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Background The Agency for Healthcare Research and Quality (AHRQ) identifies preventable hospitalizations as proxy of potentially low-quality of care. Previous studies showed as socio-economic status was associated to poor diseases outcomes and to the performance of health services. Recently a particular attention was focused on the effect of the pandemic on this context. The aim of this research is to analyze the association between poor quality of primary care and socio-economic status before and during the pandemic. Methods A retrospective observational study was conducted in Abruzzo Region, Italy. Hospital discharge records (HDR) of two different periods were selected: from April to December for 2019 and 2020. The aggregate Prevention Quality Indicator 90 (PQI-90) has been coded according to the indications of the AHRQ. The Italian socioeconomic deprivation index (DI), divided in quintiles (from 1st less deprived to the 5th most deprived) was attributed to all patient, based on the municipality of residence. A multivariate logistic regression model was performed to evaluate the association between PQI-90 and DI. Results Totally were analyzed 253,063 HDR, of which 14,845 attributable to the PQI-90. By correcting for gender, age and number of comorbidities, the DI was not associated with the PQI-90 during 2019. During 2020 the PQI-90 was associated to 4th DI quintile (aOR 1.19;95%CI 1.09-1.30) and 5th DI quintile (aOR 1.13; 95%CI 1.03-1.23), compared to the 1st quintile. Conclusions The impact of the pandemic on primary care has been substantial. Compared to the pre-pandemic era, during the pandemic, an association between potentially poor quality of care and the most disadvantaged socio-economic areas has been shown in Abruzzo. This evidence must be an interesting starting point for health planning in order to fight against inequalities in health services access. Key messages • The reduction in the primary care quality during pandemic caused potentially preventable hospitalizations and it was associated to socioeconomic deprivation. • The analysis of hospital admission linked to context indicators such as the deprivation index, can be a useful tool for the policy maker in order to reduce healthcare inequalities.

Background Current data suggest that SARS-CoV-2 reinfections are rare. Uncertainties remain, however, on the duration of the natural immunity, its protection against Omicron variant, and on the impact of vaccination to reduce reinfection rates. Methods In this retrospective cohort analysis of the entire population of an Italian Region, we followed 1,293,941 subjects from the beginning of the pandemic to the current scenario of Omicron predominance (up to mid-February 2022). We assessed the proportion of reinfections overall, and by demographic and clinical characteristics, time after primary infection, and predominant circulating variant. Cox proportional hazard analysis was used to compute the relative hazards of reinfection. Results After an average of 277 days, we recorded 729 reinfections among 119,266 previously infected subjects (overall rate: 6.1‰), eight COVID-19-related hospitalizations (7/100,000), and two deaths. Importantly, the incidence of reinfection did not vary substantially over time: after 18-22 months from the primary infection, the reinfection rate was still 6.7‰, suggesting that protection conferred by natural immunity may last beyond 12 months. The risk of reinfection was significantly higher among females, unvaccinated subjects, and during the Omicron wave. Conclusions This study confirms and expands previous findings reporting a low risk of SARS-CoV-2 reinfection, and a very low risk of severe or lethal COVID-19 for those who recovered from primary infection, suggesting that the protection conferred by the natural immunity lasts beyond 12 months. Although the marked increase of the reinfection rates during the Omicron wave is concerning, the risk of a secondary severe disease or death remained close to zero. Vaccines were able to significantly reduce the likelihood of reinfection in both pre-Omicron and Omicron waves, although the risk-benefit profile of multiple vaccine doses for this population should be carefully evaluated. Key messages • After primary infection, the risk of SARS-CoV-2 reinfection and of severe/lethal COVID-19 was low, suggesting that natural immunity lasts beyond 12 months. • Despite increasing reinfection rates with Omicron, the risk of a secondary severe/lethal disease was close to zero, and vaccines reduced the likelihood of reinfection before and during Omicron waves.

Recent trials and reviews have raised question about the safety of total parenteral nutrition (TPN), due to the increased rate of TPN related complications. Diabetic patients are vulnerable to hyperglycaemia, and poor studies have investigated hospital out-comes of diabetic patients requiring TPN. The aim of this study was to evaluate the association of in-hospital mortality, prolonged length of stay and transfer to long-term care facilities among diabetic patients with TPN.The study considered all hospital admissions of diabetic patients over 65 years of age performed between 2006 and 2015 in Abruzzo Region, Italy. To compare the outcomes of TPN and non-TPN patients, a propensity score matching procedure was performed.A total of 140,556 admissions were analyzed. After matching, 1947 patients were included into the analyses: 649 patients with TPN and 1298 controls. TPN was significantly associated to in-hospital mortality (OR=7.15; 95%CI 5.54-9.22), prolonged LOS (OR=2.78; 95%CI 2.28-3.38) and transfer to LTCF (OR=2.16; 95%CI 1.64-2.85).TPN is associated with poor outcomes among elderly diabetic patients in the Italian setting. Being aware of the risk factors among diabetic patients with TPN can be used to anticipate the patients' needs during the admission and the immediate post-discharge period.

We adopted a combined geophysical-stratigraphic approach to identify grain size anomalies in sediment distribution of the Bagnoli coastal brownfield site. A large industrial plant occupied this area during most of the 20th Century. We used 18 core logs to identify macroscopic variation in sediment stratigraphy, and 72 supplemental cores to mark changes between sandy- and silt-dominated intervals. The stratigraphy evidenced the presence of anomalous lens of silt within a sandy coastal sector inside the Bagnoli industrial harbour. Cores description helped us to calibrate the interpretation of 4 subbottom profiles, that we used to obtain information on geometries of silty deposits. The spatial layout of sediments revealed that silt intervals are present in the area bounded by the old industrial wharfs. We suggest that these silty sediments are likely the result of uncontrolled discharge occurred during the last century. Once calibrated, high-resolution mono-channel seismic profiles helped us to define the shape as well as the real extent and thicknesses of silty deposits, resulted to be ca. 515.000 m(2), with an overall volume of 480.000 m(3). These results are a first attempt to define the amount of polluted sediments in the area facing the Bagnoli industrial harbour.

Hip fracture injury is one of the principal health problems affecting the elderly. Patients reporting hip fractures often show relevant comorbidities leading to prolonged hospital stay, significant complications and higher mortality rates. This study aims to assess the risk factors associated with prolonged hospitalization after hip fracture, in-hospital mortality and transfers to other facilities.Retrospective cross-sectional study.The study considered all admissions performed between 2006 and 2015 in Abruzzo region, Italy. Logistic regression analyses were performed to evaluate odds ratios for each risk factor as predictor of in-hospital mortality, length of stay, and transfer to other facilities.Age over 85 (OR=5.38) and cancer (OR=3.62) were identified as the strongest risk predictors for in hospital mortality; diabetes (OR=2.24) and heart failure (OR=1.57) were identified as predictors of prolonged length of stay and age over 85 (OR=1.38) and atrial fibrillation (OR=1.69) were identified as predictors of transfer to other facilities.With the rising incidence of hip fractures, identification of modifiable factors may help to reduce morbidity and mortality.

