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Background The first 1000 days of life -including pregnancy and the first 2 years after birth- represent a critical window for health interventions. This systematic review aimed to summarize the evidence on the relationship between traffic-related air pollutants exposure in the first 1000 days of life and the development of wheezing and asthma, with a particular focus on windows of exposure. Methods Medline and Embase were searched from January 2000 to May 2020 to retrieve population-based birth-cohort studies, including registries, providing quantitative information on the association between exposure to traffic-related air pollutants during pregnancy or early life, and the risk of developing wheezing and asthma in childhood. Screening and selection of the articles were completed independently by three reviewers. The quality of studies was assessed using the Newcastle-Ottawa scale. Results Out of 9681 records retrieved, 26 studies from 21 cohorts were included. The most common traffic-related air pollutant markers were particulate matter (PM) and nitric oxides (NOx). The variability in terms of pollutants, exposure assessment methods, and exposure levels chosen to present the results did not allow a meta-analysis. Exposure to PM and NOx in pregnancy (10 cohorts) was consistently associated with an increased risk of asthma development, while the association with wheezing development was unclear. The second trimester of pregnancy seemed to be particularly critical for asthma risk. As for exposure during early life (15 cohorts), most studies found a positive association between PM (7/10 studies) and NOx (11/13 studies) and the risk of asthma development, while the risk of wheezing development was controversial. The period of postnatal exposure, however, was less precisely defined and a partial overlap between the period of exposure measurement and that of outcome development was present in a consistent number of studies (14 out of 15) raising doubts on the associations found. Conclusions Traffic-related air pollution during pregnancy is associated with an increased risk of asthma development among children and adolescents. The relationship between exposure in the first two years of life and the development of wheezing and asthma needs to be confirmed in studies with more precise exposure assessment.

Acute management of a severely burned patient is an infrequent and stressful situation that requires medical knowledge as well as immediate coordinated action. Many adverse events in health care result from issues related to the application of 'non-technical' skills such as communication, teamwork, leadership and decision making rather than lack of medical knowledge. Training in these skills is known as Crisis Resource Management (CRM) training. In order to create well-prepared burn teams, it is critical to teach CRM principles through high-fidelity simulation (HFS). While CRM teaches foundational non-technical skills, HFS incorporates lifelike, whole-body, fully-responsive mannequins in order to provide a realistic emergency situation. The aim of the study is to describe the development of a novel high-fidelity simulation course called "SIMBurns: High Fidelity Simulation Program for Emergency Burn Management" that uses CRM as its foundation and is focused on management of burn injuries. The course was designed by a panel of simulation and burns experts from Meyer Children's Hospital in Italy and Birmingham Children's Hospital in the U.K. Simulation Program experts were certified by Boston Children's Hospital's Simulation Program. In this paper, we describe the course's design, development, structure, and participant's assessment of the course. Since the creation of the SIMBurns course in 2013, 9 courses have been conducted and 101 participants have attended the course. The course was well-received and its "Overall Satisfaction" was rated at 4.8/5. The primary objective in the SIMBurns course - to teach teamwork and CRM skills to medical staff involved in emergency burn care - was also met at 4.8/5. Participants felt that the course developed their ability to interact with other team members, further improved their understanding of how to appropriately use resources, emphasized the importance of role clarity and developed their communication skills. Additional quantitative and qualitative analyses obtained from participants were also reviewed after each course. The SIMBurns course aims to contribute to the education of those in healthcare in order to improve patient safety and to continue advancing the education of our emergency burn care teams.

