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Introduction: Poor medication adherence in CKD patients is associated with high mortality and morbidity and can reach up to 80%. The most effective interventions to increase patients’ adherence to treatments are conducted by a multi-professional team and with the active participation of patients and their families. Narrative evidence-based medicine has been proved as a useful methodology in the care of chronic patients also in promoting their adherence to treatments. Methods: Around 50-70% of CKD patients treated in our centre will follow clinical protocol based on a narrative medicine approach: (1) patients will be invited to write a brief history related to their experience with the CKD and treatments; (2) screening for depression (HADS; PHQ-9); (3) intervention of pharmaceutical counselling aimed to explore patients’ behaviours about taking their medications; (4) sharing of decision-making: the results of the narrative histories and of questionnaires will be discussed with the patients; (5) psychoeducational groups. Results: The pilot phase of the project will last 6 months. During these months, patients will be monitored for biochemical (e.g. anemia) and anthropometric (e.g. blood pressure) parameters and depression. Medical visits or diagnostic tests missed by patients will also be recorded. Conclusions: The development of an active role of patients in taking care of themselves is one of the main challenge of clinical nephrology. The present project aims to implement in the clinical routine a protocol based on the narrative medicine approach in which the biological, psychological and social needs of CKD patients are considered and discussed with them.

Information and communication technology solutions have the potential to support active and healthy aging and improve monitoring and treatment outcomes. To make such solutions acceptable, all stakeholders must be involved in the requirements elicitation process. Due to the COVID-19 situation, alternative approaches to commonly used face-to-face methods must often be used. One aim of the current article is to share a unique experience from the Pharaon project where due to the COVID-19 outbreak alternative elicitation methods were used. In addition, an overview of common functional, quality, and emotional goals identified by six pilot sites is presented to complement the knowledge about the needs of older adults. Methods:Originally planned face-to-face co-creation seminars were impossible to carry out, and all pilot sites chose alternative requirements elicitation methods that were most suitable in their situation. The elicited requirements were presented in the form of goal models. In one summary goal model, we provide an overview of common functional, quality, and emotional goals. Results:Different elicitation methods were combined based on the digital literacy of the target group and their access to digital tools. Methods applied without digital technologies were phone interviews, reviews of literature and previous projects, while by means of digital technologies online interviews, online questionnaires, and (semi-)virtual co-creation seminars were conducted. The combination of the methods allowed to involve all planned stakeholders. Virtual and semi-virtual co-creation seminars created collaborative environment comparable to face-to-face situations, while online participation helped to save the time of the participants. The most prevalent functional goals elicited were “Monitor health,” “Receive advice,” “Receive information.” “Easy to use/comfortable,” “personalized/tailored,” “automatic/smart” were identified as most prevalent quality goals. Most frequently occurring emotional goals were “involved,” “empowered,” and “informed.” Conclusion:There are alternative methods to face-to-face co-creation seminars, which effectively involve older adults and other stakeholders in the requirements elicitation process. Despite the used elicitation method, the requirements can be easily transformed into goal models to present the results in a uniform way. The common requirements across different pilots provided a strong foundation for representing detailed requirements and input for further software development processes.

The efficacy of cardiac rehabilitation in heart-failure patients who received a left-ventricular assist device (LVAD) instead of heart transplantation (HTx) is still unclear. This study aims to evaluate whether cardiac rehabilitation is beneficial in LVAD as HTx patients in the short term and whether its effects in LVAD patients persist over time. Twenty-five LVAD patients were evaluated by functional and psychological tests at admission (T0) and discharge (T1) of a 4-week inpatient structured rehabilitation program, and follow-ups 3 (T2), 6 (T3), and 12 months (T4) after discharge. Twenty-five matched HTx patients were also studied from T0 to T1 to compare the improvements in the six-minute walk test (6MWT). The quality-of-life scores substantially improved in LVAD patients and the 6MWT showed the same functional recovery as in HTx patients from T0 to T1. After T1, numerous LVAD patients withdrew from the study. However, the 6MWT outcome increased further from T1 to T3, with a positive trend during the follow-ups. Hemoglobin and the ventilatory performance increased, and the psychological perception of heart-failure symptoms and pain further improved at T2. In conclusion, exercise-based rehabilitation programs provide similar beneficial effects in LVAD and HTx patients, without deterioration in LVAD patients up to 12 months after discharge.

