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We examine the cost-effectiveness of treating epilepsy with anti-epileptic medicines in autistic children, looking at impacts on healthcare providers (in England, Ireland, Italy and Spain) and children's families (in Ireland). We find carbamazepine to be the most cost-effective drug to try first in children with newly diagnosed focal seizures. For England and Spain, oxcarbazepine is the most cost-effective treatment when taken as additional treatment for those children whose response to monotherapy is suboptimal. In Ireland and Italy, gabapentin is the most cost-effective option. Our additional scenario analysis presents the aggregate cost to families with autistic children who are being treated for epilepsy: this cost is considerably higher than healthcare provider expenditure.

Abstract Background Risk stratification and treatment benefit prediction models are urgent to improve negative sentinel lymph node (SLN-) melanoma patient selection, thus avoiding costly and toxic treatments in patients at low risk of recurrence. To this end, the application of artificial intelligence (AI) could help clinicians to better calculate the recurrence risk and choose whether to perform adjuvant therapy. Methods We made use of AI to predict recurrence-free status (RFS) within 2-years from diagnosis in 94 SLN- melanoma patients. In detail, we detected quantitative imaging information from H&E slides of a cohort of 71 SLN- melanoma patients, who registered at Istituto Tumori “Giovanni Paolo II” in Bari, Italy (investigational cohort, IC). For each slide, two expert pathologists firstly annotated two Regions of Interest (ROIs) containing tumor cells alone (TUMOR ROI) or with infiltrating cells (TUMOR + INF ROI). In correspondence of the two kinds of ROIs, two AI-based models were developed to extract information directly from the tiles in which each ROI was automatically divided. This information was then used to predict RFS. Performances of the models were computed according to a 5-fold cross validation scheme. We further validated the prediction power of the two models on an independent external validation cohort of 23 SLN- melanoma patients (validation cohort, VC). Results The TUMOR ROIs have revealed more informative than the TUMOR + INF ROIs. An Area Under the Curve (AUC) value of 79.1% and 62.3%, a sensitivity value of 81.2% and 76.9%, a specificity value of 70.0% and 43.3%, an accuracy value of 73.2% and 53.4%, were achieved on the TUMOR and TUMOR + INF ROIs extracted for the IC cohort, respectively. An AUC value of 76.5% and 65.2%, a sensitivity value of 66.7% and 41.6%, a specificity value of 70.0% and 55.9%, an accuracy value of 70.0% and 56.5%, were achieved on the TUMOR and TUMOR + INF ROIs extracted for the VC cohort, respectively. Conclusions Our approach represents a first effort to develop a non-invasive prognostic method to better define the recurrence risk and improve the management of SLN- melanoma patients.

We report the case of a 65-year-old male patient who was deemed unfit for open surgery and underwent zone 0 endovascular repair with a physician-modified fenestrated endograft for a symptomatic penetrating ulcer. A thoracic stent graft was modified creating a large fenestration for the innominate artery and the left common carotid artery, and a second small fenestration for the left subclavian artery and the left vertebral artery, which had a common origin. No bridging stent was used for the left subclavian artery to avoid coverage of the left vertebral artery. The postoperative course was uneventful, and no leaks nor other complications were detected on postoperative computed tomography angiography. Although long-term durability needs to be better assessed, our experience suggests that physician-modified fenestrated endografts are a feasible option for the emergent treatment of aortic arch lesions in unfit patients and provide satisfactory results in the short term.

ObjectivesThe safety of cesarean myomectomy has been proven by previous studies. Our study aimed to reveal the long-term perinatal, obstetric, and surgical outcomes of cesarean myomectomy (CM) by comparing different CM techniques.Material and methodsThis retrospective multicentric case–control study involved 7 hospitals and included 226 singleton pregnancies that underwent repeated cesarean section (CS) between 2015 and 2020. Among these pregnancies, 113 of 226 cases had CM (Group A), and 113 had only CS (Group B). Of the 113 cases in which CM was performed, 58 underwent endometrial myomectomy (EM) (Subgroup A1) and 55 underwent serosal myomectomy (SM) (Subgroup A2). The groups were compared in terms of obstetric, perinatal, and surgical outcomes, and fibroid recurrence, myomectomy scar healing rate, and adhesion formation were noted.ResultsThere was no significant difference between the groups in terms of maternal age, body mass index, gravidity, parity, and fibroid diameter in previous CS (p > 0.05). In the perinatal and obstetric evaluation of the groups, there was no significant difference between the groups in terms of neonatal weight, Apgar score, fetal growth restriction, preterm premature rupture of membranes, preterm delivery, hypertension in pregnancy, and diabetes mellitus (p > 0.05). The fibroid recurrence rate was 28.3%, and the myomectomy scar good healing rate was 99.1%. There was no difference between the groups in terms of CS duration, preoperative and postoperative hemoglobin levels, perioperative blood transfusion rates, febrile morbidity, and prolonged hospitalization (p > 0.05). In terms of adhesion formation, although the adhesion rate of the SM group was higher than that of the EM group, no statistically significant difference was detected between the groups.ConclusionThis study showed that in pregnancies following CM, obstetrical, perinatal, and surgical outcomes were unaffected. Obstetricians can safely use CM, either the trans-endometrial or serosal technique, as it is a safe and effective method with long-term results.

