Knowledge and self-perceived competence about cardiopulmonary resuscitation among youths: a cross-sectional study in a sample of Italian undergraduates.

Introduction: Cardiopulmonary resuscitation is fundamental to improve the outcomes of a life-threatening event. The correct knowledge of first aid actions to provide may guarantee the victim's survival. This study was aimed at evaluating the competence about cardiopulmonary resuscitation and its predictors in a sample of Italian undergraduate students. Methods: Information on socio-demographic characteristics, first aid training, knowledge of stroke and heart attack symptoms and perceived ability to provide first aid, were collected through a web-based questionnaire. Results: On a total of 744 respondents (mean age 23.9±5.4 years, 62.5% female), 71.4% identified correctly first aid actions, 59.9% and 60.8% showed a good knowledge of stroke and heart attack symptoms, respectively. However, only 39.0% of them declared their ability to intervene in case of emergency. Attending a healthcare degree course and having had first aid training were associated with knowledge of symptoms and perceived ability to provide first aid. Female gender was negatively related with perceived ability to intervene. Conclusions: In spite of the satisfactory level of knowledge, these findings highlight the need to enhance the competence about cardiopulmonary resuscitation in the lay population, especially among females.

Can Digital Technologies Be Useful for Weight Loss in Individuals with Overweight or Obesity? A Systematic Review.

Digital technologies have greatly developed and impacted several aspects of life, including health and lifestyle. Activity tracking, mobile applications, and devices may also provide messages and goals to motivate adopting healthy behaviors, namely physical activity and dietary changes. This review aimed to assess the effectiveness of digital resources in supporting behavior changes, and thus influencing weight loss, in people with overweight or obesity. A systematic review was conducted according to the PRISMA guidelines. The protocol was registered in PROSPERO (CRD42023403364). Randomized Controlled Trials published from the database's inception to 8 November 2023 and focused on digital-based technologies aimed at increasing physical activity for the purpose of weight loss, with or without changes in diet, were considered eligible. In total, 1762 studies were retrieved and 31 met the inclusion criteria. Although they differed in the type of technology used and in their design, two-thirds of the studies reported significantly greater weight loss among electronic device users than controls. Many of these studies reported tailored or specialist-guided interventions. The use of digital technologies may be useful to support weight-loss interventions for people with overweight or obesity. Personalized feedback can increase the effectiveness of new technologies in motivating behavior changes.

Optimization of a fast and sensitive method based on matrix solid-phase dispersion-LC-ms/ms for simultaneous determination of phthalates and bisphenols in mussel samples.

Bisphenols and phthalates are wide classes of endocrine disrupting chemicals (EDCs) extensively used as additives in plastic products. In this study, a fast and reliable analytical method based on matrix solid-phase dispersion (MSPD) coupled with LC-MS/MS was developed and optimized for simultaneous determination of 8 bisphenols and 7 phthalates in raw mussel extract. The LC-MS/MS method was tested for linearity (R2), inter- and intra-day repeatability, limit of detection and quantification, both for matrix-free and matrix-matched solutions. The MSPD method was optimized in terms of ratio between sample and sorbent, and the type and quantity of the eluents in order to maximize the recoveries and to minimize matrix effects. The obtained recoveries (values between 75% and 113%), limits of detection (values between 0.048 and 0.36 µg kg-1), limits of quantification (values between 0.16 and 1.28 µg kg-1), repeatability (RSD% between 1.30% and 8.41%) and linearity (R2 > 0.998) were satisfactory and suitable for the determination of target micropollutants in food samples. In addition, the low solvent consumption and fast execution make this method ideal for routinely determinations of bisphenols and phthalates in mussels.

Balneotherapy using thermal mineral water baths and dermatological diseases: a systematic review.

