Azienda Sanitaria di Firenze

The ongoing digital transformation is reshaping organizational and care delivery models in cardiology, positioning telemedicine as a pivotal tool to address increasing clinical and demographic complexity. This ANMCO position paper presents a comprehensive and critical overview of telemedicine applications in cardiovascular care, with a focus on its role in strengthening hospital-community integration, its deployment within hospital-based healthcare systems, and the associated regulatory and operational frameworks. The analysis encompasses the management of chronic cardiovascular conditions, such as heart failure and atrial fibrillation, through telemonitoring, telecontrol, televisit, and teleconsultation. Additionally, it explores the use of digital technologies in post-myocardial infarction follow-up, oral anticoagulation management, preoperative assessment, and care for elderly patients. The position paper also highlights the challenges and opportunities linked to digital infrastructure, interoperability, data protection, and healthcare professional training.

West Nile Virus (WNV) is becoming a significant and enduring public health menace in Europe, propelled by climate changes and accelerated population aging. Most infections are asymptomatic but older adults are more prone to develop neuroinvasive disease, which is characterized by high morbidity and mortality, as well as long-term neurological disturbances and disability. To date, there is still no licensed human vaccine or specific antiviral treatment, and management is mostly supportive. This review brings together the most recent information about WNV epidemiology, pathogenesis, and clinical manifestations, with a special focus on older people in Europe. We critically analyze current and novel pharmaceutical strategies, encompassing drug repurposing, nucleoside analogues, interferon-based therapies, peptides, monoclonal antibodies, and host-directed agents, emphasizing their therapeutic potential alongside the challenges presented by age-related pharmacokinetic and immunological alterations. We also discuss some important gaps in the current evidence base, such as the frequent exclusion of older adults from clinical studies and the lack of a coordinated clinical trial infrastructure that can be quickly activated during seasonal outbreaks. Lastly, we suggest a framework that combines systematic antiviral screening with the creation of a Europe-wide network of clinical trial readiness that is built into current One Health surveillance systems.

Introduzione: l’accesso intraosseo (IO) rappresenta un’opzione rapida e affidabile nelle emergenze critiche, come l’arresto cardiaco e lo shock ipovolemico, quando l’accesso venoso periferico o centrale risulta di difficile reperimento. Sebbene le linee guida internazionali ne raccomandino l’impiego, la letteratura spesso enfatizza solo la facilità tecnica di inserimento, trascurando l’analisi delle reali performance cliniche in termini di velocità di infusione e profilo farmacocinetico tra le diverse sedi anatomiche. Questo articolo si propone di chiarire i punti di forza e i limiti dei vari siti IO, analizzando come la scelta anatomica influenzi l'efficacia del trattamento. Metodo: il lavoro si basa sull’analisi delle evidenze scientifiche più recenti, includendo meta-analisi su pazienti in arresto cardiaco extraospedaliero, studi clinici osservazionali comparativi e modelli sperimentali di farmacocinetica su soggetti umani e animali. Sono stati confrontati i parametri di successo al primo tentativo, le portate volumetriche medie in regime pressorio e i tempi di distribuzione sistemica dei farmaci per i siti sternale, omerale e tibiale. Risultati: l’accesso IO garantisce tempi di posizionamento inferiori ai 2 minuti con tassi di successo al primo tentativo superiori al 90-95%6. In termini di performance emodinamica, la sede omerale consente flussi medi di circa 150 mL/min (a 300 mmHg), risultando superiore alla sede tibiale, che si attesta sui 120-130 mL/min con una tendenza alla riduzione del flusso nel tempo. Sotto il profilo farmacocinetico, la somministrazione in sede omerale o sternale garantisce una concentrazione plasmatica massima (Cmax) e un tempo di raggiungimento della stessa (Tmax) sovrapponibili alla via endovenosa8. Al contrario, la sede tibiale mostra un ritardo nella distribuzione dei farmaci verso il cuore di circa 30-60 secondi e una Cmax inferiore del 10-15% rispetto ai siti prossimali9. Nonostante l’elevata portata, il sito sternale è limitato dall'interferenza con le manovre di rianimazione cardiopolmonare, rendendo l’omero il miglior compromesso operativo nell'adulto civile. Conclusioni: l’accesso intraosseo è una procedura sicura, con complicanze gravi inferiori all'1%. Nell'adulto critico, la sede omerale deve essere considerata la scelta d'elezione per ottimizzare la farmacocinetica dei farmaci tempo-dipendenti e garantire portate infusionali elevate, mentre la tibia prossimale rimane indicata principalmente in ambito pediatrico e formativo per la semplicità del reperimento anatomico. Per garantire l'efficacia del sito omerale, è raccomandato l'utilizzo di aghi da 45 mm (gialli) e la sostituzione del dispositivo con un accesso vascolare stabile entro 24 ore.

