Comparison of Standard vs. Relative Risk Models to Define Candidates for Deintensification in Locoregionally Advanced P16+ Oropharyngeal Cancer

PURPOSE/OBJECTIVE(S)

Various methods to identify candidates for treatment deintensification with p16+ oropharyngeal squamous cell carcinoma (OPSCC) have been used, but the optimal approach is unknown.

MATERIALS/METHODS

Multi-institutional cohort study of 385 patients with previously untreated p16+ OPSCC undergoing definitive radiotherapy (RT) with or without systemic therapy between 2009-2020. Chemotherapy intensity was categorized as high (bolus cisplatin and/or induction chemotherapy), medium (weekly cisplatin), or low (non-cisplatin or RT alone). Standard favorable vs. unfavorable risk was defined using NRG HN005 eligibility criteria. High vs. low relative risk (RR) group was defined using the HNCIG omega score (≥ 0.80 vs. < 0.80), which quantifies the proportion of a patient's overall event risk due to cancer. We used multivariable ordinal logistic regression to estimate effects of age (yrs), sex, performance status (PS), Charlson comorbidity index (CCI), T/N (AJCC 8th), current smoking, and pack-years (> 10 vs. ≤ 10) on treatment allocation. Effects on relative event hazards were estimated using generalized competing event regression.

RESULTS

Median follow-up time was 44.2 months. Chemotherapy intensity was high in 206 (54%), medium in 108 (28%), and low in 71 (18%). 280 patients (73%) were unfavorable risk and 197 (51%) were high RR. 178 patients (46%) had discordant risk classification. On univariable analysis, significant predictors of higher intensity chemotherapy (normalized odds ratio (OR)) were CCI 0-1 (OR 1.49, 95% CI: 1.23-1.79), high omega score (OR 1.46; 1.20-1.77), decreased age (OR 1.43; 1.18-1.74), and PS 0 (OR 1.22; 1.01-1.48). Controlling for CCI, higher omega score was associated with significantly higher odds of intensive chemotherapy (OR 1.35; 1.10-1.65, but unfavorable risk (HN005 ineligibility) was not (OR 1.19; 0.98-1.44). Higher omega score was also associated with significantly higher RR for cancer recurrence (Rec) vs. competing mortality (CM) events (relative HR (rHR) 1.76; 1.12-2.75), but unfavorable risk was not (rHR 1.05; 0.63-1.75). Among patients receiving cisplatin, 50 favorable risk patients (58%) had high RR; all of their event risk was due to cancer recurrence (Table). The 110 unfavorable risk patients (48%) with low omega score had significantly lower RR for cancer events compared to the high omega score group (rHR 0.49; 0.29-0.84).

CONCLUSION

Many patients with favorable risk p16+ OPSCC have high relative risk for cancer events, which correlates with a benefit of intensive treatment. The HNCIG omega score is a strong predictor of allocation to intensive chemotherapy and may help identify candidates for deintensification.

Diversity and genetic architecture of agro-morphological traits in a core collection of European traditional tomato

European traditional tomato varieties have been selected by farmers given their consistent performance and adaptation to local growing conditions. Here we developed a multipurpose core collection, comprising 226 accessions representative of the genotypic, phenotypic, and geographical diversity present in European traditional tomatoes, to investigate the basis of their phenotypic variation, gene×environment interactions, and stability for 33 agro-morphological traits. Comparison of the traditional varieties with a modern reference panel revealed that some traditional varieties displayed excellent agronomic performance and high trait stability, as good as or better than that of their modern counterparts. We conducted genome-wide association and genome-wide environment interaction studies and detected 141 quantitative trait loci (QTLs). Out of those, 47 QTLs were associated with the phenotype mean (meanQTLs), 41 with stability (stbQTLs), and 53 QTL-by-environment interactions (QTIs). Most QTLs displayed additive gene actions, with the exception of stbQTLs, which were mostly recessive and overdominant QTLs. Both common and specific loci controlled the phenotype mean and stability variation in traditional tomato; however, a larger proportion of specific QTLs was observed, indicating that the stability gene regulatory model is the predominant one. Developmental genes tended to map close to meanQTLs, while genes involved in stress response, hormone metabolism, and signalling were found within regions affecting stability. A total of 137 marker-trait associations for phenotypic means and stability were novel, and therefore our study enhances the understanding of the genetic basis of valuable agronomic traits and opens up a new avenue for an exploitation of the allelic diversity available within European traditional tomato germplasm.

A prospective registry to get insights into profile, management and outcome of cardiogenic shock patients

Background

Cardiogenic shock (CS) is the most severe form of acute heart failure, characterized by life-threatening end-organ hypoperfusion resulting from a low cardiac output state. Data on epidemiology of CS has been mostly drawn from registries focusing on acute myocardial infarction (AMI). However, recent evidence in a contemporary cohort in North America has shown that more than two thirds of all CS cases were related to causes other than AMI and that these patients had outcomes at least as poor as patients with AMICS.

Purpose

To provide data on profile, management, outcome, and evolution over time of CS patients admitted to ICCU/ICU and to compare them between patients with AMICS and acute decompensated heart failure (ADHF-CS).

Methods

The Altshock-2 Registry is a multicenter national prospective data collection, part of the Italian Altshock-2 program. Recruitment started on 2 March 2020 with 11 Italian Centers contributing to patients' enrolment. A total of 238 patients were hospitalized with confirmed diagnosis of CS between March 2020 and February 2022 in a multicenter national initiative. The mean age of this patient population was 64 years (interquartile range [IQR] 54–74) and 76% were male. Ninety-seven patients (41%) were admitted for AMICS, whereas 84 patients (35.3%) had ADHF-CS; 57 patients (24%) had other causes. As compared to AMICS patients, those admitted for ADHF-CS were younger, but with a higher burden of comorbidities (renal, liver, thyroid disease, atrial fibrillation, anemia), pre-existing decreased ejection fraction and a higher number of chronic drugs. Patients with ADHF-CS had a prevalent cardio-metabolic phenotype upon admission with prevalent congestion. Mechanical ventilation was more commonly used in patients with AMICS, compared to ADHF-CS, along with an increased inotropic score. Conversely, sodium nitroprusside was used in about sixty percent of patients with ADHF-CS. Sixty percent of the included population received a temporary mechanical circulatory support (MCS) device, which was intra-aortic balloon pump (IABP) in the eighty percent of the supported patients. Pulmonary artery catheter was used for monitoring only in the 18% of the included patients whereas an extensive echocardiographic approach was applied. Twenty-one patients (25%) underwent heart replacement therapy in the ADHF-CS patients versus 2 (2%) in the AMICS. Thirty-day mortality occurred in 32 patients (33%) in the AMICS group versus 23 (27%) in the ADHF-CS group (p=0.41).

