Identifying patient subgroups with different trends of patient-reported outcomes (PROMs) after elective knee arthroplasty.

BACKGROUND: Patient-reported outcome measures (PROMs) are increasingly being used to assess the effectiveness of elective total knee arthroplasty (TKA). However, little is known about how PROMs scores change over time in these patients. The aim of this study was to identify the trajectories of quality of life and joint functioning, and their associated demographic and clinical features in patients undergoing elective TKA. METHODS: A prospective, cohort study was conducted, in which PROMs questionnaires (Euro Quality 5 Dimensions 3L, EQ-5D-3L, and Knee injury and Osteoarthritis Outcome Score Patient Satisfaction, KOOS-PS) were administered to patients at a single center undergoing elective TKA before surgery, and at 6 and 12 months after surgery. Latent class growth mixture models were used to analyze the patterns of change in PROMs scores over time. Multinomial logistic regression was used to investigate the association between patient characteristics and PROMs trajectories. RESULTS: A total of 564 patients were included in the study. The analysis highlighted differential patterns of improvement after TKA. Three distinct PROMs trajectories were identified for each PROMs questionnaire, with one trajectory indicating the most favorable outcome. Female gender appears to be associated with a presentation to surgery with worse perceived quality of life and joint function than males, but also more rapid improvement after surgery. Having an ASA score greater than 3 is instead associated with a worse functional recovery after TKA. CONCLUSION: The results suggest three main PROMs trajectories in patients undergoing elective TKA. Most patients reported improved quality of life and joint functioning at 6 months, which then stabilized. However, other subgroups showed more varied trajectories. Further research is needed to confirm these findings and to explore the potential clinical implications of these results.

A multi-step approach to evaluate the sustainable use of groundwater resources for human consumption and agriculture.

The rapid decline in both quality and availability of freshwater resources on our planet necessitates their thorough assessment to ensure sustainable usage. The growing demand for water in industrial, agricultural, and domestic sectors poses significant challenges to managing both surface and groundwater resources. This study tests and proposes a hybrid evaluation approach to determine Groundwater Quality Indices (GQIs) for irrigation (IRRI), seawater intrusion (SWI), and potability (POT), finalized to the spatial distribution of groundwater suitability involving water quality indicator along with hydrogeological and socio-economic factors. Mean Decrease Accuracy (MDA) and Information Gain Ratio (IGR) were used to state the importance of chosen factors such as level of groundwater above the sea, thickness of the aquifer, land cover, distance from coastline, silt soil content, recharge, distance from river and lagoons, depth to water table from ground, distance from agricultural wells, hydraulic conductivity, and lithology for each quality index, separately. The results of both methods showed that recharge is the most important parameter for GQIIRRI and GQIPOT, while the distance from the coastline and the rivers, are the most important for GQISWI. The spatial modelling of GQIIRRI and GQIPOT in the study area has been achieved applying three machine learning (ML) algorithms: the Boosted Regression Tree (BRT), the Random Forest (RF), and the Support Vector Machine (SVM). Validation results showed that RF has the highest prediction for GQIIRRI, while the SVM model has the highest prediction for the GQIPOT index. It is worth to mention that the future utilization and testing of new algorithms could produce even better results. Finally, GQIIRRI and GQIPOT were combined and compared using two combine and overlay methods to prepare a hybrid map of multi-GQIs. The results showed that 69% of the study area is suitable for irrigation and potable use, due to both geogenic and anthropogenic activities which contribute to make some water resources unsuitable for either use. Specifically, the northern, western, and eastern portions of the study area are in the "very high and high quality" classes while the southern portion shows "very low and low quality" classes. In conclusion, the developed map and approach can serve as a practical guide for enhancing groundwater management, identifying suitable areas for various uses and pinpointing regions requiring improved management practices.

Fe and As geochemical self-removal dynamics in mineral waters: evidence from the Ferrarelle groundwater system (Riardo Plain, Southern Italy).

