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Background: Physical activity in the elderly is recommended by international guidelines to protect against cognitive decline and functional impairment. Objective: This Randomized Controlled Trial (RCT) was set up to verify whether medium-intensity physical activity in elderly people living in the community is effective in improving cognitive performance. Design: RCT with parallel and balanced large groups. Setting: Academic university hospital and Olympic gyms. Subjects: People aged 65 years old and older of both genders living at home holding a medical certificate for suitability in non-competitive physical activity. Methods: Participants were randomized to a 12-week, 3 sessions per week moderate physical activity program or to a control condition focused on cultural and recreational activities in groups of the same size and timing as the active intervention group. The active phase integrated a mixture of aerobic and anaerobic exercises, including drills of “life movements”, strength and balance. The primary outcome was: any change in Addenbrooke's Cognitive Examination Revised (ACE-R) and its subscales. Results: At the end of the trial, 52 people completed the active intervention, and 53 people completed the control condition. People in the active intervention improved on the ACE-R (ANOVA: F(1;102)=4.32, p=0.040), and also showed better performances on the memory (F(1;102)=5.40 p=0.022) and visual-space skills subscales of the ACE-R (F(1;102)=4.09 p=0.046). Conclusion: A moderate-intensity exercise administered for a relatively short period of 12 weeks is capable of improving cognitive performance in a sample of elderly people who live independently in their homes. Clinical Trials Registration No: NCT03858114

Introduction: The clinical significance of donor-specific anti-HLA antibodies (DSAs) in vascularized composite allotransplantation is not clear, even though their occurrence has been reported by several teams. The aim of the present multicenterc study was to assess the incidence of DSAs in upper extremity (UET) and face transplanted patients and their influence on patient outcomes.Methods and Results: Pre- and post-transplantation sera of 37 patients (23 UET, 13 face transplantations and 1 simultaneous UET and face transplantation) were screened in a single laboratory using a solid phase assay. The recipients included 29 men and 8 women, median age was 33 years. Their immunosuppressive treatment, number of HLA mismatches, number of acute rejection (AR) episodes with Banff score, occurrence of graft vasculopathy, chronic rejection and graft loss were collected. In addition, the histological impact of DSA was studied in a small cohort of these patients. For each patient from our cohort with de novo DSA, we randomly selected 2 biopsies taken before and 3 biopsies after the appearance of DSA. DSA were detected in 43.2% of the recipients (16/37), including 6 patients who had presented preformed DSA. The intensity of recipient humoral alloimmune response was estimated using the MFI of positive beads in solid-phase assay. This showed variability both among recipients and among the different DSA specificities of the same patient. From an overall perspective, the alloimmune response was not very strong (median MFI 1413). Donor and recipient age and gender as well as the immunosuppressive treatment were not statistically different between the recipients who developed DSA and those who did not do it. Interesting the number of AR and Banff score did not influence DSA occurrence. No significant correlation between the presence of DSA and chronic rejection, graft vasculopathy or graft loss was found. Five patients with DSA developed chronic rejection and 4 of them graft vasculopathy. In addition, 2 recipients with DSA experienced several episodes of atypical rejections. Longitudinal assessment showed that almost all preformed DSA disappear over time and almost 50% of de novo DSA also in those patients who developed chronic rejection and/or graft vasculopathy with graft loss. There were 5 cases of graft loss and 3 of which had developed DSA during their follow-up. The histopathological study performed on skin sections obtained after the appearance of DSA (routinely-stained and immunolabelled for CD34) did not show significant influx of inflammatory cells into the dermal capillaries endothelial, cell swelling, or microthrombosis.Conclusion: The study confirms that VCA is a sensitizing event for recipients. However, the evolution of DSA over time seems rather heterogeneous. Pre-formed DSAs tend to disappear rapidly and potentially no longer be deleterious, contrary to de novo DSA whose evolution and pathogenicity remain to be elucidated. Longer follow-up will allow to better assess the outcomes of the patients who developed DSA.

Aims Despite alcohol consumption being a dose-dependent risk factor for breast cancer, a recent study conducted in the UK found Methods The questionnaire used by the UK study was translated into Italian, slightly modified for the Italian context, validated and submitted to a sample of Italian women. Results Overall 507 women were interviewed. Among them, 160 were classified as breast cancer screening attenders (SG), 44 as symptomatic breast clinic attenders (CAG) and 303 as non-screening group (NSG). Alcohol was correctly identified as a risk factor for breast cancer by 16.9, 11.4 and 14.9% of participants of SG, CAG and NSG, respectively without differences between the three groups. Despite the methodological differences, the rates of participants who correctly identified alcohol as a risk factor among women attending breast screening programmes were surprisingly similar between the study conducted in UK (15.7%) and the present study (16.9%). Conclusion The results of the present study confirm the limited awareness of the relationship between alcohol consumption and risk of developing breast cancer among women and suggest the urgent need to conduct proper awareness-raising campaigns to counter this in the Italian female population.

Background Aging is marked by a progressive rise in chronic diseases with an impact on social and healthcare costs. Physical activity (PA) may soothe the inconveniences related to chronic diseases, has positive effects on the quality of life and biological rhythms, and can prevent the decline in motor functions and the consequent falls, which are associated with early death and disability in older adults. Methods We randomized 120 over-65 males and females into groups of similar size and timing and will give each either moderate physical activity or cultural and recreational activities. Being younger than 65 years, inability to participate in physical activity for any medical reason, and involvement in a massive program of physical exercise are the exclusion criteria. The primary outcome measures are: quality of life, walking speed, and postural sway. Participants are tested at baseline, post-treatment, and 6-month (24 weeks) and 12-month (48 weeks) follow-ups. Discussion This study aims at improving the quality of life, wellness, and cognitive functioning in the elderly through a low-cost affordable program of moderate physical activity. Given the growing aging of the world population and the social and economic burden of disability in the elderly, our results might have a major impact on future practices. Trial registration ClinicalTrials.gov NCT03858114. Registered on 28 February 2019.