Conclusions

Different diagnostic approaches and uses of mechanical circulatory support devises and inotropes are implemented in transatlantic settings. Uniform definitions and more homogenous protocols tailored on CS etiologies and clinical and biochemical phenotypes are needed in prospective initiatives in order to effectively compared results and outcome.

Funding Acknowledgement

Type of funding sources: None.

Enhancing the role of occupational health services in the battle against Corona Virus Disease 2019

Occupational risk assessment is the core of any practice in occupational health and safety at the workplace. In Italy, the implementation of the preventive measures required by law (DPCM of April 26, 2020 and subsequent modifications and integrations) can exempt the employers from legal disputes in case of COVID-19 infection among employees. However, these laws have made meaningless the risk assessment process, which is the ideal setting where the preven-tive and protective measures must be identified and enhanced by individual employers, in collaboration with health and safety managers and occupational physicians, in the true exposure conditions. In this commentary, the authors stressed the role of workplace risk assessment and occupational health services for the valuable contribution that they may give to the battle against COVID-19, in terms of prevention, contact-tracing activity and COVID-19 rates of vaccinal coverage.

Wolbachia infection and genetic diversity of Italian populations of Philaenus spumarius, the main vector of Xylella fastidiosa in Europe

Philaenus spumarius is a cosmopolitan species that has become a major threat to European agriculture being recognized as the main vector of the introduced plant pathogen Xylella fastidiosa, the agent of the “olive quick decline syndrome”, a disease which is devastating olive orchards in southern Italy. Wolbachia are bacterial symbionts of many insects, frequently as reproductive parasites, sometime by establishing mutualistic relationships, able to spread within host populations. Philaenus spumarius harbors Wolbachia, but the role played by this symbiont is unknown and data on the infection prevalence within host populations are limited. Here, the Wolbachia infection rate was analyzed in relation to the geographic distribution and the genetic diversity of the Italian populations of P. spumarius. Analysis of the COI gene sequences revealed a geographically structured distribution of the three main mitochondrial lineages of P. spumarius. Wolbachia was detected in half of the populations sampled in northern Italy where most individuals belonged to the western-Mediterranean lineage. All populations sampled in southern and central Italy, where the individuals of the eastern-Mediterranean lineage were largely prevalent, were uninfected. Individuals of the north-eastern lineage were found only in populations from the Alps in the northernmost part of Italy, at high altitudes. In this area, Wolbachia infection reached the highest prevalence, with no difference between north-eastern and western-Mediterranean lineage. Analysis of molecular diversity of COI sequences suggested no significant effect of Wolbachia on population genetics of P. spumarius. Using the MLST approach, six new Wolbachia sequence types were identified. Using FISH, Wolbachia were observed within the host’s reproductive tissues and salivary glands. Results obtained led us to discuss the role of Wolbachia in P. spumarius, the factors influencing the geographic distribution of the infection, and the exploitation of Wolbachia for the control of the vector insect to reduce the spread of X. fastidiosa.

NMR Metabolomics and Chemometrics of Lettuce, Lactuca sativa L., under Different Foliar Organic Fertilization Treatments

Lettuce plants were grown in a greenhouse affected by the fungal pathogen Fusarium oxysporum to test the effects on plant metabolomics by different organic treatments. Three foliar application treatments were applied: a commercial compost tea made of aerobically fermented plant organic matter, a pure lyophilized microalga Artrospira platensis, commonly named spirulina, and the same microalga previously exposed during its culture to a natural uptake from medium enriched with F. oxysporum fragmented DNA (NAT). The experiment is the first attempt to observe in field conditions, the use and effects of a natural microbial library as a carrier of pathogenic fungal DNA for disease control. Untargeted NMR metabolomics and chemometrics showed that foliar organic application significantly reduced fumaric and formic acids, aromatic amino acids, and nucleosides, while increasing ethanolamine. A strong decrease in phenolic acids and an increase in citric acid and glutamine were specifically observed in the NAT treatment. It is noteworthy that the exposure of a known biostimulant microalga to fungal DNA in its culture medium was sufficient to induce detectable changes in the metabolomic profiles of the fertilized plants. These findings deserve further investigation to assess the potential relevance of the presented approach in the field of crop biostimulation and biocontrol of plant pathogens.

Withdrawal of active treatments in terminally ill heart failure patients

INTRODUCTION

Heart failure (HF) constitutes a growing public health problem in aging societies: when pharmacological therapies fail, HF can be sustained intensively if patients are eligible for either orthotopic heart transplantation (OHT) or mechanical ventricular assistance, otherwise additional treatments could be inappropriate. In December 2017 Italian Legislator brought in the provisions regarding the end-of-life choices, including indications for withdrawing and withholding life-sustaining therapies. The aim of our study was to provide an overview of the daily practice of our center with regard to terminally ill HF patients.

METHODS AND RESULTS

In April 2019 the 7 intensivist cardiologists and 21 nurses of a tertiary ICCU were asked in, to complete a questionnaire relating to a hypothetical terminally ill HF patient for whom the decision to withdraw active treatment had been made. To assess current practice, we also identified patients who died in the previous 12 months. Out of 29 deceased patients, 18 were identified as terminally ill HF, with no indications for therapy upgrading. We observed a striking disparity between belief and practice.

CONCLUSIONS

Our survey showed that the care of terminally ill HF patients in our ICCU was characterized by aggressive use of medical therapy and invasive technology. The wide disparity between belief and practice could be in part a consequence of lack of professional training, with regard to law, ethics and communication techniques.

