Greenhouse investigation on the phytoremediation potential of pioneer tree Pinus halepensis Mill. in abandoned mine site.

Tailings and mine dumps are often pollutant sources that pose serious environmental threats to surrounding areas. The use of pioneer vascular plants to extract or stabilize metals is considered among the more effective mine tailing reclamation techniques. The study aimed at evaluating the phytoremediation potential of Pinus halepensis in abandoned mine-tailing (SW-Sardinia, Italy). Plant ability to tolerate high Zn, Pb, and Cd concentration and their accumulation in roots and aerial parts were assessed at greenhouse conditions. Experiments were performed on 45 seedlings planted in different substrates (mine-tailings, mine-tailings compost-amended, and reference) and on 15 seedlings grown spontaneously in the contaminated mine site investigated with their own substrates. The phytostabilization potential of plant was evaluated through biological accumulation and translocation indexes together with plant survival and biometric parameters. The outcomes showed the adaptability of P. halepensis to grow and survive in contaminated substrates. Compost addition did not improve plant survival and growth, however, it enhanced total carbon and nitrogen contents of soil, restricted metal bioavailability, and accumulation in plant aerial parts. These findings highlight that P. halepensis may be considered for phytostabilization given the great potential to limit Zn, Pb, and Cd toxicity in plant tissues by applying compost amendment in metal contaminated mine sites.

The novelty of this study is the selection of Pinus halepensis Mill. as a proper tree species for long-term phytoremediation of multi-heavy metal mine tailing sites. This plant species not only had adaptation to the Mediterranean climate and could tolerate high temperatures and high metal concentrations, but also showed high survival and growth percentage of its roots and epigean organs in highly contaminated mine tailing. Pinus halepensis could limit metal accumulation and toxicity in the aerial part of the plant with the addition of compost amendment. This study demonstrates that compost can enhance soil properties and modify metal bioavailability. The outcomes can be beneficial for the phytostabilization project and restoration of similar Mediterranean mine sites.

Chelate facilitated phytoextraction of Pb, Cd, and Zn from a lead-zinc mine contaminated soil by three accumulator plants.

This study aims to evaluate the enhancement of phytoextraction of heavy metals (Pb, Cd, and Zn) by species Marrubium cuneatum, Stipa arabica, and Verbascum speciosum, through EDTA amendment. Assisted phytoextraction pot experiments were performed at different EDTA dosages (0, 1, 3, and 5 mmol kg-1 soil). The DTPA-extractable metal content increased in the presence of EDTA, followed by their contents in the tissues of all three studied species. Resulting from oxidative stress, the activity of antioxidant enzymes such as glutathione peroxidase (GPX), superoxide dismutase (SOD), and catalase (CAT) increased when the chelating agent was added. EDTA in higher doses partially decreased chlorophyll concentration, and 5 mmol kg-1 of that reduced the biomass of the studied species. The bioconcentration factor (BCF) for Cd was notably high in all studied plants and considerably elevated for Zn and Pb with the addition of EDTA in M. cuneatum and S. arabica (BCF > 1), whilst an accumulation factor greater than one (AF > 1) was found for Cd in all species and for Pb in the case of S. arabica. In general, the results demonstrated that EDTA can be an effective amendment for phytoextraction of Cd, Zn, and Pb by M. cuneatum, V. speciosum and S. arabica in contaminated soils.

Metal phytostabilization by mastic shrub (Pistacia lentiscus L.) and its root-associated bacteria in different habitats of Sardinian abandoned mining areas (Italy).