Employing the salutogenic model, we asked how individuals in different countries cope with the COVID-19 crisis and stay healthy. We were interested in exploring the individual (i.e. sense of coherence) as well as the social and national resources (i.e. social support, sense of national coherence, and trust in governmental institutions) that could explain levels of mental health and anxiety during the outbreak of the pandemic. Data collection was conducted via convenience sampling on online platforms, during the end of March and the beginning of April 2020. The data included four samples: 640 Israeli participants (319 males), 622 Dutch participants (177 males), 924 Italian participants (338 males) and 489 Spanish participants (117 males); age range of 18–88 years. The questionnaires included standard tools (MHC-SF, GAD-7, SOC, SONC). Several questions were adapted to the context of coronavirus and measured levels of exposure to COVID-19, trust in governmental institutions, and social support. The results significantly confirmed the suggested salutogenic model regarding the contribution to individual and national coping resources to anxiety levels and mental health. The patterns of the coping resources in explaining anxiety and mental health were similar in the four samples, and SOC was the main predictor these outcomes. Despite these similarities, a different pattern and also different magnitudes of the predictive value of the coping resources were found for the two different reactions: anxiety vs. mental health. While SOC and situational factors (like financial threat) were significant in explaining anxiety levels, the SOC and national resources were found as significant in explaining mental health levels. The findings support the salutogenic approach in studying reactions during pandemic time. They also shed some light on the difference between pathogenic and salutogenic measures in studying psychological reactions to stressful situations.

Graft vasculopathy (GV) is the most severe pathologic change of chronic rejection in vascularized composite allotransplantation. Since 2012, the intimal media thickness (IMT) of radial and ulnar arteries was annually monitored by high-resolution ultrasonography in seven bilateral upper extremity transplant (UET) patients. We also investigated the IMT of seven matched healthy subjects (controls). No significant difference between IMT values of controls and UET patients was found. The median IMT values of recipient radial and ulnar arteries were 0.23 mm and 0.25 mm, respectively, while the median IMT values of grafted radial and ulnar arteries were 0.27 mm and 0.30 mm, respectively. There was a statistically significant difference in the IMT values of the grafted and recipient ulnar arteries (p = .043), but this difference was no longer significant when patient #2 was excluded. He showed a significant difference between recipient and grafted arteries and significantly higher IMT values (p = .001) of his grafted arteries compared with those of all transplanted patients. This patient developed GV leading to graft loss 11 years after the transplantation. In conclusion, this study showed a significant IMT increase in an UET recipient who developed GV.

Background: This study assesses attitudes towards vaccination in mothers of new-born babies and explores its association with different exposures to communication. Methods: Data were collected through questionnaires administered by means of interviews. Results: Data highlighted that 20% of mothers showed an orientation towards vaccine hesitancy. As for the reasons behind the attitude to vaccine hesitancy, data showed that concern is a common feature. As for the different exposures to communication, 49% of mothers did not remember having received or looked for any information about vaccination during pregnancy and post-partum, 25% stated they received information from several healthcare and non-healthcare sources, 26% declared having received or looked for information by means of healthcare and non-healthcare sources, as well as having taken part in a specific meeting during antenatal classes or at birth centres. The attitude towards vaccine hesitancy tends to reduce as exposure to different communication increases. Conclusions: This study supports the hypothesis that participation in interactive meetings in small groups focused on vaccination during the prenatal course or at the birth point may act as an enabling factor contributing to a decrease in the tendency to experience vaccine hesitation.

Introduction: Oncologic patients who develop chemotherapy-associated liver injury (CALI) secondary to chemotherapy treatment tend to have worse outcomes. Biopsy remains the gold standard for the diagnosis of hepatic steatosis. The purpose of this article is to compare 2 alternatives: Proton-Density-Fat-Fraction (PDFF) MRI and MultiMaterial-Decomposition (MMD) DECT. Materials and Methods: 49 consecutive oncologic patients treated with Chemotherapy underwent abdominal DECT and abdominal MRI within 2 weeks of each other. Two radiologists tracked Regions of Interest independently both in the PDFF fat maps and in the MMD DECT fat maps. Non-parametric exact Wilcoxon signed rank test and Cohen’s K were used to compare the 2 sequences and to evaluate the agreement. Results: There was no statistically significant difference in the fat fraction measured as a continuous value between PDFF and DECT between 2 readers. Within the same imaging method (PDFF) the degree of agreement based on the k coefficient between reader 1 and reader 2 is 0.88 (p-value < 0.05). Similarly, for single-source DECT(ssDECT) the degree of agreement based on the k coefficient between reader 1 and reader 2 is 0.97 (p-value < 0.05). Conclusions: The results of this study demonstrate that the hepatic fat fraction of ssDECT with MMD are not significantly different from PDFF. This could be an advantage in an oncological population that undergoes serial CT scans for follow up of chemotherapy response.