Background As a consequence of the Covid-19 outbreak, Italy has adopted unprecedented preventive measures such as large-scale application of social isolation and hospital rearrangements. These measures have led to difficulty in managing diseases and hospitalizations, particularly acute and severe conditions such as neurological morbidities. The aim of the present analysis is to investigate the change in hospital admissions for neurological diseases over the first nine months of 2020 in Abruzzo region. Methods Data were obtained from the Hospital Discharge Records of all Abruzzo. We analyzed all the hospitalizations included in Major Diagnostic Categories 1 (neurological diseases). First, we distinguished both between public or private hospitalizations and ordinary or day-hospital admissions. Second, we compared the first nine months of 2020 with a mean of the same months in the two previous years. Finally, we calculated the variable percentage. Results A huge reduction in MCD 1 series hospitalizations was observed in each subgroup. Specifically, ordinary regimen had a peak of -47,3% in April. Day-hospital admissions were the most affected by Covid-19 with a peak of more than 90% in April both in public and private hospitals. The largest reduction occurred in private hospitals, both in ordinary (-75% in April) and DH admissions (-93,8% in March). Conclusions Despite the severity of the diseases included in MDC 1 (i.e. ischemic stroke, intracranial hemorrhage), a significant decline was detected in hospital admissions in Abruzzo. Subsequently, a high number of subjects might have not received the necessary health assistance leading to an increase in mortality and morbidity for these severe pathologies. Additionally, patients might have avoided seeking hospital care in response to the fear of contagion triggered either by media or as a result of the stay-at-home government recommendations. Key messages An alarming reduction in all types of hospitalizations for neurological diseases occurred over the first months of pandemic in Abruzzo. Greater management efforts are needed to reduce the morbidity and mortality rates associated with the reduced hospital admissions during the pandemic.

Background Over the latest decades, Europe has been facing the spreading of vaccine hesitancy. This growing phenomenon has resulted in decreasing vaccination coverage all over Europe, particularly in Italy for measles, mumps and rubella. In order to face up this problem, in 2017 Italy introduced compulsory vaccination against 10 different infectious diseases: diphtheria, tetanus, pertussis, polio, hepatitis B, haemophilus influenzae B (all included in the hexavalent vaccine), measles, mumps, rubella (included in the MMR vaccine) and chickenpox (from the 2017 cohort). The aim of this study was to evaluate vaccination coverages in 2019 in Abruzzo, an Italian Southern Region, after the introduction of compulsory vaccinations. Methods In this study the following indicators were taken into account: vaccination coverages at 24 months of age (2017 cohort of birth), vaccination coverages at 36 month of age (2016 cohort), vaccination coverages at 5/6 years of age (2013 and 2014 cohorts) and vaccination coverages at 16 and 18 years of age (2001 and 2003 cohorts). Vaccination coverage rates were calculated as the number of vaccinated patients for each disease over the total number of patients born in the year considered. Results At the end of 2019, the 2017 cohort reached 95% coverage for all vaccinations except for chickenpox (87.9%). Conversely, the 2016 cohort showed low rates for MMR and chickenpox, up to 90.8% and 52.1% respectively. Additionally, 2013 and 2014 teenager cohorts showed coverage rates lower than 95% for all the compulsory vaccinations. Conclusions After two years of mandatory vaccination law in Italy, vaccination coverages have reached the 95% threshold only among patients of 24 months of age. Older cohorts still show inadequate vaccination coverages despite the introduction of mandatory vaccination law. Health services at regional level should develop policies and strategies aiming to improve vaccination coverages and to reach herd immunity. Key messages After the introduction on mandatory vaccination, vaccination coverages reached the 95% threshold only among patients of 24 months of age. Health services should develop strategies aiming to improve vaccination coverages.

Background The coronavirus epidemic has put unprecedented strain on health services, threatening hospital capacity in facing such a high number of Covid-19 patients in need of treatment. The aim of this study is to compare the hospitalization rate for acute coronary syndrome (ACS) in the first nine months of 2020 with the same period of 2018 and 2019. Methods This is a retrospective study of hospital discharge records. The pathologies of interest were coded as follows: all the hospitalizations with main discharge diagnosis as ICD-9-CM 410.xx, 411.xx, 413.xx for Acute Coronary Syndrome (ACS); 410.xx was used in all diagnoses except in codes 410.7x or 410.9x for acute ST-elevation myocardial infarction (STEMI); 410.7x was used in all diagnoses except 410.9.x for acute non-STEMI. Hospitalization rate ratios (HRR) comparing the study period with each of the control periods were calculated using Poisson regression. Results During the study period there was a statistically significant decrease in hospitalizations for ACS both vs 2018 (HRR 0.80;95%CI 0.80-0.81; p < 0.001) and vs 2019 (HRR 0.85;95%CI 0.84-0.86; p < 0.001). A decrease also affected STEMI vs 2018 (HRR 0.91;95%CI 0.90-0.92; p < 0.001) and vs 2019 (HRR 0.87;95%CI 0.86-0.88; p < 0.001) and NSTEMI vs 2018 (HRR 0.76;95%CI 0.75-0.77; p < 0.001) and vs 2019 (HRR 0.79;95%CI 0.78-0.80; p < 0.001). Conclusions This report shows a significant decrease in ACS-related hospitalization rates across the Region during the study period. General out-of-hospital mortality need to be further investigated, as to focus on patients died of ACS without receiving adequate assistance from the emergency network. Key messages Hospitalizations for acute coronary syndromes, STEMI and NSTEMI underwent a statistically significant decrease. During the pandemic, some health needs related to fatal emergencies were not met by the health services.

Background Overall mortality is a relevant indicator of the population burden during COVID-19 pandemic, reflecting the overload and preparedness of the healthcare system. This study aimed to analyse the distribution of deaths in SARS-CoV-2 positive patients between pandemic phases and to evaluate the characteristics of COVID-19 patients deceased during the year. Methods Data on confirmed COVID-19 cases were collected from the recording system of the Department of Prevention of the Local Health Authority of Abruzzo Region, Italy. The course of the epidemic was stratified in 4 phases: the first wave (March-May 2020), the low incidence phase (June-September 2020), the second wave (October 2020-December 2021), and the variants spread phase in our region (January-March 2021). Results From March 2020 to March 2021 we registered 17,082 cases of SARS-CoV-2 infection, of these patients 571 (3.35%) had a fatal outcome. The mortality was the highest during the first ‘peak' phase, interesting the 14.20% of the notified cases, and the lowest during the last phase (2.50%). Mortality due to COVID-19 mainly affected men (54.99%) and geriatric patients (median age: 84; IQR: 75-90). Women dying for SARS-CoV-2 infection had a more advanced median age (87; IQR: 79-92) than men (81; IQR: 73-87). The lowest median age was registered in patients deceased during the low incidence phase (75.5; IQR: 71-82). The median time span, in days, from a SARS-CoV-2 positive test to death was significant lower in the phase 1 (days:10; IQR:4-20) then in phase 4 (days:14; IQR:8-22) (p < 0.001). Conclusions Our results showed that mortality markedly decreased during the COVID-19 epidemic, and this could be likely related to an improved organisation and delivery of care, in addition to a better knowledge of disease treatment. Elderly patients were more likely to progress toward fatal outcome. The healthcare systems should pay special attention to them in order to effectively manage possible future pandemics. Key messages The COVID-19 mortality reduction highlights an improvement of health care; the elderly remains at major risk of death. Providing pandemic prevention and care models focused also on vulnerable groups is a major public health challenge.

Background The outbreak of COVID-19 was declared Public Health Emergency of International Concern on the January 2020. During an infectious disease outbreak, non-pharmaceutical interventions are essential to delay an epidemic peak and to flatten the epidemic curve, in order to wait for vaccine development. Perception or beliefs may be essential in determining adherence to official recommendations. The aim of this study was to assess whether perceptions of COVID-19 and awareness of preventive strategies effectiveness were associated to behavioural changes. Methods Web-based survey was performed in Italy between the 9 and the 15 March 2020. The survey contained six sections: subject's demographics, subject's behaviours during the latest three weeks, subject's behaviours during the latest 24 hours, perceived efficacy of behaviours, awareness raised by the government-led prevention campaign for COVID-19 and co-occurring anxiety. Results 1912 participants were enrolled in the study. 48.1% of the participants (n = 919) reported to perform at least 7 preventive behaviours. Most people reported a change in the frequency of their hand-washing (94.7%), an increment in the frequency of surface cleaning and disinfecting (58.9%), and a reduction in the use of public transport (92.5%). Behavioural changes were related to an increase in the anxiety level (OR 1.47; 95%CI 1.16-1.87). After adjusting for personal characteristics and anxiety, an association resulted between clear perception of COVID-19 high infectiousness (OR 1.25; 95%CI 1.00-1.59) and of its severe consequences (OR 1.29; 95%CI 1.05-1.59), clearness of communication about the virus (OR 1.41; 95%CI 1.17-1.71), and increased likelihood of performing the recommended behavioural changes. Conclusions To better protect people against future epidemics, health-promotion efforts should be aimed at increasing the level of awareness towards infectious diseases and at implementing and encouraging non-pharmaceutical interventions. Key messages Clear perception of COVID-19 high infectiousness and of its severe consequences are associated with an increased likelihood of performing the recommended behavioural changes. Health promotion strategies should be a critical part of infection prevention and control program.