Balneotherapy includes practices and methods using medically and legally recognized mineral-medicinal waters, muds and natural gases from natural springs for therapeutic purposes. One of the most widely used method in balneotherapy is bathing with thermal mineral water. In the course of the years, scientific community has produced an increasing number of evidences that this practice is an effective method for treating signs and symptoms of several pathologies such as rheumatic, cardiovascular and dermatological diseases. This systematic review is aimed at evaluating the effect of balneotherapy with thermal water baths as a treatment to manage signs and symptoms of patients affected by all types of dermatological diseases. The systematic review was conducted according to the PRISMA Statement, and its protocol was registered on PROSPERO platform (CRD42022295913). The research was performed on the databases Pubmed, Scopus, Web of Science and Cochrane. We included clinical trials evaluating the effects of balneotherapy using thermal mineral water baths for managing dermatological diseases in humans, published in English and Italian language. Eight studies were included, seven of them enrolled adults affected by psoriasis and one studied atopic dermatitis patients. The common result of all the articles included was a clear improvement of signs and symptoms of psoriasis and eczematous diseases after use of thermal mineral water baths. These effects seem to be strictly related to physical and chemical properties of thermal water used for balneotherapy. However, studies in this field are still limited to support robust evidence of the effectiveness of balneotherapy using thermal mineral water baths and often their quality is low. Thus, new clinical studies need to be carried out, using more correct methods for conducting the studies and for processing statistical data.

Balneotherapy for osteoarthritis: a systematic review.

This systematic review is aimed to evaluate the effects of balneotherapy with thermal mineral water for managing the symptoms and signs of osteoarthritis located at any anatomical site. The systematic review was conducted according to the PRISMA Statement. The following databases were consulted: PubMed, Scopus, Web of Science, Cochrane Library, DOAJ and PEDro. We included clinical trials evaluating the effects of balneotherapy as a treatment for patients with osteoarthritis, published in English and Italian language, led on human subjects. The protocol was registered in PROSPERO. Overall, 17 studies have been included in the review. All of these studies were performed on adults or elderly patients suffering from osteoarthritis localized to knees, hips, hands or lumbar spine. The treatment assessed was always the balneotherapy with thermal mineral water. The outcomes evaluated were pain, palpation/pressure sensibility, articular tenderness, functional ability, quality of life, mobility, deambulation, ability to climb stairs, medical objective and patients' subjective evaluation, superoxide dismutase enzyme activity, serum levels of interleukin-2 receptors. The results of all the included studies agree and demonstrated an improvement of all the symptoms and signs investigated. In particular, pain and quality of life were the main symptoms evaluated and both improved after the treatment with thermal water in all the studies included in the review. These effects can be attributed to physical and chemical-physical properties of thermal mineral water used. However, the quality of many studies resulted not so high due and, consequently, it is necessary to perform new clinical trial in this field using more correct methods for conducting the study and for processing statistical data.

Perfluorinated Compounds (PFCs) in River Waters of Central Italy: Monthly Variation and Ecological Risk Assessment (ERA).

Perfluorinated compounds (PFCs) are a wide class of emerging pollutants. In this study, we applied the US EPA method 533 for the determination of 21 PFCs in river water samples. In particular, this method was used to investigate the presence of the target PFCs in six rivers in central Italy during a 4-month-long monitoring campaign. In 73% of the analyzed samples, at least some of the target PFCs were detected at concentrations higher than the limit of detection (LOD). The sum of the 21 target analytes (∑21PFCs) ranged from 4.3 to 68.5 ng L-1, with the highest concentrations measured in the month of June, probably due to a minor river streamflow occurring in the warmer summer months. Considering the individual congeners, PFBA and PFPeA, followed by PFHxA and PFOA, were the predominantly detected compounds. Short- and medium-chain PFCs (C4-C9) prevail over the long-chain PFCs (C10-C18), likely due to the increased industrial use and the higher solubility of short-chain PFCs compared to long-chain PFCs. The ecological risk assessment, conducted by using the risk quotient method, highlighted that the risk for aquatic environments associated with PFBA, PFPeA, PFBS, PFHxA and PFOA was low or negligible. Only for PFOA, there was a medium level of risk in two rivers in the month of June. With regard to PFOS, 54% of the river water samples were classified as "high risk" for the aquatic environment. The remaining 46% of the samples were classified as "medium risk."

Consumption of Energy Drinks among Italian University students: a cross-sectional multicenter study.

