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Background Pediatric robotic-assisted surgeries have increased in recent years; however, guidance documents are still lacking. This study aimed to develop evidence-based recommendations, or best practice statements when evidence is lacking or inadequate, to assist surgical teams internationally. Methods A joint consensus taskforce of anesthesiologists and surgeons from the Italian Society of Pediatric and Neonatal Anesthesia and Intensive Care (SARNePI) and the Italian Society of Pediatric Surgery (SICP) have identified critical areas and reviewed the available evidence. The taskforce comprised 21 experts representing the fields of anesthesia (n = 11) and surgery (n = 10) from clinical centers performing pediatric robotic surgery in the Italian cities of Ancona, Bologna, Milan, Naples, Padua, Pavia, Perugia, Rome, Siena, and Verona. Between December 2020 and September 2021, three meetings, two Delphi rounds, and a final consensus conference took place. Results During the first planning meeting, the panel agreed on the specific objectives, the definitions to apply, and precise methodology. The project was structured into three subtopics: (i) preoperative patient assessment and preparation; (ii) intraoperative management (surgical and anesthesiologic); and (iii) postoperative procedures. Within these phases, the panel agreed to address a total of 18 relevant areas, which spanned preoperative patient assessment and patient selection, anesthesiology, critical care medicine, respiratory care, prevention of postoperative nausea and vomiting, and pain management. Conclusion Collaboration among surgeons and anesthesiologists will be increasingly important for achieving safe and effective RAS procedures. These recommendations will provide a review for those who already have relevant experience and should be particularly useful for those starting a new program.

Pilonidal sinus is a common disease of the natal cleft, which can lead to complications including infection and abscess formation. Various operative techniques are available options for the treatment of this pathology, but the ideal technique is still debatable. Analyzing the literature we found out that more recently minimally invasive approaches have been described. In particular, the mechanism of an endoscopic approach relies on the use of the endoscope without cutaneous tissue damage. Advantages include shorter operative time and time to discharge, which impact resource management in both primary and secondary care: patients undergoing endoscopic technique have a high satisfaction rate, probably due to the low level of postoperative pain and early return to daily activities. Published results of studies of newer approaches have demonstrated a lower short and long-term complication rate compared to open surgery. However, very poor reports are available in literature about pediatric population.

The study examined how 807 undergraduate Italian students coped with synchronous, asynchronous, and blended learning environments during the COVID-19 pandemic. Strengths and weaknesses of online learning were collected via an electronic platform (SurveyMonkey) and then categorized by grounded theory analysis using ATLAS.ti 8.0 software. The results showed technical, practical, relational, organizational, and transformative features of online learning emerged, differentiated in synchronous, asynchronous, and blended modes. Emotional aspects also affected the evaluation of distance learning because depression and fear were more frequent among the students who found distance learning to be an obstacle rather than a resource or felt ambivalent about it.

BACKGROUND In the last few years, indocyanine green (ICG) fluorescent cholangiography (FC) has been adopted to perform intra-operative biliary mapping during laparoscopic cholecystectomy (LC). This study aimed to compare the results of LC with and without use of ICG-FC. METHODS All LC operated from June 2017 to June 2021 in our unit were retrospectively reviewed. Pre-operative workup included ultrasonography to assess dilation of main biliary tree. The ICG dosage was 0.35 mg/kg and the median timing of administration was 15.5 h pre-operatively. We evaluated, analyzing videorecorded procedures, 3 parameters in both groups: the total operative time (T1), the time of cystic duct isolation, clipping and sectioning (T2), and the time of gallbladder removal from hepatic fossa (T3). RESULTS Forty-three LC were operated in the study period: 22 using standard technique (G1) and 21 using ICG-FC (G2). There were 27 girls and 16 boys, with median age at surgery of 11.5 years (range 7-17) and median weight of 47 kg (range 31-110). No conversions were reported in our series. In all ICG cases (except one patient under therapy with phenobarbital) the biliary tree was perfectly visualized during dissection. Intra-operative complications occurred in 3 G1 patients (13.6%): 2 bleedings from the Calot's triangle and 1 bleeding from the liver bed during the gallbladder removal. LC was significantly faster in G2 than in G1 (p = 0.001). In fact, the parameters analyzed (T1, T2, T3) were all significantly greater in G1 than in G2 (p = 0.001). CONCLUSIONS Based upon our experience, we strongly recommend the use of ICG-FC in all pediatric patients undergoing LC. ICG-guided fluorescence provided an excellent real-time visualization of the extrahepatic biliary tree and allowed faster and safer dissection, minimizing the risk of bile duct injuries. Furthermore, ICG use was clinically safe, with no adverse reactions to the product.

Purpose: To compare surgical scars assessed by a validated patient reported outcome questionnaire in children undergoing open (OP), laparoscopic (LP), or robotic-assisted (RALP) pyeloplasty. Secondary aim was to assess the influence on the outcomes of variables such as gender or body mass index (BMI). Materials and methods: Observational, cross-sectional, multicentric study of patients undergoing primary pyeloplasty between age 10- and 18-year at 5 tertiary Italian institutions in the period 01/2010 to 12/2019. Of 227 eligible patients, 114 (50%) participated. OP was performed in 37 (32%), LP in 30 (26%) and RALP in 47 (41%), After a median (IQR) follow-up of 5.2 (2.3-7.8) years, scars were measured and assessed by a validated Patient Scar Assessment Questionnaire (PSAQ). Scores were compared among techniques and in accordance to several variables. Results: The median length of the surgical scar at follow-up was significantly larger (p

Bone mineral abnormalities (defined as Chronic Kidney Disease Mineral Bone Disorder; CKD-MBD) are prevalent and associated with a substantial risk burden and poor prognosis in CKD population. Several lines of evidence support the notion that a large proportion of patients receiving maintenance dialysis experience a suboptimal biochemical control of CKD-MBD. Although no study has ever demonstrated conclusively that CKD-MBD control is associated with improved survival, an expanding therapeutic armamentarium is available to correct bone mineral abnormalities. In this position paper of Lombardy Nephrologists, a summary of the state of art of CKD-MBD as well as a summary of the unmet clinical needs will be provided. Furthermore, this position paper will focus on the potential and drawbacks of a new injectable calcimimetic, etelcalcetide, a drug available in Italy since few months ago.

