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Il volume nasce dall’iniziativa di un gruppo di persone confluite in un’associazione culturale Knowledge Integration for Health il cui obiettivo è superare la parcellizzazione del sapere medico in una pluralità di iperspecializzazioni formate da professionisti che spesso non comunicano tra loro. Tutto ciò si riflette non solo sulla cura dei pazienti, costretti a peregrinare tra diversi specialisti, non di rado in disaccordo tra loro, ma anche sulla ricerca scientifica, sulla formazione, sull'organizzazione dei servizi sanitari e sulla spesa pubblica. Sebbene tale esigenza sia avvertita dai cittadini, dai profes-sionisti della salute e dai ricercatori, tuttora non è emerso un modello e/o una teoria coerente dell'integrazione dei saperi per la salute a causa di barriere culturali, economiche ed organizzative. Il volume, espressione del progetto ambizioso di abbattere tali barriere, raccoglie le riflessioni scaturite da una serie di inziative (convegni, workshop, corsi di perfezionamento, sperimentazioni didattiche, ricerche sul campo, conversazioni telematiche e in-formali, e così via) realizzatesi a partire dall'anno 2010. Esso è concepito come uno strumento di lavoro e aperto alla discussione volto a creare una rete comunicativa ed informativa tra esperti di "discipline" diverse, e tra questi e gli stessi pazienti che sono portatori di conoscenze e saperi poco rappresentati nell’attuale scenario scientifico e organizzativo. Su questa falsariga è stata data voce anche a saperi "minoritari" che si configurano a volte come ipotesi di lavoro, più o meno eterodosse, ancora da provare scientificamente ma che sono un sintomo dell’esigenza sempre più sentita di una visione unitaria della salute, della malattia e della terapia. I contributi sono stati scritti da professionisti diversi appartenenti non solo al mondo accademico, ma anche istanze extrauniver-sitarie, istituzionali e non: medici di medicina generale,, ostetriche, fisioterapisti riabilitatori, pediatri, infermieri, logopedisti, tecnici di radiolo-gia, tecnici di laboratorio, epidemiologi, pedagogisti, antropo-logi, psichiatri, chimici, veterinari, statistici, urbanisti, igienisti, informatici. E'stato altresì dato spazio anche ai lavori condotti da studenti e discussi sotto forma di tesi di laurea. La struttura del volume si articola su tre livelli interconnessi: clinico, sociale ed ecologico. Il livello clinico, centrato sull'individuo e la sua malattia, ha co-me paradigma di riferimento il cosiddetto modello bio-medico, noto anche come modello dell'acuzie, fondato sul processo diagnostico-terapeutico e sulla diade terapeuta-paziente. Al secondo livello, quello sociale, il malessere del paziente è iscritto in una serie di dinamiche interpersonali, espressione di comportamenti individuali e collettivi, fattori economici, cultu-rali, e così via. Mentre il modello dell'acuzie concettualizza la malattia come un evento che ha un inizio ed una fine (almeno momentanea), il modello sociale si incentra su cronicità e disabilità che richiedono la partecipazione di familiari, badanti, servizi di riabilitazione e di supporto sociale per un tempo indefinito. I due modelli non sono mutuamente incompatibili perché spesso le condizioni di cronicità e disabilità sono costel-late da esacerbazioni o nuovi eventi che richiedono il ricorso ad interventi clinici. Il livello ecologico riguarda il modo in cui le popolazioni umane si modificano a seguito dell'interazione con altre popolazioni umane, con il mondo animale e vegetale e con l'ambiente chimi-co-fisico, formando ecosistemi la cui dinamica si dipana su scale temporali e geografiche differenti e si riflette sui profili delle malattie di ciascuna popolazione. Così, ad esempio, le grandi trasformazioni demografiche dovute ai processi migratori e alla creazione di barriere efficienti contro alcuni micro-organismi (attraverso il miglioramento delle condizioni igieniche e della conservazione degli alimenti) determinano modificazioni della composizione per età delle popolazioni che a loro volta com-portano transizioni epidemiologiche caratterizzate da cambia-menti più o meno profondi della prevalenza e l'incidenza dei diversi tipi di patologia.

Nondestructive evaluation (NDE) represents an important phase in the life cycle of a product to detect defects both in service and in production. NDE techniques most commonly used to detect surface defects are visual inspection and methods based on eddy current and ultrasound. Laser and non-contact sensors have been recently used to inspect ultrasonically without contact. Components with complex geometry are usually inspected combining several NDE techniques, or simply visually where analysis and evaluation of results are performed by an operator based on specific parameters of acceptance. This last method is currently used to inspect the clutch plates since their complex geometry, for the presence of grooves, limits the use of other methods. This work shows the possibility of using a non-contact ultrasonic technique and guided waves (Lamb) to detect surface defects in clutch plates. An appropriate source/receiver configuration allows to overcome the limitations due to the complexity of the geometry. This technique allows, compared to the visual inspection, to detect smaller and internal defects, and to obtain objective results, not depending on the evaluation of the operator. The inspection method can be very fast and applicable in the production line by using a fully automated control system.