Introduction There is evidence of improvement on mental health and well-being due to contact with green spaces, through various mechanisms and with potentially differential impacts in different populations. Many of these studies have been conducted among adults, while children have not been sufficiently investigated. This study aimed to evaluate the association between residential exposure to greenness and cognitive development at age 7 and to evaluate nitrogen dioxide (NO2) as a potential mediator of this association.Methods This longitudinal study was based on a cohort of newborns enrolled at delivery in two large obstetric hospitals in Rome. We assessed cognitive development at 7 years of age through the Wechsler Intelligence Scale for Children-III edition (WISC-III). We estimated residential surrounding greenness, using satellite derived Normalized Difference Vegetation Index (NDVI), within 300m and 500m buffers around each residential address at birth. We applied weighted multiple linear regression analyses to study the association between NDVI and the WISC-III cognitive scores, using the inverse probability weighting methodology to correct for potential selection bias. We performed a mediation analysis to evaluate the mediating role of NO2 in the association under study.Results We enrolled 719 children at birth and performed our analyses only on 465 children with data on exposure and outcome. The results were not consistent for the average residential surrounding greenness in 300m buffer. For an IQR increase in greenness within 500m buffer around home addresses at birth we found a progress in Arithmetic subtest (β:0.39; 90% CI: 0.11-0.6), a test concerning with attention, concentration and numerical reasoning, apart from an indication of the positive association with Full scale IQ and Verbal IQ. This association was partly mediated by reduction in NO2, since adding this pollutant in our model explained 35% (90% CI: 7%-62%) of our estimate.Conclusions Our findings showed an association between residential surrounding greenness within 500m and better scores on attention tests at 7 years of age. The observed association between Arithmetic subtest and NDVI was mediated, in part, by a reduction in NO2. This topic has important public health implications in supporting green urban planning policies and promoting children's well-being.

Background Environmental exposures across the life course may be a contributor to the increased worldwide prevalence of respiratory and allergic diseases occurring in the last decades. Asthma and rhinoconjunctivitis especially contribute to the global burden of disease. Greenness has been suggested to have beneficial effects in terms of reduction of occurrence of allergic respiratory diseases. However, the available evidence of a relationship between urban greenness and childhood health outcomes is not yet conclusive. The current review aimed at investigating the current state of evidence, exploring the relationship between children's exposure to residential urban greenness and development of allergic respiratory diseases, jointly considering health outcomes and study design. Methods The search strategy was designed to identify studies linking urban greenness exposure to asthma, rhinoconjunctivitis, and lung function in children and adolescents. This was a narrative review of literature following PRISMA guidelines performed using electronic search in databases of PubMed and Embase (Ovid) from the date of inception to December 2018. Results Our search strategy identified 2315 articles; after exclusion of duplicates (n = 701), 1614 articles were screened. Following review of titles and abstracts, 162 articles were identified as potentially eligible. Of these, 148 were excluded following full-text evaluation, and 14 were included in this review. Different methods for assessing greenness exposure were found; the most used was Normalized Difference Vegetation Index. Asthma, wheezing, bronchitis, rhinoconjunctivitis, allergic symptoms, lung function, and allergic sensitization were the outcomes assessed in the identified studies; among them, asthma was the one most frequently investigated. Conclusions The present review showed inconsistencies in the results mainly due to differences in study design, population, exposure assessment, geographic region, and ascertainment of outcome. Overall, there is a suggestion of an association between urban greenness in early life and the occurrence of allergic respiratory diseases during childhood, although the evidence is still inconsistent. It is therefore hard to draw a conclusive interpretation, so that the understanding of the impact of greenness on allergic respiratory diseases in children and adolescents remains difficult.

Overestimation of burn size especially in children is common. It is unclear if this may cause harm. This study was designed to assess the accuracy of burn size estimation by referring non-burn clinicians and investigate whether inaccurate estimates caused any harm. Three and a half years retrospective review of pediatric resuscitation burns (ie, ≥10% TBSA) referred to a tertiary burns center from other hospitals was performed. This included basic demographics, data from referring emergency departments (initial TBSA estimations and fluid volumes prescribed), and data on arrival to the burn center (actual burn TBSA sustained, fluid volumes given prior to arrival, and actual fluid volumes required). Clinical parameters at 8 and 24 hr after injury were also examined. Forty-six patients were identified. Mean age was 3.9 years and weight 18 kg. Mean time to arrival from initial burn injury to our tertiary center was 5 hr. Thirty-two children (70%) had their burns overestimated, seven (15%) underestimated, and another seven (15%) were correctly estimated. After accurate calculations of the burn size and the required resuscitation fluids on arrival to the burns center, only five children of the entire cohort of 46 patients (11%) had received more fluids than required. These five children were in the overestimated burn size group. Only three children received the appropriate amount of fluid prior to arrival to the burns center. There were no mortalities or significant clinical adverse events in any of the children. Overestimation led to overprescription of fluid volumes, but this did not translate into over-resuscitation, and in most cases was in fact associated with inadequate fluid administration. Although 70% of the children in our cohort had the burn size overestimated, only 11% had actually received more fluids than required before arrival. None of these children went on to have any significant complications as a result of overestimation. Training and education is essential for clinicians in emergency departments. However, estimation of size in pediatric burns, in particular scalds, is challenging and the importance of early transfer to a specialist service cannot be overemphasized.