Pistacia lentiscus L. is an excluder metallophyte proposed for the revegetation and phytostabilization of metal-contaminated sites in the Mediterranean area. The present study aims at evaluating the linking between bacterial communities and plants spontaneously growing in ecosystems chronically impacted by mining activities. Environmental properties and metal accumulation into hypogeal and epigeal tissues were analyzed in wild plants of two contrasting habitats with extreme metal contamination (> 2300 mg/kg for Zn, > 1100 mg/kg for Pb, > 10 mg/kg for Cd). The community structures of rhizospheric and root endophytic bacteria were fingerprinted by terminal restriction fragment length polymorphism of the 16S rRNA gene. The wild shrubs efficiently restrict the accumulation of the three major contaminants to the epigeal tissues in the two habitats under study (249 ± 68 mg/kg dw for Zn, 43 ± 21 mg/kg dw for Pb, and 1.4 ± 0.5 mg/kg dw for Cd). Evidence was provided that the combined but not individual effect of environmental conditions (moisture, inorganic carbon, pH) and proportion between Zn and Cd in the mine substrate play a role in structuring rhizosphere bacterial communities. The observed changes in community structures of root endophytes were found to be strongly associated with Pb level in roots and substrate properties (inorganic carbon and Zn/Cd ratio). Overall, our study highlights the importance of the analysis of multifactorial interactions among mine substrate, plant, and microbes for understanding how the environmental context affects phytoremediation under real conditions.

Investigating metal pollution in the food chain surrounding a lead-zinc mine (Northwestern Iran); an evaluation of health risks to humans and animals.

The current study aims to evaluate the health risk of heavy metals for humans and animals in the Angouran mining complex (northwest of Iran). Twenty-five plant species and their corresponding soils (natural soils) were collected along with mine tailings samples. The carcinogenic and non-carcinogenic risks of heavy metals (Zn, Pb, Cd, Cr, and Co) for humans using the hazard quotient (HQ) and hazard index (HI) were evaluated. Moreover, the health risk caused by forage feeding to grazing ruminants (cow and sheep) and the risk associated with animal products consumption by humans in the soil-plant-animal transfer system were assessed. The value of HI in natural soils (rangeland use) was less than one (HI < 1), while regarding tailings, the HQ via oral ingestion and the HI were greater than one (HI & HQ > 1). The range of total carcinogenesis risk in natural soils exceeded the target risk (Risk < 10-6) and for tailings, it showed the probability of cancer risk, 1 person per 3636 populations, which is much higher than the acceptable or tolerable range (10-4 < Risk < 10-6). Regarding the animal health risk, the content of Pb and Cd in most of the animal organs was higher than the control values. In turn, dietary exposure to Pb and Cd is worrying for residents due to exceeding the provisional tolerable weekly intake (PTWI). This comprehensive study suggests the necessity of risk assessment of mining sites in Iran and immediate control measures to diminish pollutants.

[Evaluation of the indirect impact of the Sars-CoV-2 epidemic on primary and ambulatory care processes using synthetic quality measures and graphic representations.] / Valutazione dell'impatto indiretto dell'epidemia da Sars-CoV-2 sui processi assistenziali del territorio attraverso rappresentazioni sintetiche della qualità delle cure.

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.

Pinus halepensis in Contaminated Mining Sites: Study of the Transfer of Metals in the Plant-Soil System Using the BCR Procedure.

The study aimed at evaluating the geochemical fractions of Zn, Pb, Cd and their bioavailability in soil in-depth and around the root of Pinus halepensis grown on heavily contaminated mine tailing in south-western Sardinia, Italy. The contaminated substrates were partly investigated in a previous study and are composed of pyrite, dolomite, calcite, quartz, gypsum, barite, iron-sulfate and iron-oxide. The geochemical fractions and bioavailability of Zn, Pb and Cd were measured through the BCR extractions method. Cadmium in the superficial contaminated substrates was mainly found in the exchangeable BCR fraction. Zinc and lead were often found in the residual BCR fraction. PCA confirmed that the uppermost alkaline-calcareous layers of mine waste were different with respect to the deeper acidic layers. We demonstrated that Pb and Zn were less present in the exchangeable form around the roots of P. halepensis and in soil depth. This can be due to uptake or other beneficial effect of rhizospheres interaction processes. Further studies will shed light to confirm if P. halepensis is a good candidate to apply phytostabilization in mine tailing.

