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Electron paramagnetics resonance has been used to analyze the produced effects in the single crystals undoped of potassium dihidrogen phophate (KH2PO4 or KDP) that were irradiated with electron's beams of 6 MeV energy and they received dose of 1, 21, 36 y 51 Gy. We identified the paramagnetic center (PO3)2- that they were labeled with a and b, which are stables a room tempature. The spectrum were taken to 300 °K with the magnetic field perpendicular to the c axes of the crystals. Finally the paramagnetic centers concentration was calculated as function of the provided dose. [ABSTRACT FROM AUTHOR]

Aims: Septal myectomy is the treatment of choice for hypertrophic obstructive cardiomyopathy (HOCM). Around 30-60% of patients with HOCM have a secondary mitral valve regurgitation due to systolic anterior motion (SAM). We report our experience with extended septal myectomy and its impact on the incidence of concomitant mitral valve procedures., Methods: This is a retrospective study on 84 patients who underwent SM from January 2008 to February 2022. Surgical procedure was performed according to the concept of 'extended myectomy' described by Messmer in 1994. Follow-up outcomes in terms of survival, hospital admissions for heart failure or MV disease, cardiac reoperations, and pacemaker (PMK) implantation were recorded., Results: Mean age was 61 ± 15 years. Mitral valve surgery was performed in seven cases (8%); particularly only one patient without degenerative mitral valve disease underwent mitral valve surgery, with a plicature of the posterior leaflet. In-hospital mortality was 5%. Mitral valve regurgitation greater than mild was present in four patients (5%) at discharge. Twelve-year survival was 78 ± 22%. Cumulative incidence of rehospitalization for heart failure and rehospitalization for mitral valve disease was 10 ± 4 and 2.5 ± 2.5%, respectively. PMK implantation was 5% at discharge, with a cumulative incidence of 15 ± 7%. Freedom from cardiac reoperations was 100%., Conclusion: Septal myectomy for HOCM is associated with good outcomes. Although concomitant surgery on the mitral valve to address SAM and associated regurgitation has been advocated, these procedures were needed in our practice only in patients with intrinsic mitral valve disease. Adequate myectomy addresses the underlying pathophysiology in most patients., (Copyright © 2024 Italian Federation of Cardiology - I.F.C. All rights reserved.)

Introduction: A concise representation of different primary and ambulatory care quality indicators can be very useful for quickly understanding the data and defining appropriate intervention strategies. The objectives of this study are to implement a graphical representation based on the TreeMap, a tool capable of summarizing results from heterogeneous indicators, with different measurement scales and thresholds, and take advantage of TreeMap's potential to measure the indirect impact of the Sars-CoV-2 epidemic on primary and ambulatory care processes., Methods: Seven healthcare areas were considered each defined by a set of different indicators representative of the area. A discrete score ranging from 1 (very high quality) to 5 (very low quality) was assigned to the value of each indicator, based on the level of adherence to evidence-based recommendations. Finally, the score of each healthcare area is obtained as the weighted average of the scores of the representative indicators. The TreeMap is calculated for each Local health authority (Lha) of the Lazio Region. In order to assess the impact of the epidemic, a comparison was made between the results observed in 2019 and those observed in 2020., Results: As an example, the results of one of the 10 Lhas of the Lazio Region have been reported. Compared to 2019, in 2020 there was an improvement in primary and ambulatory healthcare regarding all of the evaluated areas, with the exception of the metabolic area which remained stable. "Avoidable" hospitalizations have decreased, such as those for heart failure, Copd and diabetes. The incidence of cardio-cerebrovascular events following myocardial infarction or ischemic stroke has decreased, and inappropriate visits to emergency room have reduced. Furthermore, after decades of overprescribing, the use of drugs with a high risk of inappropriateness, such as antibiotics and aerosolized corticosteroids, has significantly decreased., Discussion: The TreeMap has proven to be a valid tool for evaluating the quality of primary care, summarizing evidence from different and heterogeneous indicators. The improvements in quality levels observed in 2020, compared to 2019, should be interpreted with extreme caution because they could represent a paradox generated by the indirect effects of the Sars-CoV-2 epidemic. If, in the case of the epidemic, the distorting factors can be easily identified, in different and more ordinary evaluative analyses the "research for the causes" could be much more complex.