Background Missing data are common in end-of-life care studies, but there is still relatively little exploration of which is the best method to deal with them, and, in particular, if the missing at random (MAR) assumption is valid or missing not at random (MNAR) mechanisms should be assumed. In this paper we investigated this issue through a sensitivity analysis within the ACTION study, a multicenter cluster randomized controlled trial testing advance care planning in patients with advanced lung or colorectal cancer. Methods Multiple imputation procedures under MAR and MNAR assumptions were implemented. Possible violation of the MAR assumption was addressed with reference to variables measuring quality of life and symptoms. The MNAR model assumed that patients with worse health were more likely to have missing questionnaires, making a distinction between single missing items, which were assumed to satisfy the MAR assumption, and missing values due to completely missing questionnaire for which a MNAR mechanism was hypothesized. We explored the sensitivity to possible departures from MAR on gender differences between key indicators and on simple correlations. Results Up to 39% of follow-up data were missing. Results under MAR reflected that missingness was related to poorer health status. Correlations between variables, although very small, changed according to the imputation method, as well as the differences in scores by gender, indicating a certain sensitivity of the results to the violation of the MAR assumption. Conclusions The findings confirmed the importance of undertaking this kind of analysis in end-of-life care studies.

Despite evidence supporting the effectiveness of best practices in infection prevention and management, many healthcare workers fail to implement them and evidence-based practices tend to be underused in routine practice. Prevention and management of infections across the surgical pathway should always focus on collaboration among all healthcare workers sharing knowledge of best practices. To clarify key issues in the prevention and management of infections across the surgical pathway, a multidisciplinary task force of experts convened in Ancona, Italy, on May 31, 2019, for a national meeting. This document represents the executive summary of the final statements approved by the expert panel.

Background The hospital discharge process plays a key role in patient care. Careggi Re-Engineered Discharge (CaRED) aimed at establishing a meaningful relationship among general practitioners (GPs) and patients, throughout the discharge process. Objective The aim is to describe the activities and results in the period 2014–17 of the CaRED. Methods CaRED is a restructured discharge protocol, which foresees a different, more direct form of communication between hospital and GPs, enabled by an ad hoc electronic medical record. The 30-day hospital readmission rate and/or accesses to the emergency department were evaluated as proxy for effective communication. A pre–post survey was launched to assess the GPs’ perceived quality, and patient and family satisfaction. Results A total of 1549 hospitalizations were included, respectively, 717 in the pre and 832 in the post-intervention period. The 30-day hospital readmission rate decreased significantly in the post-intervention period (14.4% vs. 19.4%, χ2(1) = 8.03, P Eighty-two and 52 GPs participated, respectively, in the pre- and post-survey. In the post-phase the percentage of GPs declaring the discharge letter facilitated the communication on the admission causes (χ2(1) = 0.56, P = 0.03) and on what to do if conditions change (χ2(31) = 19.0, P Two-hundred-eighty and 282 patients were enrolled in the pre- and post-survey. The level of understanding of key parts of the discharge letter (reason for hospitalization, post-discharge therapy, follow-up examinations and how to contact the hospital ward) improved significantly (P Conclusions CaRED significantly improved the discharge process and became a benchmark for local improvements in communication patterns with GPs.