Background: Virtual reality (VR) experience is the most adopted form of video-gaming to reduce preoperative anxiety. This prospective randomized clinical trial aimed to examine the feasibility and efficacy of preoperative VR experience in children undergoing elective surgery. Materials and Methods: All patients older than 13 years and scheduled for elective surgery between March and June 2021 were enrolled. Preoperative VR experience consisted in watching a 5-minute video using a head-mounted display. Four parameters were evaluated and compared between the two groups: (1) patient heart rate (HR) before anesthesia; (2) patient evaluation of preoperative anxiety using facial affective scale (FAS); (3) anesthesiologist evaluation of preoperative anxiety using FAS; and (4) subjective stress scoring using a 5-item Likert-type scale. Results: A total of 40 patients (23 boys) with a median age of 14.5 years (range 12-17) participated in the study. The patients were randomized in two groups, each of 20 patients, according to preoperative VR experience: VR group (G1) and control group (G2). No adverse events related to VR occurred. The patient median HR was significantly lower in G1 (72 bpm) than in G2 (101 bpm) (P = .001). The very relaxed/relaxed face selection rate using FAS was significantly higher in G1 than in G2, in both patient and anesthesiologist evaluations (P = .001). Finally, the subjective patient scoring of operating room experience was significantly greater in G1 [4.6 ± 0.4] than in G2 [2.15 ± 1.07] (P = .001). Conclusions: Our preliminary results showed that VR is safe and effective to relieve anxiety and improve relaxation in the preoperative period in pediatric patients undergoing elective surgery. The VR experience resulted in decreased overall anxiety and increased overall positive affect during the preoperative period in VR group compared with the control group. Further studies are needed to investigate this technology in the postoperative phase and on a larger patient cohort.

Following an ecological perspective, reactions to a disaster—such as the COVID‐19 pandemic—should be analysed in the interdependence between individual and community dimensions. The present study aims to analyse individual emotional dimensions (anxiety, joy, fear or depressive feelings) and their community dimensions (connectedness, emotional sharing and solidarity) with a longitudinal approach among university students from Italian universities. Participants were 746 university students at t1 (during the lockdown) and 361 at t2 (after the lockdown) recruited in six Italian universities from different areas of Italy. Comparing emotional dimensions in the two times, t2 is characterized by a generalized ambiguity: both happiness or joy because of the end of limitations and a kind of ‘post‐lockdown anxiety’ because of a sense of individual inadequacy in facing the return to normality, conducting daily activities and attending community spaces. Data confirms that after the so‐called ‘honeymoon phase’ in community dimensions (first phase of t1 time), a sort of ‘depressive reaction’ arises at t2: Italian university students seem more aware of the need for individual and social responsibility and that many events are not under their personal control. The reconstruction phase and exit from the emergency are perceived as necessary but also as a difficult and risky period. Please refer to the Supplementary Material section to find this article's Community and Social Impact Statement.

Il manuale, coniugando teoria, pratica ed etica secondo una prospettiva ecologico-sistemica, presenta gli elementi distintivi della psicologia di comunità. Un testo rivolto a studenti e studentesse sia dei corsi di laurea in psicologia, sia di altri ambiti disciplinari, e a tutti i/le professionisti/e che agiscono per lo sviluppo del benessere nei e dei contesti, integrando il cambiamento individuale con la trasformazione contestuale.

IgA nephropathy (IgAN) is a progressive form of kidney disease defined by glomerular deposition of IgA. We performed a genome-wide association study involving 10,146 kidney biopsy-diagnosed IgAN cases and 28,751 matched controls across 17 international cohorts. We defined 30 independent genome-wide significant risk loci jointly explaining 11% of disease risk. A total of 16 loci were novel, including TNFSF4, REL, CD28, CXCL8/PF4V1, LY86, LYN, ANXA3, TNFSF8/15, REEP3, ZMIZ1, RELA, ETS1, IGH, IRF8, TNFRSF13B and FCAR. The SNP-based heritability of IgAN was estimated at 23%. We observed a positive genetic correlation between IgAN and total serum IgA levels, allergy, tonsillectomy, and several infections, and a negative correlation with inflammatory bowel disease. All significant non-HLA loci shared with serum IgA levels had a concordant effect on the risk of IgAN. Moreover, IgAN loci were globally enriched in gene orthologs causing abnormal IgA levels when genetically manipulated in mice. The explained heritability was enriched in the regulatory elements of cells from the immune and hematopoietic systems and intestinal mucosa, providing support for the pathogenic role of extra-renal tissues. The polygenic risk of IgAN was associated with early disease onset, increased lifetime risk of kidney failure, as well as hematuria and several other traits in a phenome-wide association study of 590,515 individuals. In the comprehensive functional annotation analysis of candidate causal genes across genome-wide significant loci, we observed the convergence of biological candidates on a common set of inflammatory signaling pathways and cytokine ligand-receptor pairs, prioritizing potential new drug targets.

Background: Locoregional therapies (LRTs) are commonly used to increase the number of potential candidates for liver transplantation (LT). The aim of this paper is to assess the outcomes of LRTs prior to LT in patients with hepatocellular carcinoma (HCC) beyond the listing criteria. Methods: In accordance with the PRISMA guidelines, we searched the Medline and Web of Science databases for reports published before May 2021. We included papers assessing adult patients with HCC considered for LT and reporting intention-to-treat (ITT) survival outcomes. Two reviewers independently identified and extracted the data and evaluated the papers. Outcomes analysed were drop-out rate; time on the waiting list; and 1, 3 and 5 year survival after LT and based on an ITT analysis. Results: The literature search yielded 3,106 records, of which 11 papers (1874 patients) met the inclusion criteria. Patients with HCC beyond the listing criteria and successfully downstaged presented a higher drop-out rate (OR 2.05, 95% CI 1.45–2.88, p < 0.001) and a longer time from the initial assessment to LT than those with HCC within the listing criteria (MD 1.93, 95% CI 0.91–2.94, p < 0.001). The 1, 3 and 5 year survival post-LT and based on an ITT analysis did not show significant differences between the two groups. Patients with HCC beyond the listing criteria, successfully downstaged and then transplanted, presented longer 3 year (OR 3.77, 95% CI 1.26–11.32, p = 0.02) and 5 year overall survival (OS) (OR 3.08, 95% CI 1.15–8.23, p = 0.02) in comparison with those that were not submitted to LT. Conclusions: Patients with HCC beyond the listing criteria undergoing downstaging presented a higher drop-out rate in comparison with those with HCC within the listing criteria. However, the two groups did not present significant differences in 1, 3 and 5 year survival rates based on an ITT analysis. Patients with HCC beyond the listing, when successfully downstaged and transplanted, presented longer 3 and 5-year OS in comparison with those who were not transplanted.