By combining field research and careful laboratory analysis of samples over the course of an eight-year study, we met the challenge of assessing the life history traits and health status of eels restocked in freshwater ecosystems. We found that restocked eels exhibited good growth performance; moreover, the stocks were female-dominated, showed a good Fulton's condition factor (K) and lipid stores and had high survival probability estimated using the best model of Jolly-Seber stock assessment method for open populations. A necropsy revealed the absence of internal lesions. A swim bladder examination revealed the absence of the parasite Anguillicola crassus. Polymerase chain reaction (PCR) analyses revealed an increase of Anguillid herpesvirus-1 (AngHV-1) prevalence throughout the study. Most positive subjects expressed viral loads compatible with a latent infection and correlated positively with K. All restocked eels were contaminated by at least one of the organic pollutant congeners studied, but the pollution loads corresponded to the lowest range of pollutant concentrations reported in the available literature for European eels and did not exceed the maximum residue and contaminant limits in food and feed of several national and international regulations. Pollutant loads were negatively correlated with K, lipid content and eel density for polychlorinated biphenyls PCB 138, 153 and 180 and K for pesticides p.p'-DDE, p.p'-DDD, p.p'-DDT and PBDE47. This study highlights the potential role played by upland aquatic ecosystems in enhancing riverine silver eel production from the perspective of species conservation. To be successful, restocking must be accompanied by improved ecosystem quality and migration routes for eels in inland freshwaters. We also provide some recommendations for future research to improve the management of restocking programmes., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interest or personal relationships that could influence the work reported in this paper., (Copyright © 2021 Elsevier B.V. All rights reserved.)

The fitness of restocked European eel (Anguilla anguilla), an endangered fish species, was studied in relation to the environmental variables of habitats in six upland rivers that are typologically different in terms of their hydromorphological and physicochemical characteristics, food resources and fish communities. These rivers received a total of 76,370 imported glass eels in 2017. During a three-year period, we monitored eels with respect to total length, annual growth rate, condition factor and density using capture-mark-recapture experiments to understand the effects of the characteristics of receiving rivers on restocking success levels. Our results showed the survival of the restocked eels in the six rivers and revealed significant differences between them in terms of total length, condition factor and density. Better performance in eel yield variables was observed in a eutrophic alkaline river with greater roughness of riverbed substrates, dominant pool- and riffle-type flow facies and lower brown trout density. The variables conductivity and total hardness had higher explanatory power and were strongly associated with increased eel density. This study suggests that a well-selected habitat/river in a restocking programme can be beneficial for the species and recommends restocking practice as a management tool to achieve eel conservation goals., Competing Interests: Declaration of competing interest The authors declare no competing financial interest or personal relationships that could influence the work reported in this paper., (Copyright © 2021 Elsevier B.V. All rights reserved.)

The allocation of clinical and economic resources is an emerging issue in health management. A useful update necessarily depends on the evaluation of long-term outcomes of clinical and surgical resources that can permit emphasis on all amendable fields, improve quality of care, and reduce health costs. The PRIORITY (PRedictIng long term Outcomes afteR Isolated coronary arTery bypass surgerY) study represents the first innovative step toward the updating of health management in a selected field, surgery for coronary artery disease, which is one of the most prevalent diseases and requires allocation of high-cost resources, although information on long-term outcomes is limited. The aims of the PRIORITY study are the identification of preoperative risk factors for long-term outcomes and the development of clinical and administrative preoperative scores that can guide clinicians and the national health system to more appropriate actions for increasing quality of care and reducing costs.

Background and Objectives: A summary indicator for evaluating the breast cancer network has never been measured at the regional level. The aim is to design treemaps providing a summary description of hospitals (including breast units) and Local Health Units (LHUs) in terms of their levels of performance within the breast cancer network of the Lazio region (central Italy). The treemap structure has an intuitive design and displays information from both general and specific analyses., Methods: Patients admitted to the regional hospitals for malignant breast cancer (MBC) surgery in 2010-2017 were selected in a population-based cohort study. These quality indicators were calculated based on the international guidelines (EUSOMA, ESMO) to assess the performance in terms of volume of activity, surgery procedure, post-surgery assistance and timeliness of medical therapy or radiotherapy beginning. The quality indicators were calculated using administrative health data systematically collected at the regional level and were included in the treemap to represent the surgery or the post-surgery areas of the breast cancer clinical pathway. In order to allow aggregation of scores for different indicators belonging to the same clinical area, up to five evaluation classes were defined using the "Jenks Natural Breaks" algorithm. A score and a colour were assigned to each clinical area based on the ranking of the indicators involved. The analyses were performed on an annual basis, by the LHU of residence and by the hospital which performed the surgical intervention., Results: In 2017, 6218 surgical interventions for MBC were performed in the hospitals of Lazio. The results showed a continuous increase of the level of performance over the years. Hospitals showed higher variability in the levels of performance than the LHUs. 36% of the evaluated hospitals reached a high level of performance. An audit of the S. Filippo Neri breast unit revealed incorrect coding of the input data. For this reason, the score for the indicator for the volume of wards was re-calculated and re-evaluated, with a subsequent improvement of the level of performance. Most LHUs achieved at least an average overall level of performance, with 20% of the LHUs reaching a high level of performance., Conclusions: This is the first attempt to apply the treemap logic to a single clinical network, in order to obtain a summary indicator for the evaluation of the breast cancer care network. Our results supply decision makers with a transparent instrument of governance for heterogeneous users, directing efforts improving and promoting equity of care. The treemaps could be reproduced and adapted for other local contexts, in order to limit inappropriateness and ensure uniform levels of breast cancer care within local areas. The next step is the evaluation of audit and feedback interventions to improve the quality of care and to guarantee homogeneous levels of care throughout the region., Competing Interests: The authors have declared that no competing interests exist.