Metal removal processes in a pilot hybrid constructed wetland for the treatment of semi-synthetic stormwater

This study investigates the reliability of a pilot hybrid constructed wetland (H-CW), located in Eastern Sicily (Italy). To address the uncertainty associated with implementing representative monitoring during highly variable storm events, unique to Mediterranean conditions, a recipe for semi-synthetic stormwater was used to evaluate the removal efficiency of the system. This was characterised by metals (Cd, Cr, Fe, Pb, Cu, Zn) and relative concentrations typically found in urban stormwater runoff (SR). Approximately one month of intensive monitoring activities were carried out and quality analyses were conducted on three matrices comprising the pilot H-CW: water, biomass (Canna indica, Typha latifolia), and volcanic gravel substrate. Metal retention in early clogging matter (SS) was also examined. The results showed a significantly high H-CW efficiency for the removal of all metals (70-98%) already at the horizontal flow unit outflow, confirming its strategic role. A metal mass balance analysis was also conducted to describe the retention capacity and influence of each system component on the overall efficiency (ranging from 87.8% for Cr to 99.2% for Pb). Metal removal was mostly related to sediment and substrate processes, while plants exhibited root bioaccumulation and phytostabilisation capacity even with a limited impact on overall system retention. The pilot H-CW exhibits characteristics suitable for the treatment of metal-enriched stormwater runoff and validates the useful application of decentralised natural systems for water resource management.

Agitation and delirium in intensive cardiac care unit. A multicenter prospective registry

Background

Patients with acute cardiovascular disease admitted to the Intensive Cardiac Care Unit (ICCU), especially those with more severe critical illness, experiment agitation and delirium during hospitalization. Iatrogenic, environmental, or related to the severity of acute illness factors may concur to determine these two conditions. However, their epidemiological, clinical, and prognostic relevance in this specific clinical context are not well defined, yet. As a result, current recommendations on the evaluation and management of these complications are lacking.

The aim of this prospective, multicenter, observational registry was to evaluate the incidence of agitation and delirium in patients admitted to the ICCU for an acute cardiac event, their in-hospital prognostic impact, and their treatment.

Methods

We enrolled consecutive patients with acute cardiovascular events in four Italian tertiary-care centers. Agitation levels were ranked from Richmond Assessment Sedation Scale (RASS), and the presence of delirium was detected by Confusion Assessment Method-Intensive Care Unit (CAM ICU) at least twice a day and in case of variation of the state of consciousness. The primary endpoint was the incidence of agitation and/or delirium. The secondary endpoints were: 1) the association between these complications and in-hospital outcome and 2) the therapies adopted for their management.

Results

Overall, 723 patients were included in the registry. Of them, 116 (16%) presented agitation and/or delirium during ICCU stay. Delirium subtypes were: 6% hypoactive, 64% hyperactive, and 30% mixed. Patients with agitation/delirium had worse in-hospital outcomes than patients without.. Indeed, they had a higher ICCU mortality (10% vs. 2%; P&lt;0.001) and a higher rate of major complications: ventricular arrhythmias (26% vs. 12%; P&lt;0.001), atrial fibrillation (29% vs. 15%; P&lt;0.001), sepsis (15% vs. 9%; P=0.06), and bleeding (17% vs. 7%; P&lt;0.001). Moreover, they were more frequently treated with mechanical procedures: invasive and non-invasive ventilation (58% vs. 18%; P&lt;0.001), circulatory support (20% vs. 5%; P&lt;0.001), continuous renal replacement therapy (6% vs. 1%; P&lt;0.001). Finally, ICCU length of stay was longer (8 vs. 4 days; P&lt;0.001). The drugs more likely used for agitation treatment were benzodiazepine (32%), dexmedetomidine (31%), opioids (10%), and antipsycotic drugs (1%). Delirium was mainly treated with dexmedetomidine (46%), benzodiazepine (23%), antipsycotic drugs (16%), and opioids (8%).

Conclusions

This study demonstrates that agitation and delirium are frequent complications also in the acute cardiac setting and are associated with poor in-hospital outcome. In this particular context, the treatment of choice and its possible impact on prognosis remain to be established.

Funding Acknowledgement

Type of funding source: Private hospital(s). Main funding source(s): Centro Cardiologico Monzino, IRCCS, MIlan, Italy.

Hazardous workers and risk for third parties

Impaired workers, unable to practice their activities with effective skills and adequate safety protection because of physical or mental illness, alcohol and drug addiction, inappropriate behaviour as a consequence of fatigue, sleepiness, or distress, may be hazardous for colleagues and customers.

To properly manage these workers, public health must resolve the ethical dilemma arising from the legitimate interests of all stakeholders. The sick worker's interests include career expectations, role in organization, right to privacy, and right to freedom from discrimination. The customer's interests include protection from harm, right to autonomy, and right to informed choice. The society's interests include maintaining effective and affordable public services, as well as the benefits and burdens of any policies. Traditional ethics, oriented toward the individual relationship, failed to find an uncontroversial solution to these complex issues. Our research pointed to the organisation level.

The La.R.A. Study group on Hazardous Workers was set up in 1999 in Italy, to study how to protect the health and safety of impaired workers and that of third parties, without prejudice to the civil rights of workers. The group includes many subject matter experts like: doctors from different specialties, jurists, bioethicists, employees' and employers' representatives. It is independent and not financed.

The ethical, legal and operational aspects of each specific problem are discussed from different points of view and at the end a consensus document containing the practical indications for the prevention operators is produced. Over the years, Lara has produced 10 consensus documents on specific problems and has stimulated companies to develop policies for hazardous workers, preferably according to a bottom-up participatory model.

The collective definition of methods and solutions allows management of hazardous workers.

Key messages

Disability management is preferable to exclusion from work. A shared company policy is the basic principle of management of hazardous workers.

COVID-19 and staff mental health: is there an evidence? An Italian field study

Since the early months of the COVID-19 epidemic, a large number of scientific papers have considered the possibility that healthcare professionals (HCWs) were affected by depression, anxiety, post-traumatic stress, and psychological distress. The abundance of research has also made it possible to produce several systematic reviews and meta-analyzes. All the studies retrieved in these reviews, however, were cross-sectional. Depressive symptoms and anxiety in HCWs were compared to “normal values”, administrative staff, or external sample; moreover, some studies had no control group. No longitudinal study has been produced so far. Some studies had negative results. Overall, there is still little evidence of an increase in mental health problems and sleep disturbances in HCWs during the outbreak.

To fill this gap, we investigated the mental health of workers who have been monitored for many years in an Italian local health unit. Mental health was investigated with standardized questionnaires. 82 HCWs who tested positive at the COVID-19 nasopharyngeal swab, 152 exposed workers who tested negative and 361 unexposed controls participated in the survey. Anxiety was reported by 16.6% of COVID-19 cases and depression by 20.3%, with a significant increase in the estimated risk (OR = 4.3; CI95%=2.4-7.4 for anxiety, OR = 3.5; CI95% =2.0-6.0 for depression). In test-positive cases, sleep was a significant moderating factor in the relationship between occupational stress or PJ and anxiety. Exposed, negative HCWS also had an increased OR for anxiety (1.84, CI95% 1.1-3.1) and depression (2.2 CI95% 1.4-3.5).

