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Abstract Background Per- and polyfluoroalkyl substances (PFAS) are associated with many adverse health conditions. Among the main effects is carcinogenicity in humans, which deserves to be further clarified. An evident association has been reported for kidney cancer and testicular cancer. In 2013, a large episode of surface, ground and drinking water contamination with PFAS was uncovered in three provinces of the Veneto Region (northern Italy) involving 30 municipalities and a population of about 150,000. We report on the temporal evolution of all-cause mortality and selected cause-specific mortality by calendar period and birth cohort in the local population between 1980 and 2018. Methods The Italian National Institute of Health pre-processed and made available anonymous data from the Italian National Institute of Statistics death certificate archives for residents of the provinces of Vicenza, Padua and Verona (males, n = 29,629; females, n = 29,518) who died between 1980 and 2018. Calendar period analysis was done by calculating standardised mortality ratios using the total population of the three provinces in the same calendar period as reference. The birth cohort analysis was performed using 20–84 years cumulative standardised mortality ratios. Exposure was defined as being resident in one of the 30 municipalities of the Red area, where the aqueduct supplying drinking water was fed by the contaminated groundwater. Results During the 34 years between 1985 (assumed as beginning date of water contamination) and 2018 (last year of availability of cause-specific mortality data), in the resident population of the Red area we observed 51,621 deaths vs. 47,731 expected (age- and sex-SMR: 108; 90% CI: 107–109). We found evidence of raised mortality from cardiovascular disease (in particular, heart diseases and ischemic heart disease) and malignant neoplastic diseases, including kidney cancer and testicular cancer. Conclusions For the first time, an association of PFAS exposure with mortality from cardiovascular disease was formally demonstrated. The evidence regarding kidney cancer and testicular cancer is consistent with previously reported data.

Abstract Objective To discuss the results of the KETASER01 trial and the reasons for its failure, particularly in view of future studies. Methods KETASER01 is a multicenter, randomized, controlled, open‐label, sequentially designed, non‐profit Italian study that aimed to assess the efficacy of ketamine compared with conventional anesthetics in the treatment of refractory convulsive status epilepticus (RCSE) in children. Results During the 5‐year recruitment phase, a total of 76 RCSEs treated with third‐line therapy were observed in five of the 10 participating Centers; only 10 individuals (five for each study arm; five females, mean age 6.5 ± 6.3 years) were enrolled in the KETASER01 study. Two of the five patients (40%) in the experimental arm were successfully treated with ketamine and two of the five (40%) children in the control arm, where successfully treated with thiopental. In the remaining six (60%) enrolled patients, RCSE was not controlled by the randomized anesthetic(s). Significance The KETASER01 study was prematurely halted due to low eligibility of patients and no successful recruitment. No conclusions can be drawn regarding the objectives of the study. Here, we discuss the KETASER01 results and critically analyze the reasons for its failure in view of future trials.

Scientists and practitioners implementing citizen science projects, in which the involvement of citizens is key, often need ideas and tools that help in reaching citizens, engaging them in the project and maximizing their contributions. In this paper, we describe the creation of an open toolkit, a web-based portal citizensciencetoolkit.eu1 designed in the framework of the CitieS-Health project for the development and promotion of citizen science (CS) projects. The main focus is on projects linking urban environmental exposures and health, but it has applicability to other settings. The toolkit comprises the steps and phases during the implementation of CS activities in environmental epidemiology. A total of 28 tools are currently included, of which most were co-designed and tested within CitiesS-Health, as well as some resulting from external projects. For each tool, in addition to the details of its purpose and the specific challenges it poses, downloadable support content is available. To help facilitate inspiration and the adoption of tools provided, an illustrative step-by-step demonstration and description of its use in a CS project in a real-life setting is included, focusing on recommendations derived from the user experience. The portal is designed as a live inventory of tools, enabling interested CS practitioners not only to replicate, but also to continuously update and enrich it is content. To this end, the long-term objective of the portal is to act as a hub of resources that would enable the active inclusion of citizens in all the phases of the participatory research projects.

Introduction: Mechanisms underlying cardiac arrhythmias are typically driven by abnormalities in cardiac conduction and/or heterogeneities in repolarization time (RT) across the heart. While conduction slowing can be caused by either electrophysiological defects or physical blockade in cardiac tissue, RT heterogeneities are mainly related to action potential (AP) prolongation or abbreviation in specific areas of the heart. Importantly, the size of the area with altered RT and the difference between the short RT and long RT (RT gradient) have been identified as critical determinators of arrhythmogenicity. However, current experimental methods for manipulating RT gradient rely on the use of ion channel inhibitors, which lack spatial and temporal specificity and are commonly only partially reversible. Therefore, the conditions facilitating sustained arrhythmia upon the presence of RT heterogeneities and/or defects in cardiac conduction remain to be elucidated.Methods: We here employ an approach based on optogenetic stimulation in a low-intensity fashion (sub-threshold illumination), to selectively manipulate cardiac electrical activity in defined areas of the heart.Results: As previously described, subthreshold illumination is a robust tool able to prolong action potentials (AP), decrease upstroke velocity as well as slow cardiac conduction, in a fully reversible manner. By applying a patterned sub-threshold illumination in intact mouse hearts constitutively expressing the light-gated ion channel channelrhodopsin-2 (ChR2), we optically manipulate RT gradients and cardiac conduction across the heart in a spatially selective manner. Moreover, in a proof-of-concept assessment we found that in the presence of patterned sub-threshold illumination, mouse hearts were more susceptible to arrhythmias. Hence, this optogenetic-based approach may be able to mimic conduction slowing and RT heterogeneities present in pathophysiological conditions.