Supplemental Digital Content is available in the text., Background: Upper extremity transplantation (UET) is becoming increasingly common. This article attempts to collate data from cases contributing to the International Registry on Hand and Composite Tissue Transplantation (IRHCTT), define psychosocial themes perceived as predictors of success using statistical methods, and provide an objective measure for optimization and selection of candidates. Methods: The IRHCTT provided anonymous data on UET recipients. A supplementary psychosocial survey was developed focusing on themes of depression, posttraumatic stress disorder (PTSD), anxiety, interpersonal functioning and dependence, compliance, chronic pain, social support, quality of life, and patient expectations. We determined the risk of transplant loss and psychological factors associated with higher risk of transplant loss. Results: Sixty-two UET recipients reported to the IRHCTT. Forty-three psychosocial surveys (68%) were received, with 38 (88%) having intact transplants and 5 (12%) being amputated. Among recipients with a diagnosis of anxiety (N = 29, 67%), 5 (17%) reported transplant loss (P = 0.03). Among those with depression (N = 14, 33%), 2 recipients (14%) has transplant loss (P = 0.17); while 4 recipients (22%) with PTSD (N = 18, 42%) had transplant loss (P = 0.01). Of participants active in occupational therapy (N = 28, 65%), 2 (7%) reported transplant loss (P = 0.09). Of recipients with realistic functional expectations (N = 34, 79%), 2 (6%) had transplant loss versus 3 (34%) who were felt to not have realistic expectations (N = 9, 21%, P = 0.05). Recipients with strong family support (N = 33, 77%) had a lower risk of transplant loss compared with poor or fair family support (N = 10, 23%), but did not reach statistical significance (6% versus 30%, P = 0.14). Conclusion: Anxiety, depression, PTSD, participation in occupational therapy, expectations for posttransplant function, and family support are associated with postsurgical transplant status.

In patients undergoing noncardiac surgery risk indices can estimate patients’ perioperative risk of major cardiovascular complications. The indexes currently in use were derived from observational studies that are now outdated with respect to the current clinical context. We undertook a prospective, observational, cohort study to derive, validate, and compare a new risk index with established risk indices. We evaluated 7335 patients (mean age 63±13 years) who underwent noncardiac surgery. Based on prospective data analysis of 4600 patients (derivation cohort) we developed an Updated Cardiac Risk Score (UCRS), and validated the risk score on 2735 patients (validation cohort). Four variables (i.e. the UCRS) were significantly associated with the risk of a major perioperative cardiovascular events: high-risk surgery, preoperative estimate glomerular filtration rate

In the midst of the COVID-19 pandemic and the universal chaos created by it, this study explores the role of sense of coherence (Soc, Antonovsky, 1979) and how it enables coping with a stressful situation and staying well. SOC is a generalized orientation which allows one to perceive the world as comprehensible, manageable, and meaningful. In an attempt to understand ‘how does the SOC work’ we employed the salutogenic assumption that a strong SOC allows one to reach out in any given situation and find those resources appropriate to the specific stressor. Thus, we hypothesized that the positive impact of SOC on mental health outcomes would be mediated through coping resources that are particularly salient in times of crisis. One resource is related to the micro level (perceived family support) and the other concerns the macro level (trust in leaders and social-political institutions). Data collection was conducted in different countries during May–June 2020 via online platforms. The data included 7 samples of adult participants (age 18–90) from Israel (n ​= ​669), Italy (n ​= ​899), Spain (n ​= ​476), Germany (n ​= ​708), Austria (n ​= ​1026), Switzerland (n ​= ​147), and the U.S. (n ​= ​506). The questionnaires included standard tools (MHC-SF, SOC-13) as well as questionnaires of perceived family support and trust that were adapted to the pandemic context. As expected, SOC was associated with mental health in all the samples. Perceived family support and trust in leaders and social-political institutions mediated the relationships between SOC and mental health, controlling for age, gender, and level of financial risk. It appears that SOC has a universal meaning, not limited by cultural and situational characteristics. The discussion focuses on the theoretical, social, and political applications of the salutogenic model – and its core concept of SOC – in the context of coping with a global pandemic across different cultural contexts and countries.

Analysis of all upper extremity (UET) and face allotransplantations (FT) reported to the International Registry on Hand and Composite Tissue Transplantation (IRHCTT) by May 2017. The IRHCTT includes 66 cases of UET (18 unilateral and 38 bilateral) and 30 of FT. Acute and chronic rejections were reported in the presence of immunosuppression. Complications similar to those reported in solid organ transplantation occurred. UET patient survival was 96.7% at 1, 5, and 10 years after transplantation; graft survival was 90.4% at 1 year and 86.6% at 5 and 10 years. FT patient survival was 96.6% at 1 year and 96.2% at 5 years; graft survival was 96.6% at 1 and 5 years. The majority of UET and FT recipients were satisfied of their graft. UET and FT are complex procedures requiring long-life immunosuppression; their success requires the patients’ careful selection, through evaluation, follow-up and compliance to the immunosuppression.

This study aims to provide a picture of University of Cagliari students’ alcohol-related behaviour and to explore factors associated with it. Data were collected by administering a questionnaire to 992 freshmen university students from different programs consisting of twelve closed questions, including three questions from the Alcohol Use Disorders Identification Test for Consumption (AUDIT-C short form). Three subgroups of alcohol-related behaviour were distinguished (risky drinkers, social drinkers and abstainers). In order to explore factors associated with patterns of alcohol consumption, a multivariate logistic regression was performed. The prevalence of risky drinkers was 35%. A binge-drinking behaviour at least once in the last twelve months was declared by 65% (more widespread in men and in students living away from their parents). Risky consumption is significantly associated with age of onset of alcohol use, living away from parents’ home, drinking outside meals and attending health courses. Regarding the levels of daily alcohol consumption perceived as a health risk, 66% of men and 88% of women indicate values higher than those recommended. The results underline the need for tailored prevention measures. University could be a promising setting to implement actions according to a health promotion perspective, to empower students to control their alcohol consumption.

