate, oxidation of citric acid cycle substrates, fatty acids, lactate, and other substrates, increased mitochondrial network extension and polarization, the increased protein content of voltage-dependent anion channel (VDAC) and peroxisome proliferator-activated receptor gamma coactivator 1-alpha and changes in several key transcripts related to energy metabolism. LGm did not promote significant metabolic changes in NHDF, although mitochondrial network extension and VDAC protein content were increased compared to HGm-cultured cells. Our results indicate that short-term adaptation to OXPHOSm is ideal for studying mitochondrial health and stress in NHDF.

Colloidal stability of milk: reinterpretation of alcohol test results by digital microscopy.

In this research communication we propose a new approach by portable digital microscopy with a 200× objective to improve the visualization of microparticles of pasteurized milk submitted to the alcohol test. Not only did the method reduce the subjectivity of the readings, but also generated high resolution images of the microparticles, which allows the creation of a specific image pattern for each type of final product. In comparison to a control pasteurized milk treatment, the results confirmed the effect and the specificity of added salts (sodium citrate, disodium phosphate or their combination) on the stability of the milk to the alcohol test. Finally, the mixture of stabilizing salts of citrate/phosphate provided the highest degree of stability to pasteurized milk among the treatments studied.

Efficacy of an iodoform-based filling material for pulpectomy of primary teeth: A 24-month non-inferiority randomized clinical trial.

AIM: The aim of this non-inferiority randomized clinical trial was to compare the efficacy of an iodoform-based paste (Guedes-Pinto -(GP)) as a filling material in pulpectomies of primary teeth, and a standard material composed by calcium hydroxide and iodoform (CaOH/Iodof paste; Vitapex® ). DESIGN: A total of 104 teeth from 61 children (3-8 years old) were randomly allocated to two groups according to filling materials. Children were followed up for 24 months. The primary endpoint was the treatment success rate evaluated through clinical and radiographic examinations at follow-up, and the secondary outcome was the analysis of the canal filling quality. Differences in the proportion of treatment success was calculated based on 95% confidence intervals (95% CI) and with the Miettinen and Nurminen method in the intention-to-treat population, considering a -20% of the non-inferiority limit. RESULTS: From 104 randomized teeth, 102 were followed up after 24 months (attrition rate of 1.9%). The success rate of teeth treated with the GP paste was 86.8% (95% CI: 69.9-94.9) and 78.4% (95% CI: 61.8-89.1) with the CaOH/Iodof paste. Consequently, a non-inferiority of the GP paste was observed when compared to the CaOH/Iodof paste (P < .001). CONCLUSION: The GP paste has a non-inferior success rate than the CaOH/Iodof paste used as filling material for pulpectomy in primary teeth.

Pathogenesis of Enamel-Renal Syndrome Associated Gingival Fibromatosis: A Proteomic Approach.

The enamel renal syndrome (ERS) is a rare disorder featured by amelogenesis imperfecta, gingival fibromatosis and nephrocalcinosis. ERS is caused by bi-allelic mutations in the secretory pathway pseudokinase FAM20A. How mutations in FAM20A may modify the gingival connective tissue homeostasis and cause fibromatosis is currently unknown. We here analyzed conditioned media of gingival fibroblasts (GFs) obtained from four unrelated ERS patients carrying distinct mutations and control subjects. Secretomic analysis identified 109 dysregulated proteins whose abundance had increased (69 proteins) or decreased (40 proteins) at least 1.5-fold compared to control GFs. Proteins over-represented were mainly involved in extracellular matrix organization, collagen fibril assembly, and biomineralization whereas those under-represented were extracellular matrix-associated proteins. More specifically, transforming growth factor-beta 2, a member of the TGFß family involved in both mineralization and fibrosis was strongly increased in samples from GFs of ERS patients and so were various known targets of the TGFß signaling pathway including Collagens, Matrix metallopeptidase 2 and Fibronectin. For the over-expressed proteins quantitative RT-PCR analysis showed increased transcript levels, suggesting increased synthesis and this was further confirmed at the tissue level. Additional immunohistochemical and western blot analyses showed activation and nuclear localization of the classical TGFß effector phospho-Smad3 in both ERS gingival tissue and ERS GFs. Exposure of the mutant cells to TGFB1 further upregulated the expression of TGFß targets suggesting that this pathway could be a central player in the pathogenesis of the ERS gingival fibromatosis. In conclusion our data strongly suggest that TGFß -induced modifications of the extracellular matrix contribute to the pathogenesis of ERS. To our knowledge this is the first proteomic-based analysis of FAM20A-associated modifications.

[Family and community nursing: overview of practice in Europe]. / L'infermiere di famiglia e comunità:panoramica sull'esercizio della professione in Europa.

. Family and Community nursing: overview of practice in Europe. In this contribution, an overview of the role and functions of the family nurse in some European countries is presented. The role of family and community nursing varies with respect to contexts and changes according to the needs of the population, focusing particularly on frail conditions, or maternal and child support, or the prevention and management of chronic diseases. Family and community nurses have specialized postgraduate training, except in Finland, to gain skills to help individuals and families prevent disease conditions or cope with chronic disability. They work primarily in community centers, in patients' homes, and with families; advocate for lifestyle modification and behavioral risk factors; and care for families on wide-ranging health issues.

[Family nurses in Italy: an explorative survey]. / Gli infermieri di famiglia in Italia:indagine esplorativa.

. Family nurses in Italy: an explorative survey. INTRODUCTION: The Family and Community Nurses (FCN) are unevenly distributed throughout Italy. AIM: to describe the numbers, functions and work situation of FCNs in Italy. METHODS: A questionnaire with 24 multiple-choice questions was sent to 60 Nursing and health professions District managers, to explore numerical standards of reference, recruitment methods, training, work environments and methods, hierarchical and functional dependencies, functions performed and level of autonomy. RESULTS: 38 (63%) managers from 14 regions responded. In 26 (68%) districts, FCNs are employed with numbers ranging from 2 to 350 per district (median FCN/inhabitants ratio of approximately 1/16.000 inhabitants (IQR 10.000-40.000). Nurses with at least 2 years of work experience (in home or medical care) were selected, and all have attended or are currently attending a training course (university, regional - 40% of the districts - or internal courses). In almost all Districts FCNs hierarchically depend on the Nurse Manager while functionally from the District Nurse or Medical Director. FCNs mostly work in multidisciplinary teams and in most Districts (21, 80%) perceive good levels of autonomy. CONCLUSIONS: Although a limited number of managers responded, these data provide a cross-section of the variability of numbers and organization at district level.

[Conclusions and reflections for planning not based on average numbers]. / Alcune riflessioni generali:per una pianificazione senza numeri medi.

. Conclusions and reflections for planning not based on average numbers. Planning for the number of Family and community nurses (FCNs) needed cannot be based on average estimates issued at the national level. In fact, organizing a service requires in-depth knowledge not only of patients, but also of the local area, health, social, and volunteer services. This information is available, however not always easy to use and combine with other useful data stored in databases not connected to each other. While waiting to have enough FCNs, priorities for those available should be set at local level. The choice of priority target groups of population depends on local data but also on a careful assessment of the services already available in the area, in order to identify the populations most at risk or with limited access of services of the national health and social systems.