A theoretical pattern for Fe and As co-precipitation was tested directly in a groundwater natural system. Several monitoring wells were sampled to identify the different endmembers that govern the hydrodynamics of the Ferrarelle Groundwater System in the Riardo Plain (Southern Italy). In agreement with recent investigations, we found a mix of a deep and a shallow component in different proportions, resulting in a specific chemical composition of groundwater in each well depending on the percentages of each component. The shallow component was characterized by EC ~ 430 µS/cm, Eh ~ 300 mV, Fe ~ 0.06 µmol/L and As ~ 0.01-0.12 µmol/L, while the deep component was characterized by EC ~ 3400 µS/cm, Eh ~ 170 mV, Fe ~ 140 µmol/L and As ~ 0.59 µmol/L. A general attenuation of As and Fe concentration that was not due to a simple dilution effect was observed in the mixing process. The oxidation of Fe(II) to Fe(III) produces solid precipitates which adsorb As from solution and then co-precipitate. The reactions pattern of Fe(II) oxidation and As adsorption gave a linear function between [As] and [Fe], where the angular coefficient depends on the [O2]/[H+] ratio. Chemical data obtained from our samples showed a very good agreement with this theoretical relationship. The investigated geochemical dynamics represented a natural process of attenuation of Fe and As, two undesirable elements that usually affect groundwater quality in volcanic aquifers in central-southern Italy, which are exploited to supply drinking water.

Tracing groundwater circulation in a valuable mineral water basin with geochemical and isotopic tools: the case of FERRARELLE, Riardo basin, Southern Italy.

The Riardo basin hosts groundwater exploited for the production of high quality, naturally sparkling, bottled water (e.g., Ferrarelle water), and circulating in a system constituted by highly fractured Mesozoic carbonates, overlain by more impervious volcanic rocks of the Roccamonfina complex. The two formations are locally in hydraulic connection and dislocated by deep-rooted faults. The study aimed at elucidating groundwater origin and circulation, using isotopic tracers (δ18O, δ2H, δ11B and 87Sr/86Sr) coupled to groundwater dating (Tritium, CFCs and SF6). Besides recharge by local precipitation over the Riardo hydrogeological basin, stable isotope ratios in water indicated an extra-basin recharge, likely from the elevated surrounding carbonate reliefs (e.g., Maggiore and Matese Mts.). The mineralization process, promoted by the deep CO2 flux, controls the B and Sr contents. However, their isotopic ratios did not allow discriminating between circulation in the volcanic and in the carbonate aquifers, as in the latter the isotopic composition differed from the original marine signature. Groundwater model ages ranged from ~ 30 years for the volcanic endmember to > 70 years for the deep, mineralized end-member, with longer circuits recharged at higher elevations. Overall, the results of this study were particularly relevant for mineral water exploitation. A recharge from outside the hydrogeological basin could be evidenced, especially for the more mineralized and valuable groundwater, and an active recent recharge was detected for the whole Riardo system. Both findings will contribute to the refinement of the hydrogeological model and water budget, and to a sustainable development of the resource.

Geochemical characterization and health risk assessment in two diversified environmental settings (Southern Italy).

An integrated approach using chemical and microbial indicators has been tested in two different sites of the Campania Plain (Southern Italy) with different land use covering and different hydrogeological features in order: (1) to define the water-rock interaction processes, (2) to differentiate sources of pollution in a detailed way (3) to evaluate the degree of water quality in the studied alluvial aquifer and (4) to identify the most worrying elements for human's health. Groundwater have showed a HCO3-Ca signature for both investigated sites, and a progressive enrichment in alkali ions has been highlighted moving from the boundary of the plain toward the coastal areas, due to groundwater interaction with volcanic rocks along the flow path. The application of the Factor Analysis allowed to identify different sources of pollution, which were attributed to (a) leaks in the sewer system for the Agro-Aversano Area and also the spreading of manure as fertilizers in agricultural activities for the Caiazzo Plain. Furthermore, it has been highlighted that the use of major elements, trace elements and microbiological indicators, allows to accurately differentiate contamination processes in progress. In fact, from the results of the Factor Analysis applied in the Agro-Aversano area, no significant statistically relationships between major elements and microbiological indicators of fecal contamination were highlighted, unlike the Caiazzo plain where statistically significant correlations have been found between major and trace elements and microbiological indicators. The use of a Groundwater Quality Index has shown general poor water quality for the majority of analyzed samples due to the high amount of Nitrate and Fecal indicators. The use of a Health Risk Assessment highlighted that Nitrate coupled with Fluoride represent the most important concern for human health compared to the all investigated parameters in both sites.