Issue After the announcement of Public Health Emergency of International Concern about COVID19 by WHO, health authorities need to implement strategies to face the emergency. These responses included early diagnosis, patient isolation, quarantine and symptomatic monitoring of contacts. In this context, integrated care and telemedicine are the best instruments for COVID management. Description of the problem The COVID19 epidemic needs a real time integration of epidemiological, clinical and laboratoristic data, in order to better manage patients and to improve public health surveillance. Based on a tool previosly used by GPs for flu vaccination and diabetes integrated care, the Local Health Authority of Pescara, Abruzzo Region, Italy, developed a web-based platform (QuickwebConnect), accessible to public health practitioners (PHP), GPs, infectious diseases physicians and laboratories, in order to integrate information about COVID19 patients. This platform contain individual-level information on patients with laboratory-confirmed COVID19, symptoms, reported onset dates, and basic demographics. Information are in real time accessible to all actors involved in the process. In addition, GPs can use this tool to directly book diagnostic tests for symptomatic or suspected patients. Results With the use of this platform, the management of pandemic emergency was improved, allowing direct management of epidemic data both at person and population level. The real time evaluation of clinical and epidemiological data improved patients care, clinical survellance of COVID19 contacts and development of tailored preventive measure in areas with high incidence. Lessons COVID19 patients care need to be quick, needing the integrate support of different actors. In addition, public health actions have to be supported by strong data. The use of a cost-effective web platform allow physician and PHP to better manage patiens and develope focused interventions. Key messages Integrated care and telemedicine are best instruments for COVID management. The real time evaluation of data aimed to develop tailored preventive measure.

Background In 2020 the Covid-19 pandemic influenced the organization of all health systems, imposing new rules for accessing the hospitals and delaying or reducing the ability to cope with all the population needs. In addition, people with life-threatening conditions deferred care for their fear of contagion. The study aimed to evaluate the indirect impact of Covid-19 on hospitalization rates for cardiovascular diseases in 2020 in Abruzzo. Methods Data were obtained from the hospital discharge records of all Abruzzo. We analyzed all the hospitalizations included in Major Diagnostic Categories 5 (cardiovascular diseases). First, we distinguished both between public or private hospitalizations and ordinary or day-hospital admissions. Second, we compared the first nine months of 2020 with a mean of the same months in the two previous years. Finally, we calculated the variable percentage. Results A huge reduction in hospitalization in MCD 5 contest was observed in each subgroup. Specifically, ordinary regimen had a peak of -56,4% in April. Day-hospital admissions were the most affected by Covid-19 with a peak of -84% in April. The largest reduction in hospitalizations occurred in private hospitals, in both ordinary (-81% in April) and DH admissions (-100% in April). A rebound in admissions was reported only for ordinary private regime between June and September, with a peak of + 24% in August. Conclusions Covid-19 had a severe impact on Abruzzo hospitalizations. The medical conditions that we examined needed effective hospital treatment to avoid adverse outcomes or death. Subsequently, fewer hospitalizations for such medical conditions were almost certainly associated with patient harm. Despite the pandemic, health system leaders should manage to provide subjects with hospital care, when necessary. Key messages Covid-19 had a significant indirect impact on the rate of hospitalizations for cardiovascular disease in Abruzzo. Despite the pandemic, regional health systems should manage to provide effective hospital care for patients with cardiovascular conditions that require hospitalization.

Background In Italy, the loss of confidence in vaccines has resulted in low vaccination coverage also among healthcare workers (HCWs). Low vaccination coverage among HCWs may lead to dangerous outbreaks and may increase absenteeism. The aim of this study was to investigate vaccine coverage and the attitudes toward vaccination among HCWs. Methods A multicenter cross-sectional study was conducted from August to November 2019 among HCWs referring to all the hospitals of the Local Health Authority 02 of Abruzzo Region, Italy. The survey was based on the questionnaire proposed by the H-ProImmune Project, aiming at investigating vaccination coverage and beliefs towards vaccination. Besides a descriptive analysis of the results, a logistic regression analysis was performed to evaluate the association between vaccine coverage and type of occupation (medical doctor, nurse, obstetric nurse, other). Results A total of 347 HCWs were enrolled in the study. The 57.3% reported to have missed diphtheritis-tetanus-pertussis (DTP) vaccination, the 50.1% reported to have missed measles-mumps-rubella (MPR) vaccination, and the 62.5% reported to have missed flu vaccination. In comparison with medical doctors, obstetric nurses were more likely to be associated to MPR vaccination (OR 2.8;95%CI 1.1-7.6; p = 0.047). As far as flu vaccination was concerned, both nurses and obstetric nurses showed lower confidence (respectively OR 0.2; 95%CI 0.1-0.3; p Conclusions This survey shows that the vaccination coverage taken into consideration results to be below the 95% threshold. Training on vaccine and mandatory measures may be necessary in order to achieve better coverage. Key messages Among HCW all vaccination coverage considered resulted below the threshold. Training on vaccine and mandatory measures may be needed in order to achieve better coverage.

Background Ambulatory Care Sensitive Conditions (ACSCs) are conditions where effective community care and case management can help prevent the need for hospital admission. Even if the ACSC episode itself is managed well, an emergency admission for an ACSC is often symptom of overall poor quality of primary and community care. Lower socioeconomic status individuals show higher rates of hospitalization due to ACSCs. The purposes of this study is to examine the association between socioeconomic status and the risk of hospitalization due to an ACSC in pediatric population through a retrospective analysis of administrative data of the Abruzzo region. Methods We identified hospital discharge records from 2008 to 2018 of subjects under 18 years of age to take into consideration for the study. Hospitalizations due to ACSCs were selected by ICD9-CM coding developed by Billings et al. and implemented by Lu et al. For establishing the socioeconomic status, we used the Italian Deprivation Index (IDI) developed by Caranci et al. as a categorical variable expressed in quintiles. A multilevel logistic regression model was implemented using ACSC vs non ACSC hospitalization as dependent variables. Results In the study period, a total of 317,586 hospital discharge records were selected, 18059 (5.69%) of which related to ambulatory care sensitive hospitalization. After correcting for age, gender, and citizenship, ACSCs hospitalization was associated with lower IDI (aOR1.21;CI95%1.09-1.34) and a slight gradient as the deprivation increased. Moreover, it was also associated with emergency department admission (aOR6.53;CI95%6.19-6.89). Conclusions Avoidable hospitalization in pediatric settings is associated with lower socioeconomic status computed by IDI. This study confirms inequity in primary care or community care after adjusting for age, gender and citizenship. Italian deprivation index represents a useful tool to identify population and areas where improving prevention is necessary. Key messages The Italian deprivation index could be used to implement primary and community care strategies in pediatric settings. Socio-economic factors are associated with the performance of the health services.