Background: In Italy, Klebsiella pneumoniae carbapenemase producing K. pneumoniae (KPC-Kp) strains are highly endemic and KPC producing CC258 is reported as the widely predominating clone. In Palermo, Italy, previous reports have confirmed this pattern. However, recent preliminary findings suggest that an epidemiological change is likely ongoing towards a polyclonal KPC-Kp spread. Here we present the results of molecular typing of 94 carbapenem non susceptible K. pneumoniae isolates detected during 2014 in the three different hospitals in Palermo, Italy. Methods and Results: Ninety-four consecutive, non replicate carbapenem non susceptible isolates were identified in the three largest acute general hospitals in Palermo, Italy, in the six-month period March-August 2014. They were characterized by PCR for β-lactam, aminoglycoside and plasmid mediated fluoroquinolone resistance genetic determinants. The mgrB gene of the colistin resistant isolates was amplified and sequenced. Clonality was assessed by pulsed field gel electrophoresis and multilocus sequence typing. Eight non-CC258 sequence types (STs) were identified accounting for 60% of isolates. In particular, ST307 and ST273 accounted for 29% and 18% of isolates. CC258 isolates were more frequently susceptible to gentamicin and non-CC258 isolates to amikacin. Colistin non susceptibility was found in 42% of isolates. Modifications of mgrB were found in 32 isolates. Conclusions: Concurrent clonal expansion of some STs and lateral transmission of genetic resistance determinants are likely producing a thorough change of the KPC-Kp epidemiology in Palermo, Italy. In our setting mgrB inactivation proved to substantially contribute to colistin resistance. Our findings suggest the need to continuously monitor the KPC-Kp epidemiology and to assess by a nationwide survey the possible shifting towards a polyclonal epidemic.

Cesarean deliveries (CS) are increasing in Italy, especially in the Campania region, where they reached a peak incidence of 52% in the year 2000. This study analyses CS rate variability by hospital type, foetal risk factors (low birth-weight, prematurity, plurality, anomalous presentations), maternal characteristics (age and parity) and delivery time. Data are drawn from birth certificates of 31,182 babies, that is 64.2% of all delivered in 65 out of 98 Campania birth-places. 16,251 (52%) babies are born by CS; 559 (1.8%) by operative vaginal delivery. The Attributable Risk for foetal risk factors is 6.9%. In absence of these the CS rate would be 48.5% instead of 52%. CS rate of primigravid women was 53.2%. 63% of CS take place during morning hours and 93% on working days. CS rate is higher in private than in public hospitals (58 vs 46%), though foetal risk factors are lower. Rate of older women was higher in public hospitals, rate of primigravid women was higher in private ones. Campania data confirm the marginal role of foetal risk factors in the increase of CS rate. In order to reduce CS rates it seems reasonable to offer special support to primigravid low risk mothers and to provide behavioural obstetrical guidelines for the peculiar Italian reality.

Background: Enterai feeding for infants with birth weight1000 g (ELBWI) is still a controversial issue. The aim of the present survey was to ascertain the attitudes of Italian neonatal intensive care units (NICUs) regarding this point. Method: A questionnaire, with multiple choice answers, regarding the timing of enteral feeding, its progression, the different techniques utilised, the eventual use of fortifiers and the interrupting criteria, was mailed to 92 Italian NICUs. Results: 74 NICUs all over the country participated in the study.1153 ELBWI were hospitalised in 1996 in these Units. Enterai feeding for babies between 501 g and 750 g is started on the 1st day of life in 23.3% of the NICUs and for babies between 751 g and 1000 g in 36.5%. NICUs that start enteral feeding not later than the 3rd day of life are 75.3% and 86.5% respectively. The most frequent investigation prior to starting enterai feeding was the evaluation of gastric aspirate. Mechanical ventilation is considered a contraindication for starting enterai feeding only in 1/4 of NICUs. Enterai feeding is started most often with glucose water solution and raw human milk. The most frequent administration techniques are interminent oro- and nasogastric gavage. Pasteurization facilities are available in 31 % of NICUs, but are located mostly in the Centre and North of Italy. Conclusion: This survey shows that enterai feeding policy for ELBWI varies among different Italian NICUs. In Italy there is a common tendency to start feeding early, even in ventilated infants.