Dark fermentative volatile fatty acids production from food waste: A review of the potential central role in waste biorefineries.

Volatile fatty acids (VFAs) are high-value chemicals that are increasingly demanded worldwide. Biological production via food waste (FW) dark fermentation (DF) is a promising option to achieve the sustainability and environmental benefits typical of biobased chemicals and concurrently manage large amounts of residues. DF has a great potential to play a central role in waste biorefineries due to its ability to hydrolyze and convert complex organic substrates into VFAs that can be used as building blocks for bioproducts, chemicals and fuels. Several challenges must be faced for full-scale implementation, including process optimization to achieve high and stable yields, the development of efficient techniques for selective recovery and the cost-effectiveness of the whole process. This review aims to critically discuss and statistically analyze the existing relationships between process performance and the main variables of concern. Moreover, opportunities, current challenges and perspectives of a FW-based and fermentation-centred biorefinery layout are discussed.

A cascade biorefinery for grape marc: Recovery of materials and energy through thermochemical and biochemical processes.

The agro-industrial sector makes a high contribution to greenhouse gas emissions; therefore, proper waste management is crucial to reduce the carbon footprint of the food chain. Hydrothermal carbonization (HTC) is a promising and flexible thermochemical process for converting organic materials into energy and added-value products that can be used in different applications. In this work, grape marc residues before and after an extraction process for recovering polyphenols were hydrothermally treated at 220 °C for 1 h. The resulting hydrochar and process water were investigated to test an innovative cascade approach aimed at a multiple product and energy recovery based on the integration of HTC with anaerobic digestion. The results show that this biorefinery approach applied to grape marc could allow to diversify and integrate its potential valorisation options. The produced hydrochars possess an increased fixed carbon content compared to the feedstock (up to +70 %) and, therefore, can be used in soil, immobilizing carbon in a stable form and partially replacing peat in growing media (up to 5 % in case of hydrochar from grape marc after extraction), saving the consumption of this natural substrate. In addition, energy can be recovered from both hydrochar by combustion and from process water through anaerobic digestion to produce biogas. Hydrochars show good properties as solid fuel similar to lignite, with an energy content of around 27 MJ kg-1 (+30 % compared to the feedstock). The anaerobic digestion of the process water allowed obtaining up to 137 mL of biomethane per gram of fed COD. Finally, while HTC process waters are suitable for biological treatment, attention must be paid to the presence of inhibiting compounds that induce acute toxic effects in aerobic conditions. The proposed approach is consistent with the principles of circular economy and could increase the overall sustainability and resilience of the agro-industrial sector.

Perspectives for phytoremediation capability of native plants growing on Angouran Pb-Zn mining complex in northwest of Iran.

Phytoremediation is a cost-effective, environmentally-friendly and emerging remediation technology that treats polluted areas using plants, having the potential to restore ecosystems and make compromised areas useable again, therefore returning a resource to community use. In the present work a study was conducted on the contamination of soil by heavy metals (Zn, Pb, Cr, Cd, and Co) in the mining area of Angouran (northwestern Iran) and on their uptake by 25 native species present in the mining district, in order to evaluate their potential use in phytoremediation interventions. Plant and soils from three sites around the mine were sampled and characterized, and metals accumulation and translocation were evaluated. Principal Component Analysis (PCA) and Cluster Analysis (CA) were applied to study the behavior of species in the accumulation and translocation of the elements in their tissues. The contents of Zn, Pb, Cr, Cd, and Co in the studied plants were, respectively, 31.77-723.05, 7.78-233.25, 1.77-21.57, 0.04-7.92, and 0.15-9.97 mg/kg. Among the 25 species, 13 plants showed translocation factor greater than one (TF > 1) for Zn, 14 for Pb, 3 for Cr, 10 for Co, and 6 for Cd. Marrubium cuneatum having an accumulation factor greater than one (AF > 1) for Zn and bioconcentration factor greater than one (BCF >1) for Cd can be considered as an accumulator and stabilizer for Zn and Cd, respectively. Also, the highest value of Pb (233.25 mg/kg) and Cr (21.57 mg/kg) were found in the shoot of this plant. Psathyrostachys fragilis with BCF >1 for Co and maximum Pb accumulation in the root can be used as a stabilizer plant for Pb and Co-contaminated soils. Besides, Stipa arabica and Verbascum speciosum, with TF > 1 and rather high AF, could be considered suitable species for removing Zn and Pb through phytoextraction. This research showed that some native species in the study area have considerable potential for developing phytoremediation strategies.