OBJECTIVES To assess the independent effect of delirium on mortality and disability after 1 year of follow-up, in consecutive older patients with hip fracture hospitalized for surgical repair. DESIGN This is a prospective observational study. SETTING AND PARTICIPANTS Patients aged older than 65 years consecutively admitted for hip fracture to the Trauma and Orthopedics Centre of a third-level hospital, between March and October 2014. METHODS Patients were evaluated by a multidisciplinary team. A comprehensive geriatric assessment was performed on admission. Delirium was assessed before and after surgical repair according to the Confusion Assessment Method. Mortality and disability status were collected at 3 months and 1 year after hospital discharge. RESULTS Of 411 patients with hip fracture, 387 (mean age 82 years, female 72%) were enrolled. Delirium was assessed in 50% of the enrolled population. Patients with delirium were older, frequently affected by dementia, severe prefracture disability, history of falls, and polypharmacy. One-year mortality was 19% in all populations, and higher in patients with delirium, although delirium did not show an independent association with mortality, in multivariable analysis. Conversely, delirium was identified as an independent prognostic factor of long-term disability (B-1.606, ES 0.211, P < .001). CONCLUSION AND IMPLICATIONS This study identifies delirium as an independent long-term disability generator, regardless of associated clinical conditions and premorbid cognitive and functional status. This emphasises the importance of delirium prevention through a multidisciplinary approach and the potential role of systematic treatment of risk factors in reducing functional decline, even in subjects with preexistent disability and dementia. Moreover, these data call for research on rehabilitation interventions specifically targeted to these complex patients, with the aim of identifying approaches effective in reducing long-term disability. Conversely, a high level of clinical alertness is required in patients with delirium, as an appropriate treatment of acute diseases should reduce their high mortality risk.

Challenging times

Tip-enhanced Raman spectroscopy (TERS) is capable of amplifying the extremely weak Raman response of azobenzene self-assembled monolayers (SAMs), thus allowing for the chemical characterization of ...

The knowledge of the water vapor (WV) distribu- tion in the Earth's atmosphere is of great importance for weather prediction. Meteorological models, in particular, the so-called limited area models, can assimilate humidity measurements, increasing the reliability of the simulated atmospheric dynamics. An important improvement can be achieved, for instance, if we are able to provide the total column with a sufficient precision and accuracy. In this paper, the novel normalized differential spectral attenuation (NDSA) approach is applied to retrieve the vertical profile of WV--and thus the total column--from measurements of differential attenuation signals at microwaves. A forward model (FM) has been used to simulate the ray- tracing of a microwave signal from a transmitter to a receiver in the atmosphere by using the 3-D atmospheric parameters as provided by a numerical weather prediction (NWP) model. From the NDSA measurement, the integrated WV (IWV) content can be directly derived. A further retrieval code is able to invert the measurements of IWV along the path length, providing the vertical humidity profile, which is directly related to the total vertical column assimilated by weather prediction models. In this paper, we show that the values of the total column can be retrieved with a precision and accuracy up to about 0.6% and 2.1%, respectively, which could have a positive impact on NWP models at short time scale.

Background Procalcitonin (PCT)-guided antibiotic stewardship (ABS) has been shown to reduce antibiotics (ABxs), with lower side-effects and an improvement in clinical outcomes. The aim of this experts workshop was to derive a PCT algorithm ABS for easier implementation into clinical routine across different clinical settings. Methods Clinical evidence and practical experience with PCT-guided ABS was analyzed and discussed, with a focus on optimal PCT use in the clinical context and increased adherence to PCT protocols. Using a Delphi process, the experts group reached consensus on different PCT algorithms based on clinical severity of the patient and probability of bacterial infection. Results The group agreed that there is strong evidence that PCT-guided ABS supports individual decisions on initiation and duration of ABx treatment in patients with acute respiratory infections and sepsis from any source, thereby reducing overall ABx exposure and associated side effects, and improving clinical outcomes. To simplify practical application, the expert group refined the established PCT algorithms by incorporating severity of illness and probability of bacterial infection and reducing the fixed cut-offs to only one for mild to moderate and one for severe disease (0.25 μg/L and 0.5 μg/L, respectively). Further, guidance on interpretation of PCT results to initiate, withhold or discontinue ABx treatment was included. Conclusions A combination of clinical patient assessment with PCT levels in well-defined ABS algorithms, in context with continuous education and regular feedback to all ABS stakeholders, has the potential to improve the diagnostic and therapeutic management of patients suspected of bacterial infection, thereby improving ABS effectiveness.