Minimally invasive surgery (MIS) has represented the main innovation in the field of pediatric surgery and urology over the last 30 years. Pediatric MIS is a wide field, ranging from the standard laparoscopic surgery using 3-mm ports to robotics mainly adopted for pediatric urology indications. The aim of this paper was to summarize the current status of robotic surgery in pediatric urology and to evaluate possible future technical developments for this technique. In pediatric urology, many procedures are challenged by the narrow working space available in smaller children, the difficulty to perform complex and long suture lines to repair complex urinary malformations, and the challenge to remove renal or adrenal tumors. The main characteristic of robotic surgery is that the robotic instruments inserted into the abdominal cavity are remotely controlled by the surgeon, who is sitting at a console next to the patient or even far away, avoiding human tremor during complex suturing. Due to the magnification of the operative field view and the six degrees of freedom of the robotic instruments compared to conventional laparoscopic instruments, providing enhanced 3D vision and improved surgeon ergonomics, robot-assisted surgery appears to be beneficial over conventional MIS, especially in complex reconstructive procedures. Currently, there are two robotic systems available on the market and certified for robotic surgery in children: the DaVinci (Intuitive Surgical, since 2001) and Senhance (Transenterix, since 2020). However, almost the totality of papers published in the international literature are focused on robotic procedures using the DaVinci platform. Analyzing the current literature, there is no evidence about the indications where robotics are preferable to conventional MIS approaches. Currently, the main indications of robotic surgery in pediatric urology are: pyeloplasty for ureteropelvic junction obstruction (UPJO), ureteral reimplantation according to Lich Gregoire technique, Mitrofanoff procedure, nephrectomy or partial nephrectomy for oncological indications, removal of renal cysts, bladder neck reconstruction or removal of urinary tract stones. The future developments in this field are certainly represented by intraoperative use of indocyanine green (ICG) fluorescence imaging that permits to have a better vision of vascular anatomy or clearly identify nodes in case of tumors, and by development of 5G technology. The main limitation of robotic surgery today remains the excessive cost of the machine itself and the limited lifespan of robotic instruments. We believe that robotic surgery will surely represent the new field of development in pediatric surgery, but its widespread application will depend on the introduction of new robotic platforms in the market, that will certainly low the costs, and also to the development of smaller size instruments more suitable for pediatric use.

Background COVID-19 severity and mortality are strongly influenced by age and comorbidities. Among comorbidities, kidney dysfunction seems to play a crucial role. Indeed, acute kidney injury (AKI) is a frequent finding in hospitalized COVID-19 patients and seems to be associated to mortality and severity. On the other hand, the role of chronic kidney disease (CKD) in COVID-19 is more debated. Aims and Methods We performed a retrospective study in a cohort of 174 hospitalized COVID-19 patients in Italy from March 3rd to May 21st 2020, to investigate the role of kidney dysfunction on COVID-19 severity and mortality. Moreover, we examined in depth the relationship between kidney function, age, and progression of COVID-19, also using different equations to estimate the glomerular filtration rate (GFR). Hazard ratios (HR) and odds ratios (OR) were obtained by logistic regression, while a predictive analysis was made through a machine learning approach.Results AKI and death occurred in 10.2 % and 19.5% respectively, in our population. Serum creatinine, blood urea nitrogen, neutrophils, lymphocytes, c-reactive protein and procalcitonin were significantly correlated to mortality and severity of the disease. The major risk factors for mortality in our cohort were age [adjusted HR, 6.2; 95% confidence interval (CI) 1.8-21.4] and AKI [3.36 (1.44-7.87)], while, in these relationships, GFR at the baseline mitigated the role of age. The occurrence of AKI was influenced by baseline kidney function, D-dimer and procalcitonin and hypertension. Our predictive analysis for AKI and mortality reached an accuracy ≥ of 94% and 91%, respectively. In patients ≥ 70 years, MDRD and CKD-EPI showed a better performance in the prediction of AKI and mortality, compared to BIS-1 formula.Discussion Our study confirms the importance of AKI as a risk factor in COVID-19 disease, while it scales down the role of CKD, especially in elderly patients. BIS-1 formula demonstrated a worse performance to predict the outcomes in COVID-19 patients when compared to MDRD and CKD-EPI.

Objectives To assess and compare postoperative bladder dysfunction rates and outcomes after laparoscopic and robot-assisted extravesical ureteric reimplantation in children and to identify risk factors associated with bladder dysfunction. Patients and methods A total of 151 children underwent minimally invasive extravesical ureteric reimplantation in five international centres of paediatric urology over a 5-year period (January 2013-January 2018). The children were divided in two groups according to surgical approach: group 1 underwent laporoscopic reimplantation and included 116 children (92 girls and 24 boys with a median age of 4.5 years), while group 2 underwent robot-assisted reimplantation and included 35 children (29 girls and six boys with a median age of 7.5 years). The two groups were compared with regard to: procedure length; success rate; postoperative complication rate; and postoperative bladder dysfunction rate (acute urinary retention [AUR] and voiding dysfunction). Univariate and multivariate logistic regression analyses were performed to assess predictors of postoperative bladder dysfunction. Factors assessed included age, gender, laterality, duration of procedure, pre-existing bladder and bowel dysfunction (BBD) and pain control. Results The mean operating time was significantly longer in group 2 compared with group 1, for both unilateral (159.5 vs 109.5 min) and bilateral procedures (202 vs 132 min; P = 0.001). The success rate was significantly higher in group 2 than in group 1 (100% vs 95.6%; P = 0.001). The overall postoperative bladder dysfunction rate was 8.6% and no significant difference was found between group 1 (6.9%) and group 2 (14.3%; P = 0.17). All AUR cases were managed with short-term bladder catheterization except for two cases (1.3%) in group 1 that required short-term suprapubic catheterization. Univariate and multivariate analyses showed that bilateral pathology, pre-existing BBD and duration of procedure were predictors of postoperative bladder dysfunction (P = 0.001). Conclusion Our results confirmed that short-term bladder dysfunction is a possible complication of extravesical ureteric reimplantation, with no significant difference between the laparoscopic and robot-assisted approaches. Bladder dysfunction occurred more often after bilateral repairs, but required suprapubic catheterization in only 1.3% of cases. Bilaterality, pre-existing BBD and duration of surgery were confirmed on univariate and multivariate analyses as predictors of postoperative bladder dysfunction in this series.

