Search

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.

Introduction Patients with burn injuries are at an increased risk of venous thromboembolism (VTE). This predisposition is secondary to the endothelial injury, hyper-coagulable state and stasis (Virchow’s triad) associated with burn injury. Although the true incidence of VTE in burn patients has not been adequately quantified, symptomatic VTE occurs in 0.2–7% of this population. VTE prophylaxis has proven clinical effectiveness and affords a reduction in the morbidity associated with such events, but the benefits and risk of complications need to be balanced in order to provide the best quality of care. Owing to the lack of prospective data on VTE in burns, practice varies greatly, not only internationally, but also between local burns services. Our aim was to better understand current VTE practice within United Kingdom (UK) burn care services by performing a comprehensive survey. Methods We contacted all the inpatient burn care services in the UK and collected data on current VTE practice via a standardised questionnaire. Services were given the choice to complete the survey by telephone or email and a follow-up plan was formulated. Results Twenty-five burn care services were contacted and 23 agreed to participate (92% response rate). Responding services treated adults, children or both and lead burn nurses or senior medical staff familiar with current VTE practice were interviewed. Routine VTE prophylaxis was provided in 84% of burn services and the majority utilised a combination of chemoprophylaxis and thromboembolic deterrent stockings (TEDS). All used low molecular weight heparin (LMWH) as their choice of chemoprophylaxis. Of those treating adults, all used a VTE prophylaxis protocol, but none of these applied to children. Only 56% of services treating children had such a protocol. The majority discontinued prophylaxis once patients were mobile. Discussion and conclusion Although the true burden of VTE in burn patients is unknown, we recognise that they are a population at risk. In addition to changes in the inflammatory and clotting pathways associated with thermal injury, prolonged hospital stay, ventilatory support, multiple surgeries, numerous central venous cannulations and reduced mobility all multiply this risk. The risk associated with the administration of heparin (bleeding complications and heparin-induced thrombocytopaenia) is low and can be reduced even further to 0.1% by the use of LMWH. The risk of symptomatic VTE is far greater, therefore the benefits of VTE prophylaxis would seem to outweigh the risks of not undertaking prophylactic measures. A higher LMWH dose and routine monitoring of anti-factor Xa levels are useful for acute burn patients. Two previous surveys, performed in Canada and the United States of America (USA), found routine administration of VTE prophylaxis to be 50% and 76% respectively. Of the 71 centres in the USA participating in the survey, 30% used a combination of sequential compression devices (SCD) and heparin and 24% did not provide VTE prophylaxis at all. A lack of prospective data on VTE in burn patients appears to be associated with diverse practice, and consensus on this topic could ensure that the potential morbidity caused by VTE is reduced. A clinical tool for identifying patients at risk and guidelines for management will standardise practice, which in turn should allow us to improve and maintain high quality care for burn patients.

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.

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.

The endocrine system is frequently altered after a major burn trauma. Besides the endocrine response to stress characterized by hypercortisolism, several hypothalamus-hypophysis-target gland axes are rapidly perturbed within a few days. These alterations can persist in the long term and deserve an appropriate treatment. Disturbances in water clearance and glucidic metabolism are also common and need to be diagnosed and corrected to decrease morbidity in such patients. Bone and mineral metabolism is deeply compromised and requires correction of mineral abnormalities in order to improve symptoms and prevent bone loss. No large prospective and/or intervention trials are available to date to elaborate age-related, evidence-based recommendations to monitor and treat burn-related endocrine alterations.