On-pump techniques are the methods of choice for organ protection and heart support during thoracoabdominal aortic aneurysm surgical repair. We present a case of a patient with a symptomatic saccular aneurysm of the visceral segment of a severe atheromatous aorta requiring a surgical type IV aortic repair during which we adopted a temporary passive arterial shunt from the left axillary artery to ensure visceral and distal aortic perfusion. The old-fashioned technique of passive shunting to ensure visceral and distal aortic perfusion seems to offer an appealing alternative to on-pump techniques in selected patients.

Compared to other industrial fields, the construction sector, although encouraged by a framework of international policies that push towards spreading circular economy principles, still needs to adopt new ‘closed cycle’ resource management models. Among the barriers that hinder this transition is the limited availability of tools and methods to determine the overall outcomes of circularity actions. Although metrics to evaluate the degree of circularity of processes and products are currently available, tools that allow the evaluation of the environmental benefits achievable through the reuse of products and systems have yet to be widespread. The paper proposes a simplified method for quantifying the environmental benefits that can derive from the reuse practices of building components in building re-layout projects. Article info Received: 16/03/2024; Revised: 10/04/2024; Accepted: 17/04/2024

We present the case of an 82-year-old woman with history of bivalvular replacement (mitral mechanical prothesis and tricuspid bioprothesis) and subsequent tricuspid percutaneous valve-in-valve bioprothesis implantation. The patient developed an indication for pacemaker implantation. We describe the feasibility of leadless pacemaker implantation across the tricuspid prothesis when all other techniques fail.

Objective The growing consumers’ interest on animal welfare has raised the request of products obtained by alternative rearing systems. The present study was conducted to assess the influence of housing system on gut and muscle morphology and on microbial load in rabbits reared under free-range (FR) and cage system (CS). Methods A total of forty weaned (35 days of age) male Italian White breed rabbits were allotted according to the rearing system, and at 91 days of age were randomly selected and slaughtered for the morphological evaluation of tissue from duodenum and longissimus lumborum. Morphometric analysis of the villus height, villus width, crypt depth, villus height/crypt depth ratio, and villus surface was performed. The microbial loads on hind muscle was determined by total mesophilic aerobic count (TMAC), Escherichia coli and Enterobacteriaceae; whereas, total anaerobic bacteria count (TABC) and TMAC, E. coli and Enterobacteriaceae was determined on caecal content. Results Rearing system did not interfere with the duodenum and muscle histomorphology in both rabbit groups. Similarly, microbial load of caecal content showed no significant differences on the TABC and TMAC. Conversely, significant difference was found for E. coli strains in caecal content, with the lower counts in FR compared to CS rabbits (p

Human Papillomavirus (HPV) infection represents a global health concern. HPV infects the mucosa, particularly in the uterine cervix, where it may establish a persistent infection, exposing women to a risk of developing cancer. The available treatments include surgery or topic solutions, while a systemic treatment is still unavailable. In recent years, natural molecules such as epigallocatechin gallate (EGCG), folic acid (FA), vitamin B12, and hyaluronic acid (HA) gained importance as innovative therapies for HPV. We enrolled 163 women with a positive HPV DNA test or previous history of HPV infections, and a PAP test indicating LSIL/AGUS/ASCUS cytology. The patients in the treatment group (n = 86) received an oral combination of EGCG 200 mg, FA 400 µg, vitamin B12 1 mg, and HA 50 mg (1 cps/day) for 3 months (T1), while the control group (n = 77) underwent standard clinical surveillance. Both groups repeated a PAP test and an HPV DNA test after 3 (T1) months, and another PAP test after 6 months (T2) as a follow up. The treatment group experienced a significant reduction in HPV positivity at T1 compared to the control group. Moreover, the treatment group exhibited an improvement in cervical lesions either at T1 (p < 0.0001) or T2 (p < 0.00001).