Abstract Objectives Hydroxychloroquine has shown to have antiviral activity in vitro against coronaviruses, specifically SARS-CoV-2. It is believed to block virus infection by increasing endosomal pH required for virus cell fusion and glycosylation of viral surface proteins. In addition to its antiviral activity, hydroxychloroquine has an immune-modulating activity that may synergistically enhance its antiviral effect in vivo, making it a potentially promising drug for the prevention and the cure of SARS-CoV-19. However, randomized controlled trials are needed to assess whether it can be used safely to treat COVID-19 patients or to prevent infection. The main objective of the present study is to evaluate the efficacy of hydroxychloroquine for (I) the prevention of COVID-19 or related symptoms in SARS-CoV-2-exposed subjects, such as as household members/contacts of COVID-19 patients and (II) the treatment of early-phase asymptomatic or paucisymptomatic COVID-19 patients. Trial design This is a controlled, open label, cluster-randomized, superiority trial with parallel group design. Subjects will be randomized either to receive hydroxychloroquine or to observation (2:1). Participants SARS-CoV-2-exposed subjects, including household members and/or contacts of COVID-19 patients and healthcare professionals (Group 1) or patients with COVID-19 (positive PCR test on a rhinopharyngeal or oropharyngeal swab for SARS-CoV-2), asymptomatic or paucisymptomatic in home situations who are not undergoing treatment with any anti COVID-19 medication (Group 2), will be enrolled. Paucisymptomatic patients are defined as patients with a low number of mild symptoms. All subjects must be aged ≥18 years, male or female, must be willing and able to give informed consent and must not have any contraindications to take hydroxychloroquine (intolerance or previous toxicity for hydroxychloroquine/chloroquine, bradycardia or reduction in heart rhythm with arrhythmia, ischemic heart disease, retinopathy, congestive heart failure with use of diuretics, favism or glucose-6-phosphate dehydrogenase (G6PD) deficiency, diabetes type 1, major comorbidities such as advanced chronic kidney disease or dialysis therapy, known history of ventricular arrhythmia, any oncologic/hematologic malignancy, severe neurological and mental illness, current use of medications with known significant drug-drug interactions, and known prolonged QT syndrome or current use of drugs with known QT prolongation). The study is monocentric and will be conducted at Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS. Subjects will be enrolled from a large epidemic region (North-Central Italy). The Public Health Departments of several Italian regions will collaborate by identifying potentially eligible subjects. Intervention and comparator The participants will be randomized (2:1 randomization) to receive either hydroxychloroquine (Arm A) or to Observation (Arm B). Hydroxychloroquine will be administered with the following schedule: Group1: A loading dose hydroxychloroquine 400 mg twice daily on day 1, followed by a weekly dose of hydroxychloroquine 200 mg twice daily on days 8, 15 and 22, for a total of one month of treatment. Group 2: A loading dose hydroxychloroquine 400 mg twice daily on day 1 followed by 200 mg twice daily for a total of 5-7 days. The comparator in this trial is observation given that currently neither treatment is administered to asymptomatic or paucisymptomatic subjects, nor prophylaxis is available for contacts. Hydroxychloroquine will be shipped to subjects within 24 hours of randomization. Given the extraordinary nature of the COVID-19 pandemic, only telephonic interviews will be carried out and electronic Patient Reported Outcomes (ePRO) completed. During treatment, each subject will be contacted every other day for the first week and weekly thereafter (Group 2) or weekly (Group 1) by a study physician to assess early onset of any COVID-19 symptom or any adverse reaction to hydroxychloroquine and to check subject compliance. Furthermore, all subjects will receive periodic ePROs which may be completed through smartphone or tablets to record drug self-administration and onset of any symptom or adverse event. All subjects will be followed up for a total of 6 months by periodic telephonic interviews and ePROs. Main outcomes The primary endpoint/outcome measure for this trial is: for Group 1, the proportion of subjects who become symptomatic and/or swab-positive in each arm within one month of randomization; for Group 2, the proportion of subjects who become swab-negative in each arm within 14 days of randomization. Randomization All household members and/or contacts of each COVID-19 index case, and the COVID-19 patient himself/herself, fulfilling all inclusion criteria will be grouped into a single cluster and this cluster will be randomized (2:1) to either arm A or arm B. Information on each subject will be recorded in specific data records. Randomization lists will be stratified according to the following factors regarding COVID-19 index cases: 1. COVID-19 risk level on the basis of province of residence (high vs. low/intermediate); 2. Index case is a healthcare professional (yes vs.no) 3. Index case with COVID-19 treatment (yes vs. no) An independent statistician not otherwise involved in the trial will generate the allocation sequence, and COVID-19 response teams will be unaware of the allocation of clusters. Randomization will be performed through an interactive web-based electronic data-capturing database. An Independent Data Monitoring Committee has been established. Blinding (masking) This study is open label. Numbers to be randomized (sample size) For Group 1, a sample size of about 2000 SARS-CoV-2-exposed subjects such as household members and/or contacts of COVID-19 patients will take part in the study. Assuming around 1.5-2.0 asymptomatic household members and/or contacts for each COVID-19 patient, we expect to identify approximately 1000-1300 COVID-19 index cases to be randomized. An interim analysis on efficacy is planned using standard alpha-spending function. For Group 2, sufficient power for primary objective (negative swab within 14 days of randomization) will be reached given a sample size of 300 asymptomatic or paucisymptomatic COVID-19 subjects in home situations not treated for COVID-19 (25%-30% of about 1000-1300 expected index cases). Since up to date reduced evidence about COVID-19 infection epidemiology, the continuous update of diagnostic and therapeutic approaches, the sample size estimation could be updated after a one third of population will be recruited and eventually modified according to a substantial protocol amendment. An interim analysis at 100 enrolled COVID-19 patients is planned. We have planned a Generalized Estimating Equation analysis, which is more efficient than a cluster level analysis, to take advantage of subject-specific covariates. The above reported sample size analysis is therefore to be considered conservative. Trial Status The current version of the PROTECT trial protocol is ‘Final version, 15 April 2020’. The study started on 9th May 2020. The first patient was enrolled on 14th May 2020. Recruitment is expected to last through September 2020. Trial registration The PROTECT trial is registered in the EudraCT database (no. 2020-001501-24) and in ClinicalTrials.gov ( NCT04363827 ), date of registration 24 April 2020. Full protocol The full PROTECT protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interests of expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol (Protocol final version, 15th April 2020). The study protocol has been reported in accordance with Standard Protocol Items: Recommendations for Clinical Interventional Trials (SPIRIT) guidelines (Additional file 2).