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

Background/aim Evidence of the impact of green spaces on pregnancy outcomes is still limited. We analysed green spaces and socio-economic position (SEP) as effect modifiers of the effect of high temperatures and air pollutants (PM10, NO2 and O3) on the risk of preterm birth (PB). Methods A cohort of new-borns in Rome, from April to October, 2001–2013, were analysed. Pre-terms, identified through the Certificate of Delivery Care Registry, were defined as births between the 22nd and the 36th week of gestation. A time series approach was used, with maximum apparent temperature (MAT), PM10, NO2 and O3 as exposure variables. We used a lag of 0–2 days for all exposure when analysing preterm births, except for PM10 (lag of 12–22 days). As green indicators we considered both the distance between mothers’ residence address and green spaces and the Normalised Difference Vegetation Index (NDVI) within a 100 m buffer centred on woman’s residence address. Women were also classified according to age, SEP and education level. Results We enrolled 56 576 total births, 5.1% of which PB. In our cohort 24% of women were younger than 30 years, 36% had a low SEP and 33% completed primary school. We observed a 2.0% (95% CI: 0.7 to 3.2) increase in the daily number of PB per 1°C increase in MAT, adjusting by PM10. Among pollutants only PM10 was associated to a significant increase in PB (+0.7%; 95% CI: 0.1 to 1.3) per 1 mg/m3 increase in PM10 (adjusted by MAT). SEP was an effect modifier for both MAT/PB and PM10/PB relationship; MAT increased the risk of PB only among women of medium or low SEP while PM10 among those of high SEP. Green was an effect modifier of MAT/PB relationship, with the highest effect of MAT on PB among women living very close to green spaces (within 100 m). Conclusion Socio-economic position resulted to be an important effect modifier for both MAT/PB and PM10/PB relationship. In particular we found the highest effect of temperature on preterm birth risk in women with low socio-economic position and living very close to green areas. How green acts in modifying this association should be further investigated.

Introduction We have carried out a systematic review of epidemiological studies about the association between extreme weather conditions and work-related injuries (WRI). Furthermore, we have analysed the association between extreme temperature, air pollutants and WRI in three Italian cities identifying more susceptible workers’ categories by the means of a case cross over study. Methods We have performed a systematic review of epidemiological studies concerning the risk of WRI for extreme temperature. All occupational injuries between 2001–2010 in Milan, Turin and Rome have been extracted from the Italian workers compensation claims archives. Associations between temperature (T), air pollutants (PM10, NO2, O3) and WRI have been estimated using a time-stratified case-crossover study, separately in May-September (warm season, WS) and November-February (cold season, CS). Results The epidemiological studies for estimating the association between extreme temperature and WRI appeared to be few and conducted with different methodologies. In our study exposure to NO2 (lag 0–8) showed the highest positive effect on the risk of WRI ranging, in the warm season, between +20% (CI 95%: 1.16–1.24) in Milan and +30% (CI 95%: 1.24–1.37) in Turin. Temperature, in WS, was associated to an increased risk of WRI among those working in construction, transport and energy industry with bricklayer, metalworker, mechanic, and asphalter as the most involved workers’ categories. Conclusions The findings of our study should be considered for planning health and safety prevention programs and correctly identifying measure targeted to risk mitigation for specific categories of workers.

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.

Few studies have evaluated the significance of associated urological anomalies in vesicoureteral reflux (VUR). The aim of our study was to determine the incidence of associated urological anomalies in patients with high grade VUR and to assess their impact on renal parenchymal scarring. We retrospectively reviewed the hospital records of 1,765 consecutive cases diagnosed with high grade VUR (Grade III–V) at our hospital between 1998 and 2010. The diagnosis of VUR was made by a voiding cystourethrogram (VCUG). Renal scarring was evaluated by dimercapto-succinic acid (DMSA) scintigraphy and classified into three groups: mild (focal defects in uptake between 40 and 45%), moderate (uptake of renal radionuclide between 20 and 40%), and severe (shrunken kidney with relative uptake