PURPOSE: The aim of the study was to evaluate the caffeinated Energy Drinks (EDs) consumption among a large sample of Italian undergraduates and its association with some of the major lifestyle risk factors. METHODS: Students attending twelve public Italian universities were involved between October 2021 and May 2022. Information on socio-demographic characteristics, ED consumption, and on health-related behaviors of participants was collected by the use of a web-based questionnaire. RESULTS: A total of 2165 students participated in the study and 15.2% of them reported having used caffeinated EDs in the last six months, mainly once a month (41.5%). In comparison with non-users, ED users showed a higher proportion of males (p < 0.001) and a higher father's educational level (p = 0.003), came mainly from Northern universities (p = 0.004) and life sciences degree courses (p < 0.001). Besides, ED users reported higher BMI values (p = 0.003), more particular dietary regimens (p < 0.001), higher levels of weekly moderate-vigorous physical activity (p < 0.001) and participation in sports (p < 0.001) and in team sports (p = 0.003), and higher proportion of smokers (p < 0.001) and alcohol drinkers (p = 0.005). ED use was negatively related with female gender (OR 0.546; 95% CI 0.374-0.798), the Mediterranean diet (OR 0.587; 95% CI 0.362-0.951) and coming from the center of Italy (OR 0.500; 95% CI 0.275-0.909) and positively associated with tobacco smoke (OR 1.712; 95% CI 1.176-2.492) and participation in a team sport (OR 1.686; 95% CI 1.051-2.707). CONCLUSION: These findings could encourage figures engaged in education to increase the students' awareness on this issue in order to prevent the excessive use of EDs and associated unhealthy behaviors, especially in the most interested subgroups.

Natural Mineral Water and Diuresis: A Systematic Review.

The present systematic review is aimed at evaluating the diuretic effects determined according to the natural mineral water consumption on healthy individuals. This systematic review has been performed following the guidelines of the PRISMA (preferred reporting items for systematic reviews and meta-analyses) Statement, investigating PubMed, Scopus, Web of Science and Cochrane Library from inception to November 2022. Studies performed both on animals and on humans were considered. After screening, a total of 12 studies have been identified. Of these, 11 studies were performed in Italy and 1 in Bulgaria. The time range of publication is very wide, ranging from 1962 to 2019 for human studies and from 1967 to 2001 for animal studies. All the included studies found an increase in diuresis determined according to the consumption of natural mineral water, in some cases after just one administration of the tested water. However, the quality of the studies is not so high, especially for the research conducted many years ago. Thus, it would be desirable to carry out new clinical studies using more appropriate methodological approaches and more refined methods of statistical data processing.

Occurrence and congener profiles of dioxins (PCDDs), furans (PCDFs) and polychlorinated biphenyls (PCBs) in ovine and caprine milk samples collected in a very polluted site in Central Italy.

Concentrations of 7 polychlorinated dibenzo-p-dioxins (PCDDs), 10 polychlorinated dibenzofurans (PCDFs) and 18 polychlorinated biphenyls (PCBs), including 12 dioxin-like (DL-PCBs) and 6 non-dioxin-like PCBs (NDL-PCBs) were measured in 16 ovine and caprine milk samples collected in the territory of Bussi sul Tirino, central Italy, a Site of National Interest (SNI) due to its high and widespread environmental pollution. All the analyzed samples were compliant with the maximum levels fixed by Commission Regulation (EU) 1259/2011 for the content of PCDD/Fs and the sum of PCDD/Fs and DL-PCBs. In two cases, contamination levels of the sum of PCDD/Fs and DL-PCBs were higher than the action levels fixed by EU Recommendation 663/2014. The statistical analysis, performed by Principal Component Analysis (PCA), revealed that the differences in contamination profiles of the different milk samples were independent of the distance of the farms from the Bussi illegal landfill but likely related to local emission sources influencing the exposure to POPs of studied animals.

Consumption patterns of energy drinks in university students: A systematic review and meta-analysis.

OBJECTIVES: Energy drink (ED) use is promoted to stimulate mental and/or physical activity, and their popularity has increased over the years, especially among young people. However, the use of EDs is often improper, and can induce adverse effects for human health. The purpose of this systematic review and meta-analysis was to analyze the literature to characterize the prevalence of ED consumption and motivations for use among undergraduate students. Furthermore, adverse effects and health-related behaviors associated with ED consumption were explored. METHODS: This systematic review was carried out according to the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines, and the PubMed, Scopus, and Web of Science databases were used for data research. RESULTS: A total of 71 articles published between 2007 and 2021 met the inclusion criteria and were included in the review. The estimated overall prevalence of ED consumption was 42.9% in undergraduate students (95% confidence interval, 42.5%-43.3%), with significant heterogeneity among studies (Q test: P < 0.001; I2 = 99.4%). The main reasons for use were engagement in study, projects or examinations, stay awake or alert, and physical activity/sport engagement. Sleep disturbance and increased heart rate or blood pressure were the most commonly reported adverse effects. ED consumption was frequently associated with alcohol use and smoking. CONCLUSIONS: These findings suggest that the inappropriate use of EDs and related unhealthy behaviors should be identified early, and addressed through effective educational interventions..