Several citizen science (CS) initiatives have been adopted in environmental science to monitor air and noise pollution, and water quality related to civic concerns. Nevertheless, CS projects in environmental epidemiology remain scarce. This is because little attention has been paid to evaluate associations of environmental exposures with health effects directly. This narrative review aims to promote the understanding and application of CS in environmental epidemiology. There are many commonalities between CS and other participatory approaches in environmental epidemiology. Yet, CS can foster the democratization of scientific governance and enhance the sustainability of research projects more effectively than other existing participatory approaches. This is especially the case in projects where citizens are invited to participate, engage and become involved throughout all the phases of a research project (co-created projects). This paper identifies various challenges and opportunities specific to the implementation of co-created CS projects in environmental epidemiology. The development of more locally relevant research designs, using local knowledge, obtaining medical ethical clearance, and co-analysing the association between exposure and health, are examples of opportunities and challenges that require epidemiologists to go beyond the traditional research framework and include more outreach activities. Continued efforts, particularly the sharing of information about projects' collaborative processes, are needed to make CS a more concrete and cohesive approach in environmental epidemiology.

Abstract Background When communicating risks to the general population, the format of the epidemiological results may affect individual reactions. In environmental epidemiology, no study has compared the use of different statistical formats in communicating results to the population. The aim of this paper is to investigate whether the degree of concern expressed by residents of a high environmental risk site, regarding epidemiological results on cancer mortality in the area where they live, is influenced by the statistical indicator used in communication. Methods A sample of residents in the high environmental risk area of Livorno (Italy) was randomized to respond to different questionnaires, in which the same epidemiological results were expressed by two alternative risk indexes: percent excess risk and time needed to harm, defined as the number of days that one has to wait for, on average, to observe 1 death in excess in respect to the baseline. Participants were asked to express their concern on a quantitative scale or to rank different diseases according to their impressions. The statistical analysis was performed using an Inverse Probability of Treatment Weighting approach based on propensity score, in order to account for sample stratification and adjust for unbalance between groups occurring despite randomization. Results The probability of high concern levels was larger under time needed to harm than under percent excess, with a difference between proportions of 6.7% (95% Confidence Interval, 0.6,12.8%). Mortality from sexual glands cancer was ranked as more worrisome and mortality from thyroid gland cancer as less worrisome under time needed to harm than under percent excess. No rank change was found for lung cancer. Larger differences between the two indicators arose in subjects with higher education or better numerical skills. Conclusions Communicating epidemiological results to the population is not a neutral task. The degree of concern and judgments when comparing results on different diseases may depend on the risk indicators used. Translating scientific results into lay language should not exempt from careful evaluation of the impact of this translation on lay people.

Background: Cancer trials involving multiple treatment lines substantially increase our understanding of therapeutic strategies. However, even when the primary end-point of these studies is progression-free survival (PFS), their statistical analysis usually focuses on each line separately, or does not consider repeated events, thus missing potentially relevant information. Consequently, the evaluation of the effectiveness of treatment strategies is highly impaired. Methods: We evaluated the potentially different effect of bevacizumab (B) administered for the first- or second-line treatment of metastatic colorectal cancer (mCRC) in the ITACa (Italian Trial in Advanced Colorectal Cancer) randomized trial. The ITACa trial consisted of two arms: first-line chemotherapy (CT)+B followed by second-line CT alone versus first-line CT alone followed by second-line CT+B or CT+B+cetuximab according to KRAS status. Cox models for repeated disease progression were performed, and potential selection bias was adjusted using the inverse probability of censoring weighting method. Hazard ratios (HR) [95% confidence interval (CI)] for PFS (primary endpoint) were reported. Results: The overall effect of B across the two lines resulted in a HR = 0.80 (95% CI 0.68–0.95, p = 0.008). Evaluating the differential effect of B in first- and second-line, the addition of B to first-line chemotherapy (CT) produced a 10% risk reduction (HR = 0.90, 95% CI 0.72–1.12, p = 0.340) versus CT alone; B added to second-line CT produced a 36% risk reduction (HR = 0.64, 95% CI 0.49–0.84, p = 0.0011) versus CT alone. Conclusion: Our results seem to suggest that B confers a PFS advantage when administered in combination with second-line chemotherapy, which could help to improve current international guidelines on optimal sequential treatment strategies.

OBJECTIVES: This study aimed to (i) describe mesothelioma incidence in the Italian national priority contaminated sites (NPCS) on the basis of data available from the Italian National Mesothelioma Registry (ReNaM) and (ii) profile NPCS using Bayesian rank analysis. METHODS: Incident cases of mesothelioma and standardized incidence ratios (SIR) were estimated for both genders in each of the 39 selected NPCS in the period 2000–2011. Age-standardized rates of Italian geographical macro areas were used to estimate expected cases. Rankings of areas were produced by a hierarchical Bayesian model. Asbestos exposure modalities were discussed for each site. RESULTS: In the study period, 2683 incident cases of mesothelioma (1998 men, 685 women) were recorded. An excess of mesothelioma incidence was confirmed in sites with a known past history of direct use of asbestos (among men) such as Balangero (SIR 197.1, 95% CI 82.0–473.6), Casale Monferrato (SIR 910.7, 95% CI 816.5–1012.8), and Broni (SIR 1288.5, 95% CI 981.9–1691.0), in sites with shipyards and harbors (eg, Trieste, La Spezia, Venice, and Leghorn), and in settings without documented direct use of asbestos. The analysis ranked the sites of Broni and Casale Monferrato (both genders) and Biancavilla (only for women) the highest. CONCLUSIONS: The present study confirms that asbestos pollution is a risk for people living in polluted areas, due to not only occupational exposure in industrial settings with direct use of asbestos but also the presence of asbestos in the environment. Epidemiological surveillance of asbestos-related diseases is a fundamental tool for monitoring the health profile in NPCS.