Objective We present our experience in the treatment of distal hypospadias using a modified Koff procedure, emphasizing the importance of patient selection for a good outcome. Materials and methods In 2003–2008, 90 patients, mean age 52.1 months, underwent surgical repair of distal hypospadias using urethral advancement according to Koff, modified with a Ψ incision on the tip of the glans. Meatal defect was glanular in six (8%), subglanular in 24 (26%) and coronal in 60 (66%) cases. Mild chordee was present in 19 patients (21%). Follow-up was 8–66 months. All patients were evaluated in terms of cosmetic results, and early and late postoperative complications. Results All patients showed excellent cosmetic results with urethral meatus on the tip. There was only one postoperative fistula due to extensive use of electrocautery during urethral mobilization that was surgically corrected 8 months after appearance. One patient had a postoperative meatal stenosis treated conservatively. No cases of residual chordee were detected. Conclusions Successful use of the modified Koff procedure depends on careful selection of patients. Good candidates are those with distal or mid-shaft hypospadias, presenting with: (1) absence or low degree of ventral chordee; (2) distal plate of urethra well developed; (3) distance between meatus and tip of glans at most 10–12 mm; and (4) glanular morphology preserved.

Background: Climate change is projected to increase the number and intensity of extreme weather events, for example heat waves. Heat waves have adverse health effects, especially for the elderly, since chronic diseases are more frequent in that group than in the population overall. The aim of the study was to investigate mortality during heat waves in an adult population aged 50 years or over, as well as in susceptible subgroups of that population in Rome and Stockholm during the summer periods from 2000 to 2008. Methods: We collected daily number of deaths occurring between 15th May and 15th September each year for the population above 50 as well as the susceptible subgroups. Heat wave days were defined as two or more days exceeding the city specific 95th percentile of maximum apparent temperature (MAT). The relationship between heat waves and all-cause non-accidental mortality was investigated through time series modelling, adjusting for time trends. Results: The percent increase in daily mortality during heat waves as compared to normal summer days was, in the 50+ population, 22% (95% Confidence Interval (CI): 18-26%) in Rome and 8% (95% CI: 3-12%) in Stockholm. Subgroup specific increase in mortality in Rome ranged from 7% (95% CI:–17-39%) among survivors of myocardial infarction to 25% in the COPD (95% CI:9-43%) and diabetes (95% CI:14-37%) subgroups. In Stockholm the range was from 10% (95% CI: 2-19%) for congestive heart failure to 33% (95% CI: 10-61%) for the psychiatric subgroup. Conclusions: Mortality during heat waves increased in both Rome and Stockholm for the 50+ population as well as in the considered subgroups. It should be evaluated if protective measures should be directed towards susceptible groups, rather than the population as a whole. Daniel Oudin Åström was funded by a grant from The Swedish Council for Working Life and Social Research (FAS:2009–0454) awarded to Professor Bertil Forsberg. This work was carried out within the EU project “Public Health Adaptation Strategies to Extreme weather events–PHASE” (contract number EAHC 20101103). the EU project “Public Health Adaptation Strategies to Extreme weather events–PHASE” (contract number EAHC 20101103)

Objective. To evaluate whether public reporting of performance data was associated with a change over time in quality indicators for acute myocardial infarction (AMI) in Italian hospitals. Design. Pre–post evaluation of AMI indicators in the Lazio region, before and after disclosure of the Regional Outcome Evaluation Program, and a comparative evaluation versus other Italian regions not participating in the program. Setting/data sources. Nationwide Hospital Information System and vital status records. Participants. 24 800 patients treated for AMI in Lazio and 39 350 in the other regions. Intervention. Public reporting of the Regional Outcome Evaluation Program in the Lazio region. Main Outcome Measure. Risk-adjusted indicators for AMI. Results. The proportion of ST-segment elevation myocardial infarction (STEMI) patients treated with percutaneous coronary interventions (PCI) within 48 h in Lazio changed from 31.3 to 48.7%, before and after public reporting, respectively (relative increase 56%; P < 0.001). In the other regions, the proportion increased from 51.5 to 58.4% (relative increase 13%; P < 0.001). Overall 30-day mortality and 30-day mortality for patients treated with PCI did not improve during the study period. The 30-day mortality for STEMI patients not treated with PCI in Lazio was significantly higher in 2009 (29.0%) versus 2006/07 (24.0%) (P = .002). Conclusions. Public reporting may have contributed to increasing the proportion of STEMI patients treated with timely PCI. The mortality outcomes should be interpreted with caution. Changes in AMI diagnostic and coding systems should also be considered. Risk-adjusted quality indicators represent a fundamental instrument for monitoring and potentially enhancing quality of care.

