University of Macerata

Caustic ingestion (CI) in adults represents a potentially life-threatening condition. Diagnosis and management of CI in real life remain challenging. The aim of the survey is to evaluate on a national scale the multidisciplinary management of these patients. 24-item online Survey was sent to the mailing lists and social media of Italian Society of Endoscopic Surgery and New Technologies, Italian Society of Digestive Endoscopy, World Society of Emergency Surgery-Italy Chapter, and Italian Society of Surgical Endoscopy and Digestive Diseases. Overall, 240 subjects answered to the survey, corresponding to 22.1% of the total members of the scientific societies involved. 131 (54.5%) respondents evaluated fewer than ten CI patients per year. The recommendations provided by the WSES and SIED guidelines were followed by 133 (55.2%) and 83 (34.4%) participants, respectively. Emergency surgery was advocated by 180 (77.6%) of the respondents for patients with transmural necrosis or signs of perforation, using minimally invasive surgery in 47% of the cases and considering initial esophagojejunal anastomosis as safe in 33 (14.2%) of the responses. Our study is the first to provide real-life data on how the management of CI varies across Italian physicians, according to regional, institutional, and specialty-related factors. This survey highlights the need for standardized and uniform guidelines.

The Big Five Inventory-2 (BFI-2) is one of the most used questionnaires to assess personality traits. Its main strength regards the possibility of distinguishing the five traits into 15 facets. Despite its extended usage and validation, there is still room for research to explore its structure and potential. For instance, an examination of the facets through Rasch Analysis (RA) has not been developed yet. We investigated the psychometric properties of the BFI-2 by applying the RA (obtaining the BFI-2-R), in addition to traditional analyses, in an Italian sample of 5362 adults. First, we conducted five confirmatory factor analyses, which supported the three-facet structure of each of the five traits. This structure resulted invariant at the scalar level across sex. Second, for each facet we checked and confirmed the necessary assumptions for applying the RA (i.e., about monotonicity, local independence, unidimensionality, and differential item functioning). We then found that our data fit the Rasch model for each facet. Finally, based on the Rasch scores, we documented the discriminant and convergent validity of the BFI-2-R. Overall, the findings support the goodness of the BFI-2-R and permit to extend research on the Big Five with an instrument considering the properties of fundamental measurement.

We investigate whether hypothesis testing can be improved by a simple prompt to “think in opposites,” a strategy suggested by a growing body of literature as being beneficial in various reasoning and problem-solving contexts. We employed Wason’s rule-discovery task and designed three experimental conditions: training that prompted an analysis of the properties characterizing the initial seed triple, training that prompted the same analysis but subsequently required the identification of the opposites of each property for use in the testing phase, and a no-prompt condition. Thinking in opposites nearly doubled the success rate and led to a more frequent discovery of the rule on the first attempt. This improved efficacy was due not to the testing of more triples but to less reiteration of the same hypothesis and a greater awareness of the ascending-descending critical dimension. We discuss how thinking in opposites appears to stimulate counterfactual thinking, with respect to previous literature.

Background The prognostic value of the Geriatric 8 (G8) screening score in metastatic renal cell carcinoma (mRCC) patients receiving first-line immunotherapy remains unclear. This study aimed to evaluate the prognostic role of G8 within the context of the Meet-URO classification in mRCC patients treated with first-line ipilimumab-nivolumab. Methods This retrospective multicentre study analysed 106 mRCC patients treated with first-line ipilimumab-nivolumab. G8 and Meet-URO scores were calculated before treatment initiation. Primary endpoint was overall survival (OS), defined as duration from first administration of Nivolumab to death. OS was analysed in relation to age groups, G8 scores, and Meet-URO score categories, with data censored for patients still alive at the last follow-up. The secondary endpoint, progression-free survival (PFS), was measured from initiating Nivolumab to the earliest instance of disease progression or death. OS and PFS were assessed using Kaplan-Meier methods and Cox regression analyses. The reporting of this study conforms to the REMARK guidelines. Results Patients with G8 > 14 had more favorable IMDC and Meet-URO risk classifications and lower neutrophil-to-lymphocyte ratios. While PFS did not differ significantly between G8 ≤ 14 and >14 groups (1-year 29.3% vs 46.2%, p = 0.2), OS was significantly longer in G8 > 14 group (1-year 76.1% vs 58.6%, p = 0.006). In multivariable analysis, G8 ≤ 14 was independently associated with worse OS (HR 2.36, 95% CI 1.06-5.08, p = 0.03) but not PFS. The Meet-URO score was prognostic for both PFS and OS. In patients ≥70 years, G8 lost its prognostic value, while Meet-URO remained prognostic for OS. Conclusions The G8 score is an independent prognostic factor for OS but not PFS in mRCC patients receiving first-line ipilimumab-nivolumab. The Meet-URO score shows consistent prognostic ability for PFS and OS across age groups. These findings suggest that while G8 may be useful for individual patient-level OS prediction, the Meet-URO score may be superior for guiding treatment decisions in clinical practice.