Built in the early 1930s following the architectural rationalist principles, Manifattura Tabacchi was an important production site in Florence, until its decommissioning in 2001. The Recovery Plan in 2019 marked the beginning of a virtuous process of urban regeneration, one that draws inspiration from the uniqueness of the monumental complex, not by turning it into a museum, but by reweaving it into the urban and social fabric in which it is embedded. The transition from the urban scale of the masterplan to the detailed scale of the restoration project for the individual buildings took place through a design process conducted in dialogue with the Soprintendenza, with the aim of reconciling innovation with preservation. Attention to detail, care in the reuse of materials, have made it possible to transform through preservation, opening the renewing spaces to new functions, and returning them to the community without irreparably losing their original character.

The epidemiological transition has led to an increase in life expectancy and to a growing population of chronic patients, often with heart failure. These patients are frequently affected by comorbidities and frailty, which in turn increase the risk of disability and worsening quality of life, requiring an accurate multidimensional assessment (MDA). In this context, MDA is crucial for integrated and holistic management of elderly patients, considering not only the pathology but the patient in his complexity. MDA requires a multidisciplinary team to ensure a comprehensive and integrated assessment of the elderly patient. MDA tools assess various domains of health, using scales and validated tools to explore physical, functional, mental and socio-economic status. MDA is applied in two phases: an initial screening procedure and an in-depth analysis of individual problems for targeted interventions. MDA can be performed in various care settings, including outpatient clinics, hospitals, nursing homes, home care, and rehabilitation centers. Several studies show that MDA improves survival as well as functional and mental status, reducing hospitalization times and the frequency of institutionalization. This ANMCO position paper discusses MDA tools of older adults with chronic heart disease, highlighting the need for a holistic approach to address comorbidities and frailty in a growing population.

Abstract Problem Statement. In the wine sector, sustainability and producing a genuine product have long been priorities, with organic and agroecological practices becoming widespread. However, sustainability assessments often rely on tools like life cycle assessments (LCA), carbon footprints and water footprints, which overlook certain ecological and socio‐economic factors and fail to effectively communicate sustainability performance. Tools such as SAFA (Sustainability Assessment of Food and Agriculture Systems), TAPE (Tool for Agroecology Performance Evaluation) and OASIS (Original Agroecological Survey Indicator System) offer comprehensive evaluations of agri‐food systems, considering environmental, productive and social dimensions. The SWAT (Sustainable Wine Assessment Tool) framework, developed for the wine industry, includes socio‐cultural, governance and environmental indicators for sustainability assessment. Approach and Methods. This article applies the Agro‐Environmental Sustainability Information System (AESIS) framework to two wineries, assessing multiple dimensions of agroecosystems (physical, ecological, productive and social). AESIS uses indicators aligned with the principles of the aforementioned tools to evaluate two case studies in Tuscany and Lombardy, Italy. The Tuscany case study, Tenuta Casadei, employs the organic and biodynamic‐based BioIntegrale (BIOINT) method, while Castello di Cigognola in Lombardy uses conventional farming (CONV) and organic farming with precision techniques (ORGP). Results. The assessment used agro‐environmental indicators based on a conceptual sustainability framework, comparing CONV, ORGP and BIOINT against sustainability thresholds or critical limits for each indicator. Results showed a sustainability gradient: CONV < ORGP < BIOINT. BIOINT achieved 92% compliance with thresholds, ORGP 87% and CONV only 47%. Practical Implication. Despite differences, both case studies could benefit from agroecological interventions: improving ecological and social sustainability at Castello di Cigognola, and enhancing the physical dimension at Tenuta Casadei. AESIS provided valuable insights into the sustainability of both farms, offering multiple entry points for farmers to improve sustainability across various dimensions.