BackgroundFew studies, based on a limited number of patients using non-uniform therapeutic protocols, have analyzed Methicillin-resistant Staphylococcus aureus (MRSA) eradication.MethodsIn a randomized multicenter trial conducted on patients with new-onset MRSA infection we evaluated the efficacy of an early eradication treatment (arm A) compared with an observational group (B). Arm A received oral rifampicin and trimethoprim/sulfamethoxazole (21 days). Patients' microbiological status, FEV1, BMI, pulmonary exacerbations and use of antibiotics were assessed.ResultsSixty-one patients were randomized. Twenty-nine (47.5%) patients were assigned to active arm A and 32 (52.5%) patients to observational arm B. Twenty-nine (47.5%) patients, 10 patients in arm A and 19 in arm B, dropped out of the study. At 6 months MRSA was eradicated in 12 (63.2%) out of 19 patients in arm A while spontaneous clearance was observed in 5 (38.5%) out of 13 patients in arm B. A per-protocol analysis showed a 24.7% difference in the proportion of MRSA clearance between the two groups (z = 1.37, P(Z>z) = 0.08). Twenty-seven patients, 15 (78.9%) out of 19 in arm A and 12 (92.3%) out of 13 in arm B, were able to perform spirometry. The mean (±SD) FEV1 change from baseline was 7.13% (±14.92) in arm A and -1.16% (±5.25) in arm B (p = 0.08). In the same period the BMI change (mean ±SD) from baseline was 0.54 (±1.33) kg/m2 in arm A and -0.38 (±1.56) kg/m2 in arm B (p = 0.08). At 6 months no statistically significant differences regarding the number of pulmonary exacerbations, days spent in hospital and use of antibiotics were observed between the two arms.ConclusionsAlthough the statistical power of the study is limited, we found a 24.7% higher clearance of MRSA in the active arm than in the observational arm at 6 months. Patients in the active arm A also had favorable FEV1 and BMI tendencies.

Abstract Background Randomization procedure in randomized controlled trials (RCTs) permits an unbiased estimation of causal effects. However, in clinical practice, differential compliance between arms may cause a strong violation of randomization balance and biased treatment effect among those who comply. We evaluated the effect of the consolidation phase on disease-free survival of patients with multiple myeloma in an RCT designed for another purpose, adjusting for potential selection bias due to different compliance to previous treatment phases. Methods We computed two propensity scores (PS) to model two different selection processes: the first to undergo autologous stem cell transplantation, the second to begin consolidation therapy. Combined stabilized inverse probability treatment weights were then introduced in the Cox model to estimate the causal effect of consolidation therapy miming an ad hoc RCT protocol. Results We found that the effect of consolidation therapy was restricted to the first 18 months of the phase (HR: 0.40, robust 95 % CI: 0.17-0.96), after which it disappeared. Conclusions PS-based methods could be a complementary approach within an RCT context to evaluate the effect of the last phase of a complex therapeutic strategy, adjusting for potential selection bias caused by different compliance to the previous phases of the therapeutic scheme, in order to simulate an ad hoc randomization procedure. Trial registration ClinicalTrials.gov: NCT01134484 May 28, 2010 (retrospectively registered) EudraCT: 2005-003723-39 December 17, 2008 (retrospectively registered)

The outcome of stroke patients is complex and multidimensional. We evaluated the impact of acute-phase variables, including clinical state, complications, resource use and interventions, on 6-month survival after first-ever stroke, taking into account baseline conditions exerting a possible effect on outcome. As part of a National Research Program, we performed a prospective observational study of acute stroke patients in four Italian Regions. Consecutive patients admitted for a period of 3 months to the emergency rooms of participating hospitals were included. A total of 1030 patients were enrolled (median age 76.0 years, 52.1% males). At 6 months, 816 (79.2%) were alive, and 164 (15.9%) deceased. Survival status at the 6-month follow-up was missing for 50 (4.9%). Neurological state in the acute phase was significantly worse in patients deceased at 6 months, who showed also higher frequency of acute-phase complications. Cox regression analysis adjusted for demographics, pre-stroke function, baseline diseases and risk factors, indicated as significant predictors of 6-month death altered consciousness (HR, 1.70; 95% CI, 1.14-2.53), total anterior circulation infarct (HR, 2.13; 95% CI, 1.44-3.15), hyperthermia (HR, 1.70; 95% CI, 1.18-2.45), pneumonia (HR, 1.76; 95% CI, 1.18-2.61), heart failure (HR, 2.87; 95% CI, 1.34-6.13) and nasogastric feeding (HR, 2.35; 95% CI, 1.53-3.60), while antiplatelet therapy during acute phase (HR, 0.56; 95% CI, 0.39-0.79), and early mobilisation (HR, 0.55; 95% CI, 0.36-0.84) significantly increased 6-month survival. In a prospective observational study, stroke severity and some acute-phase complications, potentially modifiable, significantly increased the risk of 6-month death, independently of baseline variables. Early mobilisation positively affected survival, highlighting the role of early rehabilitation after stroke.

