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In this work we provide an analysis of some issues arising with geometrical representations of a family of deontic and potestative relations that can be classified as Hohfeldian modalities, traditionally illustrated on two diagrams, the Hohfeldian squares. Our main target is the lack of symmetry to be found in various formal accounts by drawing analogies with the square of opposition for alethic modalities. We argue that one should rather rely on an analogy with the alethic hexagon of opposition and exploit the notions of contingency and absoluteness in order to restore the symmetry of Hohfeldian modalities in accordance to the diagrams presented by Hohfeld. Interestingly, the investigation unveils three potestative squares defined at different levels of granularity (force, outcome and change) and allows us to further elaborate on the connections between deontic and potestative relations.

Normative positions are sometimes illustrated in diagrams, in particular in didactic contexts. Traditional examples are the Aristotelian polygons of opposition for deontic modalities (squares, triangles, hexagons, etc.), and the Hohfeldian squares for obligative and potestative concepts. Relying on previous work, we show that Hohfeld’s framework can be used as a basis for developing several Aristotelian polygons and more complex diagrams. Then, we illustrate how logical theories of increasing strength can be built based on these diagrams, and how those theories enable us to determine in a computably efficient way whether a set of normative positions can be derived from another set of normative positions.

Background and aim: An increase of vaccine hesitancy has spread worldwide and lead to reduction in coverage rates. The trivalent Measles-Mumps-Rubella (MMR) vaccine has been one of the most targeted leading due to possible (but never proven) adverse effects. This resulted in an increase of measles cases. The aim of the study is to analyze the 24-months coverage rates for the MMR vaccine in Emilia-Romagna Region (RER) between 2007 and 2018 and to correlate any significant changes to index events. Methods: Official aggregate data on vaccination coverage at 24-month provided by the RER and the Italian Ministry of health were analyzed and discussed. Results: From 2012 to 2015 a significant reduction in vaccination rates has been registered. In the following years an increase was recorded temporarily related to national and regional laws. Conclusion: The mandatory vaccination strategies seem to be in the short period effective in RER to counteract the growing population neegative attitudes towards vaccination and mitigate vaccine hesitancy.

BackgroundStigma and discrimination are a significant public health concern and cause great distress to people with mental illness. Healthcare professionals have been identified as one source of this discrimination. In this article we describe the protocol of an international, multisite controlled study, evaluating the effectiveness of READ, an anti-stigma training for medical students towards patients with mental illness. READ aims to improve students’ ability to minimise perceived discriminatory behaviours and increase opportunities for patients, therefore developing the ability of future doctors to address and challenge mental illness related discrimination. READ includes components that medical education research has shown to be effective at improving attitudes, beliefs and understanding.Methods/designREAD training was developed using evidence based components associated with changes in stigma related outcomes. The study will take place in multiple international medical schools across high, middle and low income countries forming part of the INDIGO group network, with 25 sites in total. Students will be invited to participate via email from the lead researcher at each site during their psychiatry placement, and will be allocated to an intervention or a control arm according to their local teaching group at each site. READ training will be delivered solely to the intervention arm. Standardised measures will be used to assess students’ knowledge, attitudes and skills regarding discrimination in both the intervention and control groups, at baseline and at follow up immediately after the intervention. Statistical analyses of individual-level data will be conducted using random effects models accounting for clustering within sites to investigate changes in mean or percentages of each outcome, at baseline and immediately after the intervention.DiscussionThis is the first international study across high, middle and low income countries, which will evaluate the effectiveness of training for medical students to respond effectively to patients’ experiences and anticipation of discrimination. The results will promote implementation of manualised training that will help future doctors to reduce the impact of mental illness related discrimination on their patients. Limitations of the study are also discussed.

Computational systems are traditionally approached from control-oriented perspectives; however, as soon as we move from central- ized to decentralized computational infrastructures, direct control needs to be replaced by distributed coordination mechanisms that are on par with institutional constructs observable in human societies (contracts, agreements, enforcement mechanisms, etc.). This paper presents a for- malization of Hohfeld's framework building upon a logic whose language includes primitive operators of ability and parametric deontic operators. The proposal is meant to highlight the fundamental interaction between deontic and potestative concepts and contains proofs of soundness and completeness with respect to a class of relational models.