The COVID-19 outbreak in Italy: perspectives from an orthopaedic hospital.

PURPOSE: Italy is one of the more severely affected countries in the world by the recent COVID-19 outbreak. The aim of this report is to describe how COVID-19 affected the life and organization of one of the main orthopaedic hospitals of the country, and which measures were implemented to face the outbreak. METHODS: A personal interview has been conducted with four doctors involved in the management of COVID-19 outbreak in one of the main orthopaedic hospitals of Italy. RESULTS: Hospital was re-organized, elective surgeries were cancelled, and only trauma surgeries were allowed, together with oncologic and urgent cases. Since the number of cases among patients and healthcare workers increased, the hospital management responded not only with a massive testing campaign aimed at detecting contact histories but also with an additional testing campaign for asymptomatic healthcare workers. CONCLUSION: The main lection is that any actions should be quick and decisive, for 1 week during the COVID-19 epidemic could make the difference.

Patient-reported outcome measures (PROMs) after elective hip, knee and shoulder arthroplasty: protocol for a prospective cohort study.

BACKGROUND: The number of hip, knee and shoulder arthroplasties continues to rise worldwide. The Organization for Economic Cooperation and Development has launched an initiative (called PaRIS Initiative) for the systematic collection of Patient Reported Outcome Measures (PROMs) in patients undergoing elective hip and knee arthroplasty. The Rizzoli Orthopedic Institute (IOR) was selected as a pilot center for the launch of the Initiative in Italy given that IOR hosts the Registry of Orthopedic Prosthetic Implants (RIPO), a region-wide registry which collects joint implant data from all the hospitals in the Emilia-Romagna Region. In this specific geographic area information related to PROMs after joint replacement is unknown. This paper describes the protocol of a study (PaRIS-IOR) that aims to implement the collection of a set of PROMs within an existing implant registry in Italy. The study will also investigate the temporal trend of PROMs in relation to the type of prosthesis and the type of surgical intervention. METHODS: The PaRIS-IOR study is a prospective, single site, cohort study that consists of the administration of PROMs questionnaires to patients on the list for elective arthroplasty. The questionnaires will be administered to the study population within 30 days before surgery, and then at 6 and 12 months following surgery. The study population will consist of consecutive adult patients undergoing either hip, knee or shoulder arthroplasty. The collected data will be linked with those routinely collected by the RIPO in order to assess the temporal trend of PROMs in relation to the type of prosthesis and the type of surgical intervention. DISCUSSION: The PaRIS-IOR study could have important implications in targeting the factors influencing functional outcomes and quality of life reported by patients after hip, knee and shoulder arthroplasty, and will also represent the first systematic collection of PROMs related to arthroplasty in Italy. TRIAL REGISTRATION: Protocol version (1.0) and trial registration data are available on the platform www.clinicaltrial.gov with the identifier NCT03790267 , first posted on December 31, 2018.

Evaluating the suitability of urban groundwater resources for drinking water and irrigation purposes: an integrated approach in the Agro-Aversano area of Southern Italy.

Deterioration of groundwater quality due to the introduction of pollutants from natural and anthropic sources has become a major environmental issue. We tested three methodologies in assessing groundwater quality and intrinsic aquifer vulnerability in the Agro-Aversano area (Southern Italy). A geographic information system (GIS)-based groundwater quality index (GQI) was realized to assess groundwater quality for drinking and irrigation use and, in parallel, standard SINTACS was applied to evaluate the intrinsic vulnerability of the aquifer. Nitrate concentrations and sodium absorption ratio (SAR) in groundwater samples were used to verify the reliability of vulnerability data. GQI analysis pointed to a general poor quality of groundwater both for drinking and irrigation use, especially in sub-urban areas. The spatial pattern of water quality from GQI analysis was positively related to nitrate and fluoride concentrations for drinking use and to bicarbonate and sodium concentrations for irrigation use, whose levels exceeded the WHO and FAO recommended thresholds, respectively. Standard SINTACS was found to be inadequate for describing the aquifer state, its results showing no correlation with nitrate concentration or SAR. Because of this inconsistency, we tested a novel approach combining GQI with SINTACS analysis. Results showed positive correlation with nitrate (r = 0.63) and SAR (r = 0.64) contents, thus pointing to combined SINTACS-GQI as a more reliable approach than standard methodologies.