A harmonized sampling approach in combination with spatial modelling is required to update current knowledge of fasciolosis in dairy cattle in Europe. Within the scope of the EU project GLOWORM, samples from 3,359 randomly selected farms in 849 municipalities in Belgium, Germany, Ireland, Poland and Sweden were collected and their infection status assessed using an indirect bulk tank milk (BTM) enzyme-linked immunosorbent assay (ELISA). Dairy farms were considered exposed when the optical density ratio (ODR) exceeded the 0.3 cut-off. Two ensemble-modelling techniques, Random Forests (RF) and Boosted Regression Trees (BRT), were used to obtain the spatial distribution of the probability of exposure to Fasciola hepatica using remotely sensed environmental variables (1-km spatial resolution) and interpolated values from meteorological stations as predictors. The median ODRs amounted to 0.31, 0.12, 0.54, 0.25 and 0.44 for Belgium, Germany, Ireland, Poland and southern Sweden, respectively. Using the 0.3 threshold, 571 municipalities were categorized as positive and 429 as negative. RF was seen as capable of predicting the spatial distribution of exposure with an area under the receiver operation characteristic (ROC) curve (AUC) of 0.83 (0.96 for BRT). Both models identified rainfall and temperature as the most important factors for probability of exposure. Areas of high and low exposure were identified by both models, with BRT better at discriminating between low-probability and high-probability exposure; this model may therefore be more useful in practise. Given a harmonized sampling strategy, it should be possible to generate robust spatial models for fasciolosis in dairy cattle in Europe to be used as input for temporal models and for the detection of deviations in baseline probability. Further research is required for model output in areas outside the eco-climatic range investigated.

Fasciola hepatica infection challenges health, welfare and productivity of small ruminants throughout the world. The distribution of F. hepatica in sheep in Europe is usually scattered and studies are generally concerned with a single area making it difficult to compare results from different environments, climates and management regimes. In order to elucidate the current scenario in terms of prevalence and intensity of F. hepatica infection in sheep farms across Europe, a standardized cross-sectional survey was conducted in three pilot areas in Ireland, Switzerland and Italy, all part of the EU funded GLOWORM project. Two consecutive field surveys (in 2012 and 2013) were conducted in the three countries in the same period (August-October) in 361 sheep farms in total. Harmonized procedures (from farm to laboratory) based on pooled samples and the highly sensitive and accurate, diagnostic FLOTAC technique were used. The georeferenced parasitological results were modelled (at the pilot area level) following a Bayesian geostatistical approach with correction for preferential sampling and accounting for climatic and environmental covariates. The observed F. hepatica prevalence rates did not differ between the two study years in any of the three pilot areas, but they did vary between the countries showing high values in Ireland (61.6%) compared to Italy (7.9%) and Switzerland (4.0%). Spatial patterns of F. hepatica distribution were detected by the Bayesian geostatistical approach in Ireland with a high risk of infection in the south-western part of the pilot area there. The latent factor analysis highlighted the importance of year-to-year variation of mean temperature, rainfall and seasonality within a country, while long-term trends of temperature and rainfall dominated between countries with respect to prevalence of infection.

Haemonchus contortus is a species of gastrointestinal strongyles of primary concern for sheep. This highly pathogenic, blood-feeding helminth negatively influences animal health, welfare and productivity. In order to elucidate the current scenario in terms of prevalence and intensity of H. contortus infection in sheep farms across Europe, a standardized crosssectional survey was conducted in three pilot areas in Ireland, Switzerland and Italy, all part of the EU funded GLOWORM project. Two consecutive field surveys (in 2012 and 2013) were conducted in the three countries in the same period (August-October) in 259 sheep farms in total. Harmonized, diagnostic procedures (from farm to laboratory) based on pooled samples, the FLOTAC technique and coproculture were used. The georeferenced parasitological results were modelled (at the pilot area level) following a Bayesian geostatistical approach with correction for preferential sampling and accounting for climatic and environmental covariates. The observed H. contortus prevalence rates did vary between the countries showing high values in Switzerland (77%) and Italy (73%) compared to Ireland (4%). Spatial patterns of H. contortus distribution were detected in Switzerland and Italy with a north-south gradient. The latent factor analysis highlighted the importance of seasonality and annual cyclicity within country (particularly in southern Italy), while mean temperature and rainfall dominated between country variations in the prevalence of H. contortus infection.

Participatory approaches to environmental research and decision-making require that all social stakeholders are involved from the onset of the debate. In such a setting, communication among different expertise is crucial, but language and technicalities may represent a barrier. In the clinical setting, decisions regarding treatment preferences may be influenced by the summary statistics used, but, according to the literature, no study has compared different statistical indicators for risk communication in environmental epidemiology. In this paper, we report on the qualitative results of the cognitive interviews conducted for assessing two questionnaires devoted to investigating risk perception when selected epidemiological results are communicated, by using different statistical indicators of health impact and uncertainty. The initial questionnaires were tested on 15 people residing in the high environmental risk area of Livorno (Italy). Cognitive interviewing led to substantial revision of the initial drafts. Moreover, it highlighted the difficulty of communicating statistical uncertainty and the need to account for the complex interaction between mathematical skills, affective factors and individual a priori knowledge on environmental risk perception.

Mapping and modelling helminth infections in cattle and sheep in Europe through advanced geospatial research was one of the main task of GLOWORM, a three year project (2012-2014) funded under the European Commission’s (EC) seventh framework programme (FP7). Liver flukes as Fasciola hepatica and gastrointestinal nematodes, such as Haemonchus contortus were chosen for the project since these parasites constitute a major cause of lost productivity in small and large ruminants. The output of the GLOWORM project delivered guidelines for standardized and harmonized cross-sectional surveys of helminth parasites in ruminants allowing the development of updated prevalence maps and multi-scale, spatial models for the European area.