Purpose of review To discuss alternative strategies for multimodal treatments of nonmetastatic bladder-prostate rhabdomyosarcoma performed with the aim of preserving organ function. Recent findings Bladder-prostate rhabdomyosarcomas are seldom fully resectable at presentation or after induction chemotherapy, and extensive resection might not improve survival. When an organ-sparing approach is pursued, radiotherapy might be unavoidable to achieve reliable local control of the disease. Benefits of preoperative vs. postoperative radiotherapy have yet to be investigated. Multimodal treatments may often result in bladder function impairment and erectile dysfunction. To reduce long-term side effects of radiotherapy, irradiation modalities allowing for more targeted treatment should be favoured. For this purpose, external beam proton therapy or nonradical surgery associated with brachytherapy may be viable options. Nevertheless, experience with these treatments is still limited. Advancements in lower urinary tract reconstruction make preservation of volitional voiding and erectile function possible after cystoprostatectomy. But in the context of multimodal treatment, cystoprostatectomy is reserved to patients who respond poorly to other treatments. Summary For the vast majority of bladder-prostate rhabdomyosarcoma, we believe that reliable local control of disease can only be achieved with the use of radiotherapy. Efforts should be made to find the best modality for targeted radiotherapy. Further studies are required to compare preoperative vs. postoperative radiotherapy and the best dose to be administered in order to reduce long-term side effects. If creation of an orthotopic continent diversion is deemed appropriate in patients undergoing cystoprostatectomy, it should be performed concurrently with extirpative surgery.

Laparoscopic Palomo varicocelectomy is one the most common approaches adopted to treat pediatric varicocele, but postoperative hydrocele still remains a potential problem with this procedure. This study aimed to evaluate the outcome of a new technique of lymphography using indocyanine green (ICG)-enhanced fluorescence to perform lymphatic sparing laparoscopic Palomo varicocelectomy.The records of 25 patients who underwent laparoscopic left varicocelectomy in our unit from March 2017 to March 2018 were retrospectively evaluated. The average patients' age was 13.7 years (range 12-16). All patients had a high degree varicocele associated with left testicular hypotrophy and symptoms. All procedures were performed in laparoscopy using three trocars. After trocars' positioning, 2 mL of ICG solution was directly injected into the left testicle. Using ICG fluorescence, the lymphatic vessels were clearly identified and spared, and then the entire spermatic bundle was clipped and divided according to Palomo's principle.The average operative time was 18 minutes (range 10-25). No conversions to open surgery and no allergy or other adverse reactions induced by ICG were reported. At a maximum follow-up of 18 months, no recurrence of varicocele or postoperative hydrocele was recorded.Our preliminary experience showed that ICG fluorescence lymphography is a safe and effective option to perform lymphatic sparing laparoscopic Palomo varicocelectomy in children and adolescents with high degree varicocele. The intratesticular injection of ICG and use of fluorescence vision allowed identification of lymphatic vessels in 100% of cases. No allergy to ICG or postoperative hydrocele was reported in our experience.

To evaluate the effectiveness of antenatal intervention for the treatment of congenital lower urinary tract obstruction (LUTO) in improving perinatal survival and postnatal renal function. METHODS: Electronic databases were searched from their inception until May 2018. Selection criteria included randomized controlled trials and controlled nonrandomized observational studies including fetuses with ultrasound evidence of LUTO evaluating antenatal intervention for improving perinatal outcomes. Any type of intervention was analyzed. The primary outcome was perinatal survival. The secondary outcome was postnatal survival with normal renal function. The summary measures were reported as summary odds ratio (OR) with 95% of confidence interval (CI). RESULTS: Ten articles with a total of 355 fetuses were included in the meta-analysis. Inclusion criteria of the selected studies were singleton pregnancy with severe LUTO confirmed on detailed fetal ultrasound examination. Nine studies, analyzed the efficacy of vesico-amniotic shunt performed in the second trimester. The overall estimate survival was higher in the vesico-amniotic shunt group compared to the conservative group (OR 2.54, 95% CI 1.14-5.67). 64/112 fetuses (57.1%) survived in the vesico-amniotic shunt group compared to 52/134 (38.8%) in the control group. Five studies reported on postnatal renal function between 6 months and 2 years. Postnatal renal function was higher in the vesico-amniotic shunt group compared to the conservative group (OR 2.09, 95% CI 0.74-5.9). Fetal cystoscopy was performed in only two included studies. Overall, 45 fetuses underwent fetal cystoscopy. The perinatal survival was higher in the cystoscopy group compared to the conservative management group (OR 2.63, 95% CI 1.07-6.47). Normal renal function was noted in 13/34 fetuses in the cystoscopy group versus 12/61 in the conservative management group at 6 months follow-up (OR 1.75, 95% CI 1.05-2.92) Conclusions: Antenatal bladder drainage appears to improve perinatal survival in cases of LUTO. Further randomized trials with long-term follow-up are required to determine the role of antenatal treatment in clinical setting.

COVID-19 is strongly influenced by age and comorbidities. Acute kidney injury (AKI) is a frequent finding in COVID-19 patients and seems to be associated to mortality and severity. On the other hand, the role of kidney dysfunction in COVID-19 is still debated. We performed a retrospective study in a cohort of 174 hospitalized COVID-19 patients in Italy from March 3rd to May 21st 2020, to investigate the role of kidney dysfunction on COVID-19 severity and mortality. Moreover, we examined in depth the relationship between kidney function, age, and progression of COVID-19, also using different equations to estimate the glomerular filtration rate (GFR). We performed logistic regressions, while a predictive analysis was made through a machine learning approach. AKI and death occurred respectively in 10.2% and 19.5%, in our population. The major risk factors for mortality in our cohort were age [adjusted HR, 6.2; 95% confidence interval (CI) 1.8–21.4] and AKI [3.36 (1.44–7.87)], while, in these relationships, GFR at baseline mitigated the role of age. The occurrence of AKI was influenced by baseline kidney function, D-dimer, procalcitonin and hypertension. Our predictive analysis for AKI and mortality reached an accuracy of ≥ 94% and ≥ 91%, respectively. Our study scales down the role of kidney function impairment on hospital admission , especially in elderly patients. BIS-1 formula demonstrated a worse performance to predict the outcomes in COVID-19 patients when compared with MDRD and CKD-EPI.