Objectives: Our goal was to analyse a consecutive series of patients with solid organ tumours undergoing coronary artery bypass grafting (CABG) by defining the risk factors for early and long-term outcomes., Methods: Between 2005 and 2016, a consecutive series of 4079 patients underwent isolated CABG at our institution. Of 103 patients (2.5%) with active malignancy, we enrolled 82 patients (mean age 71 ± 7 years) with solid organ tumours, divided into 4 subgroups: lung (9 patients-11%), gastroenteric (16 patients-20%), urinary (48 patients-58%) and other solid tumours (9 patients-11%). A deterministic record linkage between the clinical database and the National Hospital Information System allowed identification of long-term survival rates and freedom from major adverse cardiovascular events (acute myocardial infarction, repeated admissions for percutaneous coronary intervention and heart failure)., Results: The most common forms of cancer were prostate, colon and carcinoma of the lung. Compared to patients without cancer, patients with neoplasms were significantly older and had a higher rate of comorbidities, without significant differences among the cancer subgroups. The 30-day mortality rate was significantly higher in patients with cancer compared to those without cancer (4.9% vs 1.8%). However, on logistic regression analysis, cancer was an independent risk factor for postoperative pulmonary dysfunction but not for in-hospital death. The median follow-up time was 58 ± 12 months. The overall 5-year survival rate was 60% [95% confidence interval (CI) 47-71%], with a dismal 32% (95% CI 5-65%) survival rate among patients who had lung tumours only. The 5-year freedom from major adverse cardiovascular events was 64% (95% CI 52-74%), without significant differences among subgroups, and was comparable to that of the non-cancer population. Resolution of coronary heart disease allowed safe cancer surgical resection in 80% of the population., Conclusions: Based on the results from the present study, CABG should not be denied to patients with solid organ tumours by claiming a worse prognosis or less graft durability. Further studies with larger numbers are warranted., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Many large European rivers have undergone multiple pressures that have strongly impaired ecosystem functioning at different spatial and temporal scales. Global warming and other environmental changes have favored the success of invasive species, deeply modifying the structure of aquatic communities in large rivers. Some exogenous species could alter trophic interactions within assemblages by increasing the predation risk for potential prey species (top-down effect) and limiting the dynamics of others via resource availability limitation (bottom-up effect). Furthermore, large transboundary rivers are complex aquatic ecosystems that have often been poorly investigated so that data for assessing long-term ecological trends are missing. In this study, we propose an original approach for investigating long-term combined effects of global warming, trophic resource decrease, predation risk, and water quality variations on the trait-based structure of macroinvertebrate and fish assemblages over 26 yr (1985-2011) and 427-km stretch of the river Meuse (France and Belgium). The study of temporal variations in biological, physiological, and ecological traits of macroinvertebrate and fish allowed identifying community trends and distinguishing impacts of environmental perturbations from those induced by biological alterations. We provide evidence, for this large European river, of an increase in water temperature (close to 1°C) and a decrease in phytoplankton biomass (-85%), as well as independent effects of these changes on both invertebrate and fish communities. The reduction of trophic resources in the water column by invasive molluscs has dramatically affected the density of omnivorous fish in favor of invertebrate feeders, while scrapers became the major feeding guild among invertebrates. Macroinvertebrate and fish communities have shifted from large-sized organisms with low fecundity to prolific, small-sized organisms, with early maturity, as a response to increased predation pressure., (© 2017 by the Ecological Society of America.)