Background: Influenza vaccines are updated every year to match the vaccine strains with currently circulating viruses; consequently influenza vaccine effectiveness (IVE) has to be assessed annually.Research design and methods: A test-negative case-control study was conducted within the context of the Italian sentinel influenza surveillance network to estimate IVE by age group, virus subtype, and vaccine brand in medically attended laboratory-confirmed influenza.Results: In Italy, the 2018/19 influenza season was characterized by the co-circulation of influenza A(H1N1)pdm09 and A(H3N2) viruses. The adjusted IVE estimate in preventing influenza was moderate (44.8%, 95% CI: 18.8 to 62.5) against A(H1N1)pdm09, whereas there was no evidence of effectiveness (1.8%, 95% CI: -37.8 to 30.1) in persons affected by A(H3N2). IVE against A(H1N1)pdm09 decreased with age ranging from 65.7% to 13.1% among children/adolescents and elderly, respectively; moreover results suggest that Vaxigrip Tetra® was more effective against A(H1N1)pdm09 compared to Fluarix Tetra® [62.5% (95% CI: 34.3 to 78.6) vs 24.5% (95% CI: -40.6 to 59.6)]. Low effectiveness (35.2%, 95% CI: -50.8 to 72.1) against A(H3N2) was detected only in the elderly immunized with Fluad®.Conclusions: Findings suggest that influenza vaccines were low to moderately effective, probably due to a mismatch between circulating and vaccine strains.

Internal carotid artery (ICA) reparative techniques are nowadays widely standardized in traumatic as well as degenerative pathological conditions; therefore, the greatest difficulty encountered in the treatment of lesions at the expense of the most distal segment of the ICA is not a result of the application of these techniques as much as the difficulty in obtaining adequate exposure of the vessel and a sufficiently wide surgical field. In the past, lesions localized more toward the skull were considered to be surgically unreachable. During the last 20 years, however, various techniques have been suggested and attempted for the exposure of this difficult area. This article suggests a type of approach already carried out by the Department of Maxillofacial Surgery of the University of Rome "La Sapienza" in collaboration with the II Department of Vascular Surgery of the same university, which offers the advantage of being of simple and rapid execution with minimum repercussions on the intrasurgical time required and guarantees an excellent exposure of the most distal tract of the ICA with an adequate widening of the surgical field.

INTRODUZIONE La febbre reumatica acuta (ARF) è una patologia autoimmune che può insorgere a seguito di un’infezione faringea da Streptococcus pyogenes. Nonostante attualmente l’incidenza di ARF sia notevolmente diminuita nei paesi industrializzati, alcuni focolai si sono verificati in associazione con l’alta circolazione di determinati emm-type di S.pyogenes caratterizzati da fenotipo mucoso. In questo studio riportiamo un caso di ARF verificatosi in un bambino di una scuola elementare della provincia di Bologna. Inoltre descriviamo le caratteristiche microbiologiche del ceppo di S.pyogenes isolato dal suo tampone faringeo e dai campioni raccolti durante un programma di sorveglianza condotto nella sua classe. METODI Nel novembre 2012, ad un bambino di 11 anni viene diagnosticata una faringite da S.pyogenes, che, a seguito di un trattamento con claritromicina per 10 giorni, va incontro a completa risoluzione. Nei mesi seguenti si manifestano episodi saltuari di malessere, febbre, astenia e dolori articolari. A febbraio 2013, per comparsa di dolore al ginocchio sinistro, il medico curante consiglia il ricovero per accertamenti e sospetta ARF. Durante la degenza vengono quindi eseguiti un esame obiettivo completo, un’ecocardiografia ed un ECG. Inoltre vengono effettuati un emocromo completo, il titolo antistreptolisinico (TAS), i marker di flogosi ed un tampone faringeo per la ricerca di S.pyogenes. Durante la sorveglianza sono stati raccolti anche i tamponi faringei dei contatti. I campioni sono stati seminati su piastre di Agar Sangue ed incubati a 37°C per 24 ore. Le colonie β-emolitiche sono state identificate tramite spettrometria di massa MALDI-TOF ed i ceppi di S.pyogenes sono stati testati per la suscettibilità agli antibiotici tramite pannelli MICroSTREP plus (MicroScan®, Siemens).Tutti i ceppi di S. pyogenes sono stati caratterizzati per l’emm-type ed è stata eseguita la ricerca di 13 superantigeni (speA–speC, speF–speM, smeZ, and Ssa) con PCR Real-time. RISULTATI Durante il ricovero, l’auscultazione cardiaca evidenziava un lieve soffio sistolico mentre gli esami ematici mostravano un elevato TAS (2264 U/L), accompagnato da aumento dei marker di flogosi ed una debole leucocitosi (18.070/mmc). L’ecocardiografia e l’ECG mostravano, rispettivamente, una lieve insufficienza mitralica ed un blocco atrio-ventricolare di I grado (PR 200-440 ms). In accordo con i criteri di Jones è stata posta diagnosi di ARF. Dal tampone faringeo del bambino è stato isolato un ceppo di S.pyogenes mucoso, emm-type 18, risultato sensibile a tutti gli antibiotici testati. E’ stata somministrata una terapia con corticosteroidi e benzilpenicillina, con graduale risoluzione dei sintomi. Dei 24 compagni di classe 7 sono risultati positivi per S.pyogenes. Di questi, 2 erano emm-type 18 con fenotipo mucoso e presentavano il medesimo spettro di superantigeni del caso indice (speA, speC, speG, speL, speM). CONCLUSIONI Il caso descritto mette in evidenza come l’ARF non si possa considerare scomparsa nei paesi industrializzati. Inoltre un’elevata circolazione di ceppi mucosi di S.pyogenes, come l’emm-type 18, può essere considerato un fattore di rischio per lo sviluppo di ARF.