Background and Aims Generalized edema, non responsive to oral diuretics, is one of the main causes of hospital admission for nephrotic syndrome patients. Although hospital length of stay (LOS) may vary widely, in 2017 the average LOS in acute-care hospitals was lower than 8 days in OECD countries. The aim of the present study was to determine the factors commonly associated with a longer LOS in patients admitted for edema due to nephrotic syndrome in the Nephrology Unit of ICS Maugeri, Pavia, Italy Method In this retrospective study we reviewed the medical records of all patients admitted for nephrotic syndrome between 2012-2020 in the Nephrology Unit of ICS Maugeri. Inclusion criteria were the following: age between 18-85 years of age; severe edema non responsive to oral, low dose diuretics; patients with heart failure, serum creatinine > 3.5 g/dl or on dialysis treatment were excluded from the study. Patients were divided into two groups according to the length of stay: ≤ 7 days or ≥ 8 days. Age, gender, serum protein concentration, creatinine, and hemoglobin; serum cholesterol and tryglicerides, urinary protein excretion rate; types of glomerular disease, weight loss were recorded. Student T tests and one-way Anova were performed to evaluate the differences between the means. Results 60 patients (42 male, 18 female) with a total number of hospital accesses of 93 were enrolled in the study. Mean age was 66.8 ± 13.07 years. Average LOS was 9.02 ± 7.4 days. Protein excretion rate was 6.7 ± 3.6 g/24 hours at the admission and was not statistically changed at discharge. Mean total serum protein and creatinine concentration at the admission were 4.7 ± 0.8 g/dl and 1.8 ± 1.1 mg/dl respectively. Patients with LOS < 7 days were younger (64 ± 11.9 vs 69 ± 13.6 years, p 0.001) and a significantly higher total serum protein concentration (5.02 ± 0.77 vs 4.65 ± 0.76 g/dl, p< 0.001) and haemoglobin (12.6 ± 1.8 vs 11.4 ± 1.8 g/dl, p< 0.05) compared to patients with longer LOS. Proteinuria was not significantly different between the two groups (6.27 ± 3.36 vs 7.1 ± 3.9 g/24 hours, p= NS). While serum cholesterol and tryglicerides were higher in the group of patients with longer LOS, weight loss was similar in the two groups at discharge. Although the difference was not significant, the group with longer hospitalization had a greater number of patients with a diagnosis of focal segmental glomerulosclerosis (FSGS) Conclusion Our results demonstrate that age, total serum protein concentration, serum creatinine, higher lipids and probably the diagnosis of FSGS may affect the hospital length of stay of patients with nephrotic syndrome admitted for severe edema. A more aggressive diuretic treatment may be needed in elderly nephrotic syndrome patients with lower GFR and total serum protein concentration.

Background and Aims Roxadustat, an oral hypoxia-inducible factor prolyl hydroxylase inhibitor, induces a coordinated erythropoietic response by increasing endogenous erythropoietin levels and improving iron metabolism. This analysis was performed to examine the consistency of efficacy and cardiovascular safety results for roxadustat vs placebo or darbepoetin alfa (DA) in patients with non-dialysis-dependent (NDD) chronic kidney disease (CKD). Method Results from three phase 3, double-blind studies comparing roxadustat with placebo (ALPS, ANDES, OLYMPUS) with anaemia and stage 3-5 NDD CKD were pooled and assessed for consistency with results of an open-label study comparing roxadustat with DA (DOLOMITES) in predominantly European patients. The primary efficacy endpoint was haemoglobin (Hb) response, defined as (a) Hb ≥11.0 g/dL that changed from baseline (CFB) by ≥1.0 g/dL in patients with Hb >8.0 g/dL or (b) Hb CFB by ≥2.0 g/dL in patients with Hb ≤8.0 g/dL irrespective of and without rescue therapy for placebo-controlled (assessed for superiority) and DA-controlled (assessed for non-inferiority) studies, respectively. The secondary efficacy endpoint was Hb CFB to Weeks 28-36 using least squares mean difference (LSMD) without rescue therapy. The key safety endpoints of major adverse cardiovascular event (MACE, comprising death, myocardial infarction, and stroke) and MACE+ (MACE plus hospitalization with heart failure or unstable angina) were adjudicated in all studies. MACE and MACE+ for roxadustat vs placebo or DA were compared in the intention-to-treat sample using a Cox proportional hazards model. Results In total, 4886 patients were randomised in placebo-controlled (2386 roxadustat, 1884 placebo) and DA-controlled (323 roxadustat, 293 DA) studies. Baseline characteristics of patients treated with roxadustat vs placebo and roxadustat vs DA were similar: baseline Hb (placebo, 9.10 vs 9.10 g/dL; DA, 9.55 vs 9.55 g/dL) and iron repletion (placebo, 59.9% vs 59.8%; DA, 56.3% vs 51.9%). Roxadustat was superior to placebo for Hb response without rescue therapy (80.2% vs 8.7%; difference of proportion [DOP], 71.50%; 95% CI, 69.40-73.51) and noninferior to DA (89.5% vs 78.0%; DOP, 11.51%; 95% CI, 5.66-17.36). Mean Hb CFB (Weeks 28-36) achieved superiority in pooled analysis vs placebo (LS mean, 1.91 vs 0.14; LSMD, 1.77; 95% CI, 1.69-1.84; P Conclusion Roxadustat corrected Hb more effectively than placebo and comparably to DA in patients with anaemia and stage 3-5 NDD CKD. Cardiovascular safety was comparable between roxadustat and DA and placebo.