Impact of rehabilitation on mortality and readmissions after surgery for hip fracture.

BACKGROUND: Hip fracture in elderly patients is a rising global public health concern because of population ageing, and increasing frailty. Long-term morbidity related to poor management of hip fracture is associated with decreased quality of life, survival, and increase in healthcare costs. Receiving postoperative rehabilitation is associated with better outcomes and a higher likelihood of returning to pre-existing level of functioning. However little is known about which postoperative rehabilitation pathways are more effective to optimize patient outcomes. Few studies have analyzed postoperative rehabilitation pathways in a universal healthcare system. The aim of this study is to analyze the impact of post-acute rehabilitation pathways on mortality and readmission in elderly patients undergoing surgery for hip fracture in a large metropolitan area in Italy. METHODS: In this retrospective cohort study, we analyzed 6-month mortality from admission and 6-month readmission after hospital discharge in patients who underwent surgical repair for hip fracture in the hospitals of the Bologna metropolitan area between 1.1.2013 and 30.6.2014. Data were drawn from the regional hospital discharge records database. Kaplan-Meier estimates and multiple Cox regression were used to analyze mortality as a function of rehabilitation pathways. Multiple logistic regression determined predictors of readmission. RESULTS: The study population includes 2208 patients, mostly women (n = 1677, 76%), with a median age of 83.8 years. Hospital rehabilitation was provided to 519 patients (23.5%), 907 (41.1%) received rehabilitation in private inpatient rehabilitation facilities (IRF) accredited by the National Health System, and 782 (35.4%) received no post-acute rehabilitation. Compared with patient receiving hospital rehabilitation, the other groups showed significantly higher mortality risks (no rehabilitation, Hazard Ratio (HR) = 2.19, 95%CI = 1.54-3.12, p < 0.001; IRF rehabilitation, HR = 1.66, 95%CI = 1.54-1.79, p < 0.001). The risk of readmission did not differ significantly among rehabilitation pathways. CONCLUSIONS: Intensive hospital rehabilitation was significantly associated with a lower risk of mortality compared to IRF rehabilitation and no rehabilitation. Our results may help in the development of evidence-based recommendations aimed to improve resource utilization and quality of care in hip fracture patients. Further research is warranted to investigate the impact of the rehabilitation pathway on other outcomes, such as patients' functional status and quality of life.

Evaluating patient safety indicators in orthopedic surgery between Italy and the USA.

OBJECTIVE: To compare patient safety in major orthopedic procedures between an orthopedic hospital in Italy, and 26 US hospitals of similar size. DESIGN: Retrospective analysis of administrative data from hospital discharge records in Italy and Florida, USA, 2011-13. Patient Safety Indicators (PSIs) developed by the Agency for Healthcare Quality and Research were used to identify inpatient adverse events (AEs). We examined the factors associated with the development of each different PSI, taking into account known confounders, using logistic regression. SETTING: One Italian orthopedic hospital and 26 hospitals in Florida with ≥ 1000 major orthopedic procedures per year. PARTICIPANTS: Patients ≥ 18 years who underwent 1 of the 17 major orthopedic procedures, and with a length of stay (LOS) > 1 day. INTERVENTION: Patient Safety management between Italy and the USA. MAIN OUTCOME MEASURE: Patient Safety Indicators. RESULTS: A total of 14 393 patients in Italy (mean age = 59.8 years) and 131 371 in the USA (mean age = 65.4 years) were included. US patients had lower adjusted odds of developing a PSI compared to Italy for pressure ulcers (odds ratio [OR]: 0.21; 95% confidence interval [CI]: 0.10-0.45), hemorrhage or hematoma (OR: 0.42; CI 0.23-0.78), physiologic and metabolic derangement (OR: 0.08; CI 0.02-0.37). Italian patients had lower odds of pulmonary embolism/deep vein thrombosis (OR: 3.17; CI 2.16-4.67) compared to US patients. CONCLUSIONS: Important differences in patient safety events were identified across countries using US developed PSIs. Though caution about potential coding differences is wise when comparing PSIs internationally, other differences may explain AEs, and offer opportunities for cross-country learning about safe practices.

Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) for the prevention of migraine in adults.

BACKGROUND: This is an updated version of the original Cochrane review published in 2005 on selective serotonin reuptake inhibitors (SSRIs) for preventing migraine and tension-type headache. The original review has been split in two parts and this review now only regards migraine prevention. Another updated review is under development to cover tension-type headache.Migraine is a common disorder. The chronic forms are associated with disability and have a high economic impact. In view of discoveries about the role of serotonin and other neurotransmitters in pain mechanisms, selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) have been evaluated for the prevention of migraine. OBJECTIVES: To determine the efficacy and tolerability of SSRIs and SNRIs compared to placebo and other active interventions in the prevention of episodic and chronic migraine in adults. SEARCH METHODS: For the original review, we searched MEDLINE (1966 to January 2004), EMBASE (1994 to May 2003), the Cochrane Central Register of Controlled Trials (CENTRAL 2003, Issue 4), and Headache Quarterly (1990 to 2003). For this update, we applied a revised search strategy to reflect the broader type of intervention (SSRIs and SNRIs). We searched CENTRAL (2014, Issue 10), MEDLINE (1946 to November 2014), EMBASE (1980 to November 2014), and PsycINFO (1987 to November 2014). We also checked the reference lists of retrieved articles and searched trial registries for ongoing trials. SELECTION CRITERIA: We included randomised controlled trials comparing SSRIs or SNRIs with any type of control intervention in participants 18 years and older of either sex with migraine. DATA COLLECTION AND ANALYSIS: Two authors independently extracted data (migraine frequency, index, intensity, and duration; use of symptomatic/analgesic medication; days off work; quality of life; mood improvement; cost-effectiveness; and adverse events) and assessed the risk of bias of trials. The primary outcome of this updated review is migraine frequency. MAIN RESULTS: The original review included eight studies on migraine. Overall, we now include 11 studies on five SSRIs and one SNRI with a total of 585 participants. Six studies were placebo-controlled, four compared a SSRI or SNRI to amitriptyline, and one was a head-to-head comparison (escitalopram versus venlafaxine). Most studies had methodological or reporting shortcomings (or both): all studies were at unclear risk of selection and reporting bias. Follow-up rarely extended beyond three months. The lack of adequate power of most of the studies is also a major concern.Few studies explored the effect of SSRIs or SNRIs on migraine frequency, the primary endpoint. Two studies with unclear reporting compared SSRIs and SNRIs to placebo, suggesting a lack of evidence for a difference. Two studies compared SSRIs or SNRIs versus amitriptyline and found no evidence for a difference in terms of migraine frequency (standardised mean difference (SMD) 0.04, 95% confidence interval (CI) -0.72 to 0.80; I(2) = 72%), or other secondary outcomes such as migraine intensity and duration.SSRIs or SNRIs were generally more tolerable than tricyclics. However, the two groups did not differ in terms of the number of participants who withdrew due to adverse advents or for other reasons (one study, odds ratio (OR) 0.39, 95% CI 0.10 to 1.50 and OR 0.42, 95% CI 0.13 to 1.34).We did not find studies comparing SSRIs or SNRIs with pharmacological treatments other than antidepressants (e.g. antiepileptics and anti-hypertensives). AUTHORS' CONCLUSIONS: Since the last version of this review, the new included studies have not added high quality evidence to support the use of SSRIs or venlafaxine as preventive drugs for migraine. There is no evidence to consider SSRIs or venlafaxine as more effective than placebo or amitriptyline in reducing migraine frequency, intensity, and duration over two to three months of treatment. No reliable information is available at longer-term follow-up. Our conclusion is that the use of SSRIs and SNRIs for migraine prophylaxis is not supported by evidence.

Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) for the prevention of tension-type headache in adults.

