Volume 4

4D Free-Breathing Sequence For The Study Of Pancreatic Lesions In MRI 3 Tesla

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Submission Date: 2022-10-02
Review Date: 2022-10-05
Pubblication Date: 2022-10-08



Pancreatic cancer is the fourth leading cause of cancer death in both the United States and Europe. A fundamental role in the characterization, early diagnosis, and staging of pancreatic cancer is played by Magnetic Resonance. An innovative and recently implemented sequence, the 4D Free-Breathing sequence, is demonstrating remarkable efficiency in the characterization of pancreatic lesions, as it allows to obtain images with high temporal resolution on the arterial phase, maintaining high spatial and temporal resolution, with the patient free breathing and with compensation of respiratory movement artifacts. The aim of this study was to analyze the 4D Free-Breathing sequence technique and to evaluate its advantages in terms of image quality and diagnostic value in the characterization of pancreatic lesions. The 4D Free Breathing sequence replaces the acquisition of the classic arterial post-contrast phase obtained with the 3D-THRIVE sequence: after a first acquisition of the k-space data in the non-contrast phase (lasting 58 seconds), multiple arterial subphases, each one lasting about 5 seconds, will be acquired with a complete coverage of the post-contrast phase of about 90 seconds. This sequence exploits the k-space sampling technique called "Stack of Stars", based on a radial sampling in the XY plane. In detail, along the slice phase-encoding direction (kz), uniform Cartesian-grid sampling is maintained. Within each kz-encoded plane, radial data is collected with consecutive views (1 per sequence repetition time TR) rotated by a golden-angle of 111.25°, allowing the sampling of a complete circle, also determining a considerably reduced presence of breath artifacts.


Malignant pancreatic neoplasms, and particularly pancreatic ductal adenocarcinoma, are ranked as the fourth leading cause of cancer death in both the United States and Europe. This high percentage of mortality is due to several factors, including the difficulty of obtaining an early diagnosis. Indeed when lesions cause symptoms, the neoplastic mass in most cases has already reached a considerable size, and it will have already infiltrated adjacent structures. The latter is probably related to the anatomical position: the pancreas is located deep in the abdomen, close to vital vascular structures, which will most likely be involved in the early course of the disease. A fundamental role in the characterization of pancreatic neoplasms is played by diagnostic imaging, which over the years is undergoing a progressive evolution, allowing a diagnosis as early as possible of any malignant lesions needed for appropriate therapies aiming tumors ‘regression. The application of Magnetic Resonance Imaging (MRI) allows to obtain images with high spatial and contrast resolution, without the use of ionizing radiation. To date, in the pancreas study protocol, an innovative sequence is used, namely the “4D Free Breathing” which, through the “stack of stars” sampling technique, allows to acquire multiple arterial phases, with free-breathing and compensation of respiratory movement artifacts, obtaining a greater capacity for correct identification and characterization of lesions. A diagnosis as accurate and early as possible translates into the possibility of adopting therapeutic procedures as targeted as possible.

The aim of this study is to analyze the 4D Free-Breathing sequence technique and evaluate the resulting image quality and diagnostic advantages in the identification and characterization of pancreatic lesions.

Methods And Technical Description

We will describe the technical and technological principles of the 4D Free-Breathing sequence and the MRI pancreatic study protocol performed at our Radiology Unit (“Paolo Giaccone” Polyclinic University Hospital of Palermo), using a 3-T MRI scanner (Philips Ingenia, Philips Healthcare, Eindhoven). Representative images of modern 4D Free-Breathing sequences will then be shown. Finally, the main advantages of applying this sequence in MRI protocols for the study of the pancreas emerging from the analysis of the scientific literature will be discussed.


4D Free-Breathing Sequence: k-space technique and sampling

The 4D Free-Breathing sequence allows to obtain in “Real-Time” different acquisitions in the arterial phase of high quality in terms of Temporal, Contrast and Spatial Resolution, without requesting respiratory apnea, unlike the conventional 3D-THRIVE sequence which employ the Breath-Hold and/or Trigger Gating modalities. This allows a more accurate characterization of pancreatic lesions with the post-contrast study, even in poorly compliant patients.

This sequence uses the sampling technique called “Stack of Stars”, based on a radial sampling of the k-space in the XY plane, unlike the “classic” sequences used for the study of dynamics post-contrastographic, such as the 3D-THRIVE, which are based on a Cartesian type k-space sampling in the XY plane with an associated sequential phase shift along the Z axis to sample again in a Cartesian sequential manner on the XY plane (Fig. 1).

Fig. 1 – Representation of the two different types of sampling. Respectively “2D Cartesian sampling” (left); “2D radial sampling” (right)

The name of the sampling technique called “Stack of Stars”, specific to the 4D Free-Breathing sequence, is due to the way in which the K-space data are sampled (Figs 2 and 3). In fact, unlike the Cartesian sampling which collects data in a sequential manner, this technique allows to collect the K space data, figuratively forming a star, in which each ray will pass rigorously through the center.

It is defined as the golden angle technique, that is a radial sampling with rays always passing through the center, which are spaced from each other with an angle of 111.25 °, defined as golden angle, so called because by exploiting this angle it is possible to sample a full circle, covering only 180 °. The golden angle corresponds to 180° multiplied by the golden ratio.

Fig. 2 – Graphical representation of the “Stack of Star” data sampling method

Resuming, along the slice phase-encoding direction (kz), uniform Cartesian-grid sampling is maintained. Within each kz-encoded plane, radial data is collected with consecutive views (1 per sequence repetition time TR) rotated by a golden-angle of 111.25°, allowing the sampling of a complete circle, The center of each continuously sampled K-space will carry with it along the z axis, in addition to the data relating to the contrast resolution, also the information of the data relating to the respiratory movement which, through the Fourier Transform, along the slices, will determine an estimate of the data over time, which will allow the artifacts related to the patient’s free breath to be corrected through a data system analysis during the dynamic contrast phase.

The 4D Free-Breathing sequence then uses the core data as the midpoint of respiratory motion estimation. The use of the golden angle, that is a radial sampling with rays always passing through the center, which are spaced from each other by 111.25 °, capable of sampling a complete circle, determines a considerably reduced presence of artifacts from an incorrect respiratory movement.

Fig. 3 Graphic representation of the golden angle in the various “stacks” in the various time intervals. It can be seen that, from one “stack” to the next, the gradation of the orientation varies by 111.25 ° (value of the golden angle).

Table 1 shows in detail the acquisition parameters of the 4D Free Breathing sequence. This sequence replaces the acquisition of the classic arterial post-contrast phase obtained with the 3D-THRIVE sequence. In particular, after a first acquisition of k-space data in the pre-contrast phase (lasting 58 seconds), with substantially equal in-plane resolution and slice thickness compared to the classic 3D-THRIVE, multiple (18 in our study protocol) arterial subphases, each lasting about 5 seconds, will be acquired, with a complete coverage of the post-contrast dynamics of about 90 seconds.

Tab. 1 – Acquisition parameters for the sequence 4D Free-Breathing in the pancreas MRI study (MRI 3T, Philips Ingenia, Philips Healthcare, Eindhoven).

MRI study protocol of the pancreas with 4D Free-Breathing sequences

The MRI study protocol of the pancreas performed at our Radiology Unit using the Philips Ingenia 3-T Magnetic Resonance Scanner (Philips Healthcare, Netherlands Eindhoven), equipped with combined gradients with 45 mT/m of amplitude and 200 mT / m / ms of slew rate, is reported below.

The receiving coil used is a dStream TORSO coil surface coil, composed of a front and a rear FlexCoverage coil, which allows to obtain a body coverage of 56 cm and to adopt a maximum of 32 channels, positioned centrally to the area of ​​interest so as to capture a signal as broad and homogeneous as possible from the district concerned. The protocol used for a pancreatic study in 3 Tesla Magnetic Resonance, provides the following sequences: coronal T2 TSE-SSh, axial T2 MVXD, axial T2 SPIR MVXD, axial dual FFE OP-IP (BH), 3D MRCP RT, 2D MRCP Radial, mDIXON-Quant (BH), axial DWI, and finally DIXON dynamic and 4D Free-Breathing after the administration of an extracellular gadolinium-based contrast agent, these latter with the temporal scheme described in detail in Figure 4.

Fig. 4 – Graphic representation of the non- and post-contrast phases in the sequences: m-DIXON basal, 4D FreeBreathing, m-DIXON Thrive PORTAL, m-DIXON Thrive LATE 3 minutes, distinguishing the three main sections of the pancreas: head, body and tail

Discussion And Conclusions

The use of the 4D Free-Breathing sequence in the pancreatic study protocol means that radial acquisitions are significantly less susceptible to movement, thus allowing examinations to be performed without the usual respiratory apneas. Furthermore, this free-breathing technique, eliminating problems related to the patients’ possible difficulties in holding their breath correctly, allows to minimize the failure rates, related to breath artifacts, especially for non-compliant or elderly patients, or patients with respiratory pathologies, allowing to obtain an imaging with high contrast, spatial and temporal resolution. The rapid acquisition allows to optimally compensate for all types of movements, such as those due to the physiological intestinal peristalsis or to the patient’s difficulty in maintaining the necessary immobility. The image artifacts, which can appear as streaks, or as blurring, in particular in a restricted anatomical volume and particular in its morphology, such as that of the pancreas, can in fact invalidate the diagnostic evaluation, making it difficult to identify and distinguish the anatomical structures and any focal pancreatic tumor lesions. The arterial post-contrast phase is a crucial phase, which allows for example the differential diagnosis between neuroendocrine tumors, which frequently show early arterial enhancement and subsequent rapid wash-out, and adenocarcinomas, which are hypointense compared to the remaining pancreatic parenchyma.

Routine clinical use of sequences employing stack of star sampling techniques is feasible with current MRI systems and can serve as a replacement for conventional T1-weighted fat-suppressed sequences in applications where motion is likely to degrade the image quality.

This particular sequence plays an important role not only in pancreatic imaging, but more generally in abdominal imaging considering that the information of the arterial phase is frequently fundamental for a correct and accurate diagnosis of pathologies and that the conventional single arterial phase obtained with 3D THRIVE sequence is not infrequently inadequate for small movements of the patient or for errors in the temporal acquisition of the sequence.

These problems mentioned so far are therefore overcome by including the 4D Free-Breathing sequence in the examination protocol, since through the rapid and consequential acquisitions of 18 arterial phases, each one lasting 5 seconds, it is possible to capture and identify the maximum saturation point of the contrast media in the arterial circulation, with free-breathing, therefore also suitable for non-compliant patients and with correction of breathing artifacts.


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Refocus flip angle modulation on the pd tse sequences in the magnetic resonance imaging of the knee, for the evaluation of meniscal injuries

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Submission Date: 2022-07-25
Review Date: 2022-11-29
Pubblication Date: 2022-07-30



The Radiofrequency Refocused Echo Spin-Echo Echo-Train Rapid-Acquisition sequences, known as Turbo Spin Echo or Fast Spin Echo are the most commonly used sequences in Magnetic Resonance as they provide a notable contribution in morphological and anatomical terms, thanks to their high spatial and contrast resolution. Furthermore, they allow a higher signal noise ratio than the other families of sequences thanks to the numerous refocusing pulses and thanks to a TR so long as to allow sampling as many K-space phase encodings as possible and with a complete recovery of the Longitudinal Magnetization. Finally, the multiple 180 ° pulses of these sequences reduce the inhomogeneities of the Magnetic Field by minimizing the phenomena of magnetic susceptibility. However, their application, especially in scanners with a high intensity of static magnetic field B0(1.5T and/or 3T)is prevented by the deposition of RF due to the long echo trains, which sometimes involve exceeding the limits of the specific absorption rate for patient safety. Over time, a common solution to the SAR problem has been the use of refocusing angles smaller than 180°(160°-140°-120°),which lead to its reduction at the cost, however, of an obvious penalty in terms of signal-to-noise ratio. In this study we present a modulation method of the Refocus Flip-Angle applied to the DP-TSE sequences in the evaluation of meniscal lesions in the study protocol of the Magnetic Resonance of the Knee, which exploits the phenomenon of the Pseudo-Steady-State(PSS), leading to a noticeable SARreduction without loss of SNR and also providing excellent contrast resolution.


Magnetic Resonance is currently the method of choice in the study of joint pathology, as it is a non-invasive, multiplanar and multiparametric method. The high contrast resolution associated with a high sensitivity for pathological areas and excellent tissue characterization allows extreme diagnostic precision, assuming a role of primary importance in the diagnosis of numerous pathologies. The knee is one of the most studied joints in MRI. It is estimated that about 80-90% of meniscal tears are of a traumatic nature following sports activity and 10-20% of a degenerative nature following degradation due to dehydration with increasing age. The FSE/TSE sequences, in particular those weighted in proton density, are the most used sequences in MRI for joint study, as they allow excellent tissue discrimination (tendons, ligaments and menisci). However, one of the main limitations of these sequences is the excessive heating of the tissues, a direct consequence of a large number of 180 ° iRF echo trains (ETL 15-40). It is known that the energy deposition of an RF pulse is proportional to the square of the inversion angle (α2): this means that a 180 ° pulse deposits a SAR 4 times higher than one pulse at 90 °. To overcome this problem, various strategies have been applied over time with the aim of limiting the SAR, among these the reduction of the refocusing angle with fixed Flip Angles, has allowed lower SAR levels but with an evident reduction of the MR signal. In our study we have implemented various strategies to optimize the contribution of the signals coming from the components of the Mx and My magnetizations, in particular by modulating the Refocus Flip Angle at variable angles with the aim of exploiting the Pseudo -Steady-State (PSS) phenomenon. This strategy allowed to obtain a better visualization (contrast resolution and higher SNR) of the meniscal lesions in the TSE PD sequences of the knee MRI, thus obtaining, with a low SAR and within the expected limits, a more sensitive and specific imaging.


The aim of our study was to modulate the Refocus Flip Angle parameter, exploiting the phenomenon of PSS, applied to the TSE PD sequences, in the MRI of the knee, to obtain a better visualization of the meniscal lesions, achieving a more sensitive and more specific imaging, compared to TSE PD sequences with constant refocusing angles and less than 180°.

Materials And Methods

MRI examinations of the knee were performed at the Department of Radiology of the University hospital “Paolo Giaccone” of Palermo, using a Philips Achieva 1.5 T Philips Healthcare MRI scanner.

The receiving coil used is the Knee-Coil SENSE 8ch, within which the knee under examination is allocated.

Ten volunteer patients underwent MRI of the knee. The examinations were performed after the volunteer patients were properly and adequately informed about the study in progress, and duly signed the informed consent. The various sets of sequences for a single patient were performed in several sessions with an interval of approximately 7 days.

The joint study protocol (standard), carried out at our Institute, provides for the acquisition of Ax T2 TSE, Ax PD TSE SPAIR, Sag DP TSE, Sag T1W, Sag TSE STIR, Cor PD TSE and PD TSE SPAIR sequences.

In the PD-weighted sequences acquired in the coronal and sagittal planes we modulated the Refocus Flip Angle parameter, with the aim of obtaining a better visualization of meniscal lesions. In particular, we started with a set of images with classic 180 ° refocusing iRF, comparing it with a further 3 fixed angle sets at 160 °, 140 ° and 120 ° in terms of SAR and SNR ratio. Finally, we acquired a series in which we modulated the Refocus Flip Angle, by linearly varying the tilting angles from low values ​​of 60 °, then intermediate values ​​of 90 °, to high values ​​of 110 ° along the echo train.

Classically, with the 180 ° iRF pulses the transverse magnetization (TM) is completely and entirely refocused without any contribution from the longitudinal magnetization (LM), instead reducing the RF flip angles below 180 °, there will be a situation in which we will have both the TM and the LM. This implies that at each subsequent cycle of pulses there will be a refocusing contribution of the deflected TM, but also of the “stored” LM, which together with the TM will contribute to the generation of the echo signal. Each subsequent pulse other than 180 ° in the train of echoes will continue to divide the magnetization into longitudinal and transverse components. With this strategy we ensure that the echoes stimulated by the longitudinal component are stored and sampled in the phase encodings with low amplitude (more useful data) thus obtaining a generation of MR signal with more essential information.

In particular, the three parameters, which play a fundamental role in the PSS phenomenon, are the values ​​attributed to the overturning angles along the train of echoes. We will pass in a linear way from a minimum α value, which allows to reduce blood vessel flow artifacts, which would deteriorate the quality of the images and we will then proceed with an intermediate α value, which allows to maintain the relaxation time T2 constant when the signal of the central portion of the k space is sampled, thus obtaining a better resolution of contrast of the image. Finally, we will move on to the maximum α value, thanks to which we will have a higher SNR and, therefore, greater image sharpness.

Fig. 1 – Representative diagram of the variation of the refocusing angle in relation to the MR signal. In the first case (pink) 180 ° iRF pulses are used, in the second case (blue) 160 ° iRF constant pulses are used, in the third (green) and fourth (light blue) lines iRF pulses at 140 ° and 120 ° respectively are used. In red, on the other hand, a strategy with variable refocusing angles (60 ° / 90/110 °) is applied. Theoretical signal intensities are shown below (ignoring T1, T2 and off-resonance effects)


With the implementation of the modulation of the Refocus Flip Angle, following the values ​​α equal to 60 ° – 90 ° – 110 °, identified through the various tests performed at our Institute, as regards the visualization of meniscal lesions, better results were obtained in the series of images acquired in terms of both of contrast resolution and signal/noise ratio, with a considerable reduction in SAR. Tables 1-3 below show in detail, for the PD TSE sequences of the knee MRI protocol, the acquisition parameters compared between the standard sequences with the use of constant Refocus Flip Angle, and the sequences with the application of the technique of the modulation of the Refocus Flip Angle with tilting angles of 60 ° -90 ° -110 °.

Tab. 1 – Acquisition parameters related to the Ax PD TSE SPAIR sequence of the MR study of the knee, with constant Refocus Flip Angle, and with the Refocus Flip Angle modulation technique.
Tab. 2 – Acquisition parameters related to the Cor PD TSE sequence of the MR study of the knee, with constant Refocus Flip Angle, and with the Refocus Flip Angle modulation technique.
Tab. 3 – Acquisition parameters related to the Cor PD TSE SPAIR sequence of the MR study of the knee, with constant Refocus Flip Angle, and with the Refocus Flip Angle modulation technique.
Tab. 4 – Acquisition parameters related to the Sagittal PD TSE sequence of the MR study of the knee, with constant Refocus Flip Angle, and with the Refocus Flip Angle modulation technique.

In figure 2 it is demonstrated how, by reducing the FA from a classic value of 180 ° to 120°, the RM signal is progressively reduced, while applying the strategy of a Variable Flip Angle the RM signal is excellent.

Fig. 2 – Comparison of various refocusing angles applied to images acquired with a 1.5T scanner in Coronal PD (top) and Coronal PD SPAIR (bottom). From left to right constant FAs were applied, respectively at 180 ° 160 ° 140 ° 120 ° and finally a variable FA 60 ° / 90 ° / 110 °.

Discussion And Conclusions

By analyzing the images acquired with Refocus Flip Angle kept constant with a value of α equal to 180 °, we have achieved excellent image quality: this is because all the spins are overturned and refocused by this RF pulse, obtaining a high echo signal. Subsequently, after a careful and accurate evaluation of the various series of images, which were obtained with values ​​of α equal to 160 °, 140 ° and 120 °, it was noted that, compared to the classic iRF 180 ° pulse, both the signal and the resolution overall image contrast are slightly reduced. All these negative aspects were accentuated when reference was made to the visualization of the meniscus. Ultimately, by evaluating the series of images obtained from the Ax PD TSE SPAIR, Cor PD TSE and Cor PD TSE SPAIR and Sag PD TSE sequences with exclusive modulation of the Refocus Flip Angle parameter in variable mode, we have gained a significant reduction of the flow artifact and a significantly lower SAR than previous tests. We then achieved, during the central portion of the echo train, signal amplitudes greater than those achieved with constant RF refocusing pulses at 180 °. During this increase we proceed with the signal sampling of the central portion of the k-space; it follows that the contrast resolution and the signal/noise ratio of the entire image, but with particular emphasis on the meniscal portion, will be high. In conclusion, in the MRI examination of the knee, the choice of the sequences under study must achieve the goal of obtaining the best anatomical detail and contrast between the structures under examination. The TSE PD sequences, in which the Refocus Flip Angle modulation has been performed, satisfies these needs. In fact, the images present a better quality in the visualization of meniscal lesions, thus allowing to perform a morphological study much more accurate than the one performed in the absence of this variation, with lower SAR values.


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The Groupal Device: Value And Usage In Neuro And Psychomotor Therapy Of Developmental Age

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Submission Date: 2022-07-20
Review Date: 2022-07-25
Pubblication Date: 2022-07-30



The group represents the social element in which every individual can experience them-selves after the achievement of the main stages of the neuro-psychomotor development, particularly in the affective-relational, neuropsychological and cognitive areas, and is thus identified as a fundamental device to support rehabilitation therapy.
Early in a child’s development, social skills begin to maturate and their development path-way merges with different groups with a specific architecture which modifies and increases these skills over time. As a result, it is necessary to identify the process that leads from the exclusive belonging to the family-group to the need to prioritize comparison with peers to finally arrive at the interdependent social groups in the collectivity/community. Each group has distinct characteristics that move from its social dimension to the cross-sectional com-ponent of its matrix, where individuals’ desires and beliefs are based. The group’s evolution will allow the initial dimensional plan to be expanded, resulting in participants sharing inten-tions and goals. The group is a powerful tool at the therapist's disposal who is capable of monitoring variables that can quickly change the intra/interpersonal dynamics of patients undergoing treatment. The groupal therapy underlies clear rules within it, which ensure the observance of normative and setting parameters and the identification of the parameters of effectiveness to assess its progress.


In the developmental dimension of the human being, promoting and structuring of skills and competencies of various kinds and function goes through numerous experiences which each person feels in an individual/personal way only if immerse within valid and/or appropriate relationships. The relationship arises from continuous interactions that settle over time and produce significant effects on the emotional-affective sphere of the individuals. Every single interaction involves the participation of at least two subjects in a relationship defined as temporary, entailing the sharing of activities without any emotional/affectional involvement. Constant exposure to interactions, combined with temporal continuity, enables individuals to develop relationships that are not merely based on activities performed, but on the emotions felt and aroused by the first interactions and, in particular, those complex interactions, which over time have been distinguished by their share of emotional involvement, devotion, and loyalty. This model primarily defines the structured dyadic relationship between mother and infant, characterized by the strong influence exerted in all the relational dynamics that will be structured from the earliest stages of development, which include the family group first and then the peer group.

The group represent the system of synthesis of social development of an individual: within it there is the possibility to experiment in an all-encompassing way, engraving the functions of the group and accepting to be transformed by the dynamics that the group experience.

Within the group, each subject can experience all the elements gained in the construction of their relational patterns, which will influence their functioning in social and adaptive terms, including:

  • Need for social belonging: centrally placed on Maslow’s Pyramid (A theory of Human Motivation, 1943) as motivation theme conveys the need to be accepted by the social group where one is placed and whereon are built theme as self-confidence, self-control and mutual respect. Membership enables the individual to experience the sense of inclusion and the perception of his value in a predetermined context, to feel welcome and accepted for his quality, otherwise, differences with other group components fade into the background. This need is built on relational motivation- one of the basilar motivation of human being- which constitute for Folks (1977) an intrapsychic competence of the individual hence the internalisation of relationships, interactions, and way of being, which operate on the group in whom the subject belongs. Therefore, being internalised is not an external object but a social relationship, which is the ensemble of interactions and communications in the social-cultural context in which one is born and grows.
  • Need for holding: within a social group, this concept refers to Winnicott’s (1974) construct of attachment; this need is satisfied by the mother who acts as a container, first physical and then psychic, in which each infant (and future individual) has the opportunity to feel welcomed, supported, encouraged and reassured. The need for holding generates in each individual a tendency to develop reflective type capacities, contextually to Self, Self in connection with the other and other individual selves.
  • Principle of identification: defines the entire process that leads the child to think and act as the characteristic of another person were their own. It represents a fundamental aspect of the socialization process, which takes place when the child, after having formed a deep bond with significant persons, wishes to adhere to their modes of behaviour identifying himself with them and at the same time avoid their disapproval of his possible improper conduct (Camaioni e Di Blasio, 2002). Identification represents the mechanism whereby the individual lays the foundation for the construction of his personality, acquiring and absorbing one or more features of other individuals and shaping himself upon them. It is achieved starting from the acceptance and sharing of the group’s values discerning resemblances from differences.

Social development: the family group, the peer group, and the social groups.

The socialization process is for each child typically present from birth and defines oneself during the entire life cycle, weaving personal experiences and complex learning processes together to establish sharing behaviour models.

Socialization development matures from the earliest body contact experiences, which predicts skills of emotional attunement and co-participation mother-child, which will lead to the development of intersubjectivity in the different forms of tested relationships. The progressive child’s ability to distance himself from his parents and grow up in terms of personal autonomies will lead him to open up to his peers in an experience of sociality.

Socialization allows individuals to take part in social life placing themselves as members of groups that are diverse according to their interests, social skills, feelings, and experiences.

Inside the groups two structures may be observed:

  1. Vertical: refers to relationships with the adult, who is deputed to offer care, protection, and to assure the learning and development of the child;
  2. Horizontal (equal): based on reciprocity and learning arena for the acquisition of skills of cooperation and conflict management.

Each individual is continuously crossed by diachronic and synchronic networks. The former represents the results of the interiorization of every group relationship that the subject has already lived in a moment that takes place not necessary in the present and of all the leverages which origins from the previous generations which have left a trace. The latter has to do with everything that occurs in the here and now of the subject, therefore with his current relationships with his family members and with the various groups of social belonging. The existence of diachronic and synchronic networks present in historical and continuous time in the individual’s life enables to configure the groups as a useful instrument for learning social, relational, and emotional skills, and for the achievement of teaching skills. Belong to a group means inextricably and necessarily connecting their own experiences, actions, and results to those of other group members.  Therefore, a significant interdependence rises between subjective elements – typical of each individual or member’s intimacy- and intersubjective which are learned from the contact with the group.

Motivations, behaviours, attitudes, and relational modes take on connotations that make the individual-group relationship dynamically interdependent. It can therefore be affirmed and sustained that the personality of the individual is in part built based on this relational-group plot.

Each person is continually included in different group contexts, -family, school, other communities- and each of these contributes to shaping personality and orienting it in directions that can be shared on various levels. The child is born within the family group and grows within the peer group, thanks to which he defines their identity by comparing his attitudes and personal characteristics, and finally flows into the various group of society:

  • The first significant group for the individual is the family, in which one is placed from the earliest days of life and in which the earliest personal, emotional-affective, relational and cognitive skills are developed. These competencies contribute, as a whole, to the definition of behavioural patterns. The aspects connected to and dependent on the group dimension of the family belong to each individual member: each member of the family group will have built on different levels and typologies of his own individualisation, therefore the general assimilation of each individual trait is a direct expression of an internalized group dimension. The family group provides clear indications about the aspects of the rules and norms that must be considered and internalized in order to directly experience them in society. The family system is an organisation of people who constantly lives changes over time involving the modification of tasks, roles and meanings associated with them thanks to the analysis made by the individuals in relation to the primary and secondary actors of the social fabrics, in which they are inserted into the environment. The family falls within the vertical group structures, characterised by asymmetry, insofar as are established within partners who are on two different levels. These relations serve the fundamental function of providing protection and security from one side and transmitting knowledge from the other side (Corsaro, 2008). The family has a crucial role in characterizing the social developmental trajectories of children who belong to it; the process of socialization embeds both content aspects, which concern “that which is transmitted”, and form aspects that concern “how it is transmitted” (Molpeceres, Musitu & Lila, 1994). Therefore, the style of disciplines adopted by parents, as well as the global representation of social functioning transmitted by parental figures, will influence the child’s development. 
  • Several authors have considered and analysed family-group dynamics. Murray Bowen (1979) outlined the goals that each individual must set in order to merge with and simultaneously emerge from the group. This process occurs in a temporal condition characterised by continuity throughout the development of the subject, with a high level of adaptability, observing all the factors involved, and consists in the evolution of a construct that passes through three components: Differentiation, Self-definition, and Individuation. At one end of the scale is the “Differentiation of the Self” where are placed individuals who are unable to invest in their own resources and find an individual identity because they are tied to the family appendage; at the opposite end are those who have reached a high degree of independence and complete emotional maturity, such as to make decisions and act without being influenced by social opinion. Individuals positioned at this extreme are those who fall within the ideal of the pinnacle of social development: Bowen states that the majority of individuals are at an intermediate level between the two above mentioned extremes.
  • Salvador Minuchin (1978) assumes that human identity is an experience based on two essential principles, which are a “ sense of belonging” and a “sense of separation”, which find meaning within the familiar matrix where they are mixed/merged. The sense of belonging is formed from childhood through the construction and modelling of the sense of identity from the family during the early socialization process, the adaptation to the internal dynamics and assimilation of the transitional process of family structure. The sense of separation, instead, takes shape when the individual is involved both in the family group and in the social group; this permits the family and child to develop adaptive competencies, which will permit them to become independent over time and, as result, separate. The differentiation of a family depends on its composition, level of development, and subculture permitting the participation of different familiar subsystems or extra familiar groups which enables the single subject to create his own space or learn new relational modes, defining his own identity without missing the sense of belonging. In the process of differentiation, the family can encourage the development of self-identity with relationships that facilitate autonomy or it can inhibit development with relationships that hinder differentiation. Minuchin recognizes the importance of the role of the family but views it as a system that acts within other dynamics, which are underlying relationships with other social systems.
  • The second group is that of peers, which allows individuals to fully experience themselves thanks to the development of individual capacities distant from the defined rules and/or predetermined roles of the family context. It Is around 30 months of age that children begin to feel the tendency to stay with their peers for phylogenetic determined reasons; initially, within the group prevails on the single component a still egocentric position from the intellectual point of view, and it is the belonging to the peer group that represents the reason and facilitator of the abandonment of this type of thinking, enriching the affective, communicative, and cognitive competencies of the components and coining more and more adaptive strategies to face the social world. In this experience, the child is guided by two dimensions: the first is fusional and describes the group’s ability to offer protection, holding and guarantees to the single individual in a perspective in which one’s personality is put in the background in favour of integration and fusion in the group as an integral part of it. The second dimension is the affirmative and describes the individual’s ability to enrich his personality by drawing on the characteristics of others, through the mechanisms of projection and introjection. The presence of the group stimulates the action of the individual toward the outside world, increasing his active potentialities. The peer group allows the child to experience horizontal relationships, characterized by the symmetry between the partners that allows the child to learn new skills through sharing, cooperation and active role taking. Symmetry becomes the starting point from which experience situations that lead to living in the immediate the significance of making decisions or undergoing them, so as to be immersed in the condition of learning to reason about one’s point of view and that of others. Therefore, not only there is a constant work of the child in terms of socialization but also a continuous solicitation of higher cognitive systems which encourages the intellectual development of the child. This latter dipped on relationship with peers, is costaneuoulsy solicited in all the development areas, especially on executive functioning insofar as on relational manage are required planning skills, modification of own acts or choices, contextual appropriateness, ability to analyze and synthesize environmental information, to improve resolution time (problem-solving, decision making), inhibitory control, cognitive flexibility, verbal fluency and mnestic skills.
  • The third group is represented by the various communities seen by the individual and his family. These are group entities with a strong sense of belonging. The idea that even socio-cultural roots in smaller or medium-sized social groups (the companies of friends, the group of work colleagues, religious communities, political groups) can make a decisive contribution to the formation of the personality shows how important interpersonal factors are in determining one’s characteristics.
  • Finally, the fourth group corresponds to society in the broadest sense of the term, with the variables relating to the more general organization of the culture and social norms of each people. Also, this aspect should not be neglected since belonging to a social structure partly influences the formation of personality. 
The social groups: Origin and Mentalization

The social groups follow regular cyclic patterns: they originate (initial phase), they develop and grow through dual and group trials (intermediate phase) and finally dissolve (final phase); within various phases, it is possible to appreciate more widespread changes, which are expressed with role changing and the formation of subgroups, who are the pure expression of the dynamism of evolutionary process. Within the group reality, the development of the individual passes through the experimentation of the Self concerning the different situations according to the individual group.

In “primary” groups, individuals are involved in early socialization experiences such as values, attitudes and beliefs that determine the most relevant aspects of personality, influence cognitive patterns, and social behaviours; in “secondary” groups, roles and interpersonal relationships become clear based on the goal to be achieved, so individuals are led to adhere and share the goals of a given group, being conscious that they must integrate preconfigured norms with cultural and social patterns.

The essential characteristics of all social groups are:

  • interdependence and interpersonal relationships among members;
  • sense of belonging experienced as a collective perception of uniqueness;
  • a common objective;
  • the motivation of individuals to pursue their satisfaction;
  • the mutual influence that occurs among participants within the group interaction;
  • shared norms and roles.

The “ Becoming” group involves the structuring of a process which is constantly evolving and needy of commitment from the individual and availability from the groupal reality already placed or pre-established. Tuckman and Forsyth (1965) suggest two explanatory models of the above-mentioned process and configure different stages. In particular, Tuckman’s model unfolds in a continuum of evolution of the individual’s development processes which start from the birth, go through the phases of dependence, revolt,  and socialization and arrive at the adult maturity:

  • Stage I, defined as Forming, represents the initial phase of the group formation, in which individuals experience themselves in accordance with the dynamics of the relational matrix and their previous experiences, as the roles and mutual expectations among members are not clear;
  • Stage II, defined as Storming, reflects the conflicts resulting from the activation and/or definition of roles, norms and tasks/objectives;
  • Stage III, defined as Norming (normative period), is the stage following the period of conflict, characterized by a positive climate, in which cohesion and commitment among members are active concerning the objectives to be pursued. Therefore there is trust and mutual support among members, as well as high levels of sharing following the definition of clear rules;
  • Stage IV, defined as Performing, (period of performance), represents the period of dynamic Intra/inter-groupal maturity, during which group members are focused only on the positive result of the task/goal setting: in fact, relational conflicts between members are overcome.
  • Stage V, the Adjourning (suspension period), constitutes the terminal phase and is characterized by emotional disengagement in preparation for the group’s dissolution phase.

Tuckman’s model analyzes the being of the group as an evolutionary process characterized by the importance of relational exchanges, of whose dynamics the solution of the task becomes a function. It emphasizes the importance of conflicts not as an element to be repressed, interrupted or inhibited, but rather as a physiological phenomenon necessary for the birth and realization of the group.

Forsyth’s second model appears to be more current than Tuckman’s and was subsequently adapted by Smith and Mackie (1995):

  • The first stage is part of the cognitive-exploratory function; if this experience is successful, it can move from the initial orientation stage to the primordial group stage: the individual will be free to see himself as part of the group and the group to see him as part of itself;
  • The second stage, as Tuckman, requires the need to experience the conflict. Conflict for individuals is in both individual and intragroup terms;
  • The third stage represents the normative phase that can only occur if the group survives the conflict phase. Having overcome the conflict, members recognize the group’s existence and its values and they project their identities. Having established best practices and norms to share, real group cooperation begins;
  • The fourth stage, referred to as the executive phase, is characterized by seamless management and high efficiency; members cooperate to solve problems, make decisions, and manage conflicts in a balanced and functional manner about goals;
  • The final phase is called “the death” of the group or dissolution and occurs after achieving the objectives or because of physiological disintegration. If the previous phase has been experienced positively, this last phase can be particularly painful or distressing, so much as to take on the meaning of emotional wounding, and be experienced in a way similar to the end of an intense relationship; the dissolution of the cohesive group can be stressful for the members because it involves the modification of their identity and the loss of the security of the group container. 

The complex process of group building involves several steps, both personal and social, which require mentalization skills. Mentalization, or Reflective Function, is the skill that leads to the process of understanding the interpersonal behaviour of mental states, through the organization of the Self and the affective regulation, within the context of early attachment relationships. Mentalization involves two components, the first self-reflective thanks to which the subject is able to make his cognitive processes the object of reflection, and the second interpersonal, characterized by even greater complexity, whereby is possible to read the cognitive continents of the other in terms of beliefs, goals, desires. Both components involve the ability to distinguish external reality from internal reality, as well as the diversification of internal mental and emotional processes from interpersonal events. During the stages of child development, one proceeds to build one’s mind and the psychological Self through the continuous stimulation of interactions with more mature, attuned, and thoughtful minds. The first object relations must provide the child environment that is inclusive of their own and others’ mental states and promotes mentalization; also through the evolution of the process, it is possible to systematize the object relation over time. Closely related to mentalization is the process of maturation of affective regulation that allows individuals to modulate emotional states and reach a mentalized affectivity, which passes through the verbalization of affection identification, reworked version and re-evaluation of it, as well as the discovery of subjective meanings of their own and other’s feelings that go far beyond the easy understanding of the exclusively cognitive dynamics.

The “GROUP” Therapy and the Therapy “IN-GROUP”

The group is par excellence the place of manifestation, analysis, and evaluation of behaviours. For this reason, it is an important instrument, flexible and adaptable in the clinical area. In the field of Neuro and Psychomotor Therapy of Developmental Age (TNPEE) is necessary to describe how the sessions are articulated on the normative and therapeutic-rehabilitative levels. Within the “group” dimension in developmental age, there is the need to include individuals who have the same level of adaptive, cognitive, and social functioning in order to be able to act through a therapeutic project suitable and similar for all participants. The use of the groupal device may be necessary both at the end of individual rehabilitation interventions in order to create a reality similar to life contexts and to evaluate their transversal skills achieved in their fluid form, and simultaneously to individual treatment in order to have awareness of aspects that would be difficult to emerge with a dual therapeutic relationship. The group arise first in the therapist’s mind who must assess the appropriateness and usefulness of interweaving the clinical histories of individual patients. Within the therapeutic relationship, the therapist will be the conductor and the capillary observer of the group, both in terms of observation of participation and developmental indices and specifically in terms of the organization of roles and activities. The therapist involved, moreover, will have to consider both the vertical and the horizontal structure. Therefore, as will be necessary for him to level out with the participants by adopting competitive attitudes aimed at increasing the levels of motivation, as will be necessary to elevate himself to the group by assuming a mediator role. The foundation phase that follows a new group’s foundation is extremely important because the conductor will have to work actively on the construction of a group matrix, which is an unconscious network of communication that will eventually make significant all the future events.

The four concepts on which the group conception is based are:

  • Relation: the group makes the communicative, conscious, and unconscious aspects more visible;
  • Circularity: everyone is involved in any event that happens and it modifies the perceptual field of the group, giving way to other transformations. This concept represents a mutual interchange among members;
  • Transformation: emphasizes the drive for change that implicitly or explicitly the group induces on the individual;
  • Multiplicity: linked to the plurality of subjects that trigger the confrontation.

There is a need to distinguish two different types of group interventions:

  • The Therapy “in-group”: provides that patients who are undergoing individual treatment can be introduced -on the choice of the therapist who detects the need concerning their functional dynamic profile and their level of psychosocial development- in a small group with multiple conductions. It is important for these types of intervention that the mediation within the group is always conveyed by their therapists, who through strategies of mediation and experimentation lead the child to live peacefully the dynamic enlarged with a peer, who in turn can count initially on their therapeutic reference caregiver. The therapy IN group involves longer latency times: before reaching the full sharing of spaces and activities, as well as the full sharing and exchange of roles among participants, it will be therefore necessary a time of adaption of all the actors present within the setting;
  • The “group” Therapy: can be activated through medical prescription within a reality agreed with the affiliated with NHS and/or public often at the end of the treatment of neuro and psychomotor of developmental age as an exclusive session or in addition to the individual one. The group therapy aims at introducing patients to a social micro-context, encouraging the generalization of strategies and behaviours learned in therapy from more adaptive meaning. With the dynamics exclusively of private nature, the organization of this therapeutic extension can be managed by the professional. Group therapy is conducted by a single one, the leader may not necessarily have had contact with participants or prior knowledge of them and patients are matched by chronological and developmental age as well as by nearly similar clinical frameworks. The optimum number of participants in the group is four patients, as group therapy requires a great ability of the conductor to have control over all the individual personal dynamics of each patient, as well as being able to quickly read the common and extended dynamics among the participants. In fact, the therapist’s flexibility required in the condition of group therapy includes the promotion of therapeutic well-being in the group, the capacity for immediate reading of events, and the functional use of all the natural variables that arise or are induced for the constructive and stable evolution of conflicts that may occur between members or between members and conductor.
Setting Parameters

Within a developmental neuro and psychomotor therapy of developmental age group, the primary actors are the therapists (TNPEE) and the patients, specifically:

  • The TNPEE therapist may be a conductor, mediator, problem solver, and member of the group itself.
  • Patients can be members as well as leaders, complementary leaders, gregarious or antagonists.

In the therapeutic field, the group represents a mediator-regulator/autoregulator, namely a treatment instrument through which it is possible to modify the evolutionary process of the subject undergoing treatment. The change in the functioning of the individual goes through the work of the group, more specifically through the birth of the synchronic transferts to the actions which are performed at that specific moment. The therapy conductor has the function of supervisor and helmsman; whereas the group members, on the other hand, provide references and help the individual to look at themselves and/or recognize parts of themselves.

In the groupal therapy, a decisive role is played by the setting because it includes factors related to the mindset of the therapist who will have to calibrate his attitude according to dynamics that will be structured, the strategies to be built concerning the objectives to be pursued, the operating model to be adopted, the number of participants, the rules, the relative time for each therapy, and the time within which to dissolve the group intended both as a physical place ( room and materials) and as a weekly frequency of meeting. Group therapy, as well as individual therapy, arises first in the mind of the therapist and then it is built first within the personal and then the multiple/groupal dynamics which are built and shared with patients.

Rituals, that derive from the scan of the therapeutic times and spaces, assume relevance within the setting in which the following spatial and temporal timings that make up the session are present:

  • Reception area, in which the initial rituals, of physical nature, take place(e.g. take off the coat, put away the shoes, and wear the non-slip socks for motor activities) or conversational, such as putting the patient in a condition of psycho-physical well-being, overcoming the initial moments of emotional awkwardness typical especially of the very first sessions. To live a condition of serenity at the beginning of the treatment is essential for the preparation of the activities and their development. In this specific space and time, the group discusses relevant events or events of everyday life or the choice of activities with the mediation of the therapist who acts as a conductor;
  • Sensorimotor area, in which the group is able to experience the spontaneity, organization and purpose of the motor act with the full participation of the body in the activity and full exploration of itself with regard to space and other members. The body takes on a significant value within the group: first of all, it allows the members and the conductor to be able to actively observe each other, taking into consideration not only the purely physical connotation but above all the communicative aspects related to posture, non-verbal language, and aspects concerning motor reactivity regarding one’s mood and the capacity for self and hetero-regulation. Through the observation of the body, one becomes aware of one’s existence and that of the other, evolving towards an awareness of one’s own and other’s potential and physical and factual boundaries. In addition, in this space, though the unstructured material- without a specific function- and the motor act meaning as a transformative process the group is able to experience their creativity with full functions related to aspects of symbolism, and the experiment with evolutionary competition in the activities of clear and defined rules;
  • Decentralisation area and dissolution, in which the group members transfer the focus from the action of body dynamics to strictly cognitive skills, reducing the use of the body and investing in levels of mediated interaction through the use of structured material. In this phase, there is a synthesis of the therapeutic experience, the sharing of emotions felt, and the desire to continue the interactions on a more reflective level. In this last phase, the planning of the next therapy takes place. This represents a delicate phase since allows the positive expectations experienced by the group to keep alive. In addition, at this time the members are preparing themselves for the conclusion of the session, for the final ritual which needs to take place calmly and serenely to ensure that the feedback is positive for the individual member of the group. This can happen if, in this space and with the intervention of the therapist, there is a colloquial exchange between members and the resolution of any internal disagreements and conflicts that, if prolonged and unresolved, could affect the future performance of the group and its stability.

The expression of the group within the neuro and psychomotor setting- as well as in relationships between peers with typical development- occurs through the play. In fact, within the setting- although the situation is mixed between natural environment and laboratory built ad hoc initially by the therapist, and then with the participation of all members- the goal of each activity is that it is as likely to reality and in accordance with what outside the therapy room could happen.

The parameters related to the groupal setting are:

  • The Group Space, which evokes a circular dimension, represents the physical space within which the affective and emotional dimensions also coexist. It allows subjects to distinguish what is insider or outsider in the mental dimension of the group. In addition, the space of the group refers to the sense of belonging to what is of the group and of differentiation from what is not of the group.
  • The Time of the Group, which evokes the geometric figure of the spiral, in which time seems to have a circular but also progressive or regressive course. Time is limited, therefore it becomes fundamental that its management takes place in the awareness that it is organized and experienced, alternating with moments of stasis that lead to the reflection of the group itself.
  • The Foundation of the Group predates its inception and can be thought of in terms of fusion-individuation, namely articulated in an initial phase in which a fantasy of undifferentiation prevails ( the individual experiences the anguish of losing his or her personal- individual boundaries) and in a subsequent phase of recovery of one’s subjective dimension that will allow group members to accept and share their principles with those of the group.
  • The Body of the Group is formed through the interactions and relationships between the members that are formed within it and it assumes a central value since in a group the members observe each other and the body communicates with strength and immediacy. The body of the individual represents the physical container of all the individual aspects matured through the interrelation of neurobiological aspects with neuropsychological aspects, it has an expressive potential rich in meanings.

According to Di Maria and Lo Verso, the foundation of the group involves a first therapist’s idea (and of its members) comparable to a semi-empty structure or virtual space, in which the roles of conductor, members and observer are defined. Later, with the formation of a network of interactions, it will be possible to rebuild past and unconscious events and start with the identification play: in this phase, a strong sense of belonging to the group is acquired. Indeed, while in the group’s foundation prevails a fantasy of non-differentiation, in which the individual experiences the anguish of the loss of his individual reality, subsequently there is a phase of recovery of subjectivity that leads to experiencing the group bond as belonging.

The phases which lead to the construction of a group are characterized by spontaneous communications, sharing of emotions, thoughts, and free fantasies. According to Neri’s theory of the group process, there are two stages:

  • The Emerging Group Stage is characterised by an illusory expectation with euphoric, gratifying, narcissistic aspects, which acts as a glue and responds to the member’s need to be together when they are not yet able to establish a relationship. Participants experience phenomena of de-personalisation and de-individualisation, a dynamic loss of the boundaries of self that leads them to feel experiences and emotions referring not only to themselves but also to the context of the group. Specifically, the De-personalisation phase involves a sense of detachment and consequently, a negative perception of the interpersonal relationships of the group members related to the individual’s feeling of not yet being fully part of the group. On the other hand, the De-individualisation process allows individuals to see themselves as a group identity, thus partially losing the perception of their individual identity and considering their behaviour as guided by group norms. The concept of De-identification is strongly related to the concept of opposite significance or the concept of identification. The status of identification promotes the full control of personal acts and a correct valuation of the consequences of performed behaviours; represents the condition in which the individual can make choices which are conscious and respectful of social norms, encouraging the proper functioning of the entire society in which he lives. The identification ensures the order of the individual’s psychic activity and favours the permanence inhibitions (mechanism without which the individual would act almost instinctively, generating serious consequences both because of the negative evaluation he receives from others towards him and for the health of society as a whole). The state of de-identification on the other hand generates a different situation. The forces that prevented the performance of instinctive and harmful acts are weakened and the most unthinkable and miserable acts are reinforced. The control of action is lost and confusion and chaos are generated.
  • The Stage of the Brother’s Community arises when the group is perceived as a collective subject, that is, when the members have reached a state of fusion such that they refer to themselves using ‘we’. In this stage, there is an awareness of the existence and elaborative potential of the group as a collective subject, as a community capable of thought. Participants on the one hand develop feelings towards others as individuals, recognized as similar to themselves with their own identity. On the other hand, they perceive themselves as a brother’s community, namely as holders of a right over the group. At this stage the participants are more willing to get involved, the dependence on the conductor-therapist decreases and they communicate more and more among themselves, feeling more free to plan common goals and ways of achieving them; moreover, in this stage, the issues related to conflicts will no longer be avoided, but there will be an opportunity to confront each other and elaborate precise answers regarding the needs of individuals and of the group. Individuals perceive others symbolically as brothers and feel part of a community of brothers. The group also establishes a precise space, a ‘we-you’ boundary that Anzieu defines as The Skin-Ego: like the skin, the group is an envelope that holds individuals together and contains thoughts, words, and actions. In this way, the group can construct an internal space and its own temporality;
  • Finally, there will be the Dissolution of the Group, which is part of the phase of full maturity with consequent closure and estrangement from the group. This process will be experienced by all members with a different intensity and through different personal, intimate, and individual projections. It represents a delicate phase, in which the therapist must be able to recognize and identify the different asymmetries of the individual experience concerning the group context in order to be able to live the dismissal from the group in complete serenity so as not to be dependent on it in the future. The group must have allowed each individual to take possession of their own individuality within a group community that lives on principles and inertia driven by the fusion of different personalities and temperaments involved. Knowing how to distance oneself from the group represents the attainment of full maturity, through which each member recognizes that are able to live out their desires in full consciousness and serenity, to be part of the different social groups, and adhere to the present group projection, which differs for each social group, with their beliefs and abilities. The full realization of the experience lived in the group context must allow each member to be able to give himself freely to the new enlarged social relations, preserving from the experience lived in the group context all those aspects of evolutionary significance that have allowed the acquisition of more adaptive capacities, and of a specifically affective and relational nature that allowed the individual members to mature socially significant self-regulating and hetero-regulating skills.
Group Norms, Efficacy Parameters and Objectives in Group Therapy and Therapy IN Group

To exist and survive, any group must have Norms that are shared and accepted by all members/individuals. Social norms are all ways of thinking, feeling or behaving that are collectively accepted and identified as appropriate and correct. Norms include functions such as:

  • Individual functions, which serve as a useful reference in otherwise unstructured and anxiety-generating situations;
  • Social functions, which can:
    • help regulate social existence and, consequently, help coordinate group members’ activities. This function of social regulation is linked to the predictability to which norms contribute at an individual level;
    • be closely linked to the group’s objective. When a group develops a clearly defined objective will inevitably emerge norms that facilitate behaviours in line with the goal and discourage those that run counter to its achievement;
    • Serve to enhance or maintain group identity.

Sherif (1969), analysing the Variation of Norms, found that each group defines a certain amplitude of acceptance of norms, thus defining the degree of tolerance regarding the possibility of derogating more or less widely from certain rules.

The definition of the group passes through the specific analysis of the constitutive parameters of the group, which represent the founding links of the group structure. For each group, it is necessary to take into account the elements identified as Parameters of Effectiveness, such as:

  • Cohesion, is the force of attraction that the group exerts on each member and is closely related to the sense of belonging of the members to the group as a whole. When cohesion is strong, the subject is willing to modify relational modalities criticized by the group, but also the group can modify its own evaluation starting the adaptive spiral. The group is usually founded on a certain amount of cohesion, which represents the set of forces that hold the group together and the relational bonds between the members and the therapist. Cohesion represents the degree of solidarity among group members.
  • Alliance, is understood as a collaborative work between interacting individuals that is structured towards members and therapist. The establishment of the alliance involves both the ability to share goals, mutual tasks and the structuring of an emotional bond characterized by respect and trust;
  • Empathy, is the ability of each individual to “put oneself in the other’s shoes, perceiving in this way emotions and thoughts. It is the ability to see the world as others see it in a non-judgmental position and to understand the feelings of others while keeping them distinct from one’s own (Morelli e Poli, 2020). Empathy is a fundamentally important social skill and is one of the basic instruments for effective and rewarding interpersonal communication between individuals, allowing immediate access to the other’s state of mind and the relational world of the other;
  • Resonance, represents the emotional sharing of experiences and moods of others. This ability allows the individuals to participate emotionally in positive or negative situations brought to life within the group dimension in therapy, get emotionally closer, and experience a shared and co-participated emotional condition. Resonance differs from empathy in that it is based on using our “Self” to connect with the other person, being as receptive as possible to their experiences, feelings and ideas, without losing sight at all times of whom they belong. Empathic resonance does not imply being “identical” to the other but maintaining a sort of separation by keeping a distance to allow us to provide the appropriate help. Empathic resonance allows us to experience the other’s situation in a different, often more complete way, without these clouding our rationality because the boundaries of our “Self” are not erased, but acts as a defensive layer necessary to offer the appropriate help. Resonance is the phenomenon whereby the members of a group capture aspects of the experience of the person speaking but are deformed by the strong identifications and emotions with which each member captures them. It is therefore a phenomenon of emotional contagion, that is, the tendency to generalize, to unconsciously spread emotions in the group.
  • Reflection, represents seeing and reflecting oneself in the experiences, behaviours, gestures, words and attitudes of the other and in their respective emotional contents that refer to the awareness that the situations experienced by the individual may concern not only oneself but also and above all the peers. Reflection is of fundamental importance in forming an initial sense of Self and is the basis for creating healthy relationships with others. A mirror reflects our image: we are both the subject and the object, so the image is objectively true, but it is also a reflection of our thoughts and feelings and the way we perceive ourselves.