The frequency of anxiety and depression disorders in the population examined was not higher than that recorded in the years preceding the epidemic during periodic occupational health checks in the workplace. Mental health support and organizational interventions must mainly concern workers with positive tests and should also tend to improve sleep quality.

Environmental electroactive consortia as reusable biosensing element for freshwater toxicity monitoring

The development of tools to monitor water quality is mandatory in a scenario where clean water resources are decreasing. Here, the biosensing capability of an electroactive river sediment consortium was tested towards three model contaminants (glutaraldehyde, nickel(II) and chromium(III)). The proposed biosensor is a small membrane-less single chamber Microbial Fuel Cell (MFC), fabricated by 3D printing. Its semi-continuous mode of operation resulted in long-term current profile stability and reproducibility. A linear trend of response was obtained for glutaraldehyde in a concentration range of 5-1000 ppm. After the recovery of the electroactive consortium activity, the MFC-based biosensors were shown to be sensitive towards Ni(II) and Cr(III), at concentrations above 2 mg L^-1. To effectively analyze biosensor response, a novel algorithm was proposed, offering advantages for the realization of energy-saving protocols for MFC-biosensor data transmission. Implementation of the device and method, from laboratory test to real environment, can offer a low cost in situ system for detection of water contaminants.

Crash sign: new first-trimester sonographic marker of spina bifida

OBJECTIVES

To describe a new first-trimester sonographic sign, the 'crash sign', associated with fetal open spina bifida, and to evaluate its clinical usefulness in the first-trimester diagnosis of spina bifida.

METHODS

This was a retrospective review of patients referred to three fetal medicine centers in the first trimester (11 + 0 to 13 + 6 weeks) with suspected spina bifida. Spina bifida was confirmed by direct visualization of the spinal defect on ultrasound by two experts and, when possible, by fetal postmortem examination. Ultrasound images were reviewed for the presence of the crash sign, which is the posterior displacement of the mesencephalon and deformation against the occipital bone in the axial view. The first-trimester ultrasound images of a mixed group of 10 cases and 40 control fetuses without spina bifida were assessed for the presence of the crash sign by two assessors blinded to the diagnosis.

RESULTS

The crash sign was present in 48 out of 53 confirmed cases of spina bifida. Of these, 27 had isolated spina bifida and 21 had an associated anomaly. Of the five cases without the crash sign, one had isolated spina bifida and four had an associated anomaly. The crash sign was not reported in any of the control fetuses.

CONCLUSIONS

We have described a new first-trimester sonographic marker for the diagnosis of spina bifida. Our results suggest that the crash sign may be a useful tool in the first-trimester detection of spina bifida. Prospective evaluation of the crash sign would be beneficial, ideally in a routine clinical screening ultrasound setting. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

RAS testing of liquid biopsy correlates with the outcome of metastatic colorectal cancer patients treated with first-line FOLFIRI plus cetuximab in the CAPRI-GOIM trial

Background

Liquid biopsy is an alternative to tissue for RAS testing in metastatic colorectal carcinoma (mCRC) patients. Little information is available on the predictive role of liquid biopsy RAS testing in patients treated with first-line anti-EGFR monoclonal antibody-based therapy.

Patients and methods

In the CAPRI-GOIM trial, 340 KRAS exon-2 wild-type mCRC patients received first-line cetuximab plus FOLFIRI. Tumor samples were retrospectively assessed by next generation sequencing (NGS). Baseline plasma samples were analyzed for KRAS and NRAS mutations using beads, emulsion, amplification, and magnetics digital PCR (BEAMing). Discordant cases were solved by droplet digital PCR (ddPCR) or deep-sequencing.

Results

A subgroup of 92 patients with available both NGS data on tumor samples and baseline plasma samples were included in this study. Both NGS analysis of tumor tissue and plasma testing with BEAMing identified RAS mutations in 33/92 patients (35.9%). However, 10 cases were RAS tissue mutant and plasma wild-type, and additional 10 cases were tissue wild-type and plasma mutant, resulting in a concordance rate of 78.3%. Analysis of plasma samples with ddPCR detected RAS mutations in 2/10 tissue mutant, plasma wild-type patients. In contrast, in all tissue wild-type and plasma mutant cases, ddPCR or deep-sequencing analysis of tumor tissue confirmed the presence of RAS mutations at allelic frequencies ranging between 0.15% and 1.15%. The median progression-free survival of RAS mutant and wild-type patients according to tissue (7.9 versus 12.6 months; P = 0.004) and liquid biopsy testing (7.8 versus 13.8 moths; P < 0.001) were comparable. Similar findings were observed for the median overall survival of RAS mutant and wild-type patients based on tissue (22.1 versus 35.8 months; P = 0.016) and plasma (19.9 versus 35.8 months; P = 0.013) analysis.

Conclusion

This study indicates that RAS testing of liquid biopsy results in a similar outcome when compared with tissue testing in mCRC patients receiving first-line anti-EGFR monoclonal antibodies.

New insights in the control of antioxidants accumulation in tomato by transcriptomic analyses of genotypes exhibiting contrasting levels of fruit metabolites

Background

Tomato is an economically important crop with fruits that are a significant source of bioactive compounds such as ascorbic acid and phenolics. Nowadays, the majority of the enzymes of the biosynthetic pathways and of the structural genes controlling the production and the accumulation of antioxidants in plants are known; however, the mechanisms that regulate the expression of these genes are yet to be investigated. Here, we analyzed the transcriptomic changes occurring during ripening in the fruits of two tomato cultivars (E1 and E115), characterized by a different accumulation of antioxidants, in order to identify candidate genes potentially involved in the biosynthesis of ascorbic acid and phenylpropanoids.

Results

RNA sequencing analyses allowed identifying several structural and regulator genes putatively involved in ascorbate and phenylpropanoids biosynthesis in tomato fruits. Furthermore, transcription factors that may control antioxidants biosynthesis were identified through a weighted gene co-expression network analysis (WGCNA). Results obtained by RNA-seq and WGCNA analyses were further confirmed by RT-qPCR carried out at different ripening stages on ten cultivated tomato genotypes that accumulate different amount of bioactive compounds in the fruit. These analyses allowed us to identify one pectin methylesterase, which may affect the release of pectin-derived D-Galacturonic acid as metabolic precursor of ascorbate biosynthesis. Results reported in the present work allowed also identifying one L-ascorbate oxidase, which may favor the accumulation of reduced ascorbate in tomato fruits. Finally, the pivotal role of the enzymes chalcone synthases (CHS) in controlling the accumulation of phenolic compounds in cultivated tomato genotypes and the transcriptional control of the CHS genes exerted by Myb12 were confirmed.