Background Recent observational studies have focused on lithium treatment in the elderly, with particular reference to safety in terms of thyroid and renal functions. The purpose of this study was to compare the clinical characteristics of patients starting lithium treatment before (N = 79) or after (N = 31) the age of 65 years. Patients were followed up for 6 years with focus on renal function and prescription of levothyroxine and methimazole. Results At baseline, median lithium serum concentration was 0.55 mmol/l. The estimated glomerular filtration rate was lower than 60 ml/min/1.73 m2 in 43 (39%) patients. In a multiple regression analysis controlling for age and gender, we found a significant effect of duration of lithium treatment on estimated glomerular filtration rate (−0.85 ml/min/1.73 m2 per year of prior exposure). The annual decline during follow-up was 2.3 ml/min/1.73 m2. Two patients were prescribed levothyroxine, and two were prescribed methimazole for the first time during follow-up. Conclusions Median lithium serum concentration in this cohort of elderly patients with mainly bipolar disorders was lower than the therapeutic range indicated for younger adults. The decline in glomerular filtration rate may be accelerated by long-term lithium use. Thyroid and renal functions continue to require close monitoring throughout the course of lithium treatment. Trial registration NP/2013/3836. Registered 24 June 2013

to explore clinicians vision on hospital discharge records in order to identify useful elements to foster a more accurate compiling.qualitative research with phenomenological approach.participants were selected through purposive sampling among clinicians of two hospitals located in Sardinia; the sample included 76 people (32 medical directors and 44 doctors in training).identified codes for themes under investigation: vision of accurate compiling, difficulties, and proposals.collected data highlighted two prevailing visions, respectively focused on the importance of an accurate compiling and on the burden of such activity. The accurate compiling is hindered by the lack of motivation and training, by the limits of the registration system and the information technology, by the distortions induced by the prominent role of the hospital discharge records in the evaluation processes. Training, timely updating of the information system accompanied by a proper cross-cultural validation process, improvement of the computer system, and activation of support services could promote more accurate compiling.the implementation of services, unconnected with evaluation and control processes, dedicated to training and support in the compiling of the hospital discharge records and in the conduction of related epidemiological studies would facilitate the compliance to the compilation. Such services will make tangible the benefits obtainable from this registration system, increasing skills, motivation, ownership, and facilitating greater accuracy in compiling.

Objective.Physician’s global assessment (PGA) of disease activity is a major determinant of therapeutic decision making. This study assesses the reliability of the PGA, measured by means of 0–100 mm visual analog scale (VAS), and the additional use of separate VAS scales for musculoskeletal (PhysMSK) and dermatologic (PhysSk) manifestations in patients with psoriatic arthritis (PsA).Methods.Sixteen centers from 8 countries enrolled 319 consecutive patients with PsA. PGA, PhysMSK, and PhysSk evaluation forms were administered at enrollment (W0) and after 1 week (W1). Detailed clinical data regarding musculoskeletal (MSK) manifestations, as well as dermatological assessment, were recorded.Results.Comparison of W0 and W1 scores showed no significant variation (intraclass correlation coefficients were PGA 0.87, PhysMSK 0.86, PhysSk 0.78), demonstrating the reliability of the instrument. PGA scores were dependent on PhysMSK and PhysSk (p < 0.0001) with a major effect of the MSK component (B = 0.69) compared to skin (B = 0.32). PhysMSK was correlated with the number of swollen joints, tender joints, and presence of dactylitis (p < 0.0001). PhysSk scores were correlated with the extent of skin psoriasis and by face, buttocks or intergluteal, and feet involvement (p < 0.0001). Finally, physician and patient assessments were compared showing frequent mismatch and a scattered dot plot: PGA versus patient’s global assessment (r = 0.36), PhysMSK versus patient MSK (r = 0.39), and PhysSk versus patient skin (r = 0.49).Conclusion.PGA assessed by means of VAS is a reliable tool to assess MSK and dermatological disease activity. PGA may diverge from patient self-evaluation. Because MSK and skin/nail disease activity may diverge, it is suggested that both PhysMSK and PhysSk are assessed.

BACKGROUND AND PURPOSE Patients with multiple sclerosis (MS) have many pregnancy-related doubts and fears. Careful counselling is thus important. Mitoxantrone (MITO) is used in patients with aggressive MS and may affect reproductive capacity. The aim of this study was to investigate pregnancy planning and outcomes in patients with MS treated with MITO, both before and after the treatment. METHODS Patients with MS previously treated with MITO were recruited. Clinical, demographic and treatment data were recorded. A questionnaire regarding the planning and outcomes of all pregnancies was administered. Parametric and non-parametric tests were performed using SPSS 22 software. RESULTS A total of 238 patients (female/male, 158/80) were included; 106 subjects planned a pregnancy before MITO and 40 after MITO. Of these, respectively, 102 (97%) and 35 (85%) resulted in conception, 19 (19%) and 7 (18%) in miscarriage, 6 (6%) and 1 (3%) in abortion and 98 (96%) and 32 (91%) were full-term pregnancies. A total of 96 patients (40%) planned a pregnancy only before MITO (and not after), whereas 30 (13%) planned a pregnancy only after MITO (and not before) (P < 0.01). A total of 103 patients did not plan a pregnancy before MITO and 198 did not plan a pregnancy after MITO. The reasons included lack of interest or a partner, fear of MS and infertility. All of the babies born were healthy until the end of follow-up. CONCLUSIONS Mitoxantrone does not affect the ability to conceive or pregnancy outcomes. We found no differences in pregnancies, abortions or miscarriages before and after MITO. The tendency to plan pregnancies decreased significantly after MITO. Our findings may be useful for improving the quality of life of patients and the approach taken by neurologists.