Assessment of dietary supplement consumption among Italian university students: The multicenter DiSCo study.

OBJECTIVES: The aim of this study was to analyze the consumption of dietary supplements (DSs) and related sociodemographic characteristics or behaviors in Italian undergraduates. METHODS: A questionnaire-based, cross-sectional study was carried out between October 2021 and May 2022 involving undergraduates from 12 public universities. The use of DSs in the previous 6 mo, the aim and reason for use, the purchasing channel, and related adverse effects were explored and compared by sex. A logistic regression was performed to highlight possible associations between sociodemographic, anthropometric, and behavioral characteristics of participants and supplement consumption. RESULTS: The use of DSs was reported by 71.5% of the 2165 respondents. Supplementation was related to sex (odds ratio [OR] 0.690; 95% confidence interval [CI], 0.516-0.924, for men), vegetarian or vegan (OR 4.814; 95% CI, 1.669-13.887) and other particular diet regimens (OR 1.819; 95% CI, 1.282-2.580), sport (OR 1.688; 95% CI, 1.116-2.553), and type of sport (OR 0.629; 95% CI, 0.423-0.936, for team sports). Women were more likely to use DSs following a doctor's prescription and to buy them in a pharmacy (P < 0.001) but reported more adverse effects (P = 0.018) than men. The main aim pursued was general health; proteins, amino acids, and non-caffeinated energy supplements were consumed to improve physical performance and caffeinated energy supplements for mental performance. CONCLUSIONS: Diet supplementation was common in the sample examined, especially in women, and associated with particular dietary regimens and sports, especially individual sports. Female consumers follow specialists' indications more than males. These results highlight the need for educational interventions about diet supplementation for this category of users.

Alcohol Mixed with Energy Drinks (AmED) Use among University Students: A Systematic Review and Meta-Analysis.

In the last decades, there has been a huge increase in the consumption of both Energy Drinks (EDs) and alcohol and, concurrently, these two trends generated the additional practice of mixing ED with alcohol, known as Alcohol mixed with Energy Drink (AmED). One of the most important group of AmED consumers is represented by young. Indeed, the study population of the researches in this field are mainly represented by college students and the results evidence a great range of negative consequences for health. The purpose of the systematic review was to explore the prevalence of AmED consumption among undergraduate students, together with motivations to their use, adverse effects and health-related behaviors associated to AmEDs use. The review was conducted according to the PRISMA Statement and PubMed, Scopus and Web of Science were interrogated. 42 articles, published from 2008 to 2021, were included in the review. An overall prevalence rate of 37% was estimated for AmEDs use in undergraduates, with geographical differences. Although a decrease in consumption was observed throughout the studied period, a continuous monitoring on this phenomenon is needed for identifying those risk groups that could develop risky behaviors related to AmEDs consumption and provide them targeted educational interventions.

Studying Respiratory Symptoms Related to Swimming Pools Attendance in Young Athletes: The SPHeRA Study.

This study investigates the prevalence of respiratory symptoms and the training factors possibly associated with them in a sample of young Italian competitive swimmers. A questionnaire about training information and symptoms was administered to participants during the winter and summer 2021 training seasons. In total, 396 athletes took part in the study. In the winter training subgroup (n = 197), we found significant associations between increasing training hours per session and the presence of nasal congestion/rhinorrhoea (OR = 3.10; p = 0.039) and cough (OR = 3.48; p = 0.015). Total training hours per week were significantly associated with nasal congestion/rhinorrhoea (OR = 1.12; p = 0.010). In the summer group (n = 199), the same factors were not associated with respiratory symptoms. Having an allergy was significantly related to nasal congestion/rhinorrhea in both the logistic models (model 1 OR = 2.69, p = 0.013; model 2 OR = 2.70, p = 0.012), while having asthma significantly increased the risk of coughing (OR = 3.24, p = 0.033). The kind of environment (indoor or outdoor facilities) did not affect the studied symptoms either in summer or winter. Further investigations are needed to better understand the mechanisms involved in the development of respiratory symptoms in swimmers, particularly on how inflammation and remodelling develop and which environmental conditions can favour these processes.