[Geocoding one million of addresses using API: a semiautomatic multistep procedure]. / Geocodificare un milione di indirizzi mediante l'utilizzo di API: una procedura semiautomatica a più step.

OBJECTIVES: to geocode all residence addresses from Lazio Health Information System in order to obtain a geographical regional database. DESIGN: a semiautomatic and multistep geocoding procedure using several tools and software. SETTING AND PARTICIPANTS: all residence addresses of resident population of Lazio Region (Central Italy) in 2020. MAIN OUTCOME MEASURES: geographic coordinates at residence addresses and accuracy level of geocoding procedure for more than 1 million of addresses. RESULTS: the 99% of residence addresses in the Lazio Region have been geocoded thanks to the purposed procedure; almost 94% of the addresses have been geocoded with a good level of accuracy (more than 56% at civic number level). In the province of Rome, the percentage of addresses geocoded with a good level of accuracy is higher (97.1%), while in the province of Rieti and Frosinone is lower (82.7% and 84.2%, respectively). CONCLUSIONS: this method is useful to obtain accurate geographic coordinates of residences of the entire regional population. This database will be useful for several epidemiological studies in the Region.

Educational Inequalities in COVID-19 Vaccination: A Cross-Sectional Study of the Adult Population in the Lazio Region, Italy.

Several studies reported socioeconomic inequalities during the COVID-19 pandemic. We aimed at investigating educational inequalities in COVID-19 vaccination on 22 December 2021. We used the cohort of all residents in the Lazio Region, Central Italy, established at the beginning of the pandemic to investigate the effects of COVID-19. The Lazio Region has 5.5 million residents, mostly distributed in the Metropolitan Area of Rome (4.3 million inhabitants). We selected those aged 35 years or more who were alive and still residents on 22 December 2021. The cohort included data on sociodemographic, health characteristics, COVID-19 vaccination (none, partial, or complete), and SARS-CoV-2 infection. We used adjusted logistic regression models to analyze the association between level of education and no vaccination. We investigated 3,186,728 subjects (54% women). By the end of 2021, 88.1% of the population was fully vaccinated, and 10.3% were not vaccinated. There were strong socioeconomic inequalities in not getting vaccinated: compared with those with a university degree, residents with a high school degree had an odds ratio (OR) of 1.29 (95% confidence interval, CI, 1.27-1.30), and subjects with a junior high or primary school attainment had an OR = 1.41 (95% CI: 1.40-1.43). Since a comprehensive vaccination against COVID-19 could help reduce socioeconomic inequalities raised with the pandemic, further efforts in reaching the low socioeconomic strata of the population are crucial.

Incidence of SARS-CoV-2 Infection and Related Mortality by Education Level during Three Phases of the 2020 Pandemic: A Population-Based Cohort Study in Rome.