Oligoclonal IgM (OCMB) and IgG (OCGB) bands were found to be associated with poor multiple sclerosis (MS) prognosis. We aimed to evaluate the prognostic value of OCMB/OCGB in a cohort of Sardinian MS patients. We recruited patients from the University of Cagliari. They underwent lumbar puncture for diagnostic purposes. Demographic and the following clinical data were recorded: clinical course; time to reach EDSS 3 and 6; EDSS at last follow-up; and MS treatments. The influence of gender, clinical course, age at onset, treatments, and OCGB/OCMB on reaching EDSS 3 was analysed using Cox regression. Kaplan–Meier curves were used to study the time to reach EDSS 3 considering OCMB/OCGB and therapies. The enrolled number of subjects was 503. The variables influencing the achievement of EDSS 3.0 were: male gender (p = 0.005); progressive course (p = 0.001); age at onset (p

Background: The strongest genetic determinant for multiple sclerosis (MS) is located at the human leukocyte antigen (HLA) class II DRB1 and DQB1 loci. Objectives: To investigate the possible role of predisposing HLA genotypes in determining brain atrophy. Methods: HLA genotypes were categorized as high risk (two predisposing haplotypes) or medium/low risk (one or no predisposing haplotypes). Patients underwent a brain magnetic resonance imaging (MRI) study and volumes of white matter (WM), gray matter (GM), and whole brain (WB) were estimated with SIENAX. Longitudinal atrophy was also assessed with SIENA. Results: The study included 240 MS patients. In 51/240 (21%) subjects, a high-risk HLA genotype was observed, while medium- and low-risk HLA genotypes were 109/240 (45%) and 80/240 (34%), respectively. Multiple regression analysis found that the high-risk HLA genotype was associated with significant reduction in WB ( p = 0.02) and GM ( p = 0.03) volumes compared with the medium-/low-risk HLA genotypes, independently from MS clinical features. The longitudinal study included 60 patients and showed a brain volume loss of −0.79% in high-risk HLA genotype group versus −0.56% in low-risk HLA genotype. Conclusion: Our results suggest an influence of HLA genotype on WB and GM atrophy. Further investigations are necessary to confirm these findings.

Background and aims: Clinical learning placements provide a real-world context where nursing students can acquire clinical skills and the attitudes that are the hallmark of the nursing profession. Nonetheless, nursing students often report dissatisfaction with their clinical placements. The aim of this study was to test a model of the relationship between student’s perceived respect, role uncertainty, staff support, and satisfaction with clinical practice. Method: A cross-sectional, descriptive survey was completed by 278 second- and third-year undergraduate nursing students. Specifically, we tested the moderating role of supportive staff and the mediating role of role uncertainty. Results: We found that lack of respect was positively related to role uncertainty, and this relationship was moderated by supportive staff, especially at lower levels. Also, role uncertainty was a mediator of the relationship between lack of respect and internship satisfaction; lack of respect increased role uncertainty, which in turn was related to minor satisfaction with clinical practice. Conclusion: This study explored the experience of nursing students during their clinical learning placements. Unhealthy placement environments, characterized by lack of respect, trust, and support increase nursing students’ psychosocial risks, thus reducing their satisfaction with their clinical placements. Due to the current global nursing shortage, our results may have important implications for graduate recruitment, retention of young nurses, and professional progression.

In the healthcare setting, Community of Practice (CoP) can be defined as the learning environment where nursing students develop their attitudes toward the nursing profession. Although being part of a CoP is important for nursing students, it can sometimes result in a negative experience where students often perceive a lack of respect. The aim of this study was to expand the knowledge of the CoP in the healthcare setting by analyzing students' perception of respect during clinical placements. Important aspects, such as a professional role concept (role ambiguity and role conflict), tutor support, feedback and relationship with tutors and staff were investigated as predictors of student's perceived respect. A total of 188 Nursing Science Degree undergraduate students were recruited during 2012. Data were analyzed by using regression analysis. The findings supported the importance of role stress, feedback from CoP members, tutor support, and relationship with CoP members on nursing students' perceived respect. The results suggest that when studying nursing students in a CoP, the social context can contribute to affect students' perceived respect.

Health promotion and salutogenesis are embodied in people's everyday lives and in their stories. The assumptions of these scientific theories are similar to Gramsci's theory for better wellbeing in a community, where praxis and capacity building for reflective practice is the way forward for an equal global change. By explaining the road for transformation through narratives, particularly fables, Gramsci manages to reach people from all walks of life, from academics to children. One of these fables, the mouse and the mountain, is here presented as a trigger to health promotion action and as a metaphor for salutogenic thinking. The narrative paradigm for health promotion is the context within which the analogies among 'the mouse's plan', health promotion theory, the salutogenic model, empowerment as well as the practitioners' opinions and experience are discussed and presented. In so doing, a 'storytelling bridge' is created between academics, practitioners and other stakeholders from the health, social and pedagogical arenas in knowledge construction environments. Hence, the article confers the possible contribution of Gramsci's educational perspective within health promotion by presenting a practical example of the use of narratives for capacity building. This is described through the interpretation of the same story in a hypothetical speech told by different storytellers, communicating their personal vision of the mouse's plan and so create a narrative-centered health promotion communication for meaning-making and for embracing theories among scholars and practitioners.

Background: Mycobacterium avium subspecies paratuberculosis (MAP) is an infectious factor recently found in association with multiple sclerosis (MS) in Sardinia. Objectives: The objectives of this study were to confirm this association and evaluate its role in clinical features. Methods: A total of 436 patients and 264 healthy controls (HCs) were included. We examined the blood of each individual for MAPDNA and MAP2694 antibodies using IS900-specific PCR and ELISA, respectively. Differences in MAP presence between the MS group and HCs were evaluated. In MS patients, we considered: gender, age, age at onset, duration of disease, course, EDSS, therapy, relapse/steroids at study time, and oligoclonal bands (OBs). Results: MAPDNA and MAP2694 antibodies were detected in 68 MS and six HCs ( p = 1.14 × 10−11), and 123 MS and 10 HCs ( p = 2.59 × 10−23), respectively. OBs were found with reduced frequency in MAP-positive patients (OR = 0.52; p = 0.02). MAP2694 antibodies were detected more in patients receiving MS treatments (OR = 2.26; p = 0.01), and MAPDNA in subjects on steroids (OR = 2.65; p = 0.02). Conclusion: Our study confirmed the association of MAP and MS in Sardinia. The low OB frequency in MAP patients suggests a peripheral role as a trigger in autoimmunity. MAP positivity might be influenced by steroids and MS therapy. Studies in other populations are needed to confirm the role of MAP in MS.