This case report describes the clinical course of a child who developed staphylococcal scalded skin syndrome (SSSS) after a burn injury. The intent is to aid other units in recognizing the presentation of SSSS after a pediatric burn and to optimize subsequent management. The main clinical finding was of rapid, progressive, superficial epidermal loss at sites separate from the original burn, involving 55% of the total body surface area, 13 days after a 6% scald burn to the face, neck, and chest. Diagnosis was confirmed by multidisciplinary team clinical assessment and histopathology of an intraoperative skin biopsy. This confirmed epidermal cleavage at the granular cell layer. These findings were later supported by Staphylococcus aureus cultured from the burn wound, and a positive epidermolytic toxin A assay. Management was with general medical supportive care, clindamycin and flucloxacillin intravenous antibiotic therapy, and cleansing and dressing of the areas of epidermal loss. Key learning points from this case were that SSSS presented after a burn injury and that 13 days elapsed between the burn and SSSS. Factors differentiating it from toxic epidermal necrolysis are described, including the value of histopathology in confirming the diagnosis. The prompt use of antibiotics and attentive wound care are advocated as an effective management strategy.

ObjectivesStudies on the effect of temperature on rates of work-related injuries (WRIs) are very recent, and are evolving in depth and scope. However, less is known about potential effects of air pollutants. Our objective was to analyse the association between WRI and NO2, PM10and air temperature in three major Italian cities, and to identify groups of workers more at risk in Italy.DesignTime-stratified case-crossover study.SettingsMilan, Turin, Rome, years 2001–2010.ParticipantsA total of 468 816 WRI occurred between 2001 and 2010 in Milan, Turin and Rome were extracted from the Italian national workers’ compensation authority database.Main outcomesAssociations between WRI and temperature, PM10, NO2, separately in the warm and in the cold season (WS, May–September; CS, November–February). Effect modification was studied by economic sector, occupational activity and indoor/outdoor job activity.ResultsExposure to NO2(lag 0–8) showed the highest effect on the risk of WRI,with ORs ranging from 1.20 (95% CI 1.16 to 1.24) in Milan to 1.30 (95% CI 1.24 to 1.37) in Turin in the WS. The effect of exposure to PM10was milder but consistent across all cities: ORs from 1.09 (95% CI 1.05 to 1.12) in Turin to 1.15 (95% CI 1.11 to 1.18) in Rome. Temperature was associated with risk of WRI only among those working in construction (highest association in Rome 1.06; 95% CI 1.01 to 1.12), transportation (highest association in Milan 1.05; 95% CI 0.96 to 1.14) and the energy industry (highest association in Milan 1.57; 95% CI 1.03 to 2.38) in the WS in all cities. A weak effect of low temperatures was observed in the CS only in Rome.ConclusionsExposures to NO2resulted as strongest hazard for WRIs, mainly in warm months, while the independent effect of temperature was significant only in specific subgroups of workers. These results could be considered to better plan safety prevention programmes.

Urban green spaces have been associated with health benefits, but few studies have evaluated the role of greenness on pregnancy outcomes. We examined how the association between short-term exposure to heat and air pollution on the probability of preterm delivery is affected by the spatial variation of socioeconomic position (SEP) and greenness. We analyzed a cohort of newborns in Rome, from April to October of 2001&ndash, 2013, defining preterm as births between the 22nd and the 36th week of gestation. We used a time series approach, with maximum apparent temperature (MAT), PM10, NO2, and O3 as exposure variables. As greenness indicators, we considered maternal residential proximity to green spaces and the Normalized Difference Vegetation Index (NDVI) within a 100m buffer around each woman&rsquo, s residential address. We enrolled 56,576 newborns (5.1% preterm). The effect of a 1&deg, C increase in temperature on the daily number of preterm births was higher in women with low SEP (+2.49% (90% CI: 1.29&ndash, 3.71)) and among those living within 100 m from green spaces (+3.33% (90% CI: 1.82&ndash, 4.87)). No effect modification was observed for NDVI or PM10. SEP was an important effect modifier of the heat-preterm birth relationship. The role of greenness in modifying this association between heat and preterm delivery should be further investigated.