Background Increased life expectancy has led to an increased incidence of hip fractures in aged people. Patients reporting hip fractures often show relevant comorbidities leading to prolonged hospital stays, significant complications, and higher mortality rates. Being aware of the factors associated with in-hospital death or adverse events can help patients and healthcare providers make informed planning and management. The aims of this study were the development and validation of a score predicting in-hospital mortality among hip fractured patients. Methods Patients were selected from the hospital discharge record referring to the period 2006-15 and including data on the population aged 40 years or over in Abruzzo, a region of Southern Italy. The whole population was divided into 2 random samples in order to control the accuracy of predictions and to increase the reliability of all the statistical analyses. A multivariate logistic regression model was performed to identify the predictors of in-hospital mortality. All the diagnoses significantly associated with in-hospital mortality were included in the final model. Results The score ranged between 0 and 27 and was divided into four groups to facilitate the tool interpretation. An increase in odds ratio values was documented alongside the increase in PRIMOF score both in training and in validation groups. The score showed a good calibration and a good accuracy in predicting in-hospital mortality. Conclusions This study has shown that a simple score, based on the clinical history of the patient, allows to stratify the risk of hip fractured population in terms of in-hospital mortality. The identification of individuals at high risk of short-term death can be of great significance to health providers and public and private health services. Key messages Patients reporting hip fractures often show relevant comorbidities leading to higher in-hospital mortality rates. A simple score, based on the clinical history of the patient, allows to stratify the risk of hip fractured population in terms of in-hospital mortality.

Background Rotavirus is the most important cause of hospitalization for gastroenteritis and dehydration in children under 5 years old. In developed countries, it significantly affects public health in terms of costs and morbidity. Despites the availability of an effective vaccine, the coverage remains low in Italy. This study aimed to evaluate the epidemiological impact of rotavirus hospitalizations in Abruzzo, an Italian region, from 2008 to 2018. Methods Data were obtained from hospital discharge records of all Abruzzo hospitals. For the study, only the admissions due to rotavirus infection occurring in children aged 0 to 5 over the study period were taken into consideration. For each year, age-adjusted standardized hospitalization rates for rotavirus infection were calculated, and time trends were analyzed by joint point regression models. Results A total of 747 admissions were identified. During the study period, a significant increase of admissions was observed among children under 1 year of age (AAPC +9.8%, 95%CI 0.0;20.5, p Conclusions These results confirm that Rotavirus gastroenteritis has a heavy impact on pediatric hospitalization in Abruzzo Region. Subsequently, the study gives evidence of the need to improve vaccination coverage, in order to reduce morbidity and costs for the Italian healthcare system. Key messages In Abruzzo region, rotavirus gastroenteritis is a very important cause of morbidity and hospitalization in children under 5 years old. This study confirms the need of an improvement in vaccination coverage, that is the most effective mean to reduce the high morbidity, as well as the social and health costs.

Background Norovirus is the main causative agent of viral acute gastroenteritis. It is easily transmitted and frequently causes foodborne and waterborne outbreaks. The Food Hygiene Service of ASL 2 Abruzzo received notification of gastrointestinal illness in 33 customers who attended a lunch at an agritourism on 28 July 2019. Methods The investigation started immediately. The event was reported to the Judicial Authority and food preparation was suspended. Stool specimens and rectal swabs were collected from 18 guests and 2 food handlers and tested. A questionnaire survey was given to the customers. During the inspection, the Food Hygiene Service sampled some food leftover and water from faucets. Furthermore, it found an incomplete HACCP manual. Results The 31 cases of gastrointestinal illness occurred within 12-72 hours and didn't need hospitalization. Among the affected subjects,18 were men (58.1%) with a median age of 51 years. All the biological samples collected from the subjects were positive for Norovirus GII, as revealed by Real Time-PCR. The two food handlers resulted positive for Norovirus GII, but they were asymptomatic. They were tested up to 3 weeks after the outbreak and their feces remained positive. Water and food samples resulted negative, except for raw ham's outer surface, that resulted positive for Norovirus GII. The contamination probably occurred during food preparation. Discussion This outbreak was related to food cross-contamination by infected food handlers, likely caused by a failure in application of both personal and food hygiene measures prescribed in HACCP plan. Food preparation restarted on 12 September 2019, but infected food handlers were dismissed until they were positive. The Judicial Authority will file a lawsuit against the food operator business that could lead to imprisonment or fines. Key messages Norovirus outbreaks are recognized as a public health concern causing a high number of cases and serious health consequences in children and the elderly. HACCP manual must be customized for each food business and integrally applied by food handlers in order to attain a higher standard of food safety for prevention of foodborne illness.

Background Chronic Obstructive Pulmonary Disease (COPD) is a preventable and treatable disease characterized by persistent respiratory symptoms and airflow limitation. It is currently one of the leading cause of death worldwide. Metabolic syndrome has been recognized as one of the most relevant clinical comorbidities associated with COPD. Diabetes is more prevalent in COPD than in the general population, ranging between 10.1-23.0%. However, the link between COPD and diabetes is much less clear. The aim of this study was to investigate the effect of COPD on diabetic patients, focusing on length of stay and in-hospital mortality. Methods The study considered all hospital admissions of diabetic patients aged over 65 years performed between January 2006 and December 2015 in Abruzzo, a region of Italy. Data were collected from all hospital discharge records. A 1:1 propensity score-matching algorithm was used to match patients with and without COPD, according to their baseline characteristics. Logistic regression analysis was performed to evaluate the risk of in-hospital mortality and prolonged length of stay among diabetic patients with COPD. Results A total of 140,556 ?patients were included: 18,379 with COPD and 122,177 without COPD. After matching procedure, 36,758 patients were included into the analysis: 18,379 with COPD and 18,379 controls. After matching, all the baseline characteristics resulted well balanced, with a standardized mean difference less than 10% for all the variables considered. COPD patients showed a higher risk of in-hospital mortality (OR: 1.10; 95%CI 1.01-1.20; p = 0.036) and length of stay over 15 days (OR:1.18; 95%CI 1.06-1.31; p = 0.002). Conclusions In a cohort of Italian patients, diabetic patients with COPD showed a higher risk of in-hospital mortality and prolonged length of stay compared with diabetic patients without COPD. Defining the causes of these differences would improve public health surveillance systems and policies. Key messages Diabetes is more prevalent in COPD than in the general population. Diabetic patients with COPD showed a higher risk of in-hospital mortality and prolonged length of stay compared with diabetic patients without COPD.

Background Patients with diabetes mellitus (DM) have increased risk of developing infections and complications from infections that require hospitalization and greater healthcare utilization. This study aimed to analyze hospitalizations in DM patients with a diagnosis of infection and to assess the burden of infections on the regional healthcare system in terms of length of stay and in-hospital mortality. Methods A retrospective cross-sectional study was performed from 2006 to 2015 in Abruzzo, an Italian region. Data were collected from hospital discharge records (HDRs) of patients with a diagnosis of DM. All the admissions with an ICD-9 infection diagnostic code were identified. Logistic regression models were implemented to evaluate the association between infections and the study outcomes. Results A total of 182,709 HDRs of DM patients were identified, 12,381 (6.78%) of which related to an infectious disease. The number of admissions with a diagnosis of infection increased during the study period (+4.0%). Respiratory infections were the most common (69.8%), followed by sepsis (9%), and skin and soft tissue infections (8.7%). Factors associated with the infection were age Conclusions Over the study period, hospitalizations related to infections among diabetics rose. The increase was registered mostly among the youngest and the oldest subjects. Infectious disease diagnosis was associated with longer length of stay and higher in-hospital mortality. Cost-effective strategies for infection prevention in patients with DM are needed in order to reduce morbidity and the impact of these conditions on the healthcare system. Key messages Patients with diabetes have increased risk of developing infections. In our study, infectious disease diagnosis was associated with longer length of stay and higher in-hospital mortality. Cost-effective strategies for infection prevention in patients with diabetes are needed in order to reduce morbidity and the impact of these conditions on the healthcare system.