Background and Aims Advance care planning (ACP) enables competent patients to define goals and preferences for future treatments and care, to discuss these goals and preferences with relatives, and if appropriate to record these preferences. After many years of political and social debates, in December 2017 the first advance directive and care planning legislation was approved in Italy. Nevertheless, citizens’ awareness of these issues is scarce as well as the integration of the advance care planning process into clinical routine. The latest data reported to the Italian Parliament by the Ministry of Health indicated that advance directives have been completed by 62030 people, approximately 1.1% of Italian adult population. However, during the last months, the COVID-19 pandemic solicited taking steps towards promoting an advance care planning culture. Indeed, the need of proposing ACP to patients have been recently stressed both by medical associations and national and local institutional documents. Method Since November 2020, our nephrology unit adopted a protocol approved by Ethical committee by Physician Order of Florence, aimed to conduct ACP interventions with dialysis patients. Firstly, all patients were informed about the possibility to taking part in one or more advance care planning conversations with their nephrologist. Secondly, a semi-structured guide to the conversation was created in order to support physicians in conducting the ACP intervention. Finally, patients along with nephrologist and their relatives, could documented their preferences for future treatments and care. Results From November to March only one patient asked to receive an ACP intervention. However, since COVID-19 spread in Italy last March, the number of patients who demanded ACP raised up. In the period from April to July, 15 out of 110 hemodialysis patients treated in our center asked for an ACP intervention and filled-in an advance directive. Specifically, no patients required an immediate discontinuation of dialysis, nevertheless 80% of them stated that would not like to continue with dialysis in case he/she was no longer able to self-determine (e.g. permanent loss of capacity to communicate with others). All patients except one have appointed a personal representative (usually their partner). In the eventuality of cardiac arrest, 60% of patients asked for cardiopulmonary resuscitation. Finally, all patients expressed the wish to spend the last days of life at home. Conclusion The COVID-19 pandemic raised up the number of dialysis patients who required to taking part in a advance care planning intervention. In this sense, the pandemic can be an opportunity for consolidate advance care planning in Italy as well as in other countries, where these interventions are not well known by people and not yet regularly offered in the clinical routine. Using a semi-structured interview for the ACP interview can help the nephrologist to discuss future care and end-of-life topics with their patients.

In this paper we present and discuss the first series of results obtained during a propagation measurement campaign carried out at the French–Italian Concordia research station during last (2019/2020) summer campaign in Antarctica. Specific instrumentation has been designed and assembled, essentially consisting of a transmitting unit and a receiving one, to be let down into two boreholes in the firn. Preliminary measurement results are presented and discussed.

The first step of the intracellular phase of retroviral infection is the release of the viral capsid core in the cytoplasm. This structure contains the viral genetic material that will be reverse transcribed and integrated into the genome of infected cells. Up to recent times, the role of the capsid core was considered essentially to protect this genetic material during the earlier phases of this process. However, increasing evidence demonstrates that the permanence inside the cell of the capsid as an intact, or almost intact, structure is longer than thought. This suggests its involvement in more aspects of the infectious cycle than previously foreseen, particularly in the steps of viral genomic material translocation into the nucleus and in the phases preceding integration. During the trip across the infected cell, many host factors are brought to interact with the capsid, some possessing antiviral properties, others, serving as viral cofactors. All these interactions rely on the properties of the unique component of the capsid core, the capsid protein CA. Likely, the drawback of ensuring these multiple functions is the extreme genetic fragility that has been shown to characterize this protein. Here, we recapitulate the busy agenda of an HIV-1 capsid in the infectious process, in particular in the light of the most recent findings.