BACKGROUND: This is an updated version of the Cochrane review published in 2005 on selective serotonin re-uptake inhibitors (SSRIs) for preventing migraine and tension-type headache. The original review has been split in two parts and this review now only regards tension-type headache prevention. Another updated review covers migraine. Tension-type headache is the second most common disorder worldwide and has high social and economic relevance. As serotonin and other neurotransmitters may have a role in pain mechanisms, SSRIs and serotonin-norepinephrine reuptake inhibitors (SNRIs) have been evaluated for the prevention of tension-type headache. OBJECTIVES: To determine the efficacy and tolerability of SSRIs and SNRIs compared to placebo and other active interventions in the prevention of episodic and chronic tension-type headache in adults. SEARCH METHODS: For the original review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL 2003, Issue 4), MEDLINE (1966 to January 2004), EMBASE (1994 to May 2003), and Headache Quarterly (1990 to 2003). For this update, we revised the original search strategy to reflect the broader type of intervention (SSRIs and SNRIs). We searched CENTRAL (2014, Issue 10) on the Cochrane Library, MEDLINE (1946 to November 2014), EMBASE (1980 to November 2014), and PsycINFO (1987 to November 2014). We also checked the reference lists of retrieved articles and searched trial registries for ongoing trials. SELECTION CRITERIA: We included randomised controlled trials comparing SSRIs or SNRIs with any type of control intervention in participants 18 years and older, of either sex, with tension-type headache. DATA COLLECTION AND ANALYSIS: Two authors independently extracted data (headache frequency, index, intensity, and duration; use of symptomatic/analgesic medication; quality of life; and withdrawals) and assessed the risk of bias of trials. The primary outcome is tension-type headache frequency, measured by the number of headache attacks or the number of days with headache per evaluation period. MAIN RESULTS: The original review included six studies on tension-type headache. We now include eight studies with a total of 412 participants with chronic forms of tension-type headache. These studies evaluated five SSRIs (citalopram, sertraline, fluoxetine, paroxetine, fluvoxamine) and one SNRI (venlafaxine). The two new studies included in this update are placebo controlled trials, one evaluated sertraline and one venlafaxine. Six studies, already included in the previous version of this review, compared SSRIs to other antidepressants (amitriptyline, desipramine, sulpiride, mianserin). Most of the included studies had methodological and/or reporting shortcomings and lacked adequate power. Follow-up ranged between two and four months.Six studies explored the effect of SSRIs or SNRIs on tension-type headache frequency, the primary endpoint. At eight weeks of follow-up, we found no difference when compared to placebo (two studies, N = 127; mean difference (MD) -0.96, 95% confidence interval (CI) -3.95 to 2.03; I(2)= 0%) or amitriptyline (two studies, N = 152; MD 0.76, 95% CI -2.05 to 3.57; I(2)= 44%).When considering secondary outcomes, SSRIs reduce the symptomatic/analgesic medication use for acute headache attacks compared to placebo (two studies, N = 118; MD -1.87, 95% CI -2.09 to -1.65; I(2)= 0%). However, amitriptyline appeared to reduce the intake of analgesic more efficiently than SSRIs (MD 4.98, 95% CI 1.12 to 8.84; I(2)= 0%). The studies supporting these findings were considered at unclear risk of bias. We found no differences compared to placebo or other antidepressants in headache duration and intensity.SSRIs or SNRI were generally more tolerable than tricyclics. However, the two groups did not differ in terms of number of participants who withdrew due to adverse events or for other reasons (four studies, N = 257; odds ratio (OR) 1.04; 95% CI 0.41 to 2.60; I(2)= 25% and OR 1.55, 95% CI 0.71 to 3.38; I(2)= 0%).We did not find any study comparing SSRIs or SNRIs with pharmacological treatments other than antidepressants (e.g. botulinum toxin) or non-drug therapies (e.g. psycho-behavioural treatments, manual therapy, acupuncture). AUTHORS' CONCLUSIONS: Since the last version of this review, the new included studies have not added high quality evidence to support the use of SSRIs or venlafaxine (a SNRI) as preventive drugs for tension-type headache. Over two months of treatment, SSRIs or venlafaxine are no more effective than placebo or amitriptyline in reducing headache frequency in patients with chronic tension-type headache. SSRIs seem to be less effective than tricyclic antidepressants in terms of intake of analgesic medications. Tricyclic antidepressants are associated with more adverse events; however, this did not cause a greater number of withdrawals. No reliable information is available at longer follow-up. Our conclusion is that the use of SSRIs and venlafaxine for the prevention of chronic tension-type headache is not supported by evidence.

Volcanic carbon dioxide vents show ecosystem effects of ocean acidification.