Background Wheezing and infections are common during infancy, and the role of early-life exposures in their development is still under investigation. We examined associations between maternal mental health in pregnancy and after delivery and subsequent offspring wheezing and infections. Methods We studied 2314 mother-child pairs recruited in the Piccolipiu birth cohort (Italy) from 2011 to 2015. Maternal mental health was assessed in pregnancy and 12 months after delivery via the General Health Questionnaire-12 (GHQ-12). GHQ-12 Likert scores were collapsed into low (below the upper tercile) and high (above). Risk ratios (RR) and 95% confidence intervals (CI) between each combination of scores-during pregnancy and 1 year after delivery-and outcomes were computed by log-binomial regression models. Results High scores both in pregnancy and after delivery, compared with low scores in both periods, were associated with wheezing (RR: 1.35; 95% CI: 1.08, 1.69), recurrent (≥2 episodes) wheezing (1.35; 0.99, 1.83), any and recurrent (≥4 episodes) upper respiratory infections (1.20; 1.04, 1.41, and 1.45; 1.07, 1.97, respectively), lower respiratory infections (1.31; 1.08, 1.61), and diarrhea (1.49; 1.23, 1.80). High scores either during pregnancy or 1 year after delivery only were less consistently associated with outcomes. Conclusions Maternal mental health problems extending from pregnancy to the first year after delivery are associated with development of both wheezing and infections. As wheezing is mostly triggered by infections, increased infection susceptibility could represent a possible common biologic mechanism. This study confirms the importance of early-life exposures on childhood health.

BackgroundThe increasing burden of chronic diseases associated with the ageing of the European population constitutes one of the main challenges for the welfare systems in developed western countries, especially through its impact on the use of hospital services and the cost of care. This study aims at evaluating the cost of hospital care for older adults living in the Lazio Region, Italy, according to their level of frailty.MethodsSince 2014 a longitudinal randomized cohort study has been carried out on a sample consisting of 1280 older adults aged over 64 years resident in the Lazio region (Italy), with their being evaluated for multidimensional frailty. Accesses to Hospital Services (acute care and Day Hospital care admissions and Emergency Room accesses) during the first year after enrolment, as well as the related costs have been recorded through a regional database. Costs have been stratified on the basis of the state of frailty.ResultsThe analysis of hospital services and costs highlights the role played by pre-frail individuals who generated 49.3% of the hospital care cumulative costs. Hospital Admission (HA) costs arising from robust and pre-frail subjects are 70% of the total HA costs. Pre-frail individuals also showed the highest average HA cost per person/year (7062.89 Euros). The main determinant of the highest HA costs was given by the number of HAs during the follow-up (multivariate linear regression, ß coefficient = 0.319; pConclusionsPre-frail individuals generated the highest cost for hospital care in a sample of representative subjects living in an Italian Region with a low rate of community care services, as is the case in the Lazio region. Assessment of the multidimensional frailty of older adults permits a better definition of the important target of the pre-frail population as the main category within which interventions to prevent or mitigate frailty should be carried out.

Background Exposure to air pollution during the first 1000 days of life (from conception to the 2nd year of life) might be of particular relevance for long-term child health. Changes in molecular markers such as DNA methylation and telomere length could underlie the association between air pollution exposure and pollution-related diseases as well as serve as biomarkers for past exposure. The objective of this systematic review was to assess the association between air pollution exposure during pregnancy and the first two years of life and changes in DNA methylation or telomere length in children. Methods PubMed was searched in October 2020 by using terms relative to ambient air pollution exposure, DNA methylation, telomere length and the population of interest: mother/child dyads and children. Screening and selection of the articles was completed independently by two reviewers. Thirty-two articles matched our criteria. The majority of the articles focused on gestational air pollution exposure and measured DNA methylation/telomere length in newborn cord blood or placental tissue, to study global, candidate-gene or epigenome-wide methylation patterns and/or telomere length. The number of studies in children was limited. Results Ambient air pollution exposure during pregnancy was associated with global loss of methylation in newborn cord blood and placenta, indicating the beginning of the pregnancy as a potential period of susceptibility. Candidate gene and epigenome-wide association studies provided evidence that gestational exposure to air pollutants can lead to locus-specific changes in methylation, in newborn cord blood and placenta, particularly in genes involved in cellular responses to oxidative stress, mitochondrial function, inflammation, growth and early life development. Telomere length shortening in newborns and children was seen in relation to gestational pollutant exposure. Conclusions Ambient air pollution during pregnancy is associated with changes in both global and locus-specific DNA methylation and with telomere length shortening. Future studies need to test the robustness of the association across different populations, to explore potential windows of vulnerability and assess the role of the methylation and telomere length as mediators in the association between early exposure to ambient air pollutants and specific childhood health outcomes.