Background South-Western Sardinia (SWS) is a high risk area for Multiple Sclerosis (MS) with high prevalence and spatial clustering; its population is genetically representative of Sardinians and presents a peculiar environment. We evaluated the MS environmental risk of specific heavy metals (HM) and geographical factors such as solar UV exposure and urbanization by undertaking a population-based cross-sectional study in SWS. Methods Geochemical data on HM, UV exposure, urbanization and epidemiological MS data were available for all SWS municipalities. Principal Component Analysis (PCA) was applied to the geochemical data to reduce multicollinearity and confounding criticalities. Generalized Linear Mixed Models (GLMM) were applied to evaluate the causal effects of the potential risk factors, and a model selection was performed using Akaike Information Criterion. Results The PCA revealed that copper (Cu) does not cluster, while two component scores were extracted: 'basic rocks', including cobalt, chromium and nickel, and 'ore deposits', including lead and zinc. The selected multivariable GLMM highlighted Cu and sex as MS risk factors, adjusting for age and 'ore deposits'. When the Cu concentration increases by 50 ppm, the MS odds are 2.827 (95% CI: 1.645; 5.07) times higher; females have a MS odds 2.04 times (95% CI: 1.59; 2.60) higher than males. Conclusions The high frequency of MS in industrialized countries, where pollution by HM and CO poisoning is widespread, suggests a relationship between environmental exposure to metals and MS. Hence, we suggested a role of Cu homeostasis in MS. This is a preliminary study aimed at generating hypotheses that will need to be confirmed further.

Background: Amongst Sardinians the human leukocyte antigen (HLA) DRB1-DQB1 haplotypes *15:02-*06:01, *16:01-*05:02, *14:01-4-*05:03 are protective for multiple sclerosis (MS), while *13:03-*03:01, *04:05-*03:01, *03:01-*02:01, *15:01-*06:02 and Mycobacterium avium subspecies paratubercolosis (MAP) are predisposing factors. We studied the correlation between MAP and HLA. Methods: Five hundred thirty-one patients were searched for anti-MAP2694 antibodies, DRB1-DQB1 genotyping was performed. The haplotypes were classified as predisposing, neutral or protective. Results: Anti-MAP2694 were found in 23 % of subjects carrying one protective HLA versus 32 % without (p = 0.04). Conclusions: We showed a lower frequency of Abs in patients with protective HLA. These haplotypes could have a protective role for both MS and MAP.

Background: The theory of salutogenesis entails that the ability to use resources for one’s wellbeing is more important than the resources themselves. This ability is referred to as the Sense of Coherence (SOC). This paper present the cross-culturally adapted version of the Italian questionnaire (13 items), and the psychometric and statistical testing of the SOC properties. It offers for the first time a view of the distribution of SOC in an Italian sample, and uses a multivariate method to clarify the effects of socio-demographic determinants on SOC. Methods: The cross-cultural adaptation of the English SOC questionnaire was carried out according to the guidelines reported in literature. To evaluate the psychometric and statistical properties we assessed reliability, validity and frequency distribution of the collected data. A Generalised Linear Model was used to analyse the effects of socio demographic variables on SOC. Results: The Italian SOC scale demonstrates a good internal consistency (α = 0.825). The model obtained with factorial analysis is not related to the traditional dimensions of SOC represented in more than one factor. The multivariate analysis highlights the joint influence of gender, age and education on SOC. Conclusion: The validated Italian questionnaire is now available. Socio-demographic variables should be taken into account as confounders when SOC values among different populations are compared. Presenting data on SOC of the Italian population makes a control population available for comparisons with specific subgroups, such as patient populations. Now, the Italian challenge is to integrate the salutogenic approach into Public Health police.

Few studies to date have been performed to investigate impulsivity and aggressivity in patients with bipolar disorder (BD) and borderline personality disorder (BPD); the primary aim of the present study was to evaluate the impact of co-morbidity of BPD on impulsivity and aggressivity in patients affected by BD. A total of 57 patients (male=20, female=37) affected by BD (BD-I 51%; BD-II 49%) in clinical stable remission were recruited; 28 patients were affected by BD (49.1%), 18 by BD and BPD (31.6%) and 11 (19.3%) by BD plus other personality disorders (OPD) (19.3%). They were assessed with the Structured Clinical Interview for DSM-IV (SCID)-I and SCID-II, and were evaluated by means of the Clinical Global Impression (CGI)-severity and Global Assessment Functioning (GAF) scales, the Barratt Impulsivity Scale (BIS-11) and the Aggression Questionnaire (AQ). Mean total scores were significantly higher among BD/BPD patients with respect to BD and to BD/OPD, both on the BIS-11 and the AQ; the rate of attempted suicides was approximately three times higher in BD/BPD patients with respect to BD and 7.6 times higher than in BD/OPD patients. The results of our study suggest that patients with co-morbid BD and BPD are more impulsive and aggressive. Furthermore, this co-morbid condition may be a risk factor for suicidality.