Finally, it is necessary to take into account what are the Objectives of therapies in the groupal field addressed to developmental age, given the delicate contextual situation related to the speed of modification of events in regard to the rapid evolution of capacities. Therefore, the Developmental Neuro and Psychomotor Therapist, in relation to the priority objectives, should take into account that through groupal  work the child can:

  1. Implement the availability for co-presence and acceptance of spatial and personal sharing;
  2. Evaluate one’s own expressive/interactive modes and identify the most suitable ones to enter into a relationship with the other members of the group;
  3. Evaluate critically the expressive/interactive modes of the group members and the expressive connotation of the group;
  4. Mature personal competencies aimed at the acceptance of the group and its members so that the group can also accept the individual members within it;
  5. Compare emotions, internal states, beliefs and difficulties, sometimes mediated by adults;
  6. Share freely one’s desires and express one’s attitudes according to the modes and characteristics of individual temperamental and personality traits;
  7. Share the action plan common to all the members of the group, going through the phases of proposal, elaboration, conflict and acceptance;
  8. Define one’s own role in relation to the group context, following individual analytical work that takes into account oneself in relation to the plan of action identified and shared;
  9. Improving skills in the motor-praxis area through learning by imitation and taking advantage of the high degree of motivation given by the competitive condition and the consequent capacity for self-evaluation;
  10. Learn to manage competition positively, turning it into an instrument for personal and community growth;
  11. Increase one’s empathic skills in relation to all the members of the group to achieve a high capacity for understanding the other;
  12. Experience the group and its members as “allies”, after having been able to share intimate states of mind (resonance), to learn to manage and cope with personal and group difficulties;
  13. Experience the reflection mechanism, through which, according to the principle of universality, one realizes that one’s difficulties can be common with other-selves;
  14. Learn to relativise personal concerns, giving them the right weight, following the comparison with the other;
  15. Experience oneself as an efficacious subject in shared social dynamics, in order to compensate for any sense of inferiority/diversity experienced with peers with typical development in everyday life environments;
  16. Implement effective communication skills according to the defined action plans and roles, established based on the horizontality and verticality of the exchanges within the therapeutic group relationship;
  17. Experiment with symbolic representations in motor, interactive and reading experiences to support the maturation of higher cognitive processes;
  18. Learn strategies for solving possible conflicts through the maturation of executive functions, in particular problem solving and decision making, within interactive dynamics;
  19. Bring significant elements so that a moral conscience with a solid structure can be built, in which the observation of the rules in the social micro-community leads the individual members to appreciate and generalize respect for them;
  20. Be encouraged to acquire progressive autonomy in the self-regulation processes involved in the personal and individual dimension towards the group, the members and the therapist;
  21. Become aware of his own hetero-regulatory potential concerning the group and its members, in order to be able to manage it consciously and in a flexible manner;
  22. Experiment enriched and more functional interactive modalities, in order to favour a better insertion in the new social micro-contexts first, and then in society in the broad sense;
  23. Generalize in the new enlarged social contexts the relational skills gained personally from therapeutic group experience, through the acquisition of more adaptive tools and skills.


The present article highlights the peculiarities of the rehabilitation treatment in the developmental age and the complexity of the management of the groupal therapy in the field of Neuro and Psychomotor Therapy of Developmental Age (TNPEE). The groupal device represents one of the most powerful instruments in the perspective of rehabilitation if it is used within the parameters described by a skilled therapist capable of multiples readings within the rapid dynamics in which he himself is immersed.

Kaes’s (1994) definitions of the group produce important insights for specialists that are still relevant today, such as:

  • “the group is an intermediate space between the individual and the social”;
  • the complexity of the group is given by the ambivalence between the ability to define the identity of the individual associated with the fear of losing one’s individuality in the undifferentiated whole of the group”;
  • “the group is the space for plural confrontation where different fantasies and thoughts circulate”;
  • “in the group, the bodily dimension is relevant because within the group we observe each other, posture and non-verbal language are involved, and the body communicates with immediacy”.

These statements describe the development of the entire process of structuring the group and its management in the therapeutic context, that is the strength of the groupal instrument to settle between the individual and society, highlighting its therapeutic power. In addition, emphasis is placed on the therapist’s ability to guide each individual in the affirmation of their individuality within the group itself and acceptance of the group dimension in which they are inserted. Finally, the group is seen as an instrument for the comparison of ideas and desires for each participant, in addition to being the place where one’s bodily dimension comes to life, representing the crucial/fundamental aspect of all Neuro and Psychomotor Therapies of Developmental Age (TNPEE).


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Application of the ultrafast sequence in the dynamic contrastographic study in the magnetic resonance imaging of the breast: our experience

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Submission Date: 2022-07-19
Review Date: 2022-07-24
Pubblication Date: 2022-07-25



In the last decade, breast MRI has played a role of primary importance, as a "gold standard" method in the early diagnosis of breast cancer in high-risk women, in assessing the extent of the disease and the response to neoadjuvant chemotherapy. Currently, the 3D GRE Rapid-Acquisition sequence in dynamic acquisition without and with endovenous administration of contrast medium, is fundamental for the breast MRI protocol, as the current diagnostic approaches in Magnetic Resonance are based precisely on this sequence, able to guarantee accurate diagnostic performances detecting pathological mass and non-mass-enhancement. Ultrafast sequences are modern sequences based on the 4D Time-Resolved technique with k-space sampling modalities which allow the evaluation of post-contrast images with very high temporal resolution. The purpose of our work is to illustrate in particular the use of the 4D-THRIVE sequence implemented in our breast MRI study protocol.


Magnetic Resonance, thanks to its multiparametricity, achieves higher sensitivity and greater accuracy than mammography and breast ultrasound. These characteristics have made it, in recent years, the reference method in early diagnosis in high-risk women, in the assessment of loco-regional extension and of the response to neoadjuvant chemotherapy in patients with breast cancer, in the follow-up after surgery, as well as in the study of breast implants.

However, although multiple studies have shown that the multiparametricity of the MRI protocol is excellent, technological evolution continues to expand, presenting further innovations that can further improve the diagnosis and characterization of breast lesions.

Dynamic contrast-enhanced MRI (DCE-MRI) of the breast is well established in clinical practice as it provides high sensitivity for breast cancer detection and represents a guide to describe and classify breast lesions in accordance with BI-RADS criteria.  However, it takes a long time, making up about 40% of the total exam duration.

The introduction of Ultrafast sequences allows a desirable balance between high spatial resolution and high temporal resolution, a need that until recently required the research for a compromise between these two objectives, with the possibility of characterizing the lesions in an equally reliable and efficient way.

The aim of our work is to describe the technical characteristics, applications and advantages of modern Ultrafast sequences and in particular of the 4D-THRIVE sequence in the study protocol of Breast MRI.

Materials And Methods

In our study we will describe the technical and technological principles of the 4D-THRIVE sequences and the study protocol of Breast MRI performed at our Radiology Unit with 3 T MRI scanner (Philips Ingenia, Philips Healthcare, Eindhoven). Representative images of modern 4D-THRIVE sequences and related post-processing will then be shown. Finally, the main advantages of applying Ultrafast sequences in Breast MRI protocols, emerging from the analysis of the scientific literature, will be discussed.


Ultrafast 4D-THRIVE sequence in Breast MRI: technique and k-space sampling

The Ultrafast 4D-THRIVE sequence is based on a “Time-Resolved” technique, with Key-hole and CENTRA K-Space sampling methods. This method uses a radial sampling scheme, acquiring a limited number of central Ky-Kz profiles (central disc) in a centric elliptical manner.

The central region is acquired in each scan (low frequencies or those defined as most “useful” for the purposes of the image) while the sub-regions acquired less frequently (high frequencies or those defined as “scattered”), are shared according to a view sharing scheme alternating (Fig. 1)

Fig. 1 – Schematic representation of the centric elliptical technique with alternating view sharing

The combination of all the innovative acceleration techniques such as the CENTRA Keyhole method, the Partial Fourier, and the SENSE Parallel Imaging has allowed to obtain a very high temporal resolution (4-8 sec) while maintaining spatial and contrast resolution efficient in documenting the presence of neoplastic lesions.

In the field of breast MRI, after a complete k space sampling in the pre-contrastographic phase, multiple Ultrafast phases (10-16) are acquired continuously for about 60-90 seconds with a temporal resolution of 4-8 seconds, starting the acquisition simultaneously with the ev injection of  contrast agent, for a total scan time of 102-120 sec.

Breast MRI study protocol with Ultrafast sequences

MRI exams were performed with a very high field MRI scanner, 3T Philips Ingenia (Philips Healthcare, Netherlands Eindhoven) equipped with combined gradients with Amplitude of 45 mT/m and Slew-Rate of 200 T/m/s, using a breast coil dedicated 7-channel phased-array dSTREAM SENSE BREAST Coil. All the patients were studied in prone feet-first position, with the breasts introduced into the two cavities of the coil, with the arms raised above the head, making sure that the hands do not touch each other, in order to avoid closed circuits,  then electrical loops.In all exams, the contrast agent used is Gadobutrol (Gadovist-Bayer-Schering Pharma).

The MR scan protocol includes the evaluation of the breast parenchyma by using 3D TSE T2 (Variable Flip Angle) and STIR (IR-TSE) axial sequences, and subsequently, whereas the conventional protocol consists of a dynamic axial e-THRIVE with SPAIR fat suppression (one phase pre and five phases post-CM bolus injection), in our protocol we have replaced the first two post-CM phases with the Ultrafast 4D-THRIVE sequence consisting of 12 sub-phases each with a temporal resolution of about 5-6 seconds with a coverage overall time of about 80-120 sec. Fig. 2 represented the temporal schemes of the conventional DCE sequence and then of the “hybrid” protocol used in our study.

Fig. 2 – Temporal scheme of the “classic” DCE protocol without the application of the 4D-THRIVE at the top; temporal scheme of the DCE protocol with the acquisition in the first post-contrast phase of the 4D-THRIVE with 12 sub-phases in the first 80 seconds after the ev injection of CM.

The parameters of the conventional e-THRIVE are the following: TR 6.7 ms, TE 3.3ms, field of view (FOV), 320 mm pixel 1.10 x 1.10 x 1.50, partitions = 110, FA = 10 °, acceleration factor Sensitivity Encoding (SENSE), P = 2.3 S = 1; SPAIR fat suppression (p = 2), acquisition time, 92 seconds per phase.

The 4D-THRIVE parameters are the following TR 6.7 ms, TE 3.3ms, field of view (FOV), 320 mm pixel 1.10 x 1.10 x 2.50, partitions = 70, FA = 10 °, acceleration factor Sensitivity Encoding (SENSE), P = 3 S = 1; SPAIR fat suppression (p = 2), Keyhole Central size 32%, reference scan 17sec, TFE = 50, acquisition time 5 seconds for each phase (12).

Ultrafast images visualization and analysis

The most correct way to evaluate Ultrafast images for lesion characterization is to look at the subtraction images (Fig. 3). New parameters will be evaluated from the Ultrafast kinetic curves:

  • “Time To Enhancement (TTE)”, ie the time it takes for the lesion to enhance after the enhancement of the descending aorta (<10 s for malignant lesions);
  • Maximum Slope (unit: percent relative enhancement per second): high values ​​in malignant lesions.

Finally, the MIPs generated from the subtracted images of the Ultrafast sequences provide a real time assessment of the influx of contrast medium into the lesions, and in the case of malignant tumors a “light bulb effect” is observed, in which we see the cancer enhancing in a dark background (Figure 4).

In the case shown in figures 3 and 4, no additional findings were detected from the evaluation of the e-THRIVE images obtained at the 3rd, 4th and 5th minute post-CM (see Fig. 5).

Fig. 3 – Representation of the 4D-THRIVE sequence of the individual arterial sub-phases (12) 12 sub-phases in the first 80 seconds after the injection of gadolinium i.v. Mass-type enhancement of a heteroplastic lesion at the level of the QSE of the left breast can be noted, with a TTE <5 sec. The central vacuum signal is related to the presence of a clip.
Fig. 4 – MIP reconstruction from the individual arterial sub-phases (12) of the subtracted 4D-THRIVE, after administration of the i.v. In addition to the heteropalsic lesion, there is a package of metastatic lymph nodes to the ipsilateral axillary cavity
Fig. 5 – Temporal scheme of the dynamic contrast protocol with the use in the first post-contrast phase of the 4D-THRIVE with 12 sub-phases in the first 80 seconds after the iv injection of gadolinium

Discussion and conclusions

Breast MRI thanks to its high diagnostic accuracy in the loco-regional extension balance in patients with breast cancer and in the detection of occult mammary tumors, it allows to optimize the treatment and prevention path.

Through the acquisition of the 4D-THRIVE sequence it is possible to acquire a number of multiple phases ensuring multiple information in real-time. In particular, the Ultrafast 4D-THRIVE sequence allows to obtain not only a high temporal resolution, but also an optimal spatial and contrast resolution and with a complete anatomical coverage of the mammary gland, resulting in an improvement in the detection and characterization of focal breast lesions in various early post-contrast sub-phases, phases in which it is possible to obtain a higher specificity and sensitivity of the examination.

However, the spatial resolution compared to the e-THRIVE applied in the subsequent phases, inevitably turns out to be lower, moderate because it has resolution in plane and thicknesses slightly higher depending on the intensity of the magnetic field and on the number of channels of the coils. However, the detection rate of additional findings significant for diagnosis in the e-THRIVE sequence not highlighted in the 4D-THRIVE sequence, from scientific literature data, is not relevant or extremely low.

Finally, in recent years, the diagnostic utility of these new parameters (TTE and MS) generated by the Ultrafast sequences has been demonstrated in the differentiation between malignant and benign lesions and in improving the positive predictive value. Furthermore, several studies have shown that these parameters have an accuracy greater than or comparable to that of the classic time/intensity curves reported in the BI-RADS. In conclusion, although Ultrafast sequences are used in practice almost exclusively in combination with the conventional dynamic sequence in resulting hybrid Ultrafast-DCE protocols, there are well-founded assumptions for the Ultrafast sequence to completely replace the conventional DCE sequence in breasts MRI study protocols, resulting in a significant shortening of the acquisition time of the examinations and therefore the possibility of increasing the number of examinations per session.


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Application of the compressed sense in the study of female pelvi in magnetic resonance 3 Tesla for the diagnosis of infertility in women

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Submission Date: 2022-07-13
Review Date: 2022-07-18
Pubblication Date: 2022-07-22



Compressed Sense (CS) is a technological innovation in the field of Parallel Imaging (PI) that allows to reduce up to 50% the acquisition time per single sequence, reducing the whole duration of the MRI examination, and is based on the application of 3 principles: Incoherent k-space subsampling, sparsification transform and nonlinear iterative reconstruction. The purpose of our work was to evaluate the application of CS to the MRI protocol of the female pelvis performed for infertility, evaluating its Temporal Resolution and Signal/Noise Ratio (SNR) compared to the classic PI technique SENSE. MRI exams were performed with RM 3T scanners (Philips Ingenia, Philips Healthcare, Netherlands Eindhoven). The female pelvis MRI protocol included the following sequences: 3D PelvisView T2, 3D PelvisView T1, DWI (b0 and b1000), mDixon 3D THRIVE with ev. contrast media. The parameters of each sequence, with the exception of DWI in which the CS is not applicable, are shown in comparison between the application of Sense and Compressed Sense. The CS allows to obtain at the same spatial resolution, a protocol with faster acquisition times, correcting the effect of aliasing from data subsampling compared to conventional SENSE. In conclusion, the application of CS could bring multiple advantages in the field of MR imaging in the diagnosis of infertility in women, optimizing the image quality and the duration of each individual examination.


The condition of infertility affects about 15-20% of Italian couples. According to the data provided by the Istituto Superiore di Sanità, the cause is male-related (in 35% of cases), female-related (in 35% of cases), a couple factor (in 15% cases), and sine causa (idiopathic infertility) in remaining 15%. In recent years, MRI of the female pelvis has become the gold-standard in the study of infertility in women, thanks to the progressive diffusion of increasingly high-performance and very high-field equipment that allows, compared to hysterosalpingography and transvaginal pelvic ultrasound, an evaluation of the most associated pathologies (congenital anomalies, fibroids, adenomyosis, endometriosis). The application of MRI, a multiplanar and multiparametric method, with high spatial resolution, to research the causes of infertility could represent the turning point for obtaining a more complete study in terms of information and without the use of ionizing radiation in women of childbearing age. In recent years, the birth of Parallel Imaging (PI) has paved the way for overcoming the greatest limitation of MRI, acquisition times, through the use of phased array coils. Compressed SENSE is a modern PI technique that collects only the “essential” components of the MR signal rather than all the K-space data, minimizing the error that derives from having an insufficient number of samples. The k-space is inconsistently subsampled with priority of central data (more useful data); subsequently the sparsification transform is applied and finally a “non-linear” Iterative reconstruction method, with the final goal of achieving a balance between “data consistency” and “sparsification data”, allows to keep all useful data by removing, as much as possible, those without information. In fact, mathematically it is difficult to separate useful data from non-useful ones, but inevitably a part of them with the application of the Wavelet transform alone will be lost. The “non-linear iterative reconstruction” does exactly that: it behaves like a balance through the application of numerous algorithms that are repeated cyclically until the optimal data balance is achieved. Compressed Sense is therefore a PI technique which, by applying its 3 fundamental principles, which are inconsistent subsampling, sparsification transform and non-linear iterative reconstruction, manages to guarantee a reduction of acquisition times up to 50% without qualitative degradation of the images. A reduction in acquisition times of this level is able to balance the increased demand for MRI examinations in general and, more particularly, of the female pelvis, also for reasons related to infertility that cannot be resolved with other imaging methods.


The objective of this study was to evaluate the contribution of the new COMPRESSED-SENSE technique, comparing it with the conventional PI SENSE technique, when applied to the study of the female pelvis with 3T MRI, to the resolution of the diagnostic question of female infertility, with optimization of acquisition times and image quality.

Materials And Methods

MRI examinations of the female pelvis were performed at the Department of Diagnostic Imaging of the University hospital  Policlinico “Paolo Giaccone” (Palermo, Italy), with a Philips Ingenia 3T MRI scanner, equipped with combined gradients with Amplitude of 45 mT / m and Slew-Rate of 200 T / m / s. The receiving coil used is a Philips Healthcare surface coil, the 32-channel d-Stream SENSE Torso, positioned directly on the area of ​​interest in order to obtain the maximum possible signal amplitude. The standard 3T MRI protocol of the female pelvis, performed at our Institute, includes the acquisition of 3DPelvisView T2, 3DPelvisView T1, DWI (b0 and b1000), mDixon 3D THRIVE sequences with MdCev. For each of the sequences listed above, except for the DWI, we acquired the images first with the “SENSE” PI technique and then with the “COMPRESSED SENSE” technique, thus comparing the following parameters: spatial resolution (mm x mm), FOV , matrix, thickness, NSA, acceleration factor R and temporal resolution.


For all 3D TSE sequences (T1, T2 and SPAIR) the time saving with the CS is greater than 50% per sequence, while with mDixon 3D THRIVE the reduction of acquisition time is about 30%. Overall, including the DWI sequence (b0-b1000) which in our protocol lasts about 3 minutes, the total duration of the MRI Pelvis protocol with application of the SENSE is 30 minutes, while with the application of the COMPRESSED SENSE it is about 16 minutes, with a reduction of acquisition time of about 50%, and in particular about 15 minutes.

Tables 1-4 show in detail, for each sequence of the female pelvis MRI protocol analyzed in this study, the acquisition parameters compared with the use of the PI SENSE technique and with the COMPRESSED SENSE technique, and in particular: in plane resolution (mm x mm), FOV, matrix, NSA, acceleration factor R and time resolution.

Tab. 1 – Acquisition parameters for the Ax 3D View T2 (TSE Variable Flip Angle) sequence of the MRI study of the female pelvis with 3T MRI scanner, with the PI SENSE technique and with the COMPRESSED SENSE technique.
Tab. 2 – Acquisition parameters for the Ax 3D View T1 (TSE Variable Flip Angle) sequence of the MRI study of the female pelvis with 3T MRI scanner, with the PI SENSE technique and with the COMPRESSED SENSE technique.
Tab. 3 – Acquisition parameters for the Ax 3D TSE T2 SPAIR sequence of the MRI study of the female pelvis with 3T MRI scanner, with the PI SENSE technique and with the COMPRESSED SENSE technique.
Tab. 4 – Acquisition parameters for the m-DIXON THRIVE sequence of the MRI study of the female pelvis with 3T MRI scanner, with the PI SENSE technique and with the COMPRESSED SENSE technique.
Fig. 1 – Comparison of the images obtained respectively with the SENSE and with the COMPRESSED-SENSE from the sequence AX 3D View T1 (TSE Variable Flip Angle).
Fig. 2 – Comparison of the images obtained respectively with the SENSE and with the COMPRESSED-SENSE from the sequence AX 3D View T2 (TSE Variable Flip Angle).
Fig. 3 – Comparison of the images (obtained with reconstruction) MPR CORONAL of the sequence AX 3D View T2 (TSE Variable Flip Angle) acquired with the SENSE and with the COMPRESSED-SENSE.

Discussion And Conclusions

Our data demonstrated that the application of the COMPRESSED SENSE can led to a considerable reduction of the average scan time of the sequences considered by 30-50%: in particular, about 50% is gained on the 3D TSE T1 sequences, T2 and T2SPAIR, 30% on the m-DIXON THRIVE post-contrast sequence. The images obtained were therefore acquired in a shorter time and were even of better quality than the conventional PI SENSE technique.

The ever increasing technological advances in the field of Magnetic Resonance, and including the development of scanners more and more performing in terms of Amplitude and Slew-Rate, the introduction of ever faster sequences, the development of increasingly efficient Parallel Imaging techniques and robust to allow ever higher acceleration factors R without incurring typical artifacts from K-space data subsampling, up to the introduction of Artificial Intelligence software, have led to exponential improvements and optimizations of Magnetic Resonance imaging. If one of the limits, until recently present in Magnetic Resonance, was the acquisition time, now with the advent of subsampling applied with Compressed Sense this limit is also exceeded, allowing the increase of the number of female pelvis MRI and therefore its use on a wider scale also in the diagnostic study of infertility in women.

Thanks to the COMPRESSED SENSE it is therefore possible to use of 3D T2 sequences for the morphological study of the pelvis in just 4 minutes, instead of 10 minutes with the SENSE in which the risk is to obtain inevitable movement artifacts that can affect the quality of the images. With the CS applied to the 3D sequences it is possible to obtain high resolution images on the axial, sagittal and coronal planes, with image quality comparable to the 2D sequences performed on a single plane which would require much longer acquisition times (about 12 minutes) than the 3D TSE T2 sequences obtainable with the CS in just 4 minutes, therefore with a scan time reduction of up to 67%.

With a total temporal gain of about 50% it is possible to double the number of exams per day. In addition, the acceleration guaranteed by the CS reduces movement artifacts and decreases the degree of fear of patients related to claustrophobia as the time in which they are forced to remain motionless in the context of the MRI scanner is reduced. We can conclude that the COMPRESSED SENSE represents a significant improvement in terms of accuracy and speed of reconstruction, constituting the future of Parallel Imaging.


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Implementation In The Campania Region Of The Screening For Cancer Of The Uterine Cervix Using HR-HPV

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Submission Date: 2022-06-08
Review Date: 2022-06-30
Pubblication Date: 2022-07-21



Oncological screenings:
The screening program consists of the free and active offer (personal invitation) to the population, at risk by age, of practices that have proved to be able to significantly affect the natural history of the disease (reduction of morbidity and mortality) maintaining A convenient relationship between costs (economic, psychological, social) and the benefits (Omswilson, 1968). Oncological screenings organized currently active in our country are:
The objective of oncological screening programs is the reduction of mortality.
According to the national guidelines (PNLG) "the assumptions that are the basis of the offer of an oncological screening test to a hypothetically healthy population are:
1. that it is possible to identify the neoplasm, if present, when still asymptomatic;
2. that this anticipation of the diagnosis translates into a concrete benefit, first of all in terms of survival extension. Always the PNLG in the document at the evaluation of services stresses that:
"Screening by nature is a tool that requires caution, because it proposes to asymptomatic people, who have a perception of their positive health, a diagnostic test that can reveal the presence of a cancer in its latency period". For this reason, another professional figure represented by the "psycho-oncologist" has also become part of the last decade. As we see below the screening of the uterus's neck cancer falls more than others in the two requirements (A and (B first mentioned. Tumors that affect the uterus must be distinguished in cervix cancers and body tumors based on the segment that comes Struck by neoplasm. This work will pay attention to the first group, which by natural history, risk factors, incidence, clinical trend, therapy and finally survival. For many years, it has been the subject of public health interventions aimed at its Primary and secondary prevention.


Cancer of the uterine cervix ranks second in the world, after the breast, it is among the cancers that affect women.

It represents the first neoplasm to be recognized by the World Health Organization (WHO) as totally attributable to an infection. The etiological factor of this neoplasm consists, in fact, of a pool of high-risk strains of the sexually transmitted human papilloma virus (HPV), whose DNA has been found in almost all cases of carcinoma of the uterine cervix. (IARC Working Groupon the Evaluation of Carcinogenic Risks to Humans . IARC Monographs on the evalutation of carcinogenic risks to humans . Human Papillomaviruses . Vol 64.Lyon :

It is estimated that the risk of developing cervical cancer in a woman’s lifetime is 1 in 158. The incidence trend appears to be slightly decreasing (-0.4% / year) and has North-South gradients, with slightly lower 6 values in the south.

Unfortunately, the South loses the advantage represented by the low incidence not only due to a diagnostic delay compared to the rest of Italy, but also due to the still poor adherence to organized Screening. Unfortunately, this diagnostic advantage is not realized in the screening of mother’s cancer .

In fact, through mammography it is possible to identify only very small lesions, therefore it is not a question of prevention but rather of early diagnosis which is anything but. Especially in relation to the type of intervention, more or less demolishing, and to survival.

In Italy, there are approximately 51,100 living women diagnosed with cervical cancer. The prevalence rate is higher in the Northern Regions.

Over 80% of the prevalent cases have faced the diagnosis for over 5 years. The largest proportion of prevalent cases is observed in the 75+ age group (607 / 100,000), (Cancer numbers in Italy 2020 AIOM, AIRTUM, SIAPEC ) The incidence is influenced not only by gender, but also by age. In females, breast cancer represents the most frequent malignancy in all age groups, albeit with different percentages (40% in the young vs 22% in the elderly). In young women, tumors of the thyroid gland, melanoma, colorectal and cervical cancer appear.

The long preclinical phase of the disease and the possibility of diagnosing and thus intervening on precancerous lesions are the strengths of the Cervical Cancer Screening Program. Below is the representation of the latency of a precancerous lesion starting from the HPV infection and then the wide window in which it is possible to make the diagnosis, monitor and possibly proceed with therapy. Carcinoma represents the final evolutionary phase of a series of progressively higher risk lesions, which, particularly in the initial phases, can also regress spontaneously.

So the advantage in the field of prevention represented by the Pap test consists in the fact that pre -cancerous lesions are diagnosed and even more today, thanks to the HR-HPV DNA Test, it is possible to identify the type of HPV virus from which the woman is infected.

Risk Factors

Cervical cancer ranks second in the world, after breast, among cancers that affect women. The etiological factor of this neoplasm is constituted by a pool of high-risk strains of the sexually transmitted human papilloma virus. Carcinogenesis is long-lasting and carcinoma represents the final evolutionary phase of a series of progressively higher risk lesions, which, particularly in the initial phases, may also regress spontaneously. Among the risk factors were identified:

  1. low socio-economic level (with little access to prevention)
  2. number of partners, sexual promisqueness
  3. young age of onset of sexual activity and parity
  4. immunosuppressive states
  5. smoking of cigarette
  6. hormonal contraception, the latter only if combined with the multiplicity of partners.


Papillloma virus infection Cervical cancer represents the first neoplasm to be recognized by the World Health Organization as totally attributable to an infection.

The etiological factor of this neoplasm consists, in fact, of a pool of high-risk strains of the sexually transmitted human papilloma virus (HPV), whose DNA has been found in almost all cases of carcinoma of the uterine cervix. It is important to emphasize that only in a minority of cases does HPV infection lead to the development of cancer.

In fact, cervical cancer has been defined as the ” rare consequence of a common infection”

Papilloma belongs to the Papovavirus family , it is a virus with a DNA genome that parasites the cells of the epidermis and mucous membranes. The human papillomavirus strains , over a hundred in total, can be divided, on the basis of the possible clinical consequences of the infection, 1) into low-risk HPV, which attack the skin without causing further damage (for example strains 6, 11, 42, 43, 44,) and 2) high-risk HPV, which attack mucous membranes (e.g. strains 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59 , 68) and can cause benign tumors, such as genital warts, or malignant tumors, such as cervical cancer, oral cavity, anus, esophagus, larynx.

Of the high-risk HPV strains (or genotypes) 16 and 18 are the most frequently implicated in cervical cancer, accounting for approximately 60% and 10% of all cervical cancers, respectively. Other high-risk types are associated with cervical cancers, but less frequently, while low-risk HPVs (i.e. those not related to severe cancers) can still cause anogenital warts in both sexes.

HPV-related neoplasms in humans mainly concern the genital tract and the oropharyngeal district. 80-95% of anal cancers, at least 50% of penile cancers, and 45-90% of head and neck cancers are HPV-related.

Tumors of the oropharynx are 4 times more frequent in males than in females and are mainly caused, in at least 60% of cases, by HPV WHO GUIDANCE NOTE Comprehensive

 cervical cancer prevention and control: a healthier future for girls and women (2013) schematically represents how early it is possible to intervene and above all how many interventions we now have to fight cervical cancer.

  • Primary prevention: Vaccination
  • Secondary Prevention: Screening
  • Tertiary Prevention: Treatment

Already 12 years ago, the American Cancer Society stated that “the purpose of prophylactic vaccination is to reduce the incidence of all HPV-related genital pathology, including cancers and precancerous lesions of the uterine cervix, penis, vulva, vagina and anus”. Vaccination against the human papilloma virus, offered today as reported below, protects against currently known oncogenic strains. However, since none of the currently available vaccines prevent all cervical cancers, it is still important to carry out regular checks even after vaccination. ( Cochrane Library online 2018, published 9/5 DOI: 10.1002 / 14651858.CD009069.pub3)

Vaccination strategies in Italy

In Italy in December 2007 a State-Regions Agreement was formulated which recommended the active and free offer of vaccination against Hpv to girls during the twelfth year of life (from the age of 11 to the age of 12 ) .

Girls in the twelfth year were chosen as the primary target of the immunization program for:

ensure maximum effectiveness of vaccination, targeting girls before sexual debut to exploit the best immune response to the vaccine

addressing girls who attend compulsory school by facilitating both communication with families and active offerings to groups at risk of social deprivation.

The State-Regions Agreement left to the Regions the possibility of extending the population to be vaccinated, proposing 18 and / or 25 year olds as the recovery age (in this case exploiting access to the cervical cytological screening service).

The Pnpv 2017-2019 introduces in the vaccination calendar, and therefore in the LEA, in addition to the anti-meningococcal B, anti – rotavirus and anti-varicella vaccinations in the newborns; also anti-HPV in 11-year-old males. Twelfth year of life is the preferred age for actively offering HPV vaccination to the entire population (females and males).

Women who have undergone recent treatments for related HPV lesions, in order to reduce the risk of possible relapses, also fall within the expansion of free vaccination coverage.

The non-valent vaccine includes the main viral strains:

seven of the nine HPV types (HPV 16, 18, 31, 33, 45, 52 and 58) at high oncogenic risk that cause about 90% of cervical cancers worldwide, 90% of anal cancer cases HPV related and approximately 80% of high grade cervical lesions. The two HPV types with low oncogenic risk 6 and 11, in addition to causing 90% of genital warts, are in third place among the HPV types that cause cancer of the vagina or penis, fourth in cancer of the vulva and fifths in anus cancer.

On the basis of new and important scientific evidence, in fact, public health today aims to immunize adolescents of both sexes, for maximum protection from all related HPV diseases directly preventable with vaccination.

It is estimated that 70 to 80 percent of sexually active women and men are infected with HPV in their lifetime.

The virus tends to disappear after infection: in 70 percent of cases within one year and in 90 percent within two years.

The particularly affected age group ranges from 16 to 25 years. The frequency of HPV infections increases in proportion to the number of sexual partners; the risk of infection is highest at the start of sexual activity. The most appropriate solution is a vaccination before the start of sexual activity and therefore before any infection by the more dangerous human papilloma viruses.

preconceptional health of Italian university students conducted in the universities of Milan, Brescia, Padua, Rome, Cagliari, Messina, on 8,500 students between 18 and 30 years old, with an average age of 22, it appears that 20% of boys had their first sexual intercourse before the age of 15.

According to other sources, as much as 50% of young people under 15 are sexually active.

In the survey conducted by the ISS, 66% of sexually active students reported using a contraceptive, but 32% of them used an ineffective method against sexually transmitted diseases (STDs). Additionally, 15% of teens reported having sexual intercourse with casual partners .

22% of the girls said they had used emergency contraception on one or more occasions. It is important to underline, however, that while against AIDS, the use of so-called “barrier” contraceptive methods such as the male condom is sufficient o the female condom, protection by these devices against the HPV virus is limited, as transmission can also occur through contact between skin or mucous membranes.

Anyone who has many sexual partners should have regular checks for sexually transmitted infections.

In the case of persistent infection from a high-risk virus, a precancerous lesion can develop from which cancer can develop.

Therefore, the need to vaccinate adolescents before they start sexual activity is now consolidated by irrefutable evidence of efficacy.

Yet despite the fact that vaccination is free of charge, adherence to this important public health intervention falls into the exact same criticality as cancer screening, that is, low adherence.

The situation regarding the 2006 cohort sees Campania drop to 34.2% of membership.

The whole of Italy underwent a progressive worsening in relation to coverage; also Tuscany, which reached 82% of the 1998 cohort for the complete cycle, fell to 58.3% of the 2006 cohort (Data Ministry of Health 2018)


At the moment, screening for cervical cancer by means of colpocytological sampling and cytological Papanicolau test or Pap test is active in all AASSLL Campane. In Italy, the 2014-2018 National Prevention Plan gave indications for the introduction of the new test within the screening protocol by 2019 in all Italian cervical screening programs.

Despite the Campania Region with DCA n. 36 of 01.06.2016 for the purpose: “Transposition of the observations of the Ministry of Health and Approval with amendments to the Regional Prevention Plan of the Campania Region for the years 2014 – 2018” approved action B3 under program B “Wellbeing in the Community” “Implementation of HPV-DNA Test for cervical cancer screening” with the aim of improving the early diagnosis of tumors covered by organized screening programs through the definition and implementation of innovative pathways for cervical cancer screening (HPV-DNA test), this implementation has not started yet. The possibility of performing the HR HPV-DNA test as primary has modified the diagnostic protocols of the Screening as shown below in the flow chart approved by the Italian Cervix Screening Group (GISCI)

HPV screening allows to reduce the incidence of invasive cervical cancer by 60% -70% compared to Pap test screening.

The study also made it possible to define the optimal screening methods with the HPV test: in particular, the results show that the increase in protection mainly affects women between the ages of 30 and 35 and that screening with HPV tests every 5 years is more protective than Pap smear screening every 3 years. (Ronco et al. 2014 reported in “The implementation of DNA-HPV as a primary test in the Italian cervicocarcinoma screening programs .

Indications from the results of the MIDDIR Methods for Investments / Disinvestments and Distribution of health project technologies in Italian Regions “) Screening based on HPV testing should not begin before the age of 30/35, given the higher prevalence of HPV infections compared to older women (Ronco et al. 2015).

There is evidence that under age 30 screening based on HPV testing leads to overdiagnosis of CIN2 which would spontaneously regress, with the consequent risk of overtreatment . Furthermore, some further overdiagnosis is also plausible between 30 and 34 years.

Cytological screening is currently recommended below this age. The examination of the available literature suggests that the introduction of a new method in organized screening programs requires a redefinition of the organizational and management processes of the companies and structures involved in screening.

The Regions listed below have enabled the transition from cytological to molecular using the primary HPV-DNA test

  • Basilicata Region
  • Emilia Romagna region
  • Liguria Region
  • Lazio region
  • Piemonte region
  • Tuscany region
  • Autonomous Province of Trento
  • Umbria Region
  • Veneto region

In Campania the HPV test is currently used only as a triage test in case of low grade cytological abnormalities (L-SIL). The organizational complexity linked to the transition from the cytological to the molecular examination in a region such as Campania has added to a health context that has been suffering for years. Only last year did the Region exit the repayment plan thanks to the achievement of the Score provided for by the LEA grid.

But this delay is not responsible for the real criticality that characterizes all the Screening in Campania and we could say almost all the prevention interventions as we will see later, including the vaccination practice, that is the Low Adhesion. The table below confirms the significant difference in the various areas of our country Effective extent of cervical screening by geographical area (% of women aged 25-64 who receive the invitation letter compared to the target population in 2018) and participation (% of women who undergo the test following the invitation letter) (source survey ONS)

In fact, in the Southern Regions / Islands, where oncological screenings are still not very widespread, the reduction in mortality and the incidence of breast, colorectal and cervical cancer has not been observed as in the rest of the country. The data published in the 2018 ONS Report refer to the activity carried out by the screening programs in 2017 and tell us that, despite everything, progress continues in the development of organized programs, even if a merciless gap is confirmed between the Center, the North and the South. “The two sources: ONS universal survey and sample telephone interview Passi are different methods of investigation; in general, the ONS survey tends to underestimate the real coverage of organized programs, while the Passi survey tends to overestimate it. The combination of the two approaches offers a very realistic cross-section of the cancer prevention offer in the country “(ONS 2018).

In Italy, the monitoring of Screening activities is carried out by the National Screening Observatory (ONS), by the GISCI group and by the Istituto Superiore di Sanità, through the National Center for Epidemiology, Surveillance and Health Promotion ( Cnesps ) through the Studio Passi which is for Progress of the Health Authorities for Health in Italy. The Steps surveillance launched in 2006 is characterized as a public health surveillance with the aim of carrying out a 360-degree monitoring of the health status of the Italian adult population. It is based on sample surveys carried out on the Italian adult population (18-69 years) on lifestyles and behavioral risk factors related to the onset of chronic non-communicable diseases and on the degree of knowledge and adherence to the intervention programs that the country is implementing. for their prevention. The following table shows the data relating to the three-year period 2016-2019 regarding the screening of the cervix by pap-test inside and outside the Organized Program. The tests performed as part of the so-called “Spontaneous Screening” are therefore also considered, ie those Pap tests that are carried out at the request of the woman or on the recommendation of the private gynecologist who in any case do not fall within the path of Organized Screening which instead must respond to strict criteria, such as: Active Offer, Free, Quality Controls, Study Path, Monitoring, computerization of paths, etc. The indicators are monitored by the national GISCI Group. As you can see, Campania, like many other regions, declares a significant percentage of “spontaneous” exams, associated however with a low number of exams within the

Organized Screening

From this it can be deduced that there is a percentage of women who overexpose themselves to the test and another that does not undergo the test at all.

“The anti-HPV vaccination represents a sensational example of underutilization of a high value service: in fact, if in recent years, the evidence of efficacy has progressively consolidated and the monitoring of adverse events has shown that the anti-HPV vaccines have a adequate safety profile, vaccination coverage in Italy has plummeted, contributing to preventable morbidity and mortality, as well as an increase in health care costs.

This paradox testifies that the process of transferring the best evidence to clinical practice, the organization of health services, professional decisions and the choices of citizens and patients is an obstacle course, often unpredictable and not always adequately managed at the institutional level. “

(Anti-HPV vaccine: evidence of efficacy, safety profile and vaccination coverage in Italy FondazioneGIMBE Evidence 2018; 10 (7): e1000184 doi : 10.4470 / E1000184 Published: 9 July 2018)

The two public health interventions taken into consideration for the prevention of Cervical Cancer, Screening and Vaccination, both free for the population at risk by age, are however little exploited by the reference community as shown by the data presented. This low adhesion involves not only an increase in the incidence and mortality from cervical cancer, but also an increase in public health costs which sees a double expenditure commitment for the same woman: the organizational structure of screening modulated on the number of target population 25-64 years, regardless of whether the target is fully achieved or not, and also the cost of surgical and / or medical therapy that the woman will have to resort to for a late diagnosis. While for the pap-test it is now established that the use of private individuals is justified in some cases by the need for a more “confidential” relationship for the execution of the colpocytological sampling , the low adherence to vaccination practice apparently does not find justification. Yet free in a context of high social risk such as that of Campania should be a sufficiently captivating element. “The socio-economic gradient appears to be probably the most important explanatory factor of the quality and quantity of life and this regardless of the cultural humus in the broad sense in which an individual or a population is immersed. As happened on the occasion of the sinking of the Titanic, where survival was positively correlated with the boarding class, so in civil society those who are in a condition of greater socio-economic well-being, will benefit from greater longevity and therefore will have mortality rates. lower. (G. Domenichetti: For a Public Health policy centered on the needs of the population and not on that of services.) But it is also true that extreme social deprivation means that “The less educated and low-class people are less confident about effects that could derive in the future from the change in health-related behaviors, since other risk factors are still beyond their control, such as the adverse conditions of income, home, environment, work that are more widespread in these groups. “

From the data of the Passi Study we talked about previously, it is confirmed that the lowest socio-economic levels of the population use Screening.

Avoidable Mortality If, as previously mentioned, in the South we do not see a decrease in mortality from cervical cancer, as in the rest of the country, it means that there is a slice of the population that escapes both primary and secondary prevention. Since these are deaths that could be avoided thanks to interventions such as vaccination and screening, the latter can fall into the group of so-called Avoidable Mortality. Avoidable deaths are those deaths that occur at certain ages (within 60 years of age) and from causes that could be actively countered with primary prevention, early diagnosis and therapy, hygiene and health care interventions. The graph below shows the relationship between 5-year survival after cancer diagnosis and adherence to screening in the various regions.

“This is a geographical gap entirely within the Italian territory, which does not find a similar response in most European countries. The North-South gradient therefore remains an unsolved node, despite the enormous effort put in place by public health in terms of efficiency and appropriateness. Searching for the root causes of this gap is a complex operation, which goes far beyond the reach of epidemiology or health care, and for which social, political and historical analysis tools would be needed. Certainly, the current crisis of confidence gripping institutions can further jeopardize the participation of the population in public health initiatives such as screening, especially in areas of the country where trust in services and in the state has always been very low ” . Evaluating Avoidable Deaths from Cervical Cancer, identifying the main reasons “is the first, indispensable, tool to remedy them. The reasons are linked to a lack of primary and secondary prevention and to responsibilities linked to health planning and organization ” A.Panà

Just at a time when political planning in Campania had begun to pay attention to two critical issues typical of the region, namely the incidence of Improper Caesarean Section and the spread of cancer screening, also to be included in the LEA indicators. the CoViD -19 pandemic has been brought down, which has momentarily shifted attention to other emergencies. The latest MEV-2019 Report shows that “The component of avoidable mortality that identifies deaths linked to the quality of health services is the one that marks the greatest distances and divides Italy in two: all and only the central-northern regions, Excluding Lazio, they are better than the national average. ” However, the death toll due to lifestyle causes remains higher: smoking, alcohol, incorrect eating habits. At the regional level, the minimum values are recorded in Veneto and Marche, while Campania is confirmed at the other end of the ranking as the region with the maximum number of days lost per capita due to avoidable mortality, an indicator adopted by MEV (i) for the regional and provincial rankings which take into account not only the number of the phenomenon but also the age at death, with the deaths occurring at a younger age weighing more heavily. Among the provinces, Treviso is the one with the lowest value, below 15 lost days, followed by Siena, Florence, Rimini, Monza Brianza, Modena, Trento, all below 16.

It is evident that the low adherence to screening and / or vaccinations fall within a much broader dimension that makes the regional health system a patient who needs urgent and no longer postponable interventions. It is necessary to rebuild a public health system, aimed at a community made up of people aware of the management of their health that has gradually disappeared in recent decades, giving way to an economic-financial vision of “health” no longer understood as an objective. to be achieved, but rather as a “good to sell and therefore to buy”, the person from patient has therefore become a customer. And, while the good health became part of the investments of the Finance, inexorably, public health, especially the territorial one, was sucked into the vortex of inadequacy up to the delegitimization, thanks to the equally inexorable reduction of the resources allocated, especially in those Regions, victims of an at least improper interpretation of Fiscal Federalism.

The current pandemic has unequivocally highlighted the strategic role of public health and territorial medicine in particular, with its low-access services (pediatricians, family doctors, continuity of care doctors, family clinics, vaccination centers , diabetes centers, social and health services for the elderly, the disabled, the mentally ill, drug addicts, etc. ) which represents that advanced point of health that many countries envy us. The social emergency that is emerging post -CoviD opens up difficult scenarios for the future, for our country and in particular for Campania. This moment can represent an opportunity to redefine skills, roles and responsibilities in our very precious Health System. First of all, the requalification of territorial medicine by restoring that widespread distribution of its Agencies which in the past represented its strength by welcoming needs but above all by monitoring the state of health of the community, but the real process of renewal passes through recovery. of that de-legitimization by a non-negligible slice of society which has ended up considering the quality of the healthcare offer as a function of its cost. Furthermore, a stabilization of the regional health planning is indispensable, which pursues the pre-established objectives, whose path indicators are evaluated and monitored in time in order to be able to make appropriate changes in the procedures and that the outcome indicators are achieved. The organizational structure of Oncological Screening, of all three oncological screenings, represents a real revolution not only for the reference community, but also and above all for public health. The Screening path is nothing more than a PDTA, i.e. a therapeutic diagnostic path that starts from the territory, in the case of the Family Consultants where the colpocytological sampling is performed up to the Colposcopic Study Centers and finally to the III level Centers for surgical or chemotherapy therapy . For the path not to be an obstacle course for the patient, that is, not a performance but experienced as a service, it is necessary that there is professional recognition among the various operators involved in the different levels of assistance. Furthermore, it is necessary to identify a communication strategy suited to the needs of that particular context, and above all that the most effective strategy, that is empowerment , is put in place.


The systematic review identified several interventions that proved effective in all contexts, some of which with minimal economic and organizational impact. One of the factors that most influences the effectiveness of cancer screening programs in reducing cancer mortality and / or morbidity is the participation of the target population in the program. High participation rates must be achieved to achieve a significant impact on the health of the affected population. This objective must be achieved by encouraging an informed participation of the individual who, before joining, must be made aware of the benefits, limitations and disadvantages of the screening program.

Among The Improvement Strategies Of Non-Organized Screening:

  • there is solid evidence for systematic reminders to GPs in which people who have not undergone screening are reported;
  • there are very heterogeneous results for information and education campaigns aimed at the individual;
  • very intensive face-to-face promotion interventions proved effective, but were mainly tested in groups of deprived or at risk population;
  • there are indications of the effectiveness of mass campaigns, but they have shown many objective difficulties in the evaluation methodology;
  • there is solid evidence of the effectiveness of interventions to remove economic barriers, specifying that a woman will carry out the blood sampling increases participation in cervical screening. You must never abandon the practice of Screening in the course of adult life.

The State Of The Art In Campania

The identification of human papillomavirus as a necessary cause of cervical cancer has opened up new opportunities for prevention: the vaccine to prevent infection and the HPV test to detect infections and treat pre-invasive lesions early . Some large population trials conducted in Europe have shown that the HPV test is more sensitive than the Pap test; the follow up of these studies has then shown that this greater sensitivity translates into greater diagnostic anticipation of preinvasive lesions , finally in greater efficacy in the prevention of invasive cancer. In light of these findings, many pilot projects have begun to evaluate the feasibility of organized screening programs based on HPV as the primary screening test.

The Italian HTA report anticipates the indications of the European guidelines, the recommendations of the report were adopted by the Ministry of Health, after hearing the opinion of the Health Commission of the State Regions Conference, as a support tool to the Regions for planning cervical screening 15 . Therefore, despite the excellent results of the use of the Pap Test as the main method of screening, in recent years, numerous studies have addressed the problem of overcoming the current screening procedures 40 for cervical cancer, with the aim of verifying whether , new methods, generated by the advancement of diagnostic techniques in molecular biology, could lead to improving the management and results of this prevention path. In the context of this complex topic, which would require a discussion that goes beyond the boundaries of this work, we can simplify, underlining the acquisition of at least three basic points in the scientific literature:

  • There is clear scientific evidence that screening with clinically validated DNA tests for oncogenic HPVs (HPV tests), as a primary screening test and with an appropriate protocol, is more effective than cytology-based screening in preventing invasive neck cancers of the neck. ‘uterus.
  • HPV screening allows to reduce the incidence of invasive cervical cancer by 60% -70%, compared to Pap test screening, with an interval between two tests of 5 years instead of 3 (Ronco et al. 2014).
  • A protocol centered on the HPV test reduces the referral to second level assessments and the overdiagnosis of spontaneously regressive lesions, affecting the containment of costs and the percentages of adherence to the path.

In view of these evidences, in Italy the 2017-2019 National Prevention Plan gave indications for the introduction of the new test within the screening protocol by 2019 in all Italian cervical screening programs.

The Campania Region with DCA n. 36 of 01.06.2016 for the purpose: “Transposition of the observations of the Ministry of Health and Approval with amendments to the Regional Prevention Plan of the Campania Region for the years 2014 – 2018” approved action B3 under program B “Wellbeing in the Community” “Implementation of HPV-DNA Test for cervical cancer screening” with the aim of improving the early diagnosis of tumors covered by organized screening programs through the definition and implementation of innovative pathways for cervical cancer screening (HPV-DNA test) 14. Following these assumptions, to date in some regions the HPV test is progressively replacing the Pap test; in situations where the latter is still being used, the HPV test is used as a triage test in case of low-grade cytological abnormalities.

General objectives of the intervention:

  • Adapt the clinical and organizational path of cervical cancer screening in the Campania Region to the quality standards recommended at national level.
  • Improving the early diagnosis of tumors covered by organized screening programs through the definition and implementation of innovative pathways for cervical screening (HPV-DNA test), in order to promote a homogeneous extension of early diagnosis and an acceptable / desirable adhesion. specific to the intervention.
  • With a regional guiding document, define the methods and times for introducing the new procedure.

Define and organize the reference centers responsible for taking care of the different steps of the path.

  • Promptly initiate training for the operators involved in the program.
  • Promptly activate awareness / empowerment / information campaigns for the target population.
  • Update the operational / technological levers of the program, through the revision of the regional screening software and moving the invitation system of the target population entirely to the web- based telematic platform , guaranteeing with the same tool the informative feed-back to citizens and treating doctors .

Project Proposal

Essential elements for the preparation of an appropriate protocol The consolidated definitions and technical-scientific costrains for the implementation of the intervention must be assumed in advance, considering the evidence present in the literature. These can be summarized as follows:

  • The screening test of choice for the diagnosis and prevention of cervical cancer is the Pap test, with a three-year interval for women aged between 25 and 29, and the HPV test, with a five-year interval, for women aged between 30 and 64.
  • The Pap test is also used as a triage test in HPV positive women, during the follow – up post second level CIN2 + negative tests and post treatment.
  • HPV positive women are not to be sent directly for colposcopy but it is necessary to use cytology ( Pap test) as a triage system. If the cytology is positive, the woman is sent for colposcopy. If the cytology is negative, the woman is asked to perform
  • The Pap test is also used as a triage test in HPV positive women, during the follow – up post second level CIN2 + negative tests and post treatment.
  • HPV positive women are not to be sent directly for colposcopy but it is necessary to use cytology ( Pap test) as a triage system. If the cytology is positive, the woman is sent for colposcopy. If the cytology is negative, the woman is asked to perform a new HPV test one year later. If this test is still positive, the woman is sent for colposcopy while, if it is negative, she is invited to a new screening round within the scheduled intervals.
  • Validated oncogenic HPV DNA tests for sensitivity and specificity for high grade lesions should be used, as reported in the European Guidelines ( Antila et al. 2015).
  • There is no evidence that dual cytology and HPV testing is either more protective than HPV alone as a primary test or that it increases sensitivity. The double test strategy, on the other hand, determines a substantial increase in referral for colposcopy. For this reason, when using the HPV test as the primary test, it is recommended not to add cytology in parallel.
  • The HPV test to be used for primary screening must be a clinically validated test according to the criteria defined by the guidelines for the clinical validation of HPV DNA tests for screening.


  1. International Agency for Research on Cancer . IARC Monograph on the evaluation of carcinogenic risks to humans : Human Papillomaviruses . IARC, Lyon 1995 ( updated 1997). http://monographs.iarc.fr/ENG/Monographs/vol64/volume64.pdf Redburn JC, Murphy MFG.
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Macroangiopathy In Diabetic Patients. Role Of The Nurse In The Prevention Of Cardiovascular Complications

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Submission Date: 2022-06-08
Review Date: 2022-06-29
Pubblication Date: 2022-07-21



The subject of this paper concerns fundamental aspects of complications, management and education of the diabetic patient, especially the patient with macroangiopathic complications .
The increase in the prevalence of diabetes mellitus is now exponential and its impact on cardiovascular diseases is increasingly evident.
In fact, the patient with diabetes has a significantly increased risk of developing major cardiovascular events.
This is due to the particular aggressiveness of atherosclerotic disease at the level of the vessels, favored by endothelial dysfunction linked to the hyperglycemic state.
Diabetes is a chronic disease with very widespread diffusion all over the world, destined to increase in the near future with the progressive aging of the population and the increasing occurrence of risk conditions that precede its onset.
We are in fact in the presence of a real pandemic confirmed by epidemiological data, which indicate that more than 300 million people in the world are affected by diabetes.
In Italy, the treatment for diabetes absorbs 6.65% of the overall health expenditure, with a cost per patient that is more than double the national average.
Given the significant burden diabetes places on public health, preventing and improving the care of people with diabetes should be a primary goal for most communities and health systems.
The consequences for individuals are due to the complications that the person with diabetes can develop, in terms of a reduction in both the expectation and the quality of life, with significant repercussions, including economic ones.
The organizational quality and efficiency of diabetic care 4 are correlated with better disease control, with a better prognosis of complications, leading to a lower diabetes-related mortality rate.
Reducing morbidity and mortality and improving the quality of life of people with diabetes mellitus represent one of the current challenges for healthcare professionals, healthcare organizations and medical staff working in public healthcare facilities.
The selection and subsequent implementation of therapeutic education interventions, whose efficacy and congruence with needs have been demonstrated, are essential steps towards improving the conditions of people with diabetes.
Diabetes is a chronic disease and as such requires responsible management by those affected. Often people with diabetes forget to live with a silent disease which, in addition to acute complications, also manifests long-term complications which can become fatal.
A structured intervention is therefore necessary that increases the motivation and adherence of patients to the therapeutic plan, thus leading to a good metabolic control, to an acquisition of knowledge that allows them an adequate management of the disease and a consequent better quality of life.
The aim of this thesis is to research the results of lifestyle modification among the most important scientific evidence, taking into consideration aspects such as: metabolic control, acquired knowledge, self-management, self-efficacy, quality of life and satisfaction of the subjects.
The research was carried out by consulting international databases such as “ Pubmed ” and “ google scholar ".
The articles report that education for lifestyle change increases knowledge of one's illness, self-management skills and thus 2 an improvement in the quality of life.
As a result, there will be a reduction in the incidence of diabetes and an improvement in numerous cardiovascular factors. Furthermore, the nurse plays a role of fundamental importance both at the educational level through specific structured interventions, and at the psychological level.

The Diabetes

Definition and classification The denomination of diabetes mellitus derives from the Greek, diabetes = “pass through” (the kidneys) and mellitus = honey (in the sense of sweet, referring to the urine) (Treccani & Istituto della Enciclopedia Italiana, 2013).