BACKGROUND Improving quality and effectiveness of healthcare is one of the priorities of health policies. Hospital or physician volume represents a measurable variable with an impact on effectiveness of healthcare. An Italian law calls for the definition of «qualitative, structural, technological, and quantitative standards of hospital care». There is a need for an evaluation of the available scientific evidence in order to identify qualitative, structural, technological, and quantitative standards of hospital care, including the volume of care above or below which the public and private hospitals may be accredited (or not) to provide specific healthcare interventions. OBJECTIVES To identify conditions/interventions for which an association between volume and outcome has been investigated. To identify conditions/interventions for which an association between volume and outcome has been proved. To analyze the distribution of Italian health providers by volume of activity. To measure the association between volume of care and outcomes of the health providers of the Italian National Health Service (NHS). METHODS Systematic review An overview of systematic reviews was performed searching PubMed, EMBASE, and The Cochrane Library up to November 2016. Studies were evaluated by 2 researchers independently; quality assessment was performed using the AMSTAR checklist. For each health condition and outcome, if available, total number of studies, participants, high volume cut-off values, and metanalysis have been reported. According to the considered outcomes, health topics were classified into 3 groups: positive association: a positive association was demonstrated in the majority of studies/participants and/or a pooled measure (metanalysis) with positive results was reported; lack of association: both studies and/or metanalysis showed no association; no sufficient evidence of association: both results of single studies and metanalysis do not allow to draw firm conclusions on the association between volume and outcome. Analysis of the distribution of Italian hospitals by volume of activity and the association between volume of activity and outcomes: the Italian National Outcome evaluation Programme 2016 The analyses were performed using the Hospital Information System and the National Tax Register (year 2015). For each condition, the number of hospitals by volume of activity was calculated. Hospitals with a volume lower than 3-5 cases/year were excluded. For conditions with more than 1,500 cases/year and frequency of outcome ≥1%, the association between volume of care and outcome was analyzed estimating risk-adjusted outcomes. RESULTS Bibliographic searches identified 80 reviews, evaluating 48 different clinical areas. The main outcome considered was intrahospital/30-day mortality. The other outcomes vary depending on the type of condition or intervention in study. The relationship between hospital volume and outcomes was considered in 47 out of 48 conditions: 34 conditions showed evidence of a positive association; • 14 conditions consider cancer surgery for bladder, breast, colon, rectum, colon rectum, oesophagus, kidney, liver, lung, ovaries, pancreas, prostate, stomach, head and neck; • 11 conditions consider cardiocerebrovascular area: nonruptured and ruptured abdominal aortic aneurysm, acute myocardial infarction, brain aneurysm, carotid endarterectomy, coronary angioplasty, coronary artery bypass, paediatric heart surgery, revascularization of lower limbs, stroke, subarachnoid haemorrhage; • 2 conditions consider orthopaedic area: knee arthroplasty, hip fracture; • 7 conditions consider other areas: AIDS, bariatric surgery, cholecystectomy, intensive care unit, neonatal intensive care unit, sepsis, and traumas; for 3 conditions, no association was demonstrated: hip arthroplasty, dialysis, and thyroidectomy. for the remaining 10 conditions, the available evidence does not allow to draw firm conclusions about the association between hospital volume and considered outcomes: surgery for testicular cancer and intracranial tumours, paediatric oncology, aortofemoral bypass, cardiac catheterization, appendectomy, colectomy, inguinal hernia, respiratory failure, and hysterectomy. The relationship between volume of clinician/surgeon and outcomes was assessed only through the literature re view; to date, it is not possible to analyze this association for Italian health provider hospitals, since information on the clinician/surgeon on the hospital discharge chart is missing. The literature found a positive association for 21 conditions: 9 consider surgery for cancer: bladder, breast, colon, colon rectum, pancreas, prostate, rectum, stomach, and head and neck; 5 consider the cardiocerebrovascular area: ruptured and nonruptured abdominal aortic aneurysm, carotid endarterectomy, paediatric heart surgery, and revascularization of the lower limbs; 2 consider the orthopaedic area: knee and hip arthroplasty; 5 consider other areas: AIDS, bariatric surgery, hysterectomy, intensive care unit, and thyroidectomy. The analysis of the distribution of Italian hospitals concerned the 34 conditions for which the systematic review has shown a positive volume-outcome association. For the following, it was possible to conduct the analysis of the association using national data: unruptured abdominal aortic aneurysm, coronary angioplasty, hip arthroplasty, knee arthroplasty, coronary artery bypass, cancer surgery (colon, liver, breast, pancreas, lung, prostate, kidney, and stomach), laparoscopic cholecystectomy, hip fracture, stroke, acute myocardial infarction. For these conditions, the association between volume and outcome of care was observed. For laparoscopic cholecystectomy and surgery of the breast and stomach cancer, the association between the volume of the discharge (o dismissal) operating unit and the outcome was analyzed. The outcomes differ depending on the condition studied. The shape of the relationship is variable among different conditions, with heterogeneous slope of the curves. DISCUSSION For many conditions, the overview of systematic reviews has shown a strong evidence of association between higher volumes and better outcomes. The quality of the available reviews can be considered good for the consistency of the results between the studies and for the strength of the association; however, this does not mean that the included studies are of good quality. Analyzing national data, potential confounders, including age and comorbidities, have been considered. The systematic review of the literature does not permit to identify predefined volume thresholds. The analysis of national data shows a strong improvement in outcomes in the first part of the curve (from very low to higher volumes) for most conditions. In some cases, the improvement in outcomes remains gradual or constant with the increasing volume of care; in other, the analysis could allow the identification of threshold values beyond which the outcome does not further improve. However, a good knowledge of the relationship between effectiveness of treatments and costs, the geographical distribution and the accessibility to healthcare services are necessary to choose the minimum volumes of care, under which specific health procedures could not been provided in the NHS. Some potential biases due to the use of information systems data should also be considered. The different way of coding among hospitals could lead to a different selection of cases for some conditions. Regarding the definition of the exposure (volume of care), a possible bias could result from misclassification of health providers with high volume of activity. Performing the intervention in different departments/ units of the same hospital would result in an overestimation of the volume of care measured for hospital rather than for department/unit. For the conditions with a further fragmentation within the same structure, the association between volumes of discharge department and outcomes has also been evaluated. In this case, the two curves were different. The limit is to attribute the outcome to the discharge unit, which in case of surgery may not be the intervention unit. A similar bias could occur if the main determinant of the outcome of treatment was the caseload of each surgeon. The results of the analysis may be biased when different operators in the same hospital/unit carried out the same procedure. In any case, the observed association between volumes and outcome is very strong, and it is unlikely to be attributable to biases of the study design. Another aspect on which there is still little evidence is the interaction between volume of the hospital and of the surgeon. A MEDICARE study suggests that in some conditions, especially for specialized surgery, the effect of the surgeon's volume of activity is different depending on the structure volume, whereas it would not differ for some less specialized surgery conditions. The data here presented still show extremely fragmented volumes of both clinical and surgical areas, with a predominance of very low volume structures. Health systems operate, by definition, in a context of limited resources, especially when the amount of resources to allocate to the health system is reduced. In such conditions, the rationalization of the organization of health services based on the volume of care may make resources available to improve the effectiveness of interventions. The identification and certification of services and providers with high volume of activity can help to reduce differences in the access to non-effective procedures. To produce additional evidence to guide the reorganization of the national healthcare system, it will be necessary to design further primary studies to evaluate the effectiveness and safety of policies aimed at concentrating interventions in structures with high volumes of activity.