Background The island of Sardinia features a high incidence of multiple sclerosis (MS) characterized by early age at onset and a progressively increasing trend. The current study was aimed at examining variations in human leukocyte antigen–risk genotypes occurring over time in a cohort of patients. Methods Susceptible and neutral DRB1-DQB1 genotypes were identified in 1660 patients. Age at onset was established in 1436 patients divided into two cohorts, an older cohort (subjects born before 1949, N = 233) and a younger one (subjects born from 1960 to 1989, N = 850). Patients from the older cohort were randomly assigned to patients of the same sex from the younger cohort, matched for age at onset. The final sample included 170 pairs. Logistic conditional analysis was performed to determine the probability of a neutral genotype in both cohorts. Kaplan–Meier analysis was applied to ascertain the influence of predisposing and neutral genotypes in age at onset for both cohorts. Findings The probability of carrying a neutral genotype was 1.76-fold higher in the younger than in the older cohort ( P = 0.02) and 3.67-fold higher in men ( P = 0.005). Kaplan–Meier analysis revealed an earlier age at onset in patients of the young cohort carrying the predisposing genotype ( P = 0.004). Interpretation In the Sardinian population, an environment more prone and propitious to autoimmunity may contribute toward the rising incidence of MS or anticipate overt manifestation of the disease in genetically predisposed subjects.

Smoking represents an important world research issue because of its diffusion among people and its effects on health. This study analyses, according to gender and educational level, the prevalence of smoking, in order to highlight the relationship between sociocultural status and smoking. Prevalence was calculated, with reference to Italian national data in 2000, by dividing a weighted population of 38,720,629 into 10 five-year birth cohorts. Results suggest that smoking is no longer perceived as being socially acceptable behavior. The prevalence declines for both sexes and educational levels, but in low educational levels the decline is slower. The study limitations are noted.

We investigated the clinical and MRI effects of mitoxantrone (MITOX) administered to 45 patients during the first five years of highly active relapsing-remitting multiple sclerosis. Differences occurring between the end of treatment and follow-up (clinical mean: 3.6 years; brain MR: 1.8 years) with respect to baseline variables (EDSS, annualized relapse rate, active T2 lesions, new T1 lesions and number of Gd-enhancing lesions) were analysed using parametric and non-parametric tests. One patient developed leukemia four months after the end of the treatment; no other serious adverse events occurred during treatment and the follow-up period. A clinically relevant reduction in the annualized relapse rate ( P < 0.0001 at end of treatment and P < 0.0001 at follow-up) and improvement in the EDSS ( P < 0.0001 at end of treatment and P = 0.0005 at follow-up) was found. At the end of treatment, 53% of patients experienced no increase in active T2 lesions, while 73% showed no increase in the number of new T1 lesions. At follow-up, 41 out of 45 (91%) patients showed a stable MRI pattern and were active-scan free. Despite potential serious adverse events, MITOX may be considered an option in selected patients with very active early MS. Multiple Sclerosis 2007; 13: 975—980. http://msj.sagepub.com

Background The effects of lithium treatment on renal function have been previously shown, albeit with discrepancies regarding their relevance. In this study, we examined glomerular filtration rate in patients treated with lithium for up to 33 years. Methods All lithium patients registered from 1980 to 2012 at a Lithium Clinic were screened. Estimated glomerular filtration rate (eGFR) was calculated from serum creatinine concentration using the Modification of Diet in Renal Disease Study Group equation. A cross-sectional evaluation of the last available eGFR of 953 patients was carried out using multivariate regression analysis for gender, current age, and duration of lithium treatment. Survival analysis was subsequently applied to calculate the time on lithium needed to enter the eGFR ranges 45 to 59 mL/min/1.73 m2 (G3a) or 30 to 44 mL/min/1.73 m2 (G3b). Finally, 4-year follow-up of eGFR was examined in subgroups of patients who, after reduction to an eGFR lower than 45 mL/min/1.73 m2 either i) continued lithium at the same therapeutic range or ii) discontinued lithium or continued at concentrations below the therapeutic range (0.5 mmol/L). Results In the cross-sectional evaluation, eGFR was found to be lower in women (by 3.47 mL/min/1.73 m2), in older patients (0.73 mL/min/1.73 m2 per year of age), and in patients with longer lithium treatment (0.73 mL/min/1.73 m2 per year). Half of the patients treated for longer than 20 years had an eGFR lower than 60 mL/min/1.73 m2. The median time on lithium taken to enter G3a or G3b was 25 years (95% CI, 23.2–26.9) and 31 years (95% CI, 26.6–35.4), respectively. Progression of renal failure throughout the 4-year follow-up after a reduction to an eGFR lower than 45 mL/min/1.73 m2 did not differ between the subgroup who continued lithium as before and the subgroup who either discontinued lithium or continued at concentrations below the therapeutic range. Conclusions Duration of lithium treatment is to be added to advancing age as a risk factor for reduced glomerular filtration rate. However, renal dysfunction tends to appear after decades of treatment and to progress slowly and irrespective of lithium continuation.

Study objective: To assess how the prevalence of smokers in Italy from 1950 to 2000 has changed, in parallel with law development and the growing attention towards smoking prevention. Design, setting, and participants: Historical data on smoking trends have been obtained using data collected in 2000 by the National Institute of Statistics. A correction coefficient is proposed to overcome the bias of differential mortality reported in other papers. The sample is made up of 102 261 people aged 15–69 years. Main results: A general downward trend is seen; there is a more pronounced decrease starting from 1975 to 1980. In both sexes the peak prevalence tends to decrease according to the birth cohort because of the earlier age in which they gave up. A partial exception to the decline of tobacco use in recent years may be made for the 15–19 year-old age group, which has remained stable since 1990. Conclusions: Although a comprehensive community programme against tobacco was not developed, the different prevention actions implemented in Italy have contributed to a change in attitude and behaviour. The effect of tobacco control strategies implemented in Italy until now is more evident in relation to the breaking of the smoking habit, which happens at an increasingly younger age, although it is not clear how much it is able to prevent people from starting smoking.