Diabetes mellitus is a chronic syndrome characterized by hyperglycemia secondary to a defect in insulin secretion or activity or more often by both.

Chronic hyperglycemia is associated in the long term with damage, dysfunction and collapse of different anatomical areas such as ocular complications, macroangiopathy , nephropathy, neuropathy, erectile dysfunction.

Therefore, it requires continuous and multiple interventions on glycemic levels and cardiovascular risk factors, aimed at the prevention of acute and chronic complications; an educational activity for the patient suffering from diabetes, aimed at acquiring the knowledge necessary for the self-management of the disease; the treatment of complications of the disease, if any.

In order for glucose to enter the cells and be used as “fuel”, the presence of insulin is necessary.

 Insulin is secreted by the beta cells constituting the langherans islands , (which are part of the endocrine portion of the pancreas) which is essential for the metabolism of sugars.

All simple and complex sugars (starches), which are consumed with food, are transformed during digestion into glucose, which is the main source of energy for muscles and organs.

The concentration of glucose in the blood is measured by blood sugar.

In healthy subjects, who have a regular life and a correct diet, generally throughout the day the blood glucose values remain between 60 and 130 mg / dl.

When fasting, blood glucose values can vary from 70 to 110 mg / dl; between 110 and 125 mg / dl it is a condition of impaired fasting glycaemia (IFG), a condition that should encourage the patient to pay more attention to his lifestyle and in particular to his diet.

Blood glucose values equal to or greater than 126 mg / dL, according to American Diabetes Association , are considered probable symptoms of diabetes.

The spread of diabetes is taking on the characteristics of a real epidemic, it is estimated that there are at least 387 million diabetics in the world, and that 4.9 million die from complications of this disease.

The criteria for the classification of diabetes mellitus have undergone continuous modifications and redefinitions in recent decades, with the tendency to become increasingly rigorous and sensitive, but also increasingly simple.

The classification and diagnostic criteria of pre – diabetic states and overt diabetes mellitus were revised and reformulated in 1997 by a commission of experts sponsored by American Diabetes . Association (ADA) and subsequently updated over the years to date.

The current classification of American Diabetes Association (ADA), based on etiopathogenetic criteria, provides four classes:

  • Type I diabetes
  • Type II diabetes
  • Gestational diabetes
  • Other specific pathologies of diabetes
Type 1 diabetes mellitus (DM1)

Type 1 diabetes is a form of diabetes that occurs mainly in childhood and adolescence (although cases of onset in adulthood are not rare ).

For this reason, until recently it was referred to as childhood diabetes.

Type 1 diabetes mellitus falls into the category of autoimmune diseases because it is caused by the production of autoantibodies (antibodies that destroy their own tissues and organs, not recognizing them as belonging to the body but as external organs) that attack the Beta cells that are inside the pancreas. deputies for the production of insulin.

As a consequence, the production of this hormone, whose task is to regulate the use of glucose by the cells, is reduced to zero completely.

Therefore, there is a situation of excess glucose in the blood identified with the name of hyperglycemia.

The lack or scarcity of insulin, therefore, does not allow the body to use the sugars introduced through food which are thus eliminated in the urine.

In this situation the body is forced to produce energy in other ways, mainly through the metabolism of fats, which involves the production of so-called ketone bodies.

The accumulation of ketone bodies in the body, if not intervened in time, can lead to very dangerous consequences up to a coma.

Inadequate control can affect development, increase comorbidities , decrease life expectancy , and increase the risk of acute and chronic diabetes-related complications.

Responsibility for caring for children with diabetes has a psychosocial impact on both the child and his family.

The predisposition to develop diabetes is in part hereditary in fact the first degree relatives are at risk, while for the homozygous twins there is a certain inheritance but not total, because the susceptibility genes for diabetes are at a low degree of penetrance therefore there it must be something else to make it rise.

The regions of the human genome that induce predisposition to diabetes are 20 loci, in particular in the loci that encode human leukocyte antigens for HLA .

Subsequent studies have Subsequent studies have shown a role in the genetic predisposition for diabetes mellitus also for the insulin gene and other genes involved in the immune process.

Furthermore, viral infections are associated in the onset of diabetes in predisposed individuals.

There are 2 mechanisms through which an infection causes diabetes: the virus infecting beta cells induces a modification of the protein antigens represented by HLA class 1 and T lymphocytes or there is an immune response to viral infection which is a cross reaction towards specific antigens of the beta.

Another role is the feeding with cow’s milk as its proteins have a diabetic effect such as beta casein and bovine serum albumin which can lead to cross reactions between milk and cell proteins.

Other proteins are those of wheat such as gluten.

Protective foods are vitamin D which has immune properties modulatory linked to the alteration of vitamin D with the nuclear receptor, chemicals can cause direct toxic damage to the beta causing them to be destroyed.

The characteristic symptoms of diabetes 1 are associated with the progressive worsening of the insulin deficiency.

Initially manifests itself with polyuria, increased urine excretion, as the progressive worsening of the insulin deficiency determines a low action of insulin by reducing the hepatic production of glucose and increasing its uptake at the peripheral level, thus being a hypoglycemic action.

With the presence of deficiency the blood sugar will increase and a certain amount is exceeded or the renal absorption threshold is exceeded, the glucose is no longer reabsorbed and comes out with the urine as it recalls water due to the osmotic effect.

Polyuria is observed in a high sensation of thirst and a state of dehydration of the skin and mucous membranes.

There is an increase in appetite but with a decrease in weight because in the presence of a deficit we have excessive lipolysis and proteolysis, there will be production of ketone bodies that will lead to nausea, vomiting, abdominal pain and if you do not have a correct drug therapy you can get to a coma or to death.

Type 2 diabetes mellitus (DM2)

 It is a disease with a multifactorial etiology characterized by a great heterogeneity of molecular defects characterized by the presence of insulin resistance and often also by a relative insulin deficiency ; for this reason, this form does not provide, except in some cases, the insulin treatment.

– cell destruction does not occur in DM2 .

Type 2 diabetes mellitus typically appears after puberty and affects approximately 90 – 95% of diabetic patients.

Many patients with the aforementioned diabetic form are obese, and obesity itself is a cause of insulin resistance .

Patients who cannot be defined as obese according to the criteria based on the calculation of the BMI, will most likely have a higher percentage of visceral adipose tissue, since this too is associated with insulin resistance .

Furthermore, this diabetic form may remain undiagnosed for some years and this is because the hyperglycemia, developing gradually, may initially be asymptomatic.

We can therefore say that at the base of DM2 there is in any case a defective insulin secretion that fails to compensate for the insulin resistance present in the tissue.

However, this tissue insulin resistance may be improved through weight loss or drug treatment.

The risk of developing this form of diabetes is greater in the obese, in physically inactive people, in women with a history of gestational diabetes mellitus, in hypertensive or dyslipidemic patients , in some ethnic groups and increases with increasing age.

DM2 is often also due to a strong genetic predisposition.

However, these forms are complex and not yet fully defined.

 On the other hand, a different pathogenesis has been reported, which explains that the primary cause of DM2 is of ischemic origin due to a temporary or permanent decrease in the blood supply in the anterior hypothalamic nuclei, which causes over-excitation of the descending parasympathetic pathways and the anterior hypothalamus axis , increase in the concentration of glucose in the blood and lipids, as well as the accumulation of adipose tissue, the latter being the main one involved in insulin resistance and hyperinsulinemia .

Ischemia causes a chronic progressive deficit of insulin secretion, which favors the necrosis of the B lymphocytes due to lack of irrigation. In this sense, islets have been shown to be highly dependent on blood supply, making them very vulnerable to ischemic changes. 

Gestational diabetes mellitus (GDM):

Gestational diabetes refers to an increase in blood sugar (blood sugar levels) when fasting or after meals and which is first observed in pregnancy. The risk of developing it must be evaluated in the initial stages of gestation especially in the presence of predisposing clinical signs such as obesity, previous GDM, familiarity with DM

. It generally appears in the II – III trimester of pregnancy and represents an important risk factor for the pregnant woman and the fetus.

Due to a situation of insulin – physiological resistance that is established in pregnancy, by placental hormones, not balanced by pancreatic function.

GDM is manifesting itself more and more in parallel with the increase in juvenile obesity.

Other specific types of diabetes: These are forms of diabetes that do not fall into the previous classes and which are due to other causes.

They can be the consequence of genetic defects of β – cells (MODY1, MODY 2, MODY3, MODY4, MODY5, MODY6, mitochondrial DNA ) or in insulin action ( insulin resistance type A, leprechaunism , Rabson – Mendenhall syndrome , lipoatrophic diabetes ), exocrine pancreatic diseases (pancreatitis, trauma, neoplasms, cystic fibrosis, hemochromatosis , pancreatopathy fibrocalculosa ), of endocrinopathies (acromegaly, Cushing ‘s syndrome , glucagonoma , pheochromocytoma , hyperthyroidism, etc.) or forms induced by drugs, chemicals and drugs ( vacor , nicotinic acid, pentamidine , glucocorticoids , thyroid hormones, alpha – interferon, thiazides , etc.), infections ( cytomegalovirus , rubella congenita) rather than uncommon forms of immune- mediated diabetes ( Stiff – man syndrome , anti – insulin receptor antibodies, etc.) or deriving from other genetic syndromes (Down syndrome, Prader syndrome – Willi, Klinefelter , Turner, Wolfram, etc.). In particular, MODY diabetes ( Maturity Onset Diabetes of the Young), is characterized by a juvenile onset of type 2 diabetes mellitus in which rare genetic defects in the intracellular mechanisms of insulin action have been identified. Mature-onset diabetes of young people (MODY) is a heterogeneous group of monogenic causes of beta cell dysfunction and diabetes that arise in children and young adults. Making an accurate diagnosis of MODY is important in establishing proper management.

In recent years, no major new monogenic causes of diabetes have been identified outside the neonatal period.


The diagnosis of Diabetes Mellitus and the decrease of beta cells (responsible for the production of insulin) in the pancreas begins about 12 years before the diagnosis of 13 disease .

The importance of making an early diagnosis is reflected above all in the possibility of treating macro and micro vascular complications as soon as possible.

The onset of type 1 diabetes occurs most of the time in a sudden manner with a marked increase in thirst, the elimination of a greater quantity of urine, even during the night, a more or less marked weight loss, despite the ” increase in hunger and caloric intake, and a reduction in strength and physical efficiency: symptoms that attract the attention of the patient or family members and that lead to a quick check, perhaps with a urinary stick , to verify the possible presence of glycosuria.

Type 2 Diabetes

instead, very frequently it is not diagnosed at its onset, due to the absolute lack of any symptoms. In fact, unlike type 1, the blood glucose values are not so high as to cause the classic symptoms mentioned above.

It is therefore estimated that at least one third of all diabetic patients do not really know they are diabetic and that the diagnosis is made only after the onset of a complication such as, for example, a myocardial infarction or stroke.

Hence, the need for a more timely diagnosis that allows to implement all those therapeutic aids that today we know are able to prevent possible cardiovascular complications.

Two very simple tests are now available for the diagnosis of diabetes: the determination of fasting glycaemia and the execution of an oral glucose load. Under normal conditions, blood glucose measured on venous plasma after at least 8 hours of fasting should be below 100 mg / dl. A blood glucose equal to or greater than 125 mg / dl allows the diagnosis of diabetes to be made.

Glycemic included between 100 and 125 mg / dl define a condition which, although abnormal, is not yet diabetes and which, therefore, is simply defined as ” abnormal fasting glycaemia”.

The oral glucose load is performed by taking 75 g of glucose in the morning, on an empty stomach, and determining the glycaemia both before taking the load and after 2 hours.

Under normal conditions, blood glucose two hours after loading should be below 140 mg / dL. Values equal to or greater than 200 mg / dl lead to the undisputed diagnosis of diabetes, while intermediate values between 140 and 199 mg / dl indicate a pathological condition that is not yet diabetes and which is given the definition of “glucose intolerance”.

 It is implied that, when first resorting to the measurement of fasting glucose, where the presence of an abnormal glycaemia, between 100 and 125 mg / dl is found, it is necessary to proceed with the execution of a load test.

Both “abnormal fasting glycaemia” and “glucose intolerance” deserve the nickname of pre – diabetes, because both predispose, if not corrected by adequate therapy, to the onset of diabetes and cardiovascular atherosclerotic complications. As for the risk factors that cause this condition they are;

  • First degree diabetic family members
  • Women who have given birth to macrosomal fetuses (weight equal to or greater than 4 kg) or who have been diagnosed with gestational diabetes in the past
  • Arterial hypertension with values equal to or greater than 140/90 mmHg or in antihypertensive treatment

Hdl cholesterol values below 35 mg / dl or triglycerides above 250 mg / dl

Detection in the past of high blood glucose values even if sporadic
  • A history of cardiovascular disease
  • Women with polycystic ovary syndrome

Since age is itself a risk factor, a screening test should still be performed in all individuals over the age of 45 even in the absence of the specific risk factors listed above.

glycated hemoglobin (HbA1c) completes the diagnostic assessment but is not a necessary requirement for diagnosis.

The HbA1c expresses the average value of the glycaemia of the last two months and can give us valuable information on the metabolic balance reached in that period.

Under normal conditions it does not exceed 6%. Its determination is not useful for diagnosis, but for monitoring the effectiveness of the therapy.

Diabetes screening

In consideration of the increase in new cases of diabetes, both in developing and industrialized areas, such as Italy, it is essential to monitor the onset of the disease through screening. The recommended screening programs in the general population are those aimed at people at high risk of diabetes carried out at the time of medical check-ups.

Screening is a process of assessing asymptomatic subjects aimed at identifying preclinical pathologies, indicators of disease or indicators of risk conditions.

According to the WHO (World Health Organization) it must be simple to perform, easy to interpret, acceptable by the person to whom it is proposed, of high diagnostic accuracy, repeatable over time and with a favorable cost – benefit ratio.

There is therefore a need to identify cases of unrecognized diabetes, which make up one third of the total number of cases of diabetes.

The most suitable strategy is represented by the identification of the categories at high risk of developing diabetes, including subjects with IFG ( impaired fasting glycaemia , altered fasting blood glucose: values between 110 and 125 mg / dl), the main risk factor, and subjects with a high BMI (≥25 kg / m 2) : an increase in BMI of 1 kg / m2 increases by 8 , 4% risk of developing type 2 diabetes.


According to the data of the Passi surveillance, in the pool of ASL participants, the prevalence of diabetics increases with age (it is less than 2% in people under the age of 50 and is close to 10% among those aged 50 – 69), it is more frequent among men and women (5.1% vs 3.8%), in the socio – economically more disadvantaged segments of the population in terms of education or economic conditions, among Italian citizens compared to foreigners, and in the southern regions compared to the Center and to Northern Italy.

The prevalence of people with diabetes has not changed substantially since 2008. According to data from the Cardiovascular Epidemiological Observatory, collected since 1998 and published on the Progetto Cuore website, in Italy 10% of men and 7% of women are metabolic .

Among the elderly (aged between 65 and 74 years), 20% of men and 15% of women are diabetic while 12% of postmenopausal women (average age 62) are diabetic.

According to WHO Europe, 52 million people within the WHO European Region are living with diabetes.

The prevalence of this disease is growing throughout the region, reaching rates of 10-14% of the population in some states .

This increase is partly due to the general aging of the population but mainly to the spread of risky conditions such as overweight and obesity, poor nutrition, a sedentary lifestyle and economic inequalities.

According to the WHO, there are approximately 346 million people with diabetes worldwide and more than 80% of deaths related to this disease occur in low- and middle-income countries.

WHO also estimates that deaths from diabetes are set to double between 2005 and 2030 (in 2004, figures refer to 3.4 million people missing as a result of the consequences of high blood sugar).

 The World Health Organization has predicted that by 2025 there will be more than 300 million people with diabetes worldwide. diabetic, 8% of men and 4% of women are in a borderline condition (glucose intolerance) and 23% of men and 21% of women have diabetic syndrome.

Cardiovascular Complications

Definition and complications of diabetic macroangiopathy

Macroangiopathy , as the name itself illustrates , is altering the blood vessels, the large-caliber arteries.

Cardiovascular disease is the leading cause of mortality in Western countries, and diabetes mellitus is a condition of increased risk for this type of disease.

As the frequency and severity of acute complications have decreased, these chronic vascular complications, which can affect various areas of the body, have become clinically more important.

. The symptoms presented by the patient are related to the sites of the body where blood circulation is compromised.

More frequently, vascular complications occur in the form of impaired heart circulation (angina and myocardial infarction), cerebral (infarction and cerebral haemorrhage) and of the lower limbs (peripheral arterial disease).

Before treating these pathological conditions separately, let’s take a look at what is the root cause of vascular disease – atherosclerosis.

Atherosclerosis is a chronic inflammatory disease of large and medium-sized arteries that causes ischemic heart disease, stroke, and peripheral vascular disease collectively called cardiovascular disease.

This condition is characterized by a gradual accumulation in the intima of macrophages, smooth muscle cells, lipids and collagen; it is identified as chronic inflammation localized in the intimate vascular tunic and triggered by prolonged endothelial damage.

The inflammatory agent is LDL cholesterol. A classic atherosclerotic lesion is plaque or atheroma, that is a formation consisting of fats, proteins and fibrous tissue that takes 20 – 30 years to develop.

This plaque tends to form more easily where the flow is not laminar but swirling, such as near arterial bifurcations.

Atherosclerosis and its complications are a frequent cause of death, just think that the diseases triggered by atherosclerosis are still the number 1 killer in the world.

On a macroscopic level, atherosclerosis shows itself with 3 lesions: lipid stria, fibrous plaque and complicated plaque. The lipid striae are elongated lesions of 1 – 2 mm, yellowish in color and sharp edges, which stand out against the white color of the intima; only flat and have a smooth and continuous surface.

Histologically, the lipid striae contain lipids and macrophages.

They do not reduce the vessel lumen and do not compromise its structural integrity.

Lipid striae appear in the aorta in early childhood or be present even at birth. In the presence of cardiovascular risk factors they can progress into more advanced lesions.

Fibrous plaque (atheroma) is a circumscribed thickening, protruding into the vascular lumen, up to 1.5 cm long.

The fibrous covering capsule is formed by smooth muscle cells and dense connective tissue where underneath are macrophages, smooth muscle cells migrated from the media and a few T lymphocytes.

These muscle cells become capable of producing cell matrix proteins, including collagen.

Deeper, a necrotic nucleus is observed containing lipids (cholesterol), cell debris and cell – foamy.

The latter, originating from macrophages, are filled with lipids. In the periphery of the plates there are small newly formed vessels.

Fibrous plaques can have complications such as ulceration, bleeding, thrombosis, calcification and lead to aneurysm formation.

Plaque ulcerates when macrophages in the lesion release metalloproteases that weaken the fibrous capsule.

Intra -plaque hemorrhage , the result of the rupture of newly formed vessels, also causes plaque ulceration because the accumulation of blood causes an increase in volume.

The rupture of the capsule causes the release into the circulation of solid fragments (emboli) which can stop in the smallest vessels and cause ischemia. The contact between blood and the contents of the plaque evokes the haemostatic response with the formation of a thrombus which can rapidly occlude the vessel causing necrosis of the downstream tissue. Deposition of calcium salts in plaques is often observed in a process similar to ossification.

Fig. 1

Let us now take a closer look at the different manifestations caused by macroangiopathy in the most affected areas: the coronary arteries that supply the heart, the iliac and femoral arteries along the lower limbs, and the carotid vessels that carry blood to the brain;

  • Ischemic heart disease
  • Peripheral arterial disease
  • Cerebrovascular disease
Ischemic heart disease

The term ischemic heart disease identifies a series of clinical pictures whose common denominator is represented by myocardial ischemia, defined as a condition of myocardial distress that occurs when the coronary blood flow becomes inadequate to meet the demands for oxygen and necessary nutrients to myocardial cells to perform their contractile function. It is a disease for which deposits of fatty material (mainly cholesterol) are formed on the inner wall of the vessels. The atherosclerotic plaque narrows the lumen of the vessel and determines a reduction in blood flow with a consequent reduction in the supply of blood, and therefore of oxygen and nourishment, to the areas supplied by that specific arterial branch. The correlation between diabetes and ischemic heart disease is well known since, as evidenced in 1993 by the famous MrFIT study , diabetes increases the risk of coronary and cerebrovascular disease by two to four times . the pathophysiological mechanisms that support the correlation between diabetes and heart disease, often superimposed on other usual risk factors such as smoking, age , hypertension and other unfavorable constitutional or family predispositions. On the other hand, some new aspects, of interesting relevance, which favor the development of cardiovascular pathologies in the course of diabetes should be mentioned:

  • the reduction of nitric oxide synthesis (No), with consequent defect in action vasodilatory ;
  • the glucotoxicity and lipotoxicity associated with diabetes favor the release of proinflammatory cytokines , and therefore the maintenance of a chronic inflammatory condition responsible for endothelial damage;
  • the increase in reactive oxygen species , which are also responsible for endothelial damage;
  • the increase in inflammatory proteins and thrombogenic factors.

In practical terms this translates into: – a 2 – 5 fold increase in developing a cardiac or cerebral ischemic event; – 60% probability of death from a cardiac or cerebral ischemic event. A study has shown that over 300,000 diabetic patients followed for six years has shown not only that the increase in cardiovascular morbidity and mortality is directly proportional to the increase hemoglobin glycosylated , but also that this increase is independent of the main associated risk factors (Zhao W et al .; Diabetes Care 37: 428 – 35). A relevant aspect in cardiovascular prevention in diabetic disease is hidden morbidity.

While 50% of patients with type 2 diabetes have chronic disease, about half of them have no symptoms or ECG signs . This implies that one in eight men and one in 16 women will suffer from myocardial infarction or will need revascularization surgery; and that one in 16 men (or women) will have a stroke within ten years. Ischemic heart disease is a condition to be prevented in patients with DM as it is the most frequent cause of death in the world, just think that in the United States alone it is responsible for more than a million deaths every year. About half of these “cardiovascular deaths” are directly related to coronary heart disease, while 20% are due to stroke. Ischemic heart disease is the leading cause of death in Italy, accounting for 28% of all deaths after cancer. Considering the potential years of life lost, that is, the years that each person would have lived if he had died at an age equal to that of his life expectancy, cardiovascular diseases take away over 300,000 years of life from people under the age of 65 every year, 240,000 in men and 68,000 in women. Ischemic heart disease changes the quality of life and entails significant economic costs for society. In Italy the prevalence of citizens suffering from cardiovascular disability is equal to 4.4 per thousand (Istat data). 23.5% of the Italian pharmaceutical expenditure (equal to 1.34 of the gross domestic product) is destined to drugs for the cardiovascular system (Report on the health of the country, 2000). The data of the National Register of Coronary and Cerebrovascular Events show a substantially homogeneous picture throughout Italy, which dispels the cliché according to which one would get sick more heartily in the North than in the South of Italy. The incidence rates of heart attack , for example, are very similar in Naples and Friuli Venezia Giulia, for both men and women.

The health and social value of these data on cardiovascular diseases is accentuated by the consideration that they or, at least, the majority of them, 24 i.e. the arteriosclerotic forms, are largely preventable, at least 50% according to available estimates. Many of the risk factors of cardiovascular diseases are modifiable and, when there are more than one, they have an action that is not only additional but multiplicative or synergistic in determining the risk of disease. Ischemic heart disease can give rise to two types of events namely Angina pectoris and myocardial infarction. As for Angina Pectoris, it is characterized by chest pain, also called posterior sternal pain, caused by insufficient oxygenation of the heart muscle due to a transient decrease in blood flow through the coronary arteries. Anginal pain generally begins slowly, reaching its apex and then disappearing within 10 to 15 minutes; the pain can also spread to the organs close to the chest and this situation is called pain irradiation. In the most typical cases, the subject reports feeling a pain, more or less intense, in the center of the chest that spreads from behind the breastbone to the left arm (ulnar side) and, sometimes, to the throat (with a feeling of suffocation), to the jaw (with toothache), shoulder or pit of the stomach.

Fig. 2

Shortness of breath is due to the inability of the heart to pump effectively and causes, in some patients, a feeling of tightness in the chest like a rope or like a vise tightening the chest (constricting pain), accompanied by a sense of chest tightness and sometimes anguish with a sense of imminent death. Pain can be triggered by physical activity, such as carrying a weight, climbing stairs, or climbing quickly (exertional angina), and resolves on interruption of the activity . Angina worsens when exertion is made after a meal; it is more intense if it is cold, so an effort that does not produce symptoms during the summer can instead induce anginal attacks in the winter. Even a strong emotion, an intense anger can trigger an anginal attack. Seizures can vary in frequency, from many in a day to sporadic, interspersed with symptom-free periods of weeks, months, or years;

they may increase in frequency or disappear, for example if adequate coronary collateral circulation develops.

There are cases in which anginal pain can arise at rest, in full psycho – physical relaxation (spontaneous angina). There may be other accompanying symptoms including: shortness of breath, palpitations and cold sweats. The first onset of angina in an individual is always, by definition, unstable ( primary unstable angor ), although in reality the term is scarcely used in clinical practice.

The clinical – prognostic classification of angina is mainly of two types: Østable angina pectoris, it is a clinical condition characterized by the onset of symptoms under exertion and always at the same levels of fatigue: this is the reason why it has been defined as stable exertional angina. ØUnstable angina pectoris is a clinical condition characterized by the onset of symptoms at rest and therefore unpredictable: this is why it has been defined as unstable angina. It is also renamed ” pre – infarct syndrome”, as the first episode may be prolonged enough to lead to myocardial infarction . Ultimately, angina pectoris is due to a sudden reduction in the blood supply to the heart, or part of it, for two possible reasons: 1) The coronary arteries have narrowing (stenosis), which does not allow the blood supply to increase in some circumstances ( in particular efforts), during which the myocardial needs for nutrition and oxygenation are greater; 2)

In the coronary arteries there is a spasm, that is a transient narrowing dependent on a muscular contraction, for which the caliber of the coronary arteries is reduced and the quantity of blood that reaches the heart becomes insufficient even in conditions of rest. Myocardial infarction, on the other hand, is characterized by the obstruction of a coronary artery following the fissuring of the fibrous cap of an atheromatous plaque with the formation of an occluding thrombus and consequent necrosis of the myocardial tissue, unable to withstand hypoxic conditions even for a short time . It is divided into: 1) Myocardial infarction without ST segment elevation: it is the least dangerous infarction, due to an incomplete or temporary occlusion of the coronary vessel. In this case the level of myocardial necrosis indices is higher than normal, but the characteristic electrocardiographic picture of the infarction is missing. 2) Myocardial infarction with ST segment elevation: this is the most serious infarction, due to complete and stable occlusion of the coronary vessel. It is followed by the characteristic elevation of myocardial necrosis indices and by the characteristic electrocardiographic changes. Pain, where present, is typically localized in the region behind the breastbone, i.e. in the center of the chest. It typically tends to radiate to the left shoulder and upper limb , although irradiation to the cervical or left shoulder blade is possible. In the case of lower-type (or “diaphragmatic”) myocardial infarction, pain occurs in the epigastrium and can be confused with pain in the abdomen or stomach and therefore of non-cardiac origin. It should be noted that these are the most typical sites of cardiac pain, but there are many others which, although not typical, must be taken into consideration by the cardiologist to whom they are described: irradiation to the jaw, elbows and wrists. The intensity of the pain is usually very strong, constricting, accompanied by a cold sweat and an imminent sense of death. Minor symptoms, but almost always present: a profound asthenia, a sense of nausea and vomiting. Unlike stable angina , which lasts a maximum of 10 – 15 minutes, the pain caused by myocardial infarction lasts more than 30 – 40 minutes and is not relieved either by rest or by taking drugs such as isosorbide. dinitrate or trinitrine.

Peripheral arterial disease

Peripheral arteriopathy affecting the diabetic subject is an obstructive pathology on an atherosclerotic basis which however presents some peculiarities in terms of histopathological characteristics, anatomical distribution and clinical presentation . In fact, these patients are younger, have a higher BMI, are very often neuropathic and present a complex clinical picture in which there are a greater number of cardiovascular comorbidities than subjects without diabetes. In these subjects the AOCP manifests itself in a much more aggressive way both for the neuropathy but also for the greater tendency to infections; this leads to an increased rate of amputation between five and ten times greater than in non-diabetics (ADA 2003). The key feature of arterial disease in the diabetic is the rate at which the disease progresses, which is much faster than in the non-diabetic population. From an anatomical point of view, AD prefers medium and small caliber arteries (distal part of the superficial femoral, popliteal, arteries below – genicular ), with a relative lower aorto – iliac commitment compared to the patient with non-diabetic AOCP. The motivation for this anatomical distribution is not entirely clear; it can be hypothesized that the high inflammatory component that accompanies endothelial dysfunction, present early in the diabetic, finds a more reactive ground in the arteries with a predominantly muscular component, and that the stimulation of these cells leads to a more rapid fibroblastic differentiation. The factors most implicated in the mortality of diabetic subjects with peripheral arterial disease are ischemic heart disease, present in 50% of these patients, and non-revascularization ( Ouriel 2001) ( Leibson 2004) (Norman 2006). Furthermore, age and dialysis treatment also reduce survival. In recent decades it has been seen that a deterioration of peripheral arterial disease leads to an increase in the number of deaths from cardiovascular diseases. The objective of screening in diabetic patients must be to promptly recognize the presence of peripheral vascular disease due to the high risk of morbidity and mortality related to cardiovascular disease. In fact, it is very common to find silent and unknown ischemic heart disease in subjects with diabetes and AD rather than in those without AD (Nesto 1990) ( Wacker 2004) (Zellweger 2006). Peripheral arterial disease is considered one of the chronic diseases that most burden the health system and society in general. It has been estimated that more than 400,000 hospitalizations are performed annually in the US, including 160,000 surgeries and 69,000 minor or major amputations. AOP weighs heavily on social costs in terms of lost productivity and health expenditure and the problem is destined to widen taking into account the increased life expectancy and the continuous progress in diagnostic techniques and related instruments and intervention strategies. The economic implication of a pathology consists of two components: 1) Health expenditure which includes direct costs linked, for example, to the resources used for the diagnosis and treatment of the pathology. 2) Non-health costs which include so-called indirect costs, such as those related to the patient’s loss of productivity due to abstaining from work or reduced productivity during work, other costs such as those of transport for assistance or adaptation of the domicile in the event of amputation and finally the intangible costs due to the reduced quality of life resulting from the disease.

Cerebral vasculopathy

Cerebral vascular disease is a treatable and preventable disease that can present in different forms of severity. It is caused by the lack of or lack of blood in an area of the brain, much like what happens to the heart during angina or myocardial infarction. Often this term is used to describe atherosclerosis of the carotid arteries that supply the brain with blood. Arteries are used to carry blood and therefore oxygen and nutrients) from the heart to the muscles and organs of our body. Vascular disease can cause a number of very serious complications including stroke. Stroke is caused by a sudden lack of blood circulation (ischemia) in the brain. The cause of most strokes is due to obstruction of the carotid arteries resulting in interrupted cerebral blood flow, or to occlusion of a brain vessel by a thrombus or embolus. The resulting lack of oxygen leads to a deficit of nervous functions. If blood circulation is not restored quickly, the affected brain tissue dies. Arteriosclerosis affecting the vessels that carry blood to the brain is particularly insidious because it does not cause any disturbance. Typically stroke symptoms are sudden and hence the name stroke (lightning). For this reason, subjects who have multiple risk factors for the formation of arteriosclerotic plaques in the carotids should undergo an evaluation of these vessels even if they have never had symptoms. When there is a sudden reduction in blood reaching the brain, one or more of the following disorders can occur: sudden weakness in one part of the body, often in one half of the body, numbness or tingling in one part of the body (face, arm , leg), sudden deviation of the oral cavity (crooked mouth), sudden loss of vision, difficulty speaking, dizziness with difficulty standing, violent unusual headache (those with habitual headaches need not worry excessively), difficulty in eating and swallowing or sudden speech disturbances. When the symptoms described above last for a few minutes or hours and then disappear completely without leaving traces, it is called TIA (transient ischemic attack). It is important to recognize a TIA because it represents a risk condition, an alarm bell, which can precede a real stroke. Cerebral vascular disease is particularly dangerous because it does not often give symptoms (asymptomatic or with signs that are not identified). It is very important to understand the signs of this devious disease right away. In fact, people immediately worry if they have a heart attack, because they feel a strong pain in the chest and this is an alarm bell recognized by all. The stroke is much more subtle, often no pain is felt, if an arm or a leg tingles or does not move well, we are inclined to underestimate the problem. Diabetic patients need to be better controlled and vascular risk factors in these patients need to be treated more aggressively. These measures are almost always associated with a medicine that serves to reduce the formation of thrombi inside the diseased arteries (antiplatelet agent) such as aspirin which is the most powerful and irreversible antiplatelet agent. In patients who do not respond to medical treatment and in whom diagnostic tests have shown the presence of an arteriosclerotic narrowing (stenosis) of the vessels in the neck, vascular surgery is possible ( endarterectomy , thrombendarterectomy , ATE, carotid artery ) to try to remove encrustations of the artery and restore normal blood flow. In addition to traditional carotid surgery, it is possible to try to remove obstacles to circulation with angioplasty (PTA, percutaneous transluminal angioplasty) in which a catheter inserted in the groin is brought up to the carotid artery , an inflatable balloon dilates the stenosis and the insertion of a metal retina (called a stent ) ensures that the dilated region remains open. If a patient has a stroke, he must be immediately hospitalized and subjected to antiplatelet and anticoagulant therapy to ensure survival and reduce neurological complications as much as possible.

Cardiovascular risk in diabetes

The diabetes pandemic we are witnessing is likely to be followed in a few years by an explosion of cardiovascular disease, given the high frequency of these manifestations in diabetic patients. Several prospective observational studies and meta -analyzes have shown that the risk of macrovascular complications in diabetes mellitus correlates with HbA1c values suggesting that normalization of glycemic levels can prevent the onset of cardiovascular events. Macrovascular complications of diabetes in their coronary, cerebral and peripheral localization of the lower limbs still represent the major cause of mortality and disability in diabetic patients, and are responsible for over 75% of hospital admissions in these patients. Type II diabetes mellitus is an independent risk factor for macrovascular disease . Studies show that type 2 diabetes mellitus increases the risk of CAD by 4 times. Cardiovascular alterations are responsible for 80% of the deaths of diabetic patients. Among these deaths: – 75% are caused by coronary atherosclerosis – 25% by cerebral or peripheral vasculopathy . In addition, 50% of people with type 2 diabetes at onset have pre-existing coronary atherosclerosis. Coronary heart disease is the leading cause of morbidity and mortality in diabetic patients. Many prospective studies have evaluated morbidity and mortality from cardiovascular disease in patients with type 2 diabetes. There is a strong agreement of results indicating at least a double increase in the risk of ischemic heart disease in diabetic subjects compared to non-diabetics. Similar data are obtained for other cardiovascular complications such as heart failure, peripheral vascular disease of the lower limbs and cerebral stroke. In Italy, two studies are available, that of Verona (Verona Diabetes Studye ) that of Casale Monferrato who report total and cause-specific mortality in two cohorts of patients with type 2 diabetes in a relatively recent period. In addition to a high incidence of events, diabetic patients have a worse prognosis. For example, it is documented that mortality in the first hours after the heart attack and in the following 12 months is higher in patients with diabetes, both men and women. This suggests that attention to the problem and / or the implementation of adequate measures for the early diagnosis and prevention of these diseases still need to be improved in the diabetic patient . Finally, it should be emphasized that a significant increase in cardiovascular risk is also observed in people with impaired glycemic regulation that are not diagnostic of diabetes, such as impaired glucose tolerance (IGT) or altered fasting glycemia (IFG). This latter observation suggests that, contrary to what is observed for microvascular complications, for macrovascular complications it is probably not possible to identify a threshold glycemic value for increased risk, or that this threshold is much lower than the value used for the diagnosis of diabetes.

The new guidelines classify patients based on comorbidities and disease duration, dividing them into three groups:

  1. CV risk1) Moderate CV risk: young patients: (< 35 years for type 1 diabetes or> 50 years for type 2), who have had diabetes for less than 10 years, with no other risk factors.
  2. CV risk . diabetics for 10 years or more, with at least one other risk factor, but no target organ damage .
  3. Very high CV risk :
    • patients with stabilized diabetes and CV diseases
    • or with damage to target organs
    • or with three or more major risk factors
    • or have had type 1 diabetes for more than 20 years

Therefore, some specific risk parameters for diabetic patients are taken into account such as metabolic compensation, triglyceridemia and / or HDL cholesterol levels, micro and macroalbuminuria .

Risk Factors Based On Age

  • age> 55 y. + 1 risk factor
  • age between 45 and 54 a. + 2 risk factors
  • age between 35 and 44 a. + 3 risk factors
Risk Factors To Consider:
  1. LDL cholesterol> 115mg / dl or total cholesterol> 190 mg / dl
  2. triglycerides> 150 mg / dl or HDL cholesterol <40 mg / dl
  3. Blood pressure> 130/85 mmHg
  4. Tobacco smoke
  5. Micro and macro albuminuria
  6. Hyperglycemia (HbA1c> 7.5 %) or glycemic instability
  7. Positive family history of cardio – vascular diseases.

Prevention And Treatment

Primary prevention

The interventions that constitute primary prevention are based on lifestyle modification. This lifestyle change concerns a public health problem whose solution cannot be entrusted exclusively to the health system, but requires the involvement of many other institutional subjects and civil society (ministries, municipalities, provinces, professional and trade associations, Consumer associations, food manufacturers, advertisers, mass media, etc.) as recommended by the European Union (EU) and the World Health Organization (WHO). Primary prevention therefore has the main objective of modifying potentially modifiable factors such as excess weight in a sedentary lifestyle and incorrect nutrition.

Excess weight

Primary prevention of diabetes is identified with the prevention of excess weight. It is possible to keep the obesity epidemic under control and reverse its trend through comprehensive actions, which intervene on the social, economic and environmental determinants of lifestyles. Overweight and obesity, especially if localized viscerally, represent the main risk factor for the development of type 2 diabetes. The pathogenetic link between excess body fat and diabetes is mainly represented by the situation of insulin resistance .

The randomized and controlled intervention studies mentioned above, conducted in subjects with impaired glucose tolerance and / or impaired fasting glycaemia from different countries (China, Norway, Finland and the United States), have clearly shown that weight loss, even if of moderate entity (7% of the initial weight), together with other interventions aimed at modifying the lifestyle, can induce a reduction of about 60% in the progression from impaired glucose tolerance to type 2 diabetes.

In the Finnish DPS study, it was also observed that there is a significant relationship between the extent of weight loss and improvement in insulin sensitivity. Therefore, on the basis of these evidences, the latest nutritional recommendations for the therapy and prevention of diabetes by the “Diabetes and Nutrition” Study Group of the European Association for the Study of Diabetes (EASD), translated into Italian and recently published in Il Diabete, the journal of the Italian Diabetes Society (SID ), establish the following with regard to this specific aspect:

  1. Avoiding overweight and regular physical activity are the most appropriate means to reduce the risk of developing type 2 diabetes;
  2. in overweight subjects, weight loss and maintenance of the achieved weight represent the central point of lifestyle modifications aimed at reducing the risk of onset of type 2 diabetes.

Both of these recommendations are grade A (high), that is, based on consistent scientific evidence from randomized and controlled intervention studies, and, therefore, must definitely be put into practice.

Nutrition and eating behavior

A correct diet, understood not as a restriction but as a balanced, healthy and preventive nutrition, which allows the individual a normal growth, a better control of both blood sugar and other metabolic – clinical parameters is essential for children and adolescents with diabetes, since The severity of the prognosis (eg obesity and late complications) is closely linked to a correct management, by the patients themselves and their families, of the lifestyle in general and of the diet in particular. Children and young people with diabetes have the same nutritional needs as other subjects of the same age; those receiving regular nutritional counseling have a diet closer to LARN (Recommended Nutrient Intake Levels) than controls and not several cardiovascular risk factors. The nutritional recommendations for a healthy lifestyle for the general population are also appropriate for young people with type 1 diabetes and therefore the family and the entire relational sphere can take advantage of lifelong nutritional education, which will favor normal social integration.

Nutritional educational objectives must be commensurate with the age of the patients through the use of different teaching methods. Recognition, prevention, treatment of hypoglycemic episodes and adaptation of the diet to physical – sporting activity are priority educational objectives.

Inadequate dietary prescriptions are co-responsible for the large increase in eating disorders

Therefore, in order to avoid negative repercussions, of an organic and psychological nature, induced by a restrictive or unbalanced diet, it is necessary to ensure: – auxological and nutritional status evaluation of young people with diabetes; – dietary interviews with patients and their families, with therapeutic education techniques, in order to increase and reinforce knowledge on the proper nutrition of the family, on the groundlessness of restrictive diets and on the opportunity of a healthy diet that includes the balanced intake of all nutritional principles, respecting, as far as possible, local traditions, the needs of the family and the lifestyle of the subject; – elaboration and proposal of correct dietary models and personalized behavioral strategies for preventive nutrition; – research and improvement of motivation for change; – elaboration of information / educational interventions on selected groups of the population.

Fig. 3
Physical activity and beneficial effects on cardiovascular risk in diabetes

Regular physical activity corrects some typical cardiovascular risk factors, such as hyperinsulinemia , hyperglycemia, hyperlipidemia , impaired blood clotting and hypertension.

A 2013 study examined the effects of physical activity on the increased cardiovascular risk that accompanies diabetic disease showing that even modest levels of physical activity can reduce, and even cancel, the additional negative impact of diabetic disease on the risk of death. for cardiovascular diseases.

The Norwegian study HUNT recruited 53,587 patients (25,159 men and 28,428 women) between 1995 and 1997, asking them to report information about physical activity practiced in their free time by completing a questionnaire.

In the questionnaire, patients had to report how much time per week they spent on activities defined as light, moderate or demanding, based on definitions contained in the questionnaire, such as the presence of tachypnea.

At the end of the follow – up, the causes of death of the deceased patients and the events occurred to the surviving patients were examined. The results confirm the increased risk of cardiovascular mortality in diabetic patients compared to the general population.

By selecting diabetic patients and comparing them with non-diabetic patients who had reported being inactive, the authors then examined the combined effects of physical activity and diabetes on the risk of death from cardiovascular disease.

Examining the results, it is observed that ever increasing levels of physical activity can progressively reduce the risk of death from cardiovascular disease in diabetics, bringing them to the same risk levels as in non-diabetic and inactive patients.

These results led the authors to the conclusion that even modest levels of physical activity can negate the influence that diabetic disease has on the risk of death from cardiovascular disease.

Clinical research over the past twenty years has shown that physical activity during pregnancy is safe and offers benefits to the maternal – fetal unit.

Historically this potential benefit has been ignored due to concern that physical activity could theoretically lead to an increase in insulin secretion, free fatty acids and ketones, along with a reduction in glucose levels.

As early as 1985, the American College of Obstetrician and Gynecologist (ACOG) began recommending moderate physical activity to pregnant women, although there was still little evidence of its benefits.

Following these initial recommendations, studies carried out over the past 20 years have allowed us to consider physical activity as safe and recommendable, due to its potential benefits both before and after childbirth.

Increasing physical activity is now recommended to improve glycemic control and keep body weight under control, as over 39% of pregnant women with GDM cannot maintain optimal glycemic levels with diet alone.

The ADA and ACOG urge women who have no medical or obstetric contraindications to start or continue a moderate exercise program as part of their GDM treatment.

These recommendations are also reinforced by the observation that more physically active women appear to have a lower incidence of GDM.

As mentioned above, over 39% of pregnant women with GDM fail to obtain and maintain optimal glucose levels, so physical activity plays a fundamental role.

Muscle contraction by itself promotes the entry of glucose into cells, so it can be defined as an excellent alternative to reduced insulin functioning.

Physical activity, therefore, can improve glucose tolerance by increasing insulin sensitivity thanks to the entry of glucose into the muscles and the synthesis of glycogen, so it is essential to accompany dietary and drug therapy with constant and moderate exercise.

Secondary prevention of diabetes

Secondary prevention is implemented when the disease is already in progress, even without having manifested itself with symptoms, therefore it consists in identifying with laboratory tests which subjects are already presenting alterations due to the pathology, and to apply a series of measures aimed at blocking or slowing down the evolution of the disease.

However, attention should be paid to the continuity of care connected to new care models, such as ” disease management”, “case management” and the ” chronic care model”, which, with a very general term, can be defined as “Integrated Management” “.

These approaches share the fact that they are systems that place an informed and educated patient at the center of the entire system to play an active and preventive role in the management of the pathology from which he is affected.

However, it is necessary to negotiate goals with the patient and it is necessary to think about an integrated care system.

Integrated management, in fact, through the construction of shared care pathways, currently stands as a prototype of an organizational model aimed at improving care and preventing complications.

  • LDL cholesterol <100 mg / dl
  • Triglycerides <150 mg / dl
  • HDL cholesterol> 40 mg dl

– non-drug therapy + optimization of glycemic compensation. – if the objectives are not achieved after 3 months, start specific drug therapy. – in patients with acute coronary syndrome it is advisable to start non-pharmacological and specific pharmacological therapy at the same time.

Pharmacological and non-pharmacological treatment

Pharmacological therapy includes a correct choice of drug and must take into account the individual characteristics of the patient such as age, level of comorbidity and the risk of hypoglycemia. In addition, it must be constantly re-evaluated to ensure that blood glucose levels are reached and maintained ( Handelsman et al., 2015).

Among the best known drugs, we find oral antidiabetics such as metformin , GLP – 1 – RA, tazones (TZD), alpha – glucosidase inhibitors, salfanuliree , colesevelam and bromocriptine (Faglia & Beck – Peccoz , 2006). Insulin represents the agent with the most hypoglycemic power, its use is vital in the treatment of type 1 diabetes and is often used as a reinforcement therapy for oral antidiabetic drugs in DM2, if the latter are no longer sufficient to guarantee levels of desired Hb1Ac.

The decision to integrate it into treatment depends on cardiovascular complications , age and general health and the risk of hypoglycemia ( Handelsman et al., 2015).

There are different types of insulin (Philippe et al., 2009): 1. Ultra-fast insulin: the effect lasts 3 – 4 hours and has an almost immediate action (5 – 10 minutes) with a maximum peak at 1 – 2 hours 2. Rapid insulin: the action begins after 15 – 30 minutes and has an effect of 5 – 8 hours 3. Intermediate or slow insulins: the effect occurs 2 – 4 hours after administration and has a variable duration from 10 – 16 hours. 4. Ultra-slow insulin : first effects after 4 – 6 hours. 5. Ultra-slow analogue insulin : the action begins within two hours of administration and lasts for 21 – 24 hours, with the property of not having a maximum peak.

Fig. 4

The non-pharmacological treatment of diabetes consists mainly in lifestyle changes concerning primary prevention such as that of carrying out a balanced diet involving the intake of vegetables, low glycemic index carbohydrates, limiting saturated fats and taking proteins from poor foods. of saturated fats such as fish, beans and egg white with the aim of achieving and maintaining an ideal weight.

Other non-drug treatments consist of physical activity, cessation of cigarette smoking and group behavioral support so that the testimonies and experiences of other patients could help the person’s lifestyle.

Nursing Role

The nurse as a key element of care

At the Centennial Conference of the International Council of Nurses, held in June 1999, Dr. Gro Harlem Brundtland , Director General of the World Health Organization, said: “Nurses, as primary health care workers, are in a position without equal in the fight for world health ”.

By now constituting as many as 80% of skilled health workers in most national health systems, nurses and midwives can be a powerful force in bringing about the changes needed to meet the need for Health for All in the 21st century.

Indeed, their professional contribution spans the entire spectrum of health care. It is clear that nurses are the backbone of most health care teams. The nurse should lead the patient to sustain a critical reflection so that he himself is aware and convinced of what foods to consume and those to avoid in case of DM2.

Through these reflections, the practitioner will be able to perceive how the patient thinks and how he makes decisions, using them as tools to support the client.

During the therapeutic education process, the ability to assimilate a multitude of information is required, ranging from blood glucose monitoring, knowledge of the pathology, various treatments, including dietary recommendations.

Assistance from a nurse trained in therapeutic education is often necessary, if not mandatory ( Grégoire & Philis , 2017).

Nurses constitute the largest group of professionals in the healthcare system who provide care for patients with DM2 throughout their lives and in different settings.

Nurses with a specialization in diabetes represent a category of nurses who are adequately trained and competent to support diabetic patients. Furthermore, they must continually update themselves – for example, on ADA standards and take into account the context in which they work ( Hamric , 2014).

The current and therapeutic teaching guidelines provided by the ADA on DM2 follow ten standards that constitute “diabetes self – management education ” (DSME) ( Funnell & Freehill , 2018):

  1. The diabetes self – management education (DSME) program is recognized as an integral part of managing the DM2 patient.
  2. The DSME is provided by multiple health professionals and by patients themselves.
  3. In the DSME, the determination of education needs is structured according to the diversity and individuality of patients in terms of needs and resources.
  4. The DMSE provider must plan, implement and evaluate therapeutic teaching according to these standards. Must have an academic level or equivalent professional experience in chronic disease management and therapeutic education.
  5. The DSME provider must be constantly updated and fully aware of their limitations in the field of therapeutic teaching.
  6. A systemic and scientifically based storyline should be used for each therapeutic teaching session, particularly for diabetes – describing the disease process of DM2 and treatment options. – Integrate a nutrition plan.
  7. Integrate a physical activity plan
  8. Medicines management
  9. Self – monitoring of blood glucose
  10. Prevent and treat acute complications
  11. Prevent and treat chronic complications
  12. Develop personal development strategies
  13. Develop health promotion and lifestyle change strategies.
  14. The DSME enters into a partnership between caregivers and clients, oral and written by mutual agreement.
  15. The DSME is structured according to a plan and organization discussed by the patient and the practitioner at the beginning of the teaching.
  16. DSME results are measured by the patient and caregiver during and at the end of each educational program.
  17. The effectiveness of the therapeutic program is measured at the end of the latter and opens the possibility of evaluating further paths of therapeutic education.
Administer and teach self-administration of insulin

The correct injection technique guarantees optimal insulin action and glycemic control.

A correct method of administration must take into account:

Injection site The insulin must be injected into the intact subcutaneous tissue, avoiding intramuscular injection, which does not guarantee correct absorption and functionality of the injected insulin, causing poorly manageable glycemic variability.

Hospital nursing staff must be trained in the correct injection technique with insulin pen and syringe and the latest evidence.

Furthermore, injection into the subcutaneous tissue is less painful than into the dermis or muscle.

Intradermal injection is often associated with accelerated insulin absorption and the risk of reflux or allergic reactions is high.

Intramuscular injection (IM) is often painful, can cause hematomas, carries the risk of too rapid insulin absorption, which results in high variability in blood glucose values and a potential increased risk of hypoglycemia.

The recommended sites for insulin injection are the abdomen, thighs and buttocks.

About a third of patients use the upper arm at least once a day, making it the most convenient site to go to for injecting insulin in public.

Until recently, it was believed that the fatty tissue layer in the arm was relatively thin, and healthcare professionals recommended injecting insulin into the arm with the pinch technique only – almost impossible to do with one hand.

Contrary to what has been recommended up to now, the best site to inject insulin is immediately below the greater trochanter.

The fastest absorption occurs in the abdominal area, a little less rapidly in the arms, more slowly in the legs and even more slowly in the buttocks.

It is generally recommended that fast-acting insulin be given to the abdominal area or thighs and slow-acting insulin to the buttocks where absorption is slower.

The problem with the injection in the buttocks is that it is a difficult area to reach and the tendency is to always inject insulin in the same place.

Healthcare professionals should encourage patients to use the entire abdominal wall above and below the waist instead of always injecting insulin into a small area below the navel, which often appears to be the case.

This means that the patient repeatedly injects insulin into the same spot causing lipodystrophy to form .

In pediatric age, the use of the abdomen for the injection of rapid insulin or the rapid analogue is preferred, in order to avoid a too fast entry into the circulation with the risk of unexpected hypoglycemia if the insulin is injected into subjected areas. movement (legs and arms).

Injection technique

It has been proven that for the achievement of good glycemic control in insulin – treated patients, not only the type and dose of insulin chosen are fundamental but also the correct technique of administering the drug, which together represent the patient’s age and body mass. index (BMI), the most important variables that can affect the pharmacokinetics and pharmacodynamics of insulin. Although it is now known how essential a correct injection technique is, specific educational paths are rarely planned and even less frequently the choice of needle length is made on the basis of the patient’s subcutaneous thickness.

The new recommendations published in 2014 take into consideration the 10 points considered of fundamental importance to obtain a correct injection technique:

  1. role of health professionals;
  2. psychological aspect relating to injections;
  3. drug injection sites;
  4. absorption of the drug;
  5. preparation of the injection;
  6. patient safety;
  7. injection devices: pens, pen needles and syringes;
  8. choice of needle length;
  9. injection technique;
  10. lipohypertrophy and other complications related to the injection. – Needle selection The needle of choice for the insulin pen is the universal needle related to iso standards (4 – 5 mm), which guarantees safety and ease of injection.

Hospitalized patients who are already autonomous in the management of their disease should be allowed to continue self-management even during hospitalization, agreeing on the modalities with the care team.

If the patient is newly diagnosed or not autonomous, the insulin pen should be made available within the wards to allow the patient to learn or verify the technique by the hospital staff.

If the patient is newly diagnosed or not autonomous, the insulin pen should be made available within the wards to allow the patient to learn or verify the technique by the hospital staff.

It is not recommended to aspirate insulin with syringes from pen cartridges or pre – filled pens, both for the damage that is produced on the needle that is leaking the tip and the initial lubrication, and for the risk of contamination of the insulin itself: furthermore, it is useful to remember the higher cost of these compared to the bottle. The length of the needle is an individual decision made by the patient together with the healthcare professional and based on several factors: physical, pharmacological and psychological.

Choosing an appropriate needle in terms of length ensures a comfortable and safe injection. There are different needle lengths on the market.

Depending on the needle used, it is necessary to adapt the injection technique in order to avoid intramuscular injections.

In the 4 sites commonly used for insulin injection it is about 2 mm, while the subcutaneous varies in relation to sex, age, BMI. 4 and 5 mm needles can be inserted into the skin at 90 °; for needles of 6 mm or longer the injections should be made using the skin fold or at a 45 ° angle (pinch technique).

In the limbs and lean abdomen, to avoid the risk of IM injections, a 45 ° angle or fold is recommended.