Subacute sclerosing panencephalitis (SSPE) is a progressive neurological disorder of childhood and early adolescence caused by persistent defective measles virus. Clinical manifestations appear many years after the acute measles infection. The incidence of SSPE has substantially declined after the introduction of an effective vaccine. We report a case of a child with SSPE that began with atonia, dysarthria, and intellectual deterioration without the presence of any particular EEG anomalies. We have reported this girl who was affected by this severe affliction in the hope that, because of the rarity of SSPE, it would not go undiagnosed.

Rotator cuff tears are a common cause of pain and shoulder dysfunction. The prevalence of the rotator cuff tears increases with the age reaching the 80% in patients aged more than 80 year. Symptomatic shoulders usually are initially treated conservatively and then, in case of poor outcomes, with surgery. Different parameters are still used to decide between the conservative or surgical treatment in patients with rotator cuff tears. Aim of the current study is to characterize the various features used in decision making and to validate a “Prediction Score” that let us know which patients could have a good and stable outcome with non operative treatment. We enrolled 60 patients (mean age 52 years) with symptomatic rotator cuff tears who were assigned to conservative treatment and were evaluated at 6,9 and 12 months follow-up. We developed a score based on 18 clinical and radiographic parameters. 27 patients (“non conservative”) (45%) with a mean prediction score of 16.1 ± 1.7 interrupted the conservative treatment, while 33 patients (“conservative”) (55%) with an average prediction score of 11.3 ± 1.8 remained conservatively treated at last follow-up. The conservative patients were 14 years older than non conservative patients. According to the results of this study we identified a value of 13 points as a “cut-off” score to predict good results by conservative management of rotator cuff tear. These outcomes support the assumption that a predictive prognostic score may guarantee a rational approach in the management of subjects with RC tears, especially in elderly who continue to have the higher rate of recurrence and therefore could be well treated with standard conservative therapies.

Background: The purpose of the present study was to compare the operative time for graft prepa- ration using different techniques for graft sutur- ing. Material and methods: Flexor profundus tendons were harvested from fresh pig hind-leg trotters. Three different suture techniques were investigat- ed: the Krackow stitch (K), the Whipstitch (W), and the Modified Finger-Trap suture (MFT). Ten- dons were sutured starting at 10 mm from the dis- tal free end of the tendon. The suture configura- tions of the Krackow stitch and Whipstitch were completed with five suture throws. According to the MFT technique, the suture was wrapped five times around the tendon over a distance of 30 mm. The time required to perform a complete su- ture on each tendon was measured. Five indepen- dent examiners of different levels of training mea- sured the time required for graft preparation dur- ing 3 separate occasions to determine intraob- server repeatability and interobserver reproduci- bility. Results: The mean time required for graft prepa- ration following the Krackow technique was 69.1 seconds ± 18.3 SD (range 31.8-120). The Whip- stitch technique took an average of 59.9 seconds ± 21.2 SD (range 27-93). The MFT suture required a mean of 29.3 seconds ± 11.4 SD for completing the suture (range 21.6-33). In all examiners the time required to complete the MFT suture was significantly less than the other suture tech- niques (p < 0.05). Intraobserver intraclass correla- tion coefficients for each examiner ranged from 0.72 to 0.83. Conclusion: Low graft preparation time is re- quired to complete a MFT suture in a porcine ten- don model. Further, time required for graft prepa- ration using the MFT was shorter than other su- turing techniques such as the Krackow and Whip- stitch techniques. Clinical relevance: The MFT suture could be used for graft set-up with the main advantage of reduc- ing the time required in comparison with other su- ture techniques.

Background: Osteoarthritis (OA) is a degenerative joints disorder influenced by genetic predisposition. We reported that rs11718863 DVWA SNP was represented in Sicilian with a more severe Kellgren and Lawrence (KL) radiographic grade, displaying its predictive role as OA marker progression. Here, we describe the DVWA SNPs: rs11718863, rs7639618, rs7651842, rs7639807 and rs17040821 probably able to induce protein functional changes. Findings: Sixty-one Sicilian patients with knee OA and 100 healthy subjects were enrolled. Clinical and radiographic evaluation was performed using AKSS scores and KL. Linkage Disequilibrium (LD) analyses were performed in order to verify whether the SNPs segregate as haplotype. All DVWA SNPs'MinorAllele Frequencies (MAF) were greater than in the European. The rs7639618 SNP showed a statistical association with KL. Our analyses show that a LD exists among rs11718863 and rs7639618, as well as between rs7651842, rs7639807 and rs17040821 SNPs. We also observed that three out of the 161 individuals investigated were simultaneously homozygous carriers of the rs7651842, rs7639807 and rs17040821 MAF alleles. Conclusions: In summary, the purpose of this preliminary research was to highlight possible associations between DVWA SNPs and OA clinical and radiographic data. This work represents a multidisciplinary medicine approach to study OA where clinical, radiological and genetic evaluation could contribute to better define OA grading.