Evidence on social determinants of health on the risk of SARS-CoV-2 infection and adverse outcomes is still limited. Therefore, this work investigates educational disparities in the incidence of infection and mortality within 30 days of the onset of infection during 2020 in Rome, with particular attention to changes in socioeconomic inequalities over time. A cohort of 1,538,231 residents in Rome on 1 January 2020, aged 35+, followed from 1 March to 31 December 2020, were considered. Cumulative incidence and mortality rates by education were estimated. Multivariable log-binomial and Cox regression models were used to investigate educational disparities in the incidence of SARS-CoV-2 infection and mortality during the entire study period and in three phases of the pandemic. During 2020, there were 47,736 incident cases and 2281 deaths. The association between education and the incidence of infection changed over time. Till May 2020, low- and medium-educated individuals had a lower risk of infection than that of the highly educated. However, there was no evidence of an association between education and the incidence of SARS-CoV-2 infection during the summer. Lastly, low-educated adults had a 25% higher risk of infection from September to December than that of the highly educated. Similarly, there was substantial evidence of educational inequalities in mortality within 30 days of the onset of infection in the last term of 2020. In Rome, social inequalities in COVID-19 appeared in the last term of 2020, and they strengthen the need for monitoring inequalities emerging from this pandemic.

Ex situ phytoremediation trial of Sardinian mine waste using a pioneer plant species.

The mitigation of metals contamination is currently a crucial issue for the reclamation of mine sites. Indeed, mine wastes are often disposed in open dumps and consequently pollutants are subjected to dispersion in the surrounding areas. In this study, the potential use of Helichrysum microphyllum subsp. tyrrhenicum for phytostabilization was evaluated in ex situ conditions. Ninety specimens were randomly selected and were planted in three substrates (reference substrate, mine waste materials, and mine wastes with compost). Mineralogical compositions of substrates, rhizosphere, and roots were assessed through X-ray diffraction (XRD). Zn, Pb, and Cd concentrations of substrates, rhizosphere, soil pore waters, and plant tissues were determined. The phytostabilization potential was determined through the application of biological accumulation coefficient (BAC), biological concentration factor (BCF), and translocation factor (TF). Moreover, survival and biometric parameters were assessed on plant specimens. The polluted substrates and related rhizosphere materials were mainly composed of dolomite, quartz, pyrite, and phyllosilicate. Zn was the most abundant metal in substrates, rhizosphere, and soil pore waters. XRD analysis on roots showed the presence of amorphous cellulose and quartz and Zn was the most abundant metal in plant tissues. H. microphyllum subsp. tyrrhenicum restricts the accumulation of the metals into roots limiting their translocation in aereal parts, indicating its potential use as phytostabilizer (BCF, BAC, TF < 1). Survival and growth data showed a great adaptability to different substrates, with an evident positive effect of the implementation of compost which increased the plant survival and decreased the metals uptake into roots.

Aerobic granular sludge formation in a sequencing batch reactor treating agro-industrial digestate.

Most of nitrogen emissions can be ascribed to agro-industrial activities. Since digestate produced by fermentation of agro-industrial residues can be difficult to dispose of due to its high ammonium content, advanced technical- and cost-effective technologies must be developed and applied in order to significantly reduce its impact on the environment. In this study, aerobic granules were successfully cultivated in a granular sludge sequencing batch reactor (GSBR) fed with the ammonium-rich (approx. 2500 mg L-1) effluent of a 3-stage anaerobic digester treating agro-industrial residues. The peculiar characteristics of such wastewater required a 2-step operating strategy aimed at the selection of nitrifying biomass (Step 1) and the formation of aerobic granular sludge (Step 2). During Step 1, nitrifying biomass selection was achieved by properly regulating the cycle length: NH4+-N removal rates progressively increased from 42 to 109 mgN L-1d-1, and a corresponding increase in NH4+-N specific removal rates from 8 to 24 mgN gVSS-1d-1 was also observed. During Step 2, the increase in selective pressures (i.e. minimum settling velocity and volumetric organic loading rate) led to the formation of compact (average diameter, 1.02 ± 0.43 mm) and well-settling granules (SVI5, 28.6 ± 3.8 mL gTSS-1), which were able to remove up to 89 ± 2% of organic matter (as COD), 79 ± 3% of NH4+-N and 59 ± 4% of nitrogen (as a sum of NH4+-N, NO2--N and NO3--N). The 2-step operating strategy played a key role in biomass selection and subsequent granule formation and maintenance in the GSBR, and may be successfully adopted for the treatment of different ammonium-rich wastewaters.