The atmospheric partial pressure of carbon dioxide (p(CO(2))) will almost certainly be double that of pre-industrial levels by 2100 and will be considerably higher than at any time during the past few million years. The oceans are a principal sink for anthropogenic CO(2) where it is estimated to have caused a 30% increase in the concentration of H(+) in ocean surface waters since the early 1900s and may lead to a drop in seawater pH of up to 0.5 units by 2100 (refs 2, 3). Our understanding of how increased ocean acidity may affect marine ecosystems is at present very limited as almost all studies have been in vitro, short-term, rapid perturbation experiments on isolated elements of the ecosystem. Here we show the effects of acidification on benthic ecosystems at shallow coastal sites where volcanic CO(2) vents lower the pH of the water column. Along gradients of normal pH (8.1-8.2) to lowered pH (mean 7.8-7.9, minimum 7.4-7.5), typical rocky shore communities with abundant calcareous organisms shifted to communities lacking scleractinian corals with significant reductions in sea urchin and coralline algal abundance. To our knowledge, this is the first ecosystem-scale validation of predictions that these important groups of organisms are susceptible to elevated amounts of p(CO(2)). Sea-grass production was highest in an area at mean pH 7.6 (1,827 (mu)atm p(CO(2))) where coralline algal biomass was significantly reduced and gastropod shells were dissolving due to periods of carbonate sub-saturation. The species populating the vent sites comprise a suite of organisms that are resilient to naturally high concentrations of p(CO(2)) and indicate that ocean acidification may benefit highly invasive non-native algal species. Our results provide the first in situ insights into how shallow water marine communities might change when susceptible organisms are removed owing to ocean acidification.

[Residency in hygiene and preventive medicine: present and future]. / Specializzazione in igiene e medicina preventiva: situazione e novità.

INTRODUCTION: The changing needs and expectations of the population and the current financial distress lead the Italian health care system to face a profound challenge that requires also a new evaluation of professionals' training. Specialists in Hygiene and Preventive Medicine (HPM) are called for to develop new knowledge and skills in hygiene, public health, and management, as they fulfill leadership roles within the hospitals. OBJECTIVE: To investigate the current status of Hospital Health Management Boards (HHMB) and the specific know-how they require, in order to develop an adequate post-graduate residency training in HPM. MATERIALS AND METHODS: We conducted a literature review on the main and «gray literature¼ databases; then, we conducted three semi-structured interviews with the Chiefs of the HHMB operating in the major hospitals of Bologna (Northern Italy); lastly, we organised a workshop with residents in HPM and health workers of Emilia-Romagna hospitals. RESULTS: Interviews with Hospital Health Managers have highlighted the main issues faced by a modern HHMB. The main questions discussed were: the changing role of the hospital and its relationship with primary care; the increasing competition among professionals with different specialisations within the HHMB; the need to develop multi-professional teams; the necessity to enlarge HPM residency training programmes in order to meet the HHMB needs. CONCLUSION: The evolution of the HHMB reflects the evolution of the Italian health care system. HHMBs should better fit the organization to the context, and the post-graduate schools in HPM should follow this process. In the framework of the current rules and laws it is possible to focus for implementing training programmes that include management, coordination and negotiation skills, and help build an adequate leadership profile.

[Relationship between surgical volumes and 30-day mortality in patients with oesophagus and stomach cancer: a review of the literature and metanalysis]. / La relazione fra volumi e mortalità a 30 giorni nella chirurgia oncologica di esofago e stomaco: revisione della letteratura e metanalisi.

OBJECTIVES: to analyse the relationship between annual hospital volumes of surgery for oesophageal and gastric cancer and 30-day mortality. DESIGN: a systematic review of the literature has been carried out on these topics by searching Medline for the years 1998-2012 and using two ad hoc search strings. For oesophageal cancer, the most recent and best quality systematic review was updated by including further studies, and then a metanalysis was carried out. For gastric cancer, two different metanalyses on low and high volumes were performed. RESULTS: regarding oesophageal carcinoma, the study confirmed the association between 30-day mortality and the number of annual hospital interventions for this pathology. As for stomach cancer, the two metanalyses confirmed the role of high-volume surgery in reducing the outcome considered. CONCLUSIONS: this study confirms the association between short-term outcomes and the number of annual hospital interventions for oesophageal and gastric cancer. The results obtained may be important for health care policy makers and administrators/managers in order to improve quality of care for patients with oesophageal or stomach cancer.