Once the insulin administration is finished and before the needle is removed, the patient should slowly count to at least 10 to avoid incomplete administration.

Fig. 5
Nursing treatment when cardiovascular risk is added

“Put prevention in your daily practice “is one of the objectives to be pursued to obtain the reduction of mortality and morbidity for cardiovascular diseases.

The low incisiveness of secondary prevention interventions is documented by the data of the EUROASPIRE study conducted in 10 European countries on patients after a myocardial infarction, which highlighted the high percentage of persistence of risk factors months after the coronary event.

On the other hand, the data of the same study show that in Italy only 17% of patients after an acute myocardial infarction (AMI) are initiated into a structured program of secondary prevention, such as cardiological rehabilitation, whose results in terms of mortality , morbidity and improvement in the quality of life are now well established.

the lack of a multidisciplinary approach to a complex, multifactorial pathology, such as cardiovascular, where only a team work involving several health professionals and in particular the cardiologist, the professional nurse, the rehabilitation therapist, the dietician and the psychologist can achieve positive results. In fact, to optimize secondary prevention interventions it is necessary to organize an all-encompassing path, tailor-made for the individual patient, which starts in the immediately post – acute phase of the disease and which includes:

  • careful prognostic stratification in order to identify patients at greatest risk;
  • optimization of therapy to use the recommended drugs at the maximum tolerated doses;
  • correction of risk factors to avoid or slow down the progression of the disease; • direct action on endothelial function, also using non-pharmacological strategies such as physical training;
  • an intervention on the psychological profile of the patient, structured or not according to the severity.

In the context of the various competences, a role of primary importance is that played by professionals in the nursing area.

Carinex study Survey analyzed which professional figures are most frequently involved in secondary prevention programs within rehabilitation cardiology structures.

In the course of their daily practice, nurses, rehabilitation therapists, cardiology technicians, can come into contact with a large number of people and become promoters of “health messages”.

The nurses who work in the hospital, then, assisting patients throughout the hospital stay, from admission to discharge, actively contribute to the prevention programs constituting a fundamental link in the continuity of care.

The nurse collaborates with the doctor to carry out instrumental investigations that allow to define the risk profile of each patient.

Risk stratification is one of the central moments of any prevention strategy. The scarcity of resources makes it essential to concentrate interventions where the cost – benefit ratio is greater.

In primary prevention it is sufficient to know the risk factors to define the profile of each subject.

Nursing Counseling as a “health educator”

Counseling , a tool for health education, can be defined as “a voluntary and conscious intervention of the health and social staff in the patient ‘s decision-making processes to achieve a shared goal of improving the state of health”.

The counseling , born as a modality of psychological help developed starting from the 30s, by Rollo May and Carl Rogers , defines a consultation (in practice one or more in-depth individual interviews) conducted by a professional who is attentive to the relationship, and has a non-directive approach.

The influence of the non-directive approach has subsequently led many professionals who operate in the health and social fields and who can establish meaningful personal relationships with their users / patients to develop a less prescriptive professional practice, more attentive to listening and relating , and more respectful of the needs of the user / patient, even without practicing psychological counseling proper.

It is therefore necessary to distinguish between counseling as a therapeutic practice (psychological competence) and counseling skills , required of every operator engaged in health and social activities. According to the patient-centered approach, the best way to come to the aid of a person in difficulty is not to tell them what to do but to help them understand their current situation and manage the problem.

The aim therefore is to help the person to mobilize their personal resources in dealing with the problem that is brought within the counseling relationship .

The general goals of counseling are
  • provide support in times of crisis;
  • help the patient to find information about the disease, to assimilate it and to act accordingly;
  • encourage the patient to make lifestyle changes if necessary;
  • develop self-determination in the patient and the ability to make autonomous choices;
  • help the patient to anticipate, prevent or prevent the establishment of highly critical situations.

Health education also means providing correct information on the therapies administered.

Drugs to be taken for cardiovascular disease are usually prescribed for long periods or, in some cases, for life, and their effectiveness depends on the degree of compliance of the patients.

Often the technical and nursing staff are the first to be consulted by patients about the therapies to be taken and any side effects complained of.

It is evident that inadequate information on the purposes of the therapy, on its modalities of assumption, on the side effects determined by it frequently leads to the suspension of the therapy, with conceivable consequences. The patient education process for therapies must include information on:

  • the aims of the therapies undertaken;
  • the expected duration of therapy;
  • the need for periodic clinical and laboratory checks (for example haemostasis for patients on anticoagulant therapy);
  • the possibility of pharmacological interference, suggesting that you contact your doctor if you need to take other drugs (for example antibiotics, antipyretics or other);
  • the danger of spontaneous dose variations;
  • the need to take the drug at the prescribed times;
  • the most frequent side effects induced by the drug, clarifying their meaning, the absolute harmlessness of some of them and the potential danger of others which require the need to contact the treating physician quickly;
  • the increased risk of cardiovascular disease in women taking oral contraceptive therapies, especially when other risk factors, such as smoking and hypertension, are present.

Likewise, it is essential to inform the patient about the various diagnostic tests to which he will have to undergo, about the relative execution techniques, about the duration and the risk connected to them, about any preparatory measures, such as fasting, carrying out investigations. foreplay, etc.


The diabetic patient is certainly a patient at increased cardiovascular risk compared to the non-diabetic patient.

It is necessary to focus attention on an intervention that can direct the subject to an awareness of his own pathology and to a greater management of the same.

The strongest and most shared indication of the most recent guidelines – guidelines and consensus documents on the management of diabetic disease therefore provides for the ever-vigilant attention to the implementation of a correct lifestyle and the need for a personalization of therapy, with adaptation pharmacological and non-pharmacological prescriptions to the metabolic and clinical profile of the individual patient.

Based on the results listed above, education in lifestyle modification for the diabetic patient plays a fundamental role in the prevention of cardiovascular complications.

Consequently, the nursing teaching methodology should not be underestimated as the latter has the task of managing, supporting and motivating the patient in order to feel himself the main actor of his health path.

In order to plan adequate clinical – educational interventions related to diabetes, three fundamental aspects should be developed in particular: – the attitude of health professionals in dealing with chronic diseases, such as diabetes; – the patient’s involvement in continuous cooperation with the operator, in order to solve the motivational problem; – the development of suitable learning procedures that help the subject to self-manage with the necessary skills.


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Trimethylsulfonium: a promising new biomarker for hydrogen sulfide?


Submission Date: 2022-06-22
Review Date: 2022-07-06
Pubblication Date: 2022-07-20

Hydrogen sulfide as a naturally produced signaling molecule

Hydrogen sulfide is notoriously known as a toxic gas. However, it is known to be produced endogenously in human tissues from the amino acid cysteine by various enzymatic activities (1). The importance of endogenously produced hydrogen sulfide has been increasingly recognized and it has been established as the third gaseous signal transmitting molecule along with nitric oxide and carbon monoxide, which plays important roles in the central nervous system, cardiovascular function, and aging (2). Tissue hydrogen sulfide is produced at a high rate of 30-600 µmol h-1 Kg-1 (3), which can cause the buildup of lethal levels, and therefore hydrogen sulfide is rapidly oxidized to thiosulfate (5), which keeps tissue hydrogen sulfide levels in the low nanomolar range (e.g. 17±2.6 nM in rat tissues, 14±3.0 nM in rat brain) (4). The regulation of hydrogen sulfide and its metabolic pathways remain however largely unknown. Given the multiple health effects that can be mediated by hydrogen sulfide and the difficulty of directly studying this compound in human samples due to its high volatility, there is a need for new biomarkers that are stable, easily analyzed, and indicative of the hydrogen sulfide body pools.

Fig. 1

Thiosulfate: the currently employed biomarker for hydrogen sulfide

As an enzymatic oxidation product, thiosulfate in blood and urine has been used as an indicator of acute hydrogen sulfide poisoning (6). However attempts to use urinary thiosulfate in human clinical studies as an indicator of the endogenously produced hydrogen sulfide have not found success (7). The failure of urinary thiosulfate as a clinical biomarker for endogenous hydrogen sulfide may not be surprising. The highest enzymatic activity of the key enzyme for thiosulfate production, namely thiosulfate sulfur transferase (rhodanese), is found in the colonic mucosa relative to other tissues (8, 9), where there is also a very high production rate of exogenous hydrogen sulfide by the sulfate-reducing bacteria in the gut (8, 10). Accordingly, it can be argued that urinary thiosulfate would heavily reflect this bacterial exogenous source of hydrogen sulfide, and therefore decrease the sensitivity of this biomarker to endogenously produced hydrogen sulfide produced in various organs and tissues.

Trimethylsulfonium production in humans

It follows that a metabolite that shows less dependency on the bacterial source of hydrogen sulfide may offer significant advantages in terms of reflecting the endogenously produced hydrogen sulfide. In our recent work, we identified for the first time the existence of the methylated metabolite trimethylsulfonium (TMS) in human urine (11). TMS is known to be produced by the enzyme thioether S-methyltransferase from dimethylsulfide (12, 13). Dimethylsulfide can be produced from successive methylation of hydrogen sulfide (14). Therefore, it is plausible to hypothesize that TMS can be a simple methylation biomarker of hydrogen sulfide. Unlike the enzyme that produces thiosulfate (rhodanese), the tissue expression profile of the enzyme that produces TMS (the thioether S-methyltransferase) indicates very low activity in the colonic mucosa relative to other tissues (9). Therefore, TMS production would be expected to show much less dependency on the large bacterial source of hydrogen sulfide in the colon in contrast with thiosulfate. Indeed, the urinary levels of TMS that we found in a group of human volunteers (median concentration 34 nM, range 2.7-505 nM) (11) are on average about 100-1000 times lower than the urinary levels of thiosulfate commonly reported (6.2-61 µM) (15), and are therefore noted to be closer to and likely more representative of the nanomolar levels of tissue hydrogen sulfide concentrations previously reported (4). These observations may imply a promising role for this new metabolite in humans as a new biomarker for endogenous tissue hydrogen sulfide. Furthermore, the expression of the thioether S-methyltransferase enzyme that produces TMS is highest in the lungs (9), which suggests this enzyme evolved in mammals as a defense mechanism against volatile toxic sulfur compounds.

Human exposure to hydrogen sulfide in air

The employment of the currently used biomarker of hydrogen sulfide, thiosulfate, under conditions of low exposure level to hydrogen sulfide was reported to show only small and inconsistent increase in the human volunteers (16). There is therefore a need for a new more sensitive biomarker for hydrogen sulfide at low levels of exposure and the significance of finding sensitive biomarkers for monitoring low sub-toxic and chronic exposure to hydrogen sulfide is highlighted by the increasing role of geothermal plants as an alternative source of energy (17) and the fact that there are numerous reports about high hydrogen sulfide concentrations in ambient air of heavily populated regions worldwide. The most commonly known example is the city of Rotorua in New Zealand, with a population of roughly 77,000, where geothermal activity leads to markedly elevated hydrogen sulfide levels in air that are consistently above characteristic odor threshold (>0.001 ppm). with levels exceeding 0.05 ppm in the mid-winter months (18). The village of Larderello in the Tuscany region in Italy, with a population of about 400 people, contains multiple geothermal power plants, contributing up to about 10% of the total world’s entire supply of geothermal electricity with an output of 4,800 GWh/year. In this village, remarkably high concentrations of hydrogen sulfide within the range of 0.7-13 ppm were detected (19, 20). High concentrations of hydrogen sulfide in ambient air was also detected in Pozzuoli village in Italy with a population of about 82,000, particularly in residences around the Volcano Solfatara region (21).

In the city of Thessaloniki, Greece, with a population of about 1 million mean hydrogen sulfide up to 0.02 ppm were reported on a daily basis  in winter, and it was reported that traffic emission is a major source of the observed elevated hydrogen sulfide concentrations (22). Furthermore, a major contributor to anthropogenic hydrogen sulfide emission is the paper and pulp industry. For example, in close proximity to a pulp-mill in California, hydrogen sulfide concentrations peaked at around 0.15 ppmwhereas the average monthly concentrations of hydrogen sulfide in a Finnish town close to a pulp-mill were reported at up to 0.1 ppm(18).

The variability in the human urinary excretion of trimethylsulfonium

It is noteworthy that the interpretation of trimethylsulfonium levels in humans must be approached with care. Following our recent identification of TMS as a natural metabolite in human urine (11), we performed a small study employing a total of 50 volunteers and we found a clear association between the urinary excretion of TMS and the urinary excretion of its selenium analogue trimethylselenonium (TMSe) (18). Our results indicated significant inter-individual variability in the production of TMS.  Trimethylsulfonium  and TMSe are known to be produced by the same enzyme thioether S-methyltransferase (12), which is encoded by the INMT gene, and this gene has been found to be genetically polymorphic, with a strong impact reported on TMSe production (23, 24). It is therefore likely that the genetic polymorphisms in the INMT gene can impact the production of TMS and result in significant inter-individual variability.

Concluding remarks

Trimethylsulfonium appears to be a simple methylated product of hydrogen sulfide and may serve as a biomarker for endogenous and exogenous (i.e. inhaled) sources of this gas. However, plenty of research is needed to investigate the origin and etiology of the production of this metabolite in humans, as well as the applicability of this compound under various conditions in humans populations. We are currently investigating these aspects and future work will shed light on the significance of this human urinary metabolite.


  1. Kabil O & Banerjee R (2014) Enzymology of H2S biogenesis, decay and signaling. Antioxid Redox Signal 20(5):770-782.
  2. Kabil O, Vitvitsky V, & Banerjee R (2014) Sulfur as a signaling nutrient through hydrogen sulfide. Annu Rev Nutr 34:171-205.
  3. Vitvitsky V, Kabil O, & Banerjee R (2012) High turnover rates for hydrogen sulfide allow for rapid regulation of its tissue concentrations. Antioxid Redox Signal 17(1):22-31.
  4. Furne J, Saeed A, & Levitt MD (2008) Whole tissue hydrogen sulfide concentrations are orders of magnitude lower than presently accepted values. American Journal of Physiology-Regulatory, Integrative and Comparative Physiology 295(5):R1479-R1485.
  5. Hildebrandt TM & Grieshaber MK (2008) Three enzymatic activities catalyze the oxidation of sulfide to thiosulfate in mammalian and invertebrate mitochondria. FEBS J 275(13):3352-3361.
  6. Kage S, Takekawa K, Kurosaki K, Imamura T, & Kudo K (1997) The usefulness of thiosulfate as an indicator of hydrogen sulfide poisoning: three cases. International journal of legal medicine 110(4):220-222.
  7. Stephan C, Wilkosz J, Różański W, Ecke TH, Lein M, Bryś M, Krześlak A, Chwatko G, & Jung K (2015) Urinary thiosulfate as failed prostate cancer biomarker–an exemplary multicenter re-evaluation study. Clinical Chemistry and Laboratory Medicine (CCLM) 53(3):477-483.
  8. Furne J, Springfield J, Koenig T, DeMaster E, & Levitt MD (2001) Oxidation of hydrogen sulfide and methanethiol to thiosulfate by rat tissues: a specialized function of the colonic mucosa. Biochem Pharmacol 62(2):255-259.
  9. Uhlen M, Fagerberg L, Hallstrom BM, Lindskog C, Oksvold P, Mardinoglu A, Sivertsson A, Kampf C, Sjostedt E, Asplund A, Olsson I, Edlund K, Lundberg E, Navani S, Szigyarto CA, Odeberg J, Djureinovic D, Takanen JO, Hober S, Alm T, et al. (2015) Proteomics. Tissue-based map of the human proteome. Science 347(6220):1260419.
  10. Gibson GR, Macfarlane GT, & Cummings JH (1993) Sulphate reducing bacteria and hydrogen metabolism in the human large intestine. Gut 34(4):437-439.
  11. Lajin B & Francesconi KA (2016) The hydrogen sulfide metabolite trimethylsulfonium is found in human urine. Scientific reports 6.
  12. Mozier NM, McConnell KP, & Hoffman JL (1988) S-adenosyl-L-methionine:thioether S-methyltransferase, a new enzyme in sulfur and selenium metabolism. J Biol Chem 263(10):4527-4531.
  13. Mozier N & Hoffman JL (1990) Biosynthesis and urinary excretion of methyl sulfonium derivatives of the sulfur mustard analog, 2-chloroethyl ethyl sulfide, and other thioethers. The FASEB Journal 4(15):3329-3333.
  14. Weisiger RA, Pinkus LM, & Jakoby WB (1980) Thiol S-methyltransferase: suggested role in detoxication of intestinal hydrogen sulfide. Biochem Pharmacol 29(20):2885-2887.
  15. Chwatko G & Bald E (2009) Determination of thiosulfate in human urine by high performance liquid chromatography. Talanta 79(2):229-234.
  16. Durand M & Weinstein P (2007) Thiosulfate in human urine following minor exposure to hydrogen sulfide: implications for forensic analysis of poisoning. Forensic Toxicology 25(2):92-95.
  17. Fridleifsson IB (2003) Status of geothermal energy amongst the world’s energy sources. Geothermics 32(4):379-388.
  18. Chou, C. H., & World Health Organization. (2003). Hydrogen sulfide: human health aspects. World  Health Organization.
  19. Somma R, Granieri D, Troise C, Terranova C, De Natale G, & Pedone M (2017) Modelling of hydrogen sulfide dispersion from the geothermal power plants of Tuscany (Italy). Science of The Total Environment 583:408-420.
  20. Daniela Nuvolone, Davide Petri, Pasquale Pepe, Fabio Voller, Health effects associated with chronic exposure to low-level hydrogen sulfide from geothermoelectric power plants. A residential cohort study in the geothermal area of Mt. Amiata in Tuscany, Science of The Total Environment, Volume 659, 2019, Pages 973-982, ISSN 0048-9697, https://doi.org/10.1016/j.scitotenv.2018.12.363.
  21. Fedele, A., Pedone, M., Moretti, R., Wiersberg, T., Somma, R., Troise, C., & De Natale, G. (2017). Real-time quadrupole mass spectrometry of hydrothermal gases from the unstable Pisciarelli fumaroles (Campi Flegrei): Trends, challenges and processes. International Journal of Mass Spectrometry, 415, 44-54.
  22. Kourtidis, K., Kelesis, A., & Petrakakis, M. (2008). Hydrogen sulfide (H2S) in urban ambient air. Atmospheric Environment, 42(32), 7476-7482.
  23. Lajin B & Francesconi KA (2016) The Association between the Urinary Excretion of Trimethylselenonium and Trimethylsulfonium in Humans. PloS one 11(11):e0167013.
  24. Kuehnelt D, Engström K, Skröder H, Kokarnig S, Schlebusch C, Kippler M, Alhamdow A, Nermell B, Francesconi K, & Broberg K (2015) Selenium metabolism to the trimethylselenonium ion (TMSe) varies markedly because of polymorphisms in the indolethylamine N-methyltransferase gene. The American journal of clinical nutrition 102(6):1406-1415.

Nursing Assistance To The Patient With Acute Myocardial Infarction; Nursing Implications

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Submission Date: 2022-06-08
Review Date: 2022-06-17
Pubblication Date: 2022-06-23



In this treatise we intend to deepen the theme of Acute Myocardial Infarction (AMI), one of its main risk factors at the cardiovascular level, namely smoking, and in particular, deepen the role of the nurse in patient education. after the ischemic event and implement strategies aimed at smoking cessation.
If we look at the data from the World Health Organization (WHO), it is striking that the main cause of mortality in the modern world is heart ischemia which alone causes 7 million and 400 thousand deaths; while in second place we find stroke and cerebral vasculopathies with 6 million and 700 thousand deaths (Cesta 2014).
Having established that tobacco plays a primary role in our society and that its active or passive use has a negative impact on the health of the individual (WHO 2014), we will first briefly mention the anatomy and physiology of the cardiovascular system, then we will discuss the implications between heart and smoking and, in particular, between heart attack and smoking, trying to understand - through authoritative sources such as the WHO and databases - where the roots of such a widespread habit lie and its impact on the system cardiovascular.
Later we will address the educational issue of secondary prevention, we will examine the strategies implemented for smoking cessation. By dealing directly with patients, acquaintances and friends we realized how, despite the widespread information on the dangers of smoking, several people, even knowing the possible consequences, not only do not try to quit smoking, but almost underestimate the damage that can be caused by this “dangerous” habit of theirs is paradoxical. We believe that the role of the nurse in the post-heart attack moment is of extreme importance not only to provide specific direct assistance, also because that relationship of trust is created and to make him understand the risks to the patient in case he decides to continue smoking, but also because a correct education and the use of some strategies, personalized to each patient, to quit smoking, are essential in reducing the risk of a relapse.
The choice of the topic dealt with in this work was dictated by a strong SOCIAL motivation.
Although I am a smoker, noting the importance and the close relationship between health and a habit such as smoking, I have always been interested in being able to deepen my knowledge on the effects of the cardiovascular system and the problems that orbit around it. We still believe that an in-depth study on an issue so debated today and which will still be discussed for a long time can give the opportunity to approach smoking patients in a more conscious, personalized and adequate way and thus making treatment a better means. comprehensive within the health sector.
We believe that this work can enhance our personal and professional background, allowing us in the near future to prevent, identify and deal more effectively with clinical problems involving both doctors and nurses. Finally, the hope is to acquire greater critical capacity in problematic cardiological situations and to have a greater capacity for acceptance and respect for the patient's will.
This work aims to highlight and deepen the cardiovascular problems secondary to the phenomenon of smoking, implementing a therapy for smoking cessation.
The methodology is based on articles researched from databases, on journals specialized in cardiology and on textbooks.
From the observed articles it emerged that the nurse must use a multisystemic , multifaceted and multidisciplinary approach that includes different roles, namely: member of a working group, role of health promoter, role of teacher and communicator, of educator and expert in nursing care , and taking a look at post-ischemic nursing care.
In this treatise we intend to deepen the issue of Acute Myocardial Infarction (AMI), one of its main cardiovascular risk factors, namely smoking, and in particular, deepen the role of the nurse in patient education after the ischemic event and in implementing strategies aimed at smoking cessation. If we look at the data from the World Health Organization (WHO), it is striking that the main cause of mortality in the modern world is heart ischemia which alone causes 7 million and 400 thousand deaths; while in second place we find stroke and cerebral vasculopathies with 6 million and 700 thousand deaths (Cesta 2014).
Having established that tobacco plays a primary role in our society and that its active or passive use has a negative impact on the health of the individual (WHO 2014), we will first briefly mention the anatomy and physiology of the cardiovascular system, then we will discuss the implications between heart and smoking and, in particular, between heart attack and smoking, trying to understand
- through authoritative sources such as the WHO and databases
- where the roots of a widespread habit and its impact on the cardiovascular system lie. Later I will address the educational issue of secondary prevention, I will examine the strategies implemented for smoking cessation.
By dealing directly with patients, acquaintances and friends we realized how, despite the information seems to be more than abundant on the dangers of smoking, several people, even knowing the possible consequences, not only do not try to quit smoking, but underestimate in the damage that can be caused by this “dangerous” habit of theirs is almost paradoxical.
We believe that the role of the nurse in the post-heart attack moment is of extreme importance not only to make the patient aware of the risks in case he decides to continue smoking, but also because proper education and the use of some strategies, customized to each patient, to quit smoking, are essential in reducing the risk of a relapse.

Cardiocirculatory System

Anatomy of the cardiovascular system

It consists of a series of tubular-shaped hollow structures (the vessels), within which a defined quantity of fluid flows which is pushed by the heart.

There is a blood circulatory system and a lymphatic circulatory system:

  1. the first is characterized by the heart and the presence of a series of vessels within which blood flows, that is, arteries, capillaries and veins;
  2. the second is characterized by a series of lymphatic vessels and lymphoid organs that transport the lymph, ie a certain quantity of liquid that cannot be recovered once the exchange of substances from the bloodstream has taken place;
  3. through the lymphatic vessels this fluid enters the lymphoid organs (spleen, thymus and lymph nodes) and then returns to the bloodstream.
  4. Vessels originate from the heart, which lead towards the periphery, which take the name of arteries, while the vessels that return from the periphery to the heart are called veins. Arteries peripherally divide into multiple vessels and reduce in size to facilitate blood diffusion.

The branched veins become fewer and larger until they reach the heart to carry all the waste substances.

The heart is contained within the thoracic cavity, which starts from the spinous process of the seventh cervical vertebra and reaches the lower edge of the costal arch.

What divides the thoracic cavity from the abdominal area is the diaphragm; the heart occupies the central region of the thoracic cavity and is located in the lower and anterior part.

Specifically within the thoracic cavity there are three spaces: two very large spaces that are occupied by the lungs and pleurae (pleuropulmonary spaces), and a central median space called the mediastinum, where there are a series of splanchnic organs including the heart, which occupies the front and bottom.

The heart is in direct contact with the posterior wall of the rib cage, rests at the level of the diaphragm muscle and is surrounded by a white structure.

The heart has a frontal and two-dimensional triangular shape, with a pointed part that looks down towards the left, a flatter part facing upwards and to the right.

The whitish structure surrounding the heart is the pericardium, a kind of sac that has an externally very strong fibrous wall (fibrous pericardium) and an internal serous (serous pericardium). The outermost part through ligament structures is connected to muscular (inferiorly) or bony (anteriorly) components anchoring the heart in one position and preventing it from moving during the movements of the body.

The serous component consists of a visceral sheet, which adheres intimately to the heart, called the epicardium, and a parietal sheet, which lines the inner wall of the fibrous pericardium. The serous pericardium is constantly lubricated allowing the sliding of the heart inside the pericardium and therefore an adequate contractile activity.

Fig. 1
Anatomy of the heart

Two faces can be recognized in the heart: an anterior face, called sternocostal , due to the close relationships it contracts with the sternum and the median part of the ribs, and a postero-inferior or diaphragmatic face, which rests on the diaphragm muscle.

The three-dimensional heart has a shape similar to a slightly flattened cone at the front; we recognize two margins, a left margin of obtuse shape and a right margin of acute shape, a base (above) and an apex (below), between which an axis is drawn, called the anatomical axis of the heart, to study it.

Both the anterior and posterior faces have sulci: there is a transversal groove, called the coronary sulcus, since it surrounds the heart as a sort of crown, both on the anterior and posterior faces;

two other sulci that run perpendicular to the coronary sulcus and that lead towards the coronary sulcus both on the anterior and posterior faces towards the apex, i.e. the interventricular sulci (because they are near the ventricles).

The septum that internally divides the two ventricles is instead called anterior interventricular sulcus and posterior interventricular sulcus (based on the face where it is located).

At the level of the base of the heart, on the anterior face there is the presence of large vessels which correspond, from right to left, to the superior vena cava, to the origin of the aorta artery and to the origin of the pulmonary artery.

On the posterior side we recognize the same structures plus others, from the right: the outlet of the superior vena cava, the aorta, the pulmonary artery, which divides into two branches to reach the lungs, then the outlet of the inferior vena cava and the presence of pulmonary veins that carry blood from the lung to the left atrium.

As regards the anterior and posterior aspect of the ventricular region, there is the presence of vascular structures that run inside the adipose tissue along the interventricular sulcus and along the coronary sulcus.

These structures are the arterial branches and the venous branches that lead to supply the heart; then there are two coronary arteries, right coronary artery and left coronary artery, they supply the heart muscle and originate from the aorta artery: the right coronary artery enters the coronary sulcus, moves to the right, reaches the right (acute) margin , ad reaches the meeting point of the posterior interventricular sulcus, where it bends into a U and forms the posterior interventricular branch; during this path the right coronary artery gives branches for the right atrial region and for the right ventricular region, from an important marginal branch on the acute margin and continues to give branches for the right latero-posterior part.

The left coronary artery also originates from the aorta, and runs behind the aortic trunk; it then exits laterally to the pulmonary arterial trunk, where it divides into two branches: one that runs along the anterior interventricular sulcus, and a circumflex branch that arises inside the coronary sulcus, reaching the point where the coronary sulcus meets the interventricular sulcus rear.

These arteries are terminal arteries: they do not exchange blood between them, this means that the collaterals that will supply the individual portions of the heart muscle will be the only ones to bring nourishment to that area of the heart muscle.

Internally the heart has atrial and ventricular cavities;

they are divided right atrium, left atrium, right ventricle, left ventricle, and 8 have a particular relationship between them:

the right atrium communicates with the right ventricle through the right atrio-ventricular ostium, the left atrium communicates with the left ventricle with the left atrio-ventricular ostium;

the two ventricles are separated by septa, which prevent the passage of blood from the right half to the left half.

The heart has muscular walls of different diameters: in the right ventricle the muscular wall is thin, in the left ventricle it is thicker, as is the septum that divides the ventricles; the reason for the difference in muscle diameter is due to the two different circulations (large and small), i.e. from the left half (the thicker one) the large circulation (or systemic circulation) will start, so the blood will be pushed away from the heart and from the right half (thin) will start the small circulation (or pulmonary circulation), in which the blood is pushed to the area near the lungs. The atria have a smooth wall, with the exception of the two offshoots leading towards the front which are called auricles; they have small muscle regions that tend to propagate inwards, forming the combed muscles.

The musculature of the ventricles gives rise to reliefs with a very different morphology from that of the atria; the reliefs give life to the flesh trabeculae which can be classified into three categories: type I flesh trabeculae, or papillary trabeculae, which are represented by the introflexions inside the ventricular cavity of the musculature, which has a base adhering to the wall and an apex that leads inside the ventricular cavity;

type II carneal trabecula, which forms a sort of bridge, with two points anchored to the wall itself; flesh trabeculae of type III, some simple reliefs.

The papillary muscles are the most interesting, since from the apex of these muscles some tendon-like structures in the shape of a cord, called tendon cords, come off and reach the two atrioventricular valves.

The atrioventricular valves are the valve systems that modulate the passage from the atrial cavity to the ventricular cavity.

These have a different characteristic between the right and left halves: in the right half there is the presence of three triangular cusps (therefore it is called tricuspid), in the left half there is the presence of two cusps (called mitral or bicuspid).

These regulate the passage of blood and open when blood is pushed from the atrial to the ventricular cavity; once the blood has arrived in the ventricle, the contraction of the ventricle begins and these valves close without being able to tip over so that the blood does not come back.

This is due to the presence of tendon cords that pull the cusps downwards. Blood from the ventricular cavity is then pushed into the large arteries originating from the right and left ventricles.

There are other valves also between the ventricles and the large arteries: these valves, called semilunar, when the blood is pushed inside the vessel, squeeze and allow the outflow of blood inside the vessel.

Once the ventricular contraction is over, the blood would tend to go back, but the blood meets the lower part of the semilunar valves which is pocket-shaped, making the cusps of the semilunar valves come into contact with each other, blocking the reflux of blood to the interior of the ventricular cavity.

The valve-type structures are anchored to an intermediate zone between the atrium and the ventricle, where the atrioventricular ostia and the arterial-type ostia are anchored; this structure, of a connective type, also constitutes a sort of central skeleton to which the heart muscles can adhere and therefore allow a correct distribution of the fibers which, thanks to their arrangement, will ensure adequate contraction for the function that the heart performs. blood vessels are divided into arteries (blood to the periphery), veins (blood to the heart) and capillaries (nutritional exchanges).

The vessels are structured in internal or intimate cassock, medium cassock, and external or adventitious cassock.

Thanks to the diameter, the arteries are divided into: large caliber arteries, with a diameter that reaches 6 mm, medium caliber, when the diameter reaches 0.1 mm, and small caliber, when the diameter reaches about 20 microns.

Large caliber arteries are elastic arteries, because they contain a considerable amount of elastic tissue, while medium and small caliber arteries have non-elastic tissue; this means that the great artery is capable of, through an expansion generated by the strong pressure it undergoes, to receive the blood which is pushed into the first part; this elasticity of the great arteries is also important because when the ventricular thrust ends, thanks to the closure of the valves, it allows the blood to be pushed.

In the arteries of medium and small caliber it is instead necessary to control through the smooth muscle, located at the level of the middle layer of these arteries according to the needs of the organism. Veins can also be classified into small, medium and large caliber veins. The only structural difference that is found with respect to the arteries is that the veins of the lower part of the body have semilunar shaped valve systems similar to those located at the origins of the large arteries. The main arteries are the pulmonary artery and the aorta.

The aorta is the most important artery and can be divided into several portions: the first originates from the left ventricle and moves upwards and for this direction it is called the ascending artery, after which it undergoes a posterior flexion going to form an arch with a lower cavity, which runs above the left bronchus, and moves downwards, and this portion is called the thoracic descending artery, because contained within the thoracic cavity, it will pass the diaphragm muscle descending into the abdominal cavity, going to constitute the abdominal descending tract.

From the ascending aorta the originating vessels are the coronaries; in the curved section there are a series of collaterals that go to supply the head, neck and upper limbs; other collaterals depart from the descending thoracic aorta divided into parietal collaterals, which supply the chest wall, and visceral vessels, which supply the organs inside the thoracic cavity; also from the descending abdominal tract there are parietal branches and visceral branches, the latter divided into: uneven visceral branches that originate from the anterior region of the abdominal aorta, i.e. celiac tripod, immediately below the diaphragm, superior mesenteric artery, inferior mesenteric artery, from the celiac tripod there is blood supply to the liver, stomach and spleen, from the mesenteric the small intestine and colon; even visceral branches, i.e. renal arteries and genital arteries;

the abdominal aorta ends in a bifurcation with the two iliac arteries. The main arterial branches that supply the head originate from the arch of the aorta, which are three, are represented by a single trunk called the brachiocephalic trunk, which divides into two, i.e. on one side into a right subclavian artery (which leads to the right) and a right common carotid artery, followed by the left common carotid artery and the left subclavian artery.

The subclavian moves towards the upper limb, the common carotid towards the head; the latter divides into two large branches, an external carotid which vascularises the external surface of the skull and an internal carotid which vascularises the interior of the skull.

There is another artery that rises towards the skull, namely the vertebral artery, which detaches from the subclavian artery, running between the transverse processes of the vertebrae and moving inside the skull, in order to vascularize the nervous structures which are found within the neurocranium. The upper limb receives blood from the subclavian artery;

in the arm there are: the axillary artery which is positioned under the armpit, the brachial artery, which is in contact with the humerus, which divides into two collateral branches that lead towards the forearm following the radius and ulna , i.e. radial artery and ulnar artery, and then branch out to form a network inside the hand.

The lower limb receives blood from the abdominal aorta, which becomes the iliac artery, which moves towards the thigh first and then towards the leg, giving life to the femoral artery anterior to the knee and popliteal artery posterior to the knee, which is divides into the terminal branches which are anterior tibial artery and posterior tibial artery.

There are two venous systems: a superior venous system (or suprradiaphragmatic), which is received in a large venous vascular structure, that is the superior vena cava, which collects blood from the head, upper limbs and organs of the thoracic cavity; a lower venous system, which collects blood in the lower limbs, from the organs of the abdominal wall; the inferior venous system is received by the inferior vena cava.

Unlike arteries, which run deeply, veins can be found both deep and on the surface below the connective tissue. The superior vena cava is a trunk that originates from the confluence of two large veins: the left brachiocephalic vein and the right brachiocephalic vein, which in turn originate from the jugular and subclavian veins (on all sides). Connected to the head is the internal jugular vein, which is very large, which collects the blood that reaches the brain and the external jugular vein, which is smaller, which collects venous blood from the external part of the head; the latter flows directly into the subclavian vein, before it joins the internal jugular vein.

In the upper limb there are several superficial veins, which are useful for drawing blood;

there are several superficial veins that start from the hand up to the root of the arm, and the two main veins of the upper limb are: the basilic vein, which reaches the elbow region and then goes deep, and the cephalic vein, which is bring externally over the bicep and then go deep to the level of the shoulder.

The inferior vena cava collects blood from the entire subdiaphragmatic region; it is formed at the confluence of the two iliac veins, which collect blood from the lower limb, then there is the internal iliac vein which collects blood from the lower part of the abdominal cavity, the renal veins and the genital veins.

The drainage of most of the splanchnic organs present inside the abdominal cavity occurs through another system, called the portal vein system: it passes through the liver, which acts as a filter, and then re-enters the superior vena cava , completing the drainage of the subdiaphragmatic area.

In the lower limb there is a system called the saphenous veins: there is a small saphenous vein that leads posteriorly to the leg to merge into the popliteal vein, which is located in the fold of the knee, and the great saphenous vein which runs medially to become deep in the inguinal region and then reaches the level of the femoral vein.

Saphenous veins are known for certain pathologies, given their morphology:

presenting valvular structures that help the blood to reach the heart by muscle contraction; the increase in volume of muscle tissue inside the vein causes the internal volume of the veins to decrease, the pressure rises, the semilunar valves close, the upper ones open and the blood passes;

 the pathology intervenes when the veins lose the functionality of the semilunar valves, so the blood remains at the bottom causing a swelling evident superficially.

Physiology of the cardiovascular system

The heart is composed of a right and a left portion giving life to the systemic circulation (large circle) and to the pulmonary circulation (small circle); The functions of the two circles are complementary and they come together (being placed one after the other) at the level of the heart. The pulmonary circulation starts from the right ventricle through an arterial trunk called the common trunk of the pulmonary artery which is short and then divides into the two right and left pulmonary arteries that supply the lung.

The blood circulating in the pulmonary artery is poor in oxygen and goes to the lung to oxygenate itself: there is a network of arteries that branch out repeatedly and eventually there is a network of capillaries that envelop the pulmonary alveoli.

The wall of the alveoli of the capillaries is thin and oxygen can pass from inside the alveolar air, through the barriers, to the blood, where it is dissolved and reaches the red blood cell. The red blood cell is thus enriched with oxygen and releases carbon dioxide.

This network of capillaries pours into a network of veins, which then return to the heart. The oxygenated blood through these veins returns to the left atrium of the heart, passes into the left ventricle and here begins the great circulation. From the left ventricle the aorta artery arises, the major artery of the human body which distributes, through numerous branches, the oxygen-rich blood to all organs, including the lung (bronchial arteries).

A network of capillaries is then created at the level of the organs, which is drained (the blood is recaptured) by the veins: a subdiaphragmatic one, the inferior vena cava and a suprradiaphragmatic one, the superior vena cava. You then return to the right atrium again.

The pulmonary circulation then originates from the right ventricle. In both circulations the arteries have some characteristics.

In both circulations the arteries increase in number as they move away from the heart (through the emission of collaterals) while their caliber progressively decreases. When an artery terminates, instead of emitting collaterals, it bifurcates at an angle of about 60 ° (e.g. the iliac arteries for the aorta) into two terminal daughter arteries of equal caliber to each other (about 76% of the caliber of origin). While the collateral arteries are arteries emitted roughly at right angles (with caliber less than 50% of the origin).

During its path and the subdivision into the various arteries, the diameter of the daughter arteries, collateral emitted, is progressively reduced.

This means that the blood is distributed to all tissues. There is a decrease in the flow velocity from the aorta to its collaterals and terminals. The transverse section of the aorta has a given area (considering for example that the diameter of a 70 kg person is about 30-32 mm, it can be calculated about 7 cm2). Contractions of the heart muscle are generated by signals that originate within the muscle itself. myogenetic contractile activity.

The ability of the heart to generate signals that activate its contraction in a cyclic way is defined AUTHORITHMICITY, and is due to the action of small modified muscle cells, called autorhythmic cells , essential for the action, that is:

  1. Pacemaker cells: trigger the action potential and establish the heart rhythm. They are concentrated in two specific areas of the myocardium: the sinoatrial node (located in the upper wall of the right atrium, near the outlet of the superior vena cava) and the atrioventricular node, located in the interatrial septum near the tricuspid valve. AS cells have a higher spontaneous depolarization. Action potentials of the SA node initiate depolarization of the AV node.
  2. Conduction fibers: conduct action potentials and propagate them in the heart with a highly coordinated sequence of conduction system cells.

Then the contraction of the heart will begin in the sinoatrial node (or peacemaker), and gives rise to the depolarization which will then be transported throughout the heart, through bundles of specific conducting muscle fibers called internodal; they, usually three in number, run along the wall of the atrium, and reach another agglomeration of cells, called nodal structure or atrioventricular node (or bundle of His) due to the position in which it is located, that is, at the base of the atrium right at the limit with the atrial septum;

from here the atrioventricular node allows the origin of another bundle of fibers, which first enters the fibrous structure of the interventricular septum, that is the bundle of His, when it meets the myocardial muscle mass that constitutes the septum interventricular divides into two branches, which run one on the right wall and one on the left wall of the septum, until reaching the tip of the heart; from here these bundles of fibers divide into fine structures that reach all the single cells of the myocardium giving life to the subendothelial network of the Purkinje fibers ;

depolarization follows the path just explained: it originates from the sinoatrial node, transfers the depolarization of cells to the atrial cavities allowing them to contract, reaches the atrioventricular node where it undergoes a short slowdown so that the fibers that make up the atrial wall have already contracted and from here the depolarization quickly reaches the tip of the heart, from where the myocardial cells are stimulated.

The pacemaker cells of the SA node receive afferents from neurons of the autonomic nervous system, both orthosympathetic and parasympathetic. With the influence of the garden, the heart accelerates its beats and the action potential reaches the diastolic depolarization threshold earlier.

Conversely, with the influence of para , the heart slows down and the potential is activated more slowly with a consequent decrease in heart rate.

Orthosympathic Control Mechanism

Noradrenaline binds to SA node 1 receptors and activates the AMP system as a second messenger. The intracellular increase of AMPc stimulates the opening of funny channels and T -type Ca channels, increase in spontaneous depolarization rate and decrease in repolarization .

The onset threshold for PA is reached faster by increasing the PA rate, heart rate, and cardiac output.

Control Mechanism By The Parasympathic

The Ach binds to the muscarinic receptors placed on the cells of the SA node, causes the opening for the potassium channels and at the same time the closure of the T-type Ca channels and the funny channels . decrease of the spontaneous depolarization rate and a hyperpolarization of the membrane. Heart rate slows and cardiac output tends to decrease.

Theoretical Framework

Infarction Of The Acute Myocardium

The blood Acute myocardial infarction (AMI) is a condition in which necrosis of a portion of myocardial tissue occurs, following an ischemia , or the lack of oxygen supply (hypoxia and anoxia) to the district, caused by an occlusion arterial. The evolution takes place in a few hours and is divided into: occlusion of the vessel, ischemia, edema, haemorrhage, necrosis and cicatricial evolution.

 The obstruction may be due to the formation of a thrombus or plaque within a coronary artery (atherosclerosis).

It is a multifactorial disease that affects the arteries of medium and large caliber and leads to a gradual accumulation in the intestine of macrophages, smooth muscle cells, lipids and collagen; it is identified as chronic inflammation localized in the intimate vascular tunic and triggered by prolonged endothelial damage.

The classic atherosclerotic lesion is plaque or atheroma;

On a macroscopic level, atherosclerosis shows itself with 3 lesions: lipid stria, fibrous plaque and complicated plaque.

LIPID STRIEs are 1‐2 mm elongated lesions, yellowish in color and sharp edges, which stand out against the white color of the intima; only flat and have a smooth and continuous surface.

Histologically, the lipid striae contain lipids and macrophages. They do not reduce the vessel lumen and do not compromise its structural integrity. In the presence of cardiovascular risk factors they can progress into more advanced lesions.

The FIBROUS PLATE (atheroma) is a circumscribed thickening, which protrudes into the lumevascular , up to 1.5 cm long; the fibrous capsule of the lining is made up of smooth muscle cells and dense connective tissue; underneath are macrophages, smooth muscle cells migrated from the media and a few T lymphocytes.

These muscle cells become capable of producing cell matrix proteins, including collagen. Deeper, a necrotic nucleus is observed containing lipids, cellular debris and cell -foam.

The latter, originating from macrophages, are filled with lipids. In the periphery of the plates there are small newly formed vessels. The uncomplicated plaque is lined on the luminary side with endothelial cells. Atheromatous plaques have constant distribution.

Plaque ulcerates when macrophages in the lesion release metalloproteases that weaken the fibrous capsule.

Intra -plaque hemorrhage , the result of the rupture of newly formed vessels, also causes plaque ulceration because the accumulation of blood causes an increase in volume. The rupture of the capsule causes the release into the circulation of solid fragments (emboli) which can stop in the smallest vessels and cause ischemia.

The contact between blood and the contents of the plaque evokes the haemostatic response with the formation of a thrombus which can rapidly occlude the vessel causing necrosis of the downstream tissue.

Deposition of calcium salts in plaques is often observed in a process similar to ossification. Plaque can weaken the arterial wall which, under blood pressure, dilates to form an aneurysm.

The occlusion can be complete or incomplete, of intermittent or persistent duration. When the thrombus completely occludes the lumen of the coronary vessel for a prolonged period of time , transmural cardiac ischemia occurs which corresponds to the clinical picture of acute myocardial infarction with elevated STEMI.

intracoronary thrombus does not

determines a complete and persistent occlusion, the clinical picture of unstable angina or myocardial infarction without elevated ST (NSTEMI) is realized ( Miceli 2005).

However, it takes a certain period of time for an area of the myocardium to experience a heart attack. Initially, ischemia develops; over time, the lack of oxygen causes a heart attack, ie cellular necrosis ( Smeltzer 2010, p. 871).

Although biochemical and functional changes occur immediately at the onset of ischemia, severe loss of myocardial contractility occurs within 60 seconds, while other changes take longer; for example, the irreversible damage occurs after at least 20-40 minutes from the complete stop of the blood flow. ( Fuster , Alexander and O’Rourke 2006, p. 1468).

Heart attack is part of that syndrome called “Acute Coronary Syndrome”, SCA, which also includes unstable angina as both represent continuum of the same process. (Porter 2014). Anamnesis, laboratory diagnosis, signs and symptoms In this chapter I intend to deepen the anamnestic research to be carried out, which tests to look for, but not only, I will highlight the main signs and symptoms of a heart attack related to the smoker patient.

A typical acute myocardial infarction is diagnosed primarily by history , as the most important factor is whether you currently smoke (if you are an active smoker, former smoker or non-smoker), how much you smoke (when you started, if you stopped smoking) later, when you have resumed), how many cigarettes or packs you smoke daily, to know if you have previously had heart or respiratory problems and if you have recurrent cough, phlegm or bronchitis.

It is necessary to measure vital parameters (in particular blood pressure), check the level of LDL and HDL for the possible development of atherosclerotic processes caused by tobacco, carry out blood clotting tests – through platelet counts – and tests on coagulation factors (PTT and INR).

The diagnosis of AMI should be considered in men over thirty-five and in women over fifty who complain mainly of chest pain that must be differentiated from pain due to pneumonia, pulmonary embolism, pericarditis, rib fracture, pain in the chest muscles after trauma or after physical activity, acute aortic dissection, renal colic and various gastrointestinal pathologies.

Once the medical history has been taken, the most important diagnostic investigation in the patient with suspected AMI will be carried out, namely the ECG , which should be performed within 10 minutes of when the patient reports the painful symptom or when he arrives in the emergency room. The ECG can be used to diagnose myocardial ischaemia and heart attack , conduction rhythm disturbances, heart chamber enlargement, electrolyte imbalances, and drug toxicity. The standard 12-lead ECG uses electrodes placed on the patient’s extremities and chest to evaluate the heart from 12 different points of view. The standard 12-lead ECG consists of three standard bipolar leads (called I, II, III), three unipolar leads (to VR, to VL, to VF) and six unipolar precordial leads (C1 to C6). The exact point of contact with the skin of the leads is not really that important; it is important that the electrodes adhere well to the skin. The chest leads are positioned at specific points to ensure a faithful registration. All leads, except the precordial ones, show the heart from the frontal plane. The precordial leads show the heart from the horizontal plane. Each lead covers a specific area of the myocardium and provides an electrocardiographic photograph of the electrochemical activity of the cell membranes. The ECG measures the differences between the electrical potential of the electrode for each lead and reports it in graphical form, creating the standard ECG complex, called PQRST. At a later stage, the value of CK-MB, myoglobin and troponin will be evaluated ( Smeltzer 2010). The key symptom of an AMI is typically deep, retrosternal visceral pain, described as constricting or oppressive, often radiating to the back, jaw, or left arm. Pain can also be very mild and about 20% of acute heart attacks are silent or not recognized by the patient as a pathological event (Porter 2014). Other signs and symptoms that characterize a heart attack are chest problems and heart palpitations; tachypnea, wheezing and shallow breathing; pale, cold, sweaty and sticky skin, as well as anxiety, restlessness, and dizziness may indicate increased sympathetic stimulation or decreased cardiac contractility ( Smeltzer 2010, p. 871). In severe episodes, the patient appears distressed and may feel a sense of imminent death; nausea and vomiting may occur. On clinical examination , the patient is usually restless and anxious, with pale, cold and sweaty skin; peripheral or central cyanosis may occur while the pulse may be filiform and the BP variable (Porter 2014). Generally in a smoker there is an increase in vascular resistance and arterial pressure, heart rate and, consequently, also in output, increasing cardiac output. This causes higher cardiac work and higher myocardial oxygen consumption. Since carbon monoxide is in circulation, it binds more easily to hemoglobin and this results in a lower supply of oxygen to the myocardium. Smoking can also induce coronary vasoconstriction and helps to further decrease the oxygen supply and this sets the stage for a possible heart attack. In the medium and long term, smoking also leads to the formation of atheromatous plaques through alterations of the endothelium and coagulation, causing narrowing of the lumen of blood vessels which, once obstructed, lead to necrosis of the area where no oxygen reaches and, subsequently , heart attack of the same. This picture inevitably leads to a series of “warning” symptoms that should be known in advance by the patient (Ibidem). Infarct epidemiology Within this chapter, the theme of the epidemiology of infarction will be analyzed in depth. According to the latest Eurostat data , just over 1.9 million people died from diseases of the circulatory system (mainly heart attacks and strokes), while 1.3 million died from cancer. These were the two leading causes of death in the EU , 28 responsible for 37% and 26% of all deaths respectively. Diseases of the circulatory system were the leading cause of death in all EU Member States , with the exception of Denmark, France, the Netherlands and the UK, where cancer was the leading killer. Cardiovascular disease is a class of conditions that include heart and blood vessel disorders or disorders and that include: coronary heart disease – in turn including unstable angina, variable angina, Syndrome X, silent ischemia and acute coronary syndromes including heart attack – cerebrovascular disease, peripheral arterial disease, rheumatic heart disease, congenital heart disease, deep vein thrombosis and pulmonary embolism (WHO 2015). Worldwide 32.4 million people are affected by acute myocardial infarction every year, of which 6.7 million die, according to data updated to 2012 (WHO 2014). As far as Europe is concerned, the situation regarding the health of citizens could improve, especially if certain eating and other habits are changed. The “black list” of wrong behaviors includes the excess of fatty foods, the little sport practiced, the little fruit and vegetables, the few fibers, but above all too much stress: pointed out as one of the main causes of the new millennium of various diseases. This is what numerous experts said during the “ Winning Hearth ”, organized on February 14, 2014 in Brussels by the European Heart Network in association with the European Society of Cardiology (ESC) and the European Community. In particular, according to recently published data by British Heart Foundation, around 4 million people die each year from cardiovascular disease, which is at the origin of about half of all deaths in Europe. Of these 4 million, 1.9 million die from heart attacks. In Germany, for example, every year 1% of citizens go to their doctor accusing attacks of angina pectoris; what is most frightening, however, is that after one year 10% of these people die or have a non-fatal heart attack (Medina 2014). Another argument should be made for patients who previously suffered from a heart attack: they are the group at the highest risk for coronary occlusions and brain events. Heart attack “survivors” have a calculated risk of death that is around 5% per year; six times higher risk of people of the same age who have not had cardiovascular disease. Unfortunately cardiac infarcts, heart failure and cerebral strokes continue to occupy the first place among the causes of death, so much so that annually about 30,000 people undergo an MI (Ibidem). According to the “Health 2020” report, the decline in deaths is increasingly offset by an increase in chronic diseases caused by changing living and working conditions, demographic changes, medical and technical progress and a way of unhealthy living – too little exercise, too much food, alcohol, TOBACCO – which were once fatal. This aspect, in addition to suffering and the often limited quality of life, also weighs on the health system and the economy (FSC 2013). Despite these pitiless statistics, there is considerable scientific evidence showing how specific interventions can reduce the risk of future ischemic events in patients who have already suffered from cardiovascular problems. If these interventions were promptly implemented, about a third of fatal or non-fatal heart attacks could be prevented (WHO 2014). Furthermore, conditions such as AMI and stroke that are associated with often recurring and cost-related morbid events, if prevented in time, can reduce future costs. The results of the cost-effectiveness analyzes of secondary prevention indicate that secondary prevention measures are very cost-effective compared to many other routine medical interventions.

Risk factors

It is not possible to draw a picture of cardiovascular disease without taking into account the distribution of risk factors and the prevalence of conditions at risk. There are several known factors that increase the person’s risk of developing a heart attack condition and that predispose the body to get sick. The most important are:

  • Age: the risk of heart attack, as with almost all cardiovascular diseases, increases with age.
  • Gender: Atherosclerosis and heart attack are more common in men than women for the decades of youth and maturity. After female menopause, the risk of atherosclerosis and heart attack is similar in men and women.
  • Familiarity: those who have cases of acute cardiovascular disease in their family history are at greater risk of heart attack, especially if the cardiovascular pathology of the joint has manifested itself at a young age by modifiable factors.
  • Nutrition: A diet that is too high in calories and fat contributes to raising the level of cholesterol and other fats (lipids) in the blood, making atherosclerosis and heart attack much more likely. A healthy and balanced diet has a great value in terms of prevention of cardiovascular diseases.
  • Arterial hypertension: “high blood pressure” or arterial hypertension can have various causes and affects a large portion of the population over the age of 50. It is associated with an increased likelihood of developing atherosclerosis and its complications, such as heart or brain infarction. It creates an increase in cardiac work which over time translates into a progressive malfunction of the heart and leads to the appearance of cardiocirculatory decompensation.
  • Diabetes: the excess of glucose in the blood damages the arteries and promotes atherosclerosis, myocardial and cerebral infarction and the damage of important organs such as the kidneys, with the appearance of renal failure, in turn associated with increased cardiovascular risk.
  • Tobacco addiction: According to the World Health Organization, tobacco smoke represents the single main avoidable risk factor for early death, illness and disability. The overall health consequences of smoking are very serious, as they lead to an overall reduction in estimated life expectancy of 10 years compared to non-smokers. Every moment is good to quit smoking: scientific evidence shows that cessation of exposure to smoke halves the risk of myocardial infarction after one year of abstention; after 15 years the risk becomes equal to that of a non-smoker. Smokers who quit before the age of 50 cut their risk of dying in half in the next 15 years compared to those who continue to smoke.