Conclusions

By using transcriptomic analyses, candidate genes encoding transcription factors and structural genes were identified that may be involved in the accumulation of ascorbic acid and phenylpropanoids in tomato fruits of cultivated genotypes. These analyses provided novel insights into the molecular mechanisms controlling antioxidants accumulation in ripening tomato fruits. The structural genes and regulators here identified could also be used as efficient genetic markers for selecting high antioxidants tomato cultivars.

Electronic supplementary material

The online version of this article (10.1186/s12864-019-5428-4) contains supplementary material, which is available to authorized users.

The novel HBx mutation F30V correlates with hepatocellular carcinoma in vivo, reduces hepatitis B virus replicative efficiency and enhances anti-apoptotic activity of HBx N terminus in vitro

OBJECTIVE

We aimed to investigate HBx genetic elements correlated with hepatitis B virus (HBV) -related hepatocellular carcinoma (HCC) and their impact on (a) HBV replicative efficiency, (b) HBx binding to circular covalently closed DNA (cccDNA), (c) apoptosis and cell-cycle progression, and (d) HBx structural stability.

METHODS

This study included 123 individuals chronically infected with HBV: 27 with HCC (77.9% (21/27) genotype D; 22.1% (6/27) genotype A) and 96 without HCC (75% (72/96) genotype D; 25.0% (24/96) genotype A). HepG2 cells were transfected by wild-type or mutated linear HBV genome to assess pre-genomic RNA (pgRNA) and core-associated HBV-DNA levels, HBx-binding onto cccDNA by chromatin immunoprecipitation-based quantitative assay, and rate of apoptosis and cell-cycle progression by cytofluorimetry.

RESULTS

F30V was the only HBx mutation correlated with HCC (18.5% (5/27) in HCC patients versus 1.0% (1/96) in non-HCC patients, p 0.002); a result confirmed by multivariate analysis. In vitro, F30V determined a 40% and 60% reduction in pgRNA and core-associated HBV-DNA compared with wild-type (p <0.05), in parallel with a significant decrease of HBx binding to cccDNA and decreased HBx stability. F30V also decreased the percentage of apoptotic cells compared with wild-type (14.8 ± 6.8% versus 19.1 ± 10.1%, p <0.01, without affecting cell-cycle progression) and increased the probability of HBx-Ser-31 being phosphorylated by PI3K-Akt kinase (known to promote anti-apoptotic activity).

CONCLUSIONS

F30V was closely correlated with HBV-induced HCC in vivo, reduced HBV replicative efficiency by affecting HBx-binding to cccDNA and increased anti-apoptotic HBx activity in vitro. This suggests that F30V (although hampering HBV's replicative capacity) may promote hepatocyte survival, so potentially allowing persistent production of viral progeny and initiating HBV-driven hepatocarcinogenesis. Investigation of viral genetic markers associated with HCC is crucial to identify those patients at higher risk of HCC, who hence deserve intensive liver monitoring and/or early anti-HBV therapy.

Modulation of Tomato Response to Rhizoctonia solani by Trichoderma harzianum and Its Secondary Metabolite Harzianic Acid

The present study investigated the transcriptomic and metabolomic changes elicited in tomato plants (Solanum lycopersicum cv. Micro-Tom) following treatments with the biocontrol agent Trichoderma harzianum strain M10 or its purified secondary metabolite harzianic acid (HA), in the presence or the absence of the soil-borne pathogen Rhizoctonia solani. Transcriptomic analysis allowed the identification of differentially expressed genes (DEGs) that play a pivotal role in resistance to biotic stress. Overall, the results support the ability of T. harzianum M10 to activate defense responses in infected tomato plants. An induction of hormone-mediated signaling was observed, as shown by the up-regulation of genes involved in the ethylene and jasmonate (ET/JA) and salicylic acid (SA)-mediated signaling pathways. Further, the protective action of T. harzianum on the host was revealed by the over-expression of genes able to detoxify cells from reactive oxygen species (ROS). On the other hand, HA treatment also stimulated tomato response to the pathogen by inducing the expression of several genes involved in defense response (including protease inhibitors, resistance proteins like CC-NBS-LRR) and hormone interplay. The accumulation of steroidal glycoalkaloids in the plant after treatments with either T. harzianum or HA, as determined by metabolomic analysis, confirmed the complexity of the plant response to beneficial microbes, demonstrating that these microorganisms are also capable of activating the chemical defenses.

Unraveling the complexity of transcriptomic, metabolomic and quality environmental response of tomato fruit

BACKGROUND

The environment has a profound influence on the organoleptic quality of tomato (Solanum lycopersicum) fruit, the extent of which depends on a well-regulated and dynamic interplay among genes, metabolites and sensorial attributes. We used a systems biology approach to elucidate the complex interacting mechanisms regulating the plasticity of sensorial traits. To investigate environmentally challenged transcriptomic and metabolomic remodeling and evaluate the organoleptic consequences of such variations we grown three tomato varieties, Heinz 1706, whose genome was sequenced as reference and two "local" ones, San Marzano and Vesuviano in two different locations of Campania region (Italy).

RESULTS

Responses to environment were more pronounced in the two "local" genotypes, rather than in the Heinz 1706. The overall genetic composition of each genotype, acting in trans, modulated the specific response to environment. Duplicated genes and transcription factors, establishing different number of network connections by gaining or losing links, play a dominant role in shaping organoleptic profile. The fundamental role of cell wall metabolism in tuning all the quality attributes, including the sensorial perception, was also highlighted.

CONCLUSIONS

Although similar fruit-related quality processes are activated in the same environment, different tomato genotypes follow distinct transcriptomic, metabolomic and sensorial trajectories depending on their own genetic makeup.

Thermal evolution of MnxOy nanofibres as catalysts for the oxygen reduction reaction

The present study shows how, starting from green and low-cost precursors, nanostructured manganese oxides with good catalytic efficiencies for the oxygen reduction reaction can be fabricated through the electrospinning technique. The role of the crystalline phase and morphological features, on the electro-catalytic behaviour, is discussed.