Background Multimorbidity is defined as the presence of more than one long-term disorder and it is associated with increased use of health services. Socioeconomic deprivation and mental health conditions may lead to undesirable additional unplanned admission to hospital (urgent or emergency admission). This study examines the association among unplanned admission, multimorbidity, mental health and socioeconomic deprivation for both preventable and not preventable hospitalization. Methods We conducted a retrospective analysis of hospital discharge records between 2008 and 2018 in Abruzzo, an Italian region. Multilevel logistic regression models were implemented for both preventable and not preventable unplanned admissions. We set as levels the district of residence and Local Health Authority. As independent variables we used the Italian Deprivation Index of the district of residence to mitigate socioeconomic inequalities, unweighted count of physical health conditions (0, 1, 2, 3, ≥4), the presence of a diagnosis of mental health condition. All the models were also adjusted for age and gender. Results We selected 2,017,720 non preventable admissions, 836,808 (41.45%) of which unplanned, and 152,938 preventable admissions, 107,336 (70.18%) of which unplanned. Both unplanned and potentially unplanned admissions were associated with increasing physical multimorbidity (for ≥4 v. 0 condition, OR 4.85; CI95% 4.26-5.53 for unplanned admission and OR 1.42; CI95% 1.11-1.83 for preventable unplanned admission) and with mental health conditions (OR 1.66; CI95% 1.57-1.75 for unplanned admission and OR 1.18; CI95% 1.00-1.38 for preventable unplanned admission). Conclusions Co-occurrence of physical multimorbidity and mental health condition was associated either with unplanned admission or unplanned preventable admission. Primary care interventions targeting multimorbidity are necessary to reduce the hospital service burden. Key messages Physical multimorbidity substantially affects the use of acute hospital services. Primary care interventions targeting multimorbidity are necessary to reduce the hospital service burden.

Background Hospitalization rate for heart failure (HF) is considered a prevention quality indicator and it is used as a tool to evaluate health services quality. This study aims to assess time trends in HF hospitalizations in a region of Southern Italy, focusing on diabetes mellitus as comorbidity. Methods Data were collected from hospital discharge records. All patients aged 18 or over hospitalized for HF in Abruzzo between 2008 and 2018 were selected, either with or without a diagnostic code of diabetes. Admissions for cardiac procedures were excluded. For each year, gender- and age-adjusted standardized hospitalization rates were calculated. Predictors of HF admissions were estimated by a multivariable regression model. Results Over the study period, 60,737 HF admissions occurred, 34,518 of which among people aged more than 65 (56.8%). A total of 15,424 hospitalizations were performed among diabetic patients (25.4%). The overall age- and gender-adjusted HF hospitalization rate declined substantially from 2008 to 2018 (-12.1%). Diabetes (adjOR 2.48; 95%CI 2.41-2.55), myocardial infarction (adjOR 3.92; 95%CI 3.70-4.14), peripheral vascular disease (adjOR 2.30; 95%CI 2.16-2.44), chronic obstructive pulmonary disease (adjOR 3.97; 95%CI 3.86-4.09) and renal disease (adjOR 5.61; 95%CI 5.44-5.78) were factors associated to an increased risk of HF hospitalization. Although HF admission rates remained higher, a significant reduction was highlighted among diabetic patients (-34.7%). Instead, time trend was nearly stable among persons without diabetes (+2.7%). Conclusions This study has shown a decline in HF hospitalization rate over the period considered, particularly among diabetic patients. HF hospitalization may be potentially avoided with good outpatient care. As the causes for HF admissions may include poor quality of care or problems accessing care, it is worthwhile to identify the triggering factors and the potential targets for an early intervention. Key messages A reduction of HF admissions was observed only among diabetics and not among people without diabetes. As the HF hospitalizations are potentially preventable, the knowledge of the epidemiology is crucial for management of preventive health care.

Several social, economic and political factors have contributed to the global spread of alcohol and other drugs. Drug addiction represents a huge expense for the society in terms of direct and indirect health and social consequences, as it is associated with numerous medical issues such as HIV, other infections and psychiatric disturbances.The aim of this study was the assessment of the hospital admissions among drug addicted patients in Abruzzo Region, central Italy, from 2006 to 2015, in order to clarify the specific causes of hospitalization.Data were collected from all hospital discharge records, taking into account only the hospital discharge registrations coded 304 (drug dependence). Multivariate logistic regression was performed to evaluate factors associated with main causes of the admission.Between 2006 and 2015, an amount of 2,159 drug-addicted subjects, aged 38.0±9.7 years, were admitted to hospital. Most of the admissions occurred in public hospitals (2,039, 94.4%), through the emergency room access (1,503, 69.6%) From an amount of 2,159 hospitalizations, 1,178 (54.6%) were first and 981 (45.4%) were subsequent admissions. The most frequent cause of hospitalization was "Psychosis" (419, 19.4%). The trend by range of age showed a progressive reduction in hospital admissions for patients aged45 y. Further, an increase in the hospitalization rate was estimated over recent years among drug addict subjects aged 25-45 years. Cannabis consumption was associated with mental disorder admissions (OR: 3.16, p0.001), opioid consumption was associated with hepatic disorder admission (OR:2.16, p0.001) and cardiovascular admissions (OR: 1,78, p0.001), and cocaine was associated with cardiovascular admissions (OR:1,55, p:0.001).Mental disorders result to be the leading cause of hospitalization among drug-addicts, principally associated with cannabis abuse. Opioid and cocaine abuse was associated with hepatic and cardiovascular disorders.

In this work we provide a closed-form expression of the electromagnetic (EM) scattering from a canonical parallelepipedal target lying over an anisotropic rough surface under the Kirchhoff Approximation - Geometrical Optics solution. Starting from a recent work where we solved a similar scattering problem under the hypothesis of surface isotropy, we here generalize that model to include anistropic properties of the rough surface. The resulting formulation can be fruitfully exploited for fast evaluation of the EM field scattered from isolated buildings in built-up areas and large ships in open sea.

Noroviruses (NoVs) are one of the major causative agents of non-bacterial gastroenteritis in humans worldwide. NoVs, belonging to Caliciviridae, are classified into ten genogroups (G) and eight P-groups based on major capsid protein (VP1) and of the RNA-dependent-RNA-polymerase (RdRp), respectively. In swine, the main genogroup and P-group identified are GII and GII.P; which can infect humans too. To date, only one case of GIIP.11 have been identified in swine in Italy while the circulation of other P-types is currently unknown. In the present study, 225 swine faecal samples were collected from 74 swine herds in Veneto region through on-farm monitoring. NoV circulation was particularly high in older pigs. The phylogenetic analysis showed the co-circulation of NoVs belonging to two different P-types: GII.P11 and GII.P18, here described for the first time in Italy, presenting an extensive genetic diversity, never described before worldwide. Distinct NoV genetic subgroups and unique amino acid mutations were identified for each P-type for the first time. This study demonstrated the co-circulation of diverse swine NoVs subgroups in Italy, raising questions on the origin of such diversity and suggesting that continuous monitoring of swine NoVs is needed to track the emergence of potentially zoonotic viruses by recombination events.

Substance use may influence the onset and course of psychiatric diseases. The "Revolving door" (RD) phenomenon, which indicates repeated hospitalizations of the same patients, has become a public health.The aim of this study was detecting the risk factors associated to hospital readmission to psychiatric wards of drug-addicted patients.The study considered all the admissions performed between 2006 and 2015 in Abruzzo, Italy. Only the hospital discharge registry having code 304 (drug dependence) as diagnosis was taken into account. In addition, only the patients with a psychiatric DRG were included.325 patients performed 558 psychiatric admissions during the study period (1089 person-years). The analyses of the discharge registry showed "Psychoses" as the main DRG (73.2%). An amount of 119 patients experienced a second psychiatric admission. Psychiatric readmissions were independently predicted by Schizofrenia (HR=2.061) and Anxiety disorders (HR=0.326).Psychiatric hospitalization and readmission are frequent among drug-addicted patients. The subsequent RD phenomenon has become a public health issue, both for health and economic sides.