In our study we analysed clinical and neuropsychological data in a cohort of 57 Sardinian patients with FTD (55 apparently unrelated and two belonging to the same family), who underwent genetic screening for the C9orf72 mutation. Eight out of 56 patients were found positive for the C9orf72 mutation representing 14% of the entire cohort and 31.6% of the familial cases (6/19). C9orf72 mutated patients differed from the other FTD cases of the cohort for a younger age of onset, higher frequency of familial history for FTD and higher prevalence of delusional psychotic symptoms and hallucinations. In the neuropsychological assessment, C9orf72 mutated patients differed from non-mutated for the high frequency of visuospatial dysfunction regarding constructional apraxia (p = 0.02). In conclusion, our study confirms that Sardinian FTD patients have peculiar genetic characteristics and that C9orf72 mutated patients have a distinctive clinical and neuropsychological profile that could help differentiate them from other FTD patients. In our cohort we found that constructional apraxia, rarely reported in FTD, can properly discriminate between C9orf72 mutated and non-mutated patients and contribute to broaden the neuropsychological profile in frontotemporal dementia associated with this mutation.

Background and objective: A critical aspect of multiple sclerosis (MS) treatments is understanding the effect of disease-modifying drugs (DMDs) on the long-term risk of disability and whether the effect is related to disability at start of treatment. Methods: We performed an observational study on 3060 MS patients. The effect of therapy on progression to Expanded Disability Status Scale (EDSS) 3.0 and 6.0 from onset was analysed in treated vs untreated (UTP) patients using Cox regression analysis adjusted for propensity score and immortal time bias. Results: Compared to UTP, the risks of EDSS 3.0 were 94% and 73% lower in immunomodulant (IMTP-) and immunosuppressant (ISTP-) treated patients, respectively, while the risk of EDSS 6.0 was 86% lower in IMTP. The risk of EDSS 6.0 was, respectively, 91% and 75% lower in 1275 IMTP before and 114 after EDSS 3.0 than in 539 UTP; the risk was higher in IMTP starting therapy after EDSS 3.0 than before (HR = 4.42). Conclusions: DMDs delayed long-term disability in MS patients treated either in the early or, to a lesser extent, in the later phase of the disease. Thus, the window of therapeutic opportunity is relatively extended, assuming that early is better than late treatment, but late is better than never.

Although community participation is a component of community empowerment, it often remains a theoretical exhortation. Reporting experiences which enable people to take control of their lives, can be useful to suggest practical elements for promoting empowerment. This article describes the experience of a Sardinian village (Ulassai), that developed into a community empowerment. The Laverack’s operational domains were used to measure the community empowerment process. The process started in 1979 ‘almost by chance’ with an art performance that was the entry point for community participation. This experience has been the foundation for the community empowerment. Citizens acquired the ‘ability of thinking and planning as a community and not mere individuals’. In the following 30 years citizens gave birth to several outcomes rooted in that event. The intermediate outcomes highlight the ‘ability of action by a group to mobilize existing resources, and act collectively against opposing forces’. The long-term outcomes demonstrate the ‘ability to integrate the cultural experiences that strengthened the community’s identification into a sustainable community asset’, and the ‘ability to cope with global environmental challenges and to collaborate on an equal basis with other stakeholders. The pathways to community empowerment, showed by the community of Ulassai, overlap with the ‘operational domains’. The Ulassai experience shows that the empowerment process can start from an event apparently unrelated to health promotion. This community experience illustrates the positive role arts can play in community development. Hence, the call for health promoters to look carefully into those situations that occur naturally in communities.

Background Multiple sclerosis (MS) has a major impact on the physical, psychological and social life of patients and their families. The aim of this study was to evaluate the different perceptions of patients and caregivers about management of MS, particularly about the same items, to gather information to ameliorate the care of patients. Methods We evaluated what MS patients and caregivers perceive as unmet needs and compared patients’ opinions with caregivers’ opinions using a multidimensional questionnaire. The questionnaire was specifically designed for the study, taking into account different aspects of the global care perceived by patients and care givers, such as information about MS, medical treatment and rehabilitation, patients’ relationships with medical staff and their psychological and social life. Results We administered the questionnaire to 497 patients and 206 caregivers. Results showed that the majority of participants were satisfied with medical staff but expressed a desire that staff be more forthcoming with information about MS. As for medical treatment concerns, more patients found there to be useful a multidisciplinary approach than caregivers did. Both required psychological support for patients but patients felt a greater need for it at the time of diagnosis, whereas caregivers felt it was required post-diagnosis. Both reported significant strains on patient relationships at work but no effect on other social interactions. Conclusions A better understanding of MS patient needs, starting from the point of view of patients and caregivers, could have a great impact on quality of life and on management of the disease.

Introduction: LMNA gene mutations are associated with cardiac and skeletal muscle alterations. Methods: A cohort of 21 mutated individuals was assessed with clinical and instrumental investigations over the years. Results: The median observation period was 6 years. Cardiac compromise was detected in 16 patients. Bradyarrhythmias were the most frequent manifestations, followed by supraventricular arrhythmias. Two individuals suffered from nonsustained and 1 from sustained ventricular tachyarrhythmias. Dilated cardiomyopathy was detected in 3 patients. Evaluation of the frequencies of the clinical expressions showed a high probability of suffering from analogue heart compromise in study subjects bearing the same LMNA gene mutation. Conclusions: Cardiac involvement represents a very common phenotypic expression of LMNA gene mutation. Subjects sharing common genetic background seem to suffer from analogue pattern of cardiac manifestation. Muscle Nerve 46: 187–192, 2012