In this review, we highlight conventional agents and novel emerging therapeutic strategies to treat anemia in MF. Anemia is a common and challenging feature of myelofibrosis (MF). The pathobiology of anemia is multifactorial, including progressive bone marrow fibrosis, decreased erythropoiesis due to high hepcidin levels leading to iron sequestration in the reticuloendothelial system, hypersplenism, erythropoiesis inhibition by myelosuppressive JAK inhibitors (ruxolitinib, fedratinib), and others. MF-associated anemia has a negative impact on survival. Conventional agents to manage anemia include erythropoiesis-stimulating agents, danazol, corticosteroids, and immunomodulatory agents, but responses are infrequent and lack durability. Notable advancements have emerged in developing novel treatments for anemia in MF, including the regulatory approval of momelotinib (ACVR1/JAK1/2 inhibitor) in 2023 and development of novel promising agents targeting hemojuvelin and activins. Momelotinib and pacritinib (ACVR1/JAK2 inhibitor) are the preferred JAK inhibitors for patients with cytopenias (anemia, thrombocytopenia). Luspatercept and elritercept are activin receptor ligand traps, promoting erythroid maturation and late-stage erythropoiesis. Currently, luspatercept is being evaluated in a phase 3 trial (INDEPENDENCE™) for anemia in MF patients who are on a JAK2 inhibitor and require transfusions, and in a phase 2 trial (ODYSSEY) in combination with momelotinib in MF patients who are transfusion dependent, whether or not on a JAK inhibitor. Interim results of the RESTORE trial demonstrated that elritercept significantly decreased transfusions in MF patients. DISC-0974 is a first-in-class anti-hemojuvelin (positive hepcidin regulator) monoclonal antibody that decreased hepcidin expression, increased serum iron, and enhanced erythropoiesis in anemic patients with MF in a phase 1b/2 study. Burgeoning studies of novel anemia-targeted agents and combinations are significantly improving the quality of life and outcomes of patients with MF. The recent approval of momelotinib to treat MF with anemia and the emerging novel anemia-directed strategies in early and advanced clinical development have ushered in a new era in the treatment of MF-related anemia.

Background/Objectives: Previous studies evaluated the prognostic role of hematological parameters in predicting outcome in patients with infective endocarditis (IE). However, only a few studies evaluated the role of hematological parameters in patients undergoing surgery for IE. The aim of this study was to review our 20-year experience with the treatment of native (NVE) and prosthetic (PVE) valve endocarditis and to evaluate the role of neutrophil-to-lymphocyte ratio (NLR), neutrophil-to-platelet ratio (NPR), platelet-to-lymphocyte ratio (PLR), monocyte-to-lymphocyte ratio (MLR), neutrophil-to monocyte ratio (NMR), and systemic inflammatory index (SII) on early and long-term outcomes of patients undergoing surgery for NVE and PVE. Methods: All adult patients undergoing surgery for NVE and PVE at our institution between January 2001 and December 2022 were included in the study. Preoperative NLR, NPR, PLR, MLR, NMR, and SII were calculated using hemograms with complete blood count. Results: During the study period, 503 patients, 371 (74%) males, median age 65 (52-73) years, underwent surgery for NVE (n = 337, 67%) or PVE (n = 166, 33%). Patients with PVE had significantly more aortic annulus abscess (95 (57%) vs. 51 (15%); p < 0.001), longer CPB (180 (131-235) vs. 105 (84-145) min; p < 0.001) and aortic cross-clamping times (129 (96-175) vs. 82 (64-114) min; p < 0.001), and received more aortic homografts (47 (28%) vs. 28 (9%); p < 0.001) and postoperative pacemaker implantation (25 (15%) vs. 20 (6%); p < 0.001 compared to patients with NVE. Preoperative NLR was 3.7 (2.4-6.1), NPR was 23 (16-37), PLR was 159 (106-210), NMR was 8.4 (6.6-12), MRL was 0.41 (0.29-0.62], and SII was 790 (485-1396). NLR, NPR, and MLR were significantly lower in patients with NVE compared to patients with PVE and in survivors compared to non-survivors. Overall mean survival time was 12.2 ± 0.5 years, with patients with NVE having better early and late survival compared to patients with PVE. Patients with preoperative NLR < 3.8, NPR < 30.9, and MLR < 0.4 had significantly better mean survival time compared to patients with preoperative NLR > 3.8, NPR > 30.9, and MLR > 0.4, respectively. Conclusions: In patients undergoing surgery for IE, preoperative higher NLR, NPR, and MLR are associated with increased early and long-term mortality.