Modeling individual fish habitat selection in highly variable environments such as hydropeaking rivers is required for guiding efficient management decisions. We analyzed fish microhabitat selection in the heterogeneous hydraulic and thermal conditions (modeled in two-dimensions) of a reach of the large hydropeaking Rhône River locally warmed by the cooling system of a nuclear power plant. We used modern fixed acoustic telemetry techniques to survey 18 fish individuals (five barbels, six catfishes, seven chubs) signaling their position every 3s over a three-month period. Fish habitat selection depended on combinations of current microhabitat hydraulics (e.g. velocity, depth), past microhabitat hydraulics (e.g. dewatering risk or maximum velocities during the past 15days) and to a lesser extent substrate and temperature. Mixed-effects habitat selection models indicated that individual effects were often stronger than specific effects. In the Rhône, fish individuals appear to memorize spatial and temporal environmental changes and to adopt a "least constraining" habitat selection. Avoiding fast-flowing midstream habitats, fish generally live along the banks in areas where the dewatering risk is high. When discharge decreases, however, they select higher velocities but avoid both dewatering areas and very fast-flowing midstream habitats. Although consistent with the available knowledge on static fish habitat selection, our quantitative results demonstrate temporal variations in habitat selection, depending on individual behavior and environmental history. Their generality could be further tested using comparative experiments in different environmental configurations., (Copyright © 2016 Elsevier B.V. All rights reserved.)