A core challenge in epidemiological analysis of the impact of exposure to air pollution on health is assessment of the individual exposure for subjects at risk. Geographical information systems (GIS)-based pollution mapping, such as kriging, has become one of the main tools for evaluating individual exposure to ambient pollutants. We applied universal Bayesian kriging to estimate the residential exposure to gaseous air pollutants for children living in a high-risk area (Milazzo- Valle del Mela in Sicily, Italy). Ad hoc air quality monitoring campaigns were carried out: 12 weekly measurements for sulphur dioxide (SO2) and nitrogen dioxide (NO2) were obtained from 21 passive dosimeters located at each school yard of the study area from November 2007 to April 2008. Universal Bayesian kriging was performed to predict individual exposure levels at each residential address for all 6- to 12-years-old children attending primary school at various locations in the study area. Land use, altitude, distance to main roads and population density were included as covariates in the models. A large geographical heterogeneity in air quality was recorded suggesting complex exposure patterns. We obtained a predicted mean level of 25.78 (±10.61) μg/m3 of NO2 and 4.10 (±2.71) μg/m3 of SO2 at 1,682 children’s residential addresses, with a normalised root mean squared error of 28% and 25%, respectively. We conclude that universal Bayesian kriging approach is a useful tool for the assessment of realistic exposure estimates with regard to ambient pollutants at home addresses. Its prediction uncertainty is highly informative and can be used for both designing subsequent campaigns and for improved modelling of epidemiological associations.

Infections with parasitic helminths (nematodes and trematodes) represent a significant economic and welfare burden to the global ruminant livestock industry. The increasing prevalence of anthelmintic resistance means that current control programmes are costly and unsustainable in the long term. Recent changes in the epidemiology, seasonality and geographic distribution of helminth infections have been attributed to climate change. However, other changes in environment (e.g., land use) and in livestock farming, such as intensification and altered management practices, will also have an impact on helminth infections. Sustainable control of helminth infections in a changing world requires detailed knowledge of these interactions. In particular, there is a need to devise new, sustainable strategies for the effective control of ruminant helminthoses in the face of global change. In this paper, we consider the impact of helminth infections in grazing ruminants, taking a European perspective, and identify scientific and applied priorities to mitigate these impacts. These include the development and deployment of efficient, high-throughput diagnostic tests to support targeted intervention, modelling of geographic and seasonal trends in infection, more thorough economic data and analysis of the impact of helminth infections and greater translation and involvement of end-users in devising and disseminating best practices. Complex changes in helminth epidemiology will require innovative solutions. By developing and using new technologies and models, the use of anthelmintics can be optimised to limit the development and spread of drug resistance and to reduce the overall economic impact of helminth infections. This will be essential to the continued productivity and profitability of livestock farming in Europe and its contribution to regional and global food security.

A relationship between socio-economic status and health has been widely documented both by individual-level and ecological regression studies. We addressed the problem known in the literature as using a material deprivation index as predictor of health needs and comparing results when adjusting or not the health outcome and the deprivation index for the same confounding variables. We focus on non-linear hierarchical models. We take as example the the issue of introducing socio-economic indicators in national or regional resources allocation formulas. We fitted a series of models with different data hierarchies to evaluate both the individual effect and the aggregate (census block) effect of material deprivation on heath status, disentagling the individual from the contextual effects. Individual mortality records came from the Florence census cohort 1991-1995 which is part of the Tuscan Longitudinal Study. Data on socio-economic factors derived from individual records of the 1991 census. Our results suggested that after adjusting for age, material deprivation is a good predictor of health needs both at individual and at aggregate level (census block). The presence of a contextual effect increases the interest in using deprivatin in the allocation formula, since it would permit a better distribution of resources to disadvantaged micro-areas. In the present paper, we stress the need to estimate the association between deprivation and health appropriately adjusting for age. The ideal goal would be having information at small geographical level on the joint distribution of age and deprivation to age-standardize both the response and the predictor. A temporary solution should be to regress crude mortality rates on deprivation and age. The current common practice, in absence of individual data, to regress standardized mortality on material deprivation may be inappropriate.

In parasitological surveillance of livestock, prevalence surveys are conducted on a sample of farms using several sampling designs. For example, opportunistic surveys or informative sampling designs are very common. Preferential sampling refers to any situation in which the spatial process and the sampling locations are not independent. Most examples of preferential sampling in the spatial statistics literature are in environmental statistics with focus on pollutant monitors, and it has been shown that, if preferential sampling is present and is not accounted for in the statistical modelling and data analysis, statistical inference can be misleading. In this paper, working in the context of veterinary parasitology, we propose and use geostatistical models to predict the continuous and spatially-varying risk of a parasite infection. Specifically, breaking with the common practice in veterinary parasitological surveillance to ignore preferential sampling even though informative or opportunistic samples are very common, we specify a two-stage hierarchical Bayesian model that adjusts for preferential sampling and we apply it to data on Fasciola hepatica infection in sheep farms in Campania region (Southern Italy) in the years 2013-2014.

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In this paper the focus is on environmental statistics, with the aim of estimating the concentration surface and related uncertainty of an air pollutant. We used air quality data recorded by a network of monitoring stations within a Bayesian framework to overcome difficulties in accounting for prediction uncertainty and to integrate information provided by deterministic models based on emissions meteorology and chemico-physical characteristics of the atmosphere. Several authors have proposed such integration, but all the proposed approaches rely on representativeness and completeness of existing air pollution monitoring networks. We considered the situation in which the spatial process of interest and the sampling locations are not independent. This is known in the literature as the preferential sampling problem, which if ignored in the analysis, can bias geostatistical inferences. We developed a Bayesian geostatistical model to account for preferential sampling with the main interest in statistical integration and uncertainty. We used PM10 data arising from the air quality network of the Environmental Protection Agency of Lombardy Region (Italy) and numerical outputs from the deterministic model. We specified an inhomogeneous Poisson process for the sampling locations intensities and a shared spatial random component model for the dependence between the spatial location of monitors and the pollution surface. We found greater predicted standard deviation differences in areas not properly covered by the air quality network. In conclusion, in this context inferences on prediction uncertainty may be misleading when geostatistical modelling does not take into account preferential sampling.