This chapter will discuss the epidemiology of tobacco smoking, the phenomenon of addiction and the effects of smoking on the cardiovascular system. Addiction to smoking, or smoking, represents one of the greatest public health problems worldwide and is one of the major risk factors in the development of neoplastic, cardiovascular and respiratory diseases. Cigarette smoking continues to be a serious health hazard and contributes significantly to cardiovascular morbidity and mortality. Smoking affects all stages of atherosclerosis from endothelial dysfunction with acute clinical events, the latter largely thrombotic. Both active and passive (environmental) exposure to cigarette smoke predispose to cardiovascular events. Whether there is a distinct dose-dependent direct correlation between cigarette smoke exposure and risk is questionable , as some recent experimental clinical studies have demonstrated a non-linear relationship with cigarette smoke exposure. Recent experimental and clinical data support the hypothesis that exposure to cigarette smoke increases oxidative stress as a potential mechanism for initiating cardiovascular dysfunction.

Addiction to tobacco

Smoking has a high potential for addiction: the first symptoms can appear already after consuming a few cigarettes. In the majority of young people, occasional consumption evolves to become regular. Matteo Pacini , Stefania Pasquariello and Domenico Enea affirm that “10% of those who approach tobacco smoke develop a desire to smoke already two days after the first cigarette, to become 25% after two months” (quoted in Amato and 2013 Plan, page 167). Many believe they can control their consumption, but underestimate the addictive potential of smoking; all 8 smokers started smoking occasionally, but very few people manage to keep their consumption low for life (Amato and Piano 2013). Smoking also reduces the performance of young and fit people: those who smoke, in fact, have a shorter breath; sportsmen who smoke give less oxygen to their organs, get tired earlier and have a higher heart rate at rest. It takes a short time for nicotine to yellow your teeth and cause bad breath, as well as invade clothes and hair with a pregnant smell. Girls who use the birth control pill should not smoke, because the combination of the pill and tobacco drastically increases the risk of dangerous heart disease and thrombosis. The quantitative boundary within which these elements cease to indicate a pleasant habit and denote loss of control has not yet been defined, so that some low levels of consumption may correspond to an addiction (Amato and Piano 2013, p. 167). In the case of tobacco smoke, physical dependence is mainly caused by a neurotoxic: nicotine, which in combination with a psycho -behavioral complex corresponds to the physiopathological core of addiction. As one of the most addictive chemicals, it reaches the brain in seconds, affecting perceptions and mood for a limited period of time. Symptoms of addiction can also occur long before one switches to daily cigarette consumption; in fact, after just a few cigarettes, one tends to connect smoking to an expectation, so one smokes to relax, reward oneself, energize oneself, overcome moments of stress, etc. However, the feeling of relaxation that often comes from smoking does not amplify pleasant sensations, but rather eases the unpleasant effects of withdrawal by taking nicotine. The relationship that binds the smoker to smoking is complex and articulated on several factors: from the gratifying effects of nicotine, to gestures, to the pharyngeal stimulation, to the role of the cigarette in managing moments of stress up to the emotional memory that can link it to object. In the beginning, smoking is the result of a substantially free and voluntary choice and causes a hedonic effect on those who use it: Later it tends instead to turn into a compulsive need, in order not so much to reproduce the initial effects, but rather to avoid the disturbances caused by its lack, transforming from hedonia to an additive effect. This phenomenon, called drug addiction or addiction, is common to most drugs and is one of their most fearful and, at the same time, most complex aspects. A group of experts from the World Health Organization defined drug addiction as «a psychic and sometimes even physical state, resulting from the interaction between a living organism and a drug, characterized by changes in behavior and other reactions, which include the drive to to take the drug in a continuous and operative way , in order to recover its psychic effects and to avoid the disturbances caused by its deprivation “(WHO1973). In addition to appearing among drugs in the Diagnostic and Statistical Manual of Mental Disorders IV Edition (DMS ‐ IV) and in the Pocket Guide to the ICD ‐ 10 Classification of Mental and Behavioral Disorders (1994), nicotine has also been classified as such by the World Health Organization. Implicit in the above definition is the concept that drug addiction involves the inability to maintain a state of physical and mental well-being without taking a drug. It follows that drug addiction is a disease which, paradoxically, is relieved by the same agent that is the cause. The unifying feature of drugs is the ability to free the mind from the constraints that keep it on the perhaps narrow but safe terrain of normal behavior; as a result of addiction to the drug, sensations of pleasure, of liberation from physical and mental suffering, of strength and escape from reality. Tobacco determines, through nicotine, very complex mental effects, attributable to its coupling point, represented by neuronal ganglia that modulate various central and peripheral nervous functions. These effects, which make smoking “pleasant, desirable and sometimes even useful”, are contained in a framework which, depending on the circumstances, can respond to the need for reassurance or, conversely, for stimulation. At the same time, there is an improvement in concentration and learning ability. Probably the spread of smoking is explained by the fact that it does not satisfy only limited needs, as happens with other drugs, but to bring pleasure to larger areas. With tobacco you go from a few puffs of the first cigarette, which give a sense of daze and fun , up to 20/40 and, in extreme cases, even 80 cigarettes a day, which no longer cause any discomfort. Drug addiction leads back to a homeostatic reaction, which despite being a natural defensive process, must not lead to underestimating its extent. Reacting to the drug, the organism recovers its own functional state, but recovers it through adjustments that must be counterbalanced by a force of the opposite sign; it is an unstable equilibrium, different from the physiological one, because it requires the presence of drugs to be maintained. If the latter fails, the withdrawal crisis occurs marked by irritability, difficulty in concentration, bradycardia, even marked, and so on (Silvestrini et al. 2003). Other effects induced by nicotine are for example malaise, sweating, vomiting which disappear in a relatively short period thanks to the addiction of the body, acceleration of the heartbeat, decrease in skin temperature caused by vasoconstriction and risk of thrombosis through hormonal mechanisms ( League Against Cancer 2011). In the long run, these effects can damage the cardiovascular system. The intensity of drug addiction also varies from person to person, as well as from drug to drug; some become addicted after a few exposures to a drug, others only after prolonged exposure. Others get rid of drug addiction easily, others fail even when they suffer the devastating effects. Susceptibility to drug addiction is likely to be linked to hereditary factors, although this is difficult to ascertain with certainty. Generally speaking, there are two extreme types, among which all the others are placed: the one with a strong constitutional predisposition and a relatively modest influence of external factors; that, on the contrary, in which the latter play the fundamental role (Silvestrini et al. 2003).

Nursing role

In this chapter, the intent is to deepen, among all the various competences of the nurse, the role of health promoter, since, thanks to this specific role, the nurse is allowed to help the subject to fulfill the care of himself for a satisfying quality of life. Health reflects the object to which the promotion is aimed. WHO describes health as “a state of complete physical, social and mental well-being, and not simply the absence of disease or infirmity” ( Kickbusch & Nutbeam , 1998). The meaning of health takes on a perspective that is traced back to multiple dimensions of the human being and, more precisely to a biological, psychological, social and spiritual pattern in which human beings themselves are inserted in a network of relationships and influence the health both through specific and individual interactions (Simonelli & Simonelli, 2010). Health is considered a means aimed at an objective which, can be traced back and can be considered, a resource that allows people to lead a productive life on an individual, economic and social level (Simonelli & Simonelli, 2010). The state of health, as mentioned at the beginning of this chapter, reflects a state of complete well-being and, precisely for this reason, well-being has been defined as the equivalent of health. Some authors argue that well-being has four components, which can be traced back to the ability to adapt and adapt to changing situations, the ability to exercise one’s skills in the best possible way, the explicit declaration of feeling good and the feeling that everything is part of a whole that is in harmony with the others (Simonelli & Simonelli, 2010). With this reference, the accent is placed on the role of care providers and, more specifically, on nurses, who possess the skills to promote and enable positive changes oriented towards wellbeing and health ( Smeltzer et al., 2010). If guaranteed and promoted, health therefore becomes a resource for daily life, a positive concept that enhances the individual and social resources of the individual aimed at reaching their human potential ( Kickbusch & Nutbeam , 1998). According to the Ottawa Charter, within the concept of health promotion, health is seen as a resource of daily life rather than the goal of living. The state of health is achieved thanks to the ability of individuals to develop and mobilize their resources in the best possible way, so that they can satisfy both personal (mental and physical) and external (material and social) qualities ( Kickbusch & Nutbeam , 1998). Nurses possess and develop specific professional skills. These competences are briefly described below:

  • “Role of expert in nursing care: as experts in nursing care, nurses are responsible, within the health system, for their professional actions and related decisions and evaluations.
  • Role of communicator: as communicators, nurses allow the development of relationships of trust in their context and transmit information in a targeted manner.
  • Role of team member: as team members, nurses participate effectively and efficiently in interdisciplinary and interprofessional groups Role of managers: as managers, nurses take on specialist management, contribute to the effectiveness of the organization and develop their professional career.
  • Role of health promoter ( Health Advocate ): As health promoters, nurses rely responsibly on their expert knowledge and leverage their influence in the interests of the health and quality of life of patients / clients and society as a whole.
  • Role of learner and teacher: As apprentices and teachers, nurses are committed to lifelong learning based on reflective practice and to the development, transmission and application of evidence-based knowledge.
  • Role linked to professional membership: as belonging to their professional category, nurses are committed to the health and quality of life of individuals and society.

They are bound by professional ethics and the care of their health. ” (“SUPSI – Department of Business Economics, Health and Social Affairs – Skills of the SUP nurse”, sd) As you can see, the nurse at the end of the ” Bachelor in Nursing Care” study cycle must master multiple professional skills, including whose role as health promoter; a role that has a greater value in this chapter. Nurses, designed to promote the health of the individual user, undertake to act with respect to problems related to health and quality of life, the interests of users and those of the people most dear to them. Within nursing care programs, nurses integrate health promotion and disease prevention practices. They also try to allow the patient and their relatives to use an individual and targeted approach in order to take advantage of means to prevent and deal with the disease and to maintain the highest possible level of quality of life. Finally, they participate in the development of concepts concerning health promotion and disease prevention (“SUPSI – Department of Business Economics, Health and Social – Skills of the SUP nurse”, sd) Reporting these skills, allows us to understand how much the role of the nurse , is fundamental in maintaining a state of well-being, health and a satisfactory quality of life in the person in need of help. People nowadays seem to know more and more about their health and are showing more and more interest in promoting it. Healthcare professionals have made a considerable effort over the years to reach out and motivate members of various groups to promote their health, prevent disease and practice self-care ( Smeltzer et al., 2010). However, sometimes health is not fully perceived in all subjects. Often, we are confronted with the adoption of inappropriate behaviors that negatively affect the health of individual subjects. Stress, anxiety, depressive symptoms, inappropriate diet, lack of exercise, smoking and therefore, high-risk behaviors, are all lifestyle aspects that have a negative effect on health ( Karmali et al . ., 2014). The task of the nurses therefore becomes that of involving each individual user, stimulating him to adopt behaviors and habits that promote his own state of health. The objective is therefore to motivate people to improve the way they live, modifying, if necessary, risk behaviors, adopting the healthier ones instead (De Lorenzi et al., 2010). Due to the importance that society assigns to health and the responsibility that each person has in maintaining and promoting it , the members of the health team and, in particular, nurses, are obliged to constantly make available educational initiatives aimed at maintaining a self-care and to promote health since, without adequate knowledge, people find it difficult to make decisions about their own health (Molinari et al., 2006). More attention will then be paid to the role of therapeutic education in promoting the health of the individual user who, at times, does not adhere to the therapeutic regimen offered to cope with their illness and, in this case, to the IMA.

Nursing management of the person with AMI Chest pain is a symptom that frequently requires the use of all the emergency structures operating, both in the territory and in the hospital. Chest pain management according to ACLS guidelines of American Cardiac Life Support , provides that chest pain is managed following schemes that take into account temporal and sequential intervention logics.

The timeliness of the therapeutic intervention aimed at re-establishing coronary recanalization is an important element for the prognosis of the subject affected by AMI.

The patient affected by AMI can arrive at the hospital in different ways and using extremely different times The most common are: – arrival following a call and subsequent prescription from the family doctor 68 – direct arrival of the patient to the emergency room by own means or transported from family members – arrival after calling the emergency health service (118). Recourse to the 118 territorial emergency service is always recommended in the case of a typical onset symptomatology / or of high clinical severity (pain, loss of consciousness, severe dyspnea, imperceptible arterial pulses) .

In relation to the concentration of sudden cardiac arrest deaths in the first and second hour after the first event, different knowledge is of fundamental importance, namely; – to know the risk factors for ischemic heart disease (smoking, arterial hypertension , diabetes mellitus, dyslipdemia , family history) that make the cardiac etiology of chest pain more likely – to know the characteristic symptoms of a heart attack – to alert the emergency system territorial 118 – knowledge of cardiopulmonary resuscitation (BLS)

The nurse rescuer

The nurse, during the territorial rescue phase, is responsible for the correct functioning of the medical equipment of the rescue vehicle. He must check the quantity and quality of medical-health devices, monitors, defibrillators , respirators, drugs. In addition, it must provide both basic life support ( blsd ) and advanced cardiac life support ( als – acls ). Once the nurse arrives in the field, he must carry out an early diagnosis with subsequent therapy, therefore he will carry out: 1) Control of vital parameters = through the evaluation of: – state of consciousness (using the glasgow scale ) – Respiratory frequency and type of respiration = provides essential data to ascertain the effectiveness of breathing and to detect adventitious or abnormal breath sounds that may be indicative of acute pulmonary edema or heart failure secondary to ischemic disease – Blood pressure – Radial pulse = (rate and rhythm providing a range of data for detect the presence of cardiac arrhythmias, changes in blood volume, and compromise of the cardiovascular system – Apical pulse = (frequency and rhythm) when the perideric pulse is irregular, weak or extremely rapid. (pallor, redness, diaphoresis, peripheral cyanosis and marbling) Venous access: positioning of a needle cannula of adequate caliber for the vein – use of a defibrillator monitor; considering the high incidence of VF in the first hour of the ischemic event) 12-lead ECG performed in the field with computerized interpretations by the electrocardiograph or transmission to medical personnel in order to stratify patients with chest pain 3) Administration of drugs = above all in the presence of a subject with persistent agor without hypotension or signs of collapse, it is always advisable to administer a nitrate by the sl route (trinitrine or carvasin ) which allows a reduction in pain especially if there is hypertension.

A generic sedation intervention with oral anxiolytics at a medium-low dose can be practiced right from the first approach with the person.

The administration of opioids (morphine), certainly more effective from an analgesic point of view, must be carried out in case of pain insensitive to nitroglycerin with attention due to the side effects ie depression of the breath, nausea vomiting, hypotension.

The administration of Aspirin at doses ranging from 165 to 325 mg, depending on the product available, is recommended, even in the absence of a perfectly defined diagnosis.

The systemic administration of antiarrhythmic drugs is not justified, because there is no evidence of a real preventive efficacy of malignant arrhythmias.

Finally, the administration of thrombolytic drugs is strongly recommended, thus increasing survival by as much as 17% 4) Administration of oxygen using a resovoir mask with high flow.

Oxygen therapy increases the surrounding oxygen and therefore also that available to the myocardial tissue. In uncomplicated IMA administer O2 4lt min. For the first 2 – 3 hours4 Operating instructions during transport.

The nurse team leader of an ambulance in addition to coordinating the rescue at the place of the event, carries out the triage by assigning a color code (green, yellow, red and in some situations black) and establishes the destination of the possible transport of the patient in the the most suitable first aid, which is not always the closest, but rather that of the structure which, according to the DEA level, is able to accommodate the particular type of patient.

The nurse will also perform various tasks including:

  1. Information to be transmitted to the operations center (severity code, arrival time, activation of the doctor and setting up of the resuscitation box if necessary)
  2. continuous monitoring and constant control of consciousness, breath, heart rate, blood pressure , peripheral O2 saturation
  3. respect, comfort and safety of the user to be guaranteed with safe transport
  4. maintain radio communication with the 118 operations center
  5. in case of doubtful changes in the electrocardiographic trace, stop the vehicle to allow the monitor to correctly read the cardiac activity
  6. Do not lose control of the person’s evolution
  7. Administration of drugs according to operational protocol ( asa, trinitina , oxygen therapy, morphine, diuretics)
The Tragedy Nurse

tragic nurse does not have to make a medical diagnosis, but rather must evaluate the user’s condition and the elements that could produce a potential heart failure or the onset of complications within the short or medium term. Therefore, the timeliness of diagnosis and treatment must be a fundamentally important feature of the DEA to ensure the greatest chances of survival and a high quality of life for patients with this type of symptomatology. The nurse in this area will have to carry out various steps including:

  1. Positioning of the person on the examination bed
  2. Psychological counseling to the person and information to caregivers givers 
  • Detection of basic vital signs, including SATO2 and continuous monitoring, especially during the administration of prescribed drugs.
  • Positioning of 1 or 2 venous accesses possibly on the same limb, in order to make the other limb accessible to the detection of PA (bloody or not).
  • Collection of the first blood samples with identification of the person by labeling, and subsequently collection as per established protocols.
  • 12-lead basic ECG and then as per established protocol or when pain recurs
  • Administration of drug therapy in collaboration with the doctor
  • Constant visual monitoring, in order to detect any hemodynamic or symptomatic changes in the person
  • Beginning of reperfusion treatment as early as possible ( Ptca / Thrombolysis ).


The topic I dealt with is very topical not only in Italy but all over the world. This stimulated my curiosity in searching for articles not only on databases but also on books and specialized websites which are constantly updated. The scientific evidence of the role of smoking on the prognosis of the heart patient is indisputable and constitutes an assumption shared by all cardiologist specialists. The impact that smoking cessation has on reducing the risk of relapses is also well known and it is no coincidence that it appears in the guidelines for secondary prevention of ischemic heart disease in the first place among the interventions to be implemented. Evidence shows that the role of nurses to address these issues and the doubts they bring with them constitute a pillar of the health system and communication is the most effective means available to them. Education in getting patients to accept compliance has a better effect if the work is done in collaboration with doctors; however occasional care, but carried out by experienced nurses, improves outcomes ; moreover, nurses contribute to raising the quality of patients in the management of the disease. A holistic patient-centered approach as well as being supported by evidence and literature is the key to effective and satisfactory care also with regard to the creation of a therapeutic alliance and priorities and in this way the preferences of patients emerge with most successful. Quitting smoking, avoiding relapses of a heart attack and setting up a lifestyle cannot be isolated events but constitute a process that, if set in the long term through continuity of care, improve the patient’s quality of life and push him to a increasing autonomy.


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The new frontiers of Extracorporeal Perfusion


Submission Date: 2022-05-03
Review Date: 2022-05-17
Pubblication Date: 2022-05-31

“What we do is never second best, and what we have done is never good enough”.

This simple statement conceptualizes the passion of Spectrum Medical, a company with previous aerospace experience, for advanced technological development in healthcare especially in the field of Extracorporeal Perfusion.

Spectrum’s idea was to create a new Heart-Lung Machine that integrated hardware systems of the highest technological level and an advanced non-invasive monitoring system. This allowed to rationalize the use of patient data and improved the quality of care and the outcome of patients undergoing extracorporeal circulation. The Spectrum Quantum Perfusion was born.

 Let’s take a step back to make everyone understand what we’re talking about. Seventy years ago, the american surgeon John Gibbon successfully operated a nineteen year old girl by closing an atrial septal defect, through the support of his “Heart-Lung Machine” which allowed to exclude the heart and lungs from the blood circulation and at the same time to perfuse remaining parts of the body with artificially oxygenated blood. In the following years, the famous surgeon John Kirklin of the Mayo Clinic performed numerous open heart operations, using the Gibbon machine, laying the foundations of the pathophysiology of extracorporeal perfusion; in fact, it was necessary to establish what the ideal perfusion flows, the ideal levels of oxygenation and removal of CO2 from the blood should be. All this then had to be related to the patient’s body temperature (which was decreased to reduce metabolic demands as occurs in hibernating animals).

Fig. 1 – Gibbon’s Heart-Lung Machine

Although many years have passed since then, the clinical practice of most Perfusionists , is still based on Kirklin’s calculated parameters supported by decades of clinical practice. However, we are in the Goal Directed Therapy (GDT) era which uses advanced monitoring techniques to help clinicians establish the appropriate patient care strategy in order to improve outcome. Many scientists in the field of perfusion have applied this concept to extracorporeal procedures so that the “Goal Directed Perfusion” is no longer based on theoretical calculations but on measured parameters (which should be determined by scientific evidence) whose values are limited to a very narrow therapeutic range, indexed for each patient in each particular clinical condition. To establish, for example, the ideal flow to keep in extracorporeal circulation, reference will no longer be made to the “popular” 2.2-2.5 l / min. / M2 of Kirklin (1) and an adequate perfusion will be associated with an optimal value of Oxygen Delivery (DO2i> 272 ml / min / m2), such as to prevent postoperative acute kidney injury (AKI acute kidney injury) and the most common neurological complications such as delirium and cognitive impairment in coronary heart patients undergoing BPCP (5). Furthermore, the optimal Oxygen Delivery value must be associated with certain CO2 Production values (VCO2i) which will determine an adequate ratio between the aforementioned parameters (Perfusion Rate [PR] = DO2 ÷ VCO2 must be> 5). To obtain this optimal value, the synergy between perfusionist and anesthetist is necessary; the perfusionist is crucial to obtaining an adequate level of DO2 (which mainly depends on the pump flow and the hemoglobin value) while the anesthetist helps to keep the level of CO2 production low by deepening the narcosis. However, all of this, helps clinicians to establish  the appropriate transfusion trigger is no longer based only on the intraoperative value of hemoglobin but also on parameters which, below a certain threshold value (PR <5), are predictive of the transition from aerobic to anaerobic metabolism. Evaluating these parameters during cardiopulmonary bypass helps prevent hyperlactataemia, significantly associated with increased morbidity and related to postoperative low cardiac output syndrome. 

Recent scientific evidence has also demonstrated the effectiveness of a new parameter called DO2i AUC (Area Under the Curve), or DO2i TDR (TimeDoseResponse) which is useful in preventing acute kidney failure (AKI acute kidney injury). The relationship between the cumulative time of exposure to a low DO₂i during cardiopulmonary bypass and the postoperative risk of developing AKI was therefore demonstrated . Patients that had an AUC that was negative (meaning that they had a greater integral of amount and duration of oxygen delivery during CPB below 270 mL/min/m2) were 2.7 times more likely to experience AKI.

Spectrum Medical immediately developed with the “Best Practice App”, the parameter relating to the area under the O2 delivery curve (DO2i). The DO2i TDR value is, therefore, recorded every second and then cumulated, so that it is possible to determine how much time it has gone below (DO2i debt) or above (DO2i surplus) the reference value of 272 ml / min / m2,  providing information on perfusion quality.

Fig. 2 – Expansion of the O2 delivery (DO2i) graph recorded during an emergency cardiac surgery

The Spectrum Quantum Perfusion system (we cannot speak simplistically of Heart-Lung Machine) does all this and more. The Quantum Workstation (QWS) exploiting its great ability to interface with other devices and monitoring systems, can collect a lot of data that are processed and related to each other, through specific Applications (such as those of a smartphone) that allow you to analyze, quality of ExtraCorporeal Circulation and diagnose and prevent potentially dangerous situations for the patient.

This is an epochal breakthrough for extracorporeal perfusion! It is the first time that a monitoring system becomes “thinking”. This is realized with the possibility of customizing the “Apps”, so that the clinician’s experience and knowledge can meet with the engineering expertise of Spectrum Medical. (Figure 3 The “Quantum Perfusion”)

Fig. 3 – Quantum Perfusion at Sant’Anna e San Sebaastiano Hospital of Caserta

In conclusion,  we can say that the use of Quantum Perfusion system has positively changed the clinical practice of the entire cardiac surgery team and waiting to be able to appreciate all the possibilities offered by Spectrum Medical such as access to the statistical processing of data by the Vision Server, we increase, day after day, our passion for outcome-based-perfusion.


  1. J.W.Kirklin,R.T. Patrick, R.A. Theye. “Theory and practice in the use of a Pump-Oxigenator foor Open Intracardiac Surgery” . Thorax (1957) 12, 93
  2. Marco Ranucci MD, FESCaIanJohnsonCCPbcTimothyWillcoxCCPdeRobert A.BakerPhD, CCPfChristaBoerMD, PhDghAndreasBaumannMDijGeorge A.JustisonCCPklFilipde SomerCCPmPaulExtonBSc (Hon) ACPnSeemaAgarwalFRCAbcRachaelParkePhDdeRichard F.NewlandCCPfRenard G.HaumannCCPghDirkBuchwaldPhD, CCPijNathaenWeitzelMDklRajamiyerVenkateswaranMD FRCS(Cth)nFedericoAmbrogiPhDoValeriaPistuddia
  3. “Goal-directed perfusion to reduce acute kidney injury: A randomized trial   The Journal of Thoracic and Cardiovascular Surgery”. Volume 156, Issue 5, November 2018, Pages 1918-1927.e2
  4. J. Trent Magruder MDaTodd C.CrawfordMDaHerbert LynnHarnessCCP, LPaJoshua C.GrimmMDaAlejandroSuarez-PierreMDaChad WierschkeCCP, LPaJimBiewerCCP, LPaCharlesHogueMDbGlenn R.WhitmanMDaAshish S.Shah MDcViachaslauBarodkaMDb “A pilot goal-directed perfusion initiative is associated with less acute kidney injury after cardiac surgery”. Read at the 96th Annual Meeting of The American Association for Thoracic Surgery, Baltimore, Maryland, May 14-18, 2016.
  5. Ranucci Marco et al.  “Oxigen Delivery during Cardiopulmonary bypass and Acute Renal Faliure After Coronary Operation”. The Annals of Thoracic Surgery, 2005 Volume 80, issue 6, p. 2213-2220
  6. Jori Leenders, Ed Overdevest, Bart van Straten and Hanna Golab. “The influence of oxygen delivery during cardiopulmonary bypass on the incidence of delirium in CABG patients; a retrospective study” Perfusion 2018, Vol. 33(8) 656–662
  7. Marco Ranucci, Barbara De Toffol, Giuseppe Isgrò, Federica Romitti, Daniela Conti,1and Maira Vicentini. “Hyperlactatemia during cardiopulmonary bypass: determinants and impact on postoperative outcome” Crit Care. 2006; 10(6): R167.Published online 2006 Nov 29. doi: 10.1186/cc5113.
  8. Hiroshi Mukaida, MS, CCP,a,b Satoshi Matsushita, MD, PhD,a Kenji Kuwaki, MD, PhD,a Takahiro Inotani, CCP,b Yuki Minami, BS, CCP,b Akira Saigusa, BS,b and Atsushi Amano, MD, PhDa  “Time–dose response of oxygen delivery during cardiopulmonary bypass predicts acute kidney injury” J Thorac Cardiovasc Surg. 2019 Aug;158(2):492-499. doi: 10.1016/j.jtcvs.2018.10.148. Epub 2018 Nov 16.
  9. Richard F. Newland, BSc, CCP and Robert A. Baker, PhD, CCP.  “Low Oxygen Delivery as a Predictor of Acute Kidney Injury during Cardiopulmonary Bypass” J Extra Corpor Technol. 2017 Dec; 49(4): 224–230

COVID-19 in interventional radiology: management of the angiography room

Article Navigation

Submission Date: 2022-05-03
Review Date: 2022-05-17
Pubblication Date: 2022-05-30



One of the most significant challenges that the COVID-19 pandemic has created is the intervetional radiology practice. In order to guarantee the best patient care and avoid contamination of the operators, it was necessary to carry out specific management of the complex angiographic rooms.
This work aims to guide healthcare professionals in the safe execution of interventional radiology procedures on COVID-19 patients using suitable management strategies, guidelines and recommendations available, creating an appropriate work environment.
Research and revision work, targeted at COVID-19 patients, made use the main scientific literature databases of guidelines and scientific articles promoted or edited by international scientific societies.
After identifying and separating the pathways for infected patients and defining the dressing and undressing areas of the operators, a check-list was created to prepare the angiographic room and the surrounding spaces. The set-up includes removal of all non-essential mobile devices for the expected procedure and preparation of the sterile angiographic table with the necessary material and drugs. It is also necessary placement of containers for infected waste inside the room; cover of contrast injector, angiographic controls and patient monitoring devices; finally covering with clean sheets everything that cannot be moved. The standardization of operating procedures, staff training and the analysis of critical issues encountered lay the foundations for definition of best practices adaptable to different work environments.


The World Health Organization (WHO) declared the Coronavirus disease 2019 (COVID-19) pandemic on 11 March 2020. Approximately 20% of COVID-19 patients may develop a severe form of disease, which fortunately in most cases it is a mild disease. The current estimated mortality rate of COVID-19 is 2%, compared to rates of 10% and 34% in Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS) respectively.

One of the most significant challenges that COVID-19 pandemic has created is the practice of interventional radiology. In order to best ensure patient care and avoid contamination of operators, dedicated management of the complex environment of angiography rooms was necessary.

Angiography rooms are an extremely complex environment with specific characteristics that are unfortunately not always fully taken into account. The high degree of specialization of the professionals involved, the need to guarantee a 24/7 service, and the variety of devices and equipment present in the rooms are all factors that make it difficult to manage procedures on patients with COVID-19.

Careful hand hygiene, the correct use of protective equipment and strict adherence to sanitization procedures are essential measures to ensure continuity of infection control.

Materials And Methods

This work aims to guide healthcare professionals in the safe performance of interventional radiology procedures on patients with COVID-19, using appropriate management strategies, available guidelines and recommendations, creating a safe and appropriate working environment.

The research work made use of the main electronic databases of scientific literature, guidelines and scientific articles promoted or written by international scientific societies (CIRSE, ECDC, SERVEI).

From the research work and the analysis of the literature, it emerges that a rigorous training of the personnel involved in interventional radiology is necessary; that written protocols should be available in every department and easily accessible to all operators.

After identifying and separating the pathways for infected patients and defining the dressing and undressing areas for staff, a checklist was created for the preparation of the angiography room and surrounding areas.

Before a patient arrives in an interventional radiology department, it is mandatory that all preparations have been completed, using the checklist as a reference. This will reduce the unnecessary amount of time patients spend on the ward and avoid contamination of surfaces and environments. These measures include both the dressing of the staff with the personal protective equipment (PPE), indicated and shared according to the dedicated guidelines, and the setting up of the angiography room.

PPE includes masks, gowns, gloves, eye protection (goggles or face shield) and shoe covers. Sterile equipment, such as gowns and gloves, should be worn by operators on top of other protective equipment. These devices will also be in addition to the usual anti-x PPE (lead-lined gown, parathyroid, and lead-lined goggles).

With regard to the preparation of the angiography room, it is advisable to move all non-essential and mobile equipment out of the room to avoid possible contamination.

The fixed and essential contact surfaces inside the room should be covered with cloths, while plastic covers can be used to cover the angiograph controls, the injector, the ultrasound scanner and all the mobile equipment controls that will be needed during the procedure. The area in front of the angiography room, where the monitors for viewing and processing the images are located, should also be preserved with plastic covers.

It is also advisable to sanitize hands with a hydro-alcoholic solution (at least 70% alcohol) every time you leave the room to perform operations at the above-mentioned workstations and to replace the outermost pair of gloves.

Clean  and contaminated work areas should be clearly separated.

The angiography table and sterile equipment suitable for the procedure should be prepared prior to patient arrival and drugs and medications should be stored in a plastic box to be opened if necessary. In addition, a sufficient number of waste disposal containers should be placed in the room, which in our experience is at least four.

Interventional radiology personnel and administrative staff, who are not directly involved in the procedures but are located within the department, will be removed during the arrival of the COVID-19 patient and the radiographer will be responsible for the acceptance of the patient.

At the end of the procedure, staff will leave the angiography room. Healthcare professionals (interventional radiologists, radiology technician and nurses) are required to remove PPE using the undressing area to avoid contamination of themselves or their colleagues.

Used PPE should be collected in bags for disposal. Access to workstations in the post-procedure reporting area by the interventional radiologist will only be permitted after removal of PPE and appropriate hand washing. Strict staff discipline is required.

Proper cleaning of the imaging equipment and proper disposal of instruments and consumables must also be ensured. Non-disposable instruments should be placed in an antiseptic solution prior to sterilization. Personnel cleaning the room should use personal protective equipment such as FFP2 masks, non-sterile gowns, disposable gloves, goggles or face shields and over-shoes, in the same way as directly involved healthcare workers.

Exposed surfaces should be cleaned with 70% alcohol as sodium hypochlorite-based disinfectants may ruin surfaces. The use of such disinfectants is therefore preferably limited to the floor.

Results And Conclusions

The control measures described proved to be important in minimizing the risk of SARS-CoV-2 contamination and can be a valuable standardization tool during procedures on COVID patients.

The most critical issues encountered, especially during the first phase of the pandemic, were:

the correct and rigorous execution of the steps during room preparation, for which mutual control and the drawing up of a check-list were useful.

The long waiting times for transporting the patient from the inpatient ward to the interventional radiology service, which significantly increased the operators’ exposure time, the difficult availability of protective plastic headphones, the optimization of time especially in case of urgency, and finally the management of emotions.

The psychological impact of the virus on the operators was in fact one of the most difficult elements to overcome and manage. The professional adaptation reaction to the emergency was as immediate as it was sometimes problematic.

Guidelines will evolve and have local variations. Strict adoption of safe practices may increase the cost of equipment and procedural time and inevitably create new technical difficulties during procedures. On the other hand, the daily catastrophic onslaught of the spread of COVID-19 on global health systems requires aggressive preventive measures from all medical disciplines to do our part to combat this dangerous pandemic. The standardization of operating procedures, staff training and analysis of the critical issues encountered lay the groundwork for the definition of best practices adaptable to different work environments.


  1. WHO Director-General’s opening remarks at the media briefing on COVID-19 – 11 March 2020. Available from: https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19—11-march-2020
  2. Wu, Z., McGoogan, J.M. (2020). Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72 314 Cases From the Chinese Center for Disease Control and Prevention. JAMA, 323(13):1239-1242.
  3. Mahase E. (2020). Coronavirus covid-19 has killed more people than SARS and MERS combined, despite lower case fatality rate. BMJ, 368:m641.
  4. Forrester, J.D., Nassar, A.K., Maggio, P.M., Hawn, M.T. (2020). Precautions for Operating Room Team Members During the COVID-19 Pandemic. J Am Coll Surg, 230(6):1098-1101
  5. De Gregorio, M.A., Guirola, J.A., Magallanes, M., Palmero, J., Pulido, J.M., Blazquez, J., et al. (2020). COVID-19 Outbreak: Infection Control and Management Protocol for Vascular and Interventional Radiology Departments-Consensus Document. Cardiovasc Intervent Radiol, 43(8):1208-1215
  6. Ierardi, A.M., Wood, B.J., Gaudino, C., Angileri, S.A., Jones, E.C., Hausegger, K., et al. (2020). How to Handle a COVID-19 Patient in the Angiographic Suite. Cardiovasc Intervent Radiol, 43(6):820-826
  7. CIRSE–APSCVIR. Checklist for preparing IR service for COVID-19. Available at: https://www.cirse.org/wp-content/uploads/2020/04/cirse_APSCVIR_Checklist_COVID19_prod.pdf
  8. European Centre for Disease Prevention and Control. Checklist for hospitals preparing for the reception and care of coronavirus2019 (COVID-19) patients. ECDC: Stockholm; 2020
  9. De Gregorio, M.A., Serrano, L., Zárraga, F.L., Magallanes, M., Piquero, M.C., Guirola, J.A. Guidelines for vascular and interventional radiology units during the COVID-19 outbreak: a consensus statement from the Spanish Society of Vascular and Interventional Radiology (2020).
  10. Fananapazir, G., Lubner, M.G., Mendiratta-Lala, M., Wildman-Tobriner, B., Galgano, S.J., Lamba, R., et al. Reorganizing Cross-Sectional Interventional Procedures Practice During the Coronavirus Disease (COVID-19) Pandemic. AJR Am J Roentgenol. 2020 Dec;215(6):1499-1503.
  11. Tarantini, G., Fraccaro, C., Chieffo, A., Marchese, A., Tarantino, F.F., Rigattieri, S., et al. Italian Society of Interventional Cardiology (GISE) position paper for Cath lab-specific preparedness recommendations for healthcare providers in case of suspected, probable or confirmed cases of COVID-19. Catheter Cardiovasc Interv. 2020 Oct 1;96(4):839-843.
  12. Too, C.W., Wen, D.W., Patel, A., Abdul Syafiq, A.R., Liu, J., Leong, S.,et al. Interventional Radiology Procedures for COVID-19 Patients: How we Do it. Cardiovasc Intervent Radiol. 2020 Jun;43(6):827-836.
  13. Ferioli, M., Cisternino, C., Leo, V., Pisani, L., Palange, P., Nava, S. Protecting healthcare workers from SARS-CoV-2 infection: practical indications. Eur Respir Rev. 2020 Apr 3;29(155):200068.

Telerehabilitation As An Opportunity In Physiotherapy:


Submission Date: 2022-05-03
Review Date: 2022-05-17
Pubblication Date: 2022-05-30


Telerehabilitation (TR) is a peculiar method of rehabilitation practice that refers to the use of information and communication technologies to provide services at a distance intended to enable, restore or otherwise improve the physical and mental functioning of people of all ages, with disabilities or disorders, congenital or acquired, transitory or permanent, or at risk of developing them[1]. One possible area of application of TR is the management of patients with non-specific low back pain (NLBP). NLBP is generally localised between the margins of the lower ribs and the gluteal folds, with a high prevalence rate in the population with an associated risk of chronicization if not adequately managed, and extremely high treatment costs[1]. Conventionally, the clinical management of NLBP is based on face-to-face interactions between the healthcare provider and the patient. However, this approach is expensive and not accessible for a large number of patients, particularly those living in remote locations. As the use of technology continues to advance, TR has emerged as a potential alternative for the management of patients. To make digital technologies lead to improved quality and sustainability of care, they must be introduced as part of a diagnostic-therapeutic care modela. Therefore, this work developed a proposal for a diagnostic and therapeutic care pathway (DTCP) that includes TR in the management of patients with low back pain. The DTCP is the tool aimed at implementing the guidelines or the best scientific evidence in the literature and results from the integration of two components:

  • The recommendations of guidelines and/or good clinical practice;
  • Local contextual elements that may affect their application.

Purpose And Area Of Application Of The Dtcp

The proposed DTCP aims to achieve a gradual transition from a specialised management of NLBP to a process-based management of it, including TR; it also aims to reduce the variability of behaviour, maintaining the most appropriate and virtuous ones, by defining:

  • the best sequence of actions,
  • the optimal timing of interventions,
  • the re-examination of the experience gained by healthcare professionals[2].

The following DTCP applies to patients with NLBP who come, with a referral from the general practitioner (GP), to the outpatient territorial rehabilitation service and who are considered suitable for the activation of the TR service, after an assessment by a multidisciplinary team.


NLBP is a very frequent osteoarticular disorder in the world population: it has a lifetime prevalence of approximately 80%[2]. NLBP represents approximately 90% of all cases of low back pain and affects men and women equally. It often occurs mostly between the ages of 30 and 50 and involves very high individual and social costs in terms of diagnostic investigations and treatment, it reduces productivity and the ability to carry out daily activities. For people under 45 years of age, NLBP is the most common cause of disability[1],[2]. With this in mind, it is clear that NLBP may be one of the most frequent causes of direct access to the general practitioner (GP), since the latter is almost always the first health care provider to begin the care pathway of a patient with low back pain[2].

Prerequisites For Enabling Telerehabilitation Services

Healthcare organizations can provide TR interventions, as part of the services paid for by the National Health Service, only if they are accredited for those care activitiesc.  TR services are designed in accordance with the general principles and methodologies of telemedicinea. The TR interventions must be planned and delivered in the appropriate ways and times, according to scientific evidence, guidelines and good clinical and care practices, based on the assessment of needs and preferences of the patient and socio-environmental needs detected; this also in order to  allow the verification of the appropriateness and proper use of resources[3]. In Figure 1 is schematized the path of management of NLBP according to NICE guidelines[2].

Fig. 1 Flow chart on the management pathway for the patient with NLBP according to NICE guidelines[2].

Conditions related to telecommunication infrastructures

Connectivity at the patient’s home

In order to organise the best service for each person taking into account connectivity, it is sufficient to know:

  • if there is a WiFi or cable connection at home,
  • how far away from the router the person usually connects
  • what type of digital devices are available and connectable to the network
  • what is the level of mobile connectivity within the home

[4] NICE guidelines, 2016. Low back pain and sciatica in over 16s: assessment and management

Connectivity of the location from where the healthcare professionals operate.

Within healthcare facilities, it is recommended to perform connection speed tests and to verify the actual ability of the local network to support data traffic against the average volume of simultaneous requests[5].

Conditions related to the security of personal data and digital devices present in the user’s home

For the patient’s safety, healthcare personnel working in telemedicine are required to comply with the rules on the proper handling of patients’ personal data, as well as to avoid behaviour that may facilitate possible cyber attacks. In this respect, the “Guidance Document of the National Study Group on Cybersecurity in Health Services”[6] has been published by the Istituto Superiore di Sanità. With regard to the processing of health data, it is necessary that the TR systems are adherent to the General Data Protection Regulation, also known as General Data Protection Regulation (GDPR), approved with “EU Regulation 2016/679” of the European Parliament and Council of 27 April 2016[7] and adapted to national legislation with the issuance of Legislative Decree 10 August 2018, n.101[8].

In addition, it is necessary that the medical devices used are certified according to the new “Medical Device Regulation (EU) 2017/745 (MDR)”[9].

Conditions relating to the ability of the person at home to collaborate with healthcare professionals

In order for a telemedicine service to function properly, both healthcare professionals and patients need to be trained in its use. To this end, a periodic training plan should be put in place to ensure that the skills of staff involved in the management and use of telemedicine services are maintained over time. Patients should be trained through various forms of tutorials. In addition, it is advisable to warn the person for whom the service is intended that data traffic, when telemedicine is activated at home, will necessarily be higher than usual[5].

Strengths And Limitations Of Telerehabilitation

The introduction of TR services can offer several advantages for the physiotherapist, the patient and  society:

  • it provides continuity of care up to the patient’s home;
  • it removes barriers for the patient such as travel time, parking, and waiting rooms;
  • it better adapts the frequency and intensity of treatment to the needs and preferences of the patient, his or her family and other caregivers and it helps increase adherence to the cure;
  • it alleviates the overall burden of patients with NLBP, and/o reduces the costs of the health care service;
  • it facilitates surveillance activities, health education, and the application or adoption of sound self-management practices;
  • it facilitates a multidisciplinary approach in rehabilitation, allowing, for example, monitoring of the patient with NLBP in collaboration with a physician or psychologist[3];

However, some limitations should be kept in mind:

  • lack of a specific TR management option for the patient with NLBP[4]
  • not all physiotherapists have the adequate competences in performing remote services
  • proliferation of different digital service providers
  • possible inadequacy of the Internet connection
  • both the physiotherapist and the patient must have access to the necessary technology and be familiar with it[10].

Verification Of The Possibility Of Activating The Telerehabilitation Service In The Proposed Dtcp

Based on the preliminary conditions necessary for the activation of the TR services described above, in the proposed DTCP the inclusion and exclusion criteria of the patient with low back pain were identified. The patient who enters the territorial outpatient rehabilitation service with a referral from the GP, is evaluated, in presence, by the team composed of a physiatrist, a physiotherapist and a psychologistc. Before activating the TR service it is necessary:

  • Exclude red flags requiring urgent medical intervention: malignancy, inflammatory disorders, fractures, infections and cauda equine syndrome[11].
  • Exclude specific low back pain conditions, where pain and symptoms can be directly attributed to a pathology associated with the myo-osteo-articular system[11].
  • Ensure that the patient is able to understand requests, read and transmit relevant data, use technological devices and has an adequate Internet connection[5].

Once a patient has been accurately assessed and diagnosed with NLBP, he or she is stratified according to his/her risk of developing chronic-persistent pain, using the Keele Start back screening tool[5]. This questionnaire is a prognostic indicator validated in the literature that can be easily integrated into TR [5],[6].

Tab. 1 – Keele Start back screening tool questionnaire

Once the results of the questionnaire have been obtained, it is possible to identify 3 subgroups of patients according to their risk of chronicization:

  • 0-3 low risk
  • >3 medium risk
  • ≥ 4 in items 5 to 9, high risk

On the basis of this classification, the health care team should:

  • define the objectives that can be pursued through the individual rehabilitation project (IRP);
  • identify the most suitable type of treatment (synchronous, asynchronous or mixed);
  • define the time required to achieve the set objectives (frequency and duration of the sessions and duration of the project);
  • foresee a verification phase in TR of functional and care outcomes, also evaluated from the patient’s perspective.
  • prepare a risk assessment plan[3].

Pathway Flow Chart

Fig. 2 Flow chart diagnostic and therapeutic care pathway (DTCP) in the patient with NLBP.

Physiotherapy Digital Health Platform

A digital health platform is used in the DTCP which allows the physiotherapist to:

  • Prescribe exercise programs, present in the platform (or upload your own).
  • Provide educational material via PDF or educational videos

It also allows professionals of the team to safely perform synchronous teleconsultation.

Patients access the service by downloading a free app on their smartphone/tablet (via App Store or Google play) or by using the app directly from their computer (via Google Chrome or Firefox). Internet connection is required. The patient accesses the App via a link, sent by the physiotherapist; patients are able to view the rehabilitation programme created by the physiotherapist and do the exercises via pre-recorded videos. The system allows patients to print out the exercise programme, set exercise reminders via alerts or email and send messages to team members. The physiotherapist can modify the rehabilitation programme for the patients and view reports on the completion of the exercises performed by the patient. Furthermore, there is the possibility to administer various outcome assessment tools to monitor the patient’s results over time.

Platform Security

The platform complies with the legal framework for the processing of personal data (GDPR) for the transmission and storage of electronic medical information. Video and audio are encrypted. Certified engineering.

Synchronous Teleconsultation Activation Process

The process of activating synchronous teleconsultation by video call is managed by the district coordinator, who must be able to consult the list of all online users and all healthcare providers.

The person receiving the service should always be informed that the reference operator with whom he/she is making the video call may not always be available, but that there will always be another operator who will answer and share the information with his/her colleagues. The teleconsultation activation process is carried out through the following procedures:

  1. The patient downloads the App on the smartphone/tablet from the App Store or Google Play or opens the webpage via computer with Google Chrome or Firefox.
  2. The patient will receive a pass code to enter, along with the year of birth, to access the App.
  3. Once the patient is connected to the App, a video call begins, in which the coordinator identifies the patient and informs the patient of the date and time of the interview with the referring healthcare provider.

In order to identify the patient, at the beginning of the video call, the patient is asked to show him/herself and at the same time show a valid identity document to the camera, noting the details of the document itself. It is verified that the patient is in a quiet, spacious and well-lit environment. The appropriate camera angle is also identified. To improve audio quality, it is recommended to use a headset with a microphone. However, if you do not have a headset it is important to check that the computer microphone is working.

  •  When the time for the appointment with the physiotherapist arrives, patients simply log on to their account and wait for the call. In the meantime, informed consent and the consent to process health data is requested. The consent is repeated for each service and the risks involved are specifically explained, such as the risks associated with the lack of physical contact and direct observation in the presence of the physiotherapist[12]. The patient must be able to withdraw his or her consent to the use of TR services at any time. In this case the multidisciplinary team must re-evaluate the patient and redefine the IRP, taking into account the new needs and preferences expressed by the patientc. The patient can’t call the physiotherapist, while the latter may invite, with the patient’s consent, other users (including other health professionals).
  • After reading and giving consent, the patient can communicate with the physiotherapist via encrypted audio and video.

Patients with problems in connecting to the Internet and who are unable to use technological devices are referred to face-to-face interventions.

Treatments Performed

The physiotherapist, as a health professional, must scrupulously follow the health guidelines and protocols as defined by the Gelli-Bianco law[13]. The current practical guidelines for the management of low back pain on the website of the Istituto Superiore di Sanità, which must be followed in terms of professional responsibility, recommend: patient education, self-management, cognitive-behavioural therapy, exercise prescription and pharmacological therapy[14]. All these treatment components could be provided through TR[4] acting as a supplement to the usual physiotherapy, but not as a substitute intervention[4],[7].

Remote physiotherapy intervention

The physiotherapy intervention in TR in NLBP is carried out using the App through the hybrid modality that includes both synchronous counselling (provided in real time and therefore in on-line presence) and asynchronous counselling (provided in deferred time and off-line). The synchronous counselling takes place through video call and is used to educate and motivate the patient, to give feedback on the correct execution of the exercises and to make any changes to the rehabilitation programme; the asynchronous treatment takes place through the sharing by the physiotherapist of the rehabilitation programme that the patient can consult with pre-recorded videos of the exercises present in the digital platform and through the sending of educational material.  Basically, remote physiotherapy intervention is based on 3 components:

  • Therapeutic education:
    • provide reassurance about the benign nature of NLBP, explain that a severe disease is unlikely to be present.
    • explain that medical imaging is not required and will not change the management
    • avoid using terms such as injury, degeneration, or wear and tear
    • encourage the patient to remain active and avoid bed rest, continue daily activities, stay at work, or return as soon as possible
    • encourage the patient to take responsibility for his/her own management on an ongoing basis
    • avoid language that promotes fear of pain and catastrophic thinking (e.g. “let pain be your guide”, “stop if you feel pain” and “you must be careful”)
  • Therapeutic exercise: exercises based on the principle of “core stability” and progressive aerobic exercise.
  • Health coaching: includes motivational phone calls to support patients to gradually increase their leisure time and occasional physical activity[4],[7].
Psychological intervention

The psychological intervention is based on the principles of cognitive-behavioural therapy. In particular, the patient’s recurrent thoughts, fixed patterns of reasoning and interpretation of reality are identified; through gradual exposure of the patient to feared situations, an attempt is made to make him/her learn new ways of responding to states of discomfort.

Physiatric intervention

Definition of the individual rehabilitation project (IRP)[15] and prescription of any pharmacological therapy.

Monitoring And Control

This DTCP is controlled/monitored by the district coordinator through the following flow indicator (Table 2):

IndicatorNumeratorDenominatorExpected standardSource
Patients who have activated the TR service with the AppNumber of patients who managed to have access to the appNumber of patients contacted90%Digital patient data management platform
Tab. 2 DTCP flow indicator.

Data management

All data from the app are synchronised, stored and analysed via a digital platform managed by a team of engineers and statisticians. This digital platform provides the collection of patient data such as:

  • Pain and ability levels
  • Specific treatment outcomes from the exercise programme
  • Adherence to prescribed exercises
  • Responses to patient recorder outcome measures (PROMs).

The instruments used to measure the various patient outcomes are:

  • Owestry Disability Index (ODI) for physical function[8],[9]
  • Visual analogue scale (VAS) for pain[8],[9]
  • PROMIS-10 module for quality of life[10]
  • Fear avoidance belief questionnaire (FABQ) to measure beliefs about fear and movement avoidance[11]
  • Telehealth usability questionnaire (TUQ) to measure patient satisfaction and their perceptions of the treatment provided[12].

The data of the App are then integrated with those of the computerised medical record and interpreted by the coordinator of the territorial rehabilitation service in order to check the achievement of the planned objectives and possible deviations.

Economic Evaluation

The economic evaluation of the following DTCP is carried out through a cost-effectiveness analysisa,[13].

This analysis is carried out by comparing the costs of the treatment programme (both in TR and in presence) with the age-weighted life years gained (quality-adjusted life years, QUALYs).

For the evaluation of the costs it is necessary to take into account the material needed for remote rehabilitation:

  • Digital physiotherapy platform: x monthly per physiotherapist
  • Digital platform for data storage and analysis: x monthly
  • Connectivity costs related to the use of the platform (variable).

For the assessment of QUALY, the Owestry disability index scale is used as a tool to measure quality of life.

Remuneration Of Telerehabilitation Services

The State-Regions Agreement of 10th September 2020 concerning the “Provision of outpatient specialist services at a distance-telemedicine services “p establishes that for all the healthcare services provided at a distance, the national/regional regulatory framework that regulates access to the various Essential Levels of Care is applied. In particular, TR services provided in an outpatient setting are remunerated at the rate applied to the same services provided in a “traditional” manner[3].


The proposed DTCP for the management of the patient with NLBP takes into account the strengths and limitations of TR described in the scientific literaturec,j,[3] and can represent a reference model at national level for the application of TR in patients with NLBP accessing the outpatient territorial rehabilitation service. However, it is necessary that this DTCP proposal is adapted to the specific regional socio-legislative context, taking into consideration the various technological and economic availabilities and the skills of the healthcare professionals, with the creation of an interdisciplinary group of professionals involving also the governing bodies. Finally, once adapted to the local context, the DTCP needs to be disseminated within the specific health facility and in the general population, implemented, monitored and controlled over time, assessing both its effects on patient outcome and from an economic point of view. The integration of TR with traditional clinical practice could significantly reduce the costs of care pathways (e.g. unnecessary imaging or invasive treatments) and also avoid the transition to chronicization by promoting the self-management of patients with NLBP[6],[13],[11].


The authors would like to thank Tardioli Valentina for the translation of this paper.