Background and Aims Roxadustat regulates erythropoiesis and iron metabolism through hypoxia-inducible factor prolyl hydroxylase inhibition. This regional analysis evaluated efficacy and safety for roxadustat versus placebo/darbepoetin alfa (DA) in NDD CKD patients with anaemia. Method Results from three, double-blind phase 3 studies comparing roxadustat to placebo (ALPS, ANDES, OLYMPUS) in patients with anaemia and stage 3-5 NDD CKD were pooled and evaluated alongside results of an open-label study comparing roxadustat to DA (DOLOMITES) in the same population. Efficacy outcomes were compared in three regions (Europe, US, and other) in placebo-controlled studies (PCS) and two regions (Western Europe/Israel and Central/Eastern Europe) in the DA-controlled study (DCS). The primary efficacy endpoint in Europe was haemoglobin (Hb) response, defined as Hb ≥11.0 g/dL that changed from baseline (CFB) by ≥1.0 g/dL in patients with Hb >8.0 g/dL or as CFB ≥2.0 g/dL in patients with Hb ≤8.0 g/dL. The secondary efficacy endpoint was Hb CFB to Weeks 28-36 without rescue therapy (intravenous iron, red blood cell [RBC] transfusion, or erythropoiesis-stimulating agent [ESA] for PCS; RBC transfusion or ESA [roxadustat only] for DCS). Incidence of treatment-emergent adverse events (TEAEs) was summarised descriptively in two regions in PCS (Europe and non-Europe) and two regions in DCS (Western Europe/Israel and Central/Eastern Europe). Results A total of 4886 patients were randomised (2709 roxadustat; 1884 placebo; 293 DA). A significantly greater proportion of patients in all regions who received roxadustat had a Hb response without rescue therapy vs placebo (Europe: 77.9% vs 16.5%, difference of proportion [DOP] 61.4%, 95% CI: 56.5-66.2; US: 75.4% vs 8.3%, DOP 67.2%, 95% CI: 62.7-71.6; and other: 83.4% vs 5.5%, DOP 78.0%, 95% CI: 75.4-80.5) and a numerically greater proportion in both regions vs DA (Western Europe/Israel: 93.9% vs 83.5%, DOP 10.4%, 95% CI: 1.2-19.6; Central/Eastern Europe: 86.5% vs 75.4%, DOP 10.9%, 95% CI: 3.6-18.3). Mean Hb CFB was significantly greater with roxadustat vs placebo in Europe (2.01 vs 0.37 g/dL, LSMD 1.70, 95% CI: 1.55-1.84), US (1.80 vs 0.21 g/dL, LSMD 1.67, 95% CI: 1.53-1.82), and other (1.80 vs 0.06 g/dL, LSMD 1.77, 95% CI: 1.64-1.89) (all P Conclusion In patients with anaemia and stage 3-5 NDD CKD, roxadustat was more effective than placebo for correcting Hb and generating Hb response without rescue therapy in Europe, the US, and other countries. It was similarly effective as DA for correcting Hb and generating a Hb response without rescue therapy in Western Europe/Israel and Central/Eastern Europe. The incidence of select TEAEs was comparable and relatively low in all regions.

Roughly 3% of patients worldwide with a new diagnosis of type 2 diabetes mellitus (T2DM) already have an overt nephropathy at diagnosis and about 20–30% of the remaining ones develop a complication of this kind later in life. The early identification of kidney disease in diabetic patients is important as it slows its progression, which is important not only because this reduces the need for renal replacement therapy, but also because it decreases the high rate of mortality and morbidity associated with a reduction in kidney function. The increasing prevalence of type 2 diabetes and the consequent greater probability of finding different types of kidney diseases in diabetic patients frequently gives rise to overlapping diagnoses, a definition encompassing the differential diagnosis between diabetic and non-diabetic kidney disease. The issue is made more complex by the acknowledgement of the increasing frequency of presentations of what is termed “diabetic kidney disease” without relevant proteinuria, in particular in T2DM patients. Distinguishing between diabetes related and non-diabetes related forms of kidney disease in diabetic patients is not only a semantic question, as different diseases require different clinical management. However, while the urologic and macrovascular complications of diabetes, as well as overlapping parenchymal damage, can be diagnosed by means of imaging studies, often only a kidney biopsy will make a differential diagnosis possible. In fact, the coexistence of typical diabetic lesions, such as nodular glomerulopathy or glomerulosclerosis, with different glomerular, vascular and tubulo-interstitial alterations has been extensively described, and an analysis of the dominant histological pattern can contribute to determining what therapeutic approach should be adopted. However, due to the high frequency of kidney diseases, and to the fact that T2DM patients are often affected by multiple comorbidities, a kidney biopsy is not generally performed in T2DM patients. What follows is a review aiming to discuss the diagnostic work-up, on the base of clinical, laboratory and imaging criteria, and evaluate the present indications and alternatives to renal biopsy.

The aim of this study is to present a short form of the I COPPE scale of multidimensional well-being. We conducted two studies, which include four samples collected across three countries, namely United States, Argentina, and Italy. In the pilot study we tested during the data analysis phase whether it was feasible to reduce the full I COPPE scale by omitting the items dealing with past well-being. Prompted by the positive results of the pilot study, we launched a final validation study with a sample of 2682 Italian people who completed the I COPPE scale short form, which is designed without items referring to past well-being. Results from a series of confirmatory factor analyses show that the I COPPE scale short form presents acceptable levels of construct validity and reliability. Moreover, the 7-factor correlated-trait model proved to be the best fit for the data. We discuss advantaged of using the I COPPE scale short form along with limitations and future recommendations.

This study investigated how young Italian people experienced the period of peak spread of COVID-19 in their country by probing their emotions, thoughts, events, and actions related to interpersonal and community bonds. This approach to the pandemic will highlight social dimensions that characterized contextual interactions from the specific perspective of Community Psychology. The aim was to investigate young people's experiences because they are the most fragile group due to their difficulty staying home and apart from their peers and because they are, at the same time, the most potentially dangerous people due to their urge to gather in groups. The research involved 568 university students, 475 females, and 93 males, with an average age of 21.82 years (SD = 4.836). The collected data were analyzed with the Grounded Theory Methodology, using the Atlas 8.0 software. From the textual data, representative codes were defined and grouped into 10 categories, which reflect the individuals' prosocial attitudes, behaviors, and values. These categories formed three macro-categories, called: “Collective Dimensions,” which includes Connectedness, Solidarity, Italian-ness, Social Problems, and Collective Mourning; “Prosocial Orientation,” which includes Trust and Hope; and “Collective Values,” which includes Values of Freedom, Respect of Social Rules, and Civic-Mindedness. All these macro-categories are indicative of the shared feelings experienced by Italians during the first time of the pandemic. Further practical implications of these results will be discussed, including a consideration of the risk of developing distress and improving well-being, as well as promoting preventive behaviors.