Objectives. Acute rheumatic fever (ARF) is a post-infectious non-suppurative condition resulting from an autoimmune response to a Group A streptococcus (GAS) pharyngeal infection. In the last decades, the incidence of ARF showed a significant decrease in industrialized Countries. However, sporadic outbreaks have been reported in combination with the reappearance of certains emm-types of GAS. Here, we report a case of ARF occurred in a child from a primary school in Bologna, North of Italy. In addition, we describe the epidemiological investigation of GAS strains isolated from pharyngeal swabs collected during a surveillance program conducted in his classroom. Methods. In November 2012, a 11-year-old previously healthy white boy suffered for a GAS pharyngitis and was treated with clarithromycin for 10-days. In February 2013, he complained about left knee joint pain and retrosternal pain and was admitted to the hospital since a diagnosis of ARF was suspected. The patient underwent a complete clinical examination, an echocardiography and an electrocardiography (ECG). Several blood samples were taken to perform white blood cell count (WBC), antistreptolysine O titer (ASO) and inflammation markers. A pharyngeal swab was collected for GAS investigation. A surveillance program, based on pharyngeal swabs screening, was started in the classroom since case definition of ARF. Pharyngeal swabs were seeded on blood agar plates and β-haemolytic colonies were identified with mass-spectrometry (MALDI-TOF). In case of GAS isolation, antibiogram was performed using MICroSTREP plus1 panel (Microscan). Susceptibility was determined according to EUCAST criteria. Emm-type of each GAS isolates was determined by PCR and sequencing. Streptococcal pyrogenic exotoxin (spe) profile of each isolate, were performed by multiplex PCR Results. During hospitalization, echocardiography showed a mild mitral regurgitation. ECG revealed a first-degree atrioventricular block (PR=200-440 ms). The cardiac auscultation highlighted a faint systolic murmur. Blood tests showed an elevated ASO (2264 U/L) and inflammation markers and a mild leucocytosis (18.070/mmc). According to Jones criteria a diagnosis of ARF was established. A GAS strain showing a mucoid phenotype was isolated from pharyngeal swab of ARF case and the typing analysis conducted on it identified the presence of emm18 gene. Superantigen profile showed the presence of speA, speC, speG, speL, speM genes. Seven out of 24 pharyngeal swabs collected for surveillance resulted positive for GAS. Detailed microbiological characteristics are shown in table 1. Patient was given a therapy with corticosteroids for 21 days and benzilpenicillin (1.200.000 U im), with a gradual resolution of symptoms. Pharyngeal swab culture were negative after 2 weeks of hospitalization. Conclusion. Our case highlights that ARF has not disappeared in developed Countries. Moreover, as observed in our experience, a high circulation of certain mucoid GAS strains, like emm-type 18, could be a risk factor for ARF development.