Osteogenesis and bone remodeling are complex biological processes that are essential for the formation of new bone tissue and its correct functioning. When the balance between bone resorption and formation is disrupted, bone diseases and disorders such as Paget's disease, fibrous dysplasia, osteoporosis and fragility fractures may result. Recent advances in bone cell biology have revealed new specific targets for the treatment of bone loss that are based on the inhibition of bone resorption by osteoclasts or the stimulation of bone formation by osteoblasts. Bisphosphonates, antiresorptive agents that reduce bone resorption, are usually recommended as first-line therapy in women with postmenopausal osteoporosis. Numerous studies have shown that bisphosphonates are able to significantly reduce the risk of femoral and vertebral fractures. Other antiresorptive agents indicated for the treatment of osteoporosis include selective estrogen receptor modulators, such as raloxifene. Denosumab, a human monoclonal antibody, is another antiresorptive agent that has been approved in Europe and the USA. This agent blocks the RANK/RANKL/OPG system, which is responsible for osteoclastic activation, thus reducing bone resorption. Other approved agents include bone anabolic agents, such as teriparatide, a recombinant parathyroid hormone that improves bone microarchitecture and strength, and strontium ranelate, considered to be a dual-action drug that acts by both osteoclastic inhibition and osteoblastic stimulation. Currently, anti-catabolic drugs that act through the Wnt-β catenin signaling pathway, serving as Dickkopf-related protein 1 inhibitors and sclerostin antagonists, are also in development. This concise review provides an overview of the drugs most commonly used for the control of osteogenesis in bone diseases.

Since DX/HA was approved by the Food and Drug Administration in 2001 as an acceptable tissue-augmenting substance for subureteral injection, endoscopic treatment has become increasingly popular for treating vesicoureteral reflux (VUR). However, most paediatric urologists still continue to recommend ureteral reimplantation as the treatment of choice in the management of grade V VUR. The purpose of this study was to prospectively evaluate the effectiveness of endoscopic subureteral injection of DX/HA in the treatment of grade V reflux.During 2001-2009, 56 children (35 males, 21 females) with primary grade V VUR underwent endoscopic treatment using DX/HA. Their ages ranged from 4 months to 11 years. Forty-nine patients had unilateral grade V VUR, and seven had bilateral grade V (63 refluxing ureters including 17 duplex systems). Renal scarring on dimercaptosuccinic acid was observed in 39 kidneys (mild scarring 13, moderate scarring 14 and severe scarring 12). In all patients, endoscopic injection was made after inserting the needle within the wide ureteral orifice. Renal ultrasound and voiding cystourethrogram was performed 3 months after the endoscopic treatment. If VUR had not resolved, the patient was considered for further endoscopic treatment. After the VUR was resolved, children were followed with renal ultrasound at 1 year and every 2 years thereafter.The VUR completely resolved after first injection of DX/HA in 33 (52.4%) ureters and downgraded to grade I VUR in 7 (11.1%) ureters. 19 (30.2%) ureters required a second injection, and 4 (6.3%) ureters required a third injection to resolve VUR. No children in this series needed reimplantation of ureters or presented with ureteral obstruction during follow-up.Endoscopic treatment with DX/HA is effective in eradicating grade V primary reflux. This simple and minimally invasive treatment should be offered to all parents of children with grade V VUR as an alternative to ureteral reimplantation.