Impacts of Anthropogenic Pollutants on Benthic Prokaryotic Communities in Mediterranean Touristic Ports.

Ports and marinas are central nodes in transport network and play a strategic role in coastal development. They receive pollution from land-based sources, marine traffic and port infrastructures on one side and constitute a potential pollution source for the adjacent coastal areas on the other. The aim of the present study was to evaluate the effects of organic and inorganic co-contamination on the prokaryotic communities in sediments from three Mediterranean ports. The structure and composition of the bacterial and archaeal communities were assessed by targeted metagenomic analysis of the 16S rRNA gene, and the links of prokaryotic communities with environmental and pollution variables were investigated. The harbors presented pronounced site-specificity in the environmental properties and pollution status. Consistently, the structure of archaeal and bacterial communities in surface sediments exhibited a strong spatial variation among the three investigated ports. On the contrary, a wide overlap in composition of prokaryotic assemblages among sites was found, but local variation in the community composition and loss of prokaryotic diversity was highlighted in a heavily impacted port sector near a shipyard. We provided evidences that organic matter, metals and PAHs as well as temperature and salinity play a strong role in structuring benthic bacterial communities significantly contributing to the understanding of their responses to anthropogenic perturbations in marine coastal areas. Among metals, copper was recognized as strongly associated with the observed changes in bacterial assemblages. Overall, this study provides the first assessment of the effects exerted by multiple organic and inorganic contaminations on benthic prokaryotes in ports over a large spatial scale and designates bacterial community as a candidate tool for the monitoring of the sediment quality status in harbors.

Application of anammox within an integrated approach to sustainable food waste management and valorization.

In this study, the anammox process was applied for the first time to the treatment of ammonium-rich liquid residues produced by the two-stage anaerobic digestion of food waste (2sAD-FW); such residues may represent a significant environmental issue if not properly managed. A granular anammox reactor was fed with a progressively increasing share of partially nitritated 2sAD-FW wastewater. An alternative operating strategy based on partial by-pass of the partial nitritation unit was tested, in order to regulate the influent NO2/NH4 molar ratio without chemical addition. High nitrogen removal efficiency (89 ±â€¯1%) and negligible nitrite discharge rates were achieved, together with high nitrogen removal rate/nitrogen loading rate (NRR/NLR, 97 ±â€¯1%) and stable specific anammox activity (0.42 ±â€¯0.03 gN2-N/gVSS d). The observed NH4-removed/NO2-removed/NO3-produced molar ratio was in agreement with anammox stoichiometry, as confirmed by the low contribution (<5%) of denitrification to nitrogen removal. Moreover, the possibility of using digital color characterization of granular biomass as a novel, simple tool for the monitoring of anammox biomass enrichment and process performance was investigated under dynamic conditions, using real wastewater: changes in granule color correlated well with the increasing share of 2sAD-FW wastewater in the influent (R2 = 83%), as well as with the decrease of anammox biomass abundance in the reactor (R2 = 68%). The results suggest that anammox may be successfully integrated into a 2sAD-FW system, thus enhancing its environmental sustainability.

A Systematic Review of Case-Identification Algorithms for 18 Conditions Based on Italian Healthcare Administrative Databases: A Study Protocol.