In a context characterized by an increasing number of mergers and acquisitions (M&A) deals, it is important to analyze the impact of sustainability performance on deal outcomes. Actually, the evidence in the literature sometimes reaches quite different results. Thus, the study aims to investigate the possible existence of a relationship between the acquisition premium paid in an M&A transaction and a target firm’s environmental, social and governance (ESG) performance, as well as to understand which ESG component has the strongest influence on the takeover premium. 111 and 102 M&A transactions closed, respectively, in 2021 and 2022, involving listed target companies active in both the European and North American markets, were analyzed through a connection analysis and a regression approach. The results obtained, in line with those of others in the literature, show that the acquisition premium is not linked in any way to ESG performances. These findings shed light on the actual importance of ESG factors in the valuation of the takeover premium.

Patients with metastatic urothelial carcinoma (mUC) are typically elderly and often have other comorbidities that require the use of concomitant medications. In our study we evaluated the association of concomitant use of antibiotics (ATBs), proton pump inhibitors (PPIs), corticosteroids, statins, metformin and insulin with patient outcomes and we validated the prognostic role of a concomitant drug score in mUC patients treated with enfortumab vedotin (EV) monotherapy. Data from 436 patients enrolled in the ARON-2EV retrospective study were analyzed according to the concomitant medications used at baseline. Finally, the patients were stratified into three risk groups according to the concomitant drug score based on ATBs, corticosteroids and PPIs. Statistical analysis involved Fisher exact test, Kaplan–Meier method, log-rank test, and univariate/multivariate Cox proportional hazard regression models. Inferior survival outcomes were observed in ATB users compared to non-users (OS: 7.3 months, 95%CI 5.0 − 12.3 vs 13.7 months, 95%CI 12.2 − 47.3, p = 0.001; PFS: 5.1 months 95%CI 3.3 − 17.7 vs 8.3 months, 95%CI 7.1 − 47.3, p = 0.001) and also in corticosteroid users compared to non-users (OS: 8.4 months, 95%CI 6.6 − 10.0 vs 14.2 months, 95%CI 12.7 − 47.3, p < 0.001; PFS: 6.0 months 95%CI 4.6 − 7.9 vs 8.9 months, 95%CI 7.2 − 47.3, p = 0.004). In the Cox multivariate analysis, the concomitant drug score was a significant factor predicting both OS (HR = 1.32 [95% CI 1.03 − 1.68], p = 0.026) and PFS (HR = 1.23 [95% CI 1.01 − 1.51], p = 0.044). Our findings suggest detrimental impact of concomitant use of ATBs and corticosteroids on survival outcomes and the prognostic utility of the concomitant drug score in previously treated mUC patients receiving EV.

Background Recently, a plethora of novel systemic agents have been incorporated into the therapeutic armamentarium of advanced urothelial carcinoma (aUC). The antibody–drug conjugate (ADC), enfortumab vedotin (EV), has demonstrated relevant clinical benefit in patients with aUC refractory to platinum and immune‐checkpoint inhibitor (ICI) therapy. Our study provides a retrospective, international, real‐world analysis comparing the effectiveness of EV to chemotherapy in this setting. Methods The data were extracted from the medical records of patients treated with EV or chemotherapy following pembrolizumab for recurrent or progressive aUC after platinum‐based chemotherapy. Patients were assessed for overall survival (OS), progression‐free survival (PFS), overall response rate (ORR) and duration of response (DoR). Results Our analysis included 247 patients treated with EV (88, 36%) or chemotherapy (159, 64%). Median OS was 9.1 months (95%CI 7.2–10.7) in the overall study population, 13.6 months (95%CI 10.0–31.0) in patients receiving EV and 6.8 months (95%CI 6.0–8.9) in patients receiving chemotherapy (p < 0.001). The OS benefit of EV was not affected by primary tumour site and histology, metastatic sites, type of first platinum‐based chemotherapy or response to pembrolizumab. In the EV cohort, the median PFS was significantly longer (8.8 months [95%CI 6.5–17.0] vs. 3.0 months [95%CI 2.6–3.7]) and the ORR was significantly higher (56% vs. 23%) than in the chemotherapy cohort. Conclusions The results of our international analysis of real‐world data confirm the effectiveness of EV in the sequential strategy of aUC patients who have received prior platinum‐based chemotherapy and anti‐PD‐1 pembrolizumab, regardless of commonly considered prognostic factors. Trial Registration: ClinicalTrials.gov identifier: NCT05290038