Osteoporotic fractures are one of the major causes of increased morbidity and mortality in postmenopausal women and the overall aging population. One of the major issues in the management of postmenopausal osteoporosis is to find a safe and effective treatment in the long term (>3 years) to achieve and maintain a reduction in the risk of fracture. Strontium ranelate (PROTELOS®) is a relatively novel drug, currently approved in Europe for the treatment of postmenopausal osteoporosis. Strontium ranelate is the first agent of a new therapeutic class in osteoporosis, capable of both promoting bone formation and, to a lesser extent, inhibiting bone resorption. This uncoupling in bone turnover results in a net gain in bone mineral density (BMD), bone quality improvement and reduction in risk of vertebral and nonvertebral fractures, as initially demonstrated in the preplanned long-term registrative trials SOTI (Spinal Osteoporosis Therapeutic Intervention) and TROPOS (Treatment of Peripheral Osteoporosis) at 5 years. Recently, open-label extensions of the SOTI and TROPOS trials up to 8 and, recently, 10 years have confirmed the sustained efficacy of strontium ranelate in increasing BMD, the long-term safety profile and the high compliance to treatment, independently from baseline BMD or other risk factors for osteoporotic fractures. Recent economic impact analyses have proved that long-term treatment with strontium ranelate is highly cost effective, especially in women older than 70 years of age. Histomorphometric analyses in animals and humans participating in the phase III trials have proved that the quality of mineralization is preserved in the long term and bone microarchitecture is ameliorated, with increased bone strength. Thus, strontium ranelate has been confirmed to be an effective compound for the long-term, chronic treatment of postmenopausal osteoporosis.

Introduction: Although the prevalence of preterm births ranges from 5 to 13% and represents the leading cause of perinatal mortality and morbidity in developed countries, the etiology of preterm birth remains uncertain. We aimed to evaluate the effect of short-term exposure to high and low temperatures and air pollution on preterm delivery and to identify socio-demographic and clinical maternal risk factors enhancing individual susceptibility. Methods: We analyzed all singleton live births by natural delivery that occurred in Rome in 2001–2010. A time-series approach was used to estimate the effect of exposure to minimum temperature, maximum apparent temperature, heat waves, particulate matter with an aerodynamic diameter of 10 μm or less (PM10), ozone, and nitrogen dioxide in the month preceding delivery; the analysis was conducted separately for cold and warm seasons. Socio-demographic and clinical risk factors were included as interaction terms. Results: Preterm births comprised nearly 6% of our cohort. An increase of 1.9% (95% confidence interval (CI) 0.86–2.87) in daily preterm births per 1 °C increase in maximum apparent temperature in the 2 days preceding delivery was estimated for the warm season. Older women, women with higher education levels, and women with obstetric or chronic pathologies reported during delivery had a lower effect of temperature on the risk of preterm birth, while women with a chronic disease in the two years before delivery and mothers

Colorectal carcinoma (CRC) represents the most frequent malignancy of the gastrointestinal tract in the Western world in both genders. There is a wide variation of incidence rate for both colonic and rectal cancer among the populations of different countries: up to a 30-40fold difference is seen between North America (Canada, Los Angeles, San Francisco), NewZealand (non–Maori), Northern Italy (Trieste), Northern France (Hautand Bas-Rhin) in which the rate of CRC is around 50/100,000 inhabitants, and India (Madras, Bangalore, Tri‐ vadrum, Barshi, Paranda, Bhum, Karunagappally), Algeria (Setif), and Mali (Bamako) in which the rate is around 3/100,000 [1]. It is estimated that approximately 6% of the United States population will eventually develop a CRC, and that 6 million of American citizens who are living will die of CRC [2].

Objective To evaluate the incidence of febrile urinary tract infection (UTI) after successful endoscopic correction of intermediate and high-grade vesicoureteral reflux (VUR). Study design Medical records of 1271 consecutive children (male, 411; female, 903) who underwent successful endoscopic correction of VUR were reviewed. Factors potentially influencing postoperative UTIs, such as history of presentation, age, sex, grade of VUR, renal scarring, and agent used for the endoscopic injection, were analyzed. Results Febrile UTI developed in 73 children (5.7%) after successful endoscopic correction of VUR. Thirty-nine children had a single episode of UTI, and 34 children had two or more episodes at 1 month to 5.9 years (median, 1 year) after correction of VUR. With multivariate analysis, female sex ( P P = .005), and BBD after endoscopic correction ( P = .001) were revealed to be the most important independent risk factors for a febrile UTI after successful correction of VUR. Conclusions The incidence of febrile UTIs after successful correction of intermediate and high grade VUR is low. Female sex and BBD were the most important risk factors in the development of febrile UTI. Our data supports the importance of assessing bladder and bowel habits in older children with febrile UTIs after endoscopic correction of VUR.