This document constitutes the first Progress Report of the CryoRad-FO project, and is the project deliverable number 04.2, as required by the Technical Management Annex of the Contract between ASI and the National Research Council. The purpose of the document is to report the progress of the project in the 3 months of activity 23/06/2021 - 23/09/2021. The activities carried out, the critical issues addressed, the measures taken to mitigate them are described and the activities to be undertaken in the following quarter are indicated.

Background: Home Parenteral Nutrition (HPN) is a lifesaving clinical care process. However, undetected hazards and vulnerabilities in care transitions from hospital to community care may pose risk to patient’s safety. Avoidable complications and adverse events may hinder the benefits of treatment. Objective: The analysis carried out aims at framing through Human Factors and Ergonomics (HF/E) the critical issues for patient safety related to clinical care practices for HPN in healthcare organization. Methods: We present the results of a proactive risk assessment analysis based on the FMEA methodology (Failure Mode and Effects Analysis) carried out in three different areas of the regional health care system of Tuscany, Italy. The clinical risk management and patient safety unit assessed the risk perception of Healthcare Workers (HWs) in regard to patient safety and situational awareness throughout the HPN patient journey. Results: The analysis revealed heterogeneity in the Risk Priority Index (RPI) expressed by HWs. A lower RPI is associated with a HPN process that deploys in continuity between hospital care and community care. A higher RPI is associated with a quality and safety improvement process that is still ongoing. We also observed HWs expressing low RPI in the areas of the region where HPN has a hospital- focused approach and has limited adherence to patient safety requirements. Low RPI for HPN process may relate both to extensively deployed continuity of care and to jeopardized awareness on HPN phases and coordination. The analysis carried out enabled the definition of a common HPN workflow used as reference schema allowing for the definition of a set of recommendations for improving the quality and safety of the care processes. Moreover, the outcome of the proactive risk assessment laid the groundwork for the advancement of the patient safety regional requirements. Conclusion: The analysis had the role of promoting the contextualization of the culture of quality and safety within the HPN process resulting in an improved awareness of the criticalities and the role of nutrition units throughout the care process.

Measurement of water vapor (WV) in the lower troposphere on a continuous temporal basis would improve our knowledge of the atmospheric dynamics and the performance of numerical weather prediction models. In recent studies, a new measurement concept, the normalized differential spectral attenuation (NDSA) approach, was proposed. It is based on measurements of differential attenuation at 18.8 and 19.2 GHz performed along a tropospheric radio link. While NDSA measurement at a fixed elevation angle provides information on integrated WV (IWV), measurements at different elevation angles allow to retrieve the vertical WV content profile. A prototype NDSA demonstrator, which consists of two units, a synthesized transmitter and a software-defined radio receiver, has been designed and implemented. The system was accurately characterized through several laboratory tests, and then a first experimental campaign was conducted at fixed elevation angle along a ground-to-ground radio link. Obtained results confirm the sensitivity of the NDSA measurements to the IWV along such link with a good agreement with the existing ground-based and satellite data products.

This paper describes a distributed system for workers' safety enhancement, designed for operation in large working site and based on the LoRa network technology. The proposed system consists of a two-level network architecture. The first level consists of Body Area Networks (BAN) and Wireless Body Area Networks (WBAN) embedding specific and different wearable sensors and smart wearable devices which can gather signals related to the individual worker conditions. The information gathered by the sensors is managed and processed locally through devices belonging to the local body network itself (concentrators), in order to extract synthetic parameters. These latter are combined with information related to environmental monitoring such as presence of toxic gases and temperature, the fused information is finally transmitted with low rates through the LoRa network.