Introduction The inappropriate prescribing and use of antibiotics have contributed to the emergence and spread of antimicrobial resistance (AMR). In Zambia, there is a paucity of information on the prescribing patterns and use of antibiotics among hospitalized patients in level 1 hospitals. This study investigated antibiotic use in five level 1 hospitals in Lusaka, Zambia. Methods This cross-sectional study utilized the World Health Organization (WHO) Point Prevalence Survey (PPS) methodology among in-patients admitted in level 1 hospitals before 08:00 a.m. on the survey day in August 2024. Data were analysed using IBM SPSS version 23.0. Results The prevalence of antibiotic use among inpatients was 59.0%, with ceftriaxone being the most prescribed. Antibiotics were prescribed mainly for paediatrics and male inpatients. This study found that 53.0% of prescribed antibiotics were from the Access group while 38.2% were from the Watch group of the World Health Organization Access, Watch, and Reserve (AWaRe) classification. Adherence to national treatment guidelines was 36.0%, with most antibiotics prescribed empirically without evidence of culture and sensitivity tests. Conclusion This study found a high use of antibiotics and low adherence to treatment guidelines in level 1 hospitals in Lusaka, Zambia. The findings of this study demonstrate the need to establish and strengthen antimicrobial stewardship programs and strengthen laboratory capacity to aid clinicians in diagnosing, treating, and managing patients across level 1 hospitals in Zambia.

The incorporation of artificial intelligence (AI) in health care offers revolutionary enhancements in patient diagnostics, clinical processes, and overall access to services. Nevertheless, this technological transition brings forth various new, intricate risks that pose challenges to current safety and ethical norms. This research explores the ability of enterprise risk management as an all‐encompassing framework to tackle these arising risks, providing both a forward‐looking and responsive strategy designed for the health care industry. At the core of this method are instruments that together seek to proactively uncover and address AI‐related weaknesses like algorithmic bias, system failures, and data privacy issues. On the reactive side, it incorporates incident reporting systems and root cause analysis, tools that enable health care providers to quickly address unexpected events and consistently improve AI implementation procedures. However, some application difficulties still exist. The unclear, “black box” characteristics of numerous AI models hinder transparency and responsibility, prompting inquiries about the clarity of AI‐generated choices and their adherence to ethical benchmarks in patient treatment. The research highlights that with the progress of AI technologies, the enterprise risk management framework also needs to evolve, addressing these new complexities while promoting a culture focused on safety in health care settings.

Background Decision-making in emergency settings is inherently complex, requiring surgeons to rapidly evaluate various clinical, diagnostic, and environmental factors. The primary objective is to assess a patient’s risk for adverse outcomes while balancing diagnoses, management strategies, and available resources. Recently, indocyanine green (ICG) fluorescence imaging has emerged as a valuable tool to enhance surgical vision, demonstrating proven benefits in elective surgeries. Aim This consensus paper provides evidence-based and expert opinion-based recommendations for the standardized use of ICG fluorescence imaging in emergency settings. Methods Using the PICO framework, the consensus coordinator identified key research areas, topics, and questions regarding the implementation of ICG fluorescence-guided surgery in emergencies. A systematic literature review was conducted, and evidence was evaluated using the GRADE criteria. A panel of expert surgeons reviewed and refined statements and recommendations through a Delphi consensus process, culminating in final approval. Results ICG fluorescence imaging, including angiography and cholangiography, improves intraoperative decision-making in emergency surgeries, potentially reducing procedure duration, complications, and hospital stays. Optimal use requires careful consideration of dosage and timing due to limited tissue penetration (5–10 mm) and variable performance in patients with significant inflammation, scarring, or obesity. ICG is contraindicated in patients with known allergies to iodine or iodine-based contrast agents. Successful implementation depends on appropriate training, availability of equipment, and careful patient selection. Conclusions Advanced technologies and intraoperative navigation techniques, such as ICG fluorescence-guided surgery, should be prioritized in emergency surgery to improve outcomes. This technology exemplifies precision surgery by enhancing minimally invasive approaches and providing superior real-time evaluation of bowel viability and biliary structures—areas traditionally reliant on the surgeon’s visual assessment. Its adoption in emergency settings requires proper training, equipment availability, and standardized protocols. Further research is needed to evaluate cost-effectiveness and expand its applications in urgent surgical procedures. Graphical abstract Supplementary Information The online version contains supplementary material available at 10.1186/s13017-025-00575-w.