  1. Ajay Premkumar et. al. (2018) “Red Flags for Low Back Pain Are Not Always Really Red: A Prospective Evaluation of the Clinical Utility of Commonly Used Screening Questions for Low Back Pain”. The Journal of bone and joint surgery
  2. Peter O’Sullivan (2005) “Diagnosis and classification of chronic low back pain disorders: maladaptive movement and motor control impairments as underlying mechanism”. Manual therapy
  3. Michelle Cottrell et. al (2017) “Real-time telerehabilitation for the treatment of musculoskeletal conditions is effective and comparable to standard practice: a systematic review and meta-analysis”.  Clinical rehabilitation.
  4. Amabile Borges Dario et. al. (2017) “Effectiveness of telehealth-based interventions in the management of non-specific low back pain: a systematic review with meta-analysis”. The spine journal: official journal of the North American Spine Society
  5. Jonathan C. Hill (2008) “A primary care back pain screening tool: Identifying patient subgroups for initial treatment”. Arthritis Care & Research
  6. Tjarco Koppenaal et. al. (2020) “Effectiveness and cost-effectiveness of stratified blended physiotherapy in patients with non-specific low back pain: Study protocol of a cluster randomized controlled trial”. BMC Musculoskeletal Disorders
  7. Shizheng Du et. al. (2019) “The efficacy of e-health in the self-management of chronic low back pain: A meta-analysis”. International Journal of Nursing Studies
  8. Fuensanta Palacín-Marín et. al. (2013) “Agreement between telerehabilitation and face-to-face clinical outcome assessments for low back pain in primary care”. Spine
  9. Alessandro Chiarotto et. al. (2018) “Core outcome measurement instruments for clinical trials in nonspecific low back pain”. Pain
  10. Sang Pak et. al. (2021) “Use of the PROMIS-10 global health in patients with chronic low back pain in outpatient physical therapy: a retrospective cohort study”. Journal of patient-reported outcome
  11. Seth Peterson et. al (2018) “Use of a modified treatment-based classification system for subgrouping patients with low back pain: Agreement between telerehabilitation and face-to-face assessments”. Physiotherapy theory and practice.
  12. Bambang Permanto et. al. (2016) “Development of the Telehealth Usability Questionnaire (TUQ)”. International journal of telerehabilitation.
  13. Francis Fatoye et. al. (2020) “The Clinical and Cost-Effectiveness of Telerehabilitation for People with Nonspecific Chronic Low Back Pain: Randomized Controlled Trial”. JMIR mHealth and uHealth


  • [1]Ministry of Health, 2014: Telemedicina – Linee di indirizzo nazionali
  • [2]Stefano Govannoni, Silvia Minozzi, Stefano Negrini with the participation of the following Scientific Societies: SIMG, SIMFER, SIMLII, SIN, SINCH, SIOT, SIR, AIFI, 2006: Percorsi diagnostico terapeutici per l’assistenza ai pazienti con mal di schiena.
  • [3]Ministry of Health, 2021: Indicazioni per l’erogazione di prestazioni e servizi di TR da parte delle professioni sanitarie, dei medici e degli psicologi.
  • [4]NICE guidelines, 2016. Low back pain and sciatica in over 16s: assessment and management Assessments of the patient’s suitability to use TR services are carried out during multidisciplinary assessments in presence, aimed at defining or reviewing the Individual Rehabilitation Project (IRP). On this occasion, the multidisciplinary team, referring to the International Classification of Functioning, Disability and Health (ICF), will check the presence of enabling factors and/or barriers to the patient’s use of TR services, taking into consideration the psychoeducation and training of the patient and caregiver in relation to the activities to be performed at a distance. Where necessary and possible, the multidisciplinary team identifies strategies and implements solutions to remove these barriersc.
  • [5]Istituto Superiore di Sanità, 2020. Indicazioni ad interim per servizi assistenziali in telemedicina durante l’emergenza sanitaria COVID-19.
  • [6]Istituto Superiore di Sanità, 2019. Buone pratiche per la sicurezza informatica nei servizi sanitari.
  • [7]Official Journal of the European Union, 27th April 2016. Regulation (EU) 2016/679 of the European Parliament and of the Council on the protection of natural persons  with regard to the processing of personal data and on the free movement of such data, and repealing Directive 95/46/EC (General Data Protection Regulation).
  • [8]Official Gazette of the Italian Republic, 10th august 2018. Disposizioni per l’adeguamento della normativa nazionale alle disposizioni del regolamento (UE) 2016/679 del Parlamento europeo e del Consiglio.
  • [9]Official Journal of the European Union, 5th April 2017. Regulation (EU) 2017/745 of the European Parliament and of the Council on medical devices, amending Directive 2001/83/EC, regulation (EC) n. 178/2002 and regulation (EC) n.1223/2009 and repealing Council Directives 90/385/EEC and 93/42/EEC.
  • [11]International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT), 2020: opinion on the effectiveness of physiotherapy management of neuro-musculo-skeletal disorders by telerehabilitation
  • [12]AIFI-Commissioni di Albo dei Fisioterapisti, 2020. Nota sulla Rimodulazione degli Interventi fisioterapici nell’emergenza COVID-19.
  • [13]Official Gazette of the Italian Republic, 8th March 2017. Disposizioni in materia di sicurezza delle cure e della persona assistita, nonché in materia di responsabilità professionale degli esercenti le professioni sanitarie.
  • [14]Department of Veterans Affairs; Department of Defense, 2017. VA/DOD clinical practice guideline for diagnosis and treatment of low back pain
  • [15]Permanent Conference for relations between the State, the Regions and the Autonomous Provinces of Trento and Bolzano, 30th May 1998: Linee guida del Ministero della Sanità per le attività di riabilitazione

Communication Of Environmental Risk

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Submission Date: 2022-05-02
Review Date: 2022-05-16
Pubblication Date: 2022-05-29



Risk communication plays a key role in crisis management; as such, this paper aims to investigate the issue in the context of public debate linked to a specific case study. The case considered here is that of overflows at the outflow the sewage treatment plant of the city of Lignano and the discovery of contaminated shellfish in the lagoons of Grado and Marano between 1 February 2017 and 30 June 2019. The survey is structured through a quantitative and qualitative analysis of the media coverage content with a focus on the actual institutional control and monitoring activity in the affected region. Three of the main figures involved in the case were also interviewed in support of this investigation.
The results confirm greater interest on the part of mass media in events capable of generating controversy with multiple exchanges between the parties involved. Within the media arena, there is a proactive behaviour by the local political sources that have, indeed, guided the debate with respect to the institutions, and the competent authorities that have taken a passive stance. This choice did not favour the formation of a suitable risk perception on the part of citizens, because, since they were not exhaustive in responding to the concerns expressed by the population, inevitably the institutions have created an environment in which the trust placed in them by the people may be undermined. An example is given by the focus on the control and monitoring activities of ARPA [regional environmental regulatory agency] that shows a considerable presence in the field with over five thousand samples aimed at protecting the environment and public health; however, this Agency was widely attacked in the media as these activities were not made clear in the subsequent debate. It is therefore essential to carry out interventions in which the processes of listening to and the participation of citizens play a central role. Paying attention to and understanding the public's concerns about the dangers to health and the environment are essential aspects of risk communication in which public bodies and institutions in Italy should invest more, thus also optimising the aspects of risk management related to communication itself and, at the same time, guaranteeing citizens the right to information. Some statements made during the interviews, as well as certain activities undertaken by the competent authorities, therefore seem to be a good omen for the future insofar as greater investment in institutional communication will surely allow for an improvement both in the relationship of trust with the population and risk management. The improvement in the latter will also improve all the economic aspects related to the acceptability of the risks themselves that, at this point in history, represent the basis for a country's growth.


Given the historical period in which we are living, this article aims to investigate aspects related to the communication of environmental risk that develop in the context of public debate on a current and real case study. The case considered here is that of the spillages at the outflow of the sewage treatment plant in the city of Lignano and the discovery of contaminated shellfish in the lagoons of Grado and Marano between 1 February 2017 and 30 June 2019, the deadline set for data collection. Given the nature of the case, the study is articulated across observations of the communication dynamics between the different stakeholders involved, through an analysis of media coverage, and by carrying out a focus on the actual institutional control and monitoring activity carried out by the Regional Agency for Environmental Protection of Friuli-Venezia Giulia (ARPA FVG) in the Grado and Marano lagoons. In support of the paper, interviews were carried out with three of the main figures involved in the case.

Within the event described, there are, therefore, numerous protagonists. However, the main players around which the story was structured are: ARPA FVG, CAFC SpA, that is, the manager of the integrated water service of central Friuli, and the Five Star Movement (Movimento Cinque Stelle, M5S) that, in Friuli-Venezia Giulia, after the regional elections of 2018, is a political party belonging to the opposition .

The case

The story began in 2017 with a representative of the M5S who, having been alerted by citizens, accused the sewage treatment plant of the city of Lignano of not complying with microbiological regulations regarding its output, bringing as an example some excessive levels identified by ARPA FVG during its surveillance of the plant. Subsequently, an alert was triggered involving bivalve molluscs cultivated in the lagoons of Grado and Marano. This was due to the contamination of the seafood by the same species of bacteria due to which the sewage treatment plant exceeded regulatory levels. The political party, therefore, directly accused the plant manager of being responsible for this state of affairs. The company responded by explaining that the problem is, in fact, complex, and due to the concomitant occurrence of several contamination matrices, and that, in any case, with respect to the overruns attributed to them, the company took action to resolve the situation. Throughout all this, the competent authorities rarely took a stance in relation to the solutions and activities introduced to solve the problem. This raised concern in the population involved, especially in farms dependent on the cultivation, sale and use of the shellfish themselves. It should be noted that the ordinances issued by the Healthcare Authority No. 2 (AAS No. 2) remained active for 13 months, interspersed by two breaks, one of four and one of two months, over the course of the three years during which the affair took place. On 30 June 2019, these measures are still active. Table 1 offers a summary of the main events of the story.

Tab. 1Timeline of main events

Methodology And Materials

As already stated in the introduction, this article aims to observe and understand the communication dynamics between the different stakeholders in the context of the case study under consideration, with a focus on the institutional activity of ARPA FVG. To achieve this objective, it was decided to 1) analyse the Agency’s field work on the case; 2) carry out an analysis of the media coverage offered by the regional press; 3) interview some of the representatives involved to clarify and further investigate the story. With regard to media coverage, an analysis of the content of the articles appearing in the local press was carried out. By contrast, to outline ARPA’s work, the most significant internal documents were viewed and searches were carried out through the Agency’s reporting software.

Institutional role of ARPA FVG

The section focused on ARPA FVG analyses the activities undertaken by the Agency in the lagoon area. The information relating to the types and methods of the aforementioned activities were obtained thanks to the current legislation that regulates them and the descriptions reported on the Agency’s official website and collected during the internship activities. Finally, to obtain the data necessary to quantify the field work carried out by the different components of ARPA, the reporting software developed by SAP Business Objects was used. In addition to this, the main software of the ARPA FVG laboratory called LIMS EuSoft.Lab 10 was also used. The search analysis was carried out through the selection of prompts, that is, keywords necessary for the search itself. Below is an example:

“category: e.g. sea water, product: suitability for life of shellfish, subject: Adriatic Sea – Mollusc cultivation, municipality: Lignano Sabbiadoro, year of arrival: 2015.”

The data obtained was exported into Microsoft Excel software in order to better manage the analysis during the drafting of the paper.

Content analysis

In the 1950s, the American sociologist Bernard Berelson defined content analysis as a research technique for the objective, systematic and quantitative description of the manifest content of communication. This definition has been subject to various critiques over the years, many of which have focused on the presumption of objectivity of this type of study. Indeed, a portion of the results inevitably become subjective because they are linked to the choices and interpretations of the researcher, although at least the reproducibility of the research procedures can be guaranteed. The ultimate aim is to provide the study with the necessary characteristics of intersubjectivity to allow different scholars to reach the same results by applying the same procedures. It is therefore important that the researcher explains in advance and in detail both the objectives of their investigation and the procedures for selecting and classifying the materials examined.

To date, content analysis includes numerous quantitative-qualitative techniques for the study of images and texts, making it difficult to come to a single comprehensive definition. In the context of this paper, we have limited ourselves to examining its use in the analysis of written texts, applying it to articles published in the press. The objectives of this research methodology are to facilitate the analysis of a collection of texts by reducing their complexity and to deduce the relationships between the texts in question and the socio-cultural context in which they were produced, using reproducible procedures for classifying textual elements. Regarding the preceding point, content analysis is usually applied to the study of the mass media to investigate values, opinions, attitudes, prejudices and stereotypes that, in a given historical and cultural context, are prevalent in public opinion.

The content analysis research design must first define the realm in which it will be carried out, i.e. choose the sources of the textual corpus that will be investigated and the timeframe within which the publications have taken place. In this article, we chose the texts published by all the regional newspapers and the press releases of the bodies involved on the case of the overruns at the Lignano sewage treatment plant and the contaminated shellfish in the lagoons of Grado and Marano. The period of time analysed for the formation of the textual corpus ranges from February 2017, the month in which the M5S claims to have received the first complaints from the population, to 30 June 2019, the deadline set for the collection of data.

The next step is to outline the procedures for constructing the textual corpus, thus ensuring its reproducibility. To this end, it is necessary to consider how the aforementioned is composed of a set of analysis units, the true subject of the investigation, each of which corresponds, within this study, to a single journalistic article. Once the unit of analysis is chosen, we continue with the description of the procedure for the collection of texts. For this paper, we opted for a digital press review obtained by searching two sources capable of providing the articles of interest using appropriate keywords. These tools are the ARPA FVG intranet and the Google search engine that, to better obtain the articles published in previous years, was queried in the “news” section, setting a search by date starting from February 2017, while, for the most recent articles, we simply used keywords without any filters. The analysis units coming from the ARPA FVG intranet were thus obtained by entering the following expressions into its search engine, found under the “communication” header and then “press review”: “Lignano sewage treatment plant”, “Grado and Marano lagoon”, “Lignano”, “Grado”. On the other hand, the following keywords were used to reach news items via Google: “ban on the consumption of Lignano shellfish”, “Salmonella Lignano”, “CAFC Lignano”, “Friuli shellfish”, “FVG clams”, “Lignano sewage treatment plant”, “Lignano lagoon emergency”. It should be remembered that this research methodology for the creation of the text corpus, despite the use of keywords capable of ensuring reproducibility, is not completely free from the subjectivity of the researcher, both for the choice of the keywords themselves, and for the need to evaluate the texts as more or less relevant for the ongoing research, thus deciding on their possible inclusion or exclusion. However, if the object of study has been well delineated, this subjectivity affects a small portion of the articles, thus becoming negligible. The full text corpus is presented in Table 2. It consists of 39 journalistic articles published between 1 February 2017 and 30 June 2019. Each analysis unit reports the date of publication, the author (if any), the newspaper, the title and the link to the article page (where possible).

The last phase of the content analysis is the definition of the survey parameters, also called codes, on the basis of which the texts will be classified. It is therefore a question of defining the so-called coding frame, that is, the interactive process through which each unit of analysis will be uniquely classified according to the codes used. These survey parameters may include open answers (for example the title, the author or the header to which they belong) or closed answers (for example the presence or absence of a terminology item, images), but the values that can be attributed to them must have exclusive characteristics. Finally, codes must be chosen in such a way as to guarantee independence between them, i.e. the value of a single code must not influence that of others. At this point, the qualitative-quantitative analysis of the body of text has taken shape and the research requirements that define the text classification parameters will depend on the achievement of more or less significant results with respect to the hypotheses and objectives of the survey.


As for the interviews, as already specified, they are able to clarify and deepen some issues dealt with through a conversation with some of the subjects involved. Specifically, interviews were held with: Dr. Marco Gani, head of the institutional communication function and press office of ARPA FVG; the regional councillor of Friuli-Venezia Giulia, XII Legislature; Cristian Sergo, a member of the M5S; a Messaggero Veneto journalist, Francesca Artico, who wrote several articles on the case. In principle, we had also contacted CAFC SpA to organise an interview with one of its representatives, but the company’s communication contact stated that the official information relating to the specific case can be viewed on the company website.

The type chosen for these interviews is defined as semi-structured because it is able to remain open to the highlighting, by the interviewees, of issues that had not been considered in the first place by the interviewer, thus allowing for a more incisive integration of the story. This method allows the questions not to be restricted to a specific number or topic. On the contrary, if the possibility of investigating a further context is created, the interviewer is free to do so. In addition, if problems are encountered such as to compromise the continuation of the interview, the answer to a partial number of questions is also accepted. The structure of the conversations thus includes eight questions per subject. The first half is asked to all respondents, while the next four questions are specific to the context, thus varying from person to person. The maximum duration of each interview is set at around 45 minutes. For the carrying out of the interview, face-to-face meetings or telephone calls are accepted in line with the availability of the interviewee and the interviewer. All interviews were recorded and transcribed by the interviewers.

27/10/2017Luana de FranciscoMessaggero VenetoARPA fines the Lignano sewage plantNo
29/10/2017Viviana ZamarianMessaggero VenetoMunicipality calls for an assembly on sewage plantNo
31/10/2017NoMessaggero VenetoSergo (M5S): “Oversights on the part of the Province”No
15/05/2018DraftingUdineTodayThe ban on the direct consumption of seafood from Lignano Pineta is still in forcehttp://www.udinetoday.it/politica/m5s-sergo-divieto-consumo-diretto-molluschi-mare-di-lignano.html14/04/2019
30/05/2018NoIl PiccoloFocus on food safety of molluscsNo
07/06/2018NoIl PiccoloMolluscs, more safety without penalising fishingNo
20/09/2018NoMessaggero VenetoShellfish harvesting: no more Sergo ordinances: we deserve itNo
13/10/2018DraftingUdineTodayAfter 4 years, salmonella returns to the clams of our regionhttp://www.udinetoday.it/cronaca/salmonella-molluschi-m5s-vongole-laguna-lignano-sabbiadoro-2018.html14/04/2019
17/10/2018NoARPA FVG news archiveWater and shellfish sampling in Lignanohttp://www.arpa.fvg.it/cms/hp/news/index.html?page=1814/04/2019
17/10/2018NoIlFriuli.itShellfish: bacteria alerthttp://www.ilfriuli.it/articolo/Cronaca/Molluschi-points _alarme_per_la_presenza_di_bacteri/2/18759014/04/2019
17/10/2018DraftingUdineTodaySalmonella and escherichia coli in the water of Lignano in ARPA sampleshttp://www.udinetoday.it/cronaca/analisi-arpa-salmonella-escherichia-coli-acqua-lignano-sabbiadoro.html14/04/2019
17/10/2018Francesca ArticoMessaggero VenetoShellfish, prohibition of harvesting up to LignanoNo
17/10/2018ARC/ARPA/Redregione.fvg.itEnvironment: ARPA, water and shellfish sampling in LignanoNo
18/10/2018Antonella LanfritIl Gazzettino“Lignano, bacteria all along the coast”No
18/10/2018NoMessaggero VenetoARPA starts further laboratory analysis sampling this weekendNo
18/10/2018Francesca ArticoMessaggero VenetoBan on shellfish and clam sales dwindle in MaranoNo
21/10/2018DraftingUdineTodayContaminated shellfish water analysis: Lignano approved, Tagliamento rejectedhttp://www.udinetoday.it/cronaca/molluschi-contaminati-le-analisi-lignano-promossa-nel-tagliamento-alte-concentrazioni-batteriche.html14/04/2019
21/10/2018Francesca ArticoMessaggero VenetoContaminated shellfish in lagoon drop in Legambiente areaNo
22/10/2018NoARPA FVG news archiveARPA water analysis in Lignano: first resultshttp://www.arpa.fvg.it/cms/hp/news/index.html?page=1814/04/2019
22/10/2018NoMessaggero VenetoARPA analyses sea water: there are no dangerous bacteriaNo
22/10/2018ARC/ComArpa/EPregione.fvg.itEnvironment: Lignano seawater analysis rules out bacterial contaminationNo
01/11/2018Fabio Folisifriulisera.itLignano Sabbiadoro sewage plant: possibly not fit for purpose. In the past, the limits of escherichia coli better known as “poop” had been exceededhttps://friulisera.it/depuratore-di-lignano-sabbiadoro-ce-il-dubbio-che-sia-insufficiente-in-passato-erano-stati-superati-i-limiti-di-escherichia-coli-meglio-nota-come-cacca/14/04/2019
30/11/2018Fabio Folisifriulisera.itMarano lagoon and the Lignano sewage treatment plant. Allegations of contamination by a young biologist-fisherman are also confirmed in some aerial photosNo
22/01/2019NoIlFriuli.itSparring match regarding the Lignano sewage treatment planthttp://www.ilfriuli.it/articolo/cronaca/botta-e-risposta-sul-depuratore-di-lignano/2/19212214/04/2019
23/01/2019Lisa ZancanerIl GazzettinoLignano, controversy over the sewage treatment plantNo
23/01/2019Nicoletta SimoncelloMessaggero Veneto“Lagoon contaminated by wastewater: fault of the sewage treatment plant”No
23/01/2019Giulio GarauIl PiccoloClam farms halted but there are no more on the islandNo
23/01/2019NoIl PiccoloThe Region establishes two “focus groups” on the shellfish caseNo
12/02/2019NoARPA FVG news archiveAquafarm 2019http://www.arpa.fvg.it/cms/hp/news/index.html?page=1214/04/2019
18/02/2019DraftingTrieste All NewsSergo (M5S): “Shellfish ban, ARPA finds salmonella in the Lignano sewage treatment plant”https://www.triesteallnews.it/2019/02/18/sergo-m5s-molluschi-vietati-arpa-trova-salmonella-nel-depuratore-di-lignano/14/04/2019
18/02/2019DraftingTrieste All NewsLignano sewage treatment plant, CAFC replies to M5S: “Sergo should do his research”https://www.triesteallnews.it/2019/02/18/depuratore-lignano-cafc-replica-al-m5s-sergo-dovrebbe-studiare-meglio-le-carte/14/04/2019
14/04/2019Francesca ArticoMessaggero VenetoFewer and fewer clams at sea, shellfish consortium in crisishttps://messaggeroveneto.gelocal.it/udine/cronaca/2019/04/14/news/sempre-meno-vongole-in-mare-consorzio-molluschi-in-crisi-1.3019084714/04/2019
06/05/2019Fabio Folisifriulisera.itLagoon and coastline emergency, more than just “blue flags”. New photos show another story, one of contamination and inaccuracy/Gallery at the bottomhttps://friulisera.it/emergenza-laguna-e-litorali-altro-che-bandiere-blu-nuove-foto-mostrano-altra-storia-una-brutta-storia-di-inquinamento-e-pressapochismo-gallery-in-calce/06/05/2019
06/05/2019DraftingTrieste All NewsSergo (M5S): “Lignano sewage treatment plant spills into the lagoon, shellfish harvesting banned”https://www.triesteallnews.it/2019/05/06/sergo-m5s-depuratore-di-lignano-sversa-in-laguna-vietata-la-raccolta-dei-molluschi/06/05/2019
23/06/2019Draftingfriulisera.it“Goletta Verde” sets off from Friuli. Will the tests show a “Miracle in Lignano”? Will it be discovered that the excrement is aseptic and does not require purification?https://friulisera.it/goletta-verde-parte-dal-friuli-le-analisi-dimostreranno-un-miracolo-a-lignano-si-scoprira-che-le-deiezioni-teutoniche-sono-asettiche-e-non-necessitano-di-depurazione/23/06/2019
26/06/2019Draftingfriulisera.itWhy is Goletta Verde promoting the FVG sea if critical issues exist? The situation is not tragic… it is not even serioushttps://friulisera.it/perche-goletta-verde-promuove-il-mare-del-fvg-se-le-criticita-esistono-la-situazione-non-e-tragica-ma-non-e-neppure-seria/28/06/2019
26/06/2019Draftingfriulisera.itSergo M5s: “Goletta Verde data in line with those of ARPA. But problems remain.”https://friulisera.it/sergo-del-m5s-dati-di-goletta-verde-in-linea-con-quelli-di-arpa-ma-i-problemi-rimangono/28/06/2019
26/06/2019NoUdine20.itGoletta Verde monitoring in Friuli-Venezia Giuliahttp://www.udine20.it/il-monitoraggio-di-goletta-verde-in-friuli-venezia-giulia/28/06/2019
26/06/2019DraftingUdineTodayGoletta Verde awards Lignano Sabbiadoro beachhttp://www.udinetoday.it/cronaca/goletta-verde-lignano-26-giugno-2019.html28/06/2019
Tab. 2 Text Corpus

Results And Discussion

ARPA: actual activity in the field

The lagoons of Grado and Marano that “constitute the transition complex located along the northernmost stretch of the Adriatic Sea and fall within the Venetian lagoon system that develops from the Po delta to the mouth of the Isonzo” are, therefore, involved in a series of controls and monitoring by ARPA designed to assess and preserve the complexity of the delicate ecosystems. This activity is subject to the provisions of current legislation and in particular Articles 118 and 121 of Legislative Decree no. 152/2006. These articles have the purpose of evaluating water quality through programmes to detect the characteristics of the river basins, in fact-finding missions allowing the Regions to set up water protection plans. In these plans, through the use of the data obtained from the fact-finding missions, the monitoring and controls of the water bodies are scheduled and developed for the achievement or maintenance of the quality objectives set by the Region itself. In addition, the transposition of Directive 2008/56/EC (Marine Strategy), enacted through Legislative Decree 190/10, affects the activity in the lagoon. Indeed, Member States are required to draw up a marine strategy based on an initial assessment, the definition of a favourable environmental status, the identification of environmental targets and the establishment of monitoring programmes for the achievement of the latter.

The Agency also carries out works to monitor bathing water, pursuant to Legislative Decree no.116 of 2008 which requires monitoring and control during the bathing season set by the Ministry of Health from 1 May to 30 September. The Consolidated Environmental Text (TEU) also identifies the general and methodological criteria for the detection of the qualitative characteristics of water and for the calculation of its compliance or otherwise with the life of shellfish. These criteria apply to coastal and transitional waters in order to allow for the cultivation of shellfish and to contribute to the good quality of shellfish products intended for human consumption. The water monitoring programmes just mentioned include most of the areas classified by Regional Health for shellfish farming; therefore, monitoring is applicable as defined by the health regulations featured in the “hygiene package”.

Table 3 represents the total activities carried out by the Agency in the lagoon area over the period from 2015 to 30 June 2019. It does not include all the activities of the sewage treatment plants; only the Lignano plant is shown by way of example, and we have also excluded the values collected from the continuous sampling of the transition waters. To simplify, therefore, only the sampling performed manually by ARPA personnel were considered.

Summing up, this in-depth analysis made it possible to observe the activities undertaken by the Agency in the lagoon area and on the sewage treatment plant which, based on the public debate, were not very clear. Numerous attacks were launched against ARPA in the media regarding the control and monitoring service provided on the area involved in the case in question; however, what emerges from this analysis is considerable activity in the field, with over five thousand samples taken, aimed at protecting the environment and public health.

Monitoring of marine-coastal and transitional water quality3173652332551371307
Sampling and analysis of marine sediments11712914413053573
Checks on the fitness for life of shellfish7505946416473733005
Monitoring of consortium water engines (Draining basins)20100251065
Monitoring the discharge of sewage treatment plants6557225
Bathing water monitoring14414614414672652
Tab. 3 – Summary of ARPA activity in the lagoon from 2015 to 30.06.2019.
Analysis of media coverage

The content analysis made it possible to collect a text corpus composed of 39 journalistic articles published between 1 February 2017 and 30 June 2019 on which a quantitative and qualitative survey was conducted. The survey parameters on which the quantitative analysis was focused were the temporal trend of the publications and the identification of the various sources that took part in the debate. The qualitative analysis focused instead on the communication strategy of stakeholders within the debate and on the classification of journalistic frameworks to identify the main topics of discussion.

The temporal trend of publications refers to the counting of the number of texts published by each newspaper per day/month/year. On the basis of this definition, the texts from the local newspapers that dealt with the case from 1 February 2017 to 30 June 2019 were counted. The frequency of publications shows how the issue was initially paid little attention by the media (only 3 articles in 2017), while it increased the following year with 20 articles and finally remained relatively constant in 2019 with 16 publications (Table 4). Going into more detail, Figure 1 shows that, over the course of 2017, at the beginning of the story, the 3 articles were all published in October, when the M5S monitoring concluded, having begun in February with the reports from citizens, and the local newspapers began to take an interest in the story. During the following year, the publications resumed in May to report on the ordinances prohibiting the collection and direct consumption of shellfish from AAS No. 2. The following summer was uneventful, with just one publication about it. The case blew up once again in late September, again reporting on the ordinances that had initially been withdrawn and then reissued in October. In fact, the majority of 2018 articles were concentrated over the latter month, as many as 14, while in November press attention once again dwindled (2 articles). The publications for 2019 have a different trend compared to the previous year. Indeed, they begin in January, before maintaining a certain consistency, with an average of approximately 3 texts per month, until June, when our sample ends.

From the observation of the temporal trend, moreover, we may observe that the majority of the publications over the three years (28 articles out of 39) were published at the end of the bathing season (the latter is set by the Ministry of Health from 1 May to 30 September). Therefore, the risk was more frequently discussed at a distance from the period of possible maximum direct exposure of the population to bacteria. In this regard, Councillor Sergo, during the interview, said that “My decision to hold press conferences in this specific period […] is due to the fact that certain information came into my possession during that period. For example, to obtain the results of a test report, for shellfish or for the sewage plant, a minimum of a month or two is required. So if ARPA does the sampling in July and issues the report in September, it comes to me in October. So there was no choice of disclosure so as not to affect the bathing period. When information was released, even in summer, we communicated it anyway because it was the right thing to do with regard to the citizens.”

MonthNumber of articles in 2017Number of articles in 2018Number of articles in 2019
Tab. 4 – Number of texts published annually
Fig. 1 – Temporal trend of publications (February 2017 – 30 June 2019)

The identification of the sources that took part in the debate was built considering as the “source” of an article the person interviewed or cited or to whom an opinion referred to in the publication is attributed; what is important, however, is the explicit citation of the subject, whether it is an individual or a body. In this way, articles have been found that report a single source and others that contain more than one; therefore, the count placed more importance on the texts with the greatest number of references. The result, shown in Table 5, shows a wide distribution of players having taken part in the debate: simple citizens (traders, fishermen), various associations (environmental, purpose, business), consortia such as COGEMO (Consortium for the management of shellfish at sea) and CONOU (National Consortium for the Management, Collection and Treatment of Used Mineral Oils), a young biologist (Cristiano Mauro), CAFC, ARPA, the FVG Region, AAS No.2, the municipality of Lignano and finally the M5S.

Cristiano Mauro23.5
CAFC S.p.A.47.0
AAS No.223.5
FVG Region58.8
Municipality of Lignano23.5
LegaCoop FVG11.8
Temporary Association23.5
Tab. 5 – Type of sources and their recurrences in the textual corpus

If we group the different sources by the groups to which they belong, as in Figure 2, what emerges is a clear political and institutional prevalence with a recurrence of 32% for both, followed by associations with 18%, the entities involved (7%) and gradually all the others. Observing the results of the main stakeholders, the M5S appears 18 times (31.6%) as a reference versus 9 times (15.8%) for ARPA, the top institution mentioned; lastly, CAFC SpA stands at 7.0%. A further observation on the main sources has brought to light an important fact: we may note that the M5S speaks through C. Sergo, the Region through the councillor for environmental protection, F. Scoccimarro, and the CAFC through its managing director, while ARPA has relied on impersonal press releases. The latter choice seems less effective since, in the communication of risk, the role of the spokesperson is essential since they not only speak on behalf of the institution, but allows it to be “personified”. Giving a face and a voice to the latter allows people to place more trust in it, as we are more open to a real person rather than an abstract institution.

It is, therefore, clear that, even in the case examined here, the mass media offered an arena for discussion on risk management that has involved all stakeholders, giving a voice to both the institutions and the different groups involved. That is why the most popular publications were those where the debate was more heated, that is to say when a large number of subjects participated.

Fig. 2 – Classification of sources by type

With regard to the communication strategy of the stakeholders within the debate, the analysis focused on the propensity of the different stakeholders to adopt a proactive and more direct communication strategy to get their view across, or a passive strategy, making comment in the media only if called into question. As can be seen from Figure 3, the textual corpus can be broken down into a rather large portion containing the texts in which the stakeholders showed a proactive or passive attitude. The remaining material is represented by simple reports.

Fig. 3 – Classification of the articles contained in the text corpus

In this 85% of the material, composed of 33 units of analysis of a total of 39, we can observe 20 articles containing what until now has been defined as proactive behaviour, that is, all the criticism, accusations, complaints, etc. used by some stakeholders to remain, in a way, protagonists of the debate and to guide it. By contrast, 13 of the 39 texts are a platform for responses, expressing a more passive attitude; however, responses were not always given, and as a result they are fewer in number. The analysis shows that the M5S is responsible for the largest number of proactive articles, as many as 13 of the 20, followed by the general population and the editorial staff of the media outlets who have published 3 texts each; lastly, Legambiente generated only one article of this type. To better understand the extent of this behaviour, articles with the same content published in different newspapers were excluded from the count: the M5S is still the stakeholder that effectively held the reins of the debate with 12 articles; the numbers of the other active players remain unchanged. If we observe the targets of these criticisms, accusations, complaints, etc., the first group to stand out are the institutions (ARPA FVG, AAS No.2 and the Region), which are dealt with in 14 articles out of 20, followed by the CAFC with 10, then Legambiente with 2 and finally the M5S, which appears only once. Since in each article classified as proactive, one or more stakeholders are called into question, there are more citations than the total number of texts of this type. Regarding the answers given, according to the results of the analysis, it can be said that there was a certain reluctance on the part of the players involved in countering the attacks. That said, Figure 4 shows the stakeholders who have answered more or less directly to the accusations. First, it would seem that ARPA is the body with the largest number of pieces published by way of response (6 articles), followed by the CAFC (4 articles) and, lastly, the Region (3 articles). Here, once again, we applied the technique of removing the same articles present in several newspapers, and we observe a drastic change between the hierarchies represented in red. Indeed, the Agency falls to the last place with only 2 rebuttal articles while the CAFC and the Region have 3 articles each. What emerges, therefore, is a certain detachment of the ARPA from the media controversy involving it. Despite the many attacks, it did not appear to feel the need to comment directly, for example by specifying its activity, except on rare occasions, as occurred with the establishment of the supplementary sampling plan.

Fig. 4 – Classification of the responses given

Another noteworthy fact, regarding the answers given by the institutions, is related to the communication of the activation of certain countermeasures, such as the focus groups set up by the Region. The underlying problem is the failure to give updates on the progress of these countermeasures intended to shed light on the case. If we look at the published articles in more detail, we may note, in the final texts from late June, specific requests which, precisely, regarded the activities of the institutions, such as:

  • Has the Lignano plant been completed and is it operating in a biological regimen as provided for by the transposition of the European Directives of 1991 and the most recent ones of 1999 and 2006 in order to guarantee the required level of water quality? Are the investments declared to the press by the CAFC, which up to now have exceeded 6 million euros, consistent with a plan approved by the Region and have they now been concluded? Has the ARPA identified the cause of the frequent presence of escherichia coli in shellfish in the lagoon and at sea in the area accessible to swimmers? Has the ASL made any kind of comment? Has the Municipality of Lignano, over the course of the meetings that have been reported in the press, been properly informed and has it been able to understand the causes and solutions of the problems in order to assume the protective role in the region to which it is entitled by law? Did the task force announced by the regional councillor and the studies of the CAFC with the Institute of Experimental Oceanography (Ogs) come about? Or did they remain as unmet needs? Have the checks been intensified and deepened after the complaints of the excessive levels to the manager?
Sergo also commented on this in his last published article:

After raising the issue for two and a half years, there is still no official word on the origins and causes of the spills, nor even on the irreversible reduction of seafood.

In this way a considerable risk is created. Indeed, ignoring the concerns and needs of the public or avoiding confrontation inevitably leads to an undermining of citizens’ trust in institutions.

This issue was also pointed out by Francesca Artico, a journalist of the Messaggero Veneto, as emerges from the interview: “Communication is lacking even with regard to ARPA, which offers brief answers only if strongly called into question. I would not speak of harm, but the people are certainly losing faith in institutions. For example, the healthcare authority […] could also take a position on the matter, but even here, if not strongly called into question, the latter does not offer comment.”

Moving on to the analysis of journalistic frames, we can define framing as the positioning of news within an interpretative framework that organises and contextualizes the facts reported by emphasising (or excluding) parts of them. It is similar to assuming a point of view that suggests a certain causal interpretation or a moral assessment of what has happened. In order to identify the various journalistic frameworks, we therefore read the articles of the textual corpus, looking for the interpretative frameworks used, in support of which we used the various topics constituting the news items. It was possible to observe the presence of at least one frame per article, but often more than one was identified, in a similar manner to the source analysis. Having said that, Table 6 summarises the main topics of discussion in the context of the disputes over the case of the overflows at the Lignano sewage treatment plant and the discovery of contaminated shellfish in the lagoons of Grado and Marano. The results clearly express a considerable articulation of the debate, intertwining the various scientific, political, economic and safety aspects.

Lignano sewage treatment plant anomalies1211.1
Shellfish food safety1211.1
Research into the causes and people responsible for the contaminated shellfish1110.2
Accusations against the institutions98.3
economic impact on businesses98.3
The ARPA supplementary sampling plan98.3
Bathing safety76.5
Clarification request for citizens65.6
Human pressures on the lagoon65.6
The Goletta Verde 2019 inquiry (Legambiente)54.6
economic impact on public expenditure43.7
Countermeasures taken by the CAFC43.7
Desire to silence the story43.7
The Region takes action on the problem43.7
The complaint against Legambiente21.9
Legambiente Credibility21.9
The situation of shellfish in Grado10.9
Discrediting of the CAFC10.9
Tab. 6 – Journalistic frames

By dividing the frames into broader categories, the macro-frames, we can see how the debate takes on five main dimensions: economic, environmental risks, health risks, political-social and technical-scientific. What emerges from the analysis is a prevalence of the debate on the political-social issues that prevail over those related to risks to health and the environment (Table 7).

Economic impact (on public expenditure and businesses)1312.0
Technical-scientific (the ARPA supplementary sampling plan, the 2019 Goletta Verde inquiry)1413.0
Health risks (Bathing safety, Shellfish food safety)1917.6
Risks to the environment (Abnormalities at the sewage treatment plant, human pressures on the lagoon, the shellfish situation in Grado)1917.6
Politico-social (The countermeasures adopted by the CAFC, Accusations against the institutions, clarification requests for citizens, the search for those responsible and the causes of the contamination of the shellfish, the complaint against Legambiente, the desire to silence the story, the Region takes action on the problem, discrediting of the CAFC, Legambiente credibility)4339.8
Tab. 7 – Journalistic macro-frames

In summary, the results of the quantitative and qualitative analysis of the media coverage of the case examined confirm a greater interest of the mass media in events capable of generating controversy rich in exchanges between the parties involved, so much so that the majority of the articles analysed constitute sparring matches. Within the media arena, there is a proactive behaviour on the part of the local political sources that have, indeed, guided the debate with respect to the institutions, the competent authorities and the CAFC that have, by contrast, refrained from making comment. The latter, by showing a degree of reluctance in countering the accusations, have therefore decided to take some risks regarding citizens’ trust in them. Finally, it was noted that the debate focused more on issues of a political and social nature, placing less emphasis on health and the environment. This is definitely the result of the fact that the ranks of the public debate were held by only one stakeholder, the M5S, while the other stakeholders mostly remained passive.

A key element also emerges, namely a lack of communication clarity on the part of the institutions, the competent authorities and the CAFC. As highlighted by the journalist of Messaggero Veneto, Francesca Artico “the crisis has not been handled very well. […] From a communicative point of view, I can say that there is a lack of clear and comprehensible communication by all stakeholders. This is because it is easy to use an array of technicisms, but we must also make the story understandable for “ordinary people” who do not understand these terms, but still need to form their own opinion on the matter.” We must also bear in mind how the population of Lower Friuli is particularly sensitive to environmental issues, given the historical events due to the Torviscosa industrial site, and this is confirmed by the statements made by Artico: “In this region, for more than thirty years, there have been committees dealing with the environment and when they announce conferences, meetings, etc. there is a big response from the population”.

The choice of the institutions to take a passive stance in public debate certainly did not favour the formation of a suitable risk perception on the part of citizens, because, since they were not exhaustive in responding to the concerns expressed by the population, inevitably the institutions have created an environment in which the trust placed in them by the people may be undermined. This interpretation is confirmed in the words of Dr. Marco Gani of ARPA FVG who, called to answer regarding the possibility of speculation and repercussions on the Agency’s reputation due to this attitude, stated “Absolutely. I have seen concrete evidence from other cases too, such as, for example, the cement plant in Fanna: when we lowered our attention we had significant media repercussions, which are difficult to recover from.”

Finally, the results show the strong involvement of certain political players, with their supporting arguments. This is because in the so-called “risk society”, it is impossible to externally attribute at-risk situations to any one body. In other words, the risks depend on human decisions, and since they are produced on an industrial scale, they reflect on the political sphere. Therefore, in cases of crisis or emergency, politics carves out a significant degree of responsibility towards citizens, as Gani also confirms: “politics must have two roles: one to inspire, to bring out the problems by whistle-blowing in the media, and a second relating to finding solutions.” And again from Sergo: “Political decision-makers […] should first ask themselves what are the sources of any dangers and worry about mitigating the damage, but also prevent these dangers from being perpetrated over time. […] Furthermore, I believe that they must clearly involve all the relevant people […] but above all politics must provide the means for these institutions to play their role”.

To conclude, this case study has allowed us to confirm how risk communication plays a fundamental role in the management of a crisis. Indeed, the decision not to participate proactively in the debate by those in charge of risk management has a negative impact on all other stakeholders, and in particular on citizens, since they entrust their safety to others. It is therefore essential to carry out interventions in which the processes of listening to and the participation of citizens play a central role. Paying attention to and understanding the public’s concerns about the dangers to health and the environment are essential aspects of risk communication in which public bodies and institutions in Italy should invest more, thus also optimising the aspects of risk management related to communication itself and, at the same time, guaranteeing citizens the right to information. Therefore, ARPA FVG’s choice to place more emphasis on improving its communication strategy by investing in techniques and tools that have not been used very much so far seems virtuous, as stated by Gani: “The ideal tool would be a periodic informative magazine, also published via the web, but that keeps up with the times”. The head of the institutional communication function and press office of ARPA FVG also said: “We would like to increase direct proactive communication, involving citizens more with conferences, meetings, etc. in the areas where the problems are present, allowing ARPA technicians to speak directly to the population. We are moving in this direction. For example, this year, we held a stand at the Barcolana where we illustrated and explained certain activities”.

These statements and the activities undertaken seem to be a good omen for the future insofar as greater investment in institutional communication will surely allow for an improvement both in the relationship of trust with the population and risk management. The improvement in the latter will also improve all the economic aspects related to the acceptability of the risks themselves that, at this point in history, represent the basis for a country’s growth.


  1. ARPA FVG (Regional Environmental Protection Agency of Friuli-Venezia Giulia), 2018. Report on the state of the environment in Friuli-Venezia Giulia 2018. Michela Mauro, Stefano Micheletti, Sara Petrillo, Franco Sturzi, Udine.
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  5. Fabio Folisi, “Lagoon and coastline emergency, more than just “blue flags” […] Gallery at the bottom”, Friulisera, May 6, 2019 https://friulisera.it/emergenza-laguna-e-litorali-altro-che-bandiere-blu-nuove-foto-mostrano-altra-storia-una-brutta-storia-di-inquinamento-e-pressapochismo-gallery-in-calce/ – Visited 06/05/19
  6. Krippendorff K. (1980). Content analysis: an introduction to its methodology, Sage, London.
  7. Article, “Sergo M5s: “Goletta Verde data in line with those of ARPA. But the problems remain”, Friuli-sera, 26 June 2019 https://friulisera.it/sergo-del-m5s-dati-di-goletta-verde-in-linea-con-quelli-di-arpa-ma-i-problemi-rimangono/ – Visited 28/06/19
  8. Official ARPA FVG website “Geomorphological framework of the lagoons of Marano and Grado” http://www.arpa.fvg.it/cms/tema/acqua/acque-marino-costiere-e-lagunari/approfondimenti/schede/Inquadramento-geomorfologico-e-idrologico-delle-lagune-di-Marano-e-di-Grado.html – Visited 30.06.2019
  9. Official website of the Autonomous Region of Friuli-Venezia Giulia “Regional, municipal elections and consultative referendums of 29 April 2018” http://elezionistorico.regione.fvg.it/elezioni2018/000497_Reg/Liste/000001.html – Visited 08.06.201Sofia C. (2004). Content analysis, communication, media. Evolution, applications and techniques, Franco Angeli, Milan.
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Research on the use of videogames: effects on students of secondary upper schools of Udine territory

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Submission Date: 2022-05-01
Review Date: 2022-05-16
Pubblication Date: 2022-05-28



From the researches carried out in literature it appears how gaming is a behaviour in continuous evolution and expansion (Mauceri & Di Censi, 2020) and is widespread in the entire population, particularly among teenagers.
The present paper is the result of a multi-professional and inter-sectorial research carried out and shared with operators of the health service Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), teachers of the Regional School Office (Uff. VI), the Provincial Student Council (CPS) of Udine and with a professional educator.
One of the targets of this research was to analyse the feelings and beliefs of players regarding the use of videogames and this was done in March 2021 through a questionnaire. 596 students of upper secondary schools of Udine territory joined this survey and to reach the target four videoplayer profiles have been outlined taking into account the play time: the occasional player (N = 61; 10.2%) who uses the videogames for maximum 30 minutes per day, the habitual player – mild (N=57; 9.6%) between 30 minutes and 1 hour, the habitual player – moderate (N=250, 41.9%) between 1 and 4 hours and the severe player (N=71, 11.9%) between 4 and more than 6 hours. The analysis of the replies demonstrates how all statements (21), following the chi-squared test, have a statistically important difference with respect to the profiles, except for two. It appears how the severe players run more often into potential experiences of risk of addiction or trouble, and they prefer to play instead of going out with friends, sometime also stopping friendship relations and feeling a higher desire to going on playing at the end of the session, also forgoing some hours of sleep.
The research group, taking into consideration the spreading of the behaviour of severe players (11.9%), would deem useful to plan and carry out future interventions aimed at encouraging the technological health since the first classes of upper secondary schools, in order to allow the students the acquainted use of technologies and gaming activities and to prevent the relative risks coming from the massive and improper use of these tools and actions.


In almost 60 years after their development, the videogames have a prominent position in the cultural and creative industries, and their market is addressed in particular to teenagers and therefore gaming is in continuous expansion; in 2020 the Italians who used videogames were 16.7 millions and represented  38% of population, and having an age between 6 and 64 years; moreover during the lockdown periods or the periods of increased restrictions, the time dedicated to gaming has increased year after year of about 1 additional hour per week during the first and second infection waves (IIDEA, 2021).

On January 2022 the World Health Organization (WHO) has recognized, within the ICD 11, the gaming disorder i.e. “a series of persistent or recurrent behaviours linked to gaming, both online as well as offline, which are revealed by: an unsuccessful control on gaming, a constantly increasing priority given to gaming to the point that this becomes  more important than daily activities and interests of life, a continuous escalation of gaming despite the negative consequences on personal, familiar, social, educational, employment sectors or other important areas” (WHO, 2018).

Considering the constantly increasing use of videogames and in line with what described in the field literature and from the observations reported inside the working party, it appeared the need to embark on actions aiming at awaken, prevent and promote the health in technologies use, in particular of videogames, also taking into consideration the pandemic period just lived through.

And to this end the following research has the target to deeply understand the phenomenon of videogames among students of upper secondary schools of Udine territory, analysing the sensations and beliefs created by gaming among the profiles of videoplayers; the last ones have been outlined on the basis of the time dedicated to videogames.

Methods And Materials

The creation of a multiprofessional and multiple branches project group formed by operators of the health service Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), a contact teacher of the Provincial Student Council (CPS), the Regional School Office (Uff. VI), representative students of the CPS of Udine and with a professional educator, has allowed a shared planning in the spirit of empowered peer education where the knowledge of students meet and deal with adults’ ones; the role of adults is to accompany teenagers in finding and developing tools and efficient competences in the promotion of welfare inside the territory.

The understanding and deepening of gaming phenomenon among students were made possible through the submission of a questionnaire, carried out by the research group, containing some questions whose results refer to other results already published in local, national and international literature[1], and with new questions with the aim to integrate and update the analysis carried out.

The sections of the questionnaire were subdivided as follows:

  • Personal data of the sample, composed by questions on gender, age, attended classroom, characteristics of the family environment of the compiler;
  • Use of videogames, questions referring to frequency, period of time, moment of the day and place dedicated to gaming, the way how the interviewee uses the videogames;
  • Beliefs and sensations linked to gaming, related to perceptions experienced during gaming and possible conditionings that these have on personal everyday life.

The questionnaire did not foresee any form of identification of the participants and has been filled in anonymous and autonomous form, against signature for acceptance of the use of personal data. In the questionnaire sections relative to sensations and beliefs, the research group has decided to use a Likert scale in four points which are included among “totally in disagreement” (lower value – “0”), “totally in agreement” (higher value – “3”) and the option “don’t’ know”.

The collected data, analysed through the RStudio software, permitted to obtain both a descriptive analysis (frequences, percentages, media, median, pie chart, bar chart) as well as a statistical analysis and this one has been carried out through the statistical chi-squared test (χ²) in order to understand the significance of the replies to the questionnaire; it has been decided to adopt an alfa (α) of 0.02 and consequently all items with a p-value minor or equal to 0.02 have been considered significant (H1).

Results And Discussion

The questionnaire was submitted on March 2021 through Google Forms platform so that the students could easily answer despite distance learning activity.

Received questionnaires and presentation of the sample

The total amount of received questionnaires was 603, the students who gave their assent to the privacy informative report are 596[2] and have therefore filled in the questionnaire independently and anonymously.

Hereunder are described and discussed the obtained results, starting from the section relative to the personal data of the sample.

Tab. 1,2 – Gender and class referred to the intervention sample (values in percentage); Class attended by the intervention sample (values in percentage)

From Picture 1 you can see how the answering persons are equally subdivided between female gender (N=261; 43.8%) and male gender (N=320; 53.7%), while the students who declared “I don’t want to reply” (N=15; 2.5%) being equally distributed among different school classrooms and having answered in line with the general sample, in the subsequent data analysis, when the gender differences are considered, will not be taken into consideration and only the answers coming from the options “female” and “male” will be evaluated.

As it’s possible to deduce from Picture 2, the answering persons are equally subdivided among the classrooms, in particular each classroom is represented by a minimum of 15.6% of students who attend the IV upper class (N=93) and a maximum of 24.8% who attend the V upper class (N=148).

Distributions based on the use of videogames and identification of the corresponding gamer profile

Analysing in a second time the answers of the sample regarding the use of videogames in the last month, it is possible to find out how 157 students do never use them (26.3%), 66 students use them 1-2 times per month (11.1%), 172 students use them from 1 to 4 times per week (28.9%) and finally 201 students play at least once a day (33.7%); the total amount of students who used videogames in the last month was 439 (73.7%) and therefore the following sections have been filled in only by this part of the sample.

Following the analysis of the replies regarding the time of use of videogames during one day (be it scholastic or non-scholastic) it was possible to outline the following four profiles[3]:

  • Occasional player (uses the videogames maximum for 30 minutes): it is represented by 14.0% of players (N=61) and by 10.2% of the general interviewed sample (N=596);
  • Habitual player – mild (uses the videogames  between 30 minutes and 1 hour): it is represented by 13% of players (N=57) and by 9.6% of the general interviewed sample (N=596).
  • Habitual player – moderate (uses the videogames  between 1 and 4 hours): it is represented by 57% of players (N=250) and by 41.9% of the general interviewed sample (N=596).
  • Severe player (uses the videogames  between 4 and 6 hours): it is represented by 16% of players (N=71) and by 11.9% of the general interviewed sample (N=596); 6.4% of this (N=28) uses the videogames for more than 4 hours per day.
Differences of gender of player profiles

If we select again the profiles with gender, we can note how this can vary according to the profile and consequently to the gaming frequency: among occasional players 3 students over 4 are females, among habitual players – mild there is an equal distribution between the genders and then it becomes different again being three fourth males among habitual players – moderate and severe.

Analysis of the replies on the basis of beliefs and sensations linked to videogames use

Two sections of the questionnaire were dedicated to sensations and beliefs risen by videogames. The assertions contained in the questionnaire, to which the students answered through a Likert satisfaction scale, were outlined starting from the diagnostic criteria relative to gaming disorder (WHO; 2018) and to Internet gaming disorder (APA, 2013).

Hereunder is the table that contains all statements with relative significances and the relations existing between these and the player profiles.

0123don’t knowtotalchi-squared test
“I think I spend too much time playing”A83.6%13.1%3.3%0.0%0.0%61100.0%<2.2e-16H1
“At the end of game session I need to go on playing and I say to myself «I still play for some minutes» ”A65.6%19.7%13.1%0.0%1.6%61100.0%4.67E-05H1
“My parents say that I spend too much time playing”A77.0%13.1%3.3%3.3%3.3%61100.0%2.76E-13H1
“I can reduce the playing time if I want”A14.8%3.3%13.1%67.2%1.6%61100.0%0.0008559H1
“It happens that I prefer playing instead of going out with my friends”A83.6%8.2%3.3%1.6%3.28%61100.0%2.85E-04H1
“It happens that I stop relations because of excessive time dedicated to playing”A91.8%6.6%0.0%0.0%1.6%61100.0%0.020H1
“My school performance feels the effects of the time spent in gaming”A82.0%11.5%1.6%1.6%3.3%61100.0%1.07E-05H1
“I try to hide to my parents/friends the time dedicated to gaming”A85.2%14.8%0.0%0.0%0.0%61100.0%0.0051H1
“It happens to feel guilty after having played too much with a videogame”A63.9%9.8%11.5%4.9%9.8%61100.0%0.0034H1
“Sometime I give up some hours of sleep to play”A70.5%19.7%8.2%0.0%1.6%61100.0%1.92E-06H1
“While I’m playing I cry or I’m vexed”A50.8%19.7%16.4%13.1%0.0%61100.0%2.00E-04H1
“Generally I feel that playing improves my mood”A32.8%26.2%26.2%3.3%11.5%61100.0%<2.2e-16H1
“It happens I schedule the next gaming session”A77.0%13.1%6.6%0.0%3.3%61100.0%4.66E-11H1
“It happens I spend time online watching other people playing videogames (Youtube/Twitch)A63.9%13.1%16.4%6.6%0.0%61100.0%5.53E-13H1
“While I am playing I feel depressed, sad or moody”A82.0%9.84%6.56%1.6%0.00%61100.0%0.13H0
“While I am playing I feel energetic and excitedA41.0%19.7%31.1%4.9%3.3%61100.0%<2.2e-16H1
“I feel that life without videogames would be boring and empty”A63.9%26.2%6.6%1.6%1.6%61100.0%4.47E-10H1
“Generally I feel that playing worsen my mood”A54.1%14.8%6.6%11.5%13.1%61100.0%0.02666H0

Tab.3 – Sensations and beliefs subdivided per profile with the values of p-value of each statement with respect to videoplayer profiles [4]

It is possible to declare that all statements regarding sensations and beliefs have a statistically significant difference, but two: “While I am playing I feel depressed, sad or moody” (chi-squared = 13.79; p-value >0.02) and “Generally I feel that playing worsen my mood” (chi-squared= 18.83; p-value >0.02).