This study reports the determination of DNOC in the baits and gastric contents of poisoned dogs and wild canids collected in the Abruzzo region between 2014 and 2022. A total of 663 samples of the baits and carcasses of domestic and wild animals were analyzed for the determination of DNOC through GC-MS. DNOC was found to be present in 58 cases from 663 analyzed samples, with 49 poison baits and nine gastric content samples from dogs and red foxes. This study confirms for the first time that the banned pesticide DNOC still poisons both domestic and wild animals in the Abruzzo region. It should be considered that this study was carried out on a population of animals from a regional geographical area, and more detailed country-wide studies need to be carried out to obtain the incidence of poisoning from this herbicide in Italy. Furthermore, these findings emphasize the importance of considering this chemical in differential diagnosis during toxicological investigations of animal poisoning.

Background: To investigate whether fetal adrenal gland volume (AGV) and fetal zone volume (FZV), important components of the fetal adrenal gland, differ between women who have term and preterm births, and to determine whether these two parameters can be used to predict premature birth. Methods: A total of 238 pregnant women at 24–28 weeks of gestation were included in this case-control study. The fetal AGV and FZV were ultrasonographically evaluated, and corrected AGV (cAGV) and corrected FZV (cFZV) were assessed with adjustments for estimated birth weight. Receiver operating characteristic (ROC) curves were used to assess the ability of AGV, FZV, cAGV, and cFZV to predict preterm birth. Results: Ultrasound exams on 220 term fetuses and 18 preterm fetuses showed that preterm fetuses exhibited higher AGV (p = 0.039), FZV (p = 0.001), cAGV (p = 0.001), and cFVZ (p = 0.001) compared to term fetuses. Conclusions: These results demonstrated that term and preterm fetuses differ in their AGV and FZV within this study population. The data generated by 3D sonography between 24 and 28 weeks of gestation may be beneficial for predicting premature birth. However, larger prospective studies with a larger sample size of preterm births are needed to validate these findings.

Asynclitism, a misalignment of the fetal head with respect to the plane of passage through the birth canal, represents a significant obstetric challenge. High degrees of asynclitism are associated with labor dystocia, difficult operative delivery, and cesarean delivery. Despite its clinical relevance, the diagnosis of asynclitism and its influence on the outcome of labor remain matters of debate. This study analyzes the role of the degree of asynclitism (AD) in assessing labor progress and predicting labor outcome, focusing on its ability to predict intrapartum cesarean delivery (ICD) versus non-cesarean delivery. The study also aims to assess the performance of the AIDA (Artificial Intelligence Dystocia Algorithm) algorithm in integrating AD with other ultrasound parameters for predicting labor outcome. This retrospective study involved 135 full-term nulliparous patients with singleton fetuses in cephalic presentation undergoing neuraxial analgesia. Data were collected at three Italian hospitals between January 2014 and December 2020. In addition to routine digital vaginal examination, all patients underwent intrapartum ultrasound (IU) during protracted second stage of labor (greater than three hours). Four geometric parameters were measured using standard 3.5 MHz transabdominal ultrasound probes: head-to-symphysis distance (HSD), degree of asynclitism (AD), angle of progression (AoP), and midline angle (MLA). The AIDA algorithm, a machine learning-based decision support system, was used to classify patients into five classes (from 0 to 4) based on the values of the four geometric parameters and to predict labor outcome (ICD or non-ICD). Six machine learning algorithms were used: MLP (multi-layer perceptron), RF (random forest), SVM (support vector machine), XGBoost, LR (logistic regression), and DT (decision tree). Pearson’s correlation was used to investigate the relationship between AD and the other parameters. A degree of asynclitism greater than 70 mm was found to be significantly associated with an increased rate of cesarean deliveries. Pearson’s correlation analysis showed a weak to very weak correlation between AD and AoP (PC = 0.36, p < 0.001), AD and HSD (PC = 0.18, p < 0.05), and AD and MLA (PC = 0.14). The AIDA algorithm demonstrated high accuracy in predicting labor outcome, particularly for AIDA classes 0 and 4, with 100% agreement with physician-practiced labor outcome in two cases (RF and SVM algorithms) and slightly lower agreement with MLP. For AIDA class 3, the RF algorithm performed best, with an accuracy of 92%. AD, in combination with HSD, MLA, and AoP, plays a significant role in predicting labor dystocia and labor outcome. The AIDA algorithm, based on these four geometric parameters, has proven to be a promising decision support tool for predicting labor outcome and may help reduce the need for unnecessary cesarean deliveries, while improving maternal-fetal outcomes. Future studies with larger cohorts are needed to further validate these findings and refine the cut-off thresholds for AD and other parameters in the AIDA algorithm.