Background: The European System for Cardiac Operation Risk Evaluation (EuroSCORE) II has not been tested yet for predicting long-term mortality. This study was undertaken to evaluate the relationship between EuroSCORE II and long-term mortality and to develop a new algorithm based on EuroSCORE II factors to predict long-term survival after cardiac surgery., Methods: Complete data on 10,033 patients who underwent major cardiac surgery during a 7-year period were retrieved from three prospective institutional databases and linked with the Italian Tax Register Information System. Mortality at follow-up was analyzed with time-to-event analysis., Results: The Kaplan-Meier estimates of survival at 1 and 5 were, respectively, 95.0% ± 0.2% and 84.7% ± 0.4%. Both discrimination and calibration of EuroSCORE II decreased in the prediction of 1-year and 5-year mortality. Nonetheless, EuroSCORE II was confirmed to be an independent predictor of long-term mortality with a nonlinear trend. Several EuroSCORE II variables were independent risk factors for long-term mortality in a regression model, most of all very low ejection fraction (less than 20%), salvage operation, and dialysis. In the final model, isolated mitral valve surgery and isolated coronary artery bypass graft surgery were associated with improved long-term survival., Conclusions: The EuroSCORE II cannot be considered a direct estimator of long-term risk of death, as its performance fades for mortality at follow-up longer than 30 days. Nonetheless, it is nonlinearly associated with long-term mortality, and most of its variables are risk factors for long-term mortality. Hence, they can be used in a different algorithm to stratify the risk of long-term mortality after surgery., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Contemporary scores for estimating perioperative death have been proposed to also predict also long-term death. The aim of the study was to evaluate the performance of the updated European System for Cardiac Operative Risk Evaluation II, The Society of Thoracic Surgeons Predicted Risk of Mortality score, and the Age, Creatinine, Left Ventricular Ejection Fraction score for predicting long-term mortality in a contemporary cohort of isolated aortic valve replacement (AVR). We also sought to develop for each score a simple algorithm based on predicted perioperative risk to predict long-term survival., Methods: Complete data on 1,444 patients who underwent isolated AVR in a 7-year period were retrieved from three prospective institutional databases and linked with the Italian Tax Register Information System. Data were evaluated with performance analyses and time-to-event semiparametric regression., Results: Survival was 83.0% ± 1.1% at 5 years and 67.8 ± 1.9% at 8 years. Discrimination and calibration of all three scores both worsened for prediction of death at 1 year and 5 years. Nonetheless, a significant relationship was found between long-term survival and quartiles of scores (p < 0.0001). The estimated perioperative risk by each model was used to develop an algorithm to predict long-term death. The hazard ratios for death were 1.1 (95% confidence interval, 1.07 to 1.12) for European System for Cardiac Operative Risk Evaluation II, 1.34 (95% CI, 1.28 to 1.40) for the Society of Thoracic Surgeons score, and 1.08 (95% CI, 1.06 to 1.10) for the Age, Creatinine, Left Ventricular Ejection Fraction score., Conclusions: The predicted risk generated by European System for Cardiac Operative Risk Evaluation II, The Society of Thoracic Surgeons score, and Age, Creatinine, Left Ventricular Ejection Fraction scores cannot also be considered a direct estimate of the long-term risk for death. Nonetheless, the three scores can be used to derive an estimate of long-term risk of death in patients who undergo isolated AVR with the use of a simple algorithm., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The freshwater sculpins (genus Cottus) are small, bottom-living fishes widely distributed in North America and Europe. The taxonomy of European species has remained unresolved for a long time due to the overlap of morphological characters. Sound production has already been documented in some cottid representatives, with sounds being involved in courtship and agonistic interactions. Although the movements associated with sound production have been observed, the underlying mechanism remains incomplete. Here, we focus on two closely related species from Belgium: C. rhenanus and C. perifretum. This study aims 1) to record and to compare acoustic communication in both species, 2) to give further insight into the sound-producing mechanism and 3) to look for new morphological traits allowing species differentiation., Results: Both Cottus species produce multiple-pulsed agonistic sounds using a similar acoustic pattern: the first interpulse duration is always longer, making the first pulse unit distinct from the others. Recording sound production and hearing abilities showed a clear relationship between the sound spectra and auditory thresholds in both species: the peak frequencies of calls are around 150 Hz, which corresponds to their best hearing sensitivity. However, it appears that these fishes could not hear acoustic signals produced by conspecifics in their noisy habitat considering their hearing threshold expressed as sound pressure (~ 125 dB re 1 μPa). High-speed video recordings highlighted that each sound is produced during a complete back and forth movement of the pectoral girdle., Conclusions: Both Cottus species use an acoustic pattern that remained conserved during species diversification. Surprisingly, calls do not seem to have a communicative function. On the other hand, fish could detect substrate vibrations resulting from movements carried out during sound production. Similarities in temporal and spectral characteristics also suggest that both species share a common sound-producing mechanism, likely based on pectoral girdle vibrations. From a morphological point of view, only the shape of the spinelike scales covering the body allows species differentiation.

Objective: To analyse the results of the regional comparative evaluation of the outcome "thirty days mortality after admission for reacutized Chronic obstructive pulmonary disease (COPD)" before and after a reabstract study., Design: Reabstract study of clinical records included in the regional comparative evaluation., Setting and Participants: 232 clinical records retrieved from Grassi Hospital archives (years 2006-2007) and reviewed by two physicians and one nurse specifically trained., Main Outcome Measures: Models performed before and after reabstract study for comparative evaluation of the outcome were compared. Blind coding of diagnosis and interventions/procedures was completed according to a standard grid consistent with regional guidelines for Hospital Discharge Record coding. Other information was registered, if present on discharge record: smoking habit, number of reacutizations occurred within previous year, use of oxigen and/or other therapies, pneumological visit at discharge., Results: The majority (94%) of reviewed cases were confirmed as being cases of COPD. A total of 168 cases (72%) have been identified as reacutized COPD coherent with enrolment criteria of regional program, 49 (21%) have been identified as COPD and only 15 cases (6%) resulted not affected by COPD. Results of the regional comparative model were substantially unchanged for Grassi hospital (RR =23 vs RR =24). Accurateness of clinical documentation resulted inadequate especially regarding information at discharge (50% missing information on smoking habit, 83% on previous year reacutizations, 22% on follow-up organization after discharge)., Conclusion: This study contributes to the debate on the role of administrative data on the comparative evaluation of health outcomes. Other relevant issues are to promote the collaboration among different health professionals working in the same hospital, and to increase the awareness of the importance of the quality of health and administrative data.

Background: P.Re.Val.E. is the most comprehensive comparative evaluation program of healthcare outcomes in Lazio, an Italian region, and the first Italian study to make health provider performance data available to the public. The aim of this study is to describe the P.Re.Val.E. and the impact of releasing performance data to the public., Methods: P.Re.Val.E. included 54 outcome/process indicators encompassing many different clinical areas. Crude and adjusted rates were estimated for the 2006-2009 period. Multivariate regression models and direct standardization procedures were used to control for potential confounding due to individual characteristics. Variable life-adjusted display charts were developed, and 2008-2009 results were compared with those from 2006-2007., Results: Results of 54 outcome indicators were published online at http://www.epidemiologia.lazio.it/prevale10/index.php. Public disclosure of the indicators' results caused mixed reactions but finally promoted discussion and refinement of some indicators. Based on the P.Re.Val.E. experience, the Italian National Agency for Regional Health Services has launched a National Outcome Program aimed at systematically comparing outcomes in hospitals and local health units in Italy., Conclusions: P.Re.Val.E. highlighted aspects of patient care that merit further investigation and monitoring to improve healthcare services and equity.