This literature review aimed to assess the outcomes of robot-assisted laparoscopic extra-vesical ureteral reimplantation (RALUR/REVUR) in standard, complex and re-operative cases. Twenty-two studies (period 2008-2019) containing 1362 children receiving RALUR/REVUR, were included. Unilateral repair was faster compared to bilateral (P = .0000). The overall patient success rate was 92%. The mean post-operative complications rate was 10.7%. The mean re-operations rate was 3.9%. The available data show that RALUR/REVUR can be a first line surgical approach for pediatric vesicoureteral reflux at most centers with the caveat that learning curves for the surgeons are expected as with most new surgical procedures.

Purpose This study aimed to standardize the operative technique of indocyanine green (ICG) near-infrared fluorescence (NIRF) laparoscopic partial nephrectomy (LPN) and compare it with the standard technique. Methods In the last 4 years, we performed 22 LPN (14 right-sided, 8 left-sided) in children with non-functioning moiety of duplex kidney. Patients included 12 girls and 10 boys with a median age of 3.9 years (range 1–10). Patients were grouped according to the use of ICG-NIRF: G1 included 12 patients operated using ICG-NIRF and G2 included 10 patients receiving the standard technique. We standardized the technique of injection of ICG in three different steps. Results The median operative time was significantly lower in G1 [87 min (range 68–110)] compared with G2 [140 min (range 70–220)] (p = 0.001). One intra-operative complication occurred in G2. At post-operative ultrasound (US), the residual moiety was normal in all patients. An asymptomatic renal cyst related to the site of surgery was visualized at US in 8/22 (36%), with a significantly higher incidence in G2 (6/10, 60%) compared with G1 (2/12, 16.6%) (p = 0.001). Renogram demonstrated no loss of function of residual moiety. No allergic reactions to ICG occurred. Conclusion ICG-NIRF LPN is technically easier, quicker, and safer compared with the standard technique. The main advantages of using ICG-NIRF during LPN are the clear identification of normal ureter, vasculature of non-functioning pole, and demarcation line between the avascular and the perfused pole. The main limitation of ICG technology remains the need for specific laparoscopic equipment that is not always available.

Abstract. The purpose of this systematic review is to analyze the COVID-19 pandemic’s effects through the lens of community psychology. Our study applied PRISMA methodology, and it was carried out using the PsycInfo, PubMed, Embase, and EBSCO databases utilizing the keywords “connectedness,” “resilience,” “shared action,” “social action,” “trust,” “individual well-being,” and “social well-being.” We selected 12 of 216 eligible publications based on the inclusion criteria. The results indicated that the role of trust in institutions and others is a protective factor for communities that experience crises, such as the COVID-19 pandemic. Moreover, developing social actions promoted connections and social support and that, in the absence of in-person communication, online communication promoted connections and reduced psychological distress and isolation. Finally, the study revealed that some psychosocial factors stem from declines in people’s well-being due to the pandemic and subsequent lockdowns. Furthermore, our findings highlighted the role of technology as a positive communication tool for promoting connectedness and social support, as well as the social function of trust in institutions. Our results suggested that community interactions at the local and virtual levels should be viewed as positive actions to support institutions in detecting the most effective social intervention measures to stimulate individual and community well-being during the pandemic. These findings may serve as a guide for health policymakers in their efforts to face the effects of the COVID-19 pandemic supporting beneficial strategies for social planning and effective public policies. Finally, both the strengths and limitations of the research will be discussed in depth.

This paper aimed to report a multi-institutional 3-year experience with pediatric endoscopic pilonidal sinus treatment (PEPSiT) and describe tips and tricks of the technique. We retrospectively reviewed all patients

Purpose This study aimed to evaluate the efficacy of oxygen-enriched oil-based gel dressing on wound healing and postoperative outcome in children who underwent distal hypospadias repair. Methods We included all patients with distal hypospadias, who underwent Snodgrass urethroplasty and preputioplasty over an 18-months period. The patients were randomized in two groups according to the type of medication: oxygen-enriched oil-based gel (G1) and hyaluronic acid cream (G2). After discharge, parents changed the dressing twice a day for 2–3 weeks postoperatively. The patients were evaluated at 7, 14, 21, 30, 60 and 180 postoperative days and thereafter annually. Results One-hundred and fourteen patients (median age 18 months) were included in the study and randomized in two groups, each of 57 patients. The wound healing was significantly faster in G1 compared with G2 (p = 0.001). G1 reported significantly higher SWAS and modified HOPE scores compared with G2 (p = 0.001) at all steps of follow-up. No adverse skin reactions occurred. Foreskin dehiscence and re-operations rates were significantly lower in G1 compared with G2 (p = 0.001). Postoperative foreskin retractability was better in G1, with a significantly higher incidence of secondary phimosis in G2 (p = 0.001). The median treatment costs were significantly lower in G1 compared with G2 (p = 0.001). Conclusion Postoperative dressing using oxygen-enriched oil-based gel was highly effective, promoting a faster wound healing in patients who underwent distal hypospadias repair. It reported a lower incidence of foreskin dehiscence and better foreskin retractability compared with the control group. It was cost-effective and clinically safe without allergy or intolerance to the product.

Objective: The development of integrated multimedia operating rooms has made possible to record surgical procedures mainly in minimally invasive surgery (MIS) and robotic surgery. This modality of video storage allows the trainees to study surgical procedures based on video analysis. The aim of this study is to compare two learning methods of surgical procedures, operative textbooks and video-based coaching, in a group of 10 pediatric surgery trainees. Patients and Methods: We selected five surgical procedures to study: Three MIS procedures, Nissen fundoplication, partial nephrectomy, and cholecystectomy; and two robotic procedures, Lich-Gregoir reimplantation for vesicoureteral reflux and Henderson-Hynes pyleoplasty for ureteropelvic junction obstruction. Ten trainees were divided into two groups of 5 each, Group 1 (G1) and Group 2 (G2). G1 studied the procedures analyzing videos, G2 studied the same procedure classically reading textbooks. Tutors prepared a questionnaire of 100 multianswered questions that was submitted to both groups, divided into 20 questions for each surgical technique. The questionnaire focused on the different steps of surgical techniques. Results: Analyzing the 10 questionnaires, G1 (video group) obtained a median result of 82 exact answers (74-97), whereas G2 (textbook group) obtained a median result of 64.2 correct answers (53-79). Analyzing statistically the results of two groups, using unpaired t-Student's test with a level of statistical significance >95%, the results of G1 were statistically significantly better that G2 with a P = .0265 for the average scores. Conclusion: Video-based coaching to learn surgical techniques is a novel, feasible, and excellent modality for supplementing surgical techniques learning for pediatric surgery trainees. Objective evaluation using a multianswered questionnaire demonstrates that video-based coaching in pediatric surgery is statistically better than textbook classic education. We suggest to adopt this teaching modality in every surgical training program above all to teach MIS and robotic surgery.