Defining the role of nanonetting in the electrical behaviour of composite nanofiber/nets

The electrical behaviour of MWCNT-based composite nanofiber/nets can be tuned by controlling the morphology of the secondary nanoweb.

Healing and Long-Term Viability of Grafts in the Venae Cavae Reconstruction

The need for superior vena cava (SVC) or inferior vena cava (IVC) recon struction is not uncommon: lung cancer, mediastinal tumors, or retroperitoneal neoplasms are the most frequent indications for caval replacement. Since auto genous veins, which represent the most satisfactory venous substitute, have not been applicable to caval replacement, because of the lack of suitable length and caliber, many types of materials have been tested in the venous system. The present study was planned to compare the potential of expanded polytetrafluoroethylene (e-PTFE) and glutaraldehyde-tanned human umbilical vein (HUV) grafts as caval substitutes.

Patch (4 x 5 cm) reconstruction of the SVC was carried out in 10 dogs, tubu lar (3 x 10 mm) reconstruction of the SVC in 5 dogs, and patch (1 x 2 cm) recon struction of the IVC in 8 dogs. In the patch reconstruction groups, HUV grafts were used in half of the cases and 30 μm pore sizes e-PTFE grafts in the other half, while in the tubular SVC replacement group, only e-PTFE grafts were employed. The grafts were removed fifteen to thirty days after IVC patch re construction, thirty to two hundred seventy days after SVC patch reconstruc tion, and thirty-three to forty-one months after SVC tubular replacement. In every instance, specimens were obtained for light microscopy (LM) and scan ning electron microscopy (SEM).

HUV patches implanted in the SVC showed hemorrhagic foci at their central portion and marked constriction at the anastomotic regions. On the contrary, the inner surface of e-PTFE patch grafts was covered with a uniform and glis tening neointima. By LM, e-PTFE patches showed a smooth and regular lumi nal surface, while the inner surface of HUV patches was irregular, with hemorrhagic areas in the underlying layers. By SEM, e-PTFE patches revealed a more rapid and orderly endothelialization of their inner surface than HUV patches did. Tubular SVC reconstruction showed the good long-term viability of the e-PTFE neointima (as long as forty-one months after grafting). Only spotty areas revealed neointima alterations, such as fibrinoid degeneration, fo cal necrosis, or minor thrombotic foci. In the IVC patch reconstruction model, HUV grafts showed an exuberant fibrin deposition on their inner surface and delayed endothelialization patterns, as compared with e-PTFE grafts. Since rapid healing with rapid endothelialization is accepted as the most important factor providing the graft luminal surface with the best antithrombotic proper ties, the present study demonstrated that e-PTFE is a more suitable material than HUV for SVC and IVC reconstruction.

Long-Term Evaluation of Human Umbilical Vein as Small-Caliber Arterial Substitute

Since 1977, 61 arterial reconstruc tions using glutaraldehyde-tanned human umbilical vein (HUV) grafts were carried out in 56 patients (51 males, 5 females) with unsuitable au togenous saphenous vein. Their mean age was 69 ± 14 years. Limb salvage was the primary indication for sur gery.

HUV grafts were used to perform 44 femoropopliteal, 4 composite aor topopliteal (with a direct end-to-end anastomosis between an aortofe moral Dacron graft and a femoropo pliteal HUV graft), 5 femorotibial, and 6 axillofemoral bypasses, and 1 femorofemoral and 1 iliopopliteal by pass. Ten-year cumulative patency rates were 31 % for all HUV recon structions, 36% for femoropopliteal bypasses, and 32% for femoropopli teal bypasses carried out for limb sal vage only. Four of the 5 femorotibial reconstructions failed during the first month following surgery. Two of the 6 axillofemoral and 3 of the 4 com posite aortopopliteal bypasses throm bosed within one and three years after surgery respectively. In conclu sion, the study evidenced long-term durability of HUV grafts, supporting their use for femorodistal reconstruc tions in patients with limb-threaten ing ischemia and inadequate autoge nous saphenous vein.

Electrochemical and impedance characterization of Microbial Fuel Cells based on 2D and 3D anodic electrodes working with seawater microorganisms under continuous operation

A mixed microbial population naturally presents in seawater was used as active anodic biofilm of two Microbial Fuel Cells (MFCs), employing either a 2D commercial carbon felt or 3D carbon-coated Berl saddles as anode electrodes, with the aim to compare their electrochemical behavior under continuous operation. After an initial increase of the maximum power density, the felt-based cell reduced its performance at 5 months (from 7 to 4 μW cm(-2)), while the saddle-based MFC exceeds 9 μW cm(-2) (after 2 months) and maintained such performance for all the tests. Electrochemical impedance spectroscopy was used to identify the MFCs controlling losses and indicates that the mass-transport limitations at the biofilm-electrolyte interface have the main contribution (>95%) to their internal resistance. The activation resistance was one order of magnitude lower with the Berl saddles than with carbon felt, suggesting an enhanced charge-transfer in the high surface-area 3D electrode, due to an increase in bacteria population growth.

Exploring a Tomato Landraces Collection for Fruit-Related Traits by the Aid of a High-Throughput Genomic Platform

During its evolution and domestication Solanum lycopersicum has undergone various genetic ‘bottlenecks’ and extreme inbreeding of limited genotypes. In Europe the tomato found a secondary centre for diversification, which resulted in a wide array of fruit shape variation given rise to a range of landraces that have been cultivated for centuries. Landraces represent a reservoir of genetic diversity especially for traits such as abiotic stress resistance and high fruit quality. Information about the variation present among tomato landrace populations is still limited. A collection of 123 genotypes from different geographical areas was established with the aim of capturing a wide diversity. Eighteen morphological traits were evaluated, mainly related to the fruit. About 45% of morphological variation was attributed to fruit shape, as estimated by the principal component analysis, and the dendrogram of relatedness divided the population in subgroups mainly on the basis of fruit weight and locule number. Genotyping was carried out using the tomato array platform SolCAP able to interrogate 7,720 SNPs. In the whole collection 87.1% markers were polymorphic but they decreased to 44–54% when considering groups of genotypes with different origin. The neighbour-joining tree analysis clustered the 123 genotypes into two main branches. The STRUCTURE analysis with K = 3 also divided the population on the basis of fruit size. A genomic-wide association strategy revealed 36 novel markers associated to the variation of 15 traits. The markers were mapped on the tomato chromosomes together with 98 candidate genes for the traits analyzed. Six regions were evidenced in which candidate genes co-localized with 19 associated SNPs. In addition, 17 associated SNPs were localized in genomic regions lacking candidate genes. The identification of these markers demonstrated that novel variability was captured in our germoplasm collection. They might also provide a viable indirect selection tool in future practical breeding programs.