Incidence distribution of cutaneous melanoma depends on phenotypic characteristics of population and geographic location. In Italy, in the period 1999-2003 Friuli Venezia Giulia (FVG) region had the second highest incidence rates for males and the third for females. We analysed melanoma and lip cancer incidence data of the FVG cancer registry for the period 1995-2005. We used Bayesian hierarchical spatial models to describe the spatial pattern by gender. We decomposed the geographical distribution of the risk in two parts: a component linked to chronic exposure and a component related to intermittent exposure. In order to model the chronic component we considered the geographical distribution of incidence cases of lip cancer, for which chronic occupational solar radiation exposure is a documented risk factor. We also analysed the distribution by site and we calculated standardised rates for body surface area. This study documents a significant gradient in the incidence of cutaneous melanoma in FVG. Highstandardisedincidence rates are present in the area of Trieste and in the coastal area. The descriptive analysis by age group and by site, showed risks associated with intermittent exposures in both genders. For the coastal area the risk is especially high for sites traditionally linked to high cumulative exposures (face and neck), especially among men. The results suggest diagnostic preventive interventions in the populations living in the area of Trieste, given the high rates observed in the young age groups.

The problem of multiple testing is rarely addressed in disease mapping or descriptive epidemiology. This issue is relevant when a large number of small areas or diseases are analysed. Control of the family wise error rate (FWER), for example via the Bonferroni correction, is avoided because it leads to loss of statistical power. To overcome such difficulties, control of the false discovery rate (FDR), the expected proportion of false rejections among all rejected hypotheses, was proposed in the context of clinical trials and genomic data analysis. FDR has a Bayesian interpretation and it is the basis of the so called q-value, the Bayesian counterpart of the p-value. In the present work, we address the multiplicity problem in disease mapping and show the performance of the FDR approach with two real examples and a small simulation study. The examples consider testing multiple diseases for a given area or multiple areas for a given disease. Using unadjusted p-values for multiple testing, an inappropriately large number of areas or diseases at altered risk are identified, whilst FDR procedures are appropriate and more powerful than the control of the FWER with the Bonferroni correction. We conclude that the FDR approach is adequate to screen for high/low risk areas or for disease excess/deficit and useful as a complementary procedure to point estimates and confidence intervals.

In Environmental Epidemiology, long lists of relative risk estimates from exposed populations are compared to a reference to scrutinize the dataset for extremes. Here, inference on disease profiles for given areas, or for fixed disease population signatures, are of interest and summaries can be obtained averaging over areas or diseases. We have developed a multivariate hierarchical Bayesian approach to estimate posterior rank distributions and we show how to produce league tables of ranks with credibility intervals useful to address the above mentioned inferential problems. Applying the procedure to a real dataset from the report “Environment and Health in Sardinia (Italy)” we selected 18 areas characterized by high environmental pressure for industrial, mining or military activities investigated for 29 causes of deaths among male residents. Ranking diseases highlighted the increased burdens of neoplastic (cancerous), and non-neoplastic respiratory diseases in the heavily polluted area of Portoscuso. The averaged ranks by disease over areas showed lung cancer among the three highest positions.

The relation between disease risk and a point source of pollution is usually investigated using distance from the source as a proxy of exposure. The analysis may be based on case-control data or on aggregated data. The definition of the function relating risk of disease and distance is critical, both in a classical and in a Bayesian framework, because the likelihood is usually very flat, even with large amounts of data. In this paper we investigate how the specification of the function relating risk of disease with distance from the source and of the prior distributions on the parameters of the function affects the results when case-control data and Bayesian methods are used. We consider different popular parametric models for the risk distance function in a Bayesian approach, comparing estimates with those derived by maximum likelihood. As an example we have analyzed the relationship between a putative source of environmental pollution (an asbestos cement plant) and the occurrence of pleural malignant mesothelioma in the area of Casale Monferrato (Italy) in 1987-1993. Risk of pleural malignant mesothelioma turns out to be strongly related to distance from the asbestos cement plant. However, as the models appeared to be sensitive to modeling choices, we suggest that any analysis of disease risk around a putative source should be integrated with a careful sensitivity analysis and possibly with prior knowledge. The choice of prior distribution is extremely important and should be based on epidemiological considerations.

A cross-sectional survey was carried out on 2004-2005 in the Campania region, southern Italy, to study the multivariate geographical distribution of four different sheep helminths, i.e. Fasciola hepatica (liver fluke), Calicophoron (Paramphistomum) daubneyi (rumen fluke), Dicrocoelium dendriticum (lancet fluke), and the gastrointestinal strongyle Haemonchus contortus. A series of multivariate Bayesian hierarchical models based on square root transformation of faecal egg counts were performed. The results were consistent with theoretical knowledge of the biology and epidemiology of the four studied helminths. In particular, the impact of common intermediate hosts (F. hepatica and C. daubneyi share the same intermediate host species) was quantified and evidence of previously unknown ecological components was given. D. dendriticum was correlated to F. hepatica and H. contortus was found not to be spatially associated with the previously mentioned helminths.

Neurodegenerative Langerhans Cell Histiocytosis (ND-LCH) is a rare, unpredictable consequence that may devastate the quality of life of patients cured from LCH. We prospectively applied a multidisciplinary diagnostic work-up to early identify and follow-up patients with ND-LCH, with the ultimate goal of better determining the appropriate time for starting therapy.We studied 27 children and young adults with either ND-LCH verified by structural magnetic resonance imaging (MRI) (group 1) or specific risk factors for (diabetes insipidus, craniofacial bone lesions), but no evidence of, neurodegenerative MRI changes (group 2). All patients underwent clinical, neurophysiological and MRI studies.Seventeen patients had MRI alterations typical for ND-LCH. Nine showed neurological impairment but only three were symptomatic; 11 had abnormal somatosensory evoked potentials (SEPs), and five had abnormal brainstem auditory evoked potentials (BAEPs). MR spectroscopy (MRS) showed reduced cerebellar NAA/Cr ratio in nine patients. SEPs showed sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for predicting ND-LCH of 70.6% (95%CI, 44.0%-89.7%), 100% (69.2%-100%), 100% (73.5%-100%), and 66.7% (38.4%-88.2%), respectively. Repeated investigations in group 1 revealed increasingly abnormal EP parameters, or neurological examination, or both, in nine of fifteen patients while MRI remained unchanged in all but one patient.A targeted MRI study should be performed in all patients with risk factors for ND-LCH for early identification of demyelination. The combined use of SEPs and careful neurological evaluation may represent a valuable, low-cost, well-tolerated and easily available methodology to monitor patients from pre-symptomatic to symptomatic stages. We suggest a multidisciplinary protocol including clinical, MRS, and neurophysiological investigations to identify a population target for future therapeutic trials.