BACKGROUND: there has been a long-standing, consistent use worldwide of Healthcare Administrative Databases (HADs) for epidemiological purposes, especially to identify acute and chronic health conditions. These databases are able to reflect health-related conditions at a population level through disease-specific case-identification algorithms that combine information coded in multiple HADs. In Italy, in the past 10 years, HAD-based case-identification algorithms have experienced a constant increase, with a significant extension of the spectrum of identifiable diseases. Besides estimating incidence and/or prevalence of diseases, these algorithms have been used to enroll cohorts, monitor quality of care, assess the effect of environmental exposure, and identify health outcomes in analytic studies. Despite the rapid increase in the use of case-identification algorithms, information on their accuracy and misclassification rate is currently unavailable for most conditions. OBJECTIVES: to define a protocol to systematically review algorithms used in Italy in the past 10 years for the identification of several chronic and acute diseases, providing an accessible overview to future users in the Italian and international context. METHODS: PubMed will be searched for original research articles, published between 2007 and 2017, in Italian or English. The search string consists of a combination of free text and MeSH terms with a common part on HADs and a disease-specific part. All identified papers will be screened for eligibility by two independent reviewers. All articles that used/defined an algorithm for the identification of each disease of interest using Italian HADs will be included. Algorithms with exclusive use of death certificates, pathology register, general practitioner or pediatrician data will be excluded. Pertinent papers will be classified according to the objective for which the algorithm was used, and only articles that used algorithms with "primary objectives" (I disease occurrence; II population/cohort selection; III outcome identification) will be considered for algorithm extraction. The HADs used (hospital discharge records, drug prescriptions, etc.), ICD-9 and ICD-10 codes, ATC classification of drugs, follow-back periods, and age ranges applied by the algorithms will be collected. Further information on specific accuracy measures from external validations, sensitivity analyses, and the contribution of each source will be recorded. This protocol will be applied for 16 different systematic reviews concerning eighteen diseases (Hypothyroidism, Hyperthyroidism, Diabetes mellitus, Type 1 diabetes mellitus, Acute myocardial infarction, Ischemic heart disease, Stroke, Hypertension, Heart failure, Congenital heart anomalies, Parkinson's disease, Multiple sclerosis, Epilepsy, Chronic obstructive pulmonary disease, Asthma, Inflammatory bowel disease, Celiac disease, Chronic kidney failure). CONCLUSION: this protocol defines a standardized approach to extensively examine and compare all experiences of case identification algorithms in Italy, on the 18 abovementioned diseases. The methodology proposed may be applied to other systematic reviews concerning diseases not included in this project, as well as other settings, including international ones. Considering the increasing availability of healthcare data, developing standard criteria to describe and update characteristics of published algorithms would be of great use to enhance awareness in the choice of algorithms and provide a greater comparability of results.

A Systematic Review of Case-Identification Algorithms Based on Italian Healthcare Administrative Databases for Three Relevant Diseases of the Nervous System: Parkinson's Disease, Multiple Sclerosis, and Epilepsy.

BACKGROUND: Parkinson's Disease (PD), Multiple Sclerosis (MS), and Epilepsy are three highly impactful health conditions affecting the nervous system. PD, MS, and epilepsy cases can be identified by means of Healthcare Administrative Databases (HADs) to estimate the occurrence of these diseases, to better monitor the adherence to treatments, and to evaluate patients' outcomes. Nevertheless, the absence of a validated and standardized approach makes it hard to quantify case misclassification. OBJECTIVES: to identify and describe all PD, MS, and epilepsy case-identification algorithms by means of Italian HADs, through the review of papers published in the past 10 years. METHODS: this study is part of a project that systematically reviewed case-identification algorithms for 18 acute and chronic conditions by means of HADs in Italy. PubMed was searched for original articles, published between 2007 and 2017, in Italian or English. The search string consisted of a combination of free text and MeSH terms with a common part that focused on HADs and a disease-specific part. All identified papers were screened by two independent reviewers. Pertinent papers were classified according to the objective for which the algorithm had been used, and only articles that used algorithms for primary objectives (I disease occurrence; II population/cohort selection; III outcome identification) were considered for algorithm extraction. The HADs used (hospital discharge records, drug prescriptions, etc.), ICD-9 and ICD-10 codes, ATC classification of drugs, follow-back periods, and age ranges applied by the algorithms have been reported. Further information on specific objective(s), accuracy measures, sensitivity analyses and the contribution of each HAD, have also been recorded. RESULTS: the search strategy led to the identification of 70 papers for PD, 154 for MS, and 100 for epilepsy, of which 3 papers for PD, 6 for MS, and 5 for epilepsy were considered pertinent. Most articles were published in the last three years (2014-2017) and focused on a region-wide setting. Out of all pertinent articles, 3 original algorithms for PD, 4 for MS, and 4 for epilepsy were identified. The Drug Prescription Database (DPD) and Hospital Discharge record Database (HDD) were used by almost all PD, MS, and epilepsy case-identification algorithms. The Exemption from healthcare Co-payment Database (ECD) was used by all PD and MS case-identification algorithms, while only 1 epilepsy case-identification algorithm used this source. All epilepsy case-identification algorithms were based on at least a combination of electroencephalogram (EEG) and drug prescriptions. An external validation had been performed by 2 papers for MS, 2 for epilepsy, and only 1 for PD. CONCLUSION: the results of our review highlighted the scarce use of HADs for the identification of cases affected by neurological diseases in Italy. While PD and MS algorithms are not so heterogeneous, epilepsy case-identification algorithms have increased in complexity over time. Further validations are needed to better understand the specific characteristics of these algorithms.