Exploring a Tomato Landraces Collection for Fruit-Related Traits by the Aid of a High-Throughput Genomic Platform

During its evolution and domestication Solanum lycopersicum has undergone various genetic 'bottlenecks' and extreme inbreeding of limited genotypes. In Europe the tomato found a secondary centre for diversification, which resulted in a wide array of fruit shape variation given rise to a range of landraces that have been cultivated for centuries. Landraces represent a reservoir of genetic diversity especially for traits such as abiotic stress resistance and high fruit quality. Information about the variation present among tomato landrace populations is still limited. A collection of 123 genotypes from different geographical areas was established with the aim of capturing a wide diversity. Eighteen morphological traits were evaluated, mainly related to the fruit. About 45% of morphological variation was attributed to fruit shape, as estimated by the principal component analysis, and the dendrogram of relatedness divided the population in subgroups mainly on the basis of fruit weight and locule number. Genotyping was carried out using the tomato array platform SolCAP able to interrogate 7,720 SNPs. In the whole collection 87.1% markers were polymorphic but they decreased to 44-54% when considering groups of genotypes with different origin. The neighbour-joining tree analysis clustered the 123 genotypes into two main branches. The STRUCTURE analysis with K = 3 also divided the population on the basis of fruit size. A genomic-wide association strategy revealed 36 novel markers associated to the variation of 15 traits. The markers were mapped on the tomato chromosomes together with 98 candidate genes for the traits analyzed. Six regions were evidenced in which candidate genes co-localized with 19 associated SNPs. In addition, 17 associated SNPs were localized in genomic regions lacking candidate genes. The identification of these markers demonstrated that novel variability was captured in our germoplasm collection. They might also provide a viable indirect selection tool in future practical breeding programs.

Dissecting a QTL into Candidate Genes Highlighted the Key Role of Pectinesterases in Regulating the Ascorbic Acid Content in Tomato Fruit

Tomato (Solanum lycopersicum) is a crucial component of the human diet because of its high nutritional value and the antioxidant content of its fruit. As a member of the Solanaceae family, it is considered a model species for genomic studies in this family, especially since its genome has been completely sequenced. Among genomic resources available, Solanum pennellii introgression lines represent a valuable tool to mine the genetic diversity present in wild species. One introgression line, IL12-4, was previously selected for high ascorbic acid (AsA) content, and a transcriptomic analysis indicated the involvement of genes controlling pectin degradation in AsA accumulation. In this study the integration of data from different "omics" platforms has been exploited to identify candidate genes that increase AsA belonging to the wild region 12-4. Thirty-two genes potentially involved in pathways controlling AsA levels were analyzed with bioinformatic tools. Two hundred-fifty nonsynonymous polymorphisms were detected in their coding regions, and 11.6% revealed deleterious effects on predicted protein function. To reduce the number of genes that had to be functionally validated, introgression sublines of the region 12-4 were selected using species-specific polymorphic markers between the two Solanum species. Four sublines were obtained and we demonstrated that a subregion of around 1 Mbp includes 12 candidate genes potentially involved in AsA accumulation. Among these, only five exhibited structural deleterious variants, and one of the 12 was differentially expressed between the two Solanum species. We have highlighted the role of three polymorphic pectinesterases and inhibitors of pectinesterases that merit further investigation.

An association mapping approach to identify favourable alleles for tomato fruit quality breeding

BACKGROUND

Genome Wide Association Studies (GWAS) have been recently used to dissect complex quantitative traits and identify candidate genes affecting phenotype variation of polygenic traits. In order to map loci controlling variation in tomato marketable and nutritional fruit traits, we used a collection of 96 cultivated genotypes, including Italian, Latin American, and other worldwide-spread landraces and varieties. Phenotyping was carried out by measuring ten quality traits and metabolites in red ripe fruits. In parallel, genotyping was carried out by using the Illumina Infinium SolCAP array, which allows data to be collected from 7,720 single nucleotide polymorphism (SNP) markers.

RESULTS

The Mixed Linear Model used to detect associations between markers and traits allowed population structure and relatedness to be evidenced within our collection, which have been taken into consideration for association analysis. GWAS identified 20 SNPs that were significantly associated with seven out of ten traits considered. In particular, our analysis revealed two markers associated with phenolic compounds, three with ascorbic acid, β-carotene and trans-lycopene, six with titratable acidity, and only one with pH and fresh weight. Co-localization of a group of associated loci with candidate genes/QTLs previously reported in other studies validated the approach. Moreover, 19 putative genes in linkage disequilibrium with markers were found. These genes might be involved in the biosynthetic pathways of the traits analyzed or might be implied in their transcriptional regulation. Finally, favourable allelic combinations between associated loci were identified that could be pyramided to obtain new improved genotypes.

CONCLUSIONS

Our results led to the identification of promising candidate loci controlling fruit quality that, in the future, might be transferred into tomato genotypes by Marker Assisted Selection or genetic engineering, and highlighted that intraspecific variability might be still exploited for enhancing tomato fruit quality.

[Alcohol and work. Consensus Document of the La.R.A. (Workers representing a risk for others) group]

AIM

Current Italian legislation obliges employers to prevent workers who are occupationally at risk or who perform jobs that may be hazardous for the safety or health of third parties from consuming alcohol. The LaRA Group undertook to assess whether the law fully safeguards the health and safety of both workers and third parties, without impinging upon the civil rights of workers.

METHOD

A written document expressing agreement was produced following discussions between doctors, lawyers, bioethicists and social partners.

RESULTS

There are gaps and inconsistencies in current laws; the differences in local and regional provisions prevent authorities from applying a single strategy at national level. There should be a change in existing rules under which the employer's obligation to enforce the ban on consumption alcohol in the workplace is enacted solely by the "competent" physician whose institutional role is to safeguard and promote health. Some occupational categories that are subject to a ban on alcohol consumption do not currently under-go health surveillance. For example, if road transport drivers are not exposed to a specific occupational risk foreseen under another law, they can be placed under health surveillance only in those regions where the local laws contemplate this type of control. In other cases, the practice of assessing the risk to third parties and providing for compulsory health surveillance in the Risk Assessment Document, is considered by some jurists to be a "consuetudo praeter legem" and therefore acceptable in a field not yet covered by a specific law, but to be "contra legem" or unlawful by other jurists. Moreover, the competent physician who uses a breathanalyser or tests for alcohol addiction faces an ethical dilemma, since by communicating the results to an employer or authorities responsible for the issuing of licenses, he may be violating his professional oath of secrecy. Furthermore, the emphasis placed on testing has induced companies and inspectors to overlook educational and rehabilitation aspects. It is essential to involve general practitioners, educators and specialist services in addressing the problems of alcohol abuse so as to inform/train, recover and rehabilitate. The few studies available indicate that the rules are poorly enforced and that non-compliance may go unobserved.