Determination of Carbonyl Compounds in Different Work Environments: Comparison between LC-UV/DAD and LC-MS/MS Detection Methods.

There were two analytical methods for the determination of 12 carbonyl compounds (CCs) by using liquid chromatography (LC) coupled with mass spectrometry (MS/MS) and diode array detector (UV/DAD) that were developed and applied to 52 samples that were collected in 10 workplaces. Linearity (0.996 < R2 < 0.999), intra-day repeatability (0.7 < RSD% < 10), and inter-day repeatability (5 < RSD% < 16) were acceptable for both techniques, but the highest sensibility of the MS/MS method allowed us to correctly quantify 98% of the samples (versus 32% by UV/DAD). The comparison of the concentrations that were obtained by quantifying the same sample with both techniques showed good agreement for acetaldehyde and formaldehyde (0.1 < % deviation < 30) but much higher for the less abundant congeners. In real samples, formaldehyde was the most abundant congener (concentrations between 2.7 and 77 µg m-3), followed by acetaldehyde (concentrations between 1.5 and 79 µg m-3) and butyraldehyde (concentrations between 0.4 and 13 µg m-3). In all the beauty salon samples, instead, the most abundant congener was acetaldehyde (concentrations between 19 and 79 µg m-3), probably associated with the use of beauty products. Principal components analysis (PCA) confirms the ubiquitous character of formaldehyde and highlights the influence of minority CCs on different workplaces.

Impact of Air Pollution on the Composition and Diversity of Human Gut Microbiota in General and Vulnerable Populations: A Systematic Review.

Recently, growing attention has focused on the impact of air pollution on gut microbiota as a possible mechanism by which air pollutant exposure increased the risk for chronic diseases, as evidenced by in vivo studies demonstrating important exposure-induced alterations in the diversity and relative abundance of gut bacterial taxa. This systematic review provides updated state-of-art findings of studies examining the impact of air pollution on the human gut microbiota. Databases PubMed, Scopus, and Web of Science were searched with the following strategy: "air poll*" AND "gut micro*" OR "intestinal micro*"; moreover, a total of 10 studies were included. Overall, there is the evidence that short-term and long-term exposure to air pollutants have the potential to alter the composition and diversity of gut microbiota; some studies also correlated air pollution exposure to adverse health effects (impaired fasting glucose, adverse pregnancy outcomes, and asthma attacks) via alterations in the composition and/or function of the gut microbiota. However, the evidence on this topic is still scarce, and large cohort studies are needed globally.

Swimming at the Time of COVID-19: A Cross-Sectional Study among Young Italian Competitive Athletes.

During the coronavirus disease 2019 (COVID-19) pandemic, several restriction measures were imposed to control the virus transmission, with important repercussions on different sectors, including sport. This study aimed to explore the effects of the COVID-19 pandemic on Italian competitive swimmers by analyzing how the disease and the restriction measures affected their training. In total, 396 competitive swimmers (mean age 16.0 ± 3.2 years) participated. A questionnaire was used to collect their general information, to assess whether they had had COVID-19 and the number of training days lost due to the disease or to the closure of swimming facilities, and the possible alternative training adopted. Twenty-four (6.1%) participants had had COVID-19 and lost, on average, 32 training days. The closure of facilities caused an interruption in swimming training for about 18% of the participants. The majority of these continued their training, mainly through home-based exercise, but reduced their weekly training time (-8 median hours/week). A positive association was found between regularly adopted weekly training volume and that assumed during pandemic closure (OR 9.433, CI95% 1.644-54.137, p = 0.012), suggesting that the previous level of engagement in sport can represent a predictor of exercise maintenance in challenging situations such as a pandemic. Further studies are needed to identify personal, environmental, and social resources that can help individuals to counteract the negative effects of restriction measures.

Dataset of PAHs determined in home-made honey samples collected in Central Italy by means of DLLME-GC-MS and cluster analysis for studying the source apportionment.