Introduction Surgical site infection (SSI) is one of the most common healthcare-associated infections (HAIs). However, there is a lack of data available about SSI in children worldwide, especially from low-income and middle-income countries. This study aimed to estimate the incidence of SSI in children and associations between SSI and morbidity across human development settings. Methods A multicentre, international, prospective, validated cohort study of children aged under 16 years undergoing clean-contaminated, contaminated or dirty gastrointestinal surgery. Any hospital in the world providing paediatric surgery was eligible to contribute data between January and July 2016. The primary outcome was the incidence of SSI by 30 days. Relationships between explanatory variables and SSI were examined using multilevel logistic regression. Countries were stratified into high development, middle development and low development groups using the United Nations Human Development Index (HDI). Results Of 1159 children across 181 hospitals in 51 countries, 523 (45·1%) children were from high HDI, 397 (34·2%) from middle HDI and 239 (20·6%) from low HDI countries. The 30-day SSI rate was 6.3% (33/523) in high HDI, 12·8% (51/397) in middle HDI and 24·7% (59/239) in low HDI countries. SSI was associated with higher incidence of 30-day mortality, intervention, organ-space infection and other HAIs, with the highest rates seen in low HDI countries. Median length of stay in patients who had an SSI was longer (7.0 days), compared with 3.0 days in patients who did not have an SSI. Use of laparoscopy was associated with significantly lower SSI rates, even after accounting for HDI. Conclusion The odds of SSI in children is nearly four times greater in low HDI compared with high HDI countries. Policies to reduce SSI should be prioritised as part of the wider global agenda. ©

This work aims at assessing the impact on groundwater resources of a leachate overflow occurred in the landfill of Vizzolo-Predabissi (Milan, Italy) after its closure. Hydrogeological sections, piezometric maps, spatio-temporal and multivariate analysis of hydrochemical data enabled to define a conceptual model and to build a groundwater flow model, solved and calibrated by means of MODFLOW-NWT and PEST. The results of the study pointed out that the leachate overflow produced an impulsive contamination, currently in attenuation, which behaved differently in areas with different redox characteristics.

In this paper we present an analytical model for the evaluation of the electromagnetic (EM) scattering from a typical composite target of urban areas in a generic bistatic configuration. The considered scene comprises a canonical building modeled as a parallelepiped lying over a rough terrain. Closed-form expressions for the scattered EM field are derived under the framework of the Kirchhoff approximation, with subsequent Geometrical Optics and Physical Optics approximations adopted for evaluating scattering from building walls and ground, respectively. Single- and multiple-scattering contributions are properly modeled as well as the EM and geometric characteristics of both the composite target and the sensors, such as material composition, size, terrain roughness, building orientation, viewing angle, polarization, frequency. The proposed scattering model can be used in information retrieval procedures using bistatic radar data.

This study aimed to assess the trend of hospitalizations for DKA in adult patients with type 2 diabetes mellitus and its associated factors.A retrospective cross-sectional study was performed. Data were collected from hospital discharge records (HDRs) of patients (age ≥18) with either primary or secondary discharge diagnosis for DKA and type 2 diabetes from 2006 to 2015 in Abruzzo region. Age-adjusted hospitalization rates were computed by gender and standardized on the regional population in 2006. A logistic regression model was implemented using presence of DKA as dependent variable.We identified 160,366 HDRs with type 2 diabetes. Out of them, 1611 (1.00%) were due to DKA. The hospitalization rates for DKA increased both for male +115.9 and female +142.8%, from 2006 to 2015. The most significant predictors of DKA were age 18-44 (aOR=4.17), uncontrolled diabetes (aOR=1.79), trauma (aOR=1.38), any infection (aOR=1.68), liver disease (aOR=1.29), fluid and electrolyte disorders (aOR=2.09), psychosis (aOR=1.69).Trends of DKA in adult patients with type 2 diabetes has been increasing in both male and female. Multimorbidity is an open challenge for public health, therefore better coordination is needed among different specialist consultants to reduce the occurrence of this preventable complication.

Objective To assess predictors of recurrence following laparoscopic radical hysterectomy (LRH) for apparent early stage cervical cancer (CC). Methods This is a retrospective multi-institutional study reviewing data of consecutive patients who underwent LRH for FIGO 2009 stage IA1 (with lymphovascular space invasion (LVSI)), IA2 and IB1(≤4 cm) CC, between January 2006 and December 2017. The following histotypes were included: squamous, adenosquamous, and adenocarcinoma. Multivariable models were used to estimate adjusted odds ratio (OR) and corresponding 95% CI. Factors influencing disease-free survival (DFS) and disease-specific survival (DSS) were also explored. Results 428 patients were included in the analysis. With a median follow-up of 56 months (1–162) 54 patients recurred (12.6%). At multivariable analysis, tumor size (OR:1.04, 95%CI:1.01–1.09, p = .02), and presence of cervical residual tumor at final pathology (OR: 5.29, 95%CI:1.34–20.76, p = .02) were found as predictors of recurrence; conversely preoperative conization reduced the risk (OR:0.32, 95%CI:0.11–0.90, p = .03). These predictors remained significant also in the IB1 subgroup: tumor size: OR:1.05, 95%CI:1.01–1.09, p = .01; residual tumor at final pathology: OR: 6.26, 95%CI:1.58–24.83, p = .01; preoperative conization: OR:0.33, 95%CI:0.12–0.95, p = .04. Preoperative conization (HR: 0.29, 95%CI: 0.13–0.91; p = .03) and the presence of residual tumor on the cervix at the time of surgery (HR: 8.89; 95%CI: 1.39–17.23; p = .01) independently correlated with DFS. No independent factors were associated with DSS. Conclusions In women with early stage CC the presence of high-volume disease at time of surgery represent an independent predictor of recurrence after LRH. Conversely, preoperative conization and the absence of residual disease at the time of surgery might play a protective role.

The input flow of groundwater from the seabed to the coastal ocean, known as Submarine Groundwater Discharge (SGD), has been only recently recognized as an important component of continental margin systems. It potentially impacts physical, chemical and biological marine dynamics. Independently of its specific nature (seepage, submarine springs, etc.) or fluid chemical composition, a SGD is generally characterized by low flow rates, hence making its detection and quantification very difficult, and explaining why it has been somewhat neglected by the scientific community for a long time. Along with the growing interest for SGDs emerged the need for in-situ observations in order to characterize in details how these SGDs behave. In this work, we describe the morphology of a pockmark field, detected in the Southern Tyrrhenian Sea (Mediterranean Sea), and provide observational evidences of the presence of active submarine springs over the coastal shelf area. We describe the effect of the fluid seeps on the water column stratification close to the main plumes and in the neighbouring areas, providing quantitative estimates of the intensity of the turbulent mixing and discussing their potential impact on the seabed morphology and pockmark formation in the context of turbulent buoyant plumes analytical modelling.

We study in real time the optical response of individual plasmonic nanoparticles on a mirror, utilized as electrodes in an electrochemical cell when a voltage is applied. In this geometry, Au nanoparticles are separated from a bulk Au film by an ultrathin molecular spacer. The nanoscale plasmonic hotspot underneath the nanoparticles locally reveals the modified charge on the Au surface and changes in the polarizability of the molecular spacer. Dark-field and Raman spectroscopy performed on the same nanoparticle show our ability to exploit isolated plasmonic junctions to track the dynamics of nanoelectrochemistry. Enhancements in Raman emission and blue-shifts at a negative potential show the ability to shift electrons within the gap molecules.