Observational outcome studies represent a valid approach to evaluating comparative treatment effectiveness in real populations. The main objective of outcome research is to underline what works and what does not work in the field of health assistance. In 2004 the Italian Ministry of Health launched the Project "Mattone Misura dell'Outcome" aimed at assessing the introduction of procedures and methods for the systematic evaluation of outcomes in the national health system. A new experience, the PROGRESSI program (PROGRamma ESiti per SIVeAS e LEA), started in 2008 with the aim to further develop the methodologies for outcome evaluation. In this Supplement the final results from four clinical studies named "Sperimentazioni dell'area cardiovascolare del Progetto Mattoni" are presented. These studies started between 2005 and 2007 and their main objectives were to evaluate: --the contribution of information from current informative systems and clinical studies in risk-adjustment methodologies; --the advisability of introducing some clinical items in current informative systems to improve outcome estimates; --the goodness of follow-up procedures from current informative systems; and --the role of disease registries in the validation of comparative evaluation measures. The four studies were designed as voluntary prospective multicentre studies. Results concerning the characteristics of the enrolled populations as well as the risk-adjustment models built using information from current informative systems and/or clinical information are presented. As expected, each study produced specific remarks both in terms of clinical findings and contribution of different informative systems to the risk-adjustment models. In general, models built with information from both current informative systems and clinical information show the best performance. Findings from these analyses will provide the public health system with suitable indications to improve statistical methodologies for outcome estimates.

Objective: Comparative evaluations of clinical outcomes (e.g., in-hospital mortality, complications after a surgical procedure) or health care processes involve the definition of several indicators for each study unit. Graphical displays are best suited for highlighting the main patterns in the data. The aim of this study was to compare different graphical techniques, including target plots, radar plots, and "spie" charts, for comparing the performances of different health care providers., Study Design and Setting: Thirteen indicators were calculated and combined in eight composite indices for eight clinical categories of interest. The indices were displayed with target plots, radar plots, and "spie" charts., Results: All the three techniques had an immediate interpretation and were easy to implement. However, target plots failed to highlight small differences between indicators, whereas radar plots were strongly influenced by the order in which the indicators were displayed. Both target and radar plots assumed equal weights for the indicators, and did not allow predetermined judgments on the relative importance of the indicators. "Spie" charts overcame the primary limitations of the other two techniques. Furthermore, they are well suited to summarize the overall performance of a health care provider with a single score., Conclusion: "Spie" charts represented the best graphical tool for displaying multivariate health care data in comparative evaluations of clinical outcomes and processes of care among health care providers., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: High ambient summer temperatures have been shown to influence daily mortality in cities across Europe. Quantification of the population mortality burden attributable to heat is crucial to the development of adaptive approaches. The impact of summer heat on mortality for 15 European cities during the 1990s was evaluated, under hypothetical temperature scenarios warmer and cooler than the mean and under future scenarios derived from the Intergovernmental Panel on Climate Change Special Report on Emission Scenarios (SRES)., Methods: A Monte Carlo approach was used to estimate the number of deaths attributable to heat for each city. These estimates rely on the results of a Bayesian random-effects meta-analysis that combines city-specific heat-mortality functions., Results: The number of heat-attributable deaths per summer ranged from 0 in Dublin to 423 in Paris. The mean attributable fraction of deaths was around 2%. The highest impact was in three Mediterranean cities (Barcelona, Rome and Valencia) and in two continental cities (Paris and Budapest). The largest impact was on persons over 75 years; however, in some cities, important proportions of heat-attributable deaths were also found for younger adults. Heat-attributable deaths markedly increased under warming scenarios. The impact under SRES scenarios was slightly lower or comparable to the impact during the observed hottest year., Conclusions: Current high summer ambient temperatures have an important impact on European population health. This impact is expected to increase in the future, according to the projected increase of mean ambient temperatures and frequency, intensity and duration of heat waves.