Analysing the statements shown on Table 1, the occasional player appears as a student who prefers to go out with friends instead of using videogames (83.6%), is able to reduce the time dedicated to gaming if he wants (67.2%), the school performance does not feel the effects of the excessive time spent in gaming (82.0%) and it is not necessary to to hide to parents/friends the time dedicated to gaming (85.2%).

Then we find the habitual player – mild, with percentages similar to those of the occasional player; in fact he/she can reduce the time dedicated to gaming if he/she wants (91.2%) and prefer to go out with friends (91.2%); unlike the previous profile, a part of the players give up some sleep hours in order to play (15.8%) and to spend time online watching other people playing (42.1%).

The most important aspects can be found in the profiles of the habitual player – moderate or severe: among the first ones little more than one third declares to agree (37.2%) with the statement “I feel I spend too much time playing”, of these a minor percentage agrees totally (3.6%); some of them give up some sleep hours to play (30.4%), and this behaviour is increasing with respect to previous profiles, moreover almost one third of them feels guilty after having played a lot with videogames (30.4%). As far as time spent online watching other people playing is concerned, such action is performed by two thirds of habitual players – moderate (66.8%), in addition the more the hours dedicated to playing increase, the more the presence of the behaviour of playing some more minute at the end of the session increases (31.2%).

As far as severe player is concerned, almost two thirds agree on the fact that they spend too much time playing (64.8%) and one third thinks that at the end of the playing session needs to continue such activity (35.2%); with reference to the social network one part of severe players prefers playing than going out with friends (36.6%), sometime also interrupting the relations due to the excessive time spent to play (8.4%). Unlike previous profiles a certain percentage of subjects tries to hide its friends/parents the time spent playing (21.1%) and nonetheless some parents tell off their children for the excessive use of videogames (61.9%).

Another aspect to take into consideration is the statement “It happens to feel guilty after having played too much with a videogame”; analysing the data a first aspect that appears is how among occasional and severe players the percentage of players who answered “totally” and the percentage who answered “partially in agreement” is almost the same (16.4%; 19.7%); this means that, despite an important use of videogames, the severe players are not always aware of the gaming problems and this awareness is probably due to a reduced information regarding to gaming itself and to the negative consequences that may occur.

Discussion on obtained results

After having analysed the data it is possible to declare how the male gender is more at risk to develop problems linked to the use of videogames than the female gender; moreover, despite the aspect of gaming time is not included in the diagnostic criteria of gaming disorder or Internet gaming disorder, and there are no sources in literature that demonstrate how the time used can cause troubles linked to videogames use, observing the data of the present research we can outline that a  high number of gaming hours, from 4 to more than 6 hours every day or nearly, produces negative consequences from a personal, social and educational point of view.

The severe players therefore show more frequently potential experiences of risk of addiction or trouble: one part of them prefers gaming instead of going out with friends, sometime also interrupting friendship relations; at the end of a gaming session they feel a higher desire to proceed with it and among the selected time bands there is also the night time one in almost half of these students, unlike other player categories in which it represents a residual part only.

Moreover it is interesting to observe how for the severe players the gaming moment is a time when their mood improve and the aspect of mood worsening is almost not even taken into consideration; this means that gaming is considered among the activities that produce highest satisfaction and wellness.

Taking into consideration what just said and that the period of COVID-19 emergency determined an increase in the use of videogames (IIDEA, 2021), we can conclude that it is right now that preventive actions and wellness promotion linked to technologies should be taken, for sure addressing to students as “final” addressees, but also interesting parents, teachers and all operators of different sectors who interact with youth for a more aimed, cohesive, methodical and strategic action.

The initiatives can be carried out preferably with a participation of a multi-professional and multiple branches project group, who is oriented in unique targets such as sensitization to the positive use of technology, paying attention to the risks linked to it, sensitization and prevention of detrimental use of gaming and the consequent gaming disorder and encourage knowledge of psychological health.

And finally we deem that a sensitization to an acquainted use of videogames and of technologies has to be achieved through projects aimed to different age bands starting from primary schools, since electronic tools are now the essential base of modern life.


  1. APA. (2013). DSM-5. Manuale diagnostico e statistisco dei disturbi mentali (quinta edizione). (M. Biondi, A cura di) Milano: Cortina Raffaello.
  2. European School Survey Project on Alcohol and other Drugs (2021). ESPAD #iorestoacasa 2020. I comportamenti a rischio durante il primo lockdown tra gli studenti dai 15 ai 19 anni. Disponibile in: https://www.epid.ifc.cnr.it/wp-content/uploads/2021/01/ESPAD-iorestoacasa-2020_ISBN-22.02.2021-LEGGERO.pdf.
  3. European School Survey Project on Alcohol and other Drugs (2019). ESPAD Report 2019 Results from the European School Survey Project on Alcohol and Other Drugs. Disponibile in: http://www.espad.org/sites/espad.org/files/2020.3878_EN_04.pdf.
  4. IIDEA. (2021, Marzo 23). IIDEA presenta il nuovo rapporto annuale sul mercato dei videogiochi in Italia. Tratto da IIDEA. Italian Interactive Digital Entertainment Association: https://iideassociation.com/notizie/in-primo-piano/rapporto-annuale-mercato-2020.kl
  5. Mauceri, S., & Di Censi, L. (2020). Adolescenti iperconnessi: un’indagine sui rischi di dipendenza da tecnologie e media digitali. Armando Editore.
  6. Newzoo. (2020, Giugno 25). 2020 Global Games Market Report. Tratto da Newzoo: https://newzoo.com/insights/trend-reports/newzoo-global-games-market-report-2020-light-version/
  7. WHO. (2018). Addictive behaviours: Gaming disorder. Tratto da World Health Organization: https://www.who.int/news-room/q-a-detail/addictive-behaviours-gaming-disorder


  • [1]European School Survey Project on Alcohol and other Drugs (2021). ESPAD #iorestoacasa 2020. The risky behaviours during the first lockdown among students between 15 and 19 year old. Available in: https://www.epid.ifc.cnr.it/wp-content/uploads/2021/01/ESPAD-iorestoacasa-2020_ISBN-22.02.2021-LEGGERO.pdf. Mauceri, S., & Di Censi, L. (2020). Adolescenti iperconnessi. Un’indagine sui rischi di dipendenza da tecnologie e media digitali. Roma: Armando Editore. European School Survey Project on Alcohol and other Drugs (2019). ESPAD Report 2019 Results from the European School Survey Project on Alcohol and Other Drugs. Disponibile in: http://www.espad.org/sites/espad.org/files/2020.3878_EN_04.pdf.
  • [2]Statistically representative sample on the basis of sample size (21,000 students), considering a level on confidence of 95% and a margin of error (Confidence interval) of 0.4%.
  • [3]The research investigated the playing time both in scholastic and non scholastic days, nevertheless when the profiles have been outlined, the replies by excess for every student have been estimated.
  • [4]Profiles of videoplayers: “A” (occasional player); “B” (habitual player – mild); “C” (habitual player– moderate); “D” (severe player).

Cardiac CT: State of the art and future scenarios


Submission Date: 2022-04-21
Review Date: 2022-05-05
Pubblication Date: 2022-05-19


Coronary angiography with computed tomography (CTCA) is one of the major innovations in diagnostic medicine and is one of the methods of non-invasive investigation of the heart and coronary heart. The first experiments date back to 1999 with 4-layer computed tomography equipment while current technology can exploit equipment up to 320 layers. From the first experiences with 4-layer CT we have reached the dawn of the era of low-dose CT radiation, this means that one of the greatest reserves that have limited until now the extensive application of this mode is about to be removed. Among the major problems that need to be addressed for the clinical use of CCT have an essential role: radiation dose, training, logistics and implementation. These factors are interrelated and will have a significant impact on future diagnostic scenarios and radiology departments.

Materials and Methods

Technology and hardware requirements

The most important components of a TC apparatus are the X-ray tube and the system of detectors. The combination of fast tube-detector rotation time and multi-layer acquisition is the starting point for cardiological applications.

Fig. 1 – TC OPTIMA 64 GE layers.

64-layer CT equipment meets the basic criteria for conducting cardiological and coronary examinations. In particular, the hardware requirements of CT for cardiological imaging are:

  • high temporal resolution and synchronization with the phases of the heart cycle: the heartbeat requires that the method is able to capture images in a sufficient time to minimize or avoid movement artifacts altogether. In addition, in order to avoid such artifacts, image scanning/reconstruction must be synchronized with the ideal cardiac cycle phase, that of the least residual movement;
  • high spatial resolution: the structures under investigation and in particular the coronaries are characterized by reduced calibre (<5 mm). Therefore, the spatial resolution of the method should be able to form images with spatial resolution appropriate to the visualization of the structures and their main characteristics;
  • high contrast resolution: the distinction between the structures being studied (e.g., vascular lumen, ventricular cavities, cardiac muscle, adjacent soft tissues) requires a contrast resolution that is appropriate to the distinction of the structures themselves and their measurement;
  • High scanning speed: Scanning speed becomes important due to the fact that breathing movement determines movement artifacts. Therefore, the ability to conduct the survey in the shortest possible time (e.g., in apnea) is a factor that determines the final quality of the images.

Inclusion and exclusion criteria

Normally the inclusion criteria for scanning are:

  1. Heart rate <65 beats per minute (bpm) (spontaneous or induced by administration of β-blockers or other negative chronotropic drugs).
  2. Ability to hold breath for a period compatible with the scanning time. Bradycardization allows for a longer diastolic interval, which results in an increase in the duration of tele-diastole, at which time the heart and coronary arteries are almost devoid of movement. Although CCT can be diagnosed at higher heart rates, motion artifacts gradually reduce the number of segments that can be correctly displayed. The second criterion is to avoid artifacts related to respiratory movement. Inadequate breathing of the patient during scanning reduces the quality of the information acquired.

The exclusion criteria shall:

  1. The exclusion criteria concern technical aspects related to heart rate (cardiac arrhythmias: nonsinus rhythm, frequent ectopic beats (extrasystoles), atrial fibrillation with high ventricular response), radio-protectionist aspects and law enforcement aspects. Patients with heart rate (FC)  65 bpm, known allergy to iodized contrast agent, kidney failure (serum creatinine >140 mmol/l), pregnancy, respiratory failure, clinical unstable state and severe heart failure, body weight >150kg, are normally excluded from the study by CCT. For the assessment of coronary calcium, the exclusion criteria for heart rate and contrast agent do not apply.

Border-line situations

Patients with FC >70 bpm should not be subjected to CTC. Only patients with mild irregular heart rhythm (e.g., premature heartbeat, atrial fibrillation, left branch block, elongation of the QRS complex, FC<40 bpm, etc.) may be included in the evaluation in this case, the scan should not be performed by using the X-ray dose reduction software based on the ECG plot, which consists in the prospective modulation of the dose emitted on the basis of the wave R. in the presence of abnormality of the FC the localization of the period with lower dose will be variable and can re-enter inside the diastole. A favourable situation for CTC scanning even in the presence of high FC (>70 bpm) is that of low ejection fractions and/or hypokinetic ventricles. In these conditions, in fact, even an FC of 80-90 bpm allows to obtain images of high diagnostic quality especially if you can use the time windows of telediastolic and telesistolic reconstruction. However, considerable experience is needed to achieve a high standard of quality in these conditions.

Pharmacological management

From the first experiences with 4-layer CT equipment to the most modern, the use of drugs to reduce FC has been a constant.

Medications that can be administered to the patient before scanning in order to reduce FC are:

  • β-blockers;
  • calcium antagonists;
  • benzodiazepines;
  • nitrates.

Outline of pharmacology


Oral: 45-60 minutes before scanning, methoprol-tartrate for os with dosage between 50 and 200 mg.

Intravenous: esmolol, characterized by a short half-life, is certainly the drug of choice. Intravenous administration under pressure and ECG control allows you to reach the reference FC quickly by facilitating the flow of patients on the machine. However, a preparation with β-blockers for os allows to carry out the examination in a patient with good β-blocker basal tone. Other β-blocker drugs, higher plasma half-life, may be used via V.V., such as metropolol, ethanol, and propanolol. The latter in particular has a superior bradycardization effect. Caution in administration should take into account a short monitoring period after examination.

Calcium antagonists

As a rule used in the case of contraindications to β-blockers.


sometimes, especially in younger patients, the emotional component of “anticipation” of the examination is the prevailing one. In these cases, short-half-life benzodiazepines may be administered to reduce this component.

Algorithm of patient preparation

It has been described how high FC negatively affects the performance and success of scanning in terms of diagnostic quality. The best way to reduce FC in the patient is definitely pharmacology. Once FC is obtained, variability should be observed and, in addition, a test should be performed to assess whether the duration of the patient’s apnea is compatible with the scanning time. Generally, with 64-layer or higher generation scanners apneas are 10 sec or lower and are unlikely to be compatible with stable apnea, except for the critical and/or non-cooperative patient. If at the end and during apnea the FC remains stable the patient can perform the investigation.

The good preparation of the patient comes from a thorough knowledge of the clinical conditions associated with coronary heart disease and those independent of it and from the adequate knowledge of the mechanisms of action and of the absolute and relative contraindications of drugs used.

Positioning of the patient

The patient is in a supine position with both arms raised above the head to avoid artifact from hardening of the beam because even though the arms will remain outside the FOV, if these should be lowered, in the processing of data will also be obtained information, albeit partial, of their presence giving rise to nuances or bands artifacts that will affect the quality of the image. It is preferable for the patient to enter the head for the simple fact of a more accurate visual contact.

Method of execution

Performing a typical coronary angio-CT examination (multislice CT-coronary angiography, MSCT-CA) involves performing a first direct scan (CA-Score), performed with high collimation thickness (3-5 mm), followed by a subsequent acquisition performed during the administration of mdc, performed in the arterial phase with a thin collimation layer (0.5-0.6 mm). In the course of these investigations, a portion of the thoracic district is acquired between a plane passing under the aortic arch to the cardiac base, comprising a portion of the organs of the upper abdomen. The investigated district contains different anatomical structures:

  • Heart
  • Large vases
  • Lymphatic structures
  • Esophagus
  • Tracheo-bronchial structures
  • Lung parenchyma
  • Pleural and pericardial leaflets
  • Bone structures
  • Nerve structures
  • Diaphragm
  • Liver
  • Adrenals
  • Kidneys
  • Spleen
  • Stomach
  • Transverse colon
Fig. 2 – Representation of the scout-view on which the CT exam is set. The area colored in blue represents the volume that is normally acquired during coronary angioTC examination.

The evaluation of a cardio-CT examination involves the execution of several reconstructions using multiplanar techniques (MPR), curved multiplanars (cMPR), MIP and volume rendering, all aimed at defining the patency of the coronary tree or assessing the functionality of the heart muscle.

These methods of reconstruction are aimed at optimizing as much as possible the visualization of the vascular structures under examination, but at the same time they involve an exclusion of part of the tissues and extracardial structures that do not appear in the reconstructed images or appear there with a distorted anatomy not useful for the recognition of ancillary pathologies.

The method of carrying out the examination and its reconstruction may hinder this assessment as some thoracoabdominal sectors may not appear in the reconstructed axial images. This is because in order to obtain greater spatial resolution in the anatomical areas of interest the field of view (FOV) of reconstruction is sized to include only the mediastinal structures concerned (heart and large vessels). It will then be necessary to perform a second reconstruction using a large reconstruction FOV that contains the entire chest.

Fig. 3 – In this axial image of the thoracic district is indicated the reconstruction FOV set around the cardiac structures. All the sector highlighted in red will be excluded from the reconstruction and therefore not evaluated, even if the information related to that district has been acquired.

Contrast agent administration and general principles of contrast media attenuation to CT

Synchronized intravenous injection of the bolus of contrast agent useful to the angiographic phase, must necessarily be entrusted to the aid of an automatic injector capable of delivering a flow of at least 6ml sec. Bearing in mind that the MDC must be preheated to the average body temperature of 37 years. so that the low viscosity can be maintained. This device should preferably be equipped with a double head, in order to have a secondary bolus based on 40 50ml saline solution, useful for the function of pushing the mdc in the veins of the arm. The connection of the injector to the vein of the patient, will be entrusted to a device for spiraloid infusion, of adequate length and equipped with an antireflux valve. The agocanula to be used will be an 18 gauge gauge (green venflon). The particular anatomy of the anonymous vein on the right suggests preferring the antecubital vein of the homolateral arm (the way to the right atrium is shorter). This will avoid artifacts due to high contrast density in the vein, which could compromise the visualization of the aortic arch and the origin of supraortic trunks due to the fact that the blood route is longer. Since the journey time is shorter we will be able to have a bolus of contrast well concentrated without being diluted so much during the journey.

Fig. 4 – Acquisition Enhancement Point.
Fig. 5 – Automatic Injector.
Fig. 6 – MDC organ iodate Iomeron 400

CCT scanning and synchronization with cardiac cycle and image reconstruction

The ideal protocol for CCT is one that allows a high spatial resolution (finer collimation), a high temporal resolution (faster rotation of the tube-detector system), lower exposure to ionizing radiation (prospective modulation of the current of the tube synchronized to the electrocardiogram, etc.) compatibly with a good signal/noise ratio.

Imaging in CCT scanning should be synchronised to the heartbeat and possibly to the phase of the cardiac cycle characterized by less residual movement. For this purpose, two main scanning techniques are adopted: retrospective cardiac gating and prospective cardiac triggering. In the first case the scan is continuous spiral at low pitch (0.15-0.4) and the data can be reconstructed at any stage of the cardiac cycle, by shifting the start point of the image reconstruction relative to the R wave. In the second the scan is sequential and the acquisition time window must be determined before the start of the scan. Retrospective cardiac gating is more flexible and allows better optimization of the reconstruction time windows at the price of an average higher radiation dose; Prospective cardiac triggering is less flexible but significantly reduces the radiation dose.

Generally, the cardiac cycle stages in which images are acquired/reconstructed are the telediastolic phase (60%-80% of the RR interval; -300/-400 ms before the next R wave) and the tele-systolic phase when available (20%-40% of RR interval; +175/+325 ms after the previous R wave). The other reconstruction parameters are relevant for the production of an image that can be considered diagnostic. In particular, the actual layer thickness may be equal to or slightly larger than the minimum possible collimation in order to improve the signal/noise ratio of the image. The reconstruction increment should be about 50% of the actual layer thickness (thus increasing the spatial resolution along the z-axis). The field of view should be as small as possible including the entire heart, so that the image matrix that is constant (512 512 pixels) can be fully exploited. The convolution filter should be intermediate (medium-smooth) and still in a good balance between noise and signal. When the coronary arteries are very calcific or stents are present, higher convolution filters, even if they increase the image noise, improve the visualization of the vessel wall or stent structure and the lumen inside.

Fig. 7 – Reconstruction of cardiac images.
Fig. 8 a-c. – Synchronization techniques for the CTCA. The synchronization techniques for the CTCA are essentially two: a prospective ECG triggering in which the scan is performed with sequential axial mode (step and-shoot) calculating the position of the time window on the RR interval of the beat preceding the acquisition itself; b,c gating retrospective ECG in which scanning is performed in low pitch spiral mode and images are retrospectively synchronized with the cardiac cycle phase. The first technique allows reduced exposure to ionizing radiation but is more sensitive to moving artifacts due to the reduced or absent flexibility in the reconstruction phase. The second requires high exposure but allows a wide freedom of choice of the optimal time window. CTCA, coronary angiography with computed tomography; ECG, electrocardiogram.

Evaluation of the image

The image evaluation of a CCT survey is not yet performed using a standardised technique. In terms of reproducibility, the performance of the CCT is currently operator-dependent. Evaluation is generally performed by classification of the American Heart Association in 14-17 coronary segments. CCT is used for the identification of significant stenosis (ie reduction of the vasal lumen 50%) and the assessment is generally semi-quantitative. Images are evaluated on the axial dataset, then reconstructed using multiplanar reconstructions (MPR), maximum intensity projections (MIP) and volume rendering (VR). The coronaries can also be displayed along the longitudinal axis, either manually or semi-automatically (curved MPR).

Catalogue of artifacts, methods to avoid them and possible remedies

Artifacts from movement

Motion artifacts are generated by the voluntary and/or involuntary and/or intrinsic movement of an organ within the district being examined or the patient.

  • Type I: Volunteer. Typical example of the first case is the interruption of the inhalation apnea during the scanning phase by the patient.
  • Type II: Involuntary. Typical example of the second case is slow diaphragmatic slipping (diaphragmatic drift) during the patient’s apnea.
  • Type III: Intrinsic. An example of the third case is the natural motion of the coronaries that generates an artifact due to an inadequate ratio of vessel velocity to raw data acquisition rate (temporary resolution).

Type I artifacts are generally due to errors or lack of patient compliance and result in blatant and severe alterations in image quality. Voluntary movement artifacts of the patient can be distinguished from artifacts related to cardiac movement because in the first case the artifact is present in the anterior thoracic wall, along the cardiac margin.

Fig. 9 – Blurring and step artifact: typical appearance of two frequent movement artifacts. Blurring or blurring occurs when the motion of heart structures is greater than the temporal resolution of the scanner. The step-by-step appearance of the artifact is instead due to an interruption of the inspiratory apnea.

Some manufacturers, to compensate for motion artifacts, propose the use of “overscan” capture modes, correction software, and “cardiac gating”.

  • Overscan: for the reconstruction of the images at the ends of the scan, additional rotations are made. This is due to the fact that the maximum discrepancy between the readings of the detectors occurs at the beginning and end of the rotation. Some models use this mode, which involves the acquisition of about 10% more rotation that is added to the 360 ºμ standard: the repeated data are then “weighed” and used to reduce the severity of the artifacts by movement.
  • Correction software: Used in most scanners, they automatically weigh the initial and distal scans, reducing their contribution to the final image. However, this processing results in increased image noise.
  • Cardiac gating: the synchronization of the data acquisition with the ECG allows to obtain images of the heart in (relative) immobility, employing for the reconstructions only the data coming from the phase of the cardiac cycle with the least degree of motion; this allows to avoid the onset of the severe artifacts of movement due to the rapid and wide movements of the Heart.

Artifacts from noise

Noise in a TC image is the variability of attenuation values around the average of pixels in a homogeneous region of interest (ROI). In fact, noise can be measured by the standard deviation of the attenuations measured in an ROI located in the evaluation area. One of the main factors influencing noise is the milliamperage per second (mas) produced by the X-ray tube. Increasing the mas will increase the number of photons that hit the patient and then the detector, so as to increase the signal/noise ratio (S/R).

Fig. 10 – Noise: Graphic representation of image noise. The frame represents a region of interest (ROI) obtained from the reference image at the level of the middle segment of the right coronary artery. The area attenuation values within the individual ROI (1-3) have been reported on an attenuation graph. The increase in noise results in a progressively larger oscillation of the attenuation values. This example explains why noisy images are more difficult to evaluate.
Artifacts from partial volume

The partial volume (also known as “averaging volume”) is an artifact that occurs in all voxels of all images when there are two or more objects with different attenuation values inside a voxel. It depends on the fact that the voxels are larger than the structure you intend to represent. Another type of partial volume artifact, conceptually different from “averaging volume”, occurs when a dense object is only partially included within the X-ray beam and only when the tube-detector system is in certain positions. The inconsistency between the various points of view, in fact, determines artifacts that are appreciated as nuances in the images.

Artifacts from beam hardening

The beam hardening artifact occurs when the radiation is completely absorbed by an object with extremely high attenuation values. The beam hardening artifact can give rise to two types of effects: the so-called cupping artifact and the dark band or stripe appearance between dense objects in the image (streak artifact). In cardiac imaging, these types of artifacts can occur in various situations, such as:

  1. Pace-maker filaments, metal valve prostheses, metal surgical clips, etc.
  2. The bolus of MDC in the upper vena cava and right atrium can cause beam hardening artifact, with uncomfortable interpretation of more cranial scans of the heart in the anatomical region of the right coronary.
  3. The presence of calcific atherosclerotic plaques may prevent a proper assessment of the vascular lumen.
Artifacts from MDC

The alteration, in excess or defect, of the parameters that regulate the MDC causes artifacts from MDC.

Volume: The causes of poor enhancement are generally related to inadequate administration and/or quality of MDC. A technical error in the administration procedure is generally the cause of not displaying MDC itself in the large vessels of the chest.

Speed: various studies have reported the advantages of using high concentration of iodine MDC (>350 mgi/ml) and a high flow of administration (>4.5 ml/s) to increase the visibility and therefore the diagnostic accuracy of the vessels, species that contain a small blood volume.

Saline solution: the use of a bolus saline solution following the injection of MDC (bolus chaser) has the effect of pushing MDC and keeping it compact in its intravenous course. The bolus chaser reduces the occurrence of beam hardening artifacts and represents an advantage especially for the visualization of the right coronary artery, subject to significant hardening artifacts when hyperconcentrated MDC is located in the vena cava and right cavities of the heart.

Radiation dose reduction strategies

The reference technique for the execution of the CCT is the low pitch spiral (0.2-0.35). The radiation dose was about 3-5 times that which normally served for a similar anatomical coverage with standard thorax protocol. With 64-layer equipment the average effective dose is about 12 mSv (range 8-18 mSv) at a stage where the prospective technique has already been introduced. With the reintroduction of the prospective acquisition mode combined with an effective heart rate control, it was possible to drastically reduce the effective dose. Other techniques and methods of acquisition associated with improvements in the reconstruction phase have allowed a progressive reduction of the dose.

TechniqueDose reductionNotes
Triggherate ECG prospective modulation<50%With FC<65 bpm and stable
Automatic Exposure Control (AEC)~33% 
Low voltage50%With patients of medium-small build   (BMI<30=100 kV; BMI<25=80 kV)
Triggering prospective ECG>50%With FC<65 bpm and stable
Dual/single-beat with prospective ECG triggering and prospective ECG triggering high-pitch spiral>80%With FC<60 bpm e stable
Iterative reconstructions15%–25%
Tab. 1 – Dose reduction techniques.


CTC is a non-invasive method for the diagnosis of coronary heart disease that is rapidly expanding both in terms of availability on the territory and in terms of clinical indications. In the future, clinical applications of the method are likely to extend in parallel with technological improvements and literature evidence. The reliability and accuracy of the method will be further increased by the introduction of new solutions, such as the dual source, allowing the implementation in the field of acute chest pain. The method is increasingly becoming a new reference point for the clinical management of follow-up of patients with coronary heart disease. In this perspective, the optimization of the individual dose will become increasingly important also in the possibility of a further diffusion of the method with potential further increase of the collective exposure from medical radiation. At present, in order to be effective, this method must be used in specialized environments and by personnel with long-term training.


  1. Clinical indications for the use of computed tomography of the heart. Organized by the working group of the section of cardio-radiology of the Italian Society of Medical Radiology (SIRM) DOI 10.1007/s 11547-012-0814-x
  2. Low dose heart CT scan: an epochal leap into the new era of cardiovascular imaging. Radiol Med DOI 10.1007/s 11547-010-0566-4
  3. Heart CT in clinical practice. Filippo Cademartiri-Giancarlo Casolo-Massimo Midiri Springer-Volter-Italia 2007
  4. Mollet NR, Cademartiri F, Neiman K ET AL (2004) Multislice Spiral Computed Tomography coronary angiography in patients with angina pectoris. JAM COLL Cardiol 43:2265-2270
  5. Cademartiri F, Runza G, Belgrano M ET AL (2005) intriduction to coronary imaging with 64-slice computed tomography. Radiol Med (Turin) 110:16-41

Green Space for health promotion


Submission Date: 2022-04-06
Review Date: 2022-04-20
Pubblication Date: 2022-05-04

Historical premise

Reality is basically made up of space. We live and move in space, and the measure of space determines the scanning of time and of existence of living beings.

The consideration of space produces choices that are linked to an ancient but always current dilemma: is it possible to live within a given environment and if it is possible how is it possible?

In the last two centuries the natural space has been gradually thinning as a result of the spread of the industrial revolution and the capitalistic system, which have favored the anthropocentric model based on urbanization.

This phenomenon is evident not only in Europe, where by now the population of the cities far exceeds that of the countryside, but also in the rest of the world: it is enough to consider the Asian, African and Latin American megalopolises to understand their scope.

Industrial cities have developed based on the concept, of clear Tayloristic derivation, of the division of space according to the functions of industrial production: factories, offices, residential areas, green areas have been clearly delineating over the decades, breaking that continuous between human elements and natural elements still visible in cities until the eighteenth century.

Living and moving in the city has become increasingly problematic and the nature of the workplaces, completely artificial, has imposed sedentary conditions that in the long run have proved to be very harmful for the individuals destined to remain static in factories and offices for many hours a day.

The spaces for the movement were therefore designed and built to cope with this situation and for decades they have concentrated in fact in two types of well-defined places: city parks, the last vestiges of the natural environment, and sports centers, where you can carry out what was called physical education.

Considered by the Enlightenment culture one of the cornerstones of health, physical education became a far widespread practice first in the bourgeois class and also among many aristocrats, and later also in the popular classes.

D’Alambert considered it in the category of rational sciences and Rousseau made it one of the cornerstones of his pedagogical theory.

In June 1793 the Committee for Education included physical education among the primary objectives of public education, and on 13 August of the same year the Convention reaffirmed its importance by arguing that it should enjoy, in scholastic education, the same time reserved for study and manual activities.

The development of physical education was linked to a double practical necessity: the first derived from the adoption of the mass conscription for the constitution of the people’s army, and therefore from the need to have young people who are motorically capable; the second was inherent in the development of the industrial revolution, which the new bourgeois leadership put in place in revolutionary France and for which they needed coordinated individuals and able to work fast on the machines.

From a general point of view, the exaltation of physical activity definitively ended with centuries of mortification of the body and also paved the way for the birth of modern sport.

In the nineteenth century, the epoch in which scientific progress established itself as the supreme ideal of the nascent bourgeois ruling classes, physical practice began to be applied to the therapeutic field. In England, as well as in the German-speaking world, the prescription of physical activity in cardiopatic patients became widespread. In Sweden, in the early 1800s, Pehr Henrick Ling organized a gym in which a free body gymnastics was practiced in a structured way which then took the name of Swedish.

In the light of current biomedical knowledge, from any consideration of the questionable correctness of therapeutic indications, what must be emphasized is the gradual spread of a therapeutic approach to the disease founded, at a time when pharmacological solutions were not particularly developed, on physical exercise, modulated in duration and intensity on the pathological condition.

In the twentieth century, hand in hand with the further progress of therapeutic practices, the culture of prevention spread in a broad and structured way which, in recent years, has foreseen the role of physical activity as a fundamental element in the prophylaxis of multiple pathological conditions. From the 70s onwards, in parallel with the achievements of clinical pharmacology, diagnostic and therapeutic instrumental technology and the organization of health systems, the preventive, therapeutic and rehabilitative function of structured programs of physical activity has been fully recognized for a growing number of serious and widespread clinical conditions. Attention to lifestyle (the hippocratic memory regime) is a medical-health concept deeply rooted in the Western world, as highlighted, juxtaposed, even in the first text of medical professional ethics. One of the main objectives of physical activity is for example to demedicalize back pain through the use of a correct lifestyle, as widely recalled by the recommendations for the promotion of well-being and health given by the World Health Organization.

After the Second World War, however, the environmental situation deteriorated considerably as a result of the progress of industrialization.

Cities have incorporated growing portions of the countryside and industries have contributed greatly to the pollution of air, water and soil, flanked by the spread of motor vehicles and the extraordinary energy consumption necessary for the life of megacities.

The environment is therefore a fundamental factor for health, as the governments and entrepreneurs of industrial countries had well understood: one could not do without doctors but doctors were not sufficient to solve the complex problems of the natural and urban environment, the living and working conditions of the population,  of the misery and degradation that constituted the other side of progress.

Natural areas have mainly suffered from the effects of industrialization. Moreover, since the agricultural revolution, human societies have always striven to modify the environment to take advantage of it: for example, deforestation was carried out to prepare cultivated fields, swamps and marshes were drained, mountains were dug but everything happened within the limits that human and animal labor force imposed.

The machine has allowed operations of much wider scope and the natural environments have undergone drastic changes.

A possible solution to the harmful effects of urbanization could lie in the establishment and use of green spaces. In other words, it is a matter of restoring, within certain limits, the function that plants have played during the evolution of the planet: to give back to vegetation the role that belongs to it also for the protection of the human species.

Green Space for health promotion

During the last two years, due to the Coronavirus emergency, numerous work activities have been forced to close. One of the most affected sectors was the sports and fitness one. Since March 2020, sports events and competitions of all kinds and disciplines have been suspended, as well as all organized sporting events and activities in gyms, sports centers, swimming pools and sports facilities.

One of the few forms of physical activity allowed was physical activity in the open air, first in individual form and later in small groups. This situation has led more and more people to rediscover the pleasure and benefits that derive from carrying out physical activity outdoors.

One of the possible definitions of the expression physical activity indicates it as “any movement of the body made through the contraction of skeletal muscles that involves a significant increase in energy demands above the rest values”; walking, running, playing, and exercising in the open air can therefore be counted as forms of outdoor physical activity.

During the period marked by the pandemic, the spaces where these types of activities can be carried out have included parks, gardens, paths, cycle paths and pedestrian areas, defined below as green spaces.

Green spaces or green infrastructure or urban green spaces are defined as outdoor spaces “partially or completely covered with grass, trees, shrubs or other types of vegetation and include, among others, parks, forests and communal gardens”. The concept of green space can therefore be extended to all those green spaces where you can spend free time, play, relax, walk, or simply pause.

The European Union describes green spaces as “a strategically planned network of natural, semi-natural areas along with other environmental elements, designed and managed with the aim of  providing a wide range of ecosystem services such as water purification, better air quality, leisure space, mitigation and adaptation to climate change, the protection and increase of biodiversity in rural and urban areas as well as in natural territories”.

The set of green spaces therefore allows to improve the quality of the environment and, consequently, the health and quality of life of citizens.

Environmental Benefits

The presence of urban green spaces has a positive impact on the environment, significantly affecting the territorial microclimate through the modification of extreme temperatures, the improvement of the hydrological cycle, the protection of biodiversity of flora and fauna as well as the consolidation of soil stability.

Temperature mitigation and adaptation to climate change

As it is well known and documented, the presence of green spaces in small and large cities represents an important source of refreshment for the territory. The main processes underlying the cooling effect of vegetation on the territorial microclimate are represented by the shade provided by trees and plants and their evapotranspiration processes.  These effects can lead to temperatures being reduced by up to 8°C.  The reduction of urban vegetation involves, instead, the increase in the absorption of solar radiation contributing to the development of the urban phenomenon of the so-called “heat islands”. Rising urban temperatures adversely affect human health; in particular, certain demographic groups, such as children and the elderly, are more vulnerable to prolonged exposure to high temperatures.  In a context in which the population is increasingly elderly, the positive effects mediated by the presence of green spaces in the reduction of mortality due to heat take on great importance.

Covering buildings with vegetation, for example by designing structures with green roofs, represents an innovative solution to reduce the temperature of the latter and the spaces surrounding them.  The presence of green roofs brings numerous environmental and energy-saving benefits, since they lead to an improvement in air quality, removing carbon dioxide and releasing oxygen and water vapor, a reduction in the urban “heat island” effect and an increase in the thermal resistance of building roofs.  The presence of various types of flowers and plants, in addition to adorning the landscape, also provides habitat for the fauna, thus favoring the protection of biodiversity.

Reduction of air pollution

Green spaces, and specifically green roofs, favor a reduction in air pollutants, including those produced by car engines, and atmospheric levels of ozone (O3), whose rise in recent decades has been identified as the cause of the increase in asthma symptoms. Near green roofs, a reduction of 37% in sulphur dioxide (SO3) values and 21% in nitric oxide (NO) values was observed.

Urban green spaces also represent an important resource useful for the storage of carbon (CO2) from the atmosphere, thanks to the ability of plants to reduce their environmental level, storing it during the day. Within a day, a green roof can reduce the concentration of CO2 in the surrounding areas by about 2%.

Reduction of energy consumption

As previously emerged, the presence of green spaces leads to a modest reduction in temperatures with a consequent mitigation of the climate, aspects that partly contribute to the reduction of energy consumption of buildings and CO2 emissions.

Among the many benefits already mentioned of green roofs, we also include the possibility of reducing the energy demands of a building. A green roof is indeed able to intercept up to 87% of the solar radiation that would otherwise be absorbed by the building, resulting in a saving in the costs associated with the use of air conditioning. As a matter of fact, a significant difference was highlighted in the temperature measured in the interiors of a building covered by a green roof, in which the temperature did not exceed 30 °, compared to a building without the latter, with temperature values stably above 30 °. The increase in green infrastructure, such as an innovative saving technique, would therefore lead to a significant reduction in costs and energy related to the use of air conditioning.

Green roofs also lead to an improvement in the ability of buildings to retain heat during cold periods, reducing the demand for energy for heating.

Safeguarding biodiversity

The growing urbanization, in addition to the problems already mentioned above, determines a reduction in the habitats available for plant and fauna species. Global estimates show that, due to climate change, more than half of all species may be at risk and will have to move to territories with more suitable climates. However, biodiversity plays a fundamental role in the sustainability of nature’s ecosystem; it is therefore important to prevent, or at least limit, the reduction of biodiversity. The promotion of biodiversity through the diffusion of urban green spaces on the territory is an option to be considered.

Trees, for example, represent one of the main sources of habitat for many wildlife species; the presence of parks and spaces rich in trees and plants is of fundamental importance for the survival of these species, even in an urban context. By preserving and extending green infrastructure, therefore, not only the biodiversity of the flora will be preserved, but also the biodiversity of the fauna species that live in urban environments.

A greater variety of fauna and plant species also brings benefits to humans; green spaces offer spaces where to appreciate these biodiversity, contributing to environmental education through the promotion of respect and protection of natural environments.

Physical and social benefits

The presence on the territory of green space also involves a series of physical and social benefits. The literature suggests that frequenting urban green spaces positively affects an individual’s physical and mental health and prevents the risk of adopting incorrect lifestyles.  Numerous social facilities emerge from the organization of sports and leisure activities in the context of green infrastructure. The community as a whole also benefits from the presence of green spaces in terms of cohesion and social equity. Parks and gardens can also represent places that promote tourism, education and sustainable mobility.

Health and well-being

Numerous publications demonstrated the links between green spaces and health and well-being. Green infrastructures are a space where you can spend your free time, play, relax, walk or simply stop, with a positive effect on physical and mental health.

The importance of green spaces as a form of disease prevention is still little considered today. However, numerous researches show that outdoor physical activity favors a reduction in blood pressure, cholesterol values and stress.

Green spaces represent firstly an important form of prevention of physical inactivity; in the development of diseases, physical inactivity is a risk factor on a par with tobacco consumption and an unbalanced diet. In Italy, sedentary lifestyle is responsible for 14.6% of all deaths, equal to about 90,000 deaths per year, and an expenditure in terms of direct health costs of 1.6 billion euros per year for the four diseases most attributable to it: breast and colorectal cancer, type 2 diabetes and coronary artery disease. The mortality rate could be drastically reduced if the share of the population that is sedentary or performing levels of physical activity below those recommended by the WHO, carries out levels of physical activity in line with WHO recommendations. The social and economic impact caused by sedentary lifestyle indicates how important it is to encourage the attendance of urban green spaces to increase levels of physical activity and how it is necessary to consider this activity as a form of prevention of individual and collective health. The presence of urban green spaces is therefore a factor that favors the adoption of a more active lifestyle.

Carrying out adequate levels of physical activity leads to a slower decline in physical functions, favoring, particularly in the elderly population, a healthy aging, essential to maintain a good quality of life and adequate independence during old age. The maintenance of a good level of physical fitness, favored by carrying out outdoor physical activity, allows you to adequately complete the activities of daily life, without fatigue.

A study carried out in the United Kingdom showed a correlation between obesity and access to green spaces: people with access to green spaces had lower levels of obesity. In Italy it is estimated that about 25% of the population over 18 years of age is in excess of weight, a problem also presents in childhood: one in four children is obese. An obese individual will be at increased risk of developing conditions of arterial hypertension, hypercholesterolemia, hypertriglygeridemia and type 2 diabetes, all of which are associated with an increased cardiovascular risk. When people do not have spaces to walk, stroll or take part in sports or recreational activities they tend to gain weight; therefore, a condition of obesity is more frequent in places not suitable for carrying out physical activity. Conversely, a review of the literature in the American Journal of Preventive Medicine has shown that the creation or greater attendance of environments favorable to the performance of physical activity combined with greater information disclosure determines a 48% increase in the frequency of physical activity.  By offering opportunities for outdoor physical activity, urban green spaces therefore favor an improvement in physical health and a reduction in the body weight of such subjects. Similarly, a recent publication has demonstrated a positive relationship between frequenting green areas and reducing cardiovascular mortality.

It has also been shown that the attendance of green spaces has a positive effect not only on physical health but also on mental health. The contact with nature and the frequentation of urban green spaces exerts a positive impact on mental well-being, favoring an optimistic and proactive attitude, improving social support, reducing stress and tensions and determining greater opportunities for physical activity. Recent research conducted in the UK hypothesized that physical activity in green spaces would improve mental health and well-being. This study evaluated the effect of certain types of outdoor exercises; all these activities have resulted in benefits in terms of health and mental well-being, indicating once again the benefits of green spaces on mental health and well-being.

Outdoor activities and the presence of green spaces have important implications for public and the environment health. A further study, published in the Netherlands in 2001, highlighted the link between green spaces and health. The results showed that in environments with a greater presence of green spaces, citizens reported fewer complaints about their state of health and had a better mental health condition.  One of the authors of the study, Syerp De Vries, deals with various interventions that have as their object the renovation of slums in the city of Rotterdam, in particular school buildings. In them he redesigned the structure of the courtyards, equipping them with green spaces: the impact that these new dimensions exert on schoolchildren proves essentially positive.

The promotion of health favored by green spaces is not, however, attributable only to the performance of physical activity within them; green spaces represent an important resource that contributes to the reduction of air pollution, through the absorption, deposition and dispersion of air pollutants. Gardens, trees, parks and hedges can therefore help improve air quality and reduce noise pollution. The use of vegetation can help to counteract the propagation of noise through absorption or diffraction.

Green space and social cohesion

The creation and maintenance of urban green spaces is an effective way of promoting participation and social cohesion within a community. In Australia, for example, it has been observed that groups of individuals involved in projects to protect and improve the natural environment not only worked to restore and care for the environment but experienced a greater connection and trust in others thanks to greater interaction with their local community. This type of experience allowed citizens to spend more time in contact with nature, favoring, as previously emerged, an improvement in physical and mental health.

The presence of trees and gardens in the vicinity of residential complexes determines a habitual attendance of such spaces by residents, creating more opportunities for participation and social interaction. Compared to residents in areas without green spaces, those who live near green infrastructure are more involved in social activities, know the neighborhood better and develop a more rooted sense of belonging.

Green space and child development

Green spaces play a fundamental role for proper child development, encouraging play and recreational activities and encouraging contact with nature. Today, however, due to various factors, children are less and less frequenting parks and gardens, preferring the use of new technologies, such as computers and video games.

However, recreational activities are fundamental for the development of children, indeed playing is equivalent to learning. It is now known that play represents a critical element in child development, that can be used to strengthen muscle and basic coordination skills, basic motor patterns and cognitive functions. In addition, urban green spaces and parks encourage interaction with other children.

It is also important that schools and kindergartens have adequate green spaces to allow a wide variety of recreational and educational activities; green spaces provide spaces for school learning both formal, through training activities, and informal, carrying out play activities. Access to green spaces is associated in children with an improvement in mental health, general health and cognitive development.

Green space and aging

Numerous evidences suggest that involvement in gardening activities has benefits for physical and mental health in elderly individuals. A recent study, conducted in the United Kingdom, has highlighted how disability and chronic diseases are not inevitable consequences of aging and can be alleviated by supporting the development of community gardening programs that favor an active lifestyle for these subjects. This study also highlighted how natural landscapes have a positive impact on the mental well-being of older subjects, how the development of gardening activities contributes to the social inclusion of these subjects and favors the development of social networks and how gardening activities not only allow participants to achieve a greater sense of fulfillment and satisfaction as a result of their involvement in the protection of natural environments; it also highlights how, in taking care of the plants, they also take care of the other participants, determining the emergence of a deeper sense of community.

While the above study highlighted the benefits of establishing social networks for healthy aging, recent research in Japan highlighted the importance of areas and walking paths for the longevity of older citizens. This study found that living in areas provided with pedestrian paths positively affects the longevity of older individuals regardless of their age, gender and socioeconomic status. The importance of urban green spaces for the health of senior citizens should therefore be emphasised in the planning and design of cities.

Green space and social equity

Recent studies show that average life expectancy in OECD nations is closely related to the degree of social equity. A society with large differences in terms of equity will also be more likely to be violent, having a negative impact on the well-being and mental health of the community.

The benefits provided by the presence of urban green spaces, in this case, play an important role in promoting the social well-being of communities and favor greater livability in the neighborhoods in the center of large cities. For children, teenagers and families at risk and with a low income, who would not otherwise be able to afford to enroll in a gym or other facilities, green spaces offer the opportunity to carry out recreational activities. The parks and gardens also provide spaces in poorer neighborhoods, where residents can experience a sense of community.

The unequal distribution of public parks among different cultural groups and socioeconomic classes risks harming residents, creating significant health costs due to physical inactivity. The correlation between poverty, social status, obesity, illness and environmental factors that discourage physical activity, including the absence of parks and recreational facilities, is now known. The design of residential neighborhoods in the city center should therefore consider the presence of green spaces as a form of reducing inequalities in terms of health and sociability of its residents.

The environment, in its most complete and complex sense, including lifestyles, social and economic conditions, is a fundamental determinant for the psychophysical well-being and therefore for the health of people and populations. Many pathological processes find their etiopathogenesis in environmental factors, as evidenced also by recent acquisitions in the field of epigenetics.

The Ostrava Declaration of the Sixth Interministerial Conference on Environment and Health (WHO 2017) indicates the crucial points on which the Environment and Health Strategy for the coming years must develop: environmental degradation, indoor and outdoor pollution, climate change, indoor and outdoor exposure to hazardous chemicals, the quality and safety of drinking water, contaminated sites, waste and the destabilisation of ecosystems that exacerbate social inequalities; the need to develop systemic, cross-sectoral actions that focus on prevention, paying the utmost attention to the most disadvantaged sectors; the importance of sharing responsibilities with all levels of government, from international and national to local, involving citizens and stakeholders with actions extended on the territory, inside and outside their borders and projected on long time scales. The aforementioned Declaration recognizes that the well-being of populations is closely linked to all the objectives of the 2030 Agenda and to the objectives of the Paris Climate Agreement, signed in 2015 by the United Nations Framework Convention on Climate Change (UNFCCC – CoP 21), which must necessarily be an integral part of the strategy.

The National Biodiversity Strategy recognizes the value of the One Health approach to address the cross-cutting issue of biodiversity and human health as an integrated approach consistent with the ecosystem approach, promoting a systemic vision of health, multidisciplinary and transdisciplinary, to address potential or existing risks that originate at the interface between human health, that of ecosystems and anthropized environments.

The health sector can make a decisive contribution to safeguarding biodiversity and improving the built environment by operating systematically, promoting environmentally friendly technologies, sustainable consumption, green building and urban green spaces and more efficient management of health systems.

Climate change poses a serious threat to global health and a major challenge for the 21st century. The scenarios foresee an imbalance of ecosystems with an increase in the intensity of health risks related to disasters, extreme events, water availability, food security and changes in the appearance and spread of diseases of infectious origin (pathogenic vectors, contaminated water and food). Gender inequalities, social and economic marginalization, conflicts and migration will also increase. The WHO estimates more than 250,000 more deaths per year in the world due to climate change for the period 2030-2050. The most vulnerable subgroups will be particularly affected: children, the elderly, people with chronic diseases and deprived socio-economic groups.

Tackling climate change represents an unprecedented opportunity for public health, through climate strategies that offer significant benefits to address some of the most pressing health problems. Resilience and climate adaptation for health, as well as mitigation strategies must interconnect with health programmes and activities, and health is central to the overall framework in combating climate change.

The EU launched climate change management and mitigation policies and biodiversity strategies, which are undergoing adaptation in the various member states. The United Nations 2030 Agenda and the aforementioned Paris Climate Agreement 2015, represent two fundamental reference frameworks to combat climate change and lead towards a more sustainable development model; however, this challenge requires a radical change in production and consumption patterns.

In line with the strategy, which inspires the action of the WHO and the United Nations Framework Convention on Climate Change (UNFCCC) in interactions with the governments of different countries to define the “Country Profiles” on climate and health, the Country profile of Italy was defined in the context of the Italian Presidency of the G7 in 2017, as part of the project “Health effects of climate change in the Planetary vision  health, which provides current data and future scenarios on climate change and health in the most relevant impact areas such as air pollution, heat waves, water resources and water management, infectious and vector diseases, primary production and food security, migrations, ecosystems and biodiversity erosion, including in urban environments. The data collected indicate an intensification of threats to the health of the Italian population, for which specific prevention actions are identified, coordinated with national mitigation and adaptation policies and strategies coordinated by the Ministry of the Environment and protection of land and sea (MATTM), through the “National Strategy” and the “National Plan for adaptation to climate change”.

Moreover, considering that due to the effect of global warming in cities “heat islands” are created, much warmer than in rural areas, the Ministry of Health  has activated since 2005 the “National Operational Plan for the prevention of the effects of heat on health”, with which specific city forecasting alarm systems have been introduced on the national territory (Heat Health Watch Warning System-HHWWs ) which can foresee, 72 hours in advance, the arrival of a heat wave and promptly activate prevention interventions at local level. This monitoring system is still in vogue.

Air pollution, indoor and outdoor, is the main environmental risk factor for health. Transport and domestic heating are the main causes of emissions of pollutants of toxicological interest that raise greater concern in terms of health impact due to the high number of people exposed, in urban and extra-urban areas. Emissions from agriculture, energy production, industry and domestic settlements also contribute to polluting the air.

According to the WHO, air pollution is among the main causes of deaths due to non-communicable diseases such as stroke and cardiovascular diseases, cancers and chronic respiratory diseases.

Recent studies show that indoor household pollution is the third risk factor for the global disease burden, after high blood pressure and tobacco smoke.

Of great concern is the contribution of PM2.5 to air pollution from biomass mainly used for domestic heating.

To reduce urban air pollution, including climate-changing emissions, it is necessary to promote the use of cleaner energy sources and more sustainable urban transport systems, to design and create cities that foster healthy lifestyles and communities sustainable and resilient to climate change, as recommended by the WHO.

The burden of diseases associated with indoor and outdoor exposure to chemicals should also be highlighted. There are tens of thousands of chemicals on the EU market and an unknown number of them have a negative impact on health and the environment. exposure to multiple chemicals at once, even at low doses (cocktail effect) exacerbate or negatively alter health impacts. Exposure to chemicals can cause, for example, congenital disabilities, respiratory problems, neurodegenerative diseases, skin diseases, endocrine disruption or cancer.

In all this we cannot fail to consider the environmental impact on the part of the livestock world. The European Commission in the Green Deal strategic document, which aims to address the problems related to the climate and the environment, addresses the aspect of consumer protection by analyzing and intervening along the entire production chain according to the farm to fork approach for a sustainable food policy. This means studying and applying policies to promote and support a more sustainable supply chain, with the aim of reducing greenhouse gases and all polluting factors starting from breeding through all production processes, transport and distribution, also with a view to reducing waste and therefore the production of waste.

The Task Force Ambiente e Salute (TFAS), established at the Ministry of Health in 2017, has a significant mandate aimed at “Building a national strategy for the coordination and integration of national and regional policies and actions in the environmental and health field: identification of shared standards and actions for the prevention, evaluation, management and communication of environment-health issues”, to create initiatives (including regulations) in support of the Plan to strengthen the “environment and health” governance, at various levels, between the responsible structures/ institutions.

As part of the CCM project “Integration, training and assessment of the impact of environmental pollution on health: Rete Italiana Ambiente e Salute (RIAS)” the aforementioned Network is being built, which contributes to the work of TFAS also through the development of operational tools.

The NFP 2020-2025, in line with the European and international guidelines, and taking into account the production guidelines aimed at reducing the environmental impact, as well as the new LEAs and in continuity with the NFP 2014-2019:

proposes a cross-sectoral and integrated strategy, aimed at achieving synergies between health services, responsible for human and animal health, and those responsible for environmental protection, to strengthen the One Health approach, with the aim of reducing avoidable diseases and premature deaths related to the environmental impact of production practices to protect the health and well-being of people and animals.

Risk factors and health determinants

Based on the data illustrated above, the following categories of risk factors are identified:

  • Exposure to chemical, physical and microbiological agents in indoor and outdoor environments.
  • Climate change and extreme weather events.

In addition, there are the system criticalities indicated below, capable of affecting the activities of

  • prevention and reduction of risk factors, and which could be solved through strategies and interventions of a legal-administrative nature:
  • Sectorality of standards and competences of health surveillance and environmental monitoring activities.
  • Fragmentation of competences and lack of synergies between prevention and health promotion activities of the NHS and environmental protection activities of the SNPA.
  • Low relevance of environment and health issues in the policies of other sectors: transport, construction, urban planning, agriculture, energy, waste, instructions.
  • Inadequate application of tools to support administrations for the assessment and management of the health impacts of environmental issues.


To promote the overcoming of technical-scientific and governance critical issues at national and regional level, for health promotion, prevention, assessment and management of risks deriving from environmental, anthropogenic and natural factors, the NLP 2020-2025 proposes, following the One Health approach, to implement guidelines and actions adopted with the Ostrava Declaration combined with the objectives of the 2030 Agenda, providing for the following strategic lines:

  1. Promote advocacy interventions in the policies of other sectors (environment, transport, construction, urban planning, agriculture, energy, education).
  2. Promote and strengthen tools to facilitate integration and synergy between NHS prevention services and NHS agencies.
  3. Adopt interventions for the prevention and reduction of environmental exposures (indoor and outdoor) and anthropogenic harmful to health.