Accurate vocal fold (VF) pose estimation is crucial for diagnosing larynx diseases that can eventually lead to VF paralysis. The videoendoscopic examination is used to assess VF motility, usually estimating the change in the anterior glottic angle (AGA). This is a subjective and time-consuming procedure requiring extensive expertise. This research proposes a deep learning framework to estimate VF pose from laryngoscopy frames acquired in the actual clinical practice. The framework performs heatmap regression relying on three anatomically relevant keypoints as a prior for AGA computation, which is estimated from the coordinates of the predicted points. The assessment of the proposed framework is performed using a newly collected dataset of 471 laryngoscopy frames from 124 patients, 28 of whom with cancer. The framework was tested in various configurations and compared with other state-of-the-art approaches (direct keypoints regression and glottal segmentation) for both pose estimation, and AGA evaluation. The proposed framework obtained the lowest root mean square error (RMSE) computed on all the keypoints (5.09, 6.56, and 6.40 pixels, respectively) among all the models tested for VF pose estimation. Also for the AGA evaluation, heatmap regression reached the lowest mean average error (MAE) ( $5.87^{\circ }$ 5 . 87 ∘ ). Results show that relying on keypoints heatmap regression allows to perform VF pose estimation with a small error, overcoming drawbacks of state-of-the-art algorithms, especially in challenging images such as pathologic subjects, presence of noise, and occlusion.

This article develops a method for evaluating urban resilience by operationalizing the 15-Minute City concept. The methodology combines cluster analysis and analysis of variance (ANOVA) to identify socio-demographic patterns and disparities in access to essential services and amenities across urban neighborhoods. By leveraging open-access and georeferenced data from OpenStreetMap (OSM), we compute density metrics for a wide range of services grouped into six key domains (Education, Healthcare, Public Transport, Commerce, Living/Sport, and Entertainment). The analysis, applied to Ancona—a mid-sized city in Central Italy—maps the distribution of target groups (e.g., elderly, foreign residents) and classifies urban areas into four distinct clusters based on socio-demographic characteristics. These clusters are further evaluated to reveal significant spatial inequalities in access to services. Unlike most prior studies, our approach integrates socio-demographic data and systematically examines the functional diversity of neighborhoods. Additionally, statistical methods such as ANOVA provide robust evidence of spatial disparities across clusters, highlighting the need for targeted interventions. Our findings confirm that peripheral neighborhoods are underserved compared to central areas, which benefit from a well-connected public transport network and a richer mix of essential services and amenities. The article concludes by discussing the implications for urban planning and the potential of data-driven policies to foster inclusive and resilient urban development.

160 Background: Apalutamide+androgen deprivation therapy (ADT) showed to significantly improve overall survival in low and high volume metastatic hormone sensitive prostate cancer (mHSPC) if compared to ADT alone. However, a randomized phase II trial (ARTO, NCT03449719) suggested that stereotactic body radiotherapy (SBRT) improved clinical outcomes when administered concomitantly with abiraterone acetate in metastatic castration resistance prostate cancer (mCRPC). Nonetheless, evidence related to use of SBRT in addition to androgen receptor pathway inhibitors (ARPIs) in oligometastatic HSPC is currently lacking. PERSIAN trial is aimed to test the hypothesis that metastases directed SBRT will improve outcomes in selected subgroups of patients with oligometastatic mHSPC treated with apalutamide + ADT. Methods: PERSIAN NCT05717660 is a phase II randomized trial enrolling patients affected by metachronous oligometastatic HSPC. Patients with de novo metastatic disease or with > 5 distant metastases are excluded from the trial. All patients are randomized to standard of care with apalutamide+ADT (ARM A: Control) or the same systemic treatment combined with SBRT on all sites of metastatic disease evidenced on conventional imaging (ARM B: Treatment). Here is presented the first interim analysis focused on rate of complete biochemical response (PSA < 0.2 ng/ml) after 3 months since apalutamide + ADT start. Results: Up to date, 174 patients have been enrolled (96.6% of the target sample size), 87 of these reached a minimum follow up of 3 months. Rate of patients with a complete biochemical response was 91.1% vs 92.9% in the control vs treatment arm, respectively (OR 1.27, 95% CI 0.27-6.03, p=0.765). Patients with PSMA positive lesions undetected on conventional imaging vs patients in whom number of target lesions was consistent on conventional and PSMA imaging had similar results (OR 0.74, 95%CI 0.08-6.94, p=0.791). Presence of bone metastatic lesions did not influence rate of complete biochemical response (OR 1.39, 95%CI 0.29-6.67, p-value 0.678). When adjusted for number of lesions, a significant benefit in favour of experimental arm was detected for patients with <3 metastatic sites (OR 5.88, 95%CI 1.13-33.3, p=0.03). Conclusions: Rate of early complete biochemical response showed a non significant trend in favour of experimental arm, with a 27% odds increase in the overall population for patients undergoing SBRT. Clinical benefit of SBRT is significantly improved in patients with lower burden of disease (<3 metastatic lesions). Trial accrual will be completed within the end of 2024, early results about complete biochemical response at 6 months in the complete cohort will be available in the second half of 2025. Clinical trial information: NCT03449719 .