This paper would like to show all the data related to an intensive field campaign focused on the characterization of the Polyaromatic Hydrocarbons (PAHs) composition profile in almost 60 honey samples collected in Central Italy. The analytical data here reported are the base for a study aimed to identify the pollution sources in a region. 22 PAHs were analyzed by means of ultrasound-vortex-assisted dispersive liquid-liquid micro-extraction (DLLME) procedure followed by a triple quadrupole gas chromatograph/mass spectrometer (GC-MS). A chemometrics approach has been carried out for evaluating all the data: in particular, principal component analysis and cluster analysis has been used both for the identification of the main natural/anthropogenic pollutants affecting a site and for evaluating the air quality.

Evaluation of Risk for Thromboembolic Events in Pediatric Inflammatory Bowel Disease.

OBJECTIVES: The occurrence of thrombotic events in adult patients with inflammatory bowel disease (IBD) is linked to multiple interactions between hereditary and acquired risk factors. There are few published data concerning children with iBD. The aim of this study was to investigate the presence of thromboembolic risk factors also in children with iBD. METHODS: We enrolled three groups of children: one with Crohn disease (cD), one with ulcerative colitis (Uc), and a control group of healthy subjects. For all the participants the potential thromboembolic risk was evaluated clinically and with laboratory tests. RESULTS: We studied: 30 children (25.6%) with CD, 28 (23.9%) with UC, and 59 (50.4%) healthy control subjects. Regarding Pediatric Crohn Disease Activity Index, no significant differences between thromboembolic risk factors and disease activity were detected. Instead, in the patients with UC, stratified with the Pediatric Ulcerative Colitis Activity Index, there was a statistically significant difference in serum fibrinogen levels between patients with mild and moderate/severe disease [3.8 (3.2-4.5) g/L vs 5.7 (4.8-6.2) g/L, P  < 0.0032]. serum homocysteine levels were lower in healthy controls than in CD (P = 0.176) and UC (P = 0.026). An increased level ofhomocysteine in UC with a homozygous mutation in the methylene tetrahydrofolate reductase C677T gene was also observed. CONCLUSIONS: Our study showed that children with IBD have clinical features, acquired and congenital factors that can increase thrombotic risk, similarly to adults.

PAHs presence and source apportionment in honey samples: Fingerprint identification of rural and urban contamination by means of chemometric approach.

The quality of honey is assessed through the determination of some commodity parameters: a certain importance is to be attributed to the absence of contaminating residues, in particular of Polycyclic Aromatic Hydrocarbons (PAHs). This paper deeply investigates the presence of 22 PAHs in 57 honey samples collected in Central Italy and identifies the possible source apportionment and fingerprint identification by DLLME-GC-MS analysis and a chemometric approach. Cluster Analysis and Principal Component Analysis have allowed to identify the main PAHs responsible of the contamination, benzo[a]anthracene and phenanthrene, characteristics pollutants of areas constantly exposed. The entire database has been compared to similar ones present in literature, particularly data from Serbia and Belgrado samples. The PCA applied to overall the data confirms the combustion to be the main contamination source in Italian samples whereas highlights the importance of the role of naphthalene, added during beekeeping practices in the other data-set.

Occupational scenarios and exposure assessment to formaldehyde: A systematic review.

The objectives of the systematic review were to: identify the work sectors at risk for exposure to formaldehyde; investigate the procedures applied to assess occupational exposure; evaluate the reported exposure levels among the different settings. An electronic search of Pubmed, Scopus, Web of Science and ToxNet was carried out for collecting all the articles on the investigated issue published from January 1, 2004 to September 30, 2019. Forty-three papers were included in the review, and evidenced a great number of occupational scenarios at risk for formaldehyde exposure. All the included studies collected data on formaldehyde exposure levels by a similar approach: environmental and personal sampling followed by chromatographic analyses. Results ranged from not detectable values until to some mg m-3 of airborne formaldehyde. The riskiest occupational settings for formaldehyde exposure were the gross anatomy and pathology laboratories, the hairdressing salons and some specific productive settings, such as wooden furniture factories, dairy facilities and fish hatcheries. Notice that formaldehyde, a well-known carcinogen, was recovered in air at levels higher than outdoor in almost all the studied scenarios/activities; thus, when formaldehyde cannot be removed or substituted, targeted strategies for exposure elimination or mitigation must be adopted.