Pre-slaughter transportation may affect poultry welfare and mortality rates. A retrospective analysis was conducted to examine the effect of environmental, management and individual factors on the percentage of dead birds during pre-slaughter transportation (dead-on-arrival, DOA). The variables accounted for in the analyses included: environmental temperature, travel duration, genetic line, gender, crate type and crate stocking density. Among the 41 452 loads of turkeys (34 696 388 birds) and 3241 of end of lay hens (21 788 124 birds) transported to three large abattoirs in northern Italy in a 3-year period, the median DOA was 0.14% in turkeys, and 0.38% in hens. In turkeys, travel duration longer than 30 min, temperature higher than 26°C and high in-crate densities were associated with increased DOA. In winter (⩽2°C), high stocking densities did not reduce the mortality risk from cold stress; on the contrary, for stocking densities either near to or just above the maximum density in EC Reg. 1/2005, the DOA risk was greater than for loads with densities of 10 kg/m2 less than the EC maximum. Male birds and specific genetic lines also showed a higher DOA. In hens, transportation lasting longer than 2 h and the brown-feathered breed were associated with higher DOA. Dead-on-arrival progressively increased with travel duration, remaining constant between 4 and 6 h and peaking at 8 h (median: 0.57%). The maximum DOA increase was detected during winter. These results show that several species-specific factors may lead to increased risk of mortality.

Noroviruses (NoVs) are one of the major causative agents of non-bacterial gastroenteritis in humans worldwide. NoVs, belonging to Caliciviridae, are classified into ten genogroups (G) and eight P-groups based on major capsid protein (VP1) and of the RNA-dependent-RNA-polymerase (RdRp), respectively. In swine, the main genogroup and P-group identified are GII and GII.P; which can infect humans too. To date, only one case of GIIP.11 have been identified in swine in Italy while the circulation of other P-types is currently unknown. In the present study, 225 swine faecal samples were collected from 74 swine herds in Veneto region through on-farm monitoring. NoV circulation was particularly high in older pigs. The phylogenetic analysis showed the co-circulation of NoVs belonging to two different P-types: GII.P11 and GII.P18, here described for the first time in Italy, presenting an extensive genetic diversity, never described before worldwide. Distinct NoV genetic subgroups and unique amino acid mutations were identified for each P-type for the first time. This study demonstrated the co-circulation of diverse swine NoVs subgroups in Italy, raising questions on the origin of such diversity and suggesting that continuous monitoring of swine NoVs is needed to track the emergence of potentially zoonotic viruses by recombination events.

Background Arsenic is a toxic metalloid element frequently found in the environment. Chronic arsenic exposure is a critical public health issue in many countries since the identification of arsenic and its compounds as human carcinogens by the World Health Organization. After absorption, inorganic arsenic (iAs) is mainly methylated into monomethylated and dimethylated compounds (MMA, DMA), which are then excreted through the kidney together with unmethylated iAs. Whether the methylation process is to detoxify or potentiate arsenic toxicity, however, remains an ongoing debate. The purpose of this systematic review was to conduct a comprehensive meta-analysis to estimate the association between arsenic exposure and urothelial cancer. Methods 10 observational studies met the inclusion criteria and were included in the systematic review. IAs%, MMA% and DMA% were extracted from each paper. Weighted Mean Differences with 95% confidence intervals were defined according to Cases minus Controls. Pooled risk estimates from individual studies were assessed using random effects models. Meta-regression analysis was performed to estimate the extent of urothelial cancer risk as a function of iAs%, MMA% and DMA%. Results Results showed as patients with urothelial cancer presented higher level of urinary iAs% (WMD 2.70, 95%CI 0.64-4.76), MMA% (WMD 2.81, 95%CI 1.43-4.20) and DMA% (WMD-3.44, 95%CI-6.57–0.30). Conclusions These findings suggest that higher level of iAs% and MMA% and lower level of DMA% were associated with an increased risk of urothelial cancer. Additional population based studies are needed to understand the role of arsenic in cancer development. Understanding the meaning of arsenic metabolism could improve the risk assessment of arsenic toxicity and provide a potential tool for disease prediction and prevention. Key messages Higher level of iAs%, MMA% and DMA% were associated with an increased risk of urothelial cancer. Understanding the meaning of arsenic metabolism could improve the risk assessment of arsenic toxicity.

Background Diabetes-related preventable hospitalizations (DRPHs) are indicators of primary care effective services. The aim of this study is to compute the trends of DRPHs, and to assess the risk factors for increased in-hospital length of stay (LOS) and costs in an Italian region. Methods DRPHs were computed following the AHRQ definitions, which include four types: short-term complications (PQI-1), long-term complications (PQI-3), uncontrolled diabetes (PQI-14), lower-extremity amputations (PQI-16). Trends were direct standardized on in-habitants in 2006. Negative binomial regression model was used. Results In the study period PQI-1 increased +426.9 %, PQI-3 +175.5%, PQI-14 +231.7% and PQI-16 decreased -26.2%. Prolonged LOS was related to type 2 diabetes (p < 0.001), peripheral vascular disease (p = 0.045), uncomplicated hypertension (p < 0.001), liver disease (p < 0.001) for PQI-1; type 2 diabetes (p < 0.001), uncomplicated hypertension (p < 0.001), complicated hypertension (p < 0.001) for PQI-3; type 2 diabetes (p < 0.001 ), complicated hypertension (p = 0.001), metastasis (p = 0.042) for PQI-14; female gender (p = 0.001), congestive heart failure (CHF) (p = 0.001), valvulopathy (p = 0.024), BPCO (p = 0.028), renal failure (p < 0.001), liver disease (p = 0.015) for PQI-16.Considerable factors affecting the costs were female gender (p = 0.005), peripheral vascular disease (p = 0.006), renal failure (p = 0.050) for PQI-1; type 2 diabetes (p = 0.002), arrhythmia (p = 0.002), peripheral vascular disease (p < 0.001), BPCO (p < 0.001), renal failure (p < 0.001) for PQI-3; peripheral vascular disease (p = 0.004), uncomplicated hypertension (p = 0.005), BPCO (p = 0.011), renal failure (p = 0.009), liver disease (p < 0.001), psychosis (p = 0.027) for PQI-14; CHF (p = 0.014), arrhythmia (p = 0.001 ), uncomplicated hypertension (p = 0.003), renal failure (p = 0.008), deficiency anemia (p = 0.032) for PQI-16. Conclusions DRPHs has been increasing and some comorbidities need to be better managed in outpatient setting to reduce LOS and costs. Key messages This study addresses the effect of multimorbidity on the burden of diabetes-related preventable hospitalizations using administrative data from an entire italian region over 10 years period. This study uses Prevention Quality Indicators to measure their burden on regional public health and produces useful evidences for the improvement of diabetes management in outpatient setting.

Background Diabetic ketoacidosis (DKA) is a potentially life-threatening but largely preventable complication of diabetes and is associated with significant health care utilization and expenditure. Whereas DKA is mostly related to type 1 diabetes, over recent years an increasing number of hospital admissions for DKA have been reported in adult subjects with type 2 diabetes. The aim of this study was to assess the trend of hospitalizations for DKA in adult patients with type 2 diabetes and its associated factors. Methods A retrospective cross-sectional study was performed from 2006 to 2015 in Abruzzo region. Data were collected from hospital discharge records (HDRs) of type 2 diabetes adult patients with either primary or secondary diagnosis for DKA. Age-adjusted hospitalization rates were computed by gender and standardized on the regional population in 2006. A logistic regression model was implemented using the presence of DKA as dependent variable. Results We identified 160,366 HDRs with type 2 diabetes. Out of them, 1611 (1.00%) were due to DKA. The hospitalization rates for DKA increased both for male +115.9 and female +142.8%, from 2006 to 2015. Associated factors of DKA were age ranging from 18 to 44 (adjOR=4.17; 95%CI:3.27-4.31), uncontrolled diabetes (adjOR=1.79; 95%CI:1.60-2.01), trauma (adjOR=1.38; 95%CI:1.13-1.68), any infection (adjOR=1.68; 95%CI:1.22-.2.33), liver disease (adjOR=1.29; 95%CI:1.09-1.53), fluid and electrolyte disorders (adjOR=2.09; 95%CI:1.09-1.53), psychosis (adjOR=1.69; 95%CI:1.25-2.30). Conclusions Hospitalization trends for DKA in adult patients with type 2 diabetes have been increasing and are associated with some comorbidities. Early screening, appropriate patients, families and communities education remain an important aspect of preventing an acute diabetic complication such as DKA. Moreover, multimorbidity complicates the disease management and remains an open challenge for public health. Key messages This study addresses hospitalizations for DKA in adult patients with type 2 diabetes, an occurrence increasing worldwide for unclear reasons. For preventing DKA in type 2 diabetes patients, it is useful taking into consideration the known trigger factors, but it is also worthwhile improving the management of comorbidities in outpatients.