[The key role of public health medical resident education for future public health challenges]. / La formazione del giovane igienista per le nuove sfide della sanità pubblica.

INTRODUCTION: The Italian Committee of medical residents in Hygiene, Preventive Medicine and Public Health is a member of the Italian Society of Hygiene, Preventive Medicine and Public Health with the aim of developing a network among Italian resident in public health and promoting the educational path improvement through comparisons and debates between postgraduate medical schools. In this perspective, during last years account has been taken of some essential topics concerning education of public health medical residents, which represent future health-care and public health experts. METHODS: Cross-sectional researches were conducted among Italian public health medical residents (PHMRs) through self-administered and web-based questionnaires. Each questionnaire was previously validated by pilot studies conducted during the 46th National Conference of the Italian Society of Hygiene, Preventive Medicine and Public Health. RESULTS: Seventy percent of Italian PHMRs considered the actual length of Public Health postgraduate medical school excessively long, with regard to predetermined educational goals. Confirming this statement, 90% of respondents were inclined to a reduction from 5 to 4 years of postgraduate medical school length, established by Law Decree 104/2013. Seventy seven percent of surveyed PHMRs stand up for a rearrangement on a national setting of the access contest to postgraduate medical schools. Moreover 1/3 of Italian schools performed less than 75%of learning and qualifying activities specified in Ministerial Decree of August 2005. In particular, data analysis showed considerable differences among Italian postgraduate schools. Finally, in 2015 only four Italian Universities (Napoli Federico II, Palermo, Pavia, Roma Tor Vergata) provide for the Second Level Master qualify for the functions of occupational doctor. This offer makes available 60 positions against a request of over 200 future Public Health medical doctors who have shown interest in the Master. CONCLUSIONS: In Italy, after the introduction of Ministerial Decree 285/2005, the educational course of PHMRs was significantly improved. The standardization of learning and qualifying activities allowed for the first time the attendance at medical directions or Local Health Units. Nevertheless, the excessive lenght of postgradute schools and the differences about training among Italian Universities are critical and actual issue. Moreover, the remarkable interest shown by PHMRs in the Master could suggest a poor job replacement prospect for young medical specialist in Hygiene, Preventive Medicine and Public Health.

Methanotrophy below pH 1 by a new Verrucomicrobia species.

Mud volcanoes, mudpots and fumaroles are remarkable geological features characterized by the emission of gas, water and/or semi-liquid mud matrices with significant methane fluxes to the atmosphere (10(-1) to 10(3) t y(-1)). Environmental conditions in these areas vary from ambient temperature and neutral pH to high temperatures and low pH. Although there are strong indications for biological methane consumption in mud volcanoes, no methanotrophic bacteria are known that would thrive in the hostile conditions of fumaroles (temperatures up to 70 degrees C and pH down to 1.8). The first step in aerobic methane oxidation is performed by a soluble or membrane-bound methane mono-oxygenase. Here we report that pmoA (encoding the beta-subunit of membrane-bound methane mono-oxygenase) clone libraries, made by using DNA extracted from the Solfatara volcano mudpot and surrounding bare soil near the fumaroles, showed clusters of novel and distant pmoA genes. After methanotrophic enrichment at 50 degrees C and pH 2.0 the most distant cluster, sharing less than 50% identity with any other described pmoA gene, was represented in the culture. Finally we isolated an acidiphilic methanotrophic bacterium Acidimethylosilex fumarolicum SolV belonging to the Planctomycetes/Verrucomicrobia/Chlamydiae superphylum, 'outside' the subphyla of the Alpha- and Gammaproteobacteria containing the established methanotrophs. This bacterium grows under oxygen limitation on methane as the sole source of energy, down to pH 0.8--far below the pH optimum of any previously described methanotroph. A. fumarolicum SolV has three different pmoA genes, with two that are very similar to sequences retrieved from the mudpot. Highly homologous environmental 16S rRNA gene sequences from Yellowstone Park show that this new type of methanotrophic bacteria may be a common inhabitant of extreme environments. This is the first time that a representative of the widely distributed Verrucomicrobia phylum, of which most members remain uncultivated, is coupled to a geochemically relevant reaction.