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  3. Gascon, M., Triguero-Mas, M., Martínez, D. , Dadvand, P. , Rojas-Rueda, D. , Plasència, A. , & Nieuwenhuijsen, M. J. (2016, Gennaio) Residential green spaces and mortality: A systematic review.  Environmental International, 86, 60-67.
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  6. McCormick, R. (2017, Novembre-Dicembre) Does Access to Green Space Impact the Mental Well-being of Children: A Systematic Review. Journal of Pediatric Nursing, 37, 3-7.
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  9. Pretty, J., Peacock, J., Hine, R., Sellens, M., South, N., & Griffin, M. (2007).  Green exercise in the UK countryside: effects on health & psychological well-being and implications for policy and planning. Journal of Environmental Planning and Management, 50(2), 211-231.
  10. Sakar, C. (2017, Settembre).  Residential greenness and adiposity: Findings from the UK Biobank.  Environmental International, 106, 1-10.
  11. Taha, H. (1997). Urban Climates and Heat Islands: Albedo, evapotranspiration and anthropogenic heat.  Energy and Buildings, 25 (2), 99-103.
  12. Takano, T., Nakamura, K., & Watanabe M. (2003, dicembre). Urban residential environments and senior citizen’s longevity in mega cities: the importance of walkable green spaces.  Juornal of Epidemiology and Community Health, 56(12), 913-8.

CT-Urography study protocol: Split-Bolus technique

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Submission Date: 2022-04-05
Review Date: 2022-04-19
Pubblication Date: 2022-05-03



CTU represents the natural technical and instrumental evolution of urography. The multidetector technology, with the possibility of retro-reconstruction of the images, has allowed the direct representation of the excretory tract with a significant reduction in acquisition times, decreasing motion artifacts and increasing the definition of the processed images. Split-Bolus CT dynamic study allows us to obtain, in a single image acquisition, both the nephrographic and the renal excretory phases; at the same time, we can obtain information of the parenchymal organs in the abdominal cavity as in the portal/nephrographic phase of a standard CT protocol. The main advantage of Split-Bolus CTU is undoubtedly the significant saving of the radiation dose administered to the patient, related to the reduction in the number of phases acquired, with a reported diagnostic efficacy comparable to traditional protocols in terms of imaging quality. The Split Bolus technique has been used in several clinical contexts, such as in the characterization of focal liver lesions, in acute pulmonary embolism and in polytrauma patients.


CTU represents the natural technical and instrumental evolution of urography. The multidetector technology, with the possibility of retro-reconstruction of the images, has allowed the direct representation of the excretory tract with a significant reduction in acquisition times, decreasing motion artifacts and increasing the definition of the processed images. It represents the main imaging technique for the evaluation of renal diseases and diseases affecting the urinary tract, particularly in relation to the prevalent excretion of iodinated contrast agents through the kidneys.

CT without contrast agent has a high diagnostic accuracy for the detection of stones and hemorrhagic content of cystic lesions, while contrastographic phases (arterial, parenchymal/nephrographic, and excretory) allow the correct evaluation of renal masses or parenchymal changes. On CT, the kidneys present sharp and defined contours due to the high natural contrast with the surrounding fatty tissue. On examination without mdc, the renal parenchyma presents homogeneous parenchymatous density of about 30-60 Hounsfield Units (HU); contrast agent administration allows to distinguish the different parenchymal components, which present variable behavior depending on the study phase:

  • In the arterial or angio-cortical phase, the renal cortical shows intense enhancement. In this phase it is also possible to study the renal arteries and is acquired in cases of characterization and follow-up of renal masses.;
  • In the venous or nephrographic phase, enhancement of the medullary pyramids increases, so that the renal parenchyma appears homogeneous. In this phase it is possible to study the renal veins;
  • In the late or urographic phase, opacification of the urinary excretory pathway is detected with reduced parenchymal enhancement.

On CT, it is possible to easily detect bladder walls that exhibit muscle-like density in the pre-contrast study, with moderate and homogeneous impregnation after contrast agent, nicely delineated by perivesical pelvic fat, externally, and urine hypodensity, internally.

Significant is the concern about the radiation dose exposure of CT examinations and its potential long-term consequences. The radiation dose depends primarily on the number of steps acquired, the scanning parameters used, and the size of the patient. Depending on the diagnostic question and subsequent protocol employed, the reported radiation dose exposure for uro-CT examinations varies from 20 to 66 mSv, compared with an average effective dose of 5 to 10 mSv for intravenous urography. This may be the major concern hindering the widespread use of uro-CT in daily clinical practice, particularly when performed in young patients or for follow-up purposes. Along with the use of alternative imaging modalities (e.g., MRI or ultrasound), several techniques are generally used to reduce radiation dose exposure in CT examinations. One of the most common tools is lowering the tube voltage, but this can lead to low/medium quality images. Increasingly employed in recent years is the application of various iterative reconstruction algorithms, but when this is not available, a common approach is based simply on reducing the number of steps acquired.

Urinary tract evaluation generally requires at least one excretory step, which rarely fully answers the underlying diagnostic question when performed alone. The main goal of uro-CT protocols is to obtain fully opacified collection systems lying down to the bladder, along with adequate image quality of renal parenchyma, tumor enhancement, and vascular anatomy. According to the ALARA (As Low As Reasonably Achievable) principle, this should be achieved with as few steps as possible; however, to the best of our knowledge, no standard uro-CT protocol has been widely accepted for patients with renal or urinary tract disease.


Prior to image acquisition, preliminary patient preparation is very important, consisting of:

  • oral hydration, in which the patient should drink 1 liter of water 40-60 minutes prior to the examination, allowing optimal distension of the collector system so as to improve visualization;
  • The administration 15-20 minutes before the start of the examination of 500 ml of intravenous saline;
  • administration of an intravenous diuretic (0.1 mg/kg up to 10 mg furosemide) immediately before contrast agent administration as it promotes fluid elimination from the urinary system;
  • Because of the administration of the contrast agent, the patient must observe a fast of at least 6 to 8 hours.

A preliminary study without contrast agent administration of the abdomen and pelvis is performed before the dynamic study, mainly in cases of first examinations (especially in oncological or traumatic patients) and for the possible evaluation of cystic lesions and calcifications of various nature (perhaps not recognizable due to mdc injection). The standard patient position at all stages of the study is supine, with arms raised above the head. Occasionally, the ready position may be necessary if opacification of the upper excretory tract is to be improved, especially in the presence of hydro-uretero-nephrosis and bladder. Considering a norm type patient, a total dose of 120-130 ml of water-soluble iodinated contrast agent is administered intravenously, fractionating it into two boluses: the first bolus at bed flow infusion of 40-50 ml of mdc, followed by a second injection of the remaining 70-80 ml of mdc, 5-15 minutes after the first injection. 80-90 seconds after the second administration, images are acquired in a single combined nephro-urographic phase.

This phase allows to obtain the typical results of the nephrographic phase (with better definition of parenchymal lesions such as cysts, tumors, infections, homogeneous opacification of the renal vein and inferior vena cava) and of the excretory phase (opacification of calyces, renal pelvis, ureters and bladder for a better evaluation of the anatomy variants and filling defects of the urinary tract and a possible classification of hydronephrosis and redness of the urinary tract) allowing in turn a collateral evaluation of other abdominal parenchymal organs (especially liver, spleen and pancreas) and the portal-splenic-mesenteric venous system (variants, caliber, filling defects). In the case of oncological patients, for the evaluation of hypervascularized lesions (such as in renal carcinoma or urothelial cancer) the arterial phase is further acquired approximately 15-20 seconds after the administration of the second bolus (Fig.1), using the bolus tracking technique (Table 1).

Tab. 1
Fig. 1 -Axial image (left) and coronal MIP image (right) of an additional arterial phase acquisition in a Split Bolus uro-CT, in which the abdominal aorta to both renal arteries to the hilar regions of the kidneys are visible.

Split Bolus-CT dynamic study allows to obtain, in a single image acquisition, both the nephrographic and the renal excretory phases; at the same time, we can obtain information of the parenchymal organs in the abdominal cavity as in the portal/nephrographic phase of a standard CT protocol (Fig.2). High-resolution acquisitions then allow for additional post-processing images such as multiplanar reconstructions (MPR), maximum intensity projections (MIP), and three-dimensional (3D).

Fig. 2 – Image of a Split Bolus uro-CT acquisition in which both the nephrographic and excretory phases are represented; the homogeneous opacification of the renal cortical, right renal pelvis, and left proximal ureter is clearly visible in this image.

Main limitation of the protocol

According to some authors, there are some limitations to consider in the use of a Split Bolus uro-CT protocol and which, however, could be partially shared with standard uro-CT studies:

  • Although CT has a reported sensitivity of up to 90-95% in visualizing bladder tumors, small ones at the ureteral orifices may not be visualized, likely due to both the normal protrusion often present in that region and the blending artifacts within the bladder that can lead to false-positive or false-negative interpretations. An anatomic-only imaging approach will not provide confident identification of flat tumors of the bladder (such as carcinoma in situ), and conventional cystoscopy still remains the gold standard for evaluation of the bladder mucosa;
  • Additional reconstructions (particularly MIP) may add additional useful information, but should be interpreted in conjunction with native axial images and with standard MPR; in fact, the main evaluation is based on analysis of axial images. Appropriate window and level settings should be used for evaluation of the collecting system and ureters so that dense intraluminal contrast material does not obscure urothelial details and, potentially, small lesions;
  • Correct timing of the double bolus of contrast agent is essential to avoid partial/uneven opacification of the urinary tract or bladder;
  • The reduced amount of the first contrast agent bolus may lead to reduced HU values of iodinated urine compared with a standard CT protocol; however, the overall opacification (on which the final assessment is generally based) tends to be qualitatively similar between the two techniques.


One of the limitations of this technique is in the evaluation of neoplasms that produce minimal thickening of the bladder wall, where a sensitivity of 74% has been reported. However, patients with hematuria and risk factors for urothelial neoplasia should be considered for conventional cystoscopy, which remains the gold standard for evaluation of the bladder mucosa. The main advantage of Split Bolus uro-CT is undoubtedly the significant savings in the radiation dose administered to the patient; this is basically related to the reduction in the number of phases acquired. Traditional protocols require multiple image acquisitions (usually non-contrast images, nephrographic and excretory phases) and the average effective radiation dose has been estimated to be even higher than 60 mSv. Radiation dose exposure is consequently reduced, with reported diagnostic efficacy comparable to traditional protocols in terms of imaging quality.


  1. Chen CY, Tsai TH, Jaw TS et al. Diagnostic performance of split-bolus portal venous phase dual-energy CT urography in patients with hematuria, American Journal of Roentgenology, 2016;
  2. Scialpi M, Pierotti L, Gravante S et Al., Split-Bolus Multidetector-Row Computed Tomography Technique for Characterization of Focal Liver Lesions in Oncologic Patients, Iran J Radiol, 2016;
  3. Jinzaki M, Kikuchi E, Akita H et al. Role of computed tomography urography in the clinical evaluation of upper tract urothelial carcinoma. International Journal of Urology, 2016;
  4. Tract Imaging: Triple-Bolus Multidetector CT Urography as a One-Stop Shop – Protocol Design, Opacification and Image Quality Analysis. Radiology, 2010, Kekelidze M, Dwarkasing RS, Dijkshoorn ML et Al., Kidney and Urinary;
  5. Single-phase Whole-body 64-MDCT Split-bolus Protocol for Pediatric Oncology: Diagnostic Efficacy and Dose Radiation, M. Scialpi, R. Schiavone, A. D’Andrea, I. Palumbo, M. Magli, S. Gravante, G. Falcone, C. De Filippi, B. Palumbo;
  6. Urografia por Tomografia Computada Multicorte (UroTac): estudio descriptivo utilizando la técnica de “split bolus”; Karina Hermosilla M, Roberto Cabrera T, Benjamín Horwitz Z, Rodrigo Raurich S, Marco Barbieri H, Samuel Gac H, Pablo Soffia S, Claudia Páez A, Oscar Morgado H.
  7. Split-bolus MDCT urography with synchronous nephrographic and excretory phase enhancement; Lawrence C Chow, Sharon W Kwan, Eric W Olcott, Graham Sommer;
  8. Split-bolus MDCT urography technique: clinical applications, imaging findings and radiation dose exposure; ECR 2017; C. Valle, P. Bonaffini, S. Sironi;
  9. Split vs. Single Bolus CT Urography: Comparison of Scan Time, Image Quality and Radiation Dose; Nicole Morrison, Sherrie Bryden, Andreu F. Costa

Effectiveness of the fast-track pathway for the management of patients with diabetic foot through the network between second and third level centers

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Submission Date: 2022-04-01
Review Date: 2022-04-16
Pubblication Date: 2022-04-30



Diabetic foot is one of the most serious and expensive complications of diabetes. It requires prompt treatment in order to avoid the amputation of the foot, lower limb or even death of the patient.
The aim of this study is to evaluate the effectiveness of the Fast Track Pathway (FTP) between level I, II and III diabetes centers in the Lazio Region for the treatment of diabetic patients with injuries in order to reduce the rate of amputation and mortality.
A retrospective observational study was performed from January 2020 to December 2020. We enrolled 23 diabetic patients presenting injuries and Diabetic Foot Ulcers (DFUs) belonging to a level I and II diabetic foot care center and were divided according to the type of DFUs into uncomplicated, complicated and severe; and when necessary, sent to a specialized center for the care of level III diabetic foot. The following outcomes were evaluated: healing, healing time, minor amputation, major amputation, and survival.
Healing occurred in 15/23 patients (65.2%). Healing time averaged approximately 7 ± 5 weeks. The minor amputation rate was 17.4%. The major amputation rate was 0. The survival rate was 95.6%.
The preliminary data collected allow us to state that the FTP path guarantees excellent management of the diabetic patient with DFUs between the territory and a second and third level diabetes center.


Diabetic foot is one of the most serious and costly complications of diabetes, the result of interactions of various etiopathogenetic factors which, if not well diagnosed and treated in a timely manner, can lead to foot amputation, limb amputation and in more serious cases patient death (Bus & Ph, 2017).

The correct prevention and management of all its complications plays a key role in the ideal implementation of this strategy to reduce complications related to diabetic foot.

Of primary importance is the timing with which this pathology is treated, as often cited “Time is Tissue” (Lepäntalo et al., 2011).

Ulcer grade and severity are important predictors for healing time (Smith-str et al., 2017) and the treatment of complications such as ischemia and infection always requires urgent treatment (Lepäntalo et al., 2011). For example, a delay in the surgical debridement of an abscess in the deep space of the foot increases the level of amputation (Faglia et al., 2006).

Given the complexity of the management of diabetic foot ulcers (DFUs), it is essential to implement a multidisciplinary approach where each professional figure, while interacting with the others, maintains a differentiated role to best guarantee the achievement of the set objectives.

In this regard, it is important to build a local network for the management of DFUs in order to reduce amputation rate, reduce healing time, and improve the patient’s quality of life.

The proper approach is the one proposed in the Fast Track Pathway (FTP) (Meloni et al., 2019) which aims to identify an action strategy for the treatment of diabetic patients with DFUs (Graph 1).

It is ideal to implement the FTP on a regional level that not only serves to indicate the appropriate management of the patient, but that also creates a network between the various diabetic structures that are currently divided into levels of assistance with different skills and characteristics. Below is Table 1, published within the IWGDF of 2019, which identifies the different levels of assistance and specifies the specialists involved (Jakosz, 2019).

Graphic 1 – Fast-Track Pathway
Tab. 1 – Level of care and interdisciplinary specialist involved

This relationship between structures of different levels would guarantee an adequate management of the patient with reduction of costs, improvement of the patients’ quality of life, reduction of amputations and fewer deaths.


Evaluate the effectiveness of the management of diabetic patients with DFUs through the creation of a “Fast-Track Pathway” between level I, II and III diabetes centers in the Lazio Region.

Materials and methods

A retrospective observational study was carried out from January 2020 to December 2020. All patients diagnosed with type I and II diabetes mellitus, aged 18 to 90 years, of both sexes, who belonged to both the Diabetology UOSD of II level of the San Camillo De Lellis Hospital in Rieti both at a level I center (Podiatry Studio – Poggio Mirteto) which presented uncomplicated, complicated and severe DFUs. These patients who presented these characteristics and required level III specialist care, were sent to the Diabetic Foot Unit at the Tor Vergata Hospital – Rome. It is important to denote: the centers that participated in this study are all located in the Lazio Region. Uncomplicated DFUs were defined as superficial, uninfected, and non-ischemic wounds. Patients who did not show healing or improvement within 2 weeks of treatment (30% area reduction or absence of granulation tissue formation or signs of re-epithelialization) were referred to a specialized diabetic foot care center (Meloni et al., 2019). Complicated DFUs were defined as ischemic and/or infected or deep wounds (tendon or bone exposure) or any type of lesion present in patients with heart attack (not heart attack, but heart failure), or on dialysis. These patients had to be referred to the specialized diabetic foot care center within 4 days (Meloni et al., 2019). Severe DFUs were defined when wet gangrene and/or abscess/phlegmon were present or the patient had a fever and/or showed signs of sepsis. Such patients needed urgent hospitalization within 24 hours in a specialized diabetic foot care center (Meloni et al., 2019).

The following were excluded from the study: all diabetic patients who did not have lesions, patients who had a shortened life expectancy (<6 months) for whom conservative therapy was carried out, patients unable to travel between the various diabetes centers.

Demographic and clinical characteristics of all participants were recorded: age, gender, type of diabetes, duration of diabetes, glycosylated hemoglobin (HbA1c), ischemic heart disease (IHD), hypertension (arterial), peripheral arterial disease PAD), distal symmetrical sensory motor polyneuropathy (Diabetic Peripheral Neuropathy – DPN), chronic renal failure in dialysis, dyslipidemia, presence of previous amputation, type of access to the referral center.

The following outcomes/primary outcomes were assessed:

  • healing, understood as complete re-epithelialization of the DFUs;
  • healing time, understood as the time elapsed between the appearance of the lesion and complete healing;
  • minor amputation, amputation performed below the ankle joint;
  • major amputation, amputation performed above the ankle joint;
  • survival.

The following secondary outcomes were then evaluated:

  • ulcer regression> 50% of the initial surface;
  • recurrence of the ulcer or the formation of a new ulcerative wound;
  • resumption of walking, the patient’s ability to walk independently without the use of aids (such as canes, crutches, walkers, wheelchairs).

Only patients with a minimum follow-up of 3 months were considered. Patients were divided into 3 groups corresponding to the type of injury reported (uncomplicated, complicated, severe). The following characteristics of DFUs were evaluated: ulcer location, size and depth, presence of ischemia, infection and gangrene. All patients were treated in accordance with the 2019 IWGDF guidelines for the treatment of ischemia, infection, offloading, local treatment of the wound and management of comorbidities (Jakosz, 2019). The diagnosis of PAD was made through the palpation of the peripheral arterial pulses (pedidial and posterior tibial artery) and through the ABI (Ankle brachial Index) calculation. However, most patients with PAD and foot ulcers may have autonomic neuropathy that causes calcification of the middle layer of the arteries (Mönckeberg’s sclerosis) in the lower limbs, which negatively affects the usefulness of this test (Gentile et al., 1990). There are insufficient studies to recommend a single test to reliably rule out PAD in a patient with DFUs. For this reason it was necessary to perform a second test such as the evaluation of Doppler waveforms (Forsythe et al., 2020) and the evaluation of transcutaneous oximetry (TcPO2) (Brownrigg1 et al., 2016). Accurate identification of peripheral artery disease in these patients is important in order to carry out timely management and plan the most appropriate type of intervention, including revascularization in case of critical ischemia (Aiello et al., 2014; Jakosz, 2019).

When deemed necessary, revascularization surgery was performed in order to improve the perfusion of the foot. The TcPO2 measurements were repeated about 3-4 weeks after the surgery in order to evaluate the effectiveness or lack thereof of this procedure. A clinical diagnosis of soft tissue infection was made, based on the presence of local and/or systemic signs of infection or symptoms of inflammation. Patients with severe infections associated with the presence of other comorbidities were hospitalized. The “Probe-to-bone” test and radiography (RX) were performed for subjects with suspected osteomyelitis (Aragón-Sánchez et al., 2011; Jakosz, 2019). In case of diagnostic doubts, second level investigations were carried out (MRI, CT). In the event of infection, empirical antibiotic therapy was administered and culture examination of infected tissue was carried out and in cases in wihich the tissue resulted positive, a more specific antibiotic therapy was prescribed, targeting the pathogen identified in the culture. In the presence of a soft tissue infection, antibiotic therapy was administered for 1-2 weeks and subsequently modulated as reported in the guidelines (Jakosz, 2019); in the presence of severe infections, parenteral antibiotic therapies were performed. Topical antibiotic therapies were not used. The cleansing of the wound was carried out with a solution containing polyhexanide and betaine (Bellingeri et al., N.d.) and carried out when necessary mechanical debridement. The uninfected neuro-ischemic DFUs were treated, in accordance with the IWGDF 2019 guidelines (Jakosz, 2019), with dressings consisting of TLC (Technology lipido-colloid) combined with NOSF (Nano-oligosaccharide Factor), an innovative, patented technology. TLC-NOSF interacts with the wound microenvironment of the wound, preventing the negative effect of Matrix Metallo protease (MMP), which in excess in chronic wounds creates a continuous degradation of the extracellular matrix (Lázaro-Martínez et al., 2019). In the presence of neuropathic or neuroischemic plantar ulcers of the forefoot and midfoot, a non-removable knee relief device (TCC or non-removable walker) was prescribed as a first choice intervention. Removable relief devices, both at the knee and at the ankle, were used as a second choice, in relation to patient compliance (Lazzarini et al., 2020). For the management of all comorbidities, the intervention of a multidisciplinary team with optimization of metabolic compensation and control of cardio-vascular risk factors was necessary.


24 patients were selected for the study. Only one patient was lost (excluded) for not having continued treatment in the reference centers. Of the 23 patients included, 15 were male, 8 were female. The average age of the patients was 73 ± 10 years. 22 (95.6%) patients had type 2 diabetes mellitus and only one patient had type I diabetes mellitus. The mean duration of diabetic disease was 19 ± 9.5 years. Patients had a mean glycated hemoglobin of 7.5 ± 0.6%. They had various comorbidities including: all patients had arterial hypertension, 21 (91.3%) had dyslipidemia, 14 (60.9%) ischemic heart disease, 8 (34.8%) chronic obstructive bronchopathy. None had chronic renal failure undergoing dialysis treatment. This overview, which includes all the comorbidities examined, allows us to state that on average the patients presented 3.5 ± 0.9 (Table 2).

Variably                                                            Group (n=23)
Gender15 (65.2%)
Diabetes type (2)22 (95.6%)
Duration of diabetes (years)19.5±9.5
Glycated hemoglobin (%)7.5±0.6
Hypertension (n)23 (100%)
Dyslipidemia21 ( 91.3%)
Ischemic heart disease14 (60.9%)
Chronic renal failure in dialysis0 (0%)
Chronic obstructive bronchopathy8 (34.8%)
N. comorbidities3.5±0.9
Tab. 2 – Demographic and clinical characteristics of all participants

The characteristics of the DFUs are present in table 3. Of the 23 lesions, 2 (8.7%) were uncomplicated DFUs, 17 (73.9%) complicated DFUs, and 4 (17.4%) severe DFUs.

Ischemia was present in 16 lesions (69.5%), infection in 18 (78.3%) and only one patient had a septic condition. 9 (39.1%) lesions were larger than 5 cm² and 17 (73.9%) were deep wouds up to the bony plane. Only 9 (39.1%) patients had gangrene present.

Variably                                               Group (n=23)
DFUs classification according the Fast-Track Pathway
– 1
– 2                      
– 3

2 (8.7%)
17 (73.9%)
4 (17.4%)
Ischemia16 (69.5%)
Infection18 (78.3%)
Sepsis1 (4.3%)
Dimension  > 5 cm²9 (39.1%)
Deep wounds (up to the bony plane)17 (73.9%)
Gangrene9 (39.1%)
Tab. 3The characteristics of the DFUs

Healing occurred in 15/23 patients (65.2%). Healing time averaged approximately 7 ± 5 weeks. The minor amputation rate, despite the complexity of the clinical picture, showed relatively low data: only 4 patients (17.4%) (Graph 2) underwent a minor amputation of the lower limb. The major amputation rate was 0. The survival rate was 95.6%.

Graphic 2 – Primary outcomes

A regression of the ulcerative lesion greater than 50% was also observed in 20 patients (87%) and only one patient (4.3%) had a relapse on the contralateral foot, which required a new approach to revascularization of the limb. The resumption of walking was recorded in 22 patients (95.6%) (Graph 3).

Graphic 3 – Secondary outcomes


In this study, all patients showed significant clinical complexity, presenting various pathologies in addition to the diabetic one. Cardio-vascular compromise was among the most important comorbidities. Furthermore, the population under examination presented an advanced age, which normally aggravates the general management of the patient. The local clinical picture showed some complexity in that most of the lesions (73.9%) were lesions defined by their “complicated” characteristics. Most of the lesions (78.3%) had infections. Only one patient experienced sepsis and this shows that there was excellent control of the infection, probably related to early management and referral. The state of the lesions was also aggravated in relation to depth of the same; most (73.9%) also involved bone tissue.

The percentage of healing, or 15/23 (65.2%) is a positive outcome. It should be considered that 2 patients (8.7%) did not recover because they were subjected to conservative therapy (for the general state of the patient where there is critical ischemia with vain attempt at revascularization) and one patient died during the study. For the first time a study entered the academic literature (Meloni, Izzo, et al., 2020) describing the characteristics of diabetic patients with DFUs unable to receive revascularization treatment (defined as “no-option critical limb ischemia”) and confirming that these patients show a reduced percentage of limb salvage and increased risk of major amputation and death compared to re-vascularized patients (Caetano et al., 2020). The healing rate in our study, not taking these last 3 cases into consideration, corresponds to 75%. Patients who did not show complete wound healing did however show a noticeable improvement in wound healing with> 50% regression of the lesion. We can state that 20 out of 23 patients (87%) showed a 50% regression of the DFUs surface.

Only one patient presented a relapse on the contralateral foot, which required a new approach to revascularization of the limb. The last secondary endpoint recorded, but not of minor importance, was the resumption of walking or the patient’s ability to walk independently without the use of aids. As many as 22 patients returned to ambulate, initially thanks to the aid of discharge devices and the achievement of healing owed to the use of secondary prevention footwear with custom-made foot orthotics (López-Moral et al., 2020). Considering that a patient is deceased, we can say that all patients returned to ambulate in full autonomy. In several studies, it has been confirmed that a delayed diagnosis and therefore a delayed treatment of diabetic patients with injuries contributes to several complications, which could lead to impaired healing, amputations and death (Gavan et al., 2016; Manu et al., 2018; Sánchez-Ríos et al., 2019). An early referral allows for better management of the diabetic patient with DFUs in terms of healing, healing time, minor and major amputation (Sung et al., 2020; Wise, 2016). The fast-track pathway is a useful tool for the management of these patients, ensuring multidisciplinary (Van et al., 2020) and differentiated specialist management in the various diabetes centers (Meloni et al., 2019). The correct diagnosis and timely referral of the patient (Smith-str et al., 2017) with complicated lesions that require adequate surgical and vascular management allows to reduce the risk of  amputation strictly tied to an increased risk of death (Jupiter et al., 2015) and septic evolution of infected lesions.

The first multicenter study carried out in Italy (Meloni, Acquati, et al., 2020) confirms our argument and the same situation can be found in Europe (Manu et al., 2018). About 50% of patients were sent to the referral center one month later than the correct time for adequate management (Manu et al., 2018).

In particular, the Lazio region, where our study was carried out, shows an average delay compared to the other Italian regions, although it remains within the national average. It would be advisable to improve and speed up referral in the appropriate diabetes center, despite the fact that Italy still has the lowest rate of lower limb amputation compared to other European countries (Meloni, Acquati, et al., 2020). A well-defined path between the region and 3rd level hospital centers (Hinojosa et al., 2019) should be implemented to obtain positive outcomes as documented in this study.


A limitation of this study is the sample number, which is a small number of patients. It is also possible to understand the effectiveness of this study thanks to the data contained in the literature where it is known that the delay in the treatment of DFUs leads to a worsening of the lesion and to the general state of the patient, subjecting them to an increased risk of amputation and mortality. The small number of patients also does not allow accurate statistical analysis (multivariate analysis) to identify outcome predictors. Another limitation was the lack of a control group.


The preliminary data collected allows us to state that the FTP path guarantees excellent management of diabetic patients with lesions among the region and second and third level diabetes center. It can allow for a more rapid treatment of patients and their complications, avoiding the clinical worsening of lesions and of patients’ general conditions. It reduces the number of complications including major amputation and mortality. The different specialization of each center does not cancel out the specificity of the individual tasks, but guarantees the best approach and care in relation to the different degree of qualification. Further studies are needed to reinforce this data.

All authors declare that they have no conflicts of interest.


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Comparative Analysis of Educational Regulations of the bachelor’s degree course in “Biomedical Laboratory Techniques” in the Lombard Universities


Submission Date: 2022-03-12
Review Date: 2022-04-15
Pubblication Date: 2022-04-29


The transition from a double training system, the university and the regional one, to a single training course inserted in the university environment was, for the health professions, a gradual transition introduced with the legislative decree 30 December 1992, n.502 (Art. 6) and subsequent amendments. In particular, for the profession of laboratory technician, in addition to regional courses and schools for special purposes, qualifications obtained following some high school training courses also qualified for the profession. The law of November 19, 1990, n.341 provides for the abolition of schools for special purposes and introduces the three-year university diploma course and the Ministerial Decree of July 24, 1996 approves table XVIII-ter containing the university didactic regulations of university diploma courses of the health area in compliance with the above-mentioned law of 1990. The change introduced with the reform of the didactic systems has mainly affected the didactic objectives, the didactic areas, the study plans and the related academic disciplines. The purpose of the Ministerial Decree of 24 July 1996 is to define the national standards for each single type of Diploma Course. University teaching has undergone a profound transformation with the MM.DD. n. 509 of 11/13/1999 and n. 270 of 22/10/2004 dictating general criteria for the organization of university studies. Between the two decrees cited, other ministerial decrees followed which identified the classes of the study courses, the qualifying training objectives and the training activities indispensable to achieve them. In particular, for the health professions, the Ministerial Decree 04/02/2001 “Determination of the classes of the university degrees of the health professions” identifies the classes of the university degrees of the health professions distinguishing four degree classes:

  1. Nursing and midwifery sciences (SNT/1);
  2. Health professions for rehabilitation (SNT/2);
  3. Health professions for technical sciences (SNT/3);
  4. Health professions for preventive care (SNT/4).

In this period, we are witnessing a real revolution in the basic training of health professionals who can now count on university-level training in a bachelor’s degree. The qualifying educational objectives of the university course of the health professions for technical sciences (class that includes the profession of biomedical laboratory technician) are identified first with the inter-ministerial decree of 2 April 2001 and then updated by the subsequent inter-ministerial decree of 19/02/2009 ” Determination of the degrees of the degrees of the health professions” which reshapes the structure having regard to the decree of 22/10/2004, n.270 “Amendments to the regulation containing rules concerning the didactic autonomy of universities, approved by decree of the Minister of the University and of scientific and technological research 3 November 1999, n. 509 “. In particular, the decree defines the basic criteria that a bachelor’s degree of the third class must have and the skills that must provide the biomedical laboratory technician undergraduate.

The structure of a university degree course is based on a unit of measurement of the workload required of the student introduced with the Ministerial Decree 3/11/1999, n.509 “Regulations containing rules concerning the didactic autonomy of universities” where in the Article number five the Formative University Credit (CFU, in the Italian normative) which correspond to an European Credit Transfer System (ECTS) is defined as 25 hours of work per student with a maximum of 60 ECTS / year per course of study. Alongside the workload estimation, another pillar of the organization of a university course are the academic disciplines. The academic disciplines, called in Italy “scientific disciplinary sectors” (SSD), define the teaching subjects and are the pieces that together with the ECTS make up the didactic plan of the degree courses. Identified for the first time with the law of 15/05/1997, n. 127 “Urgent measures for streamlining administrative activities and decision-making and control procedures”.

The Ministerial Decree 3/11/1999, n.509 “Regulations containing rules concerning the didactic autonomy of universities” also in describing the formulation of the didactic regulations in article 11 specifies how the credits assigned to each training activity must be referred to one or more specific academic disciplines. The same Decree 509 also describes in article 10 paragraph 1 that:

“The ministerial decrees preliminarily identify, for each class of study courses, the qualifying training objectives and the training activities essential to achieve them, grouping them into six types:

  • a) training activities in one or more disciplinary areas relating to basic training;
  • b) training activities in one or more disciplinary areas characterizing the class;
  • c) training activities in one or more disciplinary fields related to or integrating those characterizing, with particular regard to context cultures and interdisciplinary training;
  • d) educational activities independently chosen by the student;
  • e) training activities related to the preparation of the final exam for the attainment of the qualification and, with reference to the degree, to the verification of knowledge of the foreign language […] ” (2)

In the same article in paragraph 2 it adds:

“The ministerial decrees also determine, for each class, the minimum number of credits that the teaching systems reserve for each training activity and for each disciplinary area referred to in paragraph 1 […]” (2)

For the bachelor’s degree in “biomedical laboratory techniques” this definition was implemented with the inter-ministerial decree of 2/04/2001 “Determination of the classes of university degrees in the health professions” and then updated by the subsequent inter-ministerial decree of 19/02/2009 ” Determination of the graduation classes of the health professions”.

The inter-ministerial decree of the Ministry of Health and the Ministry of University of 19 February 2009 called “Determination of the degrees of the degrees of the health professions” identifies the general objectives and the organization of the courses of three-year degree in health professions for each class. The decree sets out the qualifying training objectives and then deepens the indispensable training activities in detail.

The training activities that are indispensable for a bachelor’s degree course in the 3rd class of the health professions are set out in the decree in specific tables that consist of five columns:

  1. Training activities;
  2. Disciplinary areas;
  3. Scientific disciplinary sectors;
  4. Minimum ECTS by subject area;
  5. Minimum ECTS for training activity.

The training activities divide all the activities into two large macro areas:

  • Basic training activities (Table 1);
  • Characteristic training activities (Table 2 a / b / c).

In turn, each training activity is divided into several disciplinary areas which are macro containers for specific academic disciplines. The table also specifies for each subject area the minimum credits that must be considered in the formulation of the teaching plan and that make up a minimum of credits for the entire training activity. During the construction of the teaching plan, the university, also due to its autonomy, manages the ECTS of the various teaching modules taking into account the minimum ECTS for each disciplinary area, including in the teaching plan various courses that correspond to specific academic disciplines for that area. Among the disciplinary areas of the characterizing training activities, it is specified that in the organization of the degree course the academic disciplines of reference for each profile (for the biomedical laboratory technician it is the MED / 46 “Biotechnology and Methods in Laboratory Medicine”) must count at least 15 ECTS on the three-year plan. The indispensable training activities must be included in a minimum of 126 credits out of the 180 credits that make up the three-year degree course. This denotes the wide margin of autonomy left to individual universities in the organization of their three-year degree course. With this work we want to analyze the structure of the degree courses in “biomedical laboratory techniques” active in Lombard region, describing how each course has divided its activities into the Academic Discipline, by type and number of ECTS, in accordance with the interministerial decree of 19 February 2009 and highlighting similarities and differences.

 Tab. 1 – Subdivision of the basic training activities
Tab. 2 / a – Subdivision of the characterizing training activities
Tab. 2 / b – Subdivision of the characterizing training activities
Tab. 2 / c Subdivision of the characterizing training activities
Tab. 2 / d – Subdivision of the characterizing training activities

Methodology and Materials

The analysis started from the research on the institutional sites of the Lombard universities, and from the reading of the didactic regulations of each university from which the didactic plans divided for the three years of the course were drawn. Using Microsoft Excel, the various didactic plans were structured into tables, highlighting the subdivision that each university made of the various disciplinary areas and academic disciplines in the construction of the didactic plan, in accordance with the tables of the indispensable training activities of the decree of the 19/02/2009, and how the other “ancillary” training activities envisaged by the decree were organized in addition to the indispensable ones:

  • Activity chosen by the student;
  • Professional laboratories of the specific academic discipline of the profession;
  • Other activities such as computer science and seminars;
  • Final exam and English language course.

Once the information was collected from the various universities, a comparative analysis was carried out on a single table between the various universities, from which graphics and considerations on similarities and differences in the teaching plans were drawn.

Results and Discussion

The bachelor’s degree course in “Biomedical laboratory techniques” is currently present in Lombardy region in five universities and for the academic year 2020/2021 with decree no. 241 of 26 June 2020 of the Ministry of University, 136 places were assigned to Lombardy region for the admission test to the bachelor’s degree course in “biomedical laboratory techniques” divided as in Table 3.

University of Milan40
University of Milan-Bicocca28
University of Brescia28
University of Pavia25
University of Insubria (Varese)15
Tab. 3 – Subdivision of places available for the 2020/2021 academic year
University Of Milan

The educational offer of the University of Milan (UniMi) is divided into three years of courses for a total of 180 ECTS acquired by students at the end of their studies. In particular:

  1. The first year provides for the acquisition of 60 ECTS divided into:
    • 43 ECTS dedicated to the lessons divided into 8 training activities;
    • 8 ECTS dedicated to the Internship;
    • 2 ECTS dedicated to activities chosen by the student;
    • 2 ECTS dedicated to two specific courses: Basic chemical analysis course and Workplace safety course;
    • 3 ECTS for the assessment of IT skills;
    • 2 ECTS for the assessment of the English language.
  2. The second year provides for the acquisition of 58 ECTS divided into:
    • 33 ECTS dedicated to the lessons divided into 5 training activities;
    • 23 ECTS dedicated to the Internship;
    • 2 ECTS dedicated to activities chosen by the student.
  3. The third year provides for the acquisition of 62 ECTS divided into:
    • 20 ECTS dedicated to the lessons divided into 4 training activities;
    • 28 ECTS dedicated to the Internship;
    • 2 ECTS dedicated to activities chosen by the student;
    • 1 ECTS dedicated course on “genetic pathologies”;
    • 3 ECTS dedicated to the professionalizing laboratory in advanced laboratory medicine techniques;
    • 7 ECTS for the final exam.
University Of “Milano-Bicocca”

The educational offer of the University of Milan-Bicocca (UniMiB) is divided into three years of courses for a total of 180 ECTS acquired by students at the end of their studies. In particular:

  1. The first year provides for the acquisition of 59 ECTS divided into:
    • 39 ECTS dedicated to the lessons divided into 5 training activities;
    • 14 ECTS dedicated to the Internship;
    • 3 ECTS for the assessment of IT skills;
    • 3 ECTS for the assessment of the English language.
  2. The second year provides for the acquisition of 60 ECTS divided into:
    • 37 ECTS dedicated to the lessons divided into 6 training activities;
    • 20 ECTS dedicated to the Internship;
    • 3 ECTS dedicated to activities chosen by the student which can be chosen from a list already present in the didactic regulations of the course.
  3. The third year provides for the acquisition of 61 ECTS divided into:
    • 20 ECTS dedicated to the lessons divided into 2 training activities;
    • 26 ECTS dedicated to the Internship;
    • 3 ECTS dedicated to activities chosen by the student that can be chosen from a list already present in the didactic regulations of the course;
    • 3 ECTS dedicated to laboratory medicine seminars;
    • 3 ECTS dedicated to professionalizing laboratories;
    • 6 ECTS for the final exam.         
University Of Brescia

The educational offer of the University of Brescia (UniBs) is divided into three years of courses for a total of 184 ECTS acquired by students at the end of their studies. In particular:

  1. The first year provides for the acquisition of 62 ECTS divided into:
    • 38 ECTS dedicated to the lessons divided into 6 training activities;
    • 18 ECTS dedicated to the Internship;
    • 2 ECTS dedicated to activities chosen by the student;
    • 1 ECTS dedicated to the “Metabolic Biochemistry” course;
    • 1 ECTS dedicated to the safety training course;
    • 1 ECTS dedicated to the professionalizing laboratory of the first year;
    • 1 ECTS for the assessment of the English language.
  2. The second year provides for the acquisition of 60 ECTS divided into:
    • 33 ECTS dedicated to the lessons divided into 5 training activities;
    • 21 ECTS dedicated to the Internship;
    • 3 ECTS dedicated to activities chosen by the student;
    • 1 ECTS dedicated to the “Mycological Diagnostics” course;
    • 1 ECTS dedicated to the professionalizing laboratory of the second year;
    • 2 ECTS for the assessment of the English language.     
  3. The third year provides for the acquisition of 61 ECTS divided into:
    • 31 ECTS dedicated to the lessons divided into 5 training activities;
    • 21 ECTS dedicated to the Internship;
    • 1 ECTS dedicated to activities chosen by the student;
    • 1 ECTS dedicated to the course “The TLB and the production of scientific data in the research laboratory”;
    • 1 ECTS dedicated to the professionalizing laboratory of the third year;
    • 6 ECTS for the final exam.         

Seminar activities have been included in the teaching plan of the University of Brescia as an integral part of the modules of the training activities in particular:

  • “Analytical instrumentation” module of the training activity “Institutions of biochemistry and clinical biochemistry” of the first year of the course;
  • “General chemistry and biochemical preparatory” module of the training activity “Functional and structural sciences of biomolecules” of the first year of the course;
  • “Food analysis” module of the training activity “Clinical microbiology and hygiene” of the second year of the course;
  • “Applied computer science” module of the training activity “Interdisciplinary and integrative sciences” of the third year of the course;
  • “Radiobiology and radiation protection” module of the training activity “Sciences of prevention and health services, health promotion and ethics” of the third year of the course.

These activities in the analysis were considered part of the ancillary training activity “other activities such as information technology and seminars”

University Of Pavia

The educational offer of the University of Pavia (UniPv) is divided into three years of courses for a total of 180 ECTS acquired by students at the end of their studies. In particular:

  1. The first year provides for the acquisition of 62 ECTS divided into:
    • 38 ECTS dedicated to the lessons divided into 6 training activities;
    • 18 ECTS dedicated to the Internship;
    • 2 ECTS dedicated to activities chosen by the student;
    • 1 ECTS dedicated to the “Metabolic Biochemistry” course;
    • 1 ECTS dedicated to the safety training course;
    • 1 ECTS dedicated to the professionalizing laboratory of the first year;
    • 1 ECTS for the assessment of the English language.
  2. The second year provides for the acquisition of 60 ECTS divided into:
    • 33 ECTS dedicated to the lessons divided into 5 training activities;
    • 21 ECTS dedicated to the Internship;
    • 3 ECTS dedicated to activities chosen by the student;
    • 1 ECTS dedicated to the “Mycological Diagnostics” course;
    • 1 ECTS dedicated to the professionalizing laboratory of the second year;
    • 2 ECTS for the assessment of the English language.     
  3. The third year provides for the acquisition of 61 ECTS divided into:
    • 31 ECTS dedicated to the lessons divided into 5 training activities;
    • 21 ECTS dedicated to the Internship;
    • 1 ECTS dedicated to activities chosen by the student;
    • 1 ECTS dedicated to the course ” The TLB and the production of scientific data in the research laboratory”;
    • 1 ECTS dedicated to the professionalizing laboratory of the third year;
    • 6 ECTS for the final exam.         
University Of Insubria -Varese

The educational offer of the University of Insubria (UniInsubria)  is divided into three years of courses for a total of 180 credits acquired by students at the end of their studies. In particular:

  1. The first year provides for the acquisition of 62 ECTS divided into:
    • 38 ECTS dedicated to the lessons divided into 7 training activities;
    • 18 ECTS dedicated to the Internship;
    • 2 ECTS dedicated to activities chosen by the student;
    • 1 ECTS dedicated to the professionalizing laboratory;
    • 3 ECTS for the assessment of the English language.
  2. The second year provides for the acquisition of 63 ECTS divided into:
    • 34 ECTS dedicated to the lessons divided into 5 training activities;
    • 22 ECTS dedicated to the Internship;
    • 2 ECTS dedicated to activities chosen by the student;
    • 1 ECTS dedicated to the professionalizing laboratory;
    • 3 ECTS dedicated to seminars for in-depth professionalizing activities;
    • 1 ECTS for the assessment of the English language.     
  3. The third year provides for the acquisition of 55 ECTS divided into:
    • 17 ECTS dedicated to the lessons divided into 4 training activities;
    • 26 ECTS dedicated to the Internship;
    • 2 ECTS dedicated to activities chosen by the student;
    • 1 ECTS dedicated to the professionalizing laboratory;
    • 3 ECTS dedicated to seminars for in-depth professionalizing activities;
    • 6 ECTS for the final exam.         

Taking as a model the minimum credits and the subdivision of the training activities in disciplinary areas and academic discipline described by the interministerial decree of February 19, 2009, we made a comparison using the Microsoft Excel, application of the Office package, and creating a summary table that combined the details of the decree and the ECTS assigned by each university to each academic discipline to compare the general distribution that characterizes the Lombard training offer of the three-year degree course in “biomedical laboratory techniques”. In figure 1 it is possible to visualize, for demonstration purposes only, the table completely.

Fig. 1 – Comprehensive ECTS comparison table 

To better describe it, it will be presented in separate tables.

  • Figure 2 shows the part of the table including the basic training activities which in the 2009 decree must include at least 22 ECTS from the course study plan;
  • Figures 3a and 3b describe the distribution of the characterizing training activities which in the 2009 decree must include at least 104 ECTS from the course study plan. The MED / 46 was highlighted: specific academic discipline of the Biomedical Laboratory Technician profile which by decree must count at least 15 ECTS of the study plan (table 2 / a).
  • Figure 4 describes the distribution of the activities referred to in this document as “ancillary” (activities chosen by the student / final exam and for the English language / activities such as information technology, seminars / professional laboratories of the specific academic discipline of the profession);
  • A last column identifies the “Related or supplementary training activities” type of activity provided for in the inter-ministerial decree of 2 April 2001 “Determination of the classes of university degrees of the health professions” but which in the inter-ministerial decree of 19 February 2009 “Determination of the degree classes of the health professions “are no longer mentioned but are still present in the teaching plan of some universities.
Fig. 2 – Comparison of ECTS basic training activities
Fig. 3 / a – Comparison of ECTS characterizing training activities 
Fig. 3/ b – Comparison of ECTS characterizing training activities
Fig. 4 – Comparison of ECTS training activities “ancillary” and other activities  

Below table 4 and Figure 5 summarize the distribution of credits in the two training activities. Table 4 also presents a comparison with the minimum of ECTS present in the 2009 decree of 126 ECTS dedicated to indispensable training activities.

Tab. 4 – ECTS comparison of basic and characterizing training activities
Fig. 5 – ECTS comparison of basic and characterizing training activities

Table 5 summarizes the distribution, within the basic training activities, of ECTS by disciplinary areas in relation to the minimums required by the 2009 decree

Tab. 5 Comparison of ECTS subdivision within the basic training activities

Table 6 (same table divided into two parts) summarizes the distribution, within the characterizing training activities, of ECTS by disciplinary areas in relation to the minimum required by the decree of 2009

Tab. 6 Comparison of ECTS subdivision within the characterizing training activities

To conclude the analysis of the teaching plans, we compared the implementation by the individual universities of precise indications on the training of the biomedical laboratory technician contained in the inter-ministerial decree of February 19, 2009 “Determination of the degrees of the health professions”. In particular, the decree provides that:

Graduates in biomedical laboratory techniques must also acquire knowledge and skills in the field of activity of zooprophylaxis institutes and in the biotechnology sector. […]                        

In the didactic systems of the degree classes, didactic activity in the field of radiation protection must be envisaged according to the contents of Annex IV of the legislative decree 26 May 2000, n. 187.           

As regards the first request, we analyzed the presence in the didactic plan of the degree course of a module aimed at teaching subjects related to the activities of zooprophylaxis institutes (table 7). The analysis of the presence of activities concerning the biotechnology sector was considered superfluous due to the high presence in the course plans of this kind of activities.

Tab. 7 – Verification of the presence of teachings related to the activities of zooprophylaxis institutes

For the teaching of radiation protection, according to the contents of annex IV of the legislative decree 26 May 2000, n. 187, Table 8 analyzed the presence of this teaching during the course of the study program.

Tab. 8 – Verification of the presence of a teaching of radiation protection

The search for the documents useful for this study has highlighted the excellent service that the Lombard universities offer to users with their institutional sites in providing information relating to the degree course in Biomedical laboratory techniques. The comparative analysis of the teaching plans of the Lombard universities highlighted a substantial uniformity of the regional training offer for the degree course in “Biomedical laboratory techniques” as regards the subjects covered and the academic disciplines involved. Leaving aside the training activities whose number of academic disciplines is defined a priori by the legislation (at the student’s choice, final exam and English language, other activities such as computer science and seminars, professional laboratories and training internships in the specific professional profile) and the MED / 46, which we will discuss later, the academic disciplines present in all study plans are, in descending order of ECTS given by the sum of the individual universities: Microbiology and clinical microbiology (MED / 07), Clinical biochemistry and clinical molecular biology (BIO / 12), Pathology (MED / 08), Biochemistry (BIO / 10), Physiology (BIO / 09), Applied Physics (FIS / 07), Human Anatomy (BIO / 16), Pharmacology (BIO / 14), Experimental biology (BIO / 13), Medical Genetics (MED / 03), Medical Statistics (MED / 01), Histology (BIO / 17), Blood Diseases (MED / 15). From an overall analysis of the academic disciplines activated in the Lombardy training offer (considering the table in figure 6), out of a total of 53 academic disciplines with at least 1 ECTS in a single university, the area of Medical Sciences (MED sectors) represents more half (53%) of the credits activated, while the Biological Sciences area (BIO sectors) contributes 18.9% to the Biomedical Laboratory Technician training curriculum. Specific contributions (28.3%) come from academic disciplines (such as computer science, statistics, linguistics, economic, legal and human, physical and mathematical sciences, veterinary) that respond to the demand for skills expected by health services with respect to the Biomedical Laboratory Technician profession. As part of the basic activities, the credits reserved for biomedical sciences are higher than those related to the disciplinary areas of propaedeutic sciences and first aid. As part of the characterizing activities, it is highlighted that among the eight disciplinary areas in which the legislation divides this activity, if the professional internship is excluded, the majority of ECTS is reserved for the disciplinary area of biomedical laboratory sciences and techniques (M.D. 270/2004), as the law provides. The legislation provides that 60 ECTS must be reserved for the training internship in the specific professional profile and only one university in its study plan declares that it assigns a higher number of credits to this activity. From the general analysis it emerges that the credits reserved for the internship activity are gradually inserted into the training course of the three years with a lower number of credits assigned to the first year of the course compared to the other two. According to the regulations in the didactic systems, training activities for the final exam and for the English language must be provided for with a number of ECTS equal to 9; except in one course (which includes 10 credits), all study plans meet this criterion. It should be noted that 6 to 7 credits are assigned to the final exam and that the training activity dedicated to the foreign language is mainly present in the first year. According to the regulations, “Activities chosen by the student”, “other activities such as computer science and seminars” and ” professional laboratories of the specific academic discipline of the profession” must be provided in the didactic systems of the degree classes with a precise number of ECTS associated with them. From the analysis we observed that in all study plans the credits correspond to what is established by the law, except in a university where 10 out of the 6 required credits are assigned to the “activities chosen by the student”. The number of training activities and exams in the various study paths does not show large differences (Table 9).

Tab. 9 – Number of exams per university

With regard to the MED / 46 (Biotechnology and Methods in Laboratory Medicine) courses, specific academic discipline of the professional profile of biomedical laboratory technician, the 15 ECTS provided for by the decree of 2009 (excluding the ECTS intended for the internship which, although falling within the MED / 46 academic discipline, is a different educational activity) are strictly respected in all universities except for one which provides 2 credits more. In our opinion, the enhancement of this academic discipline is fundamental in the reality of skills development and specialization that involves, especially in this period, the figure of the Biomedical Laboratory Technician. Assigning more teachings to MED / 46 professors belonging to the professional profile is an added value to the degree course because it allows you to interact with professionals who operate and have work experience in the sector and can transmit practical and theoretical knowledge useful to better understand the professional figure and to guide the students in the work practice. Another criticality highlighted by the analysis is the presence of training activities that can be traced back to the wording “Related or supplementary training activities”. Type of activity foreseen in the inter-ministerial decree of 2 April 2001 “Determination of the classes of university degrees of the health professions” but which in the inter-ministerial decree of 19 February 2009 “Determination of the degrees of the health professions” are no longer mentioned in the organization of the course of studies. A revision of these teachings would be necessary by inserting them in the correct academic disciplines expressed by the 2009 decree.


  1. Galai T, Anelli E., Cardillo G, “Qualifications qualifying / non-qualifying for the profession of the biomedical laboratory health technician ” , FITe.La. B, (2018).
  2. Ministerial Decree 3/11/1999, n.509 “Regulations containing rules concerning the didactic autonomy of universities”.
  3. Ministerial Decree of 22/10/2004, n.270 “Amendments to the regulation containing rules concerning the didactic autonomy of universities, approved by decree of the Minister of the University and of scientific and technological research 3 November 1999, n. 509. “
  4. Law of 15/05/1997, n. 127 “Urgent measures for streamlining administrative activities and decision-making and control procedures”
  5. Interministerial Decree of 19/02/2009 “Determination of the degrees of the degrees of the health professions”.

Innovative technologies for social inclusion at the Campolieto Psychosocial Rehabilitation Community

Article Navigation

Submission Date: 2022-02-27
Review Date: 2022-04-14
Pubblication Date: 2022-04-29



Numerous scientific evidences show that people with a mental disorder suffer not only from the disorder itself, but also, and perhaps above all, for the social and relational consequences that the disorder produces and which manifest themselves in the form of stigma. The improvement of mental health, with a view to Recovery, is in fact based on the possibility of taking advantage of socio-professional contexts in which users and operators have the opportunity to live meaningful relationships, and this can translate into a form of existence as much as possible rewarding and satisfying. The main purpose of the work was to investigate how much the "Innovative Technologies for Social Inclusion" project allowed to combine the promotion of the territory and the social inclusion of people with severe mental health problems. It was possible to analyze this element through the FPS Scale (personal and social functioning) and two evaluation grids administered. The New Communication and Information Technologies (ICT) have made it possible to rethink a new relationship between Digital Technology and the world of Disability; in fact they have allowed the patients of the Psychosocial Ria Community of Campolieto a more satisfactory quality of life and a better enhancement of the territory. These results offer promising preliminary evidence that the use of ICT provides an effective tool for promoting the social inclusion of discriminated groups of the population such as people with severe mental disorders.


The Psychosocial