Background: This study was the second part of a prospective randomized clinical trial and aimed to evaluate the use of a tubular finger oxygen-enriched oil inside-coated dressing device and its effect on the post-operative outcome of children undergoing distal hypospadias repair.Methods: A prospective single-blinded randomized clinical trial was carried out between September 2019 and September 2020. We included all patients with distal hypospadias, who received Snodgrass urethroplasty and preputioplasty. The patients were randomized in two groups according to the type of dressing: tubular finger oxygen-enriched oil inside-coated device (G1) and elastic net bandage with application of oxygen-enriched oil-based gel (G2). The patients were evaluated at 7, 14, 21, 30, and 60 post-operative day (POD).Results: Sixty-four patients (median age 14 months) were included in the study and randomized in two groups, each of 32 patients. Post-operative preputial edema rate was significantly lower in G1 (3/32, 9.3%) compared with G2 (10/32, 31.2%) (p = 0.001). The median duration of preputial edema was significantly shorter in G1 compared with G2 (6 vs. 10.5 days) (p = 0.001). Penile diameter measurements at 4th, 7th, 14th POD proved that entity and duration of post-operative swelling were objectively decreased using the new dressing. The wound healing was significantly faster in G1 compared with G2 (14.2 vs. 18.5 days) (p = 0.001). The post-operative complications rate was significantly lower in G1 (0%) compared with G2 (3/32, 9.3%) (p = 0.001). Foreskin dehiscence occurred in two G2 patients (6.2%) whereas, breakdown of urethroplasty and preputioplasty occurred in one G2 patient (3.1%) due to scratching injuries. The dressing management was subjectively assessed by nurses to be easier in G1 patients compared with G2 ones (median score 1.2 vs. 3.5) (p = 0.001). The median treatment costs were significantly lower in G1 compared with G2 (55 vs. 87 eur) (p = 0.001). No adverse skin reactions occurred.Conclusions: Post-operative dressing using tubular finger oxygen-enriched oil inside-coated device was highly effective, easy to manage, cheaper and associated with a lower rate of foreskin and urethral complications compared with the standard dressing method in pediatric patients undergoing distal hypospadias repair. It was also clinically safe without allergy or intolerance to the product.

This study aimed to report a multi-institutional experience with robot-assisted laparoscopic surgery (RALS) for treatment of urinary tract stones in children. The medical records of 15 patients (12 boys), who underwent RALS for urolithiasis in 4 international centers of pediatric urology over a 5-year period, were retrospectively collected. The median patient age was 8.5 years (range 4–15). Eleven/fifteen patients (73.3%) had concurrent uretero–pelvic junction obstruction (UPJO) and 2/15 patients (13.3%) had neurogenic bladder. Stones were in the renal pelvis in 8/15 (53.3%), in the lower pole in 3/15 (20%), in the bladder in 2/15 (13.3%), and in multiple locations in 2/15 (13.3%). One patient (6.6%) had bilateral multiple kidney stones. The median stone size was 10.8 mm (range 2–30) in upper tract location and 27 mm (range 21–33) into the bladder. Eleven patients with concomitant UPJO underwent simultaneous robot-assisted pyelolithotomy and pyeloplasty in 12 kidney units. Two patients with isolated staghorn stones received robot-assisted pyelolithotomy. Robot-assisted cystolithotomy was performed in two patients with bladder stones. The median operative time was 131.8 min (range 60–240). The stone-free rate was 80% following initial surgery and 100% after secondary treatment. Clavien 2 complications (hematuria, infections) were recorded in 5/15 patients (33.3%). Three/fifteen patients (20%) with residual renal stones were successfully treated using ureterorenoscopy (Clavien 3b). RALS was a feasible, safe and effective treatment option for pediatric urolithiasis in selected cases such as large bladder stones, bilateral kidney stones, staghorn stones or concomitant anomalies such as UPJO requiring simultaneous pyeloplasty. Supplementary Information The online version contains supplementary material available at 10.1007/s00240-021-01271-5.

Vesico-ureteral reflux is a common anomaly encountered in pediatric urology practice. The diagnosis is generally made by voiding cystourethrogram (VCUG). Although not all cases of vesico-ureteral reflux need to be repaired, in cases of recurrent urinary tract infections (UTIs) or persistent high-grade reflux, surgical correction is a potential intervention to prevent pyelonephritis and future renal scarring. Due to the high postoperative morbidity associated with open reimplantation, minimally invasive techniques have been developed as alternatives. The advent of surgical telemanipulator or robotic systems solved the ergonomic problems associated with conventional laparoscopic anti-reflux surgery. Robot-assisted extravesical ureteral reimplantation (REVUR) has been proven as a safe and effective alternative to open reimplantation.

Introduction Patients on dialysis (HDPs) are a category at high risk from COVID-19 and thus a high-priority group for vaccination. COVID-19 vaccine hesitancy has been a concern since the availability of the first vaccine. The objective of this study was to determine hesitancy rates and factors associated with hesitancy toward COVID-19 vaccination in HDP. Methods HDP were surveyed with an ad hoc questionnaire in 4 large dialysis facilities in Europe: Le Mans and Paris, in France, and Cagliari and Pavia, in Italy. The questionnaire explored different domains associated with vaccine hesitancy, such as perception of disease severity, sources of information about the vaccine and the disease, and confidence in the health care system. Results A total of 417 patients (average age 69 years, 60% men) agreed to answer the questionnaire. Hesitancy was associated with younger age (P = 0.003), lower perception of disease severity (P < 0.001) and vaccine efficacy (P < 0.001), and lower trust in vaccination (P < 0.001) and in the health care system and scientists (P < 0.001) in the univariate analysis. In the multivariate models, concerns about side effects (P = 0.004) and vaccine efficacy (P < 0.001) and living in France (P = 0.04) remained associated with higher vaccine hesitancy, whereas having received an influenza vaccine (P = 0.032) and trusting scientists (P = 0.032) were associated with a more positive attitude toward vaccination. Conclusions HDPs have a good understanding of the risks associated with COVID-19. Vaccine hesitancy was not associated with educational level, age, or gender but rather with lack of confidence in vaccine efficacy and concerns about safety. HDPs were quite skeptical about the health care system but generally trusted scientists.