CONCLUSIONS

The Group urges all employers to assess the risk for third parties caused by alcohol abuse and to devise a policy on alcohol. Controlling alcohol-related risks in the workplace calls for a better definition of the roles of Vigilance Bod-ies and Company Physicians together with a shift from a reactive to a proactive attitude of all the parties involved.

Patchwork sequencing of tomato San Marzano and Vesuviano varieties highlights genome-wide variations

Background

Investigation of tomato genetic resources is a crucial issue for better straight evolution and genetic studies as well as tomato breeding strategies. Traditional Vesuviano and San Marzano varieties grown in Campania region (Southern Italy) are famous for their remarkable fruit quality. Owing to their economic and social importance is crucial to understand the genetic basis of their unique traits.

Results

Here, we present the draft genome sequences of tomato Vesuviano and San Marzano genome. A 40x genome coverage was obtained from a hybrid Illumina paired-end reads assembling that combines de novo assembly with iterative mapping to the reference S. lycopersicum genome (SL2.40). Insertions, deletions and SNP variants were carefully measured. When assessed on the basis of the reference annotation, 30% of protein-coding genes are predicted to have variants in both varieties. Copy genes number and gene location were assessed by mRNA transcripts mapping, showing a closer relationship of San Marzano with reference genome. Distinctive variations in key genes and transcription/regulation factors related to fruit quality have been revealed for both cultivars.

Conclusions

The effort performed highlighted varieties relationships and important variants in fruit key processes useful to dissect the path from sequence variant to phenotype.

Identification of candidate genes for phenolics accumulation in tomato fruit

Phenolics are antioxidants present in tomato fruit that confer healthy benefits and exhibit crucial roles for plant metabolism and response to environmental stimuli. An approach based on two genomics platforms was undertaken to identify candidate genes associated to higher phenolics content in tomato fruit. A comparative transcriptomic analysis between the S. pennellii Introgression Line 7-3, which produced an average higher level of fruit phenolics, and the cultivated variety M82, revealed that their differences are attributed to genes involved in phenolics accumulation into the vacuole. The up-regulation of genes coding for one MATE-transporter, one vacuolar sorting protein and three GSTs supported this hypothesis. The observed balancing effect between two ethylene responsive factors (ERF1 and ERF4) was also hypothesized to drive the transcriptional regulation of these transport genes. In order to confirm such model a TILLING platform was explored. A mutant was isolated harbouring a point mutation in the ERF1 cds that affects the protein sequence and its expected function. Fruits of the mutant exhibited a significant reduced level of phenolics than the control variety. Changes in the expression of genes involved in sequestration of phenolics in vacuole also supported the hypothesized key-role of ERF1 in orchestrating these genes.

Quantitative trait loci pyramiding for fruit quality traits in tomato

Fruit quality is a major focus for most conventional and innovative tomato breeding strategies, with particular attention being paid to fruit antioxidant compounds. Tomatoes represent a major contribution to dietary nutrition worldwide and a reservoir of diverse antioxidant molecules. In a previous study, we identified two Solanum pennellii introgression lines (IL7-3 and IL12-4) harbouring quantitative trait loci (QTL) that increase the content of ascorbic acid (AsA), phenols and soluble solids (degrees Brix; °Bx) in tomato fruit. The purpose of the present work was to pyramid into cultivated varieties the selected QTL for enhanced antioxidant and °Bx content. To better understand the genetic architecture of each QTL, the two ILs were crossed to the recurrent parent M82 (ILH7-3 and ILH12-4) and between them (ILH7-3+12-4). F1 hybrids (ILH7-3+12-4) were then selfed up to obtain F3 progenies in order to stabilize the favourable traits at the homozygous condition. Species-specific molecular markers were identified for each introgressed region and allowed us to select four F2 genotypes carrying both introgressions at the homozygous condition. The F3 double homozygous plants displayed AsA, total phenols and °Bx content significantly higher than M82. Therefore, they may represent suitable genetic material for breeding schemes aiming to increase antioxidant content in tomato fruit.

Anti-angiogenic therapies in the treatment of Waldenstrom's Macroglobulinemia

Bone marrow microenvironment has been shown to play a crucial role in supporting the pathogenesis and the progression of several B-cell malignancies, including Waldenstrom's Macroglobulinemia (WM). Among the different cell types within the bone marrow milieu, endothelial cells have been proven to support WM cells growth. Based on the understanding of bone marrow neo-angiogenesis in plasma cell dyscrasias, a number of anti-angiogenic molecules are now available for the treatment of these diseases. Indeed, anti-angiogenic drugs, such as proteasome-, proteins kinase-C (PKC)-, phosphatidylinositol 3-kinase/mammalian target of rapamycin (mTOR)-, and histone deacetylase (HDAC)- inhibitors are now available, playing a key role in the treatment of WM both in the preclinical settings and as part of clinical trials.

[Working parents and welfare in Italy]

This paper considers parents empoyment laws in Italy, starting with the very first one in 1902. The legislative development is comparised with Italian history in twentieth and twenty-first centuries, with a particular attention to the Mussolinian age (1922-1943), the Constitution and 1975 Family Law. Social environment is also analyzed in this complex situation.

[Radon in workplaces, a review]

Radon is a chemical radioactive element. It occurs naturally as the decay product of radium; it's responsible for the majority of the mean public exposure to ionizing radiation. It is often the single largest contributor to an individual's background radiation dose, and is the most variable from location to location. Radon gas from natural sources can accumulate in buildings, especially in confined areas such as attics, and basements. Breathing in radon is a cause of lung cancer. In Italy, high levels of radon should be found in underground spaces such as wineries, historical buildings, hot springs or mushrooms farms, and it's a hazard all this workplaces. To ensure the health and safety of employees and others who have access to their work environment, the occupational physician can program inexpensive surveys (with dosemeters) and develop an information plan.