Background and objective Children are potentially vulnerable to hot ambient temperature. However, the evidence on heat-related children's morbidity is still scarce. Our aim was to examine the association between temperatures in summer (May to September) and children's hospitalizations in two Mediterranean cities, Rome and Valencia, during the period 2001–2010. Methods Quasi-Poisson generalised additive models and distributed lag non-linear models were combined to study the relationship between daily mean temperature and hospital admissions for all natural, respiratory and gastrointestinal diseases in children under 15 years of age. Associations were summarised as the percentage of change (Ch%) in admissions at 50th, 75th, 90th, 95th and 98th percentiles of temperature in summer compared to 1.) the 50th percentile in the whole year (50th(y)) and 2.) the preceding percentile in the previous series. Cumulated risks were obtained for groups of lags showing a similar pattern: 0–1, 2–7, 8–14 and 15–21 days. Results Almost whatever increase of temperature from 50th(y) was significantly associated with an increase of paediatric hospitalizations by all natural diseases at short term (lag 0–1), while small increases at high temperatures only had a delayed effect on this outcome. The same pattern was observed in Rome for respiratory admissions, while in Valencia only a delayed association (days 8–14) was observed. The increase of temperature from 50th to 75th percentiles was associated at short time to an increase of gastrointestinal admissions in both cities. Conclusion Children's hospitalizations rose with heat in Rome and Valencia. Patterns of delays and critical windows of exposure mainly varied according the outcome considered.

Introduction: Environmental exposures have been linked to length of gestation but the question as to during which weeks of gestation pregnancies are most susceptible still remains little explored.We estimated the effect of maximum apparent temperature and air pollution levels on risk of birth by week of gestation. Methods: We analyzed two cohorts of singleton live births in Rome (2001–2010) and Barcelona (2007–2012). Maximum apparent temperature (MAT), PM10, O3 and NO2 were analyzed in the warm period (1st April–31st October).Gestational week-specific hazard ratios of giving birth associated to a 1-unit increase in exposure were estimated fitting Cox regression models adjusted for seasonality, and demographic and clinical characteristics of the mother. Results: We observed 78,633 births (5.5% preterm) in Rome and 27,255 (4.5% preterm) in Barcelona. The highest hazard ratios for 1 °C increase in MAT were in the 22nd–26th weeks of gestation, 1.071, (95% CI 1.052–1.091) in Rome and 1.071 (95% CI 1.036–1.106) in Barcelona, and decreased to 1.032 (95% CI 1.026–1.038) and 1.033 (95% CI 1.020–1.045) at the 36th week of gestation, respectively. Similar associations and trends were observed for PM10 and NO2 after adjusting for MAT. O3 showed similar trends but weaker associations. Conclusions: We found, consistently in Rome and Barcelona, an increased risk of delivery for a unit increase in MAT, PM10, NO2 and O3, especially in the second half of the second trimester, thus effectively increasing the risk of preterm and particularly early preterm birth. Results may help to increase awareness of these risks among public-health regulators and clinicians, leading to better preventive strategies. Keywords: Preterm, Gestational length, High temperature, Air pollutants, Birth cohorts

The infection of a wound is one of the major contributors to delays in healing and tissue regeneration. As multi-drug resistance to antibiotics is becoming a serious threat, research in this field has focused on finding new agents and strategies to fight infection and additionally to reduce healing times. The topical use of autologous Platelet Rich Plasma (PRP) as a biological accelerator of the healing process, has been safely used as a form of treatment for wounds since the 1990s. Although the presence or absence of leucocytes in PRP preparation was previously neglected, in the last decade more attention has been paid to their role and several studies have been conducted to explore both their immuno-metabolic effects and their antimicrobial properties. In this review, we aim to summarise the literature on the contribution of leucocytes included in PRP preparations in terms of their antimicrobial properties. This should help to inform clinical practice and additional research in this promising field.