Objectives Thirteen suspicious deaths occurred in an intensive care unit of Tuscany, Italy, in 2015. All patients developed sudden unexplained coagulopathy leading to severe bleeding. None of them had been prescribed heparin, but supertherapeutic concentrations of heparin were found. After a nurse was arrested on suspicion of murdering Human Factor and Ergonomics (HF/E) experts received a mandate to identify system failures. According to the judgment of the Court of First Instance on April 2019, the nurse was found guilty (of first degree murder? Manslaughter?) METHODS: The HF/E group used a two-pronged safety analysis: understanding the conditions in which the healthcare practitioners were working in the period when the suspicious deaths emerged and reviewing the clinical records. Results Fourteen patients admitted to the intensive care unit in 2014 and 2015 were selected on the basis of markedly abnormal coagulation tests (n = 13) or a family member's complaint (n = 1). In 13 cases, a massive, abrupt hemorrhage in the presence of an unexpected abnormality of coagulation tests occurred, whereas the fourteenth patient had the only prolongation of coagulation markers without bleeding. All cases examined classified as adverse events related to a coagulation disorder. Human factor and ergonomics analysis identified a number of latent and active failures that contributed to the event and provided a set of important recommendations for safety improvement. Conclusions When presented with a manifest, albeit suspected, wrongdoing with lethal consequences for patients, forensic investigators and safety investigators have distinctly different goals and methods. We believe that a memorandum of understanding between HF/E and forensic investigative teams provides an operative framework for allowing co-existence and fosters collaboration. The pursuit of safe care as a new emerging right for patients and balancing the right to legal justice with the right to safer healthcare merit further investigation and discussion.

Healthcare-associated infections (HAI) are adverse events exposing patients to a potentially avoidable risk of morbidity and mortality. Antimicrobial resistance (AMR) is increasingly contributing to the burden of HAIs and emerging as of the most alarming challenges for public health worldwide. Practically, harm mitigation and risk containment demand cross-sectional initiatives incorporate both approaches to infection prevention and control and methodologies from clinical risk management.

Erwinia amylovora, a Gram-negative plant pathogen, is the causal agent of Fire Blight, a contagious necrotic disease affecting plants belonging to the Rosaceae family, including apple and pear. E. amylovora is highly virulent and capable of rapid dissemination in orchards; effective control methods are still lacking. One of its most important pathogenicity factors is the exopolysaccharide amylovoran. Amylovoran is a branched polymer made by the repetition of units mainly composed of galactose, with some residues of glucose, glucuronic acid and pyruvate. E. amylovora glucose-1-phosphate uridylyltransferase (UDP-glucose pyrophosphorylase, EC 2.7.7.9) has a key role in amylovoran biosynthesis. This enzyme catalyses the production of UDP-glucose from glucose-1-phosphate and UTP, which the epimerase GalE converts into UDP-galactose, the main building block of amylovoran. We determined EaGalU kinetic parameters and substrate specificity with a range of sugar 1-phosphates. At time point 120min the enzyme catalysed conversion of the sugar 1-phosphate into the corresponding UDP-sugar reached 74% for N-acetyl-α-d-glucosamine 1-phosphate, 28% for α-d-galactose 1-phosphate, 0% for α-d-galactosamine 1-phosphate, 100% for α-d-xylose 1-phosphate, 100% for α-d-glucosamine 1-phosphate, 70% for α-d-mannose 1-phosphate, and 0% for α-d-galacturonic acid 1-phosphate. To explain our results we obtained the crystal structure of EaGalU and augmented our study by docking the different sugar 1-phosphates into EaGalU active site, providing both reliable models for substrate binding and enzyme specificity, and a rationale that explains the different activity of EaGalU on the sugar 1-phosphates used. These data demonstrate EaGalU potential as a biocatalyst for biotechnological purposes, as an alternative to the enzyme from Escherichia coli, besides playing an important role in E. amylovora pathogenicity.

Background: In the period 2013-2018 an important European study (ACTION) involving six countries, financed according to the 7° European framework, has been performed. The ACTION study dealt with the issue of advance care planning (ACP) in oncology and searched for evidence of its impact on patient and family.