Purpose Urinary Tract Infection(UTI)is the most common clinical presentation of vesicoureteral reflux(VUR).However,VUR has also been reported in children with voiding disorders with or without history of UTI.The aim of this study was to determine the prevalence of VUR in children presenting with urinary incontinence without a history of UTI among a large group of patients with intermediate and high grade VUR. Material and Methods The medical records of 1432 children diagnosed with intermediate and high grade VUR(Grade III to V)during 1998 to 2008 were reviewed. VUR was diagnosed in all patients by voiding cystourethrogram(VCUG).Renal parenchymal scarring was evaluated by DMSA scans and classified into three groups:mild with relative uptake between 40%and45%,moderate with relative uptake between 20%and40% and severe with relative uptake Results Of the 36patients with urinary incontinence,11children had day and night incontinence,6 had only daytime wetting and 19 had only bedwetting at night.There were 19boys and 17girls and their ages ranged from 4years to 12.1years(median age 6.5years).24children had unilateral VUR and 12 bilateral with a total of 48 refluxing units.VUR was grade II in 2ureters,grade III in 30ureters,grade IV in 15 and grade V in 1.Both patients with grade II VUR had a higher grade VUR on the contralateral side.11(30.5%) patients demonstrated renal scarring on DMSA scans.Scarring was mild in 5 patients,moderate in 5 and severe in 1patient. Conclusions Our large series of intermediate and high grade VUR has identified a small but definite subgroup of patients whose sole presenting symptom is urinary incontinence.We recommend VCUG in all children beyond the age of toilet training who present with urinary incontinence without UTI but sonographic evidence of pelvicalyceal and ureteral dilatation.

Purpose Urinary tract infection (UTI) is a relatively common cause of fever in infants. The association of VUR, UTI and renal parenchymal scarring (RPS) is well recognised. Susceptibility to RPS in VUR varies according to age and gender, with male infants under one year of age reported to be at greatest risk. The aim of this study was to determine the incidence of RPS and risk factors for RPS in a large cohort of male infants who were diagnosed to have VUR after first documented febrile UTI. Material and Methods Between 1985 and 2008, 363 consecutive male infants were diagnosed to have primary VUR on voiding cystourethrogram (VCUG). 308 (85%) infants were hospitalised with the first documented febrile UTI and 55 (15%) infants with febrile UTI were managed as outpatients. Age at diagnosis in the 363 infants was defined as patient's age at the time of the first VCUG. RPS was evaluated by 99mtechnetium-DMSA scan performed at least 3months after the UTI. Results Among the 363 infants (median age 7 months),reflux was unilateral in 132 infants and bilateral in 231 resulting in 594 refluxing ureters. VUR was grade II in 19 (3.2%) ureters, grade III in 217(36.5%), grade IV in 276 (46.5%) and grade V in 82(13.8%) ureters. RPS was observed in 109 (34%) of the 321 patients who had DMSA scan. RPS was mild in 43 (39.4%) infants, moderate in 51 (46.8%) and severe in 15 (13.8%) infants. Ninety nine (90.8%) of the 109 infants with RPS had grade IV or V VUR. Conclusions Our data show that primary VUR in male infants diagnosed following a febrile UTI is often bilateral, high grade and associated with a high incidence of renal parenchymal scarring. Early identification and treatment of VUR in male infants may prevent UTI-related renal parenchymal damage and progression of renal damage in congenital reflux nephropathy.

BACKGROUND AND AIM: Air pollution exposure in pregnancy can cause molecular level alterations associated with later disease susceptibility. We aimed to investigate changes in two molecular marker t...