Absence epilepsy (AE) is etiologically heterogeneous and has at times been associated with idiopathic dystonia.Based on the clinical observation that children with AE often exhibit, interictally, a disorder resembling writer's cramp but fully definable as dysgraphia, we tested the hypothesis that in this particular population dysgraphia would represent a subtle expression of dystonia.We ascertained the prevalence of dysgraphia in 82 children with AE (mean age 9.7) and average intelligence and compared them with 89 age-, gender- and class-matched healthy children (mean age 10.57) using tests for handwriting fluency and quality, based on which we divided patients and controls into four subgroups: AE/dysgraphia, AE without dysgraphia, controls with dysgraphia and healthy controls. We compared the blink reflex recovery cycle in children belonging to all four subgroups.We identified dysgraphia in 17/82 children with AE and in 7/89 controls (20.7 vs 7.8%; P = 0.016) with the former having a 3.4-times higher risk of dysgraphia regardless of age and gender (odd ratio: 3.49; 95% CI 1.2, 8.8%). The AE/dysgraphia subgroup performed worse than controls with dysgraphia in one test of handwriting fluency (P = 0.037) and in most trials testing handwriting quality (P< 0.02). In children with AE/dysgraphia the blink reflex showed no suppression at short interstimulus intervals, with a difference for each value emerging when comparing the study group with the three remaining subgroups (P

Over the past 10-15 years, significant advances have been made in the development and application of geographical information systems (GIS) and remote sensing (RS). In veterinary sciences, particularly in veterinary parasitology, GIS and RS offer powerful means for disease mapping, ecological analysis and epidemiological surveillance and have become indispensable tools for processing, analysing and visualising spatial data. They can also significantly assist with the assessment of the distribution of health-relevant environmental factors via interpolation and modelling. In this review, we first summarize general aspects of GIS and RS, and emphasize the most important applications of these tools in veterinary parasitology, including recent advances in territorial sampling. Disease mapping, spatial statistics, including Bayesian inference, ecological analyses and epidemiological surveillance are summarized in the next section and illustrated with a set of figures. Finally, a set of conclusions is put forward.

BACKGROUND: Chronic metabolic overload results in lipid accumulation and subsequent inflammation in white adipose tissue (WAT), often accompanied by non-alcoholic fatty liver disease (NAFLD). In response to metabolic overload, the expression of genes involved in lipid metabolism and inflammatory processes is adapted. However, it still remains unknown how these adaptations in gene expression in expanding WAT and liver are orchestrated and whether they are interrelated. METHODOLOGY/PRINCIPAL FINDINGS: ApoE*3Leiden mice were fed HFD or chow for different periods up to 12 weeks. Gene expression in WAT and liver over time was evaluated by micro-array analysis. WAT hypertrophy and inflammation were analyzed histologically. Bayesian hierarchical cluster analysis of dynamic WAT gene expression identified groups of genes ('clusters') with comparable expression patterns over time. HFD evoked an immediate response of five clusters of 'lipid metabolism' genes in WAT, which did not further change thereafter. At a later time point (>6 weeks), inflammatory clusters were induced. Promoter analysis of clustered genes resulted in specific key regulators which may orchestrate the metabolic and inflammatory responses in WAT. Some master regulators played a dual role in control of metabolism and inflammation. When WAT inflammation developed (>6 weeks), genes of lipid metabolism and inflammation were also affected in corresponding livers. These hepatic gene expression changes and the underlying transcriptional responses in particular, were remarkably similar to those detected in WAT. CONCLUSION: In WAT, metabolic overload induced an immediate, stable response on clusters of lipid metabolism genes and induced inflammatory genes later in time. Both processes may be controlled and interlinked by specific transcriptional regulators. When WAT inflammation began, the hepatic response to HFD resembled that in WAT. In all, WAT and liver respond to metabolic overload by adaptations in expression of gene clusters that control lipid metabolism and inflammatory processes in an orchestrated and interrelated manner.

BACKGROUND: Efforts to prevent and respond to heat-related illness would benefit by quantifying the impact of summer heat on acute population mortality. We estimated years of life lost due to heat in 14 European cities during the 1990s accounting for harvesting. METHODS: We combined the number of deaths attributable to heat estimated by the PHEWE project with life expectancy derived from population life tables. The degree of harvesting was quantified by comparing the cumulative effect of heat up to lagged day 30 with the immediate effect of heat, by geographical region and age. Next, an evaluation of years of life lost adjusted for harvesting was obtained. RESULTS: Without accounting for harvesting, we estimated more than 23,000 years of life lost per year, 55% of which was among individuals younger than 75. When 30 day mortality displacement was taken into account, the overall impact reduced on average by 75%. Harvesting was more pronounced in North-continental cities than in Mediterranean cities and was stronger among young people than among elderly. CONCLUSIONS: High ambient temperatures during summer were responsible for many deaths in European cities during the 1990s, but a large percentage of these deaths likely involved frail persons whose demise was only briefly hastened by heat exposure. Differences in harvesting across regions and classes of age could reflect different proportions of frail individuals in the population or could be indicative of heterogeneous dynamics underlying the entry and exit of individuals from the high-risk pool which is subject to mortality displacement.