Background Lower extremity amputations (LEAs) are common among people with diabetes, resulting in high disability and mortality. Understanding trends in diabetes-related LEAs is important for assessing the quality of care. Aim of this study was to evaluate predictors and time trends in LEAs in a region of Southern Italy, focusing on gender difference. Methods Hospital discharge records were used to identify all diabetic adult patients hospitalized for LEAs between 2006 and 2015. For each year, gender- and age-adjusted standardized hospitalization rates for major and minor amputations were calculated and time trends were analyzed by gender. Predictors of LEAs were estimated by a multivariable regression model. Results In the study period, 579 major and 1345 minor amputations were performed in Abruzzo. Gender- and age-adjusted standardized admission rates decreased for minor amputations among both males (-29.96%) and females (-5.33%), whereas major amputations rates decreased only for males (-44.73%). Males were at higher risk of undergoing major (Rate Ratio [RR] 1.41, 95%CI 1.19-1.67) and minor (RR 1.62, 95%CI 1.45-1.82) amputations, but the male-to-female rate ratio decreased for major and minor amputations. Peripheral vascular disease was the main predictor of major (adjOR 4.09, 95%CI 3.31-5.06) and minor amputations (adjOR 12.90, 95%CI 11.00-15.12). Age over 85 (adjOR 9.07, 95%CI 1.84-44.71) and more than 3 comorbidities (adjOR 2.51, 95%CI 1.75-3.60) were parameters associated only with major amputations. Conclusions Reducing the number of LEAs represents a healthcare priority. This study emphasizes the existence of gender disparities in LEAs, highlighting a significant reduction of LEAs for males and a lack of improvement for females. Thus, it is worthwhile to investigate potential clinical, behavioral and healthcare-related causes of this difference, in order to plan health system changes aimed at improving care and facilitating access to health care for women. Key messages Time trends in LEAs showed a substantial improvement only for males, highlighting the existence of gender difference. Understanding the underlying causes is essential to improve the quality of care.

13 pages, 12 figures, 5 tables, Sample disturbance is still a key issue in offshore investigations, especially when logistic and financial limitations do not allow the use of drilling equipment. This paper focuses on the comparison between the disturbance induced by a conventional free-fall piston corer (FF) and a modified piston corer (AD) equipped with a velocity control (Angel Descent method). Twin core samples were retrieved in two successions of pelitic sediments with a prevailing non-clayey fraction and a non-negligible sandy fraction. Comparison was based on different acquisition, physical and mechanical parameters ranging from accelerometer data to magnetic susceptibility logs and geotechnical parameters from laboratory investigations, including oedometer compression tests and cyclic simple shear tests. Accelerometer data highlighted the sharp reduction in velocity obtained for AD samples. Magnetic susceptibility logs, characterized by a pattern of peaks induced by several volcaniclastic levels present in the succession, indicated that the AD method significantly reduces core shortening. Among geotechnical investigations, cyclic shear tests provided small-strain shear moduli always higher in AD samples, whilst the response of oedometer compression tests was equivocal. In fact, methods for assessing sample disturbance have demonstrated to bear limited effectiveness when applied to soils with relatively low clay content and significant overconsolidation as it is the case of the studied sediments, R. Urgeles and J. Llopart acknowledge funding from project INSIGHT (CTM2015-70155-R) jointly funded by the Spanish Ministerio de Economía y Competitividad and the European Regional Development Fund. The research was funded by grants awarded to FB, AC and PT from the National Research Program Flagship Projects RITMARE – The Italian Research for the Sea - coordinated by the Italian National Research Council

Background Studies evaluating the relationship between platelet indices and cardiovascular outcome yielded conflicting results. In particular, the evidence from large, population-based, prospective studies with extended follow-up duration is scarce. Purpose We investigated the incidence of major adverse events in relation to baseline values of platelet count, mean platelet volume (MPV) and platelet distribution width (PDW) in the prospective cohort of the Malmö Diet and Cancer Study. Methods A total of 30,314 middle-aged individuals (mean age 57±8 years; 40% men) were overall included and followed up for a median of 16 years (in total, 468,490 person-years). The following outcome measures were considered: all-cause death, myocardial infarction (MI) and ischemic stroke. Results There was no relationship between increase in MPV or PDW values and adverse events during follow-up. In particular, the incidence of all-cause death, MI and stroke in patients in the 4thquartile of MPV was 19.8% (vs. 20.7% in the 1stquartile; p=0.08), 8.5% (vs. 8.2%; p=0.78) and 7.9% (vs. 7.1%; p=0.09), respectively. The rates of all-cause death, MI and stroke in patients in the 4thquartile of PDW were 20.1% (vs. 20.7% in the 1stquartile; p=0.16), 8.7% (vs. 8.1%; p=0.30) and 8.1% (vs. 7.2%; p=0.09), respectively. There was a significant rise in mortality by platelet count increase (log-rank p264 x 109/L) showed a significantly higher incidence of all-cause death (HR 1.17, 95% CI 1.07–1.28; p=0.001), MI (HR 1.24, 95% CI 1.08–1.43; p=0.003) and stroke (HR 1.20, 95% CI 1.04–1.39; p=0.014) vs the 1stquartile. The higher mortality in the 4thquartile of platelet count was independent of the history of previous stroke, was significant in patients without prior MI (HR 1.18, 95% CI 1.08–1.29; p Conclusions In this population-based, prospective, cohort study there was no difference in the incidence of adverse events across various strata of baseline platelet morphology. However, patients with highest platelet count at baseline showed a significantly higher risk of all-cause death, MI and stroke. Whether or not these individuals should be targeted by more aggressive primary prophylactic measures including antiplatelet treatment, remains to be proven.

Introduction Cerebral side effects have long been recognized as complications to beta-blocker treatment. However, evidence of a longitudinal relationship between the use of beta-blockers and incident dementiais still controversial. Objective To evaluate the longitudinal relationship between use of beta-blockers, as a class, and incident risk of all-cause dementia, vascular dementia, Alzheimer and mixed dementia. Methods From the prospective, population-based, Malmö Preventive Project, 18,063 individuals (mean age 68.2, males 63.4%) were included at baseline and followed for 84,506 person-years. Patients with prevalent cerebrovascular disease and dementia were excluded. In order to weight the risk of incident dementia associated with beta-blocker consumption, we performed propensity score matching analysis, resulting in 3,720 matched pairs of beta-blocker users and non-users at baseline, and multivariable Cox proportional-hazardsregression. Results Overall, 122 study participants (1.6%) were diagnosed with dementia over the course of follow-up. Use of beta-blockers was independently associated with increased risk of developing vascular dementia, regardless of confounding factors (HR: 1.72, 95% CI 1.01–3.78; p=0.048). Conversely, treatment with BB was not associated with increased risk of all-cause, Alzheimer and mixed dementia (HR: 1.15; 95% CI 0.80–1.66; p=0.44; HR: 0.85; 95% CI 0.48–1.54; P=0.59 and HR: 1.35; 95% CI 0.56–3.27; p=0.50, respectively). Conclusions and relevance We observed that use of beta-blockers, as a class, is associated with increased longitudinal risk of vascular dementia in the general elderly population, regardless of cardiovascular risk factors, prevalent or incident history of atrial fibrillation, stroke, coronary events and heart failure. Further studies are needed to confirm our findings in the general population and to explore the mechanisms underlying the relationship between use of beta-blockers and increased risk of vascular dementia.