Objective: In countries where the National Health Service provides universal health coverage, socioeconomic position should not influence the quality of health care. We examined whether socioeconomic position plays a role in short-term mortality and waiting time for surgery after hip fracture., Design: Retrospective cohort study., Setting: and participants From the Hospital Information System database, we selected all patients, aged at least 65 years and admitted to acute care hospitals in Rome for a hip fracture between 1 January 2006 and 30 November 2007. The socioeconomic position of each individual was obtained using a city-specific index of socioeconomic variables based on the individual's census tract of residence., Main Outcome Measures: Three different outcomes were defined: waiting times for surgery, mortality within 30 days and intervention within 48 h of hospital arrival for hip fracture. We used a logistic regression to estimate 30-day mortality and a Cox proportional hazard model to calculate hazard ratios of intervention within 48 h. Median waiting times were estimated by adjusted Kaplan-Meyer curves. Analyses were adjusted for age, gender and coexisting medical conditions., Results: Low socioeconomic level was significantly associated with higher risk of mortality [adjusted relative risk (RR) = 1.51; P < 0.05] and lower risk of early intervention (adjusted RR = 0.32; P < 0.001). Socioeconomic level had also an effect on waiting times within 30 days., Conclusions: Individuals living in disadvantaged census tracts had poorer prognoses and were less likely than more affluent people to be treated according to clinical guidelines despite universal healthcare coverage.

Background: In Lazio region (Italy), mortality data are currently available from the death cause registry (DCR), which reports only underlying causes. Mortality due to other causes, defined concurrent mortality, are need to appropriately estimate the health impact from chronic diseases. The aims of the study were to estimate concurrent mortality from chronic obstructive pulmonary disease (COPD), using hospital discharge registry (HDR), to discuss the validity and limits of this method, and to compare underlying and concurrent mortality from COPD in the Lazio region., Methods: A mortality study was carried out for residents who died in 1996-2000 with COPD listed as the underlying cause of death and those who died in the hospital with a different underlying cause of death listed but with a discharge diagnosis of COPD. Age-standardized mortality rates were obtained for males and females separately, using the direct method. A random sample of death certificates was used to validate concurrent causes of death as defined from discharge diagnoses., Results: Age-standardised mortality for COPD as underlying cause of death was 3.68/10,000 in male and 2.29/10,000 in female residents. Mortality increased slightly in the study period for women, but no trend was evident. Age-standardised mortality for COPD as concurrent cause of death was 2.39/10,000 in male and 1.31/10,000 in female residents. The positive predictive value for concurrent COPD mortality was 54.3%., Conclusions: Concurrent COPD mortality contributed 62.3% to the whole mortality. The estimates of concurrent COPD mortality were comparable to those reported in other countries, though using hospital data may overestimate the real concurrent mortality as estimated from death certificates.

Study Objective: To investigate geographical and temporal variations in the temperature-mortality relation., Design: The relation between mortality and maximum apparent temperature (Tappmax) in 2003, 2004, and a previous reference period was explored by using segmented regression and generalised additive models., Setting: Four Italian cities (Bologna, Milano, Roma, and Torino), included in a national network of prevention programmes and heat health watch warning systems (HHWWS) were considered., Participants: Daily mortality counts of the resident population dying in each city during summer (June to September)., Main Results: The impact of Tappmax on mortality differed between cities and varied in the three periods analysed. The geographical heterogeneity of the J shaped relation was seen in the reference period with Tappmax thresholds ranging from 28 degrees C in Torino to 32 degrees C in Milano and Roma. In all cities, the percentage variation in mortality was greatest in 2003. In Torino and Roma a significant increase was seen also at lower Tappmax values that are usually not associated to an increase in mortality (26-28 degrees C). In summer 2004 the exposure levels were similar to the reference period; only in Torino the effect of Tappmax on mortality remained relevant even if reduced compared with 2003, while in Bologna no statistically significant effect was seen for any temperature range., Conclusions: The observed heterogeneous reduction in the impact of temperature on mortality from 2003 to 2004 may be partly explained by the lower levels of exposure. Changes in the ability of individuals and communities to adjust to high temperatures as a consequence of the implementation of public health interventions, based on HHWWS, characterised by a diverse effectiveness, may also have played an important part.

This study evaluates the impact of the 2003 heat wave on cause-specific mortality and the role of demographic characteristics and socioeconomic conditions that may have increased the risk of mortality in four Italian cities: Bologna, Milan, Rome and Turin. Daily mortality counts, for the resident population by age, sex and cause of death were considered. Daily excess mortality was calculated as the difference between the number of deaths observed and the smoothed average. The impact of heat on health is measured in terms of maximum apparent temperature. The greatest excess in mortality was observed in the north west of Italy (Turin, +23% and Milan, +23%). The old (75-84 years) and the very old (85+ years) were the age groups most affected, and when stratifying by sex, the increase in mortality seemed to be greater among females. The greatest excess in mortality was registered in those with low socioeconomic status in Rome (+17.8%) and in those with lower education levels in Turin (+43%). The analysis of cause-specific mortality not only confirms results from previous studies of an increase in heat-related mortality by respiratory and cardiovascular diseases, but also shows a significant excess in mortality for diseases of the central nervous system and for metabolic/endocrine disorders. Results from 2003 highlight the necessity of targeting future prevention programmes at the susceptible sub-groups identified. The introduction of warning systems alongside efficient preventive plans and the monitoring of mortality during heat waves may represent a valid tool for the reduction of heat-related deaths.