The aim of this work is the analysis of the contact area in a knee prosthesis using two different approaches. In particular, the interface between the femoral component and the polyethylene insert has been studied both numerically and experimentally. The interest in studying the contact area is related to the fact that the wear of the polyethylene insert, due to the high contact pressures, represents one of the major causes of failure of the total knee prosthesis. The possibility to evaluate the contact area at different loads and mutual position between femur and tibia is, therefore, of fundamental importance to study the service life of a prosthesis and to improve its performance. The finite element numerical approach has required the acquisition, through reverse engineering, and CAD modelling of the prosthetic components. Then the FEM simulations have been developed considering two different load conditions. In order to compare the calculated data, the same load configurations have been used for experimental tests based on ultrasonic method. In this case, some preliminary tests were required to calibrate the system depending on the particular characteristics of materials, geometries and surface finish of the prosthesis. The results show a good correlation between the data obtained with the two different approaches and, consequently, a good level of reliability of the procedures developed for the numerical and experimental evaluation of the contact area. The numerical procedure can be used to determine the area for different angles and loads, but especially in the design phase. The ultrasonic technique can be used to validate the numerical data.

We describe polyclonal spread of colistin-resistant Klebsiella pneumoniae in an acute general hospital in Italy. Between June and December 2011, 58 colistin-resistant K. pneumoniae isolates were recovered from 28 patients admitted to different wards, but mainly in the intensive care units. All isolates were tested for drug susceptibility and the presence of beta-lactamase (bla) genes. Clonality was investigated by repetitive extragenic palindromic (rep)-PCR and multilocus sequence typing (MLST). Fifty-two isolates had minimum inhibitory concentrations (MICs) for colistin of 6-128 mg/L, carried blaKPC3 and were attributed to sequence type ST258. The remaining six isolates were susceptible to carbapenems, exhibited MICs for colistin of 3-32 mg/L, and belonged to two different types, ST15 and ST273. Rep-PCR included all isolates in three clusters, one containing all ST258 KPC-3-producing isolates and two containing ST15 and ST273 isolates. Cross-transmission containment measures and intensification of staff and environmental hygiene could not stop the outbreak. Selective pressure and horizontal transmission probably contributed to emergence and spread of three different strains of colistin-resistant K. pneumoniae in the hospital. Strict implementation of the above measures and a wider awareness of the antimicrobial resistance threat are crucial to preserve the last therapeutic options of the multidrug-resistant Gram-negative infections. .

INTRODUCTION: Osteoarthritis (OA) is considered to be a multifactorial and polygenic disease and diagnosis is mainly clinical and radiological. Correlation between radiographic data and clinical status has been reported. However, very few studies, especially in Caucasian people, describe the association between the Kellgren and Lawrence OA grading scale (KL) and genetic alterations to better understand OA etiopathogenesis and susceptibility. In order to update the knee OA grading, in this study we assessed the associations between KL grade, clinical features such as American Knee Society Score (AKSS), age, and polymorphisms in the principal osteoarthritis susceptibility (OS) genes in Sicilian individuals. METHODS: In 66 Sicilian individuals affected by primary knee OA, the clinical and radiographic evaluation was performed using 2 sub-scores of AKSS (knee score (KS) and function score (FS)) and KL. The patients were also classified according to age. Online Mendelian Inheritance in Man (OMIM) and Database of Single Nucleotide Polymorphisms (dbSNP) Short Genetic Variations databases were used to select gene regions containing the following polymorphisms to analyze: FRZB rs288326 and rs7775, MATN3 rs77245812, ASPN D14 repeats, PTHR2 rs76758470, GDF5 rs143383 and DVWA rs11718863. Patient genotypes were obtained using Sanger DNA sequencing analysis. RESULTS: In our cohort of patients a statistical association between the variables analyzed was reported in all associations tested (KL versus KS, FS and age). We observed that a mild to severe OA radiographic grade is related to severe clinical conditions and loss of articular function and that the severity of symptoms increases with age. Concerning the genotyping analysis, our results revealed a significant statistical association between KL grading and GDF5 rs143383 and DVWA rs11718863 genetic alterations. The latter was also associated with a more severe radiographic grade, displaying its predictive role as OA marker progression. Statistically significant association between clinical, radiographic and genetic signs observed, suggests extending the actual grading of knee OA based mainly on X-ray features. CONCLUSIONS: This work represents a multidisciplinary and translational medicine approach to study OA where clinical, radiological, and OS5 and OS6 SNPs evaluation could contribute to better define grading and progression of OA and to the development of new therapies.