A Systematic Review of Case-Identification Algorithms Based on Italian Healthcare Administrative Databases for Two Relevant Diseases of the Respiratory System: Asthma and Chronic Obstructive Pulmonary Disease.

OBJECTIVES: to identify and describe all asthma and Chronic Obstructive Pulmonary Disease (COPD) case-identification algorithms by means of Italian Healthcare Administrative Databases (HADs), through the review of papers published in the past 10 years. METHODS: this study is part of a project that systematically reviewed case-identification algorithms for 18 acute and chronic conditions by means of HADs in Italy. PubMed was searched for original articles, published between 2007 and 2017, in Italian or English. The search string consisted of a combination of free text and MeSH terms with a common part that focused on HADs and a disease-specific part. All identified papers were screened by two independent reviewers; exclusion criteria were the following: no description of reported algorithms, algorithm developed outside of the Italian context, exclusive use of death certificates, pathology register, general practitioner or pediatrician data. Pertinent papers were classified according to the objective for which the algorithm had been used, and only articles that used algorithms for primary objectives (I disease occurrence; II population/cohort selection; III outcome identification) were considered for algorithm extraction. The HADs used (hospital discharge records, drug prescriptions, etc.), ICD-9 and ICD-10 codes, ATC classification of drugs, follow-back periods, and age ranges applied by the algorithms have been reported. Further information on specific objective(s), accuracy measures, sensitivity analyses and the contribution of each HAD, have also been recorded. RESULTS: the search string led to the identification of 98 and 147 papers, respectively for asthma and COPD. By screening the references, 2 papers for asthma and 7 for COPD were added. At the end of the screening process, 14 pertinent papers were identified for asthma and 31 for COPD. Half of these used healthcare data covering a time period between 2008 and 2014. More than 75% considered the age range 6-17 for asthma and >=45 for COPD. About one-third of the articles used algorithms to estimate the occurrence of these diseases. Fourteen algorithms for asthma and 16 for COPD were extracted from the papers and characterized. The Drug Prescription Database (DPD) was used by almost all asthma case-identification algorithms, while only 7 COPD algorithms used this data source. The spectrum of active ingredients was strongly overlapping between the two diseases, with different combinations of drugs and administration routes, as well as specific number of prescriptions, follow-back years, and age ranges. Age class and chronic treatment were the main disease-specific traits that emerged from the algorithms. Three external validation processes have been performed for asthma and three for COPD. High accuracy levels have been found for asthma. COPD sensitivity analyses were unsatisfactory, while a high specificity was found for algorithms based on hospital discharge records. CONCLUSION: elements from the review on the use of healthcare administrative databases represent a useful tool to decide which algorithm to adopt, based on the algorithm's individual requirements, limits